CHRONIC KIDNEY DISEASE
Non-pharmacological
management of chronic
kidney disease
Courtney J Lightfoot
Thomas J Wilkinson
Alice C Smith
Abstract
Non-pharmacological management of long-term conditions includes
components such as diet, physical activity and lifestyle behaviour
modification, and plays an integral role in optimal person-centred
care for people living with chronic kidney disease (CKD). However,
in order for these approaches to be successful, they require active
engagement from the individual. Activating and empowering individ-
uals to take an active role in their own health and healthcare is the
focus of person-centred care. Identifying and improving an individual’s
level of activation and ability to effectively self-manage their condition
can help to tailor interventions which could lead to better health out-
comes and improved quality of life. This article provides an overview
of non-pharmacological management strategies and the evidence
for their benefits in CKD. It also describes the role of the patient and
how adherence to non-pharmacological therapies is underpinned by
patient activation and self-management. Finally, the paper discusses
interventions aimed at improving patient activation and strategies
such as education and support, which have the potential to activate
and empower people in their health and make effective use of non-
pharmacological interventions.
Keywords Diet therapy; exercise; health behaviour; health educa-
tion; health promotion; healthy lifestyle; patient education; patient
participation; psychosocial intervention
Introduction
Alongside the pharmacological management of chronic kidney
disease (CKD), there is increasing evidence that adjunct non-
pharmacological strategies can improve the health outcomes
and physical and mental well-being of people living with CKD.
Courtney J Lightfoot PhD is Research Associate with the Leicester
Kidney Lifestyle Team, Department of Health Sciences, University of
Leicester, and the Leicester NIHR Biomedical Research Centre, UK.
Competing interests: none declared.
Thomas J Wilkinson PhD is Research Fellow with the NIHR Applied
Research Collaboration East Midlands (ARC-EM), Leicester Diabetes
Centre, UK. Competing interests: none declared.
Alice C Smith PhD is Professor of Lifestyle Medicine with the
Leicester Kidney Lifestyle Team, Department of Health Sciences,
University of Leicester, and the Leicester NIHR Biomedical Research
Centre, UK. Competing interests: none declared.
MEDICINE 51:3
Key points
C There is increasing evidence to support the importance of non-
pharmacological lifestyle and dietary modifications in chronic
kidney disease (CKD)
C More novel approaches such as nature-based interventions
and art therapy can also have a positive impact on the well-
being of people with CKD
C Self-management underpins most non-pharmacological ther-
apies and requires substantial knowledge, skills and confi-
dence (patient activation)
C Engagement and maintenance with non-pharmacological in-
terventions, and optimization of their benefits, is more suc-
cessful when individual characteristics characteristics and
choices are considered
What is non-pharmacological management?
Non-pharmacological management can be defined as therapies
or interventions not directly involving medication which attempt
to optimize an individual’s complex health needs or better
manage their health. These often relate to diet, physical activity
(and exercise), or other lifestyle components. Additionally, non-
pharmacological interventions such as cognitive behavioural
therapy (CBT) have been shown to have favourable effects on
psychological health.
Overview of non-pharmacological therapies in chronic
kidney disease
Physical activity and exercise therapy
Arguably, the most widely researched non-pharmacological
therapies involve physical activity and/or exercise. Key system-
atic reviews and meta-analyses from the last 5 years on the
benefits of physical activity and/or exercise are detailed in
Table 1. In summary, there is substantial evidence that physical
activity and exercise has numerous beneficial effects across all
stages of CKD. These include a reduced risk of premature mor-
tality and adverse clinical outcomes, improved cardiorespiratory
fitness and exercise capacity, and positive impacts on physical
function and strength and quality of life (QoL). This growing
body of evidence has led to the first National Institute for Health
and Care Excellence-endorsed clinical practice guidelines for
exercise and lifestyle in CKD, published in 2022.1 Nonetheless,
despite a wider recognition of the benefits, only 10e30% of
people with CKD are physically active.2
Optimum gains in physical activity and exercise behaviours
are likely to be achieved through personalized progressive pro-
grammes supported by appropriately trained exercise pro-
fessionals. However, where these are not available, any increase
in physical activity has potential benefits and general advice
should encourage patients to set realistic goals and plans that fit
with their capabilities and lifestyle.
170 Ó 2022 Published by Elsevier Ltd.
 CHRONIC KIDNEY DISEASE

Summary of key systematic reviews and meta-analyses examining the effects of exercise and physical activity in people
with CKD
CKD stage Author Aim/objectives Summary of findings of benefits

Non-dialysis Nakamura et al. (2020) Systematic review and meta-analysis of 18
RCTs investigating the effects of exercise on
mortality and kidney and physical function
MacKinnon et al. (2018) Systematic review of 29 studies exploring the
association of physical activity and physical
function with adverse clinical outcomes and
all-cause mortality
Thompson et al. (2019) Systematic review and meta-analysis of 12
RCTs examining the effect of exercise on blood
pressure
Pei et al. (2019) Meta-analysis of 31 RCTs assessing the effect
of aerobic exercise training
Ferreira et al. (2021) Systematic review and meta-analysis of 12
RCTs examining the effects of exercise on
depression and anxiety
Transplant Wilkinson et al. (2022) Systematic review and meta-analysis of 16
RCTs assessing the effect of exercise training
interventions
Chen et al. (2019) Systematic review and meta-analysis of 12
RCTs assessing the effect of exercise training
on cardiovascular risk factors
Haemodialysis Pu et al. (2019) Systematic review and meta-analysis of 27
RCTs assessing the efficacy and safety of
intradialytic exercise
Clarkson et al. (2019) Systematic review and meta-analysis of 27
RCTs examining the effect of exercise
interventions for improving objective physical
function
Lu et al. (2019) Systematic review and meta-analysis of 21
RCTs investigating the effect of exercise on
muscle fitness
Salhab et al. (2019) Systematic review and meta-analysis of 22
RCTs examining aerobic intradialytic exercise
interventions
Young et al. (2018) Systematic review and meta-analysis of 13
RCTs
C Improvements in VO2 peak/max
C Improvements in physical and walking
capacity
C Inconclusive effect on all-cause mortality
C Inconclusive effect on eGFR
C Unclear effects on muscle strength
C Reduced all-cause and cardiovascular
mortality
C Reduced risk of rapid decline in renal
function
C Reduced prevalence of frailty and
sarcopenia
C Significant short-term blood pressure-
lowering effect
C Short-term antihypertensive effect
C No effect of systolic blood pressure
C Improvements in cardiorespiratory func-
tion (VO2 peak) and exercise duration
C Improvements in HDL-C
C Improvements in health-related QoL
C Improvements in depression and anxiety
symptoms
C Improvements in cardiorespiratory func-
tion and exercise capacity
C Improvements in strength
C Improvements in HDL concentrations
C Increased maximum heart rate
C Improvements in QoL
C Improvements in arterial stiffness
C Improvements in exercise tolerance
C Improvements in QoL
C Inconsistent effects on key modifiable CVD
risk factors such as hypertension, dyslipi-
daemia, hyperglycaemia, decreased kidney
function and obesity
C Improvements in haemodialysis adequacy
C Improvements in exercise capacity
C Reductions in blood pressure
C Improvements in depression
C Improvements in QoL
C Improvements in physical function
C Improvements in exercise capacity
C Improvements in muscle mass
C Improvements in muscle strength
C Improvements in QoL
C No effect on dialysis efficiency
C No effect on serum phosphorus

(continued on next page)

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 CHRONIC KIDNEY DISEASE

Table 1 (continued )
CKD stage Author Aim/objectives Summary of findings of benefits

Peritoneal dialysis Thangarasa et al. (2018)
Tarca et al. (2022)
Systematic review and meta-analysis of 12
studies examining the effects of physical
activity
Systematic review of 25 studies reporting
exercise or physical activity-related adverse
events
C Improvements in QoL
C Improvements in VO2 max and peak heart
rate
C Increased muscle mass
C Improvements in serum glucose
C Improvements in markers of inflammation
C Low risk of adverse events
C Most commonly reported adverse event
were musculoskeletal (e.g. muscle/joint
pain, etc.), followed by fatigue
C Most events were mild to moderate in
severity and resolved by exercise pro-
gramme modification, education or rest

CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein-cholesterol, VO2, maximal aerobic capacity.

Table 1

Diet and nutrition
Diet forms an important part of a healthy lifestyle and is a key
component in the management of many long-term conditions
(LTCs). In CKD, dietary approaches are used to address meta-
bolic and nutritional complications.3 For more advanced stages
of CKD with disturbed blood chemistry, nutritional management
is complex and involves personalized specialist renal dietitian
support. However, review findings generally suggest that a
tailored healthy diet that includes bioactive nutrients could
potentially prevent and treat CKD and its complications.3
For individuals with CKD, restricting salt intake can lead to
superior blood pressure control and reduced proteinuria/albu-
minuria. Restricting protein intake may slow the deterioration of
kidney function and CKD progression, reduce rates of end-stage
kidney disease (ESKD) and potentially enhance the conserva-
tive management of CKD. However, there is no clear evidence of
an impact on risk of death or adverse effects such as protein
eenergy wasting.
Increasing fruit and vegetable consumption and fibre intake
has the potential to prevent or delay ESKD. Plant-based diets
have mineral risks but possible benefits for the primary pre-
vention of CKD, management of symptoms and metabolic com-
plications, and progression for those living with non-dialysis
CKD. Beneficial effects of plant-based diets have also been
observed in kidney transplant recipients.
Other lifestyle interventions
Evidence supporting weight management interventions (i.e. ex-
ercise, dietetic or combined) is limited, with minimal effects
observed on body weight and body mass index, in individuals
who are overweight and obese or experiencing post-transplant
weight gain. A consensus report from renal dietitians suggests
that the key to successful clinical management requires a
multifactorial approach including dietary education and other
therapeutic interventions. Clinical practice guidelines in CKD
also recommend that people with CKD stop smoking, keep
alcohol consumption within national guidelines (no more than
14 units of alcohol a week, spread across 3 days) and avoid
recreational drugs.1
Psychological therapy
Non-pharmacological psychological interventions represent an
evidence-based strategy to manage depressive disorders in CKD.
A systematic review in ESKD, including psycho-education, CBT
and problem-solving therapy, found significant benefits for
depressive symptoms. CBT is considered to be a safe, low-risk
strategy to treat major depressive disorder in CKD. Other prac-
tical approaches such as stress management training (e.g.
mindfulness) can also support the mental health of people living
with CKD. Mindfulness-based interventions (MBIs) are an
emerging complementary therapy in people undergoing dialysis.
Novel non-pharmacological therapies
Cool dialysate has demonstrated numerous beneficial effects in
people undergoing dialysis, such as reduced intradialytic hypoten-
sion, fatigue, ischaemic damage, cardiovascular mortality and
restless leg syndrome, along with improved sleep quality, well-
being and activities of daily living. Neuromuscular electrical stim-
ulation (NMES) may improve muscle strength, functional capacity
and QoL in people given haemodialysis and peritoneal dialysis.
NMES has been recommended to improve muscle strength in peo-
ple with CKD experiencing acute flare-ups and unable to exercise.
Nature-based therapeutic interventions (NBIs) can have pos-
itive impacts on psychological and physiological well-being in
people with LTCs. However, evidence is limited, especially in
people with CKD, and further research guided by rigorous
evidence-based research is needed. There is increasing evidence
that art therapy can improve mental health, well-being and QoL
in individuals with LTCs, alongside the management of these
complex conditions. A mixed methods feasibility study in people
undergoing haemodialysis has shown promising results for self-
esteem, motivation and overall haemodialysis experience. In
the UK, the Renal Arts Group has developed guidance on
implementing intradialytic arts activities.

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 CHRONIC KIDNEY DISEASE
The need for or prioritization of non-pharmacological
management in kidney disease
The balance of evidence increasingly supports the importance of
non-pharmacological management in CKD. Optimizing the con-
trol of key health risk factors can be addressed by targeting a
range of lifestyle and dietary strategies, including physical ac-
tivity, obesity, salt intake, smoking, blood pressure and blood
glucose.1 Aside from improving health and clinical outcomes,
lifestyle modification can improve the well-being and life
participation of people with CKD. Life participation has been
identified as a critically important outcome for people living with
CKD, which involves prioritizing life values and the ability to
engage in meaningful activities (see Further reading).
The role of self-management in the use of non-
pharmacological therapies
The nature of many of the non-pharmacological approaches to
CKD management described above means that the individual
must take on a considerable role in adopting and sustaining
positive behaviour change. This requires a substantial level of
knowledge, motivation and active engagement from them.
Therefore, effective self-management underpins the use of many
non-pharmacological therapies.
Self-management and kidney disease
Self-management is an essential component in the management of
LTCs, empowering individuals to take a more active role in their
health. It comprises a complex set of tasks (medical management,
role or behavioural management, emotional management) and
processes (decision-making, using resources, forming partnerships
with healthcare professionals, problem solving and taking action),
that require self-efficacy to engage with and execute them. The
goal of self-management is to control the condition with clear
strategies to achieve the desired outcomes while leading a full and
productive life.4 There is increasing evidence that supporting
people to self-manage their health and care can lead to improve-
ments in clinical and patient outcomes, a reduction in healthcare
usage, and significantly better health status and symptom control.
CKD management guidelines increasingly include the pro-
motion of self-management behaviours as standard care in an
effort to decelerate CKD progression and prevent complications4
It is widely recommended that individuals are aware of their
diagnosis, involved in shared treatment decisions, provided with
access to their medical data and given information on blood
pressure control, exercise, diet, medication management and
smoking cessation. Knowledge of and information about the
successful and effective management of CKD can allow in-
dividuals to make adjustments to the management of their con-
dition, which can reduce symptom burden, improve QoL and
slow progression of CKD and cardiovascular and other co-
morbidities. However, many individuals lack knowledge and
understanding about the importance of self-management and
how to perform the necessary behaviours to manage their CKD.
Patient activation
Patient activation is a behavioural concept that describes an in-
dividual’s understanding of their role in their healthcare, and
MEDICINE 51:3
their competency in performing that role. It is defined as the
knowledge, skills and confidence a person has in managing their
health and healthcare. Patient activation incorporates elements
of self-efficacy, self-determination and readiness to change, and
can thus be modified. The accumulation of knowledge, skills,
confidence and self-determination an individual has for man-
aging their own health is a cyclical process, which ultimately
results in increased levels of patient activation.
Patient activation in kidney disease
Low levels of patient activation (43e60%) are widely prevalent in
people with CKD (see Further reading) and are associated with
older age, lower kidney function, a greater number of co-
morbidities and cardiovascular disease risk factors (see Further
reading), higher levels of depression and anxiety, higher symptom
burden and reduced QoL (see Further reading). A high disease and
treatment burden can affect an individual’s patient activation and
self-management abilities; thus, those with advanced CKD, who
have more complex healthcare needs, may find self-management
difficult (see Further reading). In addition, the number of co-
morbidities an individual is required to manage can influence
activation levels and potentially result in an inability to cope (see
Further reading). Consequently, interventions designed to facili-
tate self-management, as well as patient activation, are required to
support the needs of people living with CKD.
Assessing patient activation
The Patient Activation Measure (PAM-13) is the most commonly
used instrument to assess patient activation, and is the only
evidence-based tailoring tool to support services in building an
individual’s skill, knowledge and confidence to manage their
health and care.5 PAM-13 provides a useful tool for informing
and tailoring healthcare discussions, assessing quality of care
and evaluating the effects of interventions.4,5 It is a reliable and
suitable measure to assess patient activation in individuals with
LTCs, including CKD (see Further reading) and has been shown
to be effective in quantifying an individual’s ability to self-
manage.
Relationship between patient activation and self-
management
Having the appropriate knowledge, skills and confidence (i.e.
patient activation), and the ability to use these to manage health
and identify and access resources and support, are likely to be
fundamental components of effective self-management behav-
iour. Patient activation and self-management are closely related
to changes in one subsequently followed by changes in the other
in the same direction.4 As patient activation underpins effective
and sustained self-management, its improvement provides an
attractive goal for interventions aiming to promote and facilitate
self-management behaviours (see Figure 1 and Further reading).
Individuals with higher levels of activation are more likely to
engage with disease-specific management behaviours in LTCs
such as diabetes and cardiovascular disease; they are also more
likely to engage in physical activity, pay attention to their diet
and manage their well-being (e.g. stress). Although the rela-
tionship between patient activation and disease-specific
173 Ó 2022 Published by Elsevier Ltd.
 CHRONIC KIDNEY DISEASE

The relationship between patient activation, self-management and non-pharmacological management

in CKD

Non-pharmacological management

Other lifestyle components

Physical activity/exercise Diet/nutrition
(e.g. smoking, alcohol)

Psychological Novel/emerging therapies

(e.g. CBT, mindfulness) (e.g. cool dialysate, NMES, NBIs)

Self-efficacy Self-regulation

Active engagement Motivation

Self-management

Medical Behavioural Emotional

management management management

Patient activation

Knowledge Confidence

Skills

NBI, nature-based intervention

Figure 1

behaviours have been observed in other LTCs, this has not yet
been explored in CKD.4
Interventions to increase patient activation
Interventions aiming to improve patient activation in LTCs are
limited in number, but interest in their development is
increasing. Findings across trials using PAM-13 as an outcome
have consistently shown that participants with the lowest acti-
vation levels experienced the greatest increase in PAM-13 after
intervention, and those in the highest levels had limited
improvements.
Despite increasing interest in patient activation in CKD (see
Further reading), no studies have yet been published that eval-
uate interventions designed to target patient activation in CKD.
However, an online education and self-management programme
called My Kidneys & Me, designed to improve patient activation
in people with non-dialysis CKD, has been co-developed with
patients and stakeholders and is undergoing evaluation in a
multicentre randomized controlled trial. To our knowledge, this
is the first self-management intervention for people with CKD
targeting patient activation and using PAM-13 as the primary
outcome.
Activation for non-pharmacological therapies
When determining the most appropriate non-pharmacological
therapy, it is imperative to consider the individual’s characteris-
tics and choices (including their needs, preferences and circum-
stances) to engage and sustain the person. Ensuring that activities
are self-determined and meaningful to the individual, alongside
their readiness to engage effectively, which can be assessed via

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 CHRONIC KIDNEY DISEASE
their patient activation level, can potentially further increase
engagement and maintenance with non-pharmacological in-
terventions and optimization of their benefits. A
KEY REFERENCES
1 Baker LA, March DS, Wilkinson TJ, et al. Clinical practice guideline
exercise and lifestyle in chronic kidney disease. BMC Nephol 2022;
23: 75.
2 Wilkinson TJ, Clarke AL, Nixon DGD, et al. Prevalence and corre-
lates of physical activity across kidney disease stages: an obser-
vational multicentre study. Nephrol Dial Transplant 2019; 36:
641e9.
3 Mafra D, Borges NA, Lindholm B, Shiels PG, Evenepoel P,
Stenvinkel P. Food as medicine: targeting the uraemic phenotype
in chronic kidney disease. Nat Rev Nephrol 2021; 17: 153e71.
4 Lightfoot CJ, Nair D, Bennett PN, et al. Patient activation: the
cornerstone of effective self-management in chronic kidney dis-
ease? Kidney Dial 2022; 2: 91e105.
5 Roberts NJ, Kidd L, Dougall N, Patel IS, McNarry S, Nixon C.
Measuring patient activation: the utility of the Patient Activation
Measure within a UK context e results from four exemplar studies
TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.
Question 1
A 75-year-old frail woman presented with distress and anxiety
about the future. She was being given unit-based haemodialysis
for chronic kidney disease.
Which of the following non-pharmacological approaches is
most likely to help?
A. Cool dialysate
B. A weight management programme
C. Combined aerobic and resistance exercise training
D. Reducing dietary salt intake
E. Mindfulness technique
Question 2
A 45-year-old man presented with disappointment that, despite
having been given a kidney transplant 10 months previously, he
still lacked the strength and stamina to engage in his favourite
leisure activities as he would wish. The kidney was functioning
well and his estimated glomerular filtration rate was 48 ml/
minute/1.73 m2.
MEDICINE 51:3
and potential future applications. Patient Educ Couns 2016; 99:
1739e46.
FURTHER READING
Lightfoot CJ, Wilkinson TJ, Memory KE, Palmer J, Smith AC. Reliability
and validity of the patient activation measure in kidney disease:
results of Rasch analysis. Clin J Am Soc Nephrol 2021; 16: 880e8.
Magadi W, Lightfoot CJ, Memory KE, et al. Patient activation and its
association with symptom burden and quality of life across the
spectrum of chronic kidney disease stages in England. BMC
Nephrol 2022; 23: 45.
Nair D, Cavanaugh KL. Sincere integration of patients’ perspectives
into kidney care: affirming and adopting patient activation. Clin J
Am Soc Nephrol 2021; 16: 840e2.
Tong A, Manns B, Wang AYM, et al. Implementing core outcomes in
kidney disease: report of the Standardized Outcomes in
Nephrology (SONG) implementation workshop. Kidney Int 2018;
94: 1053e68.
Wilkinson TJ, Memory K, Lightfoot CJ, Palmer J, Smith AC. De-
terminants of patient activation and its association with cardio-
vascular disease risk in chronic kidney disease: a cross-sectional
study. Health Expect 2021; 24: 843e52.
What non-pharmacological intervention is most likely to help?
A. Increasing dietary protein intake
B. A course of cognitive behavioural therapy (CBT)
C. A progressive exercise programme
D. Neuromuscular electrical stimulation (NMES)
E. Art therapy as an alternative to more physically active
pastimes
Question 3
A 55-year-old woman was under review for chronic kidney dis-
ease associated with type 2 diabetes. With the careful use of self-
management skills such as diet, exercise and medication adher-
ence it was hoped that dialysis or transplant could be postponed.
What is the most appropriate tool to assess these capabilities
in a clinical setting?
A. Patient Activation Measure (PAM-13)
B. EuroQoL-5 Dimension (EQ5D)
C. Kidney Failure Risk Equation (KFRE)
D. Palliative Outcome Scale-Renal (POS-Renal)
E. Hospital Anxiety and Depression Scale (HADS)
175 Ó 2022 Published by Elsevier Ltd.