**6. Nutrition and exercise**

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 protein intake and add protein supplements if needed.

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.

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Fats are needed, in the first hand, the essential fatty acids. But any fat to get the important energy balance is important.

Fruit and vegetables are recommended to sportsmen and sportswomen. However, due to risk of hyperpotassemia and high water content in fruits, caution is needed for patients in dialysis. The patients should have lists from dieticians to find the most proper fruits.

Vitamins are needed. Especially C-vitamins since they are removed at hemodialysis or hemofiltration (Fehrman-Ekholm et al 2008). D-vitamins are needed for the skeleton and in treatment of secondary hyperparathyroidism. Iron is necessary in anemia treatment and today most patients have intravenous iron supply at dialysis sessions.

General recommendation is to eat often and to eat after the exercise to fill up the glycogen stores again.

In co work with other team members the physical therapist works to motivate the patient to continue exercises for the rest of life. Regular check-ups by physiotherapist with knowledge of renal medicine and transplant medicine are of greatest importance to maintain maximal physical performance whatever CKD treatment the patient has. We also know that there are several national guidelines that include exercise training and physical activity as part of the treatment for problems that are common in patients with CKD, i.e. high blood pressure, hyperlipidemia and cardiovascular diseases. Within renal care and -medicine we spend a lot of time trying to find ways to optimise the outcome of the care that is given to our patients. But there is already an easy, low-tech intervention that has multiple advantages for these patients' health and well-being, but which hasn't been implemented as a part of the standard care for patients with CKD: Exercise training and physical activity in daily living! Another question is if aerobic exercise and strength training starting early in renal disease could play an important role in prevention or progression of CKD (Moinuddin et al 2008).
