Notes: **General about CKD 4-5**

 For patients with secondary kidney diseases it is important to consider the original disease at assessment of physical capacity, general advice and follow-up. For patients

The Importance of Exercise Programs in Haemodialysis Patients 439

 The amount of fluid, sodium, potassium and blood pressure is constantly variable in a dialysis patient. As a physical therapist it is important to consider these factors in planning the training schedule and in every training opportunity. Consider the restriction of water in individual patients! However, in jogging and running all need water. The simplest method is to instruct the patient to weigh himself/herself before

 The signs of exercise-induced hyponatremia should be recognized by everyone handling dialysis patients. These are symptoms of cerebral over hydration: nausea, malaise when sodium is below 125-130 mmol/L. If plasma sodium falls below 115 to 120 mmol/L there are adding symptoms with headache, lethargy, seizures, and coma.

 Avoid circular pressure in the arm with arteriovenous (AV)-fistula/graft. The blood pressure should not be measured in that arm because of risk to strangle and destroy the

 Before surgery of AV-fistula/graft it is important to perform endurance training of the muscles in the forearm and the hand. This may increase the size of the vena cephalica which is valuable. During a short period after the surgery the patient should not use watches, bracelets or carry heavy bags which may hamper the blood flow in the important AV access. Training the arm with squeezing a soft ball could be important to increase the blood flow in the vein. This makes the AV-fistula more strong and useful. Shoulder and elbow move ability should be alerted and the arm/hand could be used for easier house and family work. Depending on the surgeon's prescription and the status of the patient it may be valuable to start strength training after 3-4 weeks to

 Patients with central dialysis catheters (CDK) on the neck or frontal thorax may start training of muscle and motility. If the sutures cause pain or prevent movements in the neck/shoulder, the physician is consulted for possible adjustment. Considering the risk

Nutrition is a most important issue in CKD patients. Before start of dialysis many patients have protein restricted diet. This has to be changed as soon as dialysis treatment is initiated. The protein intake has instead to be increased. Both the dialysis process and the physical activities need proteins and amino acids. We usually calculate the PCR = protein catabolic rate every month in the dialysis patients based on urea determinations before and after dialysis session and urea before the next dialysis. The patients could get feedback on their

Carbohydrates are important to refill the glycogen stores in the liver and the muscles. The more glycogen, the more energy is available for the exercise. It is considered that 5-7

g/kg/day on training days are needed. If we eat too much more fat is stored instead.

of infection the patient with CDK is not allowed to exercise in a pool.

This is a risk identified in marathon runners (Ayes et al 2000).

different treatments within the team.

and after the running episodes.

important blood flow to the access.

maintain muscular fitness.

**6. Nutrition and exercise** 

protein intake and add protein supplements if needed.

is a problem for the patient, for instance far distance to travel, confinement to the hospital etc, the training may be performed before the dialysis treatment or during the first two hours in dialysis. It is not recommended to do the exercise after dialysis treatment since the patients are dehydrated and there is great risk of hypotensive episodes. Since the patients often have lack of time, it is important to coordinate the

with diabetes mellitus for instance it is important to consider the present foot status and the insulin regimen.


### **Concerning haemodialysis patients:**

 When is the physical training to be performed? It is the medical condition of the patient and the desire of the patient which decide the optimal timing for the training. The most optimal training effect is obtained with the physical activity on dialysis free days. If this

 Patients with polycystic kidney disease should avoid contact sports like karate since hard hits against the kidneys may cause bleeding and pain. There is also a higher risk of hernia of the abdominal wall in this disease. Patients with kidney transplants should also avoid

Health results

More advanced exercise 3 times/w

30 min of daily exercise

contact sports like ice-hockey and land-hockey due to risk of tackling moments. Patients with CKD 4 and 5 suffer more easily from tendinitis. Treatment with chinolones means increased risk of tendinitis. Because of this it is important with heating and cool-down to be prolonged. Also the training of mobility and agility should

Fig. 1. The amount of training and training effects in CKD patients in a schematic form

 When is the physical training to be performed? It is the medical condition of the patient and the desire of the patient which decide the optimal timing for the training. The most optimal training effect is obtained with the physical activity on dialysis free days. If this

**Concerning haemodialysis patients:** 

be prolonged and the training intensity and duration increase smoothly.

the insulin regimen.

with diabetes mellitus for instance it is important to consider the present foot status and

is a problem for the patient, for instance far distance to travel, confinement to the hospital etc, the training may be performed before the dialysis treatment or during the first two hours in dialysis. It is not recommended to do the exercise after dialysis treatment since the patients are dehydrated and there is great risk of hypotensive episodes. Since the patients often have lack of time, it is important to coordinate the different treatments within the team.

