Sports Med 2005; 35 (6): 485-499

REVIEW ARTICLE 0112-1642/05/0006-0485/$34.95/0

 2005 Adis Data Information BV. All rights reserved.

Exercise and Chronic Kidney Disease

Current Recommendations
Kirsten L. Johansen
Department of Medicine, University of California San Francisco and San Francisco VA Medical
Center, San Francisco, California, USA

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
1. Aerobic Exercise Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
2. Resistance Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
3. Combined Resistance and Aerobic Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
4. Risks of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
5. Exercise Participation by Patients with Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
6. Healthcare Provider Involvement in Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
7. What Can the Literature Tell Us About the Optimal Exercise Programme? . . . . . . . . . . . . . . . . . . . . . . 494
8. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
9. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497

Abstract Patients with chronic kidney disease (CKD) are inactive and have reduced
physical functioning and performance. Aerobic exercise interventions have been
shown to increase maximal oxygen consumption in selected patients. In addition,
preliminary evidence, although mixed, suggests that aerobic exercise training can
improve blood pressure control, lipid profiles and mental health in this population.
A few larger studies are now available showing that aerobic training can also
improve physical functioning and performance. The impact on survival or hos-
pitalisation has not been determined. Resistance exercise training, although less
studied, appears to increase muscle strength and size and may also improve
functioning. There have been several reports of successful combined exercise
interventions, but the designs have not allowed evaluation of the relative benefits
of aerobic and resistance training on physical functioning. Despite the evidence
that exercise is safe and beneficial in patients with CKD, dialysis patients remain
inactive, and exercise assessment, counselling and training is not widely offered to
patients with CKD.
Studies of the barriers to patient participation in exercise and to provider
assessment and recommendations are needed so that more widely generalisable
interventions can be developed. However, in the interim, patients should be
encouraged to participate in moderate physical activity to meet the US Surgeon
General’s recommendations. Patients who are weak can benefit from strength-
-training interventions. Resistance and aerobic exercise programmes should be
initiated at relatively low intensity in patients with CKD and progressed as slowly
as tolerated in order to avoid injury and discontinuation of exercise. For patients
486
on haemodialysis, incorporation of exercise into the dialysis session may increase
patient participation and tolerance of exercise.
Patients with chronic kidney disease (CKD) are
physically inactive[1] and have markedly reduced
peak oxygen consumption (V̇O2peak),[2-9] self-re-
ported physical functioning[10,11] and physical per-
formance[10,12] compared with individuals with nor-
mal kidney function. Reduced physical functioning
is associated with increased mortality and poor qual-
ity of life (QOL) in this population.[11,13] Preliminary
results suggest that, as for the general population,
sedentary behaviour is associated with increased
mortality in patients with end-stage renal disease
(ESRD).[14]
Furthermore, patients with CKD have a high
burden of other chronic diseases for which exercise
is beneficial. Specifically, 45% of incident dialysis
patients in the US have diabetes mellitus and 79%
have a history of hypertension.[15] Patients with
CKD also have a higher prevalence of cardiovascu-
lar disease than the general population,[16] and car-
diovascular disease is the number one cause of mor-
tality in this group, accounting for approximately
50% of all deaths.[15] Thus, the potential benefits of
exercise training in this population are numerous
and include improvements in:
• exercise capacity
• strength
• QOL, related to improved functional capacity or
direct effects on mood
• blood pressure control
• control of diabetes
• survival.
Unfortunately, despite the myriad potential bene-
fits of exercise in patients with CKD, research con-
firming these benefits has been limited and is often
of poor quality. The optimal programme of exercise
training for patients with CKD has not been identi-
fied,[17] and prescription of exercise to these patients
is not routine.[18] Nephrologists caring for patients
with CKD do not regularly evaluate their patients
for exercise participation or physical functioning
and do not generally provide advice about exercise
 2005 Adis Data Information BV. All rights reserved.
Johansen
to their patients. The focus of care is on disease
management rather than prevention, and exercise is
under-utilised as a therapeutic tool. The purpose of
this review is to examine the evidence available
upon which to make recommendations about exer-
cise in patients with CKD and then provide recom-
mendations for exercise to achieve specific desired
results.
1. Aerobic Exercise Training
It was noted in the 1980s that patients with ESRD
have markedly reduced V̇O2peak compared to age-
and sex-matched norms for sedentary individu-
als.[4,6,19-21] As a result, several studies have been
performed to examine the effects of aerobic exercise
training on V̇O2peak in this population.[5,7-9,22-31] Al-
though the intensity and duration of exercise in the
studies vary, all have included initial moderate aero-
bic training progressing to vigorous training for ≥30
minutes three times per week for ≥8 weeks up to 12
months (most studies 3–6 months). On average,
aerobic exercise training for 8 weeks to 6 months
improves V̇O2peak by about 15% (figure 1), but the
variability is wide from study to study, and many
studies have been uncontrolled.[5,7,9,22-25,29,30] Only
two of these studies included patients on peritoneal
dialysis;[24,28] otherwise, these data pertain entirely
to haemodialysis patients. The majority of studies
were conducted before the routine use of erythro-
poietin to control the anaemia associated with CKD,
but the effects of aerobic training appear to be
similar among patients receiving erythropoietin (fig-
ure 1). Thus, although it is firmly established in the
literature that aerobic exercise training increases
V̇O2peak in patients with ESRD, the total number of
patients studied is small, particularly if one consid-
ers only those for whom a control group was also
assembled. Furthermore, the improvement in
V̇O2peak is modest, and patients do not approach
their predicted V̇O2peak levels even after training.
Data on the effects of aerobic exercise training
Sports Med 2005; 35 (6)
Exercise and Kidney Disease
Average n = 163
Study a 9*
b 23*
c 9
d 14*
e 18*
f 9
g 11
h 9*
i 8
j 14*
k 14
l 14*
m 5*
n 6
-30 -20 -10 0 10 20
Fig. 1. Effects of aerobic exercise training on peak oxygen con-
sumption (V̇O2peak). The black bars indicate the change in V̇O2peak
observed after exercise training in each study. The numbers to the
right of the bars indicate the number of patients who exercised in
each study. Studies below the dividing line were performed prior to
the introduction of erythropoietin and those above included patients
receiving erythropoietin. The average represents a weighted aver-
age according to the size of each study. Studies: a = Sakkas et
al.[31]; b = Painter et al.[27]; c = Violan et al.[30]; d = Suh et al.[29]; e =
Koufaki et al.[28]; f = Akiba et al.[26]; g = Moore et al.[33]; h = Ross et
al.[25]; i = Lennon et al.[24]; j = Painter et al.[23]; k = Shalom et al.[7]; l
= Goldberg et al.[8]; m = Zabetakis et al.[22]; n = Goldberg et al.[9] *
indicates that the observed change was statistically significant with
p < 0.05.
among patients with less severe degrees of renal
dysfunction are even more limited than those for
patients receiving haemodialysis, but the available
evidence suggests that the degree of benefit is simi-
lar in patients with advanced CKD not yet receiving
dialysis.[2,32]
These studies of the effects of exercise on
V̇O2peak have provided important information. Be-
cause V̇O2peak is a well recognised physiological
measure related to exercise capacity, it is an ideal
measure to test whether patients with CKD could
respond to exercise training in a manner similar to
other patient groups (a finding that was by no means
predetermined). Furthermore, several studies ex-
amined the determinants of V̇O2peak to elucidate the
mechanisms of exercise intolerance in patients with
CKD.[5,33] However, the qualified success of vigor-
ous aerobic exercise training designed to increase
V̇O2peak should be put into a wider perspective.
First, the patients who have been studied to date
have generally been the healthiest individuals re-
 2005 Adis Data Information BV. All rights reserved.
487
ceiving haemodialysis, usually a small fraction of
available patients.[7,29] Secondly, this strategy is re-
source-intensive. For these reasons, it is unclear to
what extent this type of programme can be general-
ised to the larger population of patients with CKD,
at least within the current framework of delivery of
care for this group. Specifically, it is not clear that
more typical (i.e. less healthy) patients with CKD
will be willing to undergo vigorous exercise train-
ing, and reimbursement for ‘renal rehabilitation’ is
non-existent. Furthermore, it is not clear whether
such vigorous training is necessary to derive many
30
of the potential benefits of exercise.
Another important caveat to be considered when
interpreting the increases in V̇O2peak as a result of
aerobic exercise training is that the links between
change in V̇O2peak and improvements in physical
performance, self-reported physical functioning, or
health-related QOL (HR-QOL) have not been estab-
lished in this population. Thus, the extent to which a
15% increase in V̇O2peak actually improves the lives
of patients with CKD has not been established. This
lack of information may further limit patient and
provider enthusiasm for committing to such train-
ing.
While the focus has largely been on V̇O2peak in
selected healthy patients receiving haemodialysis,
some additional information is available to address
the issues of generalisability to a wider group of
patients and of the clinical benefit of training. First,
several studies have considered other outcomes in
addition to or instead of V̇O2peak. Secondly, alterna-
tives to supervised in-centre training have been ex-
plored. Alternative outcomes to V̇O2peak have in-
cluded measures of physical functioning and out-
comes not related to physical function. These other
outcomes have included anaemia, lipid levels, blood
pressure control, mental health and HR-QOL.
Although a few small studies have reported an
improvement in anaemia with vigorous aerobic ex-
ercise training,[8,9] the majority of studies have not
reported this benefit.[7,22,23,25] Studies of the lipid
effects of vigorous aerobic exercise training have
also been mixed, with some showing a decrease in
triglyceride[8,9] or an increase in high-density lipo-
Sports Med 2005; 35 (6)
488
protein-cholesterol[8,9] and others not showing any
changes.[23-25] Given the small numbers of patients
and lack of control groups in most of these reports,
the effect of aerobic exercise training on lipid me-
tabolism remains unclear. An early study reported
that there were improvements in blood pressure
control after aerobic exercise training,[8] while
others reported no changes in blood pressure control
or medication.[7,24-26]
Miller et al.[34] designed a study specifically to
investigate the effects of exercise on blood pressure
control in patients on haemodialysis. The exercise
programme was a 6-month cycling exercise pro-
gramme during dialysis in which patients initially
exercised as long as possible with encouragement to
increase time up to 30 minutes. When the patients
reached 30 minutes, they were encouraged to in-
crease resistance. The programme was offered to 92
eligible patients from a total of 107 patients dialys-
ing in a single dialysis unit. Of these, 40 agreed to
participate, and 35 served as non-exercising con-
trols. At the end of 6 months, 24 patients were still
participating in the exercise programme. The au-
thors noted that at the end of 6 months, every patient
had increased exercise time, but only 21% had in-
creased resistance. Of the 16 patients who discontin-
ued exercise, 10 patients (25%) did so voluntarily
for reasons ‘not related to medical problems’. The
patients who completed 6 months of training had no
changes in blood pressure before or after dialysis but
were, on average, taking fewer antihypertensive
medications to achieve that blood pressure than
before the programme, while the control group did
not have any significant change in blood pressure or
antihypertensive medications. Thus, to date, the on-
ly study specifically designed to evaluate blood
pressure control demonstrated a beneficial effect of
exercise training.
A few studies have focused on the effects of
aerobic exercise training on mental health or HR-
QOL among patients on haemodialysis. Carney et
al.[35] reported that patients who underwent vigorous
aerobic exercise training three times per week for 6
months (n = 10) reduced their scores on the Beck
Depression Index (BDI) by an average of 4.3 points
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Johansen
compared with an increase of 2.5 points in patients
(n = 7) who did not exercise (p < 0.05). At the
baseline evaluation, five patients in the exercise
training group and three in the control group met the
Diagnostic and Statistical Manual of Mental Disor-
ders III (DSM III) criteria for major depression.
Following 6 months of exercising, only one of the
exercisers continued to meet the criteria, whereas
two additional control patients were clinically de-
pressed. Suh et al.[29] conducted a study involving 14
patients on maintenance haemodialysis who under-
went moderate-intensity aerobic exercise training
three times per week for 12 weeks. They reported a
trend towards a decrease in depression using a Self-
rating Depression Scale (p = 0.073). In addition,
they reported a significant reduction in anxiety and
an improvement in quality-of-life measured using
an ESRD-specific instrument. Kouidi et al.[36] re-
ported a significant improvement in overall QOL
and specifically in depression measured by the BDI
after 6 months of aerobic exercise training in 24
patients. In contrast, Painter et al.[37] included the
Medical Outcomes Study Short Form 36-Item ques-
tionnaire (SF-36) as a major outcome in a much
larger study (see paragraph below) and found no
improvement in the mental health components with
16 weeks of aerobic exercise.
The Painter study,[37] called the Renal Exercise
Demonstration Project, was unique in its large size
and its focus on physical performance and HR-QOL
rather than on V̇O2peak as the primary outcome
measures. The study included 286 patients and in-
cluded an 8-week home-based training intervention
followed by 8 weeks of cycling exercise during
dialysis sessions. Home-based training included rec-
ommendations for strengthening and flexibility ex-
ercises as well as walking or stationary cycling of
gradually increasing duration three to four times per
week. Cycling during dialysis was begun for as long
as tolerated at an intensity that was determined by
the patients’ level of perceived exertion. Patients
were encouraged to increase cycling time to a goal
of 30 minutes per session and to increase intensity as
tolerated based on perceived exertion. Outcomes
included physical performance measures such as
Sports Med 2005; 35 (6)
Exercise and Kidney Disease
gait speed, 6-minute walk distance, and the ability to
stand from a chair as well as self-reported physical
functioning using the SF-36. The authors were able
to demonstrate that physical performance and HR-
QOL improved with exercise training and declined
in those who were not assigned to the exercise
interventions. For example, gait speed increased
from 66% to 69% of age-expected norms in the
exercising group and decreased from 66% to 59% of
age-expected norms among non-exercisers. The
Physical Functioning score of the SF-36 increased
12% in the group assigned to exercise and decreased
12% in the control group. The authors noted that the
impact of these interventions was more profound in
the patients who had worse functioning at base-
line.[38] The intervention did include a recommenda-
tion for low-intensity strengthening exercises in ad-
dition to aerobic exercise training. However, this
aspect of the programme was not directly supervised
even during the dialysis centre training phase of the
study, and <10% of the patients reported following
this recommendation. For these reasons, it seems
likely that the majority of the reported benefits can
be ascribed to aerobic exercise training. This study
demonstrated that a broader and less heavily select-
ed group of patients on haemodialysis could partici-
pate in exercise training with improvements in func-
tioning. In fact, from the point of view of physical
performance and self-reported functioning, it ap-
pears that patients who are less able stand to benefit
more from beginning an exercise programme.
There is less information available for other
groups of patients with CKD. However, preliminary
data in patients with CKD before the need for dialy-
sis [2] and patients after kidney transplantation[39]
suggest that aerobic exercise training improves
V̇O2peak and strength.
2. Resistance Exercise
Muscle strength is an important determinant of
physical performance and ability to live indepen-
dently in the geriatric population.[40,41] Patients re-
ceiving dialysis are weak when compared with
1 The use of trade names is for product identification purposes only and does not imply endorsement.
 2005 Adis Data Information BV. All rights reserved.
489
healthy sedentary controls,[42-47] and it is likely that
weakness is an important limitation to physical
functioning in patients with CKD. We recently
showed that muscle strength was an important pre-
dictor of gait speed in patients on dialysis,[42] and
Diesel et al.[48] showed that isokinetic muscle
strength was an important determinant of V̇O2peak in
a group of patients on dialysis. Thus, it seems likely
that resistance exercise training could be of benefit
to these patients, and it is surprising that there have
been few studies to focus on resistance exercise
training or to include resistance training as part of
the programme.
Castaneda et al.[3] studied resistance exercise
training for 12 weeks to mitigate the effects of a
low-protein diet in patients with advanced CKD
prior to the initiation of dialysis. The average glo-
merular filtration rate was 24.8 mL/min in the
trained (n = 14) and 27.5 mL/min in the control (n =
12) groups. Patients were trained three times per
week on five exercise machines and performed three
sets of eight repetitions at 80% of one-repetition
maximum (1RM). Those who completed the resis-
tance training improved their strength an average of
32% compared with a 13% decline in the group who
did not exercise (p < 0.001), and muscle biopsies
showed hypertrophy of type 1 and type 2 muscle
fibres.
Headley et al.[49] reported on the results of a
12-week resistance exercise training programme in
a group of ten patients on haemodialysis. The pro-
gramme consisted of two supervised training ses-
sions per week during which, after a 5- to 10-minute
warm-up period, subjects performed eight to nine
weight machine exercises designed to strengthen the
whole body. The programme began with one
10-repetition set for each exercise with additional
sets and increased weight added as tolerated. In
addition to supervised training sessions, subjects
were given Theraband 1 exercise bands and in-
structed to follow a video at home once per week
that covered nine exercises. The resistance of the
bands and the number of sets were also progressed,
and subjects kept logs of the dates on which they
Sports Med 2005; 35 (6)
490
completed exercise training at home. At the end of
the training programme, the patients increased their
peak torque of the leg extensors of the dominant leg
at the 90°/sec velocity by 12.7 ± 3.6%, but there was
no significant change in peak torque at 120°/sec or
150°/sec or in grip strength in either hand. Patients
improved on several physical performance tests af-
ter the training, including a 6-minute walk test,
normal and maximum gait speed, and time to com-
plete a sit-to-stand test 10 times. There were no
complications or injuries related to the exercise
training. A randomised, controlled trial of resistance
exercise training during dialysis sessions is under-
way,[50] but results are not yet available.
3. Combined Resistance and
Aerobic Exercise
Kouidi et al.[51] enrolled seven patients receiving
chronic haemodialysis into a 6-month exercise reha-
bilitation programme that included aerobic exercise
and strengthening exercise. The programme consist-
ed of 90-minute sessions three times per week on
non-dialysis days. Specifically, the training routine
included a 10-minute warm-up followed by 50 min-
utes of aerobic exercises, 10 minutes of low-weight
resistance exercise, 10 minutes of stretching exer-
cises and 10 minutes of cool-down. They examined
the effect of this programme on V̇O2peak and on
muscle morphology. The programme resulted in an
average increase in V̇O2peak of 48%, an increase that
is more than double the magnitude of any pro-
gramme involving aerobic exercise training alone
(figure 1). They also reported a remarkable im-
provement in muscle atrophy, with a 25.9% increase
in the mean area for type 1 fibres and a 23.7%
increase in mean area of type 2 fibres. Although they
characterised their training programme as ‘mainly
of aerobic type’, the notable muscle hypertrophy
and the stunning improvement in V̇O2peak suggest
that the strength training portion may have contrib-
uted important additive or synergistic effects to the
aerobic training. It is possible that muscle atrophy in
some patients with ESRD is so severe as to limit
V̇O2peak because of the small mass of working mus-
cle. Unfortunately, the design of this study did not
 2005 Adis Data Information BV. All rights reserved.
Johansen
allow the separate contributions of aerobic and resis-
tance training to be delineated.
Two other studies of mixed exercise interven-
tions have included control groups.[52,53] Mercer et
al.[52] conducted a non-randomised controlled trial
of an exercise rehabilitation programme that oc-
curred over a 12-week period and included a combi-
nation of intermittent aerobic exercise on a cycle
ergometer and a local muscular endurance circuit of
eight exercises. 212 patients were potentially availa-
ble to participate, but only 22 volunteered and were
eligible. Thirteen were slated for the exercise, but
only seven completed the study. These patients
showed improvements in performance of a 50m
walk (15 ± 5.8%), stair climbing (22 ± 11%) and
stair descent (18 ± 12%) after the exercise interven-
tion.
DePaul et al.[53] conducted a randomised trial of a
mixed exercise intervention among patients on
haemodialysis who were receiving erythropoietin.
The intervention consisted of progressive resisted
isotonic quadriceps and hamstrings exercise and
training on a cycle ergometer three times weekly for
12 weeks. Cycling exercise was performed during
dialysis, and weight training took place before or
after dialysis according to patient preference. Twen-
ty subjects were randomised to the exercise group,
of whom 15 were available to be retested after 12
weeks. The exercise group increased the workload
at which their rating of exertion on the Borg scale[54]
was ‘somewhat strong’ by 20 ± 18W, compared
with an increase of 6 ± 13W for the control group (p
= 0.02). At 12 weeks, the intervention group also
increased their combined hamstring and quadriceps
strength by 21.2 ± 22.4kg (p = 0.02 vs control
group). There were no significant or clinically im-
portant differences in disease-specific QOL or per-
formance on a 6-minute walk test between the study
groups. The authors noted that the group was partic-
ularly high-functioning at baseline, with scores on
the Physical Functioning scale of the SF-36 and on
the 6-minute walk test that were close to reported
values for healthy groups. These values were signif-
icantly higher than baseline scores in the Renal
Exercise Demonstration Project,[37] in which it was
Sports Med 2005; 35 (6)
Exercise and Kidney Disease
noted that patients with lower functioning at base-
line improved to a greater degree.[38]
As for other types of exercise training, less infor-
mation is available about patients with CKD not yet
requiring dialysis. However, one study compared
the response to 12 weeks of combined resistance and
endurance training in patients aged >60 years with
an average glomerular filtration rate of 18 ± 5 mL/
min and healthy control subjects.[55] The exercise
programme in patients with CKD resulted in in-
creases in quadriceps strength measured by 1RM
from 8 ± 5kg to 13 ± 5kg and an increase in dynamic
muscular endurance of 30% on average. These re-
sults were similar to changes observed in healthy
controls. In addition, the CKD patients increased
their 6-minute walking distance from 390 ± 128m to
452 ± 99m (p = 0.002) and their functional mobility
measured by the timed ‘Up & Go’ test[56] by an
average of 2 seconds or 18% after exercise training.
Taken together, these results suggest that com-
bined training programmes can be quite beneficial in
patients on dialysis and possibly those with ad-
vanced CKD not yet on dialysis. However, the study
of combined exercise programmes in patients with
CKD is still in its early stages with small studies of
varying interventions. Few data are available to
allow comparisons of different exercise modalities
or programmes. Such data would facilitate develop-
ment of more widespread programmes and would be
a first step towards targeting interventions to suit
individual patient needs. Fortunately, a trial is cur-
rently underway to compare aerobic exercise, resis-
tance exercise and a combination of these two mo-
dalities (Kopple J, personal communication), and
information gained from this endeavour will be
highly illuminating.
4. Risks of Exercise
The most common risk of exercise participation
in the general population is musculoskeletal injury,
whereas the most serious risks are those of cardiac
origin, ranging from dysrhythmia to ischaemia to
sudden death. The risk of both types of adverse
events is higher with high-intensity exercise than
with submaximal exercise.[57]
 2005 Adis Data Information BV. All rights reserved.
491
There have been no studies specifically designed
to assess the risk of exercise among patients with
CKD; available information comes from case re-
ports and from mentions of side effects that occurred
during studies of the effects of exercise. Musculo-
skeletal risk may be increased in patients with CKD
as a result of hyperparathyroidism and bone disease.
Their bone disease may place them at higher risk of
fracture,[58] and spontaneous quadriceps tendon rup-
tures have been reported,[59-61] probably as a result of
poorly controlled secondary hyperparathyroidism.
However, it is possible that weight-bearing or
strengthening exercises could, in the long term, de-
crease the risks of falls and increase bone density,
further lowering the risk of fracture. The up-front
risks of injury can be minimised by less strenuous
testing, when feasible, such as the use of 3RM or
5RM in lieu of 1RM for strength testing, and by
beginning training programmes at lower intensity
and progressing gradually as tolerated. These strate-
gies have been employed in many of the studies
reviewed in this article with great success, since the
number of adverse events associated with exercise
testing and training has been extremely low. Fur-
thermore, improved muscle strength and overall fit-
ness achieved through an appropriately prescribed
programme of progressive exercise could reduce the
likelihood of injury during exercise and associated
with falls, possibly lowering the overall risk of
musculoskeletal injury.[57] Specific studies designed
to assess balance of risks and benefits of exercise
training among patients with CKD would be of great
value.
The risk of cardiac events during maximal exer-
cise testing is low, in the order of 0.5 per 10 000
tests for death, and 3.6 per 10 000 tests for myocar-
dial infarction, estimates that are based on tests
conducted in healthy and diseased popula-
tions.[57,62-64] There are no data specifically address-
ing the risks in patients with CKD. It is likely that
their risk is higher than in the healthy general popu-
lation because of the high prevalence of risk factors
for cardiac disease and known cardiac disease, but
their risk is probably not significantly higher than
the risk in populations undergoing diagnostic tests
Sports Med 2005; 35 (6)
492
40
35
No. of patients (%)
30
25
20
15
10
5
0
Almost <1 x/ 1 x/ 2−3 x/ 4−5 x/
never or wk wk wk wk
never
Exercise frequency
Fig. 2. Assessment of physical activity among patients on haemodi-
alysis. Data from the United States Renal Data System Dialysis
Morbidity and Mortality Study wave 2 (n = 2264) showing the num-
ber of days per week on which patients perform physical exer-
cise.[14]
for cardiovascular disease. Again, no untoward car-
diac events have been reported in any of the pub-
lished studies of exercise testing in patients with
ESRD and, although these patients were a highly
select group, the risk appears to be low.[57] The risk
of cardiac events during submaximal exercise (i.e.
training) is even lower than that for maximal test-
ing.[65] Although the risk of a cardiac event is tran-
siently increased during exercise, overall that risk is
attenuated in individuals with higher levels of habit-
ual physical activity.[57]
A major purpose of medical screening prior to
exercise participation is to determine which patients
are at increased risk of cardiovascular events. How-
ever, all patients with ESRD or advanced CKD are
at increased risk for cardiopulmonary disease. Thus,
the existing guidelines provide little assistance in
determining whether exercise testing should be per-
formed before initiating an exercise programme or
which patients should be tested.[57,66] The necessity
for testing should be related to the proposed intensi-
ty of training and the patient’s symptom or disease
status. Patients with symptoms suggestive of cardiac
disease or with known disease should undergo exer-
cise testing prior to participation in vigorous training
programmes.[66] However, many of the reported
studies of moderate-intensity exercise training in
patients with CKD have relied on history, physical
examination, and in some cases ECG testing, to
determine whether patients may participate in exer-
 2005 Adis Data Information BV. All rights reserved.
Johansen
cise training programmes without adverse events,
suggesting that this strategy is appropriate when
moderate-intensity training is involved.
In addition to proper medical screening, the risks
related to exercise in patients with CKD can be
minimised by including appropriate warm-up and
cool-down exercises, ensuring that the environment
Daily or and equipment are optimal (including proper foot-
almost wear), starting a programme slowly and progressing
daily
exercise gradually, avoiding high-impact activities,
and ensuring proper performance of exercise, partic-
ularly weight-lifting exercise. Some disease-specific
considerations may also reduce risk. Attention to
patients’ volume status and blood pressure control is
important in this population. Patients with advanced
CKD often have increased extracellular fluid that
may contribute to reduced exercise tolerance, and
judicious use of diuretic medications may be help-
ful. Similarly, patients with ESRD should have their
dry weights assessed frequently to avoid volume
overload and may tolerate exercise best either dur-
ing dialysis or on a day after a dialysis session.
5. Exercise Participation by Patients with
Chronic Kidney Disease
Unfortunately, despite >20 years of published
data on the effects of exercise in patients with CKD,
participation in exercise or physical activity by these
patients remains low, as evidenced by several recent
reports.[1,14,37,67] In a study using data from the Unit-
ed States Renal Data System (USRDS) Dialysis
Morbidity and Mortality Study, 35% of 2264 dialy-
sis patients reported performing no leisure time
physical activity whatsoever, and less than half re-
3.5
3
2.5
Time (h)
2
1.5
1
0.5
0
Job-related, Job-related, Leisure, Leisure,
moderate vigorous moderate vigorous
Type of exercise
Fig. 3. Amount of time per week patients on haemodialysis spent in
various types of exercise (n = 39).[67]
Sports Med 2005; 35 (6)
Exercise and Kidney Disease 493

180
6. Healthcare Provider Involvement
Accelerometry (arbitrary units)

160
140
120
100
80
60
40
20
0 surveying 505 nephrologists attending a national
Dialysis Control
Group
Fig. 4. Physical activity of patients on haemodialysis (n = 34) and
sedentary control subjects (n = 80) measured by accelerometry.[1]
The difference is statistically significant, p < 0.0001.
ported exercising more than once per week[14] (fig-
ure 2). In another study, 37% of 99 patients undergo-
ing haemodialysis reported no regular exercise par-
ticipation,[67] a finding that is in very close
agreement with the USRDS data. This study also
tallied the amount of time patients spent in various
types of activities (figure 3). Overall, patients re-
ported spending only 4.5 hours per week in all types
of activity, including job- or housework-related and
leisure activity. This extremely low amount of time
spent in activities may explain, in part, why these
patients have been shown to be significantly less
active than even sedentary controls when activity is
measured objectively by accelerometry[1] (figure 4).
Compared with healthy subjects who perform no
formal exercise, patients on dialysis appear to per-
form less activity related to daily living. A final
study that assessed activity in patients with ESRD
did so in a way that determined whether patients
in Exercise
One factor that affects patient participation in
exercise is input from healthcare providers. A recent
study addressed the extent of nephrologist assess-
ment and encouragement of physical activity by
meeting.[18] Thirty-eight percent of the nephrologists
surveyed said that they assessed patients’ level of
physical activity and counselled inactive patients to
increase activity ‘often’ or ‘almost always’. Young-
er, less active, and male nephrologists were less
likely to provide exercise counselling. Nephrolo-
gists who did not provide routine counselling en-
dorsed the following barriers to counselling: lack of
time; lack of confidence in their ability to counsel
patients; and lack of conviction that patients would
respond. In addition, non-counselling nephrologists
were more likely to think that other medical issues
were more important than exercise. These findings
highlight three needs. First, more information is
needed about whether exercise provides long-term
benefit and a survival advantage in this population.
Such data would potentially address the concern that
other medical issues are more important. Secondly,
more information is needed about patient prefer-
ences regarding exercise so that successful strate-
gies can be implemented and providers can be confi-
dent that a reasonable proportion of patients will
participate. Thirdly, nephrologists need training in
70
60
No. of patients (%)

were meeting the Surgeon General’s recommenda- 50

tions to exercise for at least 30 minutes on ≥3 days 40
per week.[37,68] They reported that 59% of the pa- 30
tients reported no physical activity beyond basic 20

activities of daily living and only 12% met the 10

0
Surgeon General’s recommendations (figure 5). y ... r d
l th la
Thus, it is clear that research reports of the effects of on ng cu de
L r e as en
AD /st iov m
m
exercise in patients with CKD have not translated to hi ng rd co
tc ca re
e
widespread participation in physical activity. The tre m SG
S So
challenge now is to develop and implement Level of exercise participation
programmes that can increase activity levels in large Fig. 5. Level of participation in different types of exercise (n =
numbers of patients with CKD. 286).[37] ADL = activities of daily living; SG = Surgeon General.

 2005 Adis Data Information BV. All rights reserved. Sports Med 2005; 35 (6)
494
methods of exercise assessment and counselling.
This could address the lower rates of exercise coun-
selling among fellows and younger nephrologists
and the nephrologists’ concern about a lack of com-
petence in this area.
Preliminary data suggest that exercise counsel-
ling can increase physical activity among patients on
dialysis. Tawney et al.[67] performed a randomised
trial of an exercise assessment and counselling strat-
egy to increase patients’ physical activity and func-
tioning. Baseline questionnaires were completed by
217 patients. Of these, 99 passed the medical screen-
ing and agreed to be randomly assigned to receive
the intervention or not. The intervention consisted
of: (i) an assessment of the patient’s current level of
activity and functional ability; (ii) collaborative goal
setting between patient and the provider that ac-
counted for the patient’s preferences and lifestyle;
(iii) problem solving with the patient about barriers
to physical activity; and (iv) identifying supports
that help the patient maintain an increased level of
physical activity.[67] Unfortunately, the barriers
identified by patients and the problem solving strate-
gies employed were not explicitly reported. Howev-
er, the patients randomly assigned to the interven-
tion increased their total activity time (time spent
engaged in any type of moderate or vigorous activi-
ty) by an average of 1.75 hours per week (p < 0.05)
compared with no increase in activity time among
the patients in the control group. Most of the in-
crease was in moderate-intensity leisure activity, the
target of the intervention, but it is important to note
that activity time was assessed by patient report
rather than objective measures. In addition, there
was a trend toward improvement in the Physical
Function score of the SF-36 among the patients
assigned to the exercise assessment and counselling
(p = 0.085). This is a preliminary demonstration that
counselling can increase activity levels among pa-
tients on haemodialysis.
7. What Can the Literature Tell Us About
the Optimal Exercise Programme?
In order to design successful exercise program-
mes that will be accessible and acceptable to large
 2005 Adis Data Information BV. All rights reserved.
Johansen
numbers of patients with CKD, it is important to
know what types of exercise produce the greatest
clinical benefit in this population and what types of
training programmes can recruit and retain large
numbers of patients on dialysis. Much of this work
has yet to be done, but some information can be
gleaned from the available literature. As for compar-
isons of the benefits of different programmes, little
is known. Konstantinidou et al.[69] compared the
effects of centre-based training to those of dialysis
unit-based and home-based training on V̇O2peak.
They reported a higher dropout rate among the pa-
tients assigned to in-centre training and cited lack of
time, transportation difficulties and medical reasons
unrelated to exercise as the reasons. The patients
benefited from all three types of training, but the
cardiovascular effects were greatest with the centre-
based training. The authors concluded that intense
exercise training on non-dialysis days is the most
effective way of training. However, this conclusion
should be tempered somewhat because it only refers
to exercise-induced changes in V̇O2peak and not
other potential benefits. Furthermore, the exercise
interventions were so different in the three groups
that it is uncertain whether the differences in
V̇O2peak were related to different intensities of train-
ing, different activities used for training, or different
levels of adherence to the programme since adher-
ence to the home training was not monitored. There
is a great need for systematic comparison of the
effects of different exercise interventions on out-
comes of interest to patients with CKD and their
healthcare providers, including physical perform-
ance, self-reported physical functioning and HR-
QOL. More concrete information about benefits that
affect QOL should help motivate providers to rec-
ommend exercise more enthusiastically and patients
to adopt it. However, it is also important to under-
stand what types of exercise are most acceptable to
patients.
Many of the studies of exercise training in pa-
tients with CKD have included a highly selected and
relatively healthy subset of the population. In some
cases, this was by design because a relatively vigor-
ous intervention was under study and because the
Sports Med 2005; 35 (6)
Exercise and Kidney Disease
goal was to test whether the healthiest group of
patients could demonstrate an effect of training.
However, it is also clear that it is difficult to enlist
patients with CKD into exercise programmes.
Shalom et al.[7] were one of the first groups to
report on the number of patients excluded from
study participation. They planned an in-centre, su-
pervised aerobic training programme to be per-
formed on non-dialysis days. Of 174 patients on
dialysis, 70 (40%) lived too far away to participate,
and 54 (31%) were excluded because of coexistent
medical problems. Consequently only 50 patients
(29%) remained eligible for participation. Although
all were offered the chance to participate, only 14
actually enrolled. Of those who enrolled in the exer-
cise programme, only 50% attended more than half
of the training sessions. These data highlight two
problems with implementation of widespread exer-
cise programmes for patients on dialysis. First, a
large number of patients were excluded for medical
reasons because the planned intervention was a vig-
orous training programme. Secondly, because the
training was to occur in an exercise facility on non-
dialysis days, geographic considerations limited
participation by many patients, and most of those
who did not live a prohibitive distance from the
centre still found the burden of additional visits for
exercise training to be too high.
Incorporation of exercise into the dialysis ses-
sions is a way to reduce the time burden of exercise
for patients on haemodialysis, and several studies
have used this venue. However, even with this strat-
egy, participation has been low in some studies.
Miller et al.[34] incorporated exercise training into
dialysis sessions in a programme that was imple-
mented by dialysis personnel in an attempt to make
exercise available to all patients. Unfortunately,
they found that, despite no cost to the patient and no
extra time requirement for exercise, <40% of the
patient population participated.[34] Of the patients
who initially participated, only 60% still were exer-
cising at 6 months, and only 22% of potential exer-
cisers completed the programme. They concluded
that reasons for low participation in this population
 2005 Adis Data Information BV. All rights reserved.
495
need to be investigated and strategies to increase
participation tested.
The Renal Exercise Demonstration Project also
tested an exercise programme that included dialysis
unit-based training supervised by existing dialysis
unit staff after an initial home-based phase.[37] Pa-
tients were encouraged to begin exercising mostly
by walking. Walking is an activity that is less vigor-
ous than typical training programmes and perhaps
less threatening to patients who were very sedentary
at baseline. Thus, medical criteria for patient exclu-
sion were less stringent and patient enthusiasm for
the programme was higher than for many of the
supervised programmes. The relatively low intensi-
ty of initial exercise followed by exercise during
dialysis may be responsible for the large numbers of
patients they were able to recruit. Nevertheless, the
success of this programme may be difficult to dupli-
cate. It was performed in selected dialysis units
where staff indicated enthusiasm for the programme
in advance and, despite the initial interest of the
staff, documentation of patients’ exercise participa-
tion was incomplete (Painter P, personal communi-
cation). This study suggests that home-based or
dialysis-based training beginning at moderate inten-
sity can be a more successful way to initiate training
in lower functioning patients. However, more infor-
mation is needed on ways to increase dialysis unit
staff participation and support of exercise program-
mes.
Finally, since most of the available data are de-
rived from studies of patients undergoing haemodi-
alysis, more information about the effects of differ-
ent training programmes in other groups of patients
with CKD is needed. This includes pre-ESRD pa-
tients, peritoneal dialysis patients and kidney trans-
plant recipients.
8. Recommendations
While there are insufficient data available in pa-
tients with CKD to make definite recommendations,
the available data and information gathered in stud-
ies of exercise in healthy individuals or other chron-
ic disease groups can be used to form the basis for
some preliminary recommendations. The first re-
Sports Med 2005; 35 (6)
496
quirement is that the care team consider exercise and
physical functioning in individuals with CKD. Pa-
tients should be routinely evaluated to determine
their level of exercise participation, cardiac risk
factors and physical functioning so that an exercise
programme can be prescribed when appropriate.
Prior to prescription of moderate or vigorous exer-
cise, patients should be screened for symptoms sug-
gestive of cardiac disease. Low- to moderate-inten-
sity aerobic exercise three or more times per week
should be recommended to all patients who are able
to do so because of the well established benefits in
the general population.[68] The association between
inactivity and mortality in ESRD[14] provides further
support to the notion that increased activity would
be beneficial in this population. Strength training
should definitely be recommended for patients who
report or manifest muscle weakness or poor physical
performance such as difficulty walking, climbing
stairs, or rising from a chair. However, it is possible
that all patients could benefit from strength training
because: (i) they are generally weaker than healthy
individuals even if they do not report weakness; and
(ii) strength is likely to be a major determinant of
physical functioning and thus QOL.
Aerobic training should focus on large muscle
activities such as walking or cycling. Exercise
should begin at low intensity (i.e. 50–60% of peak
heart rate or V̇O2peak if known) and short duration
(10–20 minutes per session). Although these guide-
lines are based on peak heart rate and V̇O2peak, it
may also be useful to base the initial exercise pre-
scription on patients’ rating of perceived exertion
(RPE) using the Borg scale.[54] This is because heart
rate and blood pressure responses may be varia-
ble[31] and because RPE is a direct measure of exer-
cise tolerance, an important factor for adherence.
Exercise should progress gradually to higher inten-
sity and longer duration. Selected patients may
reach a target of 85% predicted maximal heart rate
and/or V̇O2peak for 30–60 minutes per session for ≥3
days per week. However, the low participation rates
and high drop-out rates of the more vigorous train-
ing studies suggest that many patients may be un-
willing or unable to exercise this vigorously. It
 2005 Adis Data Information BV. All rights reserved.
Johansen
should be recognised that any increase in aerobic
activity is likely to be beneficial, and patients should
be encouraged to progress at a pace that is accept-
able to them and to continue to exercise at whatever
level they can achieve.
Haemodialysis patients should perform exercise
during dialysis if possible or on their non-dialysis
days. Peritoneal dialysis patients may be more com-
fortable performing high-intensity exercise without
fluid in the abdomen, but exercise should first be
tried with fluid in for patients on continuous therapy.
Exercise without drainage of peritoneal fluid is pref-
erable because it avoids the added time or complexi-
ty that would be necessary to coordinate exercise
with the dialysis exchanges and also prevents a
decrement in dialysis dose because of exercise. Pa-
tients should only be advised to drain the peritoneal
fluid before exercise participation if they are uncom-
fortable exercising with abdominal fluid in place.
Resistance exercise should also be initiated at
low intensity and progressed gradually as tolerated.
Free weights, weight machines, isokinetic ma-
chines, or resistance bands can be used as long as
patients are educated on proper technique and start-
ed at low intensity to avoid injury. Using free
weights, for example, it is recommended that the
initial prescription be based on 3RM or higher rather
than 1RM to avoid tendon injuries. Initial training
should be initiated at approximately 50% of this
value rather than a higher intensity as is common in
healthy populations. Training can then be pro-
gressed gradually to high intensity as long as no
difficulties are encountered. Although there are no
data specific to patients with CKD, strength training
in older individuals increases tendon stiffness, de-
creasing the risk of subsequent injury.[70] Therefore,
with gradual progression, there is probably no maxi-
mum weight that can be safely lifted.
All major muscle groups should be trained in
three sessions per week. The lower extremities can
be emphasised in individuals with impaired ability
to ambulate, climb stairs, or rise from a chair unas-
sisted. Haemodialysis patients with permanent vas-
cular access devices in the arm often avoid exercis-
ing their upper extremities out of fear of damaging
Sports Med 2005; 35 (6)
Exercise and Kidney Disease
their access. Such patients should be encouraged to
exercise the access arm as long as weight is not
borne directly on the access itself. Patients on perito-
neal dialysis should be cautioned to avoid the Val-
salva manoeuvre while lifting weights.
Warm-up and cool-down sessions of 5–10 min-
utes should proceed and follow each aerobic or
resistance exercise session. In addition, flexibility
exercises such as stretching or yoga could help
patients maintain or improve their range of motion
and might also improve gait, balance and coordina-
tion. Proper instruction on stretching should be giv-
en. In particular, patients should be advised to main-
tain each stretch below the discomfort threshold.[17]
9. Conclusions
Patients with CKD and ESRD are a sedentary
population with low V̇O2peak, poor self-reported
physical functioning, and a high burden of cardiac
disease and other comorbid conditions potentially
improved with exercise. It has been shown that
vigorous aerobic exercise training can improve
V̇O2peak and self-reported physical functioning, but
the effects of exercise training on cardiovascular
risk have not been well studied.
More research is necessary to determine the opti-
mal exercise programme for patients with CKD. It is
likely that different subgroups of patients will bene-
fit from different exercise programmes tailored to
their specific needs and abilities. Such programmes
need to be easily accessible to patients with CKD.
Acknowledgements
This work was supported by a grant from the National
Institutes of Health (DK-56182). There are no conflicts of
interest to report.
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Nephrology Section 111J, San Francisco VA Medical
Center, 4150 Clement Street, San Francisco, CA 94121, USA.
Sports Med 2005; 35 (6)