Journal of Physical Activity and Health, (Ahead of Print)

https://doi.org/10.1123/jpah.2020-0652
© 2021 Human Kinetics, Inc. REVIEW

Home-Based Exercise for People With Chronic Kidney Disease:

A Systematic Review and Meta-Analysis
Renata Valle Pedroso, Miguel Adriano Sanchez-Lastra, Laura Iglesias Comesaña, and Carlos Ayán

Background: Exercise performed at home could be a useful therapy for people with chronic kidney disease. This systematic
review and meta-analysis aimed at describing the characteristics, main findings, methodological quality, and adherence rate
reported in the existent randomized controlled trials that have provided information regarding the impact of home-based
exercise programs on people with chronic kidney disease. Methods: Electronic databases (MEDLINE/PubMed, SPORT-
Discus, Scopus, and CENTRAL) were searched up to April 2021, using the keywords: “Exercise”; “Home”; “Kidney Disease.”
Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was adopted. Jadad scale and Cochrane’s tool
were used to assess the methodological quality and risk of bias. Results: Out of the 14 studies finally selected, 11 were included
in the meta-analysis and most presented high methodological quality. The meta-analysis showed significant effects of home-
based exercise on fitness and quality of life, but a little impact on renal function. Although exercise performed at home was
mostly feasible and safe, adherence was not high and a considerable number of dropouts were observed. Conclusion: Home-
based exercise has positive effects on the fitness’ level and on the quality of life on people with chronic kidney disease. Future
studies are needed to identify whether exercise performed at home is a better physical therapy option than center-based
exercise.

Keywords: physical exercise, fitness, quality of life

Chronic kidney disease (CKD) is a condition that alters the
function and structure of the kidney irreversibly, over months or
years.1 The progression of CKD causes functional limitation and
severe disability with poor quality of life (QoL). Therefore,
structured programs based on reducing the risk factors for CKD
and rehabilitation strategies aimed at reducing the burden of
disability in this population are strongly encouraged.2
Among the aforementioned strategies, exercising stands out as
an interesting option due to its favorable effects on a number of
CKD symptoms, such as inflammation, cachexia, and hyperten-
sion. In addition, its practice leads to a reduced cardiovascular risk
and improved physical function and health-related QoL across all
stages of CKD.3–5 Indeed, regular physical activity is associated
with reduced morbidity and mortality in this population.5
However, a change of behavior toward an active lifestyle is
difficult to achieve among CKD patients, due to the existence of
several exercise barriers, such as lack of guidance from health care
practitioners or lack of facilities, time, and access.6
One possible suggestion to resolve the lack of orientation from
health professionals is to provide the most accurate evidence-based
guidelines currently available for the prescription of physical
exercise and its potential benefits within people with CKD. This
goal can be achieved through conducting systematic reviews that
summarize and critically analyze the existing scientific evidence on
this topic. Regarding the lack of facilities, time, and access, home-
Pedroso is with the Department of Gerontology, Federal University of São Carlos
(UFSCar), São Carlos, São Paulo, Brazil. Sanchez-Lastra is with the Department of
Special Didactics, University of Vigo, Vigo, Galicia, Spain. Ayán is with the IIS
Galicia Sur, Vigo, Galicia, Spain; and the Well-Move Research Group, Department of
Special Didactics, University of Vigo, Vigo, Galicia, Spain. Comesaña is with the
University of Vigo, Vigo, Galicia, Spain. Pedroso (re.pedroso@hotmail.com) is
corresponding author.
based exercise seems to be a plausible solution for overcoming
such barriers. However, few systematic reviews have addressed
this topic so far.
To the very best of the authors’ knowledge, only one
systematic review has been recently published regarding the
effects of home-based exercise on CKD patients.7 However,
the scientific evidence regarding the feasibility and potential
benefits of this rehabilitation approach provided in this review
was limited. For instance, the authors performed a meta-analysis
of the the impact of home exercise on physical function, while its
effects on important outcomes related to health-related physical
fitness were omitted. This is an important fact to be considered,
since improvements in fitness dimensions, such as maximal
oxygen consumption, are linked to better metabolic health in
this population.8 In addition, although Ju et al7 informed about the
exercise modality and duration of the proposed interventions,
they did not report detailed data regarding the characteristics of
the exercise programs (ie, intensity, duration, or resting periods).
This lack of information difficult the generation of basic guide-
lines for accurate exercise prescription in people with CKD.
Finally, no data were provided regarding adherence or reasons
for dropping out. This is an interesting matter that should be
further studied, since patients’ adherence to home-based exercise
programs can be very low, and it is important to know the reasons
behind this lack of commitment.9
Although traditionally it was accepted that study reviews
should be updated every 2 years, it has recently been suggested
that updating must be based on need and priority.10 Considering
what has been published up to this point, it seems that the
performance of a more comprehensive systematic review and
meta-analysis on the impact of home-based exercise programs
on CKD patients is justified. Under these circumstances, the
purpose of this study was to conduct a systematic review and a
1
2 Pedroso et al
meta-analysis aimed at describing the methodological quality,
intervention characteristics, main findings, and adherence rate
reported in the existent randomized controlled trials (RCTs) that
have provided information regarding the impact of home-based
exercise programs on people with CKD.
Methods
This systematic review was conducted following the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
guidelines.11
Search Strategy
Four electronic databases (MEDLINE/PubMed, SPORTDiscus,
Scopus, and Cochrane Central Register of Controlled Trials—
CENTRAL) were searched from the inception of each database
to April 2021. The following search terms, Boolean operators, and
combinations were used: “Exercise” OR “Home” AND “Kidney
Disease.” The detailed search strategy for each database could
be accessed on Supplementary Material 1 (available online).
The full texts of the studies that met the inclusion criteria were
also manually screened for any additional possibly relevant
investigations.
Eligibility Criteria
The RCTs that provided information regarding the effects of home-
based exercise on people with CKD, compared with no therapy or
to other nonhome-based exercise interventions, were considered
eligible. Investigations were excluded if: (1) exercise was per-
formed in combination with other rehabilitation strategies, (2) the
full text of the study was not available in English, Portuguese, or
Spanish language, and (3) the research was a review, a case report,
a letter to the editor, or an abstract from a congress.
Study Selection
Two authors screened the titles and abstracts of the identified
studies for eligibility. After independently reviewing the selected
studies for inclusion, these were compared by both authors to
reach an agreement. Once the agreement had been reached, a full-
text copy of every potentially relevant study was obtained. If it
was unclear whether the study met the selection criteria, advice
was sought from a third author and a consensus of opinion was
reached.
Data Extraction
Information regarding the country in which every study was carried
out; participant characteristics (total number, sex, age, and CKD
stage); interventions (exercise modality, intensity, duration, fre-
quency per week, time of session, and rest intervals); adverse
effects, adherence, outcomes (variables assessed and tests used
to this purpose); and intervention effects were extracted from
the original reports by one researcher and checked by a second
investigator. To this aim, a data extraction form, together with
coding instructions for data collection, was designed. Missing data
were obtained from the study authors, whenever possible. All
discrepancies were reviewed and an agreement was reached by
discussion.
(Ahead of Print)
Quality Appraisal and Risk of Bias
The methodological quality of the selected RCTs was directly
retrieved from the Jadad scale,12 which has presented good validity
and reliability evidence.13 The Jadad scale consists of 3 items:
randomization (0–2 points), blinding (0–2 points), and dropouts
and withdrawals (0–1 points). The score of Jadad varies from 0 to 5
points, in which <2 is considered to be of low quality, and >3 is
considered high quality.12 Risk of bias was assessed by means of the
Cochrane Collaboration’s tool.14 In addition, the Grading of Re-
commendations Assessment, Development and Evaluation Working
Group (GRADE) approach was used to assess the quality of the
evidence.15,16 The downgrade of the evidence of the main outcomes,
from high quality by one level, was determined by the presence of
each of the following: attrition bias (where withdrawal rates were
>15%), detection bias (when assessors of outcomes were not blinded
to group allocation), publication bias (when publication bias was
suspected), and inconsistency (when I2 > 50 % for heterogeneity).
Data Analyses
The meta-analysis was conducted when at least 3 studies reported
baseline and posttreatment data of the same outcome and compared
“home-based exercise group” versus “control group.” All out-
comes in this meta-analysis are continuous (presented as mean
[SD]). In those studies where the results were reported as mean and
95% confidence interval (CI), baseline and postintervention SD
was estimated using the formula from Cochrane Handbook of
Systematic Reviews of Interventions.17 To obtain the change from
baseline and
qpostintervention SD, the following formula was used:ffi
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
SDchange = ðSD2baseline þ SD2postintervention Þ − ð2 × Corr × SDbaseline
2 þ SD2postintervention Þ, where Corr = .5. Following previous stud-
ies,18,19 we imputed the value for Corr on the assumption of
moderate correlation between baseline and postintervention mea-
surements. Mean differences (MD) with 95% CI were used to
estimate the pooled effects and the results were considered signifi-
cant when the CI excluded zero.
Heterogeneity across the studies was checked by the chi-
square test, and its degree was quantified using the I2 statistic.
I2 values of 25%, 50%, and 75% were considered as low, moderate,
and high heterogeneity, respectively.20 We used fixed-effect mod-
els for all meta-analyzed variables with low heterogeneity. When a
high/moderate heterogeneity was detected, a random effects model
was applied.17 In order to assess the possible existence of publica-
tion bias, we provided funnel plots for all the outcomes evaluated.
All meta-analyses were conducted using Review Manager 5 (ver-
sion 5.3; The Cochrane Collaboration), and P < .05 was considered
as statistically significant.
Results
Design and Sample
Out of the 313 references initially screened, 14 of them met the
inclusion criteria and were selected for qualitative synthesis and 11
studies were pooled in the meta-analysis, as they included compa-
rable pretest and posttest outcome data (Figure 1). These outcomes
included estimated glomerular filtration rate (eGFR), systolic blood
pressure (SBP), diastolic blood pressure (DBP), body mass index
(BMI), cardiorespiratory (VO2max and 6-min walking test), mus-
cular fitness (handgrip), and QoL (Kidney Disease Quality of Life
Instrument [KDQOL]).

Figure 1 — Flow chart of the systematic review process.
The characteristics of the included RCTs are shown in Table 1.
Studies were conducted in Europe (n = 6),21–26 Asia (n = 3),27-29
Oceania (n = 2),30,31 South America (n = 2),32,33 and North America
(n = 1).34
The samples were made up of patients in hemodialysis
(n = 8),21–23,25–27,31,34 stages 3 to 4 CKD (n = 5),24,28,30,32,33 and
patients in stages 1 to 2 CKD (n = 1).29 In total, 919 patients were
included (413 allocated to home-based exercise, 420 assigned to
the control group, and 86 performed other type of interventions).
The mean age of the participants included in the home-based
exercise groups ranged from 43.929 to 75.0 years.21
Quality Assessment and Risk of Bias
All studies were considered of high methodological quality, except
one, which showed low quality22 (Table 2).
All studies presented low risk of selection bias, except Ortega
Pérez de Villar et al22 and Baria et al33 that showed unclear risk for
not presenting more information about the randomization method. A
high performance was detected in most of studies; although, 3
specified the existence of blinding of the assessors.24,27,33 Detection
and reporting risk of bias were high and low in all the studies,
respectively. Half were considered of unclear and the rest of low risk
of attrition bias to describe the intention-to-treat analysis (Table 3).
The quality of evidence, as qualified by GRADE, was high
for the outcomes BMI and VO2max, moderate for eGFR, SBP,
(Ahead of Print)
Exercise and Chronic Kidney Disease 3
6-minute walking test, handgrip, KDQOL “Symptom/problem list”
and “Symptom/problem list,” and low for DBP and KDQOL
“Burden of kidney disease.” Summary of Findings, evidence
according to GRADE, are available in the Table 4.
Intervention Characteristics
A detailed description of the interventions is presented in
Supplementary Material 2 (available online). Aerobic exercise was
the home-based intervention most frequently proposed.21,23–26,29,31–34
Three studies included a combination of aerobic and resistance
exercises,22,27,28 while one investigation focused on the performance
of multimodal exercises.30
Exercise was performed at moderate intensity in 10 stud-
ies.22,24,25,28–34 Uchiyama et al27 and Manfredini et al26 conducted
a low-/moderate-intensity program, while the intensity proposed by
Baggetta et al,21 was low. Manfredini et al23 did not provide
information in this regard. In the majority of cases, exercise
intensity was monitored by means of perceived exertion scales,
while other parameters, such as heart rate, ventilator threshold, or
walking speed were less frequently used.
Home-based programs were usually supervised, either by
phone calls,29–33 visits,24,28,34 or diaries.22,23,26 Three interventions
were not supervised.21,25,27 Interventions lasted between 324,27,29,33
and 12 months,28,30 with a frequency of 2 to 3 days per week22,27–34
4 Pedroso et al

Table 1 General Characteristics of the Included Studies, Participants, and Type of Interventions
Participants
Study Sample size pre/ Health
reference Country post; % women Age, y status Intervention type
Baggetta et al21 Italy EG: 83/53; 36% EG: 73.0 (5.0) HD EG: home-based walking exercises. Without supervision
CG: 77/62; 34% CG: 75.0 (6.0) CG: generic advice to maintain an active lifestyle
Ortega Pérez de Spain EG1: 9/5; NR EG1: 67.0 (7.6) HD EG1: home-based exercises (aerobic + resistance exercise).
Villar et al22 EG2: 8/2; NR EG2: 70.5 (9.1) Supervised by diary and in dialysis
EG2: exercise during hemodialysis (cycling + resistance
exercise). Monitored in session
Manfredini Italy EG: 31/28; 29% EG: 66 (14) HD EG: home-based walking exercises. Monitoring by diary
et al23 CG: 28/26; 42% CG: 68 (13) CG: generic advice to maintain an active lifestyle
Van Craenen- Belgium EG: 25/19; 42% EG: 51.5 (11.8) CKD, EG: home-based intermittent aerobic exercises in stationary
broeck et al24 CG: 23/21; 48% CG: 54.7 (14.1) stages 3 bike. Supervised by visit in the first 2 wk
and 4 CG: no intervention
Konstantinidou Greece EG1: 12/10; 20% EG1: 51.4 (12.5) HD EG1: home-based exercise (cycling). Without supervision
et al25 EG2: 12/10; 20% EG2: 48.3 (12.1) EG2: supervised exercise (aerobic, in stationary bike + resis-
EG3: 21/16; 31% EG3: 46.9 (13.9) tance exercise) during hemodialysis
CG: 13/12; 66% CG: 50.2 (7.94) EG3: supervised exercise (aerobic, in stationary bike or
treadmill + resistance exercise) in non-HD days
CG: no intervention
Manfredini Italy EG: 151/104; 36% EG: 63 (13) HD EG: home-based walking exercises. Monitoring by diary
et al26 CG: 145/123; 32% CG: 64 (14) CG: generic advice to maintain an active lifestyle
Uchiyama Japan EG: 24/24; 21% EG: 64.9 (9.2) HD EG: home-based exercises: aerobic (walking) + resistance
et al27 CG: 23/23; 30% CG: 63.2 (9.5) exercises (upper and lower body muscle groups, using thera-
band). Without supervision
CG: no intervention
Hiraki et al28 Japan EG: 18/14; 0% EG: 69.0 (6.8) CKD, EG: home-based exercises: aerobic (walking) + resistance
CG: 18/14; 0% CG: 67.8 (6.9) stages 3 exercises (handgrip strengthening, squats, and calf raises).
and 4 Supervised by visit every 2–3 mo
CG: no intervention
Tang et al29 China EG: 45/42; 33.4% EG: 46.1 (15.6) CKD, EG: home-based exercises (walking, cycling, and jogging) +
CG: 45/42; 45.3% CG: 43.9 (12.4) stages 1 educational orientation. Supervised by call phone
to 3 CG: no intervention
Huppertz et al30 Australia EG: 81/56; 43.9% EG: 58.8 (9.7) CKD, EG: gym-based exercises, using swiss-ball and theraband.
CG: 80/57; 47.4% CG: 62.1 (8.6) stages 3 Supervised by call phone
and 4 CG: no intervention
Koh et al31 Tasmania EG1: 21/15; 25% EG1: 52.1 (13.6) HD EG1: home-based walking exercise. Monitored by call-phone
EG2: 27/15; 33% EG2: 52.3 (10.9) EG2: cycling during hemodialysis. Monitored by physiologist
CG: 22/16; 50% CG: 51.3 (14.4) CG: no intervention
Aoike et al32 Brazil EG1: 14/12; 33.5% EG1: 56.0 (8.3) CKD, EG1: home-based walking exercises. Supervised by call-phone
EG2: 16/13; 30.8% EG2: 56.3 (7.9) stages 3 EG2: center-based aerobic exercise using a treadmill. Monitored
CG: 15/15; 33.4% CG: 54.3 (8.7) and 4 by physiologist
CG: no intervention
Baria et al33 Brazil EG1: n = 9/8; NR EG1: 50.8 (7.7) CKD, EG1: home-based walking exercises. Supervised by call-phone
EG2: n = 10/10; NR EG2: 52.1 (11.4) stages 3 EG2: center-based aerobic exercise in a treadmill. Monitored by
CG: n = 10/9; NR CG: 53.4 (9.6) and 4 physiologist
CG: no intervention
Bohm et al34 Canada −EG1: 30/23; 40% EG1: 53.0 (16.9) HD EG1: home-based walking exercise. Supervised by physiol-
EG2: 30/20; 27% EG2: 52.0 (14.5) ogist, every 2 wk
EG2: cycling during hemodialysis. Monitored by physiologist,
every 2 wk
Abbreviations: CG, control group; CKD, chronic kidney disease; EG, exercise group; HD, hemodialysis; NR, not reported.

to 4 times daily.24 The sessions lasted between 1023,24 and 30 to 60 Biochemical Parameters. Biochemical data were extracted
minutes.25,34 from plasma and urine in 6 studies. 24,26–28,32,33 Home-
based exercise was shown to be effective in increasing
Outcomes urinary sodium in one study, 32 while Baria et al,33 only
found significant improvements for this parameter in the cen-
A number of variables were assessed (Supplementary Material 2 ter-based exercise group. Exercise at home had no significant
[available online]) in the selected studies and grouped in categories effects on urinary protein,28,32 albumin, 26,27,32 and
for the purpose of this review as follows: cholesterol. 24,26,27
(Ahead of Print)
 Table 2 Quality Assessment Based on Jadad Scale of the Studies Included in the Systematic Review
Ortega Van
Pérez de Craenen- Konstan-
Baggetta Villar Manfredini broeck tinidou Manfredini Uchiyama Hiraki Tang Huppertz Koh Aoike Baria Bohm
et al21 et al22 et al23 et al24 et al25 et al26 et al27 et al28 et al29 et al30 et al31 et al32 et al33 et al34
(1) Described 2 1 2 2 2 2 2 2 2 2 2 2 1 2
as randomized
(2) Described 0 0 0 1 0 0 1 0 0 0 0 0 1 0
as double bind
(3) Describe 1 1 1 1 1 1 1 1 1 1 1 1 1 1

(Ahead of Print)
withdrawals
and dropouts
Total score 3 2 3 4 3 3 4 3 3 3 3 3 3 3

5
6 Pedroso et al

Table 3 Risk of Bias Assessed by the Cochrane Risk of Bias Tool

Selection bias
Detection bias
Random Performance bias (blinding of Attrition bias Reporting
Study sequence Allocation (blinding of participants outcome (incomplete bias (selective
reference generation concealment and personnel) assessment) outcome data) reporting)
Baggetta et al21 Low risk Low risk High risk High risk Low risk Low risk
Ortega Pérez de Unclear risk Unclear risk High risk High risk Unclear risk Low risk
Villar et al22
Manfredini Low risk Low risk High risk High risk Unclear risk Low risk
et al23
Van Craenen- Low risk Low risk Low risk High risk Low risk Low risk
broeck et al24
Konstantinidou Low risk Low risk High risk High risk Unclear risk Low risk
et al25
Manfredini Low risk Low risk High risk High risk Low risk Low risk
et al26
Uchiyama Low risk Low risk Low risk High risk Low risk Low risk
et al27
Hiraki et al28 Low risk Low risk High risk High risk Low risk Low risk
Tang et al29 Low risk Low risk High risk High risk Unclear risk Low risk
Huppertz et al30 Low risk Low risk High risk High risk Unclear risk Low risk
Koh et al31 Low risk Low risk High risk High risk Low risk Low risk
Aoike et al32 Low risk Low risk High risk High risk Unclear risk Low risk
Baria et al33 Unclear risk Unclear risk Low risk High risk Unclear risk Low risk
Bohm et al34 Low risk Low risk High risk High risk Low risk Low risk

Only one33 of the 4 studies that analyzed the impact of home-
based exercise on eGFR,24,28,32,33 reported significant improve-
ments in this parameter. Accordingly, the performed meta-analysis
suggested no effects of home-based exercise on eGFR (pooled
n = 121 participants; MD = 1.71 mL/min/1.73 m2; 95% CI, −3.17
to 6.59; P = .49; I2 = 0%; moderate evidence according to the
GRADE; Figure 2).
Hemodynamic Parameters. A total of 8 studies provided infor-
mation regarding the effects of home-based exercise on hemo-
dynamic parameters,23,24,26,27,30–33 with mixed results. A
significant impact on SBP and DBP was found in one30 of the
2 studies,24,30 in which both parameters were analyzed. Baria
et al33 found reduced mean blood pressure values in both home-
and center-based exercise groups. Regarding arterial stiffness,
one23 of the 2 studies,23,27 that included this variable, reported
increments in the control group, but not in the home-based
exercise group.
Regarding the effects of home-based exercise on rest SBP and
DBP, Huppertz et al30 reported a decrement in rest SBP, while
Aoike et al32 found decrements in both variables after both home-
and center-based exercise. On the contrary, Koh et al31 and
Manfredini et al26 did not find significant effects on rest SBP
and DBP. The pooled estimated data of these investigations is
shown in Figure 3. The meta-analysis performed did not suggest
effects of home-based exercise on resting SBP (pooled n = 171
participants; MD = −4.70 mm Hg; 95% CI, −15.4 to 6.00; P = .39;
I2 = 73%; moderate evidence according to the GRADE; Figure 3)
and resting DBP (pooled n = 171 participants; MD = −1.88 mm Hg;
95% CI, −8.51 to 4.75; P = .56; I2 = 73%; low evidence according
to the GRADE; Figure 3). Manfredini et al26 was not included in
(Ahead of Print)
the meta-analysis due to not presenting the data from the
postintervention.
Body Composition. Variables related to body composition were
reported in 5 studies.24,27,30,32,33 The 2 studies that analyzed the
effects of home-based exercise on body weight found significant
reductions in this parameter.30,33 Total body and visceral fat, waist
circumference, and body and leg lean mass were included in one
study.33 Exercise at home showed significant effects on the first 3
variables, while center-based exercise did not have an impact on
body fat, but resulted in significant improvements on visceral fat,
waist circumference, and body and leg lean mass.33
The 5 studies that analyzed the effects of home-based exercise
on BMI, were included in the meta-analysis.24,27,30,32,33 The ob-
tained results indicated no effects of home-based exercise on this
parameter (pooled n = 244 participants; MD = −0.89 kg/m2; 95%
CI, −2.10 to 0.32; P = .15; I2 = 0%; high evidence according to the
GRADE; Figure 4).
Fitness. All the assessed investigations included outcomes
related to either cardiorespiratory endurance, muscular strength,
or flexibility.
Cardiorespiratory fitness was reported in all studies, except in
Hiraki et al.28 Out of the 6 studies that analyzed the effects of home-
based exercise on oxygen consumption (VO2max; in milliliter per
minute per kilogram), 4 reported significant effects,24,25,30,32 while
the remaining 2 did not report significant findings.33,34 Notably, in
the studies by Aoike et al32 and Konstantinidou et al,25 home-based
exercise was equally effective as the other exercise interventions
proposed in improving VO2max. Regarding the effects of home-
based exercise versus control groups, the meta-analysis performed
 Exercise and Chronic Kidney Disease 7

Table 4 Summary of Findings, Evidence According to GRADE

Overall effects
Outcome Author and year of publication (CI: low to high) GRADE: evidence summary
eGFR Van Craenenbroeck et al24; Hiraki 1.71 (−3.17 to 6.59) Risk of bias: no downgrading
et al28; Aoike et al32; Baria et al33 Inconsistency/heterogeneity: I2 = 0% → no downgrading
Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: no downgrading → moderate
SBP at rest Huppertz et al30; Koh et al31; Aoike −4.70 (−15.40 to 6.00) Risk of bias: downgrading
et al32 Inconsistency/heterogeneity: P < .65; I2 = 0% → no down-
grading
Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: downgrading by one level → moderate
DBP at rest Huppertz et al30; Koh et al31; Aoike 1.88 (−8.51 to 4.75) Risk of bias: downgrading
et al32 Inconsistency/heterogeneity: I2 = 73% → downgrading
Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: downgrading by 2 levels → low
BMI Van Craenenbroeck et al24; Uchiyama −0.89 (−2.10 to 0.32) Risk of bias: no downgrading
et al27; Huppertz et al30; Aoike et al32; Inconsistency/heterogeneity: I2 = 0% → no downgrading
Baria et al33 Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: no downgrading → high
VO2max Van Craenenbroeck et al24; Konstanti- 3.34 (1.83 to 4.85) Risk of bias: no downgrading
nidou et al25; Huppertz et al30; Aoike Inconsistency/heterogeneity: I2 = 0% → no downgrading
et al32; Baria et al33 Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: no downgrading → high
6-min walk test Baggetta et al21; Manfredini et al26; −0.15 (−0.45 to 0.15) Risk of bias: downgrading
Tang et al29; Koh et al31; Aoike et al32; Inconsistency/heterogeneity: I2 = 21% → no downgrading
Baria et al33 Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: downgrading by one level→ moderate
Handgrip Uchiyama et al27; Hiraki et al28; Koh 1.63 (−1.26 to 4.52) Risk of bias: downgrading
strength et al31 Inconsistency/heterogeneity: I2 = 0% → no downgrading
Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: downgrading by one level→ moderate
KDQOL Baggetta et al21; Van Craenenbroeck 1.37 (−0.55 to 3.28) Risk of bias: downgrading
“Symptom/ et al24; Manfredini et al26; Uchiyama Inconsistency/heterogeneity: I2 = 0% → no downgrading
problem list” et al27; Tang et al29 Imprecision: no downgrading
Publication bias: no downgrading
Conclusion: downgrading by one level→ moderate
KDQOL “Ef- Baggetta et al21; Van Craenenbroeck 2.93 (0.48 to 5.38) Risk of bias: downgrading
fects of kidney et al24; Manfredini et al26; Uchiyama Inconsistency/heterogeneity: I2 = 0% → no downgrading
disease” et al27; Tang et al29 Imprecision: no downgrading Publication bias: no down-
grading
Conclusion: downgrading by one level→ moderate
KDQOL Baggetta et al21; Van Craenenbroeck 7.31 (3.27 to 11.35) Risk of bias: downgrading
“Burden of et al24; Manfredini et al26; Uchiyama Inconsistency/heterogeneity: I2 = 57% → downgrading
kidney et al27; Tang et al29 Imprecision: no downgrading
disease” Publication bias: no downgrading
Conclusion: downgrading by 2 levels → low
Abbreviations: BMI, body mass index; CI, confidence interval; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; GRADE, Grading of
Recommendations Assessment, Development and Evaluation Working Group; KDQOL: Kidney Disease Quality of Life Instrument; SBP, systolic blood pressure.

indicated favorable results for exercising at home (pooled n = 219 parameter,21,23,26,29,32,33 while the remaining 3 did not report any
participants; MD = 3.34 mL/kg/min; 95% CI, 1.83 to 4.85; P < .01; effect.22,31,34 Home-based was as equally effective as center-based
I2 = 0%; high evidence according to the GRADE; Figure 5). exercise on improving this parameter, as reported by Aoike et al32
Cardiorespiratory endurance, as assessed by means of the 6- and Baria et al.33 The meta-analysis performed showed significant
minute walk test was included in the analysis of 9 investigations, 6 results favoring home-exercise versus the controls in 6-minute
of them showing significant benefits of home-based exercise on this walk test (pooled n = 501 participants; MD = 39.79 m; 95%
(Ahead of Print)
8 Pedroso et al

Figure 2 — Forest plot of mean difference in eGFR (mL/min/1.73 m2) in home-based exercise group versus control group. CI indicates confidence
interval; eGFR, estimated glomerular filtration rate; IV, inverse variance.

Figure 3 — Forest plot of mean difference in systolic blood pressure and diastolic blood pressure at rest in home-based exercise group versus control
group. CI indicates confidence interval; IV, inverse variance.

Figure 4 — Forest plot of mean difference in BMI (in kilogram per meter squared) in home-based exercise group versus control group. BMI indicates
body mass index; CI, confidence interval; IV, inverse variance.

CI, 31.26 to 48.33; P < .01; I2 = 21%; moderate evidence according
to the GRADE; Figure 5).
Home-based exercise also resulted in significant improve-
ments in several variables related to cardiorespiratory function
and showed similar effects to other exercise interventions (see
Table 1 for further information).
Muscular fitness was included in 10 studies.21,22,26-29,31–34
Two22,32 of the 522,27,28,31,32 investigations that informed about
the effects of home-based exercise on upper body muscular fitness
did not report significant effects on this variable.
The meta-analysis indicated that home-based exercise was not
effective in improving upper-body muscular strength, as measured
by handgrip test (pooled n = 106 participants; MD = 1.63 kgf/kg;
(Ahead of Print)
95% CI, −1.26 to 4.52; P = .27; I2 = 0%; moderate evidence
according to the GRADE; Figure 6).
Except for Ortega Pérez de Villar et al22 and Uchiyama et al,27
the remaining 8 studies21,22,26,28,29,32-34 that analyzed the effects of
home-based exercise on lower limb muscular strength reported
significant results. Exercising at home seemed to be as equally
effective as other exercise interventions.32–34
Improvements were also observed in flexibility, both in the
home and center-based exercise groups32 and also during
hemodialysis.34
Functional Mobility. Out of the 3 investigations that included
functional mobility as an outcome studies,22,31,32 only Aoike et al32
reported significant improvements due to exercising at home.
 Exercise and Chronic Kidney Disease 9

Figure 5 — Forest plot of mean difference in VO2max (in milliliter per kilogram per minute) and 6-minute walk test (in meters) in home-based exercise
group versus control group. CI indicates confidence interval; IV, inverse variance.

Figure 6 — Forest plot of mean difference in handgrip strength in home-based exercise group versus control group. CI indicates confidence interval;
IV, inverse variance.

Quality of Life. The effects of home-based exercise on QoL were
reported in 7 investigations.21,24,26,27,29,31,34 All the studies found a
significant effect of exercising at home, except for Bohm et al34 and
Koh et al.31 A meta-analysis of the 5 studies that used the
KDQOL21,24,26,27,29 was performed including the following catego-
ries: “Symptom/problem list,” “Effects of kidney disease,” and
“Burden of kidney disease” categories of KDQOL. Manfredini
et al23 was not included in the meta-analysis because it was a
subsample from the EXCITE trial, reported by Manfredini et al.23
The results showed that home-based exercise significantly improved
“Effects of kidney disease” (MD = 2.93; 95% CI, 0.48 to 5.93;
P = .02; I2 = 0%; moderate evidence according to the GRADE), and
“Burden of kidney disease” (MD = 7.31; 95% CI, 3.27 to 11.35;
P < .01; I2 = 57%; low evidence according to the GRADE), com-
pared with the controls (Figure 7). Results were not significant for
the “Symptom/problem list” (MD = 1.37; 95% CI, −0.55 to 3.28;
P = .16; I2 = 0%; moderate evidence according to the GRADE).
Depression and Anxiety. Tang et al29 included an assessment of
anxiety and depression and found that home-based exercise could
reduce these disorders.
Dropouts, Adherence, and Adverse Events. Dropouts were
reported in all studies and ranged from a total of 69 (exercise =
47; control = 22)26 to none.27 Adherence in home-based exercise
intervention was informed in 8 studies,21–24,26,27,31,34 by using
(Ahead of Print)
either percentage of session really performed, which varied from
58%34 to 83%,26 or percentage of high adherence, which ranged
from 51% high21 to 71%.23
Adverse effects were reported in 8 studies.21,26–29,31,32,34 One
study found events related to home-based exercise, which included
moderate fatigue, leg pain, moderate dyspnea, and joint pain.21
Manfredini et al26 reported moderate fatigue (n = 31), “heavy legs”
or leg pain (n = 35), and moderate dyspnea (n = 29).
Publication Bias and Heterogeneity. Funnel plots did not show
the presence of publication bias for any of the outcomes assessed
(Supplementary Material 3 [available online]). The heterogeneity
was examined using the chi-square test and I2 statistics. All
variables presented low heterogeneity, except “Burden of kidney
disease,” which presented moderate heterogeneity, and SBP and
DBP at rest, which presented high heterogeneity.
Discussion
This research aimed at identifying and critically analyzing the best
available evidence regarding the characteristics and effects of
home-based exercise interventions on people with CKD. A con-
siderable number of RCTs were found, including a wide variety of
outcomes. As a result, a comprehensive review was carried out.
Indeed, using a broader inclusion criteria allowed us to find 14 new
10 Pedroso et al
Figure 7 — Forest plot of mean difference in KDQOL categories “Symptom/problem list,” “Effects of kidney disease,” and “Burden of kidney
disease” in home-based exercise group versus control group. CI indicates confidence interval; IV, inverse variance; KDQOL, Kidney Disease Quality of
Life Instrument.
investigations and to include in the meta-analysis a total of 11
studies, while in the review by Ju et al,7 a total of 7 studies were
analyzed and included in the meta-analysis. Moreover, most of the
RCTs showed a good methodological quality and a meta-analysis
could be performed in some outcomes. In this regard, we provide
novel information on the effects of home-based exercise on several
parameters not analyzed by Ju et al,7 such as VO2max, SBP, DBP,
and BMI.
According to the findings of the meta-analysis, home-based
exercise was mostly effective in improving cardiovascular fitness
and QoL. These results are, in a way, contrary to those obtained by
Ju et al,7 who corroborates with cardiovascular benefits, but
informed that handgrip strength improved after home exercise,
and QoL was not positively affected by this kind of intervention.
These discrepancies could be due to the fact that we included more
studies in the meta-analysis and the data were analyzed using both
fixed and random effects models, depending on the level of hetero-
geneity. The strength of the evidence regarding the cardiovascular
fitness and QoL was overall high to moderate, except for the
category “Burden of kidney disease” of KDQOL, which was low.
The benefits obtained in cardiovascular fitness and QoL might
be due to the fact that most interventions used aerobic exercise
performed at moderate intensity. This training modality usually
results in significant improvements in both outcomes in people with
CKD, as previously reported.35
Resistance exercises performed at home were also useful for
increasing muscular fitness, and more specifically lower body
strength. This is an important point to consider, since impaired
physical performance of the lower extremities is strongly
(Ahead of Print)
associated with all-cause mortality in this population.36 It is
plausible to think that improvements in leg strength could be
obtained through skeletal muscle hypertrophy, as suggested by
Cheema et al.37 The lack of effects observed in handgrip strength
could be due to the patients’ characteristics. Indeed, out of the 3
studies that evaluated this outcome, 2 of them included people in
HD and did not find significant results. On the contrary, the only
investigation in which a significant effect was reported, included
patients with CKD stages 3 to 4. Nevertheless, exercise training
performed in HD has resulted in significant improvements in
handgrip strength in previous research.38 Thus, the prescription
of home-based exercise might not be the best option for improving
this important marker of health on CKD populations. It is important
to highlight that the quality of the evidence related to handgrip was
moderate, suggesting that further trials could be useful.
This review also provides 2 main findings of relevance. First,
according to our meta-analysis, this kind of therapy seemed
ineffective for improving renal function in nondialysis CKD
patients, and more specifically on patients with CKD stages 3
and 4. In this regard, scientific evidence is controversial. On the one
hand, Zhang et al39 reported that exercise could increase eGFR
while reducing SBP, DBP, and BMI in patients with CKD stages 2
to 5. This finding would call into question the comparative
advantages of prescribing home-based exercise. On the other
hand, in the review by Vanden Wyngaert et al,40 it was shown
that exercise could have a small benefit on eGFR, but not on BP in
patients with CKD stages 3 to 4. In this line, Thompson et al41
found that scientific evidence regarding the impact of exercise
on BP was weak and strongly related to the duration of the

intervention. In addition, according to the revised literature, exer-
cise did not have a significant effect on measures of cholesterol39
arterial stiffness.41 Thus, whether exercise performed at home is not
as effective as other exercise training programs in improving renal
function, is still open to question.
Second, although exercise performed at home was mostly
feasible and safe, adherence was not high and a considerable
number of dropouts were observed. This finding is in line with
previous observations suggesting that patients’ adherence to self-
managed physical rehabilitation therapies is usually low.9 Future
studies should focus on identifying exercise barriers for people
with CKD, in order to design home-based intervention programs
that guarantee exercise adherence.
In closing, those health professionals interested in prescribing
home-based exercise for people with CKD, should be aware that
aerobic or resistance training, performed 2 to 3 times per week
could result in fitness and QoL improvements. Nevertheless, if
renal function could improve remains unclear. They also should
consider that, according to the reviewed literature, exercise effects
are noticeable after 3 months of training.
This review provides useful information on the impact that
home-based exercise training programs have on people with CKD,
still is an under researched area. Nevertheless, there are some
limitations that should be acknowledged. First, although a meta-
analysis could be performed, few studies were included in the
analysis of several outcomes (eg, QoL). Second, we only found 3
studies comparing home-based exercise versus other interventions.
Therefore, we could not analyze whether home-based was superior
to center-based programs, neither determine the differences
between supervised and nonsupervised programs. Finally, there
are limitations related to the language restrictions, to the fact that
we did not review the gray literature, and to the publication bias,
which may have conditioned the results of this review.
Conclusion
Home-based exercise has positive effects on the fitness’ level and
on the QoL on people with CKD. However, it doesn’t seem
effective to improve renal function. Future studies are needed,
especially in those variables which presented low–moderate cer-
tainty of the evidence, such as eGFR, SBP, DBP, and handgrip
strength, to identify whether exercise performed at home is a better
physical therapy option than center-based exercise.
Acknowledgment
This research is supported by a grant from the São Paulo Research
Foundation (FAPESP) (grant number: 2017/18808-5).
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