**5. Risks associated with physical inactivity in patients with CKD**

#### **5.1 Why to improve HRQoL in patients with ESRD?**

Patients on dialysis, like those with cancer or heart failure, have lower HRQoL and quality of life than the general population [44]. Treatment for end-stage renal disease (ESRD) has advanced significantly, but mortality and morbidity remain high and the quality of life for those on dialysis is declining. A patient's well-being and survival chances are taken into account when a treatment plan's success is assessed. ESRD patients are more likely to die or be hospitalised if their quality of life (QoL) is low, according to new research [45].

Despite improvements in care outcomes such as dialysis adequacy (Kt/V), phosphorus management, and haemoglobin levels, HRQoL among dialysis patients has not changed much over the preceding 10 years. The quest for therapies to improve dialysis patients' HRQoL has been undertaken by a number of studies. Renal replacement therapy's primary goal is to improve HRQoL in dialysis patients by increasing patient satisfaction and by improving their overall prognosis [46].

Overall survival has been linked to a range of clinical outcomes, including HRQoL (health-related quality of life). HRQoL measures both mental and physical health. The prevalence of depression in dialysis patients (up to 30%) has been linked to hospitalisation and mortality [47, 48]. A better mental health status can be achieved with the appropriate management [49]. Identifying and assessing the mental health state of these people is so critical. Another reason for low HRQoL is a patient's worsening physical health. Patient's PA and physical function are typically impaired in dialysis patients. There is a link between reduced PA and physical performance on an on-going basis and symptoms of depression and anxiety, and dialysis patients with lower physical function have a lower chance of survival [50, 51]. Patients on haemodialysis who are in poor physical health 3 months after dialysis begins are more likely to die [52].

As a result of these findings, we feel that HRQoL in ESRD patients must be improved in order to boost functional ability, psychological status, and patient satisfaction, lower mortality and hospitalisation rates, and improve the overall prognosis of the patients.

#### **5.2 Exercise in patients with ESRD**

On the day of dialysis, dialysis patients are much less physically active than the general aged population, as they are sedentary throughout the process and suffer from post-dialysis weariness. On days when they are not receiving dialysis, dialysis patients are 17% less physically active than non-dialysis patients. With decreased physical activity comes several risks, such as catabolic disorders that can cause muscle loss and lead to sarcopenia, mitochondrial dysfunction, and other conditions such as anaemia, mineral disorders, protein energy loss, diabetes, neurological dysfunction, and cardiovascular dysfunction [20]. Dialysis patients may also be at risk for these conditions.

Better results are strongly linked to increased levels of physical activity and healthy exercise habits. In all DOPPS countries, independent of physical state or social circumstances, patients who regularly exercised more than once a week had superior outcomes, according to the Dialysis Outcomes and Practice Pattern Study (DOPPS) [53]. Patients on CKD and dialysis who receive PA had a decreased death rate [20]. In addition, dialysis patients who completed a median of around 4000 steps daily and had PA of more than 50 minutes per day had better outcomes [54]. A less sedentary lifestyle is related to the improved results even in CKD patients with various impairments [20].

#### **5.3 Factors leading to poor physical function**

Exercise is hindered by factors that prevent genuine clinical practice from following the evidence. A study conducted in the United Kingdom found some important characteristics linked to CKD patients' behavioural alterations. Their physical health (frailty, anaemia, and age-related problems) and mental health (fear of damage or worsening of their ailment) were hindering their ability to engage in regular physical activity. People with concurrent illnesses and CKD-related symptoms including weariness and joint discomfort rated this as the biggest challenge to doing enough exercise [55]. Fear of injury was one of the biggest psychological barriers to physical activity. Some patients' fears about exercise may stem from the fact that healthcare providers are not adequately informing them about the health benefits of physical activity [56]. Individuals wanted individualised guidance and support from their healthcare providers on safe and effective exercises for those with kidney disease.

Further research from Canada found that weariness, dyspnoea, and weakness were the most common barriers to PE in a patient-reported outcome study (PRO). Regardless of modality or age group, PE patients preferred to exercise at home (73%) using a combination of AE and RE (41%). Despite the fact that most research has shown good effects on biochemical indicators and the potential for reduced mortality, these PRO studies suggest that these hopeful results are less meaningful for dialysis patients and may not encourage them to adhere to an "exercise regimen." Instead, they are looking for ways to reduce exhaustion and regain energy so they can go about their regular activities normally. As a result, it is critical that we identify and address these challenges in order to ensure high levels of patient satisfaction. In other words, custom programmes must be approved in order to start and sustain regular PE adherence.

### **6. Exercise has an effect on patients with CKD**

As stated previously, patients with CKD are less fit and functionally compromised. When compared to healthy persons, their aerobic capacity is about half as poor, and

they have weak physical strength and mobility problems. They are more likely to suffer from many disorders. People often complain of back, hip, and leg discomfort, tiredness, and muscle weakness due to electrolyte imbalance and other reasons [57].
