Physical activity and exercise in peritoneal dialysis: international society for peritoneal dialysis and the global renal exercise network practice recommendations

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.

диализат, диализ, физические нагрузки, место выхода, ослабленность, перитонеальный диализ, физическая активность, симптомы, dialysate, dialysis, exercise, exit site, frailty, peritoneal dialysis, physical activity, symptoms

1. Ulutas O., Farragher J., Chiu E. et al. Functional disability in older adults maintained on peritoneal dialysis therapy. Perit Dial Int. 2016. 36(1):71-78.

2. Manera K.E., Tong A., Craig J.C. et al. An international Delphi survey helped develop consensus-based core outcome domains for trials in peritoneal dialysis. Kidney Int. 2019. 96(3):699-710.

3. Atkins D., Best D., Briss P.A. et al. Grading quality of evidence and strength of recommendations. Br Med J. 2004. 328(7454):1490.

4. Wilkinson T.J., McAdams-DeMarco M. et al. Advances in exercise therapy in predialysis chronic kidney disease, hemodialysis, peritoneal dialysis, and kidney transplantation. Curr Opin Nephrol Hypertens. 2020. 29(5):471-479.

5. Isnard-Rouchon M., West M., Bennett P.N. Exercise and physical activity for people receiving peritoneal dialysis: Why not? Semin Dial. 2019. 32(4):303-307.

6. Bennett P.N., Kohzuki M., Bohm C. et al. Global policy barriers and enablers to exercise and physical activity in kidney care. J Renal Nutrit. 2021. Epub ahead of print 12 August 2021. doi: 10.1053/j.jrn.2021.06.007.

7. Perl J., Davies S.J., Lambie M. et al. The peritoneal dialysis outcomes and practice patterns study (PDOPPS): unifying efforts to inform practice and improve global outcomes in peritoneal dialysis. Perit Dial Int. 2016. 36(3):297-307.

8. Bennett P.N., Eilers D., Yang F. et al. Perceptions and practices of nephrology nurses working in home dialysis: an international survey. Nephrol Nurs J. 2019. 46(5):485-495.

9. Sheshadri A., Kittiskulnam P., Lazar A.A. et al. A walking intervention to increase weekly steps in dialysis patients: a pilot randomized controlled trial. Am J Kidney Dis. 2020. 75(4):488-496.

10. Painter P.L., Agarwal A., Drummond M. Physical function and physical activity in peritoneal dialysis patients. Perit Dial Int. 2017. 37(6):598-604.

11. Wilund K., Thompson S., Bennett P.N. A global approach to increasing physical activity and exercise in kidney care: the international society of renal nutrition and metabolism global renal exercise group. J Renal Nutrit. 2019. 29(6):467-470.

12. Viana J.L., Martins P., Parker K. et al., eds. Sustained exercise programs for hemodialysis patients: The characteristics of successful approaches in Portugal, Canada, Mexico, and Germany. Semin Dial. Wiley Online Library. 2019.

13. Twardowski Z.J., Khanna R., Nolph K.D. et al. Intraabdominal pressures during natural activities in patients treated with continuous ambulatory peritoneal dialysis. Nephron. 1986. 44(2):129-135.

14. Perez Diaz V., Sanz Ballesteros S., Hernandez Garcia E. et al. Intraperitoneal pressure in peritoneal dialysis. Nefrologia. 2017. 37(6):579-586.

15. Jegatheswaran J., Warren J., Zimmerman D. Reducing intra-abdominal pressure in peritoneal dialysis patients to avoid transient hemodialysis. Semin Dial. 2018. 31(3):209-212.

16. Nova Scotia Health Authority. Day surgery peritoneal dialysis catheter insertion. 2019. Available from: http://www.nshealth.ca/sites/nshealth.ca/files/patientinformation/1226.pdf (accessed 1 July 2021).

17. University Health Network AfhwucPHIHTDPDCIdip. Going home after peritoneal dialysis catheter insertion or buried peritoneal catheter insertion. 2019. Available from: https://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/Peritoneal_Dialysis_Catheter_Insertion_discharge_information.pdf (accessed 1 July 2021).

18. Oxford University Hospitals. Advice after the insertion of your peritoneal dialysis (PD) catheter. 2020. Available from: https://www.ouh.nhs.uk/patient-guide/leaflets/files/62968Pcatheter.pdf (accessed 1 July 2021).

19. Sigogne M., Kanagaratnam L., Mora C. et al. Identification of the factors associated with intraperitoneal pressure in ADPKD patients treated with peritoneal dialysis. Kidney Int Rep. 2020. 5(7):1007-1113.

20. Dejardin A., Robert A., Goffin E. Intraperitoneal pressure in PD patients: relationship to intraperitoneal volume, body size and PD-related complications. Nephrol Dial Transplant. 2007. 22(5):1437-1444.

21. Leblanc M., Ouimet D., Pichette V. Dialysate leaks in peritoneal dialysis. Semin Dial. 2001. 14(1):50-54.

22. Ohmura N., Tamura H., Kawaguchi Y. et al. The influence of dialysis solution on the exercise capacity in patients on CAPD. Adv Perit Dial. 1989. 5:46-48.

23. Bleyer A.J., Casey M.J., Russell G.B. et al. Peritoneal dialysate fill-volumes and hernia development in a cohort of peritoneal dialysis patients. Adv Perit Dial. 1998. 14.102-104.

24. Lee A. Swimming on peritoneal dialysis: recommendations from Australian PD Units. Perit Dial Int. 2019. 39(6):527-531.

25. Szeto C.C., Li P.K., Johnson D.W. et al. ISPD catheter-related infection recommendations: 2017 update. Perit Dial Int. 2017. 37(2):141-154.

26. Hoekstra B.P., de Vries-Hoogsteen A., Winkels B. et al. Exit site care in the Netherlands: the use of guidelines in practice. J Renal Care. 2017. 43(3):156-162.

27. Kopriva-Altfahrt G., Konig P., Mundle M. et al. Exit-site care in Austrian peritoneal dialysis centers - a nationwide survey. Perit Dial Int. 2009. 29(3):330-339.

28. Cugelman A. Steps to safe swimming for patients on peritoneal dialysis. CANNT J. 2011. 21(2):53-54.

29. Duncanson E., Chur-Hansen A., Jesudason S. Psychosocial consequences of gastrointestinal symptoms and dietary changes in people receiving automated peritoneal dialysis. J Renal Care. 2019. 45(1):41-50.

30. Raj V., Patel D.R., Ramachandran L. Chronic kidney disease and sports participation by children and adolescents. Transl Pediatr. 2017. 6(3):207-214.

31. Derici U., Canseven N., Sindel S. Dialysate leakage in CAPD patients. Edtna Erca J. 2005. 31(1):13-14.

32. Uchiyama K., Washida N., Muraoka K. et al. Exercise capacity and association with quality of life in peritoneal dialysis patients. Perit Dial Int. 2019. 39(1):66-73.

33. Chojak-Fijalka K. Rehabilitacja pacjent´ow dializowanych otrzewnowo. Dializa i Ty. 2019. 1(34):28-29.

34. Hamodraka Mailis A. Pathogenesis and treatment of back pain in peritoneal dialysis patients. Perit Dial Bull. 1983. 3(3):41-43.

35. Manera K.E., Johnson D.W., Craig J.C. et al. Establishing a Core outcome set for peritoneal dialysis: report of the SONG-PD (standardized outcomes in nephrology-peritoneal dialysis) consensus workshop. Am J Kid Dis. 2020. 75(3):404-412.

36. Kwan T.H., Kit-Fan Lee M., Au T.C. The impact of CAPD on sexual life of renal patients. Hong Kong J Nephrol. 1999. 1(1):41-48.

37. Azevedo P., Santos R., Duraes J. et al. Sexual dysfunction in men and women on peritoneal dialysis: Differential link with metabolic factors and quality of life perception. Nefrologia. 2014. 34(6):703-709.

38. Thodis E., Passadakis P., Ossareh S. et al. Peritoneal catheter exit-site infections: predisposing factors, prevention and treatment. Int J Artif Organs. 2003. 26(8):698-714.

39. Groenhoff C., Delgado E., McClernon M. et al. Urgent-start peritoneal dialysis: nursing aspects. Nephrol Nurs J. 2014. 41(4):347-352; quiz 53.

40. Jegatheesan D., Johnson D.W., Cho Y. et al. The relationship between body mass index and organism-specific peritonitis. Perit Dial Int. 2018. 38(3):206-214.

41. Nessim S.J., Komenda P., Rigatto C. et al. Frequency and microbiology of peritonitis and exit-site infection among obese peritoneal dialysis patients. Perit Dial Int. 2013. 33(2):167-174.

42. Heiwe S., Jacobson S.H. Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev. 2011. 10:CD003236.

43. Heiwe S., Jacobson S.H. Exercise training in adults with CKD: a systematic review and meta-analysis. Am J Kid Dis. 2014. 64(3):383-393.

44. Clarkson M.J., Bennett P.N., Fraser S.F. et al. Exercise interventions for improving objective physical function in patients with end-stage kidney disease on dialysis: a systematic review and meta-analysis. Am J Physiol Renal Physiol. 2019. 316(5):F856-F872.

45. Barcellos F.C., Santos I.S., Umpierre D. et al. Effects of exercise in the whole spectrum of chronic kidney disease: a systematic review. Clin Kid J. 2015. 8(6):753-765.

46. Sy J., Johansen K.L. The impact of frailty on outcomes in dialysis. Curr Op Nephrol Hypertens. 2017. 26(6):537.

47. Ng J.K.C., Kwan B.C.H., Chow K.M. et al. Frailty in Chinese peritoneal Dialysis patients: prevalence and prognostic significance. Kid Blood Press Res. 2016. 41(6):736-745.

48. Garonzik-Wang J.M., Govindan P., Grinnan J.W. et al. Frailty and delayed graft function in kidney transplant recipients. Arch Surg. 2012. 147(2):190-193.

49. McAdams-DeMarco M.A., Law A., Salter M.L. et al. Frailty and early hospital readmission after kidney transplantation. Am J Transplant. 2013. 13(8):2091-2095.

50. Bennett P.N., Hussein W., Matthews K. et al. An exercise program for peritoneal dialysis patients in the United States (PDEx): a feasibility study. Kidney Med. 2020. 2:267-275.

51. Manfredini F., Mallamaci F., D’Arrigo G. et al. Exercise in patients on dialysis: a multicenter, randomized clinical trial. J Am Soc Nephrol. 2017. 28(4):1259-1268.

52. Kang S.H., Do J.Y., Jeong H.Y. et al. The clinical significance of physical activity in maintenance dialysis patients. Kidney Blood Press Res. 2017. 42(3):575-586.

53. Cheng Y.Y., Wong Y.F., Chu B.Y., et al. Rehabilitating a dialysis patient. Perit Dial Int. 2003. 23(2_suppl):81-83.

54. Artom M., Moss-Morris R., Caskey F. et al. Fatigue in advanced kidney disease. Kidney Int. 2014. 86(3):497-505.

55. Lo C.Y., Li L., Lo W.K. et al. Benefits of exercise training in patients on continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1998. 32(6):1011-1018.

56. Straub C.K., Murphy S.O., Rosenblum R. Exercise in the management of fatigue in patients on peritoneal dialysis. Nephrol Nurs J. 2008. 35(5):469-475.

57. Smart N.A., Williams A.D., Levinger I. et al. Exercise & sports science Australia (ESSA) position statement on exercise and chronic kidney disease. J Sci Med Sport. 2013. 16(5):406-411.

58. Nataatmadja M., Evangelidis N., Manera K.E. et al. Perspectives on mental health among patients receiving dialysis. Nephrol Dial Transplant. 2021. 36(7):1317-1325.

59. Bohm C., Schick-Makaroff K., MacRae J.M. et al., eds. The role of exercise in improving patient-reported outcomes in individuals on dialysis: a scoping review. Semin Dial. Wiley Online Library. 2019.

60. Hargrove N., El Tobgy N., Zhou O. et al. Effect of aerobic exercise on dialysis-related symptoms in individuals undergoing maintenance hemodialysis: a systematic review and meta-analysis of clinical trials. Clin J Am Soc Nephrol. 2021. 16(4):560-574.

61. Thangarasa T., Imtiaz R., Hiremath S. et al. Physical activity in patients treated with peritoneal dialysis: a systematic review and meta-analysis. Can J Kidney Health Dis. 2018. 5:2054358118779821.

62. Mustata S., Groeneveld S., DavidsonW. et al. Effects of exercise training on physical impairment, arterial stiffness and healthrelated quality of life in patients with chronic kidney disease: a pilot study. Int Urol Nephrol. 2011. 43(4):1133-1141.

63. Maughan R.J., Burke L.M., Dvorak J. et al. IOC consensus statement: dietary supplements and the high-performance athlete. Int J Sport Nutrit Exercise Metab. 2018. 28(2):104-125.

64. Lo W.K. Metabolic syndrome and obesity in peritoneal dialysis. Kidney Res Clin Prac. 2016. 35(1):10-14.

65. Quero M., Comas J., Arcos E. et al. Impact of obesity on the evolution of outcomes in peritoneal dialysis patients. Clin Kidney J. 2021. 14(3):969-982.

66. National Kidney Foundation. Staying fit with kidney disease. 2013. Available from: https://www.kidney.org/sites/default/files/11-10-0502_IBD_stayfit.pdf (accessed 1 July2021).

67. Khan S.F., Ronco C., Rosner M.H. Counteracting the metabolic effects of glucose load in peritoneal dialysis patients; an exercise-based approach. Blood Purif. 2019. 48(1):25-31.

68. World Health Organization. Physical Activity. 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/physical-activity (accessed 1 July 2021).