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Physical activity promotes health also among dialysis patients
International Journal of Cardiology 72 (2000) 299–300 www.elsevier.com / locate / ijcard
Letter to the Editor
Physical activity promotes health also among dialysis patients ´ ´ P. Stenvinkel*, C.-G. Elinder, P. Barany Division of Renal Medicine, K56, Department of Clinical Science, Karolinska Institutet, Huddinge University Hospital, 141 86 Huddinge, Sweden Received 2 November 1999; accepted 10 November 1999
It is with great interest we read the paper by Deligiannis et al. [1] in which the cardiac effects of exercise training in hemodialysis patients have been studied. The authors demonstrate that intense exercise training improves left ventricular systolic function in hemodialysis patients and that both intense and moderate physical training enhance cardiac performance during supine submaximal exercise. Indeed, exercise training has been shown to prevent a number of major diseases and promote health in the general population [2]. Previous studies of patients with chronic renal failure have demonstrated that aerobic training may not only improve physical capacity and well being, but also have beneficial metabolic and haemodynamic effects, such as improved lipid profile and carbohydrate tolerance and improved control of hypertension [3–5]. Strength or resistance training may also increase muscle mass and improve nutritional status in renal failure [5]. In view of the significant interactions that has been demonstrated in uremic patients between malnutrition and atherosclerosis [6] it could be speculated that exercise-induced improvements in the nutritional and metabolic status also might have long-term beneficial effects on development of atherosclerosis and subsequent cardiovascular morbidity and mortality. It should be recognized that although the survival on renal replacement therapy has improved somewhat between 1975 and 1992 [7], cardiovascular disease is still the leading cause of mortality in dialysis patients [8]. *Corresponding author. E-mail address: [email protected] (P. Stenvinkel)
However, although short-term regular exercise training might have a beneficial effect on both cardiac performance and the nutritional status in dialysis patients it must be pointed out that the the long-term effects and the overall effects in a non-selected dialysis population have not been elucidated. In many countries, the dialysis population is much older than the patients in most of the published studies of exercise training. A large proportion of the dialysis patients has significant co-morbid conditions and inflammatory disorders which may affect the response to exercise. However, in addition patients with old age and cardiovascular disease have been shown to benefit from physical activity, albeit the risk for cardiovascular events is elevated during the training programme [2]. This holds true also for persons without cardiovascular disease, but the somewhat increased risk for cardiovascular events during exercise is clearly outweighed by the decreased risk between exercise periods [2]. Nevertheless, the exercise programme for dialysis patients must be individualised as many patients may suffer from anaemia, uremic bone disease, myopathy and also they initially may have an extremely low physical capacity. Thus, available evidence strongly indicates that regular exercise training would be of great benefit for dialysis patients with regard to cardiac performance and nutritional status. Therefore, we believe that an exercise programme should, together with other therapeutic measures such as adequate nutrition and dialysis, control of anaemia, secondary hyperparathyroidism and hypertension be implemented as a
0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 99 )00201-6
300
P. Stenvinkel et al. / International Journal of Cardiology 72 (2000) 299 – 300
cornerstone in the care and rehabilitation of patients with chronic renal failure. To be self-critical, it is possible that nephrologists over the years have neglected the beneficial effects of exercise training in dialysis patients in their ‘one-eyed’ desire to optimize factors associated with the dialysis procedure per se. In fact, whereas the dose and time of dialysis might affect survival, no data are yet available showing that factors associated with the dialysis procedure (such as bioincompatibility, sodium profiling and haemofiltration) will affect cardiovascular morbidity and mortality. In addition, the costs for these latter procedures to improve the survival and prognosis of dialysis patients may be considerably higher than for an exercise-training program. We hope that prospective clinical trials are initiated in which the long-term effects of regular physical activity programs on the unacceptable high cardiovascular morbidity and mortality rate in dialysis patients are investigated.
References [1] Deligiannis A, Kouidi E, Tassoulas E, Gigis P, Tourkantonis A, Coats A. Cardiac effects of exercise rehabilitation in hemodialysis patients. Int J Cardiol 1999;70:253–66.
[2] US Department of Health and Human Services. Physical activity and health: a report of the surgeon general, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. [3] Painter P. The importance of exercise training in rehabilitation of patients with end-stage renal disease. Am J Kidney Dis 1994;24(Suppl 1):S2–9. [4] Boyce ML, Robergs RA, Avasthi PS, Roldan C, Foster A, Montner A et al. Exercise training by individuals with predialysis renal failure: cardiorespiratory endurance, hypertension and renal function. Am J Kidney Dis 1997;30:180–92. [5] Castanada C, Grossi L, Dwyer J. Potential benefits of resistance exercise training on nutritional status in renal failure. J Renal Nutr 1998;8:2–10. ¨ [6] Stenvinkel P, Heimburger O, Paultre F, Diczfalusy U, Wang T, Berglund L et al. Strong associations between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int 1999;55:1899–911. [7] Elinder C-G, Jones E, Briggs ID, Mehls O, Mendel S, Piccolo G et al. Improved survival in renal replacement therapy in Europe between 1975 and 1992; an ERA-EDTA registry study. Nephrol Dial Transpl 1999;14:2351–6. [8] Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal failure. Am J Kidney Dis 1998;32(Suppl 5):S112–9.
Letter to the Editor
Physical activity promotes health also among dialysis patients ´ ´ P. Stenvinkel*, C.-G. Elinder, P. Barany Division of Renal Medicine, K56, Department of Clinical Science, Karolinska Institutet, Huddinge University Hospital, 141 86 Huddinge, Sweden Received 2 November 1999; accepted 10 November 1999
It is with great interest we read the paper by Deligiannis et al. [1] in which the cardiac effects of exercise training in hemodialysis patients have been studied. The authors demonstrate that intense exercise training improves left ventricular systolic function in hemodialysis patients and that both intense and moderate physical training enhance cardiac performance during supine submaximal exercise. Indeed, exercise training has been shown to prevent a number of major diseases and promote health in the general population [2]. Previous studies of patients with chronic renal failure have demonstrated that aerobic training may not only improve physical capacity and well being, but also have beneficial metabolic and haemodynamic effects, such as improved lipid profile and carbohydrate tolerance and improved control of hypertension [3–5]. Strength or resistance training may also increase muscle mass and improve nutritional status in renal failure [5]. In view of the significant interactions that has been demonstrated in uremic patients between malnutrition and atherosclerosis [6] it could be speculated that exercise-induced improvements in the nutritional and metabolic status also might have long-term beneficial effects on development of atherosclerosis and subsequent cardiovascular morbidity and mortality. It should be recognized that although the survival on renal replacement therapy has improved somewhat between 1975 and 1992 [7], cardiovascular disease is still the leading cause of mortality in dialysis patients [8]. *Corresponding author. E-mail address: [email protected] (P. Stenvinkel)
However, although short-term regular exercise training might have a beneficial effect on both cardiac performance and the nutritional status in dialysis patients it must be pointed out that the the long-term effects and the overall effects in a non-selected dialysis population have not been elucidated. In many countries, the dialysis population is much older than the patients in most of the published studies of exercise training. A large proportion of the dialysis patients has significant co-morbid conditions and inflammatory disorders which may affect the response to exercise. However, in addition patients with old age and cardiovascular disease have been shown to benefit from physical activity, albeit the risk for cardiovascular events is elevated during the training programme [2]. This holds true also for persons without cardiovascular disease, but the somewhat increased risk for cardiovascular events during exercise is clearly outweighed by the decreased risk between exercise periods [2]. Nevertheless, the exercise programme for dialysis patients must be individualised as many patients may suffer from anaemia, uremic bone disease, myopathy and also they initially may have an extremely low physical capacity. Thus, available evidence strongly indicates that regular exercise training would be of great benefit for dialysis patients with regard to cardiac performance and nutritional status. Therefore, we believe that an exercise programme should, together with other therapeutic measures such as adequate nutrition and dialysis, control of anaemia, secondary hyperparathyroidism and hypertension be implemented as a
0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 99 )00201-6
300
P. Stenvinkel et al. / International Journal of Cardiology 72 (2000) 299 – 300
cornerstone in the care and rehabilitation of patients with chronic renal failure. To be self-critical, it is possible that nephrologists over the years have neglected the beneficial effects of exercise training in dialysis patients in their ‘one-eyed’ desire to optimize factors associated with the dialysis procedure per se. In fact, whereas the dose and time of dialysis might affect survival, no data are yet available showing that factors associated with the dialysis procedure (such as bioincompatibility, sodium profiling and haemofiltration) will affect cardiovascular morbidity and mortality. In addition, the costs for these latter procedures to improve the survival and prognosis of dialysis patients may be considerably higher than for an exercise-training program. We hope that prospective clinical trials are initiated in which the long-term effects of regular physical activity programs on the unacceptable high cardiovascular morbidity and mortality rate in dialysis patients are investigated.
References [1] Deligiannis A, Kouidi E, Tassoulas E, Gigis P, Tourkantonis A, Coats A. Cardiac effects of exercise rehabilitation in hemodialysis patients. Int J Cardiol 1999;70:253–66.
[2] US Department of Health and Human Services. Physical activity and health: a report of the surgeon general, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. [3] Painter P. The importance of exercise training in rehabilitation of patients with end-stage renal disease. Am J Kidney Dis 1994;24(Suppl 1):S2–9. [4] Boyce ML, Robergs RA, Avasthi PS, Roldan C, Foster A, Montner A et al. Exercise training by individuals with predialysis renal failure: cardiorespiratory endurance, hypertension and renal function. Am J Kidney Dis 1997;30:180–92. [5] Castanada C, Grossi L, Dwyer J. Potential benefits of resistance exercise training on nutritional status in renal failure. J Renal Nutr 1998;8:2–10. ¨ [6] Stenvinkel P, Heimburger O, Paultre F, Diczfalusy U, Wang T, Berglund L et al. Strong associations between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int 1999;55:1899–911. [7] Elinder C-G, Jones E, Briggs ID, Mehls O, Mendel S, Piccolo G et al. Improved survival in renal replacement therapy in Europe between 1975 and 1992; an ERA-EDTA registry study. Nephrol Dial Transpl 1999;14:2351–6. [8] Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal failure. Am J Kidney Dis 1998;32(Suppl 5):S112–9.