Clinical Practice Guideline: Exercise and Lifestyle in Chronic Kidney Disease

This Guidelines summary covers exercise and lifestyle management of people with non-dialysis chronic kidney disease (CKD) and kidney transplant recipients (KTRs). Physical activity recommendations comprise the majority of this guideline.

Refer to the full guideline for a complete set of recommendations including for haemodialysis patients.

Non-dialysis Chronic Kidney Disease

Physical Activity and Exercise

• Physical activity should be encouraged in the non-dialysis CKD population without contraindications and with stable, controlled comorbidities
• Non-dialysis CKD patients should follow the UK Chief Medical Officers’ Physical Activity Guidelines (2019), slightly adapted for this population:
  • non-dialysis CKD patients should:
    • participate in daily physical activity. Some physical activity is better than none
    • maintain or improve their physical function by undertaking activities aimed at improving or maintaining muscle strength, balance, and flexibility on at least 2 days a week
    • aim to accumulate 150 minutes of moderate-intensity aerobic activity per week, building up gradually from current levels. Those who are already regularly active can achieve these benefits through 75 minutes of vigorous intensity activity per week, or a combination of moderate and vigorous activity
    • break up prolonged periods of being sedentary with light activity when physically possible, or at least with standing
• Increasing physical activity or exercise levels in non-dialysis CKD patients will contribute to the following:
  • improvements in blood pressure
  • improvements in physical function and capacity
  • improvements in functional limitations
  • improvements in health-related quality of life
• Exercise may improve mental wellbeing, for example, symptoms of depression and anxiety
• A prescribed combination of aerobic and muscle strengthening should be utilised to improve muscle function
• Physical activity should be monitored through the use of a validated physical activity questionnaire, such as the General practice physical activity questionnaire (GPPAQ)—a NICE-recommended survey to help identify those inactive and in need of support—or the Physical Activity Vital Sign (PAVS; endorsed by the American College of Sports Medicine [acsm.org] Exercise is Medicine®).

Points for Implementation

• Healthcare professionals in renal settings should be aware of local exercise prescription policies and other localised physical activity referral programmes, to be able to refer patients to these services
• Regular conversations about exercise should be held with patients during their clinical visits to raise awareness of the benefits of exercise
• Non-dialysis CKD patients should aim to minimise the amount of time spent being sedentary, and when physically possible should break up long periods of inactivity with at least light physical activity
• Physical activity can comprise general work- or leisure-time physical activities, structured exercise, or sport, as appropriate
• When possible, exercise should be supervised for greatest compliance and efficacy by an appropriately trained individual (for example, physiotherapist, sport scientist, cardiac rehabilitation specialist, or an assistant physiotherapist/dietitian/nurse with additional training from one of the former groups), particularly in patients with complex medical comorbidities. However, lack of access to trained individuals should not prevent facilitating patients to increase their physical activity.

Weight Management 

• Anthropometrics should be measured and monitored (self-monitored if necessary) at regular intervals in individuals with non-dialysis CKD
• Multi-professional weight management services should be available to all non-dialysis CKD patients, with referral made to tier 3 services (in line with regional referral pathways) where appropriate (for example, when notable changes to anthropometrics are observed).

Other Lifestyle Considerations (Smoking, Alcohol Intake, Drug Use)

• Individuals diagnosed with non-dialysis CKD (stages 1–4) should stop smoking
• Alcohol consumption should be within national guidelines
• Individuals should avoid all recreational drug use.

For recommendations for haemodialysis patients, refer to the full guideline.

Transplantation

Physical Activity and Exercise

• General physical activity should be encouraged in kidney transplant recipients (KTRs) without contraindications
• Sufficient physical activity, pre- and post-transplant, can reduce all-cause and cardiovascular mortality
• KTRs should aim for 150 minutes of moderate to vigorous physical activity a week (or 75 minutes of vigorous physical activity), as per the UK Chief Medical Officers’ Guideline
• Individual barriers and activators to physical activity need to be identified and addressed to optimise programme uptake and adherence
• Structured exercise should be considered as a method of:
  • enhancing cardiorespiratory fitness
  • enhancing muscular strength and physical function
  • improving health-related quality of life and increasing high-density lipoprotein levels
• Structured exercise alone is not sufficient to attenuate increases in body mass following transplantation; a multi-professional approach to appropriate weight management strategies is suggested
• Structured exercise should be performed at least three times per week in KTRs without contraindications
• KTRs without contraindications should undertake both aerobic and resistance exercise to maximise the effects on exercise capacity and muscle function
• A structured exercise routine should be devised (and supervised if possible) by appropriately trained staff
• Exercise programmes should be individualised based on underlying patient goals/expectations, pathophysiology, level of experience, and graft status
• Healthcare professionals should take the opportunity, whenever possible, to identify inactive patients and levels of physical activity should be routinely checked. This could be by simply asking the patient about their activity levels or via a formal validated screening tool such as the PAVS (endorsed by the American College of Sports Medicine [www.acsm.org] Exercise is Medicine®). The PAVS consists of two questions:
  • ‘On average, how many days per week do you engage in moderate to strenuous exercise like a brisk walk?’
  • ‘On average, how many minutes do you engage in exercise at this level?’
• The PAVS is highly associated with decreased levels of body mass index (BMI) and odds of obesity and has been tested for face and discriminant validity
• Alternatively, physical activity status may be assessed by the GPPAQ—a NICE-recommended survey to help identify those inactive and in need of support. All patients who receive a score of less than ‘active’ should be provided with appropriate advice to increase their physical activity levels or offered a brief intervention in physical activity in line with the NICE guidance
• Healthcare professionals should help patients identify their circumstances, preferences, and barriers to being physically active. The NICE guideline, Physical activity: brief advice for adults in primary care has recommendations on how to deliver and follow up on brief physical activity advice.

Implementing Physical Activity and Exercise Guidance

• The following guidance is suggested for implementation of physical activity and exercise in KTRs:
  • KTRs should be encouraged to follow current UK general physical activity guidelines (150 minutes [2.5 hours]) of moderate (such as brisk walking or cycling) to vigorous (such as running) physical activity a week (or 75 minutes of vigorous physical activity) relevant for their age:
    • nhs.uk/live-well/exercise
    • gov.uk/government/collections/physical-activity-guidelines
  • KTRs should aim to minimise the amount of time spent being sedentary, and when physically possible should break up long periods of inactivity with at least light physical activity
  • physical activity can comprise of general leisure-time physical activities, structured exercise, or sport, if appropriate
  • exercise should be supervised for greatest compliance and efficacy by an appropriately trained individual (for example, physiotherapist [including specialist renal if available], sport scientist, cardiac rehabilitation specialist, or an assistant physiotherapist/dietitian/nurse with additional training from one of the former groups)
  • aerobic exercise should be performed at an intensity of more than 60% of maximum (either based on heart rate or VO₂ peak) in KTRs without contraindications
  • resistance training, comprising of upper and lower body components, should be performed at an intensity of more than 60% one-repetition maximum at least two times per week in KTRs without contraindications
  • exercise volume, both aerobic and resistance in nature, should be progressed gradually by adjusting duration, frequency, and/or intensity until the desired exercise goal (maintenance) is attained
  • exercise should be followed by cooldown activities (for example, exercising for a minimum of 5 minutes, starting at one half of prescribed training intensity and gradually decreasing intensity until exercise is stopped)
  • to maintain exercise behaviour, behavioural strategies such as social support, goal setting of outcomes, instruction (modelling) of exercise behaviours, and motivational interviewing should be implemented
  • provide information about local opportunities to be physically active for patients with a range of abilities, preferences, and needs.

Prehabilitation for Transplantation

• Exercise interventions prior to surgery (prehabilitation) may help increase pre-transplant physical activity levels and aid recovery post-transplant.

For immediate post-transplantation period recommendations, refer to the full guideline.

Safety and Contraindications

• KTRs should avoid traumatic damage to the transplanted kidney and participation in contact sports (for example, rugby, American football, martial arts, ice hockey, boxing) and/or prolonged extreme exercise (for example, marathons, Ironman triathlons) must be considered carefully
• KTRs should avoid the use of sport-enhancing dietary supplements, given the largely unknown potential adverse effects on immune function and potential for unregulated components.

Weight Management

• Regular anthropometric measurements should be taken to assess changes in body composition
• Candidates and KTRs should have their body mass (and BMI) accurately examined by a healthcare professional at the time of evaluation and while on the waiting list
• It is recommended not to exclude candidates based on BMI alone
• Potential recipients, not on dialysis, with a BMI greater than 35 kg/m² should be actively supported to lose weight via appropriate interventions
• Multi-professional weight management services should be available to all KTRs
• Post-transplantation, an ideal weight should be targeted (BMI less than or equal to 25 kg/m²)
• Bariatric surgery can be used to reduce BMI in those with morbid obesity (for example, BMI greater than 40 kg/m²).

Other Lifestyle Considerations (Smoking, Alcohol Intake, Drug Use)

• Smoking should be strongly discouraged in transplant recipients
• Alcohol consumption should be within national guidelines
• KTRs should avoid all recreational drug use.