Exercise and CKD: Skeletal Muscle Dysfunction and Practical Application of Exercise to Prevent and Treat Physical Impairments in CKD

Abstract

Patients with chronic kidney disease experience substantial loss of muscle mass, weakness, and poor physical performance. As kidney disease progresses, skeletal muscle dysfunction forms a common pathway for mobility limitation, loss of functional independence, and vulnerability to disease complications. Screening for those at high risk for mobility disability by self-reported and objective measures of function is an essential first step in developing an interdisciplinary approach to treatment that includes rehabilitative therapies and counseling on physical activity. Exercise has beneficial effects on systemic inflammation, muscle, and physical performance in chronic kidney disease. Kidney health providers need to identify patient and care delivery barriers to exercise in order to effectively counsel patients on physical activity. A thorough medical evaluation and assessment of baseline function using self-reported and objective function assessment is essential to guide an effective individualized exercise prescription to prevent function decline in persons with kidney disease. This review focuses on the impact of kidney disease on skeletal muscle dysfunction in the context of the disablement process and reviews screening and treatment strategies that kidney health professionals can use in clinical practice to prevent functional decline and disability.

Keywords: CKD; ESRD; Kidney disease; exercise; frailty; muscle; muscle dysfunction; older adults; physical function; prevention; recommendations.

Figure 1

Panel A: Non-diabetic CKD patients have lower muscle mitochondrial coupling (P/O) efficiency of mitochondrial oxidative phosphorylation. Panel B: Among non-diabetic CKD patients lower GFR is associated with lower P/O. P-values are adjusted for age. Reproduced from Roshanravan et al with permission of Elsevier.

Figure 2

CKD leads to muscle impairment promoting functional decline, mobility disability, and frailty. This figure represents CKD in the context of the Nagi disablement model. Abbreviations: PCMD – preclinical mobility disability. Source: Newman & Cauley.

Figure 3

Left panel: Lower kidney function by measured creatinine clearance (Clcr) is associated with consistently lower gait speed throughout follow up among older adults. Right panel: Lower Clcr at baseline is also associated with more rapid decline in knee extension strength over time. Reproduced from Roshanravan et al with permission of Elsevier.

Figure 4

Left panel: Lower specific quadriceps muscle endurance (specific work) is associated with increased risk of persistent and severe mobility limitation among older adults enrolled in the Health Aging and Body Composition study. Associations were consistent when restricted to those with CKD. Right panel: Lower quadriceps maximal isometric strength (specific torque) is associated with increased risk of persistent and severe mobility limitation among older adults. Associations were consistent when restricted to those with CKD. Models are adjustment for age, sex, race, education, height, weight, study site, and eGFRcysc. Source: Roshanravan et al. Adapted from Roshanravan et al with permission of Oxford University Press.

Figure 5

Algorithm for two-step screening of functional impairments among high-risk patients with CKD and early referral for rehabilitative therapies prior to initiation of exercise. Source: Brown and Flood. Abbreviations: SPPB – short physical performance battery, CV- cardiovascular, MS – musculoskeletal, Neuro – neurologic, PT – physical therapy.