**1. Introduction**

428 Progress in Hemodialysis – From Emergent Biotechnology to Clinical Practice

Williams, S.W., Tell, G.S., Zheng, B., Shumaker, S., Rocco, M.V., & Sevick, M.A. (2002).

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The lifestyle today is new. We sit with our computers, televisions etc. Usually, we do not carry heavy things. We gain weight and loose muscle strength. Through history the life has included moments with physical efforts. The body has not changed. It still needs physical training and efforts. The person who is untrained gets quickly tired. Therefore it is important to make the efforts regularly. The capacity of the heart to transport oxygen increases and the energy increases with physical training. The muscle condition is important. The mitochondria in the muscles cells may increase with 30-40 % after one month of exercise. With more mitochondria more fat is consumed and less carbohydrate is needed. Consequently, less lactic acid is formed and the blood does not change the pH towards acidosis as easily.

Thus, modern people need exercise. You need not to go to a gym or run every day. It is more about having an active life. Take the cycle or walk to the job or to the shop, take the stairs instead of escalator or elevator. The exercise is a part of the natural common life and the body is a tool which needs to be used. It could be enough with 30 minutes of activity to reach physical efforts the heart rate has to increase, maybe to 120 beats/minute. This could be a dilemma for many patients since they have decreased maximal capacity and interacting medication. The training program has to be individualized but the goal is to improve the capacity. If success the daily normal activities feel easier and the patients get more improved trust and comfort. Physical activities mean also better control and less fear of having fall accidents. With a feeling of control there are fewer obstacles.

Thus exercise and effort are important to all of us which are true for many people with different diseases. For patients with cardiac diseases, hypertension, diabetes mellitus there are often exercise programs but for patients with different stages of chronic kidney disease, CKD, there is no obvious exercise treatment program. However, more and more evidence exists that exercises are important for these patients. The dialysis treatment hours have increased more and more to increase KT/V, the dialysis dose, but this also means less time for activities like exercise, work, family life and spear time. How could we help these patients?

The Importance of Exercise Programs in Haemodialysis Patients 431

Many patients with CKD have hypertension. In dialysis the hypertension is most linked to salt and water over load. After kidney transplantation the immunosuppressive drugs CNI (calcineurin inhibitors such as tacrolimus and ciclosporin) and corticosteroids contribute to hypertension. In transplants patients with CAN (chronic allograft nephropathy) ischemia in the kidneys aggravate the situation and give severe hypertension with often therapy

The basis of treatment in hypertension is life style changes, exercise, stop smoking habits and decrease of the sodium chloride in the diet. These are basic advice applicable also to the CKD patients. Many patients have treatment with diuretics to decrease salt and water. Betablockers protect the heart from stress and lower the pulse rate, sometimes hamper maximal training efforts. Calcium blockers are frequently used, cause relaxation of the muscles and

ACE-inhibitors block the angiotensin system and are often well tolerated. It could however be important to be aware of the fact that severe dehydration could be dangerous due to risk of high serum potassium and loss of blood pressure which is a severe condition. This information is important to give to the patient in case of any situation with loss of water like

Regular physical activity lowers the blood pressure but the blood pressure increases during exercise, mostly the systolic blood pressure. With a stress ECG the individual patient could get information about the level of blood pressure and ECG changes during efforts. There are

Regular physical activity affects the nerves. The coordination, the balance and the ability to react becomes better. Most of the persons who do regular exercise have better sleep, less

The exercise increases the insulin sensitivity in the skeletal muscle and decreases the insulin in the blood. This means less adiposities and a more healthy profile of the lipids with increased HDL-cholesterol and decreased triglycerides. For body builders the growth hormone may increase. Also testosterone levels have been found to increase and androgen receptors which increase the effect of testosterone (Kraemer et al 2005). Added testosterone has a much stronger effect, both increasing the muscle mass and adding new cells. However, this substance is classified as doping preparation. Cortisol is a catabolic substance and could be increased at stress caused by some exercises and exercisers. However, cortisol is a life-necessary substance. Catecholamine (noradrenalin and adrenalin) are also produced in the moments of stress, fight and flight response. There is probably an anabolic effect on the skeletal muscles which has been shown in certain animal studies. That is why these preparations are on the doping list. Insulin-like growth factor (IGF-1) could also be

**3. Physical fitness and physical functioning and self-evaluation in patients** 

The physical fitness and physical functioning (= the ability and capacity to perform activities of daily living) is severely reduced in adults with CKD (Kettner-Melsheimer et al 1987;

produced locally in the muscle but the systemic effect is unclear.

resistant blood pressure.

gastrointestinal acute diseases.

recommended levels not to exceed.

depressions and more self-esteem.

vasodilatation.

**Nerve system** 

**Hormone system** 

**with CKD** 

Hence, this chapter is chosen with the intention to provide the reader with information concerning exercise capacity and level of physical activity in adults with chronic kidney disease. It also has the aim to make health-care providers within renal medicine aware of exercise training as an evidence-based intervention to improve health and well-being in adults with CKD. Despite the fact that exercise training is easy, cost effective and preventive, exercise training has not been implemented into clinical practice. We hope that this chapter will stimulate to action and provide some knowledge about these patients and their problems in order to understand why exercise training should be included in the standard care for adults with CKD. The chapter also contains general information about exercise and expected effects in healthy individuals.
