Renal Rehabilitation

*Glomerulonephritis and Nephrotic Syndrome*

[17] Cattran DC, Kim ED, Reich H, et al. Membranous nephropathy: Quantifying remission duration on outcome. Journal of the American Society of Nephrology.

[18] Cravedi P, Ruggenenti P, Remuzzi G. Circulating anti-PLA2R autoantibodies to monitor immunological activity in membranous nephropathy. Journal of the American Society of Nephrology. 2011;**22**:1400

2017;**28**:995

**100**

**103**

**Chapter 7**

**Abstract**

Movement

renal hemodialysis units.

**1. Introduction**

*Jorge Enrique Moreno Collazos* 

*and Diana Carolina Zona Rubio*

Renal Rehabilitation: A

Perspective From Human Body

The prevalence and incidence of advanced chronic kidney disease has grown progressively in most countries of the world. Hemodialysis is the most common treatment that replaces the renal function, and although it allows to replace the function of the kidney, the patients who undergo it can present numerous alterations that lead to a loss of functional physical capacity and a decrease in the quality of life related to health. It is unknown to what extent low physical activity, uremia and anemia determine the decrease in functional capacity of these patients. The functional tests most frequently used in the published literature are characterized by their ease of application and their low cost, since they do not require large measuring instruments to quantify basic qualities in subjects with impaired or dysfunction of the renal system from the aerobic capacity, muscle performance and flexibility as axes within the kinetic wellbeing which is committed in the stay of the

Rehabilitation specialists currently perform in a variety of important intervention areas, positively diminishing the impact of various alterations, such as, renal dysfunction in hemodialysis care units [1]. Survival of patients with this disease at 5 years is 40% and the life expectancy of patients on dialysis is one fourth to one fifth of the general population [2]. Chronic kidney disease is becoming a serious health problem throughout the world and is one of the most known risk factors for cardiovascular disease, being this the main cause of morbidity and mortality in this patient population. On the other hand, physical inactivity has become a significant and independent risk factor for the accelerated deterioration of renal function, physical function, cardiovascular function and the quality of life of people in all stages of the disease. That is why we must prioritize good practices based on specific research, together with strong evidence on the multiple health benefits of regular and adequate amounts of physical activity in other cardio metabolic conditions, has led to physical inactivity be identified by national and international clinical practice guidelines as one of the multiple risk factors that require simultaneous intervention and principles for optimal prevention/management in rehabilitation. Despite

**Keywords:** rehabilitation, exercise, renal dialysis, physiotherapy

#### **Chapter 7**

## Renal Rehabilitation: A Perspective From Human Body Movement

*Jorge Enrique Moreno Collazos and Diana Carolina Zona Rubio*

#### **Abstract**

The prevalence and incidence of advanced chronic kidney disease has grown progressively in most countries of the world. Hemodialysis is the most common treatment that replaces the renal function, and although it allows to replace the function of the kidney, the patients who undergo it can present numerous alterations that lead to a loss of functional physical capacity and a decrease in the quality of life related to health. It is unknown to what extent low physical activity, uremia and anemia determine the decrease in functional capacity of these patients. The functional tests most frequently used in the published literature are characterized by their ease of application and their low cost, since they do not require large measuring instruments to quantify basic qualities in subjects with impaired or dysfunction of the renal system from the aerobic capacity, muscle performance and flexibility as axes within the kinetic wellbeing which is committed in the stay of the renal hemodialysis units.

**Keywords:** rehabilitation, exercise, renal dialysis, physiotherapy

#### **1. Introduction**

Rehabilitation specialists currently perform in a variety of important intervention areas, positively diminishing the impact of various alterations, such as, renal dysfunction in hemodialysis care units [1]. Survival of patients with this disease at 5 years is 40% and the life expectancy of patients on dialysis is one fourth to one fifth of the general population [2]. Chronic kidney disease is becoming a serious health problem throughout the world and is one of the most known risk factors for cardiovascular disease, being this the main cause of morbidity and mortality in this patient population. On the other hand, physical inactivity has become a significant and independent risk factor for the accelerated deterioration of renal function, physical function, cardiovascular function and the quality of life of people in all stages of the disease. That is why we must prioritize good practices based on specific research, together with strong evidence on the multiple health benefits of regular and adequate amounts of physical activity in other cardio metabolic conditions, has led to physical inactivity be identified by national and international clinical practice guidelines as one of the multiple risk factors that require simultaneous intervention and principles for optimal prevention/management in rehabilitation. Despite

this awareness, physical inactivity is not systematically addressed by the renal care teams from the care of the physiotherapist's professional in this section of the hemodialysis units [3].

Other disease conditions can accelerate the loss of kidney function as it is: diabetes, obesity, high blood pressure among others can cause dysfunction of multiple systems. [4, 5]. That is why physical activity at adequate levels and regularly prescribed allow positive contribution to the impact of muscle mass loss and weakness, low aerobic capacity, vascular reserve capacity, frailty and disability, where the latter are evidenced in a quality of life compromised in chronic kidney disease [6–10].

Among the changes resulting from chronic renal failure, muscle dysfunctions occur, where studies have shown the presence of atrophy of muscle fibers resulting from an imbalance between the synthesis and degradation of muscle protein. There may even be decreased synthesis and/or increased degradation [11–15]. Several mechanisms lead to muscle dysfunction, among which are: the depletion of amino acids; chronic inflammation; inactivity; malnutrition syndrome; changes in capillary perfusion; peripheral neuropathy, among others.

Thus, the literature reports exercise intolerance associated with anemia and hypervolemia in users with chronic renal failure; studies have already shown the treatment of these conditions, however, does not improve the tolerance to exercise, and therefore, this intolerance consequently leads to a sedentary lifestyle, which further decreases the physical capacity, creating a vicious circle within of the condition of chronic kidney disease translated into implications in their quality of life [16–18].

The foregoing evidences the need to complement the processes of renal rehabilitation with the clear participation of the physiotherapist as a promoter of the human body movement from the areas of secondary, tertiary prevention and rehabilitation with the aim of diminishing the negative impact of the burden of the disease in the user and carer.

#### **1.1 Physiotherapy in the field of renal rehabilitation**

The treatment of patients with progressive renal failure can be divided into several components, including health promotion and primary prevention programs (based on risk groups), early planning of renal replacement therapy and the establishment of interventions to treat the progression of chronic kidney disease and increase the quality of life of patients. Physiotherapy is included in this component of the treatment, based mainly on specific programs of supervised physical exercise, with the aim of increasing the level of physical fitness and, consequently, improving the quality of life and reducing the need for antihypertensive medications; morbidity and mortality [19].

The physiotherapeutic action in renal hemodialysis units is based on the prescription of their therapeutic actions based on physical activity, where it has been possible to demonstrate the benefits of physical activity for patients with chronic renal failure [20] including: increase in tolerance to exercise; reduction of inflammatory mediators; increase in synthesis and decrease in muscle protein degradation; increase in the number and size of muscle fibers, thus increasing muscle strength; increase in hematocrit and hemoglobin. Central effects also occur: improvement of left ventricular function, decrease in the occurrence of cardiac arrhythmias, in addition to beneficial effects on coronary artery disease risk factors (hypertension, lipid disorders).

Physical exercise is derived from the concept of physical activity, which is any movement of the body that spends energy above the basal level. Exercise then is all

**105**

*Renal Rehabilitation: A Perspective From Human Body Movement*

planned, structured and repetitive physical activity that aims to improve or maintain one or more components of physical condition. Therefore the prescription of physical exercise is the orderly and systematic process by which a regime of physical activity and/or exercise is recommended individually, according to needs and

From this perspective, health professionals require a multidisciplinary work [22] that mainly involves physiotherapists [23] to counteract the progress of noncommunicable chronic diseases (NCD), using cost-effective actions that cover the

**1.2 Renal rehabilitation based on the strategy of the physical exercise in the** 

The criteria for examination (anamnesis), evaluation and diagnosis, intervention processes, prognosis and evolution to contribute to the goals of the interdisciplinary group of renal rehabilitation at the hemodialysis units are set out in the process schema of the American Physiotherapy Practice Guide (APTA) [26].

The criteria for examination (anamnesis), evaluation and diagnosis, intervention processes, prognosis and evolution to contribute to the goals of the interdisciplinary group of renal rehabilitation are set out in the process schema of the

Among the fundamental aspects in the process of the anamnesis with the user is the process of collecting important data for the development of the clinical history in physiotherapy as are the physical qualities that are immersed in the stay of hemodialysis units. Likewise, comorbidities, medications, postural changes, vital signs, and anthropometric data will be analyzed in order to evaluate the physical condition in health, to subsequently plan the prescription of the appropriate exercise

Among the contraindications for the practice of physical activity prescribed by physiotherapy, some exclusion criteria are considered: recent myocardial infarction; uncontrolled arrhythmias; uncontrolled hypertension (systolic blood pressure > 200 mm Hg and diastolic blood pressure > 120 mm Hg); unstable angina; severe decompensated diabetes (blood glucose > 300 mg/dL); dysfunction of the left ventricle; presence of neurological or motor impeding dysfunction, for the

At the beginning of each exercise session, if the patient has any symptoms that prevent them from performing the exercises, the team of the hemodialysis unit should be informed, where they will report some important aspects such as: perceived muscle fatigue, angina pectoris, lipotimias, pallor, syncope, pre-syncope, disproportionate dyspnea in relation to intensity of effort, arrhythmias and hypotension or the hypertensive response of being detected any of these symptoms is important to study the admission to the physiotherapy program in hemodialysis

Patients with chronic kidney disease are inactive, which reduces physical performance. Aerobic exercise interventions have been shown to increase maximum oxygen consumption in selected patients. In addition, preliminary evidence,

preferences, to obtain greater benefits with the lowest risk to health [21].

*DOI: http://dx.doi.org/10.5772/intechopen.86156*

entire population [24, 25].

**unit of hemodialysis**

**the hemodialysis unit**

American Physiotherapy Practice Guide (APTA).

application of the protocol of physical activity.

within the rehabilitation program renal.

**1.4 Effects of the physical exercise in renal rehabilitation**

according to the degree of severity of chronic kidney disease.

**1.3 Contraindications and precautions in the physical exercise in** 

*Renal Rehabilitation: A Perspective From Human Body Movement DOI: http://dx.doi.org/10.5772/intechopen.86156*

*Glomerulonephritis and Nephrotic Syndrome*

lary perfusion; peripheral neuropathy, among others.

**1.1 Physiotherapy in the field of renal rehabilitation**

hemodialysis units [3].

disease [6–10].

life [16–18].

disease in the user and carer.

tions; morbidity and mortality [19].

(hypertension, lipid disorders).

this awareness, physical inactivity is not systematically addressed by the renal care teams from the care of the physiotherapist's professional in this section of the

Other disease conditions can accelerate the loss of kidney function as it is: diabetes, obesity, high blood pressure among others can cause dysfunction of multiple systems. [4, 5]. That is why physical activity at adequate levels and regularly prescribed allow positive contribution to the impact of muscle mass loss and weakness, low aerobic capacity, vascular reserve capacity, frailty and disability, where the latter are evidenced in a quality of life compromised in chronic kidney

Among the changes resulting from chronic renal failure, muscle dysfunctions occur, where studies have shown the presence of atrophy of muscle fibers resulting from an imbalance between the synthesis and degradation of muscle protein. There may even be decreased synthesis and/or increased degradation [11–15]. Several mechanisms lead to muscle dysfunction, among which are: the depletion of amino acids; chronic inflammation; inactivity; malnutrition syndrome; changes in capil-

Thus, the literature reports exercise intolerance associated with anemia and hypervolemia in users with chronic renal failure; studies have already shown the treatment of these conditions, however, does not improve the tolerance to exercise, and therefore, this intolerance consequently leads to a sedentary lifestyle, which further decreases the physical capacity, creating a vicious circle within of the condition of chronic kidney disease translated into implications in their quality of

The foregoing evidences the need to complement the processes of renal rehabilitation with the clear participation of the physiotherapist as a promoter of the human body movement from the areas of secondary, tertiary prevention and rehabilitation with the aim of diminishing the negative impact of the burden of the

The treatment of patients with progressive renal failure can be divided into several components, including health promotion and primary prevention programs (based on risk groups), early planning of renal replacement therapy and the establishment of interventions to treat the progression of chronic kidney disease and increase the quality of life of patients. Physiotherapy is included in this component of the treatment, based mainly on specific programs of supervised physical exercise, with the aim of increasing the level of physical fitness and, consequently, improving the quality of life and reducing the need for antihypertensive medica-

The physiotherapeutic action in renal hemodialysis units is based on the prescription of their therapeutic actions based on physical activity, where it has been possible to demonstrate the benefits of physical activity for patients with chronic renal failure [20] including: increase in tolerance to exercise; reduction of inflammatory mediators; increase in synthesis and decrease in muscle protein degradation; increase in the number and size of muscle fibers, thus increasing muscle strength; increase in hematocrit and hemoglobin. Central effects also occur: improvement of left ventricular function, decrease in the occurrence of cardiac arrhythmias, in addition to beneficial effects on coronary artery disease risk factors

Physical exercise is derived from the concept of physical activity, which is any movement of the body that spends energy above the basal level. Exercise then is all

**104**

planned, structured and repetitive physical activity that aims to improve or maintain one or more components of physical condition. Therefore the prescription of physical exercise is the orderly and systematic process by which a regime of physical activity and/or exercise is recommended individually, according to needs and preferences, to obtain greater benefits with the lowest risk to health [21].

From this perspective, health professionals require a multidisciplinary work [22] that mainly involves physiotherapists [23] to counteract the progress of noncommunicable chronic diseases (NCD), using cost-effective actions that cover the entire population [24, 25].

#### **1.2 Renal rehabilitation based on the strategy of the physical exercise in the unit of hemodialysis**

The criteria for examination (anamnesis), evaluation and diagnosis, intervention processes, prognosis and evolution to contribute to the goals of the interdisciplinary group of renal rehabilitation at the hemodialysis units are set out in the process schema of the American Physiotherapy Practice Guide (APTA) [26].

The criteria for examination (anamnesis), evaluation and diagnosis, intervention processes, prognosis and evolution to contribute to the goals of the interdisciplinary group of renal rehabilitation are set out in the process schema of the American Physiotherapy Practice Guide (APTA).

Among the fundamental aspects in the process of the anamnesis with the user is the process of collecting important data for the development of the clinical history in physiotherapy as are the physical qualities that are immersed in the stay of hemodialysis units. Likewise, comorbidities, medications, postural changes, vital signs, and anthropometric data will be analyzed in order to evaluate the physical condition in health, to subsequently plan the prescription of the appropriate exercise according to the degree of severity of chronic kidney disease.

#### **1.3 Contraindications and precautions in the physical exercise in the hemodialysis unit**

Among the contraindications for the practice of physical activity prescribed by physiotherapy, some exclusion criteria are considered: recent myocardial infarction; uncontrolled arrhythmias; uncontrolled hypertension (systolic blood pressure > 200 mm Hg and diastolic blood pressure > 120 mm Hg); unstable angina; severe decompensated diabetes (blood glucose > 300 mg/dL); dysfunction of the left ventricle; presence of neurological or motor impeding dysfunction, for the application of the protocol of physical activity.

At the beginning of each exercise session, if the patient has any symptoms that prevent them from performing the exercises, the team of the hemodialysis unit should be informed, where they will report some important aspects such as: perceived muscle fatigue, angina pectoris, lipotimias, pallor, syncope, pre-syncope, disproportionate dyspnea in relation to intensity of effort, arrhythmias and hypotension or the hypertensive response of being detected any of these symptoms is important to study the admission to the physiotherapy program in hemodialysis within the rehabilitation program renal.

#### **1.4 Effects of the physical exercise in renal rehabilitation**

Patients with chronic kidney disease are inactive, which reduces physical performance. Aerobic exercise interventions have been shown to increase maximum oxygen consumption in selected patients. In addition, preliminary evidence, although mixed, suggests that aerobic exercise training may improve blood pressure, lipid profile, and mental health in this population.

The training with resistance exercises, although less studied, where an increase in muscular resistance and performance is observed, translates into an increase in functioning in their activities of daily life. Despite the evidence that exercise is safe and beneficial in patients with chronic kidney disease, dialysis patients remain inactive, where it is necessary to establish parameters from the evaluation, the advice of the physiotherapy intervention based on the physical exercise directed to the patients with this pathology.

The actions of physiotherapy are based on the evaluation of exercise capacity: measures of aerobic capacity assessment of exercise, muscle strength, and overall quality of life [27].

#### **1.5 Muscular strength**

The loss of muscle mass is the most important predictor of mortality in HD patients [28]. Muscular atrophy and, consequently, the organism is a generalized weakness, caused by the loss of strength, compared with normal subjects is 30–40% lower, making the patient physical deconditioning [29, 30]. Physical training is an important factor in the control and reversal of the loss, although the effects of this population have yet to be fully understood [31].

In this sense, Cantareli et al. [32] applied 5 months of resistance and strength training during HD, demonstrating the increase in muscle strength of the knee extensors and the average loads tolerated by MID: 4.71 ± 3.03 vs. 6.07 ± 2.62 vs. 8.42 ± 3.30 kg; MIE 4.85 ± 3.13 vs. 6.21 ± 2.82 vs. 8.57 ± 3.99 kg, p < 0.05. Other authors [33–36], studied the effect of aerobic and/or resistance also found a significant improvement in muscle strength.

Muscle fiber atrophy, type I and II, particularly type IIB, is an important factor that together with histochemical changes at low concentration of aerobic enzymes, low oxidative capacity, loss of capillarity and low levels of contractile proteins contribute to the muscle dysfunction [37, 38].

To verify the effects of exercise on the alterations present in patients with chronic renal failure in HD muscle, Sakkas et al. [12] examined the morphology of twin muscles in 12 patients before and after an aerobic exercise program performed three times a week for 6 months. The results showed that the proposed training improved muscle tropism, increased cross-sectional area by 46% and reduced the atrophy of muscle fibers of type I (51–15%), type IIA (5821%) and type IIB (62–32%). In addition, significant differences were found with respect to increased muscle capillarity.

Muscle strength is usually measured as maximal force by isokinetic dynamometry [39] and maximum torque, and absolute muscle strength using one maximum repetition [40] being the maximum weight that can be lifted in a single repetition of a given exercise by the physiotherapist.

#### **1.6 Aerobic capacity**

Several studies have shown that patients with chronic kidney disease on hemodialysis have reduced functional capacity and exercise capacity by about 50% lower compared to healthy subjects [41, 42]. Several factors associated with this reduction include decreased physical activity, muscle weakness, anemia, ventricular dysfunction, abnormal metabolic and hormonal controls [31]. Currently, great interest has been attributed to the assessment of the functional capacity of these patients through the six-minute walk test (PM6M) and other tests such as sitting and

**107**

professionals [51, 52].

*Renal Rehabilitation: A Perspective From Human Body Movement*

standing up. These tests are simple and measure functional capacity through basic information, and provide important data to monitor the progress of the patient in the course of the disease thus evaluating the benefits of rehabilitation programs [43].

Research has shown that chronic kidney disease and hemodialysis are some of the pathologies and therapies that most affect the quality of life, since they lead to the limitation of cardiorespiratory and physical capacity, which can degrade performance in work activities and social life [41, 44, 45]. Studies show that physical activity can contribute to an improvement in the quality of life of patients with

Painter et al. [46] found the effect of a program consisting of 8 weeks of exercises at home, of 8 weeks of cycle ergometer during dialysis on the quality of life of chronic kidney patients. After 4 months, the authors observed a significant increase in the following dimensions of SF-36: functional capacity (47.7 ± 28.3 vs. 53.4 ± 27 p = 0.004), physical (40.4 ± 40, 3 vs. 54.5 ± 21.4 p < 0.001), pain (60.5 ± 28.1 vs. 66.6 ± 28.6 p = 0.003) and general health (45 ± 21.9 vs. 49, 1 ± 22.5 p = 0.05). According to the authors of the SF-36 results clearly indicate that specific physical activity affects the physical aspects of health, because there were no changes in mental health scores in any group of patients. Consequently, Vilsteren et al. [35] at 12 weeks of intra-dialysis aerobic training observed a significant change in the components of vitality and the general state from the application of the SF-36

However, Cantareli et al. [32] in his clinical trial of seven patients showed that the average values of the physical aspects, pain, general health and vitality increased after achieving an increase in muscle mass, but it was not very significant.

Physical inactivity is a strong predictor of mortality in patients with end-stage renal disease and is associated with physical malfunction. Patients with terminal stage kidney disease are inactive even compared to sedentary individuals without kidney disease. Therefore, it is necessary to identify those existing barriers that have been described by some researches in hemodialysis units such as: Early muscular fatigue in the execution of movement, asthenia and adynamia, post-dialysis fatigue [47]. However, the lack of guidance from nephrologists is probably not the only reason for patient's low levels of physical activity. In a study by Goodman and colleagues [48], lack of motivation and interest were some of the factors cited as the

The deficit in physical activity among patients on dialysis has been theorized that it is due to a lack of motivation secondary to the patient's barriers, including socioeconomic, psychological and the perception of physical disability, although the motivation towards the practice and adherence of A physical activity program may be related to the previous level of physical exercise performed by the subject [49, 50]. However, given the potential obstacles to providing exercise opportunities in the dialysis unit, a possible alternative would be to promote health education mechanisms towards tertiary prevention aimed at users with the goal of identifying times in their daily routine (outside of dialysis) and thus incorporate physical activity effectively in their activities of daily life. Some guidance and encouragement should be guided by recommendations directed at older people from health

**1.8 Existing barriers for participation in physical activity programs** 

limitation of the patient's participation in physical activity.

*DOI: http://dx.doi.org/10.5772/intechopen.86156*

**1.7 Quality of life**

chronic kidney disease.

questionnaire (p = 0.001).

**in renal units**

standing up. These tests are simple and measure functional capacity through basic information, and provide important data to monitor the progress of the patient in the course of the disease thus evaluating the benefits of rehabilitation programs [43].

#### **1.7 Quality of life**

*Glomerulonephritis and Nephrotic Syndrome*

patients with this pathology.

quality of life [27].

muscle capillarity.

**1.6 Aerobic capacity**

**1.5 Muscular strength**

sure, lipid profile, and mental health in this population.

population have yet to be fully understood [31].

cant improvement in muscle strength.

a given exercise by the physiotherapist.

contribute to the muscle dysfunction [37, 38].

although mixed, suggests that aerobic exercise training may improve blood pres-

The training with resistance exercises, although less studied, where an increase in muscular resistance and performance is observed, translates into an increase in functioning in their activities of daily life. Despite the evidence that exercise is safe and beneficial in patients with chronic kidney disease, dialysis patients remain inactive, where it is necessary to establish parameters from the evaluation, the advice of the physiotherapy intervention based on the physical exercise directed to the

The actions of physiotherapy are based on the evaluation of exercise capacity: measures of aerobic capacity assessment of exercise, muscle strength, and overall

The loss of muscle mass is the most important predictor of mortality in HD patients [28]. Muscular atrophy and, consequently, the organism is a generalized weakness, caused by the loss of strength, compared with normal subjects is 30–40% lower, making the patient physical deconditioning [29, 30]. Physical training is an important factor in the control and reversal of the loss, although the effects of this

In this sense, Cantareli et al. [32] applied 5 months of resistance and strength training during HD, demonstrating the increase in muscle strength of the knee extensors and the average loads tolerated by MID: 4.71 ± 3.03 vs. 6.07 ± 2.62 vs. 8.42 ± 3.30 kg; MIE 4.85 ± 3.13 vs. 6.21 ± 2.82 vs. 8.57 ± 3.99 kg, p < 0.05. Other authors [33–36], studied the effect of aerobic and/or resistance also found a signifi-

Muscle fiber atrophy, type I and II, particularly type IIB, is an important factor that together with histochemical changes at low concentration of aerobic enzymes, low oxidative capacity, loss of capillarity and low levels of contractile proteins

Muscle strength is usually measured as maximal force by isokinetic dynamometry [39] and maximum torque, and absolute muscle strength using one maximum repetition [40] being the maximum weight that can be lifted in a single repetition of

Several studies have shown that patients with chronic kidney disease on hemodialysis have reduced functional capacity and exercise capacity by about 50% lower compared to healthy subjects [41, 42]. Several factors associated with this reduction include decreased physical activity, muscle weakness, anemia, ventricular dysfunction, abnormal metabolic and hormonal controls [31]. Currently, great interest has been attributed to the assessment of the functional capacity of these patients through the six-minute walk test (PM6M) and other tests such as sitting and

To verify the effects of exercise on the alterations present in patients with chronic renal failure in HD muscle, Sakkas et al. [12] examined the morphology of twin muscles in 12 patients before and after an aerobic exercise program performed three times a week for 6 months. The results showed that the proposed training improved muscle tropism, increased cross-sectional area by 46% and reduced the atrophy of muscle fibers of type I (51–15%), type IIA (5821%) and type IIB (62–32%). In addition, significant differences were found with respect to increased

**106**

Research has shown that chronic kidney disease and hemodialysis are some of the pathologies and therapies that most affect the quality of life, since they lead to the limitation of cardiorespiratory and physical capacity, which can degrade performance in work activities and social life [41, 44, 45]. Studies show that physical activity can contribute to an improvement in the quality of life of patients with chronic kidney disease.

Painter et al. [46] found the effect of a program consisting of 8 weeks of exercises at home, of 8 weeks of cycle ergometer during dialysis on the quality of life of chronic kidney patients. After 4 months, the authors observed a significant increase in the following dimensions of SF-36: functional capacity (47.7 ± 28.3 vs. 53.4 ± 27 p = 0.004), physical (40.4 ± 40, 3 vs. 54.5 ± 21.4 p < 0.001), pain (60.5 ± 28.1 vs. 66.6 ± 28.6 p = 0.003) and general health (45 ± 21.9 vs. 49, 1 ± 22.5 p = 0.05). According to the authors of the SF-36 results clearly indicate that specific physical activity affects the physical aspects of health, because there were no changes in mental health scores in any group of patients. Consequently, Vilsteren et al. [35] at 12 weeks of intra-dialysis aerobic training observed a significant change in the components of vitality and the general state from the application of the SF-36 questionnaire (p = 0.001).

However, Cantareli et al. [32] in his clinical trial of seven patients showed that the average values of the physical aspects, pain, general health and vitality increased after achieving an increase in muscle mass, but it was not very significant.

#### **1.8 Existing barriers for participation in physical activity programs in renal units**

Physical inactivity is a strong predictor of mortality in patients with end-stage renal disease and is associated with physical malfunction. Patients with terminal stage kidney disease are inactive even compared to sedentary individuals without kidney disease. Therefore, it is necessary to identify those existing barriers that have been described by some researches in hemodialysis units such as: Early muscular fatigue in the execution of movement, asthenia and adynamia, post-dialysis fatigue [47].

However, the lack of guidance from nephrologists is probably not the only reason for patient's low levels of physical activity. In a study by Goodman and colleagues [48], lack of motivation and interest were some of the factors cited as the limitation of the patient's participation in physical activity.

The deficit in physical activity among patients on dialysis has been theorized that it is due to a lack of motivation secondary to the patient's barriers, including socioeconomic, psychological and the perception of physical disability, although the motivation towards the practice and adherence of A physical activity program may be related to the previous level of physical exercise performed by the subject [49, 50].

However, given the potential obstacles to providing exercise opportunities in the dialysis unit, a possible alternative would be to promote health education mechanisms towards tertiary prevention aimed at users with the goal of identifying times in their daily routine (outside of dialysis) and thus incorporate physical activity effectively in their activities of daily life. Some guidance and encouragement should be guided by recommendations directed at older people from health professionals [51, 52].

### **2. Conclusions**

Studies of the barriers to the participation of renal users in hemodialysis units where exercise programs are being carried out are needed.

It is also important to consolidate elements of the evaluation, recommendations from physiotherapy and its contribution to the rehabilitation program in order to continue on the path of evidence-based practice.

However, participants must be motivated to participate in moderate physical activity according to the current recommendations or consensus of the renal rehabilitation. Users who experience early fatigue or asthenia may benefit from strength training interventions, taking into account that aerobic and resistance exercises should be initiated at relatively low intensity in patients with this disease and progress taking into account the level of tolerance to exercise in order to avoid undesirable effects or even the suspension of therapeutic exercise.

#### **Acknowledgements**

The authors express their gratitude to the Manuela Beltrán University for its projection and interest in research topics in the field of kidney disease and human body movement.

### **Conflict of interest**

The authors do not present conflicts of interest in the process of the narrative review type investigation.

#### **Author details**

Jorge Enrique Moreno Collazos\* and Diana Carolina Zona Rubio Cardiorespiratory Therapy Unit, Manuela Beltran University, Bogota, Colombia

\*Address all correspondence to: jorge.moreno@docentes.umb.edu.co

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**109**

*Renal Rehabilitation: A Perspective From Human Body Movement*

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[10] Heiwe S, Jacobson S. Original investigation: Exercise training in adults with CKD: A systematic review and meta-analysis. American Journal of Kidney Diseases. 2014;**64**:383-393

[11] Bohannon RW, Smith J, Hull D, Palmeri D, Barnhard R. Deficits in lower extremity muscle and gait performance among transplant kidney candidates. Archives of Physical Medicine and Rehabilitation. 1995;**76**(6):547-551

[12] Sakkas GK, Sargeant AJ, Mercer TH, Ball D, Koufaki P, Karatzaferi C, et al. Changes in muscle morphology in dialysis patients after 6 months of aerobic exercise training.

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[13] Kosmadakis GC, Bevington A, Smith AC, Clapp EL, Viana JL, Bishop NC, et al. Physical exercise in patients with severe kidney disease. Nephron. Clinical Practice. 2010;**115**(1):c7-c16

[14] Adams GR, Vaziri ND. Skeletal muscle dysfunction in chronic renal failure: Effects of exercise. American Journal of Physiology. Renal Physiology.

[15] Hopman WM, Harrison MB, Coo H, Friedberg E, Buchanan M, VanDenKerkhof EG. Associations between chronic disease, age and physical and mental health status. Chronic Diseases in Canada.

[16] Carvalho T. Diretriz de reabilitação

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*DOI: http://dx.doi.org/10.5772/intechopen.86156*

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2016;**50**(5):317-318

[6] Segura-Ortí E. Exercise in haemodyalisis patients: A literature systematic review. Nefrología: Publicación Oficial de la Sociedad Española Nefrologia.

[7] Koufaki P, Kouidi E. Current best evidence recommendations on measurement and interpretation of physical function in patients with chronic kidney disease. Sports Medicine.

[8] Phan K, Jia F, Kamper SJ. Effects of regular physical exercise training in adults with chronic kidney disease. British Journal of Sports Medicine.

in Dialysis. 2012;**25**(6):649-656

Diseases. 2006;**46**:863-870

**References**

### **References**

*Glomerulonephritis and Nephrotic Syndrome*

where exercise programs are being carried out are needed.

undesirable effects or even the suspension of therapeutic exercise.

continue on the path of evidence-based practice.

Studies of the barriers to the participation of renal users in hemodialysis units

It is also important to consolidate elements of the evaluation, recommendations from physiotherapy and its contribution to the rehabilitation program in order to

However, participants must be motivated to participate in moderate physical activity according to the current recommendations or consensus of the renal rehabilitation. Users who experience early fatigue or asthenia may benefit from strength training interventions, taking into account that aerobic and resistance exercises should be initiated at relatively low intensity in patients with this disease and progress taking into account the level of tolerance to exercise in order to avoid

The authors express their gratitude to the Manuela Beltrán University for its projection and interest in research topics in the field of kidney disease and human

The authors do not present conflicts of interest in the process of the narrative

**2. Conclusions**

**Acknowledgements**

body movement.

**Author details**

**Conflict of interest**

review type investigation.

**108**

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Cardiorespiratory Therapy Unit, Manuela Beltran University, Bogota, Colombia

Jorge Enrique Moreno Collazos\* and Diana Carolina Zona Rubio

\*Address all correspondence to: jorge.moreno@docentes.umb.edu.co

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[7] Koufaki P, Kouidi E. Current best evidence recommendations on measurement and interpretation of physical function in patients with chronic kidney disease. Sports Medicine. 2010;(12):1055

[8] Phan K, Jia F, Kamper SJ. Effects of regular physical exercise training in adults with chronic kidney disease. British Journal of Sports Medicine. 2016;**50**(5):317-318

[9] Smart N, Williams A, Fassett R, et al. Review: Exercise & Sports Science Australia [ESSA] position statement on exercise and chronic kidney disease. Journal of Science and Medicine in Sport. 2013;**16**:406-411

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[15] Hopman WM, Harrison MB, Coo H, Friedberg E, Buchanan M, VanDenKerkhof EG. Associations between chronic disease, age and physical and mental health status. Chronic Diseases in Canada. 2009;**29**(2):108-116

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Arquivos Brasileiros de Cardiologia. 2006;**86**(1):74-82

[17] Martins MRI, Cesarino CB. Quality of life in chronic kidney failure patients receiving hemodialysis treatment. Revista Latino-Americana de Enfermagem. 2005;**13**(5):670-676

[18] Reboredo MM, Henrique DMN, Bastos MG, Paula RB. Exercício físico em pacientes dialisados. Revista Brasileira de Medicina do Esporte. 2007;**13**(6):427-430

[19] Miranda G, Souza B, Oliveira F. Impact of physical therapy on functional capacity and life quality of patients with chronic kidney disease/ Impacto da fisioterapia na qualidade de vida e capacidade funcional em pacientes com doença renal crônica. Fisioterapia Em Movimento. 2014;(4):643

[20] Nascimento LCA, Coutinho EB, Silva KNG. Effectiveness of physical exercise in chronic renal failure. Fisioterapia e Pesquisa. 2012;**25**(1):231-239

[21] Fortier M, Tulloch H, Hogg W. A good fit integrating physical activity counselors into family practice. Canadian Family Physician. 2006;**52**(8):942-944

[22] Moore GE. The role of exercise prescription in chronic disease. British Journal of Sports Medicine. 2004;**38**(1):6-7

[23] Quality Assurance Agency for Higher Education. Benchmark Statement: Health Care Programmes. Phase 1: Physiotherapy. London: Frontier Print & Design Limited; 2001

[24] WCPT. European Core Standards of Physiotherapy Practice General Meeting of the European Region of the WCPT; Athens: WCPT; 2008. pp. 1-46

[25] De Vries TP, Henning RH, Hogerzeil HG, Fresle DA. El proceso de la terapéutica razonada. En: Guía de la Buena Prescripción. Barcelona: OMS; 1998. pp. 6-12

[26] Task Force for the Development of Student Clinical Performance Instruments. The development and testing of APTA clinical performance instruments. American Physical Therapy Association. Physical Therapy. 2002;**82**(4):329

[27] Johansen KL. Exercise and chronic kidney disease. Sports Medicine. 2005;**35**(6):485-499

[28] Cheema BS, Smith BC, Singh MA. A rationale for intradialytic exercise training as standard clinical practice in ESRD. American Journal of Kidney Diseases. 2005;**45**(5):912-916

[29] Soares A, Zehetmeyer M, Rabuske M. Atuação da fisioterapia durante a hemodiálise visando à qualidade de vida do paciente renal crônico. Revista de Saúde da Universidade Católica de Pelotas. 2007;**1**(1):7-12

[30] Medeiros RH, Pinent CEC, Meyer F. Aptidão física de indivíduo com doença renal crônica. Jornal Brasileiro de Nefrologia. 2002;**24**(2):81-87

[31] Coelho DM, Ribeiro JM, Soares DD. Exercícios físicos durante a hemodiálise: uma revisão sistemática. Jornal Brasileiro de Nefrologia. 2008;**30**(2):88-98

[32] Cantareli F, Corrêa LB, Oliveira RN, Cunha LS. Efeito do treinamento muscular periférico na capacidade funcional e qualidade de vida nos pacientes em hemodiálise. Jornal Brasileiro de Nefrologia. 2009;**31**(1):18-24

[33] Storer TW, Casaburi R, Sawelson S, Kopple JD. Endurance exercise training during haemodialysis

**111**

*Renal Rehabilitation: A Perspective From Human Body Movement*

on muscle atrophy in haemodialysis patients. Nephrology, Dialysis, Transplantation. 1998;**13**:685-699

[40] Heiwe S, Clyne N, Tollback A, Borg K. Effects of regular resistance training on muscle histopathology and morphometry in elderly patients with chronic kidney disease. American

Journal of Physical Medicine & Rehabilitation. 2005;**84**:865-874

2009;**16**(2):155-160

[41] Cunha MS, Andrade V, Guedes CAV, Meneghetti CHZ, Aguiar AP, Cardoso AL. Avaliação da capacidade funcional e da qualidade de vida em pacientes renais crônicos submetidos a tratamento hemodialítico. Fisioterapia e Pesquisa.

[42] Jatobá JPC, Amaro WF, Andrade APA, Cardoso FPF, Monteiro AMH, Oliveira MAM. Avaliação da função pulmonar, força muscular respiratória e teste de caminhada de seis minutos em pacientes portadores de doença renal crônica em hemodiálise. Jornal Brasileiro de Nefrologia. 2008;**30**(4):280-287

[43] Cury JL, Brunetto AF, Aydos RD. Efeitos negativos da insuficiência

pulmonar e a capacidade funcional. Revista Brasileira de Fisioterapia.

[44] Barbosa LMM, Andrade MP Jr, Bastos KA. Preditores de qualidade de vida em pacientes com doença renal crônica em hemodiálise. Jornal Brasileiro de Nefrologia.

[45] Castro M, Caiuby AVS, Draibe A, Canziani ME. Qualidade de vida de pacientes com insuficiência renal crônica em Hemodiálise avaliada através do instrumento genérico SF-36. Revista da Associação Médica Brasileira.

[46] Painter P, Carlson L, Carey S, Paul SM, Myll J. Physical functioning and

renal crônica sobre a função

2010;**14**(2):91-98

2007;**29**(4):222-229

2003;**49**(3):245-249

*DOI: http://dx.doi.org/10.5772/intechopen.86156*

improves strength, power, fatigability

maintenance haemodialysis patients. Nephrology, Dialysis, Transplantation.

[34] Cheema B, Abas H, Smith B, O'Sullivan A, Chan M, Patwardhan A, et al. Progressive exercise training for anabolism in kidney disease [PEAK]: A randomized, controlled trial of resistance training during hemodialysis. Journal of the American Society of Nephrology. 2007;**18**(15):94-601

[35] Vilsteren MCBA, Greef MHG, Huisman RM. The effects of a low-to-moderate intensity preconditioning exercise programme linked with exercise counseling for sedentary haemodialysis patients in the Netherlands: Results of a randomized clinical trial.

Nephrology, Dialysis, Transplantation.

[36] Molsted S, Eidemakb I, Sorensena HT, Kristensen JH. Five months of physical exercise in hemodialysis patients: Effects on aerobic capacity, physical function and self-rated health. Nephron. Clinical Practice.

[37] Moreira PR, Barros E. Atualização em fisiologia e fisiopatologia renal: Bases fisiopatológicas da miopatia na insuficiência renal crônica. Jornal Brasileiro de Nefrologia.

[39] Kouidi E, Albani M, Konstantinos N. The effects of exercise training

2005;**20**(1):141-146

2004;**96**(3):c76-c81

2000;**22**(1):40-44

2007;**1**(3):29-41

[38] Coelho MC, Godoy CG, Tavares H, Navarro F, Almeida AL. Avaliação funcional e prescrição de treinamento para paciente portador de insuficiência renal crônica submetido a hemodiálise: Um relato de caso. Revista Brasileira de Prescrição e Fisiologia do Exercício.

and physical performance in

2005;**20**(1):429-437

#### *Renal Rehabilitation: A Perspective From Human Body Movement DOI: http://dx.doi.org/10.5772/intechopen.86156*

improves strength, power, fatigability and physical performance in maintenance haemodialysis patients. Nephrology, Dialysis, Transplantation. 2005;**20**(1):429-437

*Glomerulonephritis and Nephrotic Syndrome*

Arquivos Brasileiros de Cardiologia.

[25] De Vries TP, Henning RH, Hogerzeil

HG, Fresle DA. El proceso de la terapéutica razonada. En: Guía de la Buena Prescripción. Barcelona: OMS;

[26] Task Force for the Development of Student Clinical Performance Instruments. The development and testing of APTA clinical performance instruments. American Physical Therapy Association. Physical Therapy.

[27] Johansen KL. Exercise and chronic kidney disease. Sports Medicine.

[28] Cheema BS, Smith BC, Singh MA. A rationale for intradialytic exercise training as standard clinical practice in ESRD. American Journal of Kidney

[29] Soares A, Zehetmeyer M, Rabuske M. Atuação da fisioterapia durante a hemodiálise visando à qualidade de vida do paciente renal crônico. Revista de Saúde da Universidade Católica de

[30] Medeiros RH, Pinent CEC, Meyer F. Aptidão física de indivíduo com doença renal crônica. Jornal Brasileiro de Nefrologia. 2002;**24**(2):81-87

[31] Coelho DM, Ribeiro JM, Soares DD. Exercícios físicos durante a hemodiálise: uma revisão sistemática. Jornal Brasileiro de Nefrologia.

[32] Cantareli F, Corrêa LB, Oliveira RN, Cunha LS. Efeito do treinamento muscular periférico na capacidade funcional e qualidade de vida nos pacientes em hemodiálise. Jornal Brasileiro de Nefrologia.

[33] Storer TW, Casaburi R, Sawelson S, Kopple JD. Endurance exercise training during haemodialysis

Diseases. 2005;**45**(5):912-916

Pelotas. 2007;**1**(1):7-12

2008;**30**(2):88-98

2009;**31**(1):18-24

1998. pp. 6-12

2002;**82**(4):329

2005;**35**(6):485-499

[17] Martins MRI, Cesarino CB. Quality

treatment. Revista Latino-Americana de Enfermagem. 2005;**13**(5):670-676

[18] Reboredo MM, Henrique DMN, Bastos MG, Paula RB. Exercício físico em pacientes dialisados. Revista Brasileira de Medicina do Esporte.

[19] Miranda G, Souza B, Oliveira F. Impact of physical therapy on functional capacity and life quality of patients with chronic kidney disease/ Impacto da fisioterapia na qualidade de vida e capacidade funcional em pacientes com doença renal crônica. Fisioterapia Em Movimento.

[20] Nascimento LCA, Coutinho EB, Silva KNG. Effectiveness of physical exercise in chronic renal failure. Fisioterapia e Pesquisa.

[21] Fortier M, Tulloch H, Hogg W. A good fit integrating physical activity counselors into family practice. Canadian Family Physician.

[22] Moore GE. The role of exercise prescription in chronic disease. British Journal of Sports Medicine.

[23] Quality Assurance Agency for Higher Education. Benchmark Statement: Health Care Programmes. Phase 1: Physiotherapy. London: Frontier Print & Design Limited; 2001

[24] WCPT. European Core

Standards of Physiotherapy Practice General Meeting of the European Region of the WCPT; Athens: WCPT;

of life in chronic kidney failure patients receiving hemodialysis

2006;**86**(1):74-82

2007;**13**(6):427-430

2014;(4):643

2012;**25**(1):231-239

2006;**52**(8):942-944

2004;**38**(1):6-7

**110**

2008. pp. 1-46

[34] Cheema B, Abas H, Smith B, O'Sullivan A, Chan M, Patwardhan A, et al. Progressive exercise training for anabolism in kidney disease [PEAK]: A randomized, controlled trial of resistance training during hemodialysis. Journal of the American Society of Nephrology. 2007;**18**(15):94-601

[35] Vilsteren MCBA, Greef MHG, Huisman RM. The effects of a low-to-moderate intensity preconditioning exercise programme linked with exercise counseling for sedentary haemodialysis patients in the Netherlands: Results of a randomized clinical trial. Nephrology, Dialysis, Transplantation. 2005;**20**(1):141-146

[36] Molsted S, Eidemakb I, Sorensena HT, Kristensen JH. Five months of physical exercise in hemodialysis patients: Effects on aerobic capacity, physical function and self-rated health. Nephron. Clinical Practice. 2004;**96**(3):c76-c81

[37] Moreira PR, Barros E. Atualização em fisiologia e fisiopatologia renal: Bases fisiopatológicas da miopatia na insuficiência renal crônica. Jornal Brasileiro de Nefrologia. 2000;**22**(1):40-44

[38] Coelho MC, Godoy CG, Tavares H, Navarro F, Almeida AL. Avaliação funcional e prescrição de treinamento para paciente portador de insuficiência renal crônica submetido a hemodiálise: Um relato de caso. Revista Brasileira de Prescrição e Fisiologia do Exercício. 2007;**1**(3):29-41

[39] Kouidi E, Albani M, Konstantinos N. The effects of exercise training

on muscle atrophy in haemodialysis patients. Nephrology, Dialysis, Transplantation. 1998;**13**:685-699

[40] Heiwe S, Clyne N, Tollback A, Borg K. Effects of regular resistance training on muscle histopathology and morphometry in elderly patients with chronic kidney disease. American Journal of Physical Medicine & Rehabilitation. 2005;**84**:865-874

[41] Cunha MS, Andrade V, Guedes CAV, Meneghetti CHZ, Aguiar AP, Cardoso AL. Avaliação da capacidade funcional e da qualidade de vida em pacientes renais crônicos submetidos a tratamento hemodialítico. Fisioterapia e Pesquisa. 2009;**16**(2):155-160

[42] Jatobá JPC, Amaro WF, Andrade APA, Cardoso FPF, Monteiro AMH, Oliveira MAM. Avaliação da função pulmonar, força muscular respiratória e teste de caminhada de seis minutos em pacientes portadores de doença renal crônica em hemodiálise. Jornal Brasileiro de Nefrologia. 2008;**30**(4):280-287

[43] Cury JL, Brunetto AF, Aydos RD. Efeitos negativos da insuficiência renal crônica sobre a função pulmonar e a capacidade funcional. Revista Brasileira de Fisioterapia. 2010;**14**(2):91-98

[44] Barbosa LMM, Andrade MP Jr, Bastos KA. Preditores de qualidade de vida em pacientes com doença renal crônica em hemodiálise. Jornal Brasileiro de Nefrologia. 2007;**29**(4):222-229

[45] Castro M, Caiuby AVS, Draibe A, Canziani ME. Qualidade de vida de pacientes com insuficiência renal crônica em Hemodiálise avaliada através do instrumento genérico SF-36. Revista da Associação Médica Brasileira. 2003;**49**(3):245-249

[46] Painter P, Carlson L, Carey S, Paul SM, Myll J. Physical functioning and

health related quality-of-life changes with exercise training in hemodialysis patients. American Journal of Kidney Diseases. 2000;**35**(3):482-492

[47] Jafarzadeh Esfehani A, Dashti S. Barriers to exercise participation among dialysis patients. Nephrology, Dialysis, Transplantation. 2012;**27**(10):3964-3964

[48] Goodman ED, Ballou MB. Perceived barriers and motivators to exercise in hemodialysis patients. Nephrology Nursing Journal. 2004;**31**:23-29

[49] King AC, Castro C, Wilcox S, et al. Personal and environmental factors associated with physical inactivity among different racial ethnic groups of U.S. middle-aged and olderaged women. Health Psychology. 2000;**19**:354-364

[50] Delgado C, Johansen KL. Deficient counseling on physical activity among nephrologists. Nephron. Clinical Practice. 2010;**116**:330-336

[51] Bennett PN, Breugelmans L, Barnard R, et al. Sustaining a hemodialysis exercise program: A review. Seminars in Dialysis. 2010;**23**:62-73

[52] Pianta TF. The role of physical therapy in improving physical functioning of renal patients. Advances in Renal Replacement Therapy. 1999;**6**:149-158

*Glomerulonephritis and Nephrotic Syndrome*

health related quality-of-life changes with exercise training in hemodialysis patients. American Journal of Kidney

Diseases. 2000;**35**(3):482-492

Dialysis, Transplantation. 2012;**27**(10):3964-3964

2000;**19**:354-364

2010;**23**:62-73

1999;**6**:149-158

[47] Jafarzadeh Esfehani A, Dashti S. Barriers to exercise participation among dialysis patients. Nephrology,

[48] Goodman ED, Ballou MB. Perceived barriers and motivators to exercise in hemodialysis patients. Nephrology Nursing Journal. 2004;**31**:23-29

[49] King AC, Castro C, Wilcox S, et al. Personal and environmental factors associated with physical inactivity among different racial ethnic groups of U.S. middle-aged and olderaged women. Health Psychology.

[50] Delgado C, Johansen KL. Deficient counseling on physical activity among nephrologists. Nephron. Clinical Practice. 2010;**116**:330-336

[51] Bennett PN, Breugelmans L, Barnard R, et al. Sustaining a hemodialysis exercise program: A review. Seminars in Dialysis.

[52] Pianta TF. The role of physical therapy in improving physical

in Renal Replacement Therapy.

functioning of renal patients. Advances

**112**

### *Edited by Thomas Rath*

Chronic kidney disease is a worldwide disease affecting up to 4% of the population. In many cases, glomerulonephritis is the underlying disease leading to kidney failure. One hallmark of glomerulonephritis is proteinuria, which may in its most severe form lead to nephrotic syndrome. In seven chapters, this book puts light on different aspects related to the pathophysiology and clinical aspects of glomerulonephritis.

In addition, chapters dealing with the importance of biomarkers in patients with glomerulonephritis will be beneficial for the open-minded reader.

Nevertheless, new insights in renal rehabilitation in patients with chronic kidney disease will be provided.

Published in London, UK © 2019 IntechOpen © Ronik89 / iStock

Glomerulonephritis and Nephrotic Syndrome

Glomerulonephritis

and Nephrotic Syndrome

*Edited by Thomas Rath*