Patients who suffering with Covid-19 virus are highly benificial by getting physicaltherapy Treatment. Physicaltheapy perform specialized exercises for lungs and peform hihly skilled prone position exercises by using postural drainage techniqes.

Oxygen transport from the lungs to body tissues can be limited in patients with an ineffective cough or an impairment of normal mechanisms of mucociliary clearance. An array of techniques for assisting the mobilization of airway secretions is available for patients and caregivers to augment a patient’s own mechanisms. When prescribing an optimal method of airway clearance, the caregiver must consider the pathophysiology and the clinical manifestations of the disease, the physiological basis of the method, availability of the technique to the patient, and the patient’s acceptance of the technique.

This chapter reviews the physiological basis of each airway clearance technique (ACT), the history of its use, and research on its effectiveness. An introduction to the application of these techniques to patients is presented. Also addressed are the benefits and burdens of each technique, contraindications and precautions, and practical concerns regarding patient care.

Evidence for the use of airway clearance techniques is often difficult to evaluate, in part due to agreement that top-level evidence on this topic is lacking.^1a-b The components of a given treatment have not been standardized and the literature refers to ACTs using a variety of terms, including chest physiotherapy, chest physical therapy (CPT), bronchial drainage, postural drainage (PD) therapy, and bronchial hygiene. In addition, the availability of equipment and cultural differences in its application confound research results. Differences in the outcome measures for a given technique also occur—some studies use wet or dry (dehydrated) sputum volume or radioaerosol clearance, whereas other studies use pulmonary function tests, radiographic evidence, or arterial blood gases to asses the effectiveness of a specific technique. The majority of secretion clearance research has been focused on patients with cystic fibrosis, as the need for ongoing secretion removal is apparent in this population. However, results showing a treatment to be effective in one cross section of patients must not be generalized to apply to the treatment across all patients with pulmonary disease.

Historically, the gold standard of airway clearance has been a combination of postural drainage, percussion, and vibration with cough. This has been challenged^1b-c as more techniques have been demonstrated to be effective. Postural drainage and percussion have been shown to be ineffective in some cases and, in fact, to be detrimental to pulmonary status in others. Caregivers have also been shown to suffer from the performance of percussion; repetitive-motion injuries of the wrists have been documented as a result of regular performance of percussion.^2,3

Alternative techniques have arisen out of the need to find effective methods for those patients not responsive to traditional methods. A desire to increase adherence with airway clearance, especially in patients approaching adolescence and adulthood, has led to an investigation of more independent techniques.⁴ Many of these techniques have been practiced longer in other countries, but are now commonly used by practitioners in the United States.

It is important to remember, however, that secretion clearance is just one step toward realizing effective gas exchange in the complex oxygen transport pathway.⁵ Airway clearance, when indicated, should be integrated into a comprehensive plan of care, including positioning and mobilization, to optimize oxygen transport.

Airway Clearance Techniques

Airway clearance techniques differ with respect to equipment needs, the skill level required to perform them, and their usefulness with various clinical problems. Matching a patient with an appropriate method or combination of methods may increase effectiveness, reduce complications, and promote long-term adherence to the treatment. This will, in turn, assist with achieving the goals of airway clearance: reducing airway obstruction, improving ventilation, and optimizing gas exchange.

Preparation for any secretion removal technique should include evaluation of the patient’s pulmonary status so that measures may be compared before and after a treatment is provided. A physical examination, including inspection, palpation, measurement of vital signs, and chest auscultation, provides assessment of a treatment’s effectiveness. Other outcome measures include chest radiographs, arterial blood gas measurements, and pulmonary function studies. An adequate intake of fluids (as allowed) decreases the viscosity of the secretions, allowing easier mobilization.

Several factors must be taken into account when scheduling an optimal time for airway clearance. At least 30 minutes to 1 hour should be allowed for the completion of tube feedings or meals. The inhalation of bronchodilator medications should take place before airway clearance maneuvers to improve secretion removal by opening the airways. Inhaled antibiotics are best scheduled after airway clearance has taken place for optimal deposition of medication. If necessary, adequate pain control should be provided to receive a patient’s best effort and cooperation with a treatment.

Exercise for Airway Clearance

In addition to improving many outcomes in patients with lung disease, exercise has been shown to assist in secretion clearance.^25-28 Exercise increases mucociliary transport in patients with chronic bronchitis.²⁸ Higher transpulmonary pressure with aerobic exercise may open closed bronchi, as well as increase collateral ventilation to allow mucus to be moved.²⁶ It has also been shown that exercise-induced hyperventilation is more effective than eucapnic hyperventilation in mobilizing bronchial secretions.²⁹ The contribution of increased expiratory airflow and exercise-induced coughing are other factors in improving secretion removal. Exercise for secretion clearance has focused on aerobic or endurance exercise; however, any form of exercise must be adapted to the individual patient’s status and abilities.

Based on a lack of decrease in lung function following the cessation of PD and percussion but the continuation of an exercise program, or based on the improvement in pulmonary function, exercise has been recommended as a replacement for a conventional chest physiotherapy routine in some patients or at some stages of lung disease.^26,27,30,31 In hospitalized patients with cystic fibrosis, no significant change in pulmonary function was reported when exercise was substituted for two of three daily treatments of PD, percussion, and vibration, and the weight of the sputum produced was equivalent.³⁰ In terms of mucus cleared, no significant differences were found among exercise on a cycle ergometer, postural drainage, and PEP mask breathing.³² Increases in sputum expectoration on exercise days as opposed to nonexercise days have also been reported.^27,33

However, other studies conclude that exercise alone is not sufficient and recommend its use as a complement to other forms of airway clearance. Airway clearance using PD and FET was shown to be more effective than exercise with a cycle ergometer in inducing sputum expectoration.³⁴ Results from Bilton and colleagues³⁵ demonstrated that any modality that included the active cycle of breathing technique (ACBT) in PD positions alone or in combination with exercise is better than exercise alone at clearing sputum.

It is difficult to compare these studies, however, because the mode and length of exercise differ, as do the outcome measures of effectiveness of airway clearance. Exercise as an airway clearance technique is not suitable for the very young (younger than 4 to 5 years of age), for patients with neuromuscular limitations, or for patients with limited exercise tolerance. Moreover, the potential need for supplemental oxygen during exercise should be monitored. Nonetheless, evidence suggests that an exercise program, in addition to clearing secretions, may decrease morbidity and mortality by improving exercise capacity.^36,37

Treatment with Exercise

A walking program requires only a suitable pair of shoes and a safe location. Higher-impact exercise, because of increased stress on the knees, requires shoes specifically for that purpose. Clothing should be appropriate for the weather if exercising outdoors.

Exercise equipment suitable for a patient who is beginning an exercise program includes the treadmill, bicycle ergometer, elliptical trainer, mini-trampoline, or arm ergometer. For more accomplished exercisers or patients with a higher exercise tolerance, equipment may include a stair climber, cross-country ski machine, or rowing machine. Numerous other exercise equipment options are available; the patient’s interests should be the primary factor for choosing.

Tools to monitor a patient’s response to exercise include a sphygmomanometer, stethoscope, heart rate monitor, pulse oximeter, and a scale to measure patient’s level of perceived exertion (Figure 21-1). In a home setting, patients should be knowledgeable in self-monitoring exercise intensity. For those patients who require closer monitoring, a pulse oximeter may be rented from an oxygen supply company. Monitoring of vital signs before and during exercise, and during recovery, will allow titration of the workload for optimal performance.

Supplemental oxygen and oxygen delivery supplies will be necessary for those patients who exhibit oxygen desaturation during exercise.

Patients with hyperreactive airways should be premedicated with a prescribed bronchodilator before an exercise session.

The principles of an exercise prescription addressing mode, intensity, duration, and frequency, as well as principles of “warm up” and “cool down,” should be followed when using exercise as a form of airway clearance. Individualizing an exercise program for each patient is of the utmost importance.

Patients hospitalized for an acute exacerbation may not be able to initially perform endurance exercise. These patients should be started slowly and progressed as tolerated; consider using interval training.

The patient should be instructed in huffing or controlled coughing to expectorate secretions as they are loosened.

A regular, consistent program of exercise should be scheduled around the patient’s daily activities to achieve adherence (e.g., walking the dog, sports at school, stopping by the health club after work).

Advantages and Disadvantages of Exercise

Exercise has the advantage of being the only airway clearance technique that is performed regularly by people without lung disease. This factor can make it appealing to those patients who do not want to call attention to their differences from their peers. Exercise may improve self-esteem, a sense of well-being, and quality of life. Higher levels of exercise tolerance in patients with cystic fibrosis have been demonstrated to improve survival.³⁷

Some patients may not tolerate the amount or frequency of exercise necessary for this to be the sole method of airway clearance. Thus various airway clearance techniques can be used as adjuncts to exercise. This is particularly true during an acute exacerbation when activity tolerance is limited, or in infants or patients with neurological or musculoskeletal limitations. Andreasson²⁶ observed that regular contact with a caregiver seems to be necessary for successful exercise training, as does family support, especially in young children. This points out the difficulty with adherence to a home program. Adherence will also be affected by a patient’s preference for a particular activity, scheduling conflicts, and commitment by friends and family members.

Precautions for Using Exercise

Several precautions must be observed when using exercise as a form of airway clearance. Care must be taken in prescribing exercise to patients with hyperreactive airways or a tendency toward oxygen desaturation. Desaturation has been shown to occur with exercise in individuals with pulmonary disease,^38,39 and therefore it becomes prudent to monitor oxygen saturation, providing supplemental oxygen for the exercise period when indicated. Exercise-induced bronchospasm must also be considered when pulmonary compromise is seen with exercise, especially with higher-intensity exercise.⁴⁰ When medication is indicated, it is recommended to provide an inhaled bronchodilator 20 to 30 minutes before exercise to alleviate this symptom.⁴¹ Use of bronchodilator medication and supplemental oxygen may be necessary to improve exercise tolerance, but these patients require closer monitoring as well. Andreasson²⁶ reports a risk for pneumothorax associated with exercise in patients with extensive bullae.

Contraindications and Precautions for Manual and Mechanical Airway Clearance Techniques

In patients who are very young, who have limited ability to cooperate, or who are not adherent to other ACTs, percussion, shaking, and vibration offer methods for dislodging retained secretions. However, because of the force transmitted to the thoracic cage with these techniques, there are many precautions and contraindications to consider. The therapist should not make this decision alone but should seek direction from the medical team. These treatments are not completely benign and should not be performed in the absence of good indications.⁴²

Percussion has been shown to contribute to a fall in PaO₂ in acutely ill patients,⁴³ especially in patients with cardiovascular instability⁴⁴ and in neonates.⁴⁵ The factor that seems most closely associated with or predictive of this effect is the patient’s baseline PaO₂.⁴² Cardiac dysrhythmias have been associated with chest percussion for bronchial drainage¹¹ and Huseby⁴⁶ hypothesizes that hypoxemia may be the underlying mechanism of CPT-caused cardiac arrhythmias.

Patients with hyperreactive airways (e.g., asthma) show intolerance for percussion as part of airway clearance. Campbell and colleagues⁴⁷ demonstrated a fall in FEV₁ associated with percussion; it was not evident when percussion was omitted. Administration of a bronchodilator before treatment with percussion precluded the fall in FEV₁. Wheezing has also been associated with percussion and vibration in patients with cystic fibrosis and COPD.^48,49

Box 21-1 summarizes the precautions and contraindications for external manipulation of the thorax associated with percussion, shaking, and high-frequency chest compression. Vibration involves less force to the thorax and may be better tolerated than the aforementioned techniques. A nebulized bronchodilator may be administered during a treatment of high-frequency chest compression to avoid the consequences of hyperreactive airways. Box 21-1 Contraindications to External Manipulation of the Thorax in Addition to Contraindications for Postural Drainage

Subcutaneous emphysema

Recent epidural spinal infusion or spinal anesthesia

Recent skin grafts or flaps on the thorax

Burns, open wounds, and skin infections of the thorax

Recently placed pacemaker

Suspected pulmonary tuberculosis

Lung contusion

Bronchospasm

Osteomyelitis of the ribs

Osteoporosis

Coagulopathy

Complaint of chest-wall pain

Additional contraindications for percussion of a neonate

Intolerance to treatment as indicated by low oxygen saturation values

Rib fracture

Hemoptysis From AARC Clinical Practice Guideline: Postural drainage therapy, Respiratory Care 36:1418-1426, 1991; and Crane L: Physical therapy for the neonate with respiratory disease. In Irwin S, Tecklin JS, editors: Cardiopulmonary physical therapy, St. Louis, 1985, Mosby.

Postural Drainage

Postural drainage, also known as bronchial drainage, is a passive technique in which the patient is placed in positions that allow gravity to assist with the drainage of secretions from the bronchopulmonary tree. PD is accomplished by positioning the patient so that the angle of the lung segment to be drained allows gravity to have its greatest effect (Figure 21-2). Positioning the patient to assist the flow of bronchial secretions from the airways has been a standard treatment for some time in patients with retained secretions.⁵⁰

Knowledge of the anatomy of the tracheobronchial tree is vital to effective treatment. Each lobe to be drained must be aligned so that gravity can mobilize the secretions from the periphery to the larger, more central airways. The mechanism of postural drainage is considered to be a direct effect of gravity on bronchial secretions, although observations made by Lannefors (1992)³² that gravity also influences regional lung ventilation and volume suggest that these mechanisms are also involved.

PD has been shown to be effective in mobilizing secretions in patients with cystic fibrosis,^51,52 bronchiectasis,¹⁰ and other pulmonary diseases.^53,54 Other treatments, such as percussion, vibration, and the active cycle of breathing technique (ACBT), may be used while the patient is in postural drainage positions.

There are, however, many contraindications to gravity-enhancing positioning for PD. Recent studies have reported adverse effects of head-down or Trendelenburg positions required for the lower lobes. Modified positions should be used for head-down positions unless it has been shown to be effective in a particular patient. The head of the bed should remain flat instead of being tipped into the Trendelenburg (head down) position.

Preparation for Postural Drainage

For the hospitalized patient, electric beds allow patients to be positioned more easily. Air therapy beds, most often used in the intensive care unit (ICU), are valuable aids for positioning, especially in patients who are large or unresponsive.

In the ICU, it is imperative to be familiar with the multiple lines, tubes, and other devices attached to the patient (see Chapter 16). Allow enough slack from each device to position a patient for postural drainage.

Ensure there are enough staff members to position the patient with as little stress to both patient and staff as possible.⁵⁵

For treatment in the clinic, have foam wedges or pillows available for positioning.

For home treatment, aids in positioning might include pillows, sofa cushions, or a bean-bag chair.

Nebulized bronchodilators or mucolytics before PD may facilitate the mobilization of sputum.

For the patient with an adequate cough to expectorate secretions, have tissues or a specimen cup available. Have suctioning equipment ready to remove secretions from an artificial airway or the patient’s oral or nasal cavity after the treatment. Refer to Chapter 43 for a discussion of suctioning.

Treatment with Postural Drainage

After determining the lobe of the lung to be treated by auscultation and chest x-ray, position the patient in the appropriate position, supporting the patient comfortably in the position indicated (see Figure 21-2).

If postural drainage is used exclusively, each position should be maintained for 5 to 10 minutes, if tolerated, or longer when focusing on a specific lobe. Coordinating the positioning with nursing care for skin pressure relief may allow the time spent in a position to be extended. If postural drainage is used in conjunction with another technique, the time in each position may be decreased. For example, if percussion and vibration are performed while the patient is in each PD position, 3 to 5 minutes is sufficient.

A patient who requires close monitoring should not be left unattended, but this may be appropriate if a patient is alert and able to reposition himself or herself.

It is not always necessary to treat each affected lung segment during every treatment; this may prove to be too fatiguing for the patient. The most affected lobes should be addressed with the first treatment of the day, with the other affected areas addressed during subsequent treatment(s).

The patient should be encouraged to take deep breaths and cough after each position, if possible, and again after the treatment is completed. Having the patient sit upright or lean forward optimizes this effort by allowing the use of the abdominals for a stronger cough.⁵⁵

Mobilization of secretions may not be apparent immediately after the treatment, but this may occur up to 1 hour later. The patient should be thus informed and reminded to clear secretions at a later time. A health care practitioner or family member should be included in this aspect of treatment, especially with patients who need encouragement.⁵⁵

Advantages and Disadvantages of Postural Drainage

Postural drainage is relatively easy to learn; the patient and/or caregiver must be familiar with the appropriate positioning for the affected lung fields. Treatment in the hospital may be coordinated with other patient activities, such as positioning for skin pressure relief, bathing, or positioning for a test or procedure. Home treatment can be coordinated with activities such as reading or watching television.

For many patients, optimal PD positions will be contraindicated for a variety of reasons and modified positions should be used. Adherence to PD may be a challenge because of the length of the treatment; this is especially challenging in the pediatric population, who will require considerable distraction to maintain a desired position for the appropriate length of time. Children who are able to role-play the treatment—for instance, with a doll or stuffed toy—may better understand what is expected and be more cooperative with therapy.

The cost of the equipment required for PD is minimal. The cost of a caregiver’s time to provide the treatment, however, especially in the case of a chronic disease, may be substantial. A family member should be taught the procedure, if possible, to decrease the cost and provide flexibility in scheduling.

General Precautions and Contraindications to Postural Drainage Positioning

It is essential that the therapist and the health care team discuss treatment priorities when deciding to use PD positions. A decision to use postural drainage might be made despite a contraindication if the benefits are thought to outweigh the risks in a particular case. For example, it is known that use of the Trendelenburg (head-down) position increases intracranial pressure in patients after neurosurgery.⁵⁶ However, if the patient develops atelectasis, the stress of respiratory embarrassment may also increase intracranial pressure. In this instance, the decision may be made to position the patient to clear the atelectasis and subsequently return to a modified conservative regimen.⁵⁵

A fall in arterial O₂ saturation has been reported with the use of postural drainage for airway clearance, although the effects of PD were not separated from additional techniques.^46,57 Therefore O₂ saturation levels should be monitored during treatment, especially in patients with known low PaO₂ values.

Caution must also be used in treating a patient with end-stage lung disease in postural drainage positions because of the risk for hemoptysis.^58,59 Decreased cardiac output^60,61 has been associated with chest physiotherapy treatment; however, the effects of postural drainage were not separated from those of percussion and vibration.

Many physical therapists working with the pediatric population almost never use the head-down position in treating infants but rather a modified routine that excludes the Trendelenburg position. The head-down position has been shown to increase the incidence of gastroesophageal reflux in neonates.¹⁶ Button and colleagues⁶² found that the head-down position is associated with gastroesophageal reflux, distressed behavior, and lower oxygen saturation in infants with cystic fibrosis. It should be noted that a finding of gastroesophageal reflux can occur even 1 hour after treatment. A modified routine that eliminates head-down positioning is associated with fewer respiratory complications.⁶³ Box 21-2 summarizes the precautions and contraindications concerning postural drainage. Box 21-2 Contraindications for Postural Drainage

All Positions Are Contraindicated for the Following

Intracranial pressure (ICP) >20 mm Hg

Head and neck injury until stabilized

Active hemorrhage with hemodynamic instability

Recent spinal surgery (e.g., laminectomy) or acute spinal injury

Active hemoptysis

Empyema

Bronchopleural fistula

Pulmonary edema associated with heart failure (HF)

Large pleural effusions

Pulmonary embolism

Older, confused, or anxious patients

Rib fracture, with or without flail chest

Surgical wound or healing tissue

Trendelenburg Position Is Contraindicated for the Following

Patients in whom increased ICP is to be avoided

Uncontrolled hypertension

Distended abdomen

Esophageal surgery

Recent gross hemoptysis related to recent lung carcinoma

Uncontrolled airway at risk for aspiration

Trendelenburg Position Is Contraindicated for the Following Cases in Neonates

Untreated tension pneumothorax

Recent tracheoesophageal fistula repair

Recent eye or intracranial surgery

Intraventricular hemorrhage (grades III and IV)

Acute heart failure or cor pulmonale From AARC Clinical Practice Guideline: Postural drainage therapy, Respiratory Care 36:1418-1426, 1991; and Crane L: Physical therapy for the neonate with respiratory disease. In Irwin S, Tecklin JS, editors: Cardiopulmonary physical therapy, St. Louis, 1985, Mosby.

Percussion

Percussion, sometimes referred to as chest clapping, is a traditional approach to secretion mobilization. A rhythmical force is applied with a caregiver’s cupped hands against the thorax, over the involved lung segments, trapping air between the patient’s thorax and the caregiver’s hands (Figure 21-3), with the aim of dislodging or loosening bronchial secretions from the airways so they may be removed by suctioning or expectoration. This technique is performed during both the inspiratory and expiratory phases of breathing. Percussion is used in postural drainage positions for increased effectiveness64,65 and may also be used during ACBT. For individuals with pulmonary disease, percussion in conjunction with postural drainage continues to be a mainstay of the treatment, especially for pediatric patients and patients who are unresponsive.

The proposed mechanism of action of percussion is the transmission of a wave of energy through the chest wall into the lung. This wave loosens secretions from the bronchial wall and moves them proximally, where ciliary motion and cough (or suction) can remove them. The combination of postural drainage and percussion has been shown to be effective in secretion removal.^66-68

A handheld mechanical percussor can be used by a caregiver to minimize fatigue or may be used by the patient to self-administer percussion. The effectiveness of mechanical as opposed to manual percussion has been studied. Maxwell and Redmond⁶⁹ found mechanical percussion equivalent to manual percussion in effecting removal of secretions. Although there was a significant increase in pulmonary function with manual techniques, Pryor and colleagues^70,71 supported the use of mechanical percussion in patients, using the forced expiration technique. A study by Rossman and colleagues⁷² was in disagreement, finding that mechanical percussion did not enhance postural drainage in secretion removal.

There are contraindications to percussion. If a patient’s pulmonary status is of greater concern than the relative contraindications, a decision may be made to administer the treatment, with appropriate modifications.

Preparation for Percussion

The only equipment required for manual percussion is the caregiver’s cupped hands to deliver the force to mobilize secretions.

For the adult and older pediatric population, electric or pneumatic percussors that mechanically simulate percussion are available. This enables a patient to apply self-percussion more effectively. Several models have variable frequencies of percussion, as well as different levels of intensity.

Several devices, including padded rubber nipples, pediatric anesthesia masks, padded medicine cups, or the bell end of a stethoscope may be used to provide percussion to infants whose chest walls are too small to accommodate the size of an adult’s hand.

Placing the patient in appropriate PD positions (as the patient’s condition allows) enhances the effect of percussion.

A thin towel or hospital gown should cover the patient’s skin where the percussion is to be applied. The force of percussion over bare skin may be uncomfortable; however, padding that is too thick absorbs the force of the percussion without benefit to the patient.

Adjust the level of the bed so that the caregiver may use proper body mechanics during the treatment. The caregiver may become excessively fatigued or injured as a result of lengthy or numerous treatments if proper body mechanics are ignored.

Treatment with Percussion

Position the hand in the shape of a cup with the fingers and thumb adducted. It is important to maintain this cupped position with the hands throughout the treatment, while letting the wrists, arms, and shoulders stay relaxed.

The sound of percussion should be hollow as opposed to a slapping sound. If erythema occurs with percussion, it is usually a result of slapping or not trapping enough air between the hand and the chest wall.⁷³

The patient will better tolerate an even, steady rhythm. The rate of manual percussion delivered by caregivers can vary between 100 and 480 times per minute.⁷³

The force applied to the chest wall from each hand should be equal. If the nondominant hand is not able to keep up with the dominant hand, the rate should be slowed to match that of the slower hand. It might be helpful to start with the nondominant hand and let the dominant hand match the nondominant hand.⁵⁵ The force does not have to be excessive to be effective; the amount of force should be adapted to the patient’s comfort.

If the size of an infant does not allow use of a full hand, percussion may be done manually with four fingers cupped, three fingers with the middle finger “tented,” or the thenar and hypothenar surfaces of the hand.⁷⁴

Hand position should be such that percussion does not occur over bony prominences of the patient. The spinous processes of the vertebrae, the spine of the scapula, and the clavicle should all be avoided. Percussion over the floating ribs should also be avoided because these ribs have only a single attachment.

Percussion should not be performed over breast tissue. This will produce discomfort and diminish the effectiveness of the treatment. In the case of very large breasts, it may be necessary to move the breast out of the way with one hand (or ask the patient to do this) and percuss with the other hand.

A patient may be taught to perform one-handed self-percussion to those areas that can be reached comfortably, either manually or with a mechanical percussor. This does, however, virtually preclude the treatment of the posterior lung segments.

Advantages and Disadvantages of Percussion

The addition of percussion to a PD treatment may enhance secretion clearance and shorten the treatment. Patients, especially young children and infants, often find the rhythm soothing and are relaxed and sedated by percussion.

Patients with chronic lung disease who have used PD and percussion for many years and have found it effective may be reluctant to try an alternative method of airway clearance. Acceptance of this method is dependent on the consistent availability of a family member or other caregiver to provide the treatment. Mechanical percussors allow a patient more independence or decrease fatigue of a caregiver, and they are especially useful in patients requiring ongoing treatment at home.

Percussion is not well tolerated by many patients postoperatively without adequate pain control. The force of percussion may also be contraindicated in patients with osteoporosis or coagulopathy. Percussion has been associated with a fall in oxygen saturation, which can be eliminated with concurrent thoracic expansion exercises and pauses for breathing control.⁷⁵

Delivering percussion for extended periods on an ongoing basis can result in injury to the caregiver, whether a family member or a health care provider; repetitive motion injuries of the upper extremities may occur in long-term delivery of percussion for airway clearance.

The expense of a mechanical device for percussion is minimal compared with the ongoing cost of a caregiver to provide percussion and PD, either in the hospital setting or at home. In the case of young children or unresponsive patients, there are few choices for airway clearance. For other populations, however, a more independent method can prove to be more cost-effective if adequate adherence is achieved.

Vibration and Shaking

The techniques of vibration and shaking are on opposite ends of a spectrum. Vibration involves a gentle, high-frequency force, whereas shaking is more vigorous in nature. Vibration is delivered through a sustained co-contraction of the caregiver’s upper extremities to produce a vibratory force while applying pressure to the chest wall over the involved lung segment. Shaking is similar in application to vibration, and is described as a bouncing maneuver, sometimes referred to as “rib springing,” supplying a concurrent, compressive force to the chest wall. Like percussion, vibration and shaking are used in conjunction with PD positioning. Unlike percussion, they are performed only during the expiratory phase of breathing, starting with peak inspiration and continuing until the end of expiration. The compressive forces follow the movement of the chest wall. Both techniques require the assistance of a caregiver, but a mechanical vibrator may be used in place of manual vibration.

It is proposed that vibration and shaking enhance mucociliary transport from the periphery of the lung fields to the larger, central airways. Because the compressive force to the thorax is greater with shaking than vibration, it produces increased chest wall displacement, and the stretch of the respiratory muscles may produce an increased inspiratory effort and lung volume.⁷⁶ The same relative contraindications for percussion should be observed for shaking, because it involves the application of force to the thorax.

Pavia⁷⁷ demonstrated a higher, though not statistically significant, rate of secretion clearance and sputum production with vibration. However, this study was conducted while subjects were in the upright position only, which does not replicate the use of vibration clinically. Many studies do not separate the effects of vibration from the components of PD and percussion because they are often used in conjunction. In fact, many studies describe the techniques of PD, percussion, and vibration or shaking as a single entity and refer to the treatment as chest physical therapy or postural drainage therapy. Mackenzie and colleagues⁷⁸ demonstrated significant improvement in total lung/thorax compliance after treatment with postural drainage, percussion, and vibration in mechanically ventilated patients. Feldman and colleagues⁴⁸ demonstrated improved ventilatory function by improved expiratory flow rates in patients receiving postural drainage, percussion, vibration, and directed coughing.

Preparation for Vibration and Shaking

For manual techniques, the caregiver’s hands are the only “equipment” required.

Mechanical vibrators are available to administer the treatment and are useful for self-treatment by a patient or to reduce fatigue in the caregiver.

For infants, a padded electric toothbrush may be used.⁷⁴

Place the patient in the appropriate PD position or modified position, as the patient’s status allows.

Place a thin towel or hospital gown over the patient’s skin. The material should not be thick enough to absorb the effect of the vibration or shaking.

Proper body position of the caregiver is important to deliver an effective treatment and to decrease caregiver fatigue.

Treatment with Vibration and Shaking

For vibration, the hands may be placed side by side or on top of each other, as shown in Figure 21-4. As with shaking, the patient is instructed to take in a deep breath while in a proper PD position. A gentle but steady co-contraction of the upper extremities is performed to vibrate the chest wall, beginning at the peak of inspiration and following the movement of chest deflation. The frequency of manual vibration is between 12 and 20 Hz.44,53

For shaking, with the patient in the appropriate PD position, place your hands over the lobe of the lung to be treated and instruct the patient to take in a deep breath. At the peak of inspiration, apply a slow (approximately 2 times per second), rhythmic bouncing pressure to the chest wall until the end of expiration. The hands follow the movement of the chest as the air is exhaled. The frequency of shaking is 2 Hz.^44,53

If the patient is mechanically ventilated, the previously described techniques needs to be coordinated with ventilator-controlled exhalation.

If the patient has a rapid respiratory rate, either voluntary or ventilator-controlled, it may be necessary to apply vibration or shaking only during every other exhalation.

A mobile chest wall is necessary to apply a compressive force without causing discomfort. If a patient has limited chest wall compliance, vibration will probably be better tolerated than shaking.

Mechanical vibrators may be used by the unattended patient, although only limited attention can be paid to the posterior portions of the lungs.

Advantages and Disadvantages of Vibration and Shaking

The use of vibration and/or shaking in addition to PD may enhance the mobilization of secretions. Shaking or vibration may be better tolerated than percussion, especially in the postsurgical patient. Manual vibration and shaking allows the caregiver to assess the pattern and depth of respiration. The stretch on the muscles of respiration during expiration may encourage a deeper subsequent inspiration. A mechanical vibrator, more commonly used with pediatric patients, may be preferable for delivery of airway clearance in the long-term.

The patient cannot apply these techniques without assistance, except in a limited manner with a mechanical vibrator, so adherence and regular administration of vibration depends on caregiver availability.

The same contraindications for percussion apply because shaking and vibration involve compression to the thorax. The technique of vibration is less constrained by these contraindications than is shaking.

Manual Hyperinflation

The technique of manual hyperinflation was used more commonly in the past for patients requiring mechanical ventilation. However there is not enough evidence to promote the regular use of this technique that has many contraindications and that is not well known in the United States.⁸⁰ A brief description of the technique and its precautions follows. Two caregivers are needed to perform the technique with the patient placed in PD positions.⁷⁹ One caregiver uses a manual inflation bag to hyperinflate the lungs with a slow, deep inspiration and, after a short pause, provides a quick release to allow rapid exhalation. A second caregiver applies shaking or vibration at the beginning of exhalation to mobilize secretions. The technique is promoted to mobilize secretions and reinflate collapsed areas of the lung and is likened to simulating a cough—deep inspiration, pause, and forceful exhalation.

Clement⁸⁰ reported that this method of airway clearance enabled patients to be maintained on ventilators for long periods while retaining normal lung function. It was also demonstrated that the addition of positioning and vibrations enhanced the treatment of atelectasis by hyperinflation and suctioning.⁸¹

Scientists advised President Trump we need to do more testing before opening the country, we cannot just open up everything, that will put us in more dangerous conditions.

According to CDC.COM, USA is one among the top in list who is having COVID -19. local leaders are recommending more testing before opening up or easing social distancing guidelines.

At the briefing, Trump said he plans to speak to governors on Thursday “and we will have some information on some openings. I would say we have 20 states, but probably 29, that are in really good shape. We miss sports, we miss everything. We want to get our country open again. “

Deborah Birx, MD, the coronavirus task force response coordinator, said social distancing has to continue despite some progress in reducing the spread of the coronavirus. Birx said they will look at states and metropolitan areas individually as they come up with the new guidelines, which are expected to be announced Thursday.

Coronavirus Disease 2019 (COVID-19)

Most people who get sick with COVID-19 will have only mild illness and should recover at home.* Care at home can help stop the spread of COVID-19 and help protect people who are at risk for getting seriously ill from COVID-19.

*Note: Older adults and people of any age with certain serious underlying medical conditions like lung disease, heart disease, or diabetes are at higher risk for developing more serious complications from COVID-19 illness and should seek care as soon as symptoms start.

COVID-19 spreads between people who are in close contact (within about 6 feet) through respiratory droplets produced when an infected person coughs, sneezes, or talks. Recent studies indicate that people who are infected but do not have symptoms likely also play a role in the spread of COVID-19.

If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*:

• Trouble breathing
• Persistent pain or pressure in the chest
• New confusion or inability to arouse
• Bluish lips or face

*This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning.

Watch for symptoms

Reported illnesses have ranged from mild symptoms to severe illness and death for confirmed coronavirus disease 2019 (COVID-19) cases.

These symptoms may appear 2-14 days after exposure (based on the incubation period of MERS-CoV viruses).

• Fever
• Cough
• Shortness of breath

Rehabilitation Services for Elderly DialysisPatientsSarbjit Vanita JassalDivision of Nephrology, University Health Network, Toronto, CanadaBased on recent data, Canadians starting dialysisbetween the ages of 75 and 79 yr will have an averagelife expectancy of 3.2 yr.1In the United States, pa-tients 65 to 79 yr of age starting dialysis have a re-ported life expectancy of 25 mo.2During this time,patients may experience transient or permanentloss of personal independence, which, in turn, has anegative impact on their quality of life and financialsituation and a significant impact on health careutilization.3In general, older patients have complexmedical histories and a higher incidence of chronicailments such as arthritic pain, vision loss, or fa-tigue. Often patients adapt by walking more slowlyor taking more rests and developing fixed routineswith little variability or limiting activities. Overtime, these symptoms and adaptations have a cu-mulative effect on functional status, possibly lead-ing to dependency. In the renal literature, prevalentpatients on hemodialysis seem to have high levels offunctional loss.4Preliminary studies show that thisis exacerbated by acute hospitalization.5The impactof a lower functional status may be reduced by of-fering rehabilitation to dialysis patients. In the non-dialysis literature such programs are common andseem to limit the impact of functional disability onpatients, their families, and the healthcare system.6,7In this chapter, I will review the benefits and con-cepts of geriatric rehabilitation, the role of thenephrologists, and highlight some common com-plications.WHAT IS GERIATRIC REHABILITATION?Rehabilitation can be defined as a process by whichform and function is restored after injury or illness,such that life can be lived to the fullest capacitycompatible with the degree of abilities and disabil-ities.8This definition recognizes two important char-acteristics of rehabilitation in the older population—first that restoration of function is most likely to occurin those with a recent loss of function and, second, thatrehabilitation involves a process by which patientsboth learn new ways to restore function but also meth-ods which help them adapt to the new disability.Geriatric rehabilitation depends highly on amodel of interdisciplinary care. In this model, dif-ferent team members have both overlapping andcomplementary skills. Unlike acute care unitswhere the physician often heads the team, rehabili-tation teams do not depend on leadership from oneparticular discipline. Rather, treatment decisionsare led by the team member most involved with thepatient. Team members include physicians, nurses,social workers, occupational therapists, physiother-apists, speech therapists, psychologists, and phar-macists. Nurses play a key role because they spendthe most time with the patient. Through theirdaily interactions with patients, nurses empowerpatients to assume self-care and responsibilityand evaluate their psychosocial needs. Oftennurses help reduce muscle deconditioning by en-couraging patients to perform self-care activitiesoutside of their formal therapy sessions. Aftermultiple team members assess the impact of dis-ease on functionality from a variety of perspec-tives, they identify, through discussion, which ofthe disciplines is best suited to developing solu-tions before working in a collaborative manner.As an example, one patient with difficulty walk-ing indoors may work with a physiotherapist toincrease muscle strength, whereas another maybenefit from occupational therapy sessions tolearn to overcome visual limitations.Correspondence:S. V. Jassal, Associate Professor, University ofToronto, Staff Physician, University Health Network, Director, Ge-riatric Dialysis Rehabilitation Program, Toronto Rehab Institute,8NU-857, 200 Elizabeth Street, Toronto M5G 2C4, Canada.Phone: 416-340-3196; Fax: 416-340-4999;E-mail: vanita.jassal@uhn.on.caCopyright
2009 by the American Society of NephrologyAmerican Society of NephrologyGeriatric Nephrology Curriculum1PUBLISHED BENEFITS OF REHABILITATION INDIALYSIS CARENumerous programs have reported using rehabilitation intheir dialysis units. Most develop exercise programs designedto build muscle strength through exercise regimens during di-alysis or within the home.9–14Such programs have been largelysuccessful but are often confounded by high drop-out ratesand the high costs of providing staff to supervise the exercises.Cardiac rehabilitation is recommended for dialysis patientswho have recently survived myocardial infarction, had bypasssurgery, or those with chronic stable angina. Dialysis patientshave been shown to benefit from actively participating in car-diac rehab, with outcome studies showing a 35% reduced riskfor cardiac mortality.15However, cardiac rehab seems to beunderused in dialysis patients, with only 10% of dialysis pa-tients, compared with 23% of the general population, under-going cardiac rehabilitation after coronary artery bypass graft(CABG) surgery.15Reasons behind this apparent paradox havenot been clearly identified.In the older individual, building muscle can be challenging,because patients do not have the strength or capacity to per-form strenuous or repetitive exercises. Sensory changes, suchas in hearing or vision, or decreases in cognitive function alsolimit the ability to learn new exercises. Geriatric renal rehabil-itation has not been widely formalized and, in many cases, isavailable only on a case-by-case basis. Published results of out-comes with dialysis rehabilitation are available but often lim-ited by small study size and the inclusion of young patients(
70 yr of age) with few comorbid conditions (Table 1).16–22Success rates, as measured by the proportion of patients re-turning home, vary from 20 to 100%. In the largest and mostrecent report, approximately 70% of patients23,24met theirpersonalized goals and returned home (Figure 1). At the timeof admission, patients had a significant burden of comorbidityand high levels of functional dependence. In our unit, dialysisis offered on site on a daily dialysis schedule. Staffing levelshave been increased in both the dialysis suite and on the wardto accommodate the higher burden of comorbidity and higherdependency levels.24ISSUES UNIQUE TO REHABILITATION OF ELDERLYDIALYSIS PATIENTSComorbidity BurdenElderly dialysis patients have a high incidence of comorbiditywith recent studies in prevalent hemodialysis patients showingthe mean number of medical conditions to be around 10.53.5.25The high number of comorbid illnesses place a heavymedical burden on the rehabilitation unit staff and the phar-macy. Elderly dialysis patients have a high rate of transfer outto acute care for new or recurrent acute illnesses. Of those whoed CareLong-term careOther020406080100120HomeAssistNumber of patientsFigure 1.Graph showing discharge disposition of patients ad-mitted to the Toronto Dialysis Geriatric Rehabilitation Program.Patients who did not return to rehabilitation after an acute inter-current illness or who transferred to palliative care are shown ashaving been discharged to Other.Table 1.Summary of studies evaluating inpatient rehabilitation in dialysis patientsPublicationNPercentPatients WithDiabetesComorbidityDetailsMeanAge (yr)AverageLOS (d)PercentDischargedHomeCommentsLi (2008)2416451CCI7.82.5 74.548.568Majority had a high burden of comorbid diseases.24% patients required transfer to an acute careinstitution, of whom 40% did not return to rehabForrest (2005)1940 Not reported Not reported 62.312.180.0 Prior medically complicated conditions in 8 patients(20%)Forrest (2004)1834 Not reported Not reported 68.716.072.2 Mostly admitted post-procedure. Prior acutehospitalization in 27%Frank (2002)205 Not reported Not reported 76.4—20.0 Used Berg Balance Scores and mobility forfunctional assessmentGarrison (1997)21310010050.0 18.0–34.0 100.0 Small sample size, postamputation onlyCzyrny (1994)1719 Not Reported Not Reported 59.027.079.0 PostamputationCowen (1995)1628 Not reported Not reported 61.517.589.0 Reported converted functional impairment measurescoresGreenspun (1986)224100Not reported 55.244.2n/aPostamputationLOS, length of stay; CCI, Charlson Comorbidity Index.2American Society of NephrologyAmerican Society of Nephrologyare transferred, almost 40% are too unwell to return to reha-bilitation.24Dialysis SchedulingShort daily dialysis is recommended where possible. It is welltolerated and may lead to improved nutrition and better par-ticipation in therapy sessions. Patients report less fatigue andfewer symptoms associated with rapid fluid shifts. Scheduleddialysis and rehabilitation therapy sessions lead to improvedoutcomes and shorter length of hospital stay.19Enforced Immobility During DialysisPatients may benefit from occupational therapy and physio-therapy assessment during the dialysis session. Customizedseating aids may improve seating balance while simple physio-therapy exercises may reduce the impact of remaining rela-tively immobile for longer sessions.THE SICK ROLE: THE IMPORTANCE OFENCOURAGEMENTMany healthcare workers perceive dialysis patients as beingheavily dependent and unable to participate in exercise. In con-trast, patients are interested in maintaining their functional inde-pendence and taking part in exercise. In a study to identify thebarriers to exercise, one important factor identified was that nei-ther nurses nor doctors encourage elderly patients to be active.26Studies to see whether changing staff attitudes can alter patientperceptions or activity levels are underway.ROLE OF THE NEPHROLOGIST IN DIALYSIS-RELATED GERIATRIC REHABILITATIONThe nephrologist role is to work with the team and to take alead position on identification and referral of patients who maybenefit from rehabilitation; customization of the individualmedical goals and targets (goals should be adapted to allow thepatient to best achieve personal independence and functionand yet maintain long-term health); and reduction of polyp-harmacy and rationalization of medication.One of the more difficult roles a nephrologist must play isthe identification of patients who would benefit from rehabil-itation. Few nephrologists are formally trained in rehabilita-tion medicine, and there is little literature to advise on screen-ing or referral protocols. Nevertheless, it is the nephrologistwho follows the chronic predialysis and dialysis patient mostclosely and who is involved in their long-term care planning.The nephrologist is therefore best placed to identify functionaldecline and question if rehabilitation would improve function-ality. A practical first step is to perform a full geriatric assess-ment after major events such as dialysis initiation and at setintervals thereafter. Unfortunately, this field is relatively newand it remains unclear whether all patients should be screened,and if so, how often and with what tools. Clearly clinical eventssuch as hospitalization, falls, or a change in social status (e.g.,moving home or the death of a spouse or carer) should prompta functional reassessment by either the primary physician ormembers of the allied health team.Nephrologists should also work closely with the rehabilita-tion team to evaluate and, if necessary, reset health targets forolder dialysis patients. Although nephrologists routinely adjustultrafiltration/target weight and blood sugar targets, some pa-tients may require temporary relaxation in these goals partic-ularly during periods of functional loss. Relaxation of dietaryrestrictions may allow improved nutrition and allow patientsto meet their calorie requirements during a period of repairand recovery. Minor adjustments in volume status can have asignificant effect on fatigue. In our experience, debilitated in-dividuals often report or manifest symptoms during theirphysiotherapy or occupational therapy sessions. Adjustmentof target weight based on these observations or symptoms canimpact function, with small changes (e.g.,an increase or de-crease of 200 ml of ultrafiltration) being effective in some cases.(We have maximized this through the use of short daily dialysisregimens.) Some flexibility around blood sugar control mayalso be helpful for individuals who are prone to labile diabetes.Although tight blood sugar control is always a long-term ob-jective, we have found it necessary to relax blood sugar goalsduring the initial rehabilitation period. By having a tolerancefor a higher mean blood sugar, the patient may feel more ableto focus on other aspects of care. Success in these other aspectsof personal functioning, empowers them to then address self-care issues around blood sugar management. Sadly, the need tofulfill benchmark targets may limit the longer-term use of in-dividualized care plans in patients with borderline functionalindependence.Nephrologists play a key role in helping to rationalize med-ications. Many dialysis patients experience polypharmacy. In-patient rehabilitation care is an ideal setting for discontinua-tion of medications such as gastric acid suppressants, sedatives,and laxatives, the aim being to reduce unnecessary drugs andminimize drug interactions.Pain management and detection and treatment of depres-sion are two important aspects of rehabilitation care. Manypatients undergoing rehabilitation report chronic pain. Ar-thritic knees or hands can limit the use of aids and thereforeimpact both functionality and recovery. The presence ofchronic uncontrolled pain may lead to depression and ofcoursevice versa, meaning that pain management strategiesshould include antidepressants if appropriate.IDENTIFYING AND MANAGING COMMONPROBLEMS IN DIALYSIS REHABILITATIONPainPain management is a major issue in ESRD. The topic is largeand complex because of the altered metabolism of many drugs,American Society of NephrologyAmerican Society of Nephrology3and the reader is encouraged to read further on the topic.27–29Key summary principles are discussed below.Appropriate drugs include acetaminophencodeine andopiates. Nonsteroidal anti-inflammatory drugs (NSAIDs) canbe used in anuric patients with arthritic symptoms. Ideallythese should only be used in short courses at low dose becauseof the lower drug clearance and high risk of gastrointestinalside effects.Preferred opiates include hydromorphone, fentanyl, andmethadone. Morphine,meperidine, and detroporoxypheneshould be avoided because of accumulation of the drug. Cau-tion must be exercised with transdermal administration of fen-tanyl because it seems to have a variable absorption dependingon the location of the patch. In addition, absorption may varydepending on the temperature of the skin in that area. (Per-sonal note: We avoid the use of fentanyl in our unit.)If prescribing opiates, aim to use regular doses of long-act-ing agents at set times,e.g.,twice a day; doses should be sup-plemented with additional breakthrough medications, partic-ularly initially because the use of breakthrough medicationshelps determine how much uptitration is needed. Medicationdoses can be reassessed every 3 to 5 d. The regular dose of along-acting agent should be increased to be equal to the totalaverage dose of opiate used since the last titration. Therefore, ifthe patient is taking 3 mg hydromorphone long acting twicedaily and is, on average, taking an additional 1-mg break-through dose five times a day, one would increase the totallong-acting hydromorphone doses to 6 mg twice a day (for atotal of 12 mg opiate/24 h) in the hope that pain will be suffi-ciently well controlled to not require breakthrough drugs.Down titration is best done by a gradual reduction in the opiatedoses administered twice daily.The use of adjuvant therapies such as heat packs, transder-mal electrical nerve stimulation therapy, acupuncture, and an-tidepressants nortriptyline (in preference to amitriptyline) andgabapentin is encouraged.Sleep DisordersSleep disorders and chronic fatigue are common symptoms indialysis patients. Sleep hygiene programs include regular sleepscheduling, keeping the patient out of bed and the bedroomuntil bedtime, a snack before bedtime, and instruction onmental imagery or deep breathing relaxation techniques.Sleeping during dialysis, although common, should be dis-couraged. A patient with a poor sleep pattern may be sufferingfrom concomitant depression, and assessment is advised. Ifassociated with depression, the use of antidepressants with amildly sedative effect may be beneficial. Mirtazapine is oftenused because it causes relatively short-term drowsiness (6 to8 h) and also acts as an appetite stimulant.DepressionDepression is common in both dialysis patients and those un-dergoing rehabilitation. Frail elderly dialysis patients are there-fore at particularly high risk, especially around the time of di-alysis initiation. Unfortunately, symptoms, such as fatigue orpoor sleep and loss of appetite, can be attributed both to dial-ysis dependency and to depression, and therefore, depressionis best detected by having a high index of suspicion. Patientsrespond well to antidepressants. In our unit, the preference isfor the newer agents such as citalopram and sertraline in par-ticular because they have a lower incidence of drug–drug in-teractions. As mentioned previously, mirtazapine is particu-larly useful in patients with poor appetite and/or sleepproblems. Venlafaxine is our preferred choice for patients withsignificant anxiety symptoms.Confusional StatesCognitive impairment is common in dialysis patients30andmay significantly impact the success rates with rehabilitation.Associated delirium or agitation is not uncommon and mayimprove after medication rationalization or treatment of anyintercurrent illness. Careful assessment of sensory functions,such as hearing or vision, may be beneficial. Patients with re-duced vision or hearing may not be aware of “normal” externalstimuli and what may be a simple startle reaction may be mis-interpreted as agitation. Agitated patients may respond well toroutine. If possible, dialysis scheduling should facilitate dialysisin the same station at the same time each day for vulnerablepatients.CONCLUSIONSWidespread development of programs offering rehabilitationto dialysis patients is likely increasingly worthwhile as the av-erage age of the dialysis patients increases. Programs seem ef-fective in minimizing the disability associated with aging andchronic disease. Nephrologists play an important role in iden-tification of patients; setting appropriate medical goals; andmanaging common problems such as pain control. Specifictraining in care of the elderly patient may be of benefit to neph-rologists.TAKE HOME POINTS•There is a high burden of dependency and disability in the older dialysispopulation•Recent onset dependence and disability may be reversed throughtargeted rehabilitation programs•Rehabilitation outcomes are improved if nephrologists work in conjunc-tion with rehabilitation specialist teams; important areas for collabora-tion include identification of appropriate candidates, medical goal ad-justment, and pain and medication management•Scheduled dialysis sessions are associated with better rehabilitationoutcomes; short daily dialysis sessions are best tolerated (opinion)DISCLOSURESNone.4American Society of NephrologyAmerican Society of NephrologyREFERENCES*Key References1. Jassal SV, Trpeski L, Zhu N, Fenton SSA, Hemmelgarn BR: Changes insurvival over the years 1990–1999 for elderly patients initiating dialy-sis.CMAJ177: 1033–1038, 20072. Kurella M, Covinsky KE, Collins AJ, Chertow GM: Octogenarians andnonagenarians starting dialysis in the United States.Ann Intern Med146: 177–183, 20073. USRDS Data report. http://www.usrds.org/adr_2007.htm 20074. Cook WL, Jassal SV: Functional dependencies among the elderly onhemodialysis.Kidney Int73: 1289–1295, 2008*5. Lo D, Chiu E, Jassal SV: A prospective pilot study to measure changesin functional status associated with hospitalization in elderly dialysis-dependent patients.Am J Kidney Dis52: 956–961, 20086. Forster A, Young J, Lambley R, Langhorne P: Medical day hospitalcare for the elderly versus alternative forms of care.Cochrane Data-base Syst RevCD: 001730, 20087. Clark GS, Siebens HC: Rehabilitation of the geriatric patient. In:Re-habilitation Medicine, edited by DeLisa JA, Philadelphia, Lippincott,1993, pp 642–6658. Eisenberg MG:Dictionary of Rehabilitation. New York, Springer, 19959. Johansen KL, Painter PL, Sakkas GK, Gordon P, Doyle J, Shubert T:Effects of resistance exercise training and nandrolone decanoate onbody composition and muscle function among patients who receivehemodialysis: a randomized, controlled trial.J Am Soc Nephrol17:2307–2314, 200610. Painter P, Johansen KL: Improving physical functioning: time to be apart of routine care.Am J Kidney Dis48: 167–170, 200611. Painter P, Carlson L, Carey S, Paul SM, Myll J: Low-functioning hemo-dialysis patients improve with exercise training.Am J Kidney Dis36:600–608, 200012. Johansen KL, Shubert T, Doyle J, Soher B, Sakkas GK, Kent-Braun JA:Muscle atrophy in patients receiving hemodialysis: effects on musclestrength, muscle quality, and physical function.Kidney Int63: 291–297, 200313. Painter P: The importance of exercise training in rehabilitation ofpatients with end-stage renal disease.Am J Kidney Dis24: S9, 199414. Painter P: Why exercise can make a difference.Nephrol News Issues20: 52, 200615. Kutner NG, Zhang R, Huang Y, Herzog CA: Cardiac rehabilitation andsurvival of dialysis patients after coronary bypass.J Am Soc Nephrol17: 1175–1180, 200616. Cowen TD, Huang CT, Lebow J, DeVivo MJ, Hawkins LN: Functionaloutcomes after inpatient rehabilitation of patients with end-stagerenal disease.Arch Phys Med Rehabil76: 355–359, 199517. Czyrny JJ, Merrill A: Rehabilitation of amputees with end-stage renaldisease. Functional outcome and cost.Am J Phys Med Rehabil73:353–357, 199418. Forrest GP: Inpatient rehabilitation of patients requiring hemodialysis.Arch Phys Med Rehabil85: 51–53, 200419. Forrest G, Nagao M, Iqbal A, Kakar R: Inpatient rehabilitation ofpatients requiring hemodialysis: improving efficiency of care.ArchPhys Med Rehabil86: 1949–1952, 2005*20. Frank C, Morton AR: Rehabilitation of geriatric patients on hemodial-ysis; a case series.Geriatr Today5: 136–139, 200221. Garrison SJ, Merritt BS: Functional outcome of quadruple amputees withend-stage renal disease.Am J Phys Med Rehabil76: 226–230, 199722. Greenspun B, Harmon RL: Rehabilitation of patients with end-stagerenal failure after lower extremity amputation.Arch Phys Med Rehabil67: 336–338, 198623. Jassal SV, Chiu E, Li M: Geriatric hemodialysis rehabilitation care.AdvChronic Kidney Dis15: 115–122, 200824. Li M, Porter E, Lam R, Jassal SV: Quality improvement through theintroduction of interdisciplinary geriatric hemodialysis rehabilitationcare.Am J Kidney Dis50: 90–97, 2007*25. Cook WL, Jassal SV: Prevalence of falls among seniors maintained onhemodialysis.Int Urol Nephrol37: 649–652, 200526. Kontos PC, Miller KL, Brooks D, Jassal SV, Spanjevic L, Devins GM, DeSouza MJ, Heck C, Laprade J, Naglie G: Factors influencing exerciseparticipation by older adults requiring chronic hemodialysis: a quali-tative study.Int Urol Nephrol39: 1303–1311, 200727. Arnold RM, Verrico P, Davison SN: Opioid use in renal failure #161.JPalliat Med10: 1403–1404, 200728. Davison SN: Pain in hemodialysis patients: prevalence, cause, severity,and management.Am J Kidney Dis42: 1239–1247, 2003*29. Davison SN: Chronic pain in end-stage renal disease.Adv ChronicKidney Dis12: 326–334, 200530. Murray AM, Tupper DE, Knopman DS, Gilbertson DT, Pederson SL, Li S,Smith GE, Hochhalter AK, Collins AJ, Kane RL: Cognitive impairment inhemodialysis patients is common.Neurology67: 216–223, 2006American Society of NephrologyAmerican Society of Nephrology5REVIEW QUESTIONS: REHABILITATION SERVICESFOR ELDERLY DIALYSIS PATIENTS1. A 72-yr-old lady presents with acute chest pain to the emer-gency room. She has been living independently in her ownhome for some years without difficulty. She is noted to havechronic kidney disease on initial bloodwork. Over the follow-ing few days, her cardiac condition deteriorates. Because ofmarked fluid overload and her background CKD, she needs tostart dialysis emergently. One month after initiating dialysis,she is noted by the dialysis staff to be unsteady on her feet whencoming to dialysis. Since discharge, she is known to have hadmultiple falls at home and is currently complaining of pain inher left shoulder after a fall. She has no fracture but has signif-icant bruising and pain and has limited movements of the arm.Her BP is 160/85 mmHg predialysis and 140/78 mmHg post-dialysis. Her medications include a renal vitamin, aspirin 81mg OD, ramipril 10 mg OD, metoprolol 50 mg po twice daily,atorvastatin 20 mg qHS, lorazepam 10 mg qHS, quinine sulfate300 mg OD on dialysis days for cramps, allopurinol 100 mgOD, hydroxyzine 25 mg three times daily for itch, omeprazole20 mg OD, zopiclone 7.5 mg qHS, and acetaminophen 1000mg QID prn for pain. Which of the following statements istrue:a. Her falls are likely only happening on postdialysis days andtherefore related to hypotension; the most appropriate ac-tion is adjustment of target weightb. The most appropriate first step is to manage her pain byintroduction of an opiate on a regular schedulec. The most appropriate first step is to prescribe a walker tohelp with her unsteadinessd. Her falls are likely multifactorial and, taken together withher unsteadiness and polypharmacy, she may benefit fromreferral to a rehabilitation specialist for evaluation, andtreatment.2. An 85-yr-old hemodialysis patient is referred for rehabilita-tion after the family notice a decline in his functional statusover the past few months. The rehabilitation team review theliterature for clinical evidence about the effectiveness of inpa-tient geriatric rehabilitation in elderly, dialysis patients. Whichof the following statements is true:a. Strong, grade A (randomized controlled trial) evidencethat rehabilitation is effective in elderly dialysis patientsb. Some Grade B evidence (from observational studies) thatrehabilitation is effective in elderly dialysis patientsc. No evidence in either direction (either supporting effec-tiveness or no effectiveness) in elderly dialysis patientsd. Strong evidence (randomized controlled trial) that reha-bilitation is not effective in elderly dialysis patients3. A 68-yr-old man is admitted to an acute medical ward withsymptoms consistent with pneumonia. He is seen by thephysio as part of the discharge planning process and is noted tobe having difficulty walking and transferring because of mus-cle weakness. His bone mineralization profile shows he hasmild secondary hyperparathyroidism with elevated PTH lev-els. He starts undergoing physiotherapy and rehabilitationwith the physio on an adhoc basis. He is a dialysis patient andreceives dialysis in the outpatient dialysis suite on Monday,Wednesday, and Friday mornings where possible. He is apleasant man who is cooperative and readily amenable tochanging his dialysis time to later in the afternoon to suit thestaff. There is concern that he does not appear to be makingany progress in his walking. Which of the following statementsis true:a. Rehabilitation provided on an acute medical ward is inef-fectiveb. Changing patients to a fixed dialysis schedule may reducethe length of stayc. Dialysis patients are likely to require twice as long for re-habilitation as nondialysis patientsd. The muscle weakness is unlikely to resolve with exercisesas it is related to a myopathy associated with secondaryhyperparathyroidism6American Society of NephrologyAmerican Society of Nephrology

Exercise rehabilitation program may present long-term benefits to patients with CKD

Patients with CKD who attended a 10-week exercise rehabilitation program were more likely to continue exercising at 1 year than those who did not attend the program, according to a study published in Clinical Kidney Journal. Participation may also be associated with improved physical function.

“To our knowledge, this is the first study to evaluate the long-term effect of a clinical exercise rehabilitation program on physical function in individuals with CKD,” Nicholas Hargrove, of Max Rady College of Medicine at the University of Manitoba in Canada, and colleagues wrote.“In addition, the diversity of the study population in terms of age, sex, race, CKD stage and comorbidities resulted in a sample that was more characteristic of the general CKD population than previous investigations, which were predominately focused on CKD stages 3 and 4, maximizing generalizability.”

To evaluate the impact of an exercise rehabilitation program on physical function, researchers divided adults with CKD who were registered in the Manitoba Renal Program from January 2011 to March 2016 into the attenders group (n = 53) or one of two control groups which included the non-attenders (n = 40) and the CanFIT Controls (individuals with CKD enrolled in a concurrent longitudinal observational study of frailty status; n = 207).

Attenders consisted of individuals who were referred to and attended the 10-week exercise rehabilitation program. The program included weekly classes of 1 hour of education and 1 hour of group fitness activity (aerobics and strength training). They first attended an exercise counseling clinic. Non-attenders also attended the exercise counseling clinic and were referred to the rehabilitation program but did not attend. The CanFIT participants did not attend either counseling or rehabilitation.

The primary outcome of the study was change in physical function based on short physical performance battery score. Secondary outcomes included change in health-related quality of life, physical activity behavior, exercise behavior and hospitalization over 1 year.

Researchers observed no significant differences between the three groups in any of the secondary outcomes except for physical activity behavior where 35% of non-attenders and 60% of attenders were found to be exercising regularly at 1 year.

Patients with CKD who attended a 10-week exercise rehabilitation program were more likely to continue exercising at 1 year than those who did not attend the program.

Source: Adobe Stock

Further, although mean change in short physical performance battery score over 1 year was not significantly different between groups, researchers found that attenders with baselines scores less than 12 trended toward increased likelihood of improved score at 1 year (OR = 2.18; 95% CI, 0.95-5.02) and that participation in the program may be associated with a clinically meaningful change in short physical performance battery score compared with those who did not attend the program.

“In ‘real-world’ conditions, attendance at a single 10 week session of exercise rehabilitation appears to be associated with sustained exercise participation and improved physical function over time,” Clara Bohm, MD, MPH, assistant professor at the University of Manitoba and nephrologist at the Manitoba Renal Program, told Healio/Nephrology. “Future studies with larger sample sizes are needed to confirm the above observations and determine if the effects of exercise rehabilitation persist for longer than 1 year and if benefits to physical function translate to a decrease in hospitalization and mortality over the long term. In addition, studies that investigate how barriers to attending exercise programs can be overcome for individuals with CKD are needed. Finally, research that examines the effect of exercise rehabilitation on patient-important outcomes is needed.” – by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.

The Rehabilitation Role in Chronic Kidney and End Stage Renal Disease

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Abstract

Chronic kidney disease (CKD) worldwide is rising markedly becoming a priority public health problem. The progression of CKD cause functional limitation and severe disability with poor quality of life. The aim of present review was to highlight the effect of rehabilitation in CKD and ESRD subjects. The rehabilitative process is unique in treating disabled people according to a holistic approach with the aim of supporting a person’s independent living and autonomy. CKD are associated with an increased risk of functional impairment, independent of age, gender, and co-morbidities. Clinicians should counsel patients with CKD including frail elder people to increase physical activity levels and target that regular physical activity including aerobic or endurance exercises training benefits health. In old subjects with CKD and multiple functional impairments, the traditional disease based model should be changed to individualized patient-centered approach that prioritizes patient preferences. Patients receiving haemodialysis have a considerably lower exercise tolerance, functional capacity, and more muscle wasting than healthy subjects or patients with less severe CKD. Exercise training or comprehensive multi-dimensional strategy and goal-oriented intervention should be also provided in ESRD older subjects. Structured prevention programs based on reducing the risk factors for CKD and rehabilitative strategies could reduce disability occurrence.

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Introduction

Rehabilitation role and rehabilitative project

Rehabilitation has been defined by the World Health Organization (WHO) as ”the use of all means aimed at reducing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration”. This definition incorporates clinical rehabilitation but also, importantly, endorses the concept of social participation as requiring a matching of the social environment to the needs of people with disabilities. The overall aim of rehabilitation is to enable people with disabilities to lead the life that they would wish, given any restriction imposed on their activities by impairments resulting from illness or injury as well as from their personal context [11]. The rehabilitative process is unique in treating people according to a holistic approach or a bio-psycho-social model with the aim of supporting a person’s independent living and autonomy. Rehabilitation has been demonstrated effective and efficient in reducing the burden of disability and enhancing the opportunities for disabled people. On the base of clinical, affective and functional evaluation, physiatrists have to plan the rehabilitative project including all structural body and functional areas that need of reparative and rehabilitative interventions. Rehabilitative project has to forecast time and intervention type, to individuate recoverable limitations and the functional objectives that can be reached. Furthermore, suitable rehabilitative methods and techniques have to be described in reaching the results as well as the specific role of involved personnel staff in the rehabilitative process. The role of rehabilitation intervention and how much specific strategies can affect functional recovery have to be communicated and discussed with patients and his/her family. Indeed, discussion regarding goals of care and advance care planning ought to be common place in executing rehabilitative project. Patients and caregivers should be discouraged from setting unrealistic rehabilitation goals, whenever required functional abilities are not recoverable. The rehabilitation project should be tailored on the individual effective needs of CKD people according to the holistic approach considering stage of disease, complications and co-morbidities. As a patient-centered process, it has to be appropriate to optimize both activity and participation to ameliorate person’s quality of life. People with CKD could complain of complex functional impairments and multi-system clinical disorders needing of specialized care and specific rehabilitative interventions. In this case, the rehabilitative project can be only executed by an interdisciplinary approach with a multi-professional team work that include physiatrist, geriatrician, nephrologist and other medical practitioner such as nurses, social worker, and occupational or physical therapist in order to obtain the best benefit by the one’s own expert and competent contribute.

Chronic Kidney disease and disability

CKD are associated with an increased risk of functional impairment, independent of age, gender, co-morbidities, and cardiovascular events [12]. The association with functional limitation has been observed not only in patients with ESRD [13] and moderate-severe CKD (mean GFR 25 ml/min/1.73 m²) [14], but also in subjects with milder CKD (mean GFR 50 ml/min/1.73 m² ) [12]. Several causes can contribute to limitations occurrence in these subjects including anemia, protein-energy malnutrition, lower muscle strength, metabolic disturbances resulting in reduction exercises tolerance, independence and ability to perform activities of daily living (ADL). Because ability decline occurring in adult CKD subjects, rehabilitative strategies should be planned on the base of age, functional limitations, residual abilities, participation and co-morbidities. In CKD adult subjects with retained ADL and IADL (instrumental activity of daily living) capacities, clinicians have to recommend active life style with regular physical exercise to prevent functional decline. In subjects who present reduced abilities and more complex limitations, a multi-disciplinary approach should be carried out.

Hemodialitic patients ad rehabilitation

The association between ESRD and functional impairment is well established [13]. Cross-sectional reports have found that individuals with ESRD have lower physical functioning than the general population. Furthermore, ESRD subjects receiving maintenance haemodialysis (HD) have a considerably lower exercise tolerance, functional capacity, endurance and strength, and more muscle wasting and fatigue than healthy subjects or patients with less severe CKD who do not yet need renal replacement therapy [33]. Similar rehabilitative strategies delivered in CKD persons can be applied to dialysis subjects, particularly the exercise training. Individual recommendations by stage and/or treatment modality of kidney disease do not presently exist, however, the following suggestions may guide exercise prescription for the CKD/ESRD patient. Patients with peak VO₂ values (<17.5mlkg^-1 min^-1) may obtain the largest survival benefit from exercise training [34]. Before starting exercise therapy, patients should be evaluated to define their suitability for exercise and to tailor individualized exercise prescriptions by exercise tolerance and functional capacity tests. Same recommendations and contraindications for older adults (65 years and above) of the American College of Sports Medicine and the American Heart Association [35], can be applied to patients with HD [36]. Benefits associated with exercise training are improved peak VO_2, cardiac function, quality of life, and sympatho-adrenal activity [37]. Significant improvements in lean body mass, quadriceps muscle area, knee extension, hip abduction and flexion strength have been also reported [37]. Exercise training may be delivered in non-dialysis time, either as outpatients or at home, and also during dialysis, termed inter-dialytic exercise. Sophisticated machine such as leg press and free weights have been used to improve strength and to preserve physical function. On the other hand, simple and cheap elastic bands that can be used for resistance exercises during dialysis sessions may be an attractive alternative [38]. Doubts remain about the proper physical programs to obtain benefit, but no differences has been found between intra-dialytic versus home-based aerobic exercise training on physical function and vascular parameters in HD patients [39]. It should be emphasized that the most frail and incapacitated patients are probably those most in need of physical rehabilitation as a part of their clinical care. Although dialysis initiation is associated with a functional decline that is independent of age, gender, and prior functional status, this finding is more dramatic in old people. Sterky et al. observed that dialysis elderly subjects had 50% less functional capacity than gender- and age-matched healthy subjects [40]. Only 13% of subjects after one year of HD maintain stable functionality [13]. The accelerate functional decline that occurs in dialysis old people promote mobility impairment, falls, fractures and functional limitations predisposing HD subjects to increased health utilization and long-term institutionalization. According to data from the US Data System, 25% of patients starting dialysis are over the age of 75 years and older patients represent the fastest growing group on dialysis [41,42]. Elderly subjects with HD share many of same co-morbidities including diabetes, coronary artery disease, heath congestive failure, multilevel arthritis, pain, neuropathy, affective disorders and cognitive impairments that produce severe functional limitation and decrement of quality of life. A step-by step approach selecting the outcome to improve [43] and more recently, a patient centered intervention rather than disease treatment has been proposed [22]. In elderly subjects with advanced CKD, providers have to be prepared to adopt an integrative, individualized oriented-patient approach. Comprehensive multi-dimensional strategy and goal-oriented intervention should be provided in ESRD older subjects presenting multiform disability and requiring hospitalization. In this way, specialized geriatric rehabilitation units with on-site dialysis have been proposed in which integrated multidisciplinary care by experts in rehabilitation, geriatric medicine, and nephrology and reciprocal continued medical education among staff can help older dialysis patients with new-onset functional decline return to their home [44,45]. Discussion regarding goals of care and advance care planning ought to be common place for such patients. Patients and caregivers should be discouraged from setting unrealistic “rehabilitation goals,” such as attaining a level of independence that the patient has not had for several years or reversing a permanent impairment [46]. On average, the life expectancy of HD subjects aged more than 75 years is estimated to be 2.6 to 3.2 years from the dialysis initiation [47]. Since, these patients have increased risk of early death, it is need to be determined whether patients and their families prefer more effort be directed at achieving quantity of life versus quality of life [48].

Conclusion

The number of patients with CKD worldwide is rising markedly becoming a priority public health problem. Rehabilitation is effective and efficient in reducing the burden of disability and enhancing activities and participation for disabled people. Exercise training or comprehensive multi-dimensional strategy and goal-oriented intervention should be provided in CKD and ESRD subjects according to clinical condition and functional impairments. Since severe CKD/ESRD disabled subjects present complex dysfunction, goals and expected outcomes of treatment should be discussed with the patient and caregiver. Structured prevention programs based on reducing the risk factors for CKD and rehabilitative strategies could reduce disability occurrence and related social cost.

Disclosure Statement

The author of this article confirm that there are no conflicts to state.

References

1. Levey AS, de Jong PE, Coresh J El Nahas M, Astor BC, Matsushita K, Gansevoort RT, Kasiske BL, Eckardt KU: The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report. Kidney Int 2011;80:17-28.
2. van Blijderveen JC, Straus SM, Zietse R, Stricker BH, Sturkenboom MC, Verhamme KM: A population-based study on the prevalence and incidence of chronic kidney disease in the Netherlands. Int Urol Nephrol 2014;46:583-592.
3. Mahmoodi BK, Matsushita K, Woodward M, Blankestijn PJ, Cirillo M, Ohkubo T, Rossing P, Sarnak MJ, Stengel B, Yamagishi K, Yamashita K, Zhang L, Coresh J, de Jong PE, Astor BC; Chronic Kidney Disease Prognosis Consortium: Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without hypertension: a meta-analysis. Lancet 2012;380:1649-1661.
4. Stengel B, Metzger M, Froissart M, Rainfray M, Berr C, Tzourio C, Helmer C: Epidemiology and prognostic significance of chronic kidney disease in the elderly—the Three-City prospective cohort study. Nephrol Dial Transplant 2011;26:3286-3295.
5. Formiga F, Ferrer A, Cruzado JM, Padros G, Fanlo M, Roson B, Pujol R: Geriatric assessment and chronic kidney disease in the oldest old: the Octabaix study. Eur J Intern Med 2012;23:534-538.
6. Zhang QL, Rothenbacher D: Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health 2008;8:117.
7. Bowling CB, Sawyer P, Campbell RC, Ahmed A, Allman RM: Impact of chronic kidney disease on activities of daily living in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2011;66:689-694.
8. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS: Prevalence of chronic kidney disease and decreased kidney function in the adult US population: third national health and nutrition examination survey. Am J Kidney Dis 2003;41:1-12.
9. Lysaght MJ: Maintenance dialysis population dynamics: current trends and long-term implications. J Am Soc Nephrol 2002;13:37-40.
10. El Nahas AM, Bello AK: Chronic kidney disease: the global challenge. Lancet 2005;365:331-340.
11. Negrini S, Ceravolo MG: The White Book on Physical and Rehabilitation Medicine in Europe: A contribution to the growth of our specialty with no boundaries Am J Phys Med Rehabil 2008;87:601-606.
12. Smyth A, Glynn LG, Murphy AW, Mulqueen J, Canavan M, Reddan DN, O’Donnell M: Mild chronic kidney disease and functional impairment in community-dwelling older adults. Age Ageing 2013;42:488-494.
13. Kurella Tamura M, Covinsky K, Chertow G, Yaffe K, Landefeld C, McCulloch C: Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009;361:1539-1547.
14. Harris LE, Luft FC, Rudy DW, Tierney WM: Clinical correlates of functional status in patients with chronic renal insufficiency.Am J Kidney Dis 1993;21:161-166.
15. Heiwe S, Jacobson SH: Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev 2011;5:CD003236.
16. Painter P, Roshanravan B: The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Curr Opin Nephrol Hypertens 2013;22:615-623.
17. Bronas UG: Cochrane review: In adults with chronic kidney disease regular exercise improves physical fitness, walking capacity, heart rate and blood pressure and some nutritional parameters. Evid Based Nurs 2012;15:95-96.
18. Greenwood SA, Lindup H, Taylor K, Koufaki P, Rush R, Macdougall IC, Mercer TH: Evaluation of a pragmatic exercise rehabilitation programme in chronic kidney disease. Nephrol Dial Transplant 2012;27:III126-134.
19. Tentori F, Elder SJ, Thumma J, Pisoni RL, Bommer J, Fissell RB, Fukuhara S, Jadoul M, Keen ML, Saran R, Ramirez SP, Robinson BM: Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes. Nephrol Dial Transplant 2010;25:3050-3062.
20. Fried LF, Lee JS, Shlipak M, Chertow GM, Green C, Ding J, Harris T, Newman AB: Chronic kidney disease and functional limitation in older people: health, aging and body composition study. J Am Geriatr Soc 2006;54:750-756.
21. Shlipak MG, Stehman-Breen C, Fried LF, Song X, Siscovick D, Fried LP, Psaty BM, Newman AB: The presence of frailty in elderly persons with chronic renal insufficiency. Am J Kidney Dis 2004;43:861-867.
22. Bowling CB, Muntner P, Sawyer P, Sanders PW, Kutner N, Kennedy R, Allman RM: Community Mobility Among Older Adults With Reduced Kidney Function: A Study of Life-Space. Am J Kidney Dis 2014;63:429-436.
23. Roshanravan B, Robinson-Cohen C, Patel KV, Ayers E, Littman AJ, de Boer IH, Ikizler TA, Himmelfarb J, Katzel LI, Kestenbaum B, Seliger S: Association between physical performance and all-cause mortality in CKD. J Am Soc Nephrol 2013;24:822-830.
24. Johansen KL: Exercise in the end-stage renal disease population. J Am Soc Nephrol 2007;18:1845-1854.
25. Castaneda C, Gordon PL, Parker RC, Uhlin KL, Roubenoff R, Levey AS: Resistance training to reduce the malnutrition-inflammation complex syndrome of chronic kidney disease. Am J Kidney Dis 2004;43:607-616.
26. Kopple JD, Wang H, Casaburi R, Fournier M, Lewis MI, Taylor W, Storer TW: Exercise in maintenance hemodialysis patients induces transcriptional changes in genes favoring anabolic muscle. J Am Soc Nephrol 2007;18:2975-2986.
27. Chin A, Paw MJ, van Uffelen JG, Riphagen I, van Mechelen W: The functional effects of physical exercise training in frail older people: a systematic review. Sports Med 2008;38:781-793.
28. Sugawara J, Miyachi M, Moreau KL, Dinenno FA, DeSouza CA, Tanaka H: Age-related reductions in appendicular skeletal muscle mass: association with habitual aerobic exercise status. Clin Physiol Funct Imaging 2002;22:169-172.
29. Intiso D, Di Rienzo F, Russo M, Pazienza L, Tolfa M, Iarossi A, Maruzzi G: Rehabilitation strategy in the elderly. J Nephrol 2012;25:S90-95.
30. Stel VS, Smith JH, Pluijm SM, Lips P: Consequences of falling in older men and women and risk factors for health service use and functional decline. Age Ageing 2004;33:58-65.
31. Brenneman SK, Barrett-Connor E, Sajjan S, Markson LE, Siris ES: Impact of recent fracture on health-related quality of life in postmenopausal women. J Bone Miner Res 2006;21:809-816.
32. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148-157.
33. McIntyre CW, Selby NM, Sigrist M, Pearce LE, Mercer TH, Naish PF: Patients receiving maintenance dialysis have more severe functionally significant skeletal muscle wasting than patients with dialysis-independent chronic kidney disease. Nephrol Dial Transplant 2006;21:2210-2216.
34. Sietsema KE, Amato A, Adler SG, Brass EP: Exercise capacity as a predictor of survival among ambulatory patients with end-stage renal disease. Kidney Int 2004;65:719-724.
35. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-Sceppa C: American College of Sports Medicine; American Heart Association. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007;116:1094-1105.
36. Kosmadakis GC, Bevington A, Smith AC, Clapp EL, Viana JL, Bishop NC, Feehally J: Physical exercise in patients with severe kidney disease. Nephron Clin Pract 2010;115:c7-c16.
37. Smart N, Steele M: Exercise training in haemodialysis patients: a systematic review and meta-analysis. Nephrology (Carlton) 2011;16:626-632.
38. Bullani R, El-Housseini Y, Giordano F, Larcinese A, Ciutto L, Bertrand PC, Wuerzner G, Burnier M, Teta D: Effect of intradialytic resistance band exercise on physical function in patients on maintenance hemodialysis: a pilot study J Ren Nutr 2011;21:61-65.
39. Koh KP, Fassett RG, Sharman JE, Coombes JS, Williams AD: Effect of intradialytic versus home-based aerobic exercise training on physical function and vascular parameters in hemodialysis patients: a randomized pilot study. Am J Kidney Dis 2010;55:88-99.
40. Sterky E, Stegmayr BG: Elderly patients on haemodialysis have 50% less functional capacity than gender-and age-matched healthy subjects. Scand J Urol Nephrol 2005;39:423-430.
41. Collins AJ, Foley R, Herzog C, Chavers B, Gilbertson D, Ishani A, Kasiske B, Liu J, Mau LW, McBean M, Murray A, St Peter W, Xue J, Fan Q, Guo H, Li Q, Li S, Li S, Peng Y, Qiu Y, Roberts T, Skeans M, Snyder J, Solid C, Wang C, Weinhandl E, Zaun D, Zhang R, Arko C, Chen SC, Dalleska F, Daniels F, Dunning S, Ebben J, Frazier E, Hanzlik C, Johnson R, Sheets D, Wang X, Forrest B, Constantini E, Everson S, Eggers P, Agodoa L: Excerpts from the United States Renal Data System 2007 annual data report. Am J Kidney Dis 2008;51:S1-S320.
42. Holley JL: Age, eGFR, and CKD complications. Clin J Am Soc Nephrol 2011;6:2729-2731.
43. Sehgal AR: Improving hemodialysis patient outcomes: a step-by-step approach. Semin Dial 2002;15:35-37.
44. Li M, Porter E, Lam R, Jassal SV: Quality improvement through the introduction of interdisciplinary geriatric hemodialysis rehabilitation care. Am J Kidney Dis 2007;50:90-97.
45. Jassal SV, Chiu E, Li M: Geriatric hemodialysis rehabilitation care. Adv Chronic Kidney Dis 2008;15:115-122.
46. Farragher J, Jassal SV: Rehabilitation of the geriatric dialysis patient. Semin Dial 2012;25:649-656.
47. US Renal Data System: morbidity and mortality, in USRDS 2006 Annula data Report, chap 6. The National Institutes of Health, national Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2006, pp. 121-124.
48. Schell JO, Germain MJ, Finkelstein FO, Tulsky JA, Cohen LM: An integrative approach to advanced kidney disease in the elderly. Adv Chronic Kidney Dis 2010;17:368-377.
49. www.kidneynest.com

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Everything You Need to Know About Kidney Failure

14-18 minutes

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Your kidneys are a pair of organs located toward your lower back. One kidney is on each side of your spine. They filter your blood and remove toxins from your body. Kidneys send toxins to your bladder, which your body later removes toxins during urination.

Kidney failure occurs when your kidneys lose the ability to sufficiently filter waste from your blood. Many factors can interfere with your kidney health and function, such as:

• toxic exposure to environmental pollutants or certain medications
• certain acute and chronic diseases
• severe dehydration
• kidney trauma

Your body becomes overloaded with toxins if your kidneys can’t do their regular job. This can lead to kidney failure, which can be life-threatening if left untreated.

Usually someone with kidney failure will have a few symptoms of the disease. Sometimes no symptoms are present. Possible symptoms include:

• a reduced amount of urine
• swelling of your legs, ankles, and feet from retention of fluids caused by the failure of the kidneys to eliminate water waste
• unexplained shortness of breath
• excessive drowsiness or fatigue
• persistent nausea
• confusion
• pain or pressure in your chest
• seizures
• coma

Early signs of kidney failure

Symptoms of early stage kidney disease may be difficult to pinpoint. They’re often subtle and hard to identify. If you experience early signs of kidney disease, they may include:

• decreased urine output
• fluid retention that leads to swelling in limbs
• shortness of breath

Kidney failure can be the result of several conditions or causes. The cause typically also determines the type of kidney failure.

People who are most at risk usually have one or more of the following causes:

Loss of blood flow to the kidneys

A sudden loss of blood flow to your kidneys can prompt kidney failure. Some conditions that cause loss of blood flow to the kidneys include:

• a heart attack
• heart disease
• scarring of the liver or liver failure
• dehydration
• a severe burn
• an allergic reaction
• a severe infection, such as sepsis

High blood pressure and anti-inflammatory medications can also limit blood flow.

Urine elimination problems

When your body can’t eliminate urine, toxins build up and overload the kidneys. Some cancers can block the urine passageways, such as:

• prostate (most common type in men)
• colon
• cervical
• bladder

Other conditions can interfere with urination and possibly lead to kidney failure, including:

• kidney stones
• an enlarged prostate
• blood clots within your urinary tract
• damage to your nerves that control your bladder

Other causes

Some other things that may lead to kidney failure include:

• a blood clot in or around your kidneys
• infection
• an overload of toxins from heavy metals
• drugs and alcohol
• vasculitis, an inflammation of blood vessels
• lupus, an autoimmune disease that can cause inflammation of many body organs
• glomerulonephritis, an inflammation of the small blood vessels of the kidneys
• hemolytic uremic syndrome, which involves the breakdown of red blood cells following a bacterial infection, usually of the intestines
• multiple myeloma, a cancer of the plasma cells in your bone marrow
• scleroderma, an autoimmune condition that affects your skin
• thrombotic thrombocytopenic purpura, a disorder that causes blood clots in small vessels
• chemotherapy drugs that treat cancer and some autoimmune diseases
• dyes used in some imaging tests
• certain antibiotics
• uncontrolled diabetes

5 types of kidney failure

There are five different types of kidney failure:

Acute prerenal kidney failure

Insufficient blood flow to the kidneys can cause acute prerenal kidney failure. The kidneys can’t filter toxins from the blood without enough blood flow. This type of kidney failure can usually be cured once your doctor determines the cause of the decreased blood flow.

Acute intrinsic kidney failure

Acute intrinsic kidney failure can result from direct trauma to the kidneys, such as physical impact or an accident. Causes also include toxin overload and ischemia, which is a lack of oxygen to the kidneys.

The following may cause ischemia:

• severe bleeding
• shock
• renal blood vessel obstruction
• glomerulonephritis

Chronic prerenal kidney failure

When there isn’t enough blood flowing to the kidneys for an extended period of time, the kidneys begin to shrink and lose the ability to function.

Chronic intrinsic kidney failure

This happens when there’s long-term damage to the kidneys due to intrinsic kidney disease. Intrinsic kidney disease develops from a direct trauma to the kidneys, such as severe bleeding or a lack of oxygen.

Chronic post-renal kidney failure

A long-term blockage of the urinary tract prevents urination. This causes pressure and eventual kidney damage.

There are several tests your doctor can use to diagnose kidney failure.

Urinalysis

Your doctor may take a urine sample to test for any abnormalities, including abnormal protein or sugar that spills into the urine.

They may also perform a urinary sediment examination. This test measures the amount of red and white blood cells, looks for high levels of bacteria, and searches for high numbers of tube-shaped particles called cellular casts.

Urine volume measurements

Measuring urine output is one of the simplest tests to help diagnose kidney failure. For example, low urinary output may suggest that kidney disease is due to a urinary blockage, which multiple illnesses or injuries can cause.

Blood samples

Your doctor may order blood tests to measure substances that are filtered by your kidneys, such as blood urea nitrogen (BUN) and creatinine (Cr). A rapid rise in these levels may indicate acute kidney failure.

Imaging

Tests like ultrasounds, MRIs, and CT scans provide images of the kidneys themselves as well as the urinary tract. This allows your doctor to look for blockages or abnormalities in your kidneys.

Kidney tissue sample

Tissue samples are examined for abnormal deposits, scarring, or infectious organisms. Your doctor will use a kidney biopsy to collect the tissue sample. A biopsy is a simple procedure that’s usually performed while you’re awake.

Your doctor will give you a local anesthetic so you don’t feel any pain. They’ll then insert a biopsy needle through your skin and down into your kidney to get the sample. X-ray or ultrasound equipment will locate the kidneys and help your doctor in guiding the needle.

These tests can help determine whether your kidneys are functioning as they should. Other kidney function tests may also help your doctor determine what’s causing the symptoms.

Kidney failure is classified into five stages. These range from very mild (stage 1) to complete kidney failure (stage 5). Symptoms and complications increase as the stages progress.

Stage 1

This stage is very mild. You may experience no symptoms and have no visible complications. Some damage is present.

It’s still possible to manage and slow progression by maintaining a healthy lifestyle. This includes eating a balanced diet, regularly exercising, and not using tobacco products. Maintaining a healthy weight is important, too.

If you have diabetes, it’s important to manage your blood sugar.

Stage 2

Stage 2 kidney disease is still considered a mild form, but detectable issues like protein in urine or physical damage to the kidneys may be more obvious.

The same lifestyle approaches that helped in stage 1 are still used in stage 2. Also talk with your doctor about other risk factors that could make the disease progress more rapidly. These include heart disease, inflammation, and blood disorders.

Stage 3

At this stage kidney disease is considered moderate. Your kidneys aren’t working as well as they should.

Stage 3 kidney disease is sometimes divided into 3A and 3B. A blood test that measures the amount of waste products in your body differentiates between the two.

Symptoms may become more apparent at this stage. Swelling in hands and feet, back pain, and changes to urination frequently are likely.

Lifestyle approaches may help. Your doctor may also consider medications to treat underlying conditions that could speed up failure.

Stage 4

Stage 4 kidney disease is considered moderate to severe. The kidneys aren’t working well, but you’re not in complete kidney failure yet. Symptoms can include complications like anemia, high blood pressure, and bone disease.

A healthy lifestyle is still vital. Your doctor will likely have you on treatments designed to slow damage.

Stage 5

In stage 5, your kidneys are nearing or are in complete failure. Symptoms of the loss of kidney function will be evident. These include vomiting and nausea, trouble breathing, itchy skin, and more.

At this stage you’ll need regular dialysis or a kidney transplant.

There are several treatments for kidney failure. The type of treatment you need will depend on the reason for your kidney failure.

Dialysis

Dialysis filters and purifies the blood using a machine. The machine performs the function of the kidneys. Depending on the type of dialysis, you may be connected to a large machine or a portable catheter bag.

You may need to follow a low-potassium, low-salt diet along with dialysis.

Dialysis doesn’t cure kidney failure, but it can extend your life if you go to regularly scheduled treatments.

Kidney transplant

Another treatment option is a kidney transplant. A transplanted kidney can work normally, and dialysis is no longer needed.

There’s usually a long wait to receive a donor kidney that’s compatible with your body. If you have a living donor the process may go more quickly.

You must take immunosuppressive drugs after the surgery to prevent your body from rejecting the new kidney. These drugs have their own side effects, some of which are serious.

Transplant surgery might not be the right treatment option for everyone. It’s also possible for the surgery to be unsuccessful.

Talk with your doctor about whether you’re a good candidate for a kidney transplant.

There’s no specific diet for people with kidney failure. The guidelines for what you eat will often depend on the stage of kidney disease you have and your individual health. Some recommendations might include:

• Limit sodium and potassium. Keep track of how much you’re taking in of these two nutrients. Aim to eat fewer than 2,000 milligrams per day of both.
• Limit phosphorus. Like sodium and potassium, it’s good to keep a cap on the amount of phosphorus you eat in a day. Try to stay below 1,000 milligrams.
• Follow protein guidelines. In early and moderate kidney disease, you might want to cut back on protein consumption. In end-stage kidney failure, however, you may eat more protein, depending on your doctor’s recommendations.

Beyond these general guidelines, you may also be told to avoid certain foods if you have kidney disease.

The color of your urine is a small window into your body’s health. It doesn’t tell you much about the state of your kidney function until damage to the kidneys has progressed.

Still, changes to urine color may alert you of some issues.

• Clear or pale yellow. This color indicates you’re well hydrated. This is the ideal color in most cases.
• Dark yellow or amber. You may be dehydrated. Try drinking more water and cutting down on dark sodas, tea, or coffee.
• Orange. This could be a sign of dehydration, or it might be a sign of bile in your bloodstream. Kidney disease doesn’t typically cause this.
• Pink or red. Urine with a pink tint or bit of red could have blood in it. It could also be caused by certain foods, like beets or strawberries. A quick urine test can tell the difference.
• Foamy. Urine with excess bubbles is a sign that it likely has a lot of protein in it. Protein in urine is a sign of kidney disease.

Urine color can raise flags for potential problems. Learn about the common color causes and what’s most likely to affect the shade of your pee.

Diabetes is the most common cause of kidney failure. Uncontrolled high blood sugar can damage kidneys. The damage can become worse over time.

Diabetic nephropathy, or kidney damage caused by type 1 or type 2 diabetes, can’t be reversed. Managing blood sugar and blood pressure can help reduce damage. Taking medicines prescribed by your doctor is important, too.

If you have diabetes, your doctor will likely perform regular screenings to monitor for kidney failure.

Your risk for diabetic nephropathy increases the longer you live with the condition. Find out what other factors may increase your risk for this type of kidney disease.

It’s not possible to know exactly how long a person with kidney failure will live. Every person with kidney failure is different.

In general, a person on dialysis can expect to live for an average of 5 to 10 years as long as they follow their treatment.

Some factors that play a role in life expectancy are:

• age
• stage of kidney disease
• other coexisting conditions

A young person in midstage kidney failure who has no complicating risk factors or other conditions will likely live longer than an older individual with stage 4 or stage 5 kidney failure plus diabetes or cardiovascular disease.

Once you reach end-stage kidney failure, you will need dialysis to live. Missing even one treatment can decrease your life expectancy.

A kidney transplant is likely to last for about 5 to 10 years. It’s possible to get a second transplant after the first transplant fails.

If you have kidney failure and drink alcohol, your kidneys will be forced to work harder than they already are.

Alcohol doesn’t metabolize out of your system, so you’ll feel its effects until you receive dialysis to filter it out of your blood.

Beer and wine contain large amounts of phosphorous. It can cause severe heart issues and even death if your kidneys are unable to filter it out. However, most hard liquor doesn’t carry the same risk.

If you have kidney failure or late-stage kidney disease, your doctor may recommend you limit how often you drink alcohol. For some people, completely eliminating alcohol from the diet may be best.

Drinking alcohol with kidney failure can hurt the normal function of other organs. Over time, long-term, heavy alcohol use can lead to liver disease.

Alcohol use may cause additional symptoms, such as pain. Find out how drinking alcohol causes back and flank pain.

The prognosis, or outlook, for people with kidney failure depends on several factors. These include the underlying cause, how well that cause is treated, and any complicating factors, like high blood pressure or diabetes.

Proper treatment and healthy lifestyle changes may be able to improve your outlook. Eating a healthy diet, cutting back on kidney-damaging foods, and treating any underlying issues can help extend your health and your life.

There are steps you can take to reduce your risk for kidney failure.

Follow directions when taking over-the-counter medications. Taking doses that are too high (even of common drugs like aspirin) can create high toxin levels in a short amount of time. This can overload your kidneys.

Many kidney or urinary tract conditions lead to kidney failure when they’re not properly managed. You can help reduce your risk for kidney failure by:

• maintaining a healthy lifestyle
• following your doctor’s advice
• taking prescribed medicine as directed
• treating common causes of kidney failure, such as high blood pressure and diabetes

If you have any concerns about your kidneys, don’t hesitate to reach out to your doctor.

Credit

Helathline.com

The 20 Best Foods for People With Kidney Problems

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Kidney disease is a common problem affecting about 10% of the world’s population (1).

The kidneys are small but powerful bean-shaped organs that perform many important functions.

They are responsible for filtering waste products, releasing hormones that regulate blood pressure, balancing fluids in the body, producing urine and many other essential tasks (2).

There are various ways in which these vital organs can become damaged.

Diabetes and high blood pressure are the most common risk factors for kidney disease. However, obesity, smoking, genetics, gender and age can also increase the risk (3Trusted Source).

Uncontrolled blood sugar and high blood pressure cause damage to blood vessels in the kidneys, reducing their ability to function at an optimal level (4Trusted Source).

When the kidneys aren’t working properly, waste builds up in the blood, including waste products from food (5Trusted Source).

Therefore, it’s necessary for people with kidney disease to follow a special diet.

Dietary restrictions vary depending on the level of kidney damage.

For example, people in the early stages of kidney disease have different restrictions than those with kidney failure, also known as end-stage renal disease (ESRD) (6Trusted Source, 7Trusted Source).

If you have kidney disease, your health care provider will determine the best diet for your individual needs.

For most people with advanced kidney disease, it’s important to follow a kidney-friendly diet that helps decrease the amount of waste in the blood.

This diet is often referred to as a renal diet.

It helps boost kidney function while preventing further damage (8Trusted Source).

While dietary restrictions vary, it is commonly recommended that all people with kidney disease restrict the following nutrients:

• Sodium: Sodium is found in many foods and a major component of table salt. Damaged kidneys can’t filter out excess sodium, causing its blood levels to rise. It’s often recommended to limit sodium to less than 2,000 mg per day (9Trusted Source, 10).
• Potassium: Potassium plays many critical roles in the body, but those with kidney disease need to limit potassium to avoid dangerously high blood levels. It’s usually recommended to limit potassium to less than 2,000 mg per day (11Trusted Source, 12).
• Phosphorus: Damaged kidneys can’t remove excess phosphorus, a mineral in many foods. High levels can cause damage to the body, so dietary phosphorus is restricted to less than 800–1,000 mg per day in most patients (13, 14Trusted Source).

Protein is another nutrient that people with kidney disease may need to limit, as waste products from protein metabolism can’t be cleared out by damaged kidneys.

However, those with end-stage renal disease undergoing dialysis, a treatment that filters and cleans the blood, have greater protein needs (15Trusted Source, 16Trusted Source).

Each person with kidney disease is different, which is why it’s important to talk to your healthcare provider about your individual dietary needs.

Luckily, many delicious and healthy options are low in phosphorus, potassium and sodium.

Here are 20 of the best foods for people with kidney problems.

Cauliflower is a nutritious vegetable that is high in many nutrients, including vitamin C, vitamin K and the B vitamin folate.

It’s also full of anti-inflammatory compounds like indoles and an excellent source of fiber (17Trusted Source).

Plus, mashed cauliflower can be used in place of potatoes for a low-potassium side dish.

One cup (124 grams) of cooked cauliflower contains (18):

• Sodium: 19 mg
• Potassium: 176 mg
• Phosphorus: 40 mg

Blueberries are packed with nutrients and one of the best sources of antioxidants you can eat (19Trusted Source).

In particular, these sweet berries contain antioxidants called anthocyanins, which may protect against heart disease, certain cancers, cognitive decline and diabetes (20).

They also make a fantastic addition to a kidney-friendly diet, as they are low in sodium, phosphorus and potassium.

One cup (148 grams) of fresh blueberries contains (21):

• Sodium: 1.5 mg
• Potassium: 114 mg
• Phosphorus: 18 mg

Sea bass is a high-quality protein that contains incredibly healthy fats called omega-3s.

Omega-3s help reduce inflammation and may help decrease the risk of cognitive decline, depression and anxiety (22Trusted Source, 23Trusted Source, 24Trusted Source).

While all fish are high in phosphorus, sea bass contains lower amounts than other seafood choices.

However, it’s important to consume small portions in order to keep phosphorus levels in check.

Three ounces (85 grams) of cooked sea bass contain (25):

• Sodium: 74 mg
• Potassium: 279 mg
• Phosphorus: 211 mg

Not only are red grapes delicious, they also deliver a ton of nutrition in a small package.

Red grapes are high in vitamin C and contain antioxidants called flavonoids, which have been shown to reduce inflammation (26Trusted Source).

Additionally, red grapes are high in resveratrol, a type of flavonoid that has been shown to benefit heart health and protect against diabetes and cognitive decline (27Trusted Source, 28Trusted Source).

These sweet fruits are kidney-friendly, with a half cup (75 grams) containing (29):

• Sodium: 1.5 mg
• Potassium: 144 mg
• Phosphorus: 15 mg

Although egg yolks are very nutritious, they contain high amounts of phosphorus, making egg whites a better choice for people following a renal diet.

Egg whites provide a high-quality, kidney-friendly source of protein.

Not to mention, they are an excellent choice for people undergoing dialysis treatment, as they have higher protein needs but need to limit phosphorus.

Two large egg whites (66 grams) contain (30):

• Sodium: 110 mg
• Potassium: 108 mg
• Phosphorus: 10 mg

People with kidney problems are advised to limit the amount of sodium in their diet, including added salt.

Garlic provides a delicious alternative to salt, adding flavor to dishes while providing nutritional benefits.

It’s a good source of manganese, vitamin C and vitamin B6 and contains sulfur compounds that have anti-inflammatory properties.

Three cloves (9 grams) of garlic contain (31):

• Sodium: 1.5 mg
• Potassium: 36 mg
• Phosphorus: 14 mg

Many whole grains tend to be high in phosphorus, but buckwheat is a healthy exception.

Buckwheat is highly nutritious, providing a good amount of B vitamins, magnesium, iron and fiber.

It is also a gluten-free grain, making buckwheat a good choice for people with celiac disease or gluten intolerance.

A half cup (84 grams) of cooked buckwheat contains (32):

• Sodium: 3.5 mg
• Potassium: 74 mg
• Phosphorus: 59 mg

Olive oil is a healthy source of fat and phosphorus-free, making it a great option for people with kidney disease.

Frequently, people with advanced kidney disease have trouble keeping weight on, making healthy, high-calorie foods like olive oil important (33).

The majority of fat in olive oil is a monounsaturated fat called oleic acid, which has anti-inflammatory properties (34Trusted Source).

What’s more, monounsaturated fats are stable at high temperatures, making olive oil a healthy choice for cooking.

One ounce (28 grams) of olive oil contains (35):

• Sodium: 0.6 mg
• Potassium: 0.3 mg
• Phosphorus: 0 mg

Bulgur is an ancient grain that makes a terrific, kidney-friendly alternative to other whole grains that are high in phosphorus and potassium.

This nutritious grain is a good source of B vitamins, magnesium, iron and manganese.

It’s also an excellent source of plant-based protein and full of dietary fiber, which is important for digestive health.

A half-cup (91-gram) serving of bulgur contains (36):

• Sodium: 4.5 mg
• Potassium: 62 mg
• Phosphorus: 36 mg

Cabbage belongs to the cruciferous vegetable family and is loaded with vitamins, minerals and powerful plant compounds.

It’s a great source of vitamin K, vitamin C and many B vitamins.

Furthermore, it provides insoluble fiber, a type of fiber that keeps your digestive system healthy by promoting regular bowel movements and adding bulk to stools (37Trusted Source).

Plus, it’s low in potassium, phosphorus and sodium with one cup (70 grams) of shredded cabbage containing (38):

• Sodium: 13 mg
• Potassium: 119 mg
• Phosphorus: 18 mg

Although a limited protein intake is necessary for some people with kidney issues, providing the body with an adequate amount of high-quality protein is vital for health.

Skinless chicken breast contains less phosphorus, potassium and sodium than skin-on chicken.

When shopping for chicken, choose fresh chicken and avoid pre-made roasted chicken, as it contains large amounts of sodium and phosphorus.

Three ounces (84 grams) of skinless chicken breast contains (39):

• Sodium: 63 mg
• Potassium: 216 mg
• Phosphorus: 192 mg

Bell peppers contain an impressive amount of nutrients but are low in potassium, unlike many other vegetables.

These brightly colored peppers are loaded with the powerful antioxidant vitamin C.

In fact, one small red bell pepper (74 grams) contains 158% of the recommended intake of vitamin C.

They are also loaded with vitamin A, an important nutrient for immune function, which is often compromised in people with kidney disease (40).

One small red pepper (74 grams) contains (41):

• Sodium: 3 mg
• Potassium: 156 mg
• Phosphorus: 19 mg

Onions are excellent for providing sodium-free flavor to renal-diet dishes.

Reducing salt can be difficult for many patients, making finding flavorful salt alternatives a must.

Sautéeing onions with garlic and olive oil adds flavor to dishes without compromising your kidney health.

What’s more, onions are high in vitamin C, manganese and B vitamins and contain prebiotic fibers that help keep your digestive system healthy by feeding beneficial gut bacteria (42Trusted Source.

One small onion (70 grams) contains (43):

• Sodium: 3 mg
• Potassium: 102 mg
• Phosphorus: 20 mg

Many healthy greens like spinach and kale are high in potassium and difficult to fit into a renal diet.

However, arugula is a nutrient-dense green that is low in potassium, making it a good choice for kidney-friendly salads and side dishes.

Arugula is a good source of vitamin K and the minerals manganese and calcium, all of which are important for bone health.

This nutritious green also contains nitrates, which have been shown to lower blood pressure, an important benefit for those with kidney disease (44Trusted Source).

One cup (20 grams) of raw arugula contains (45):

• Sodium: 6 mg
• Potassium: 74 mg
• Phosphorus: 10 mg

Most nuts are high in phosphorus and not recommended for those following a renal diet.

However, macadamia nuts are a delicious option for people with kidney problems. They are much lower in phosphorus than popular nuts like peanuts and almonds.

They are also packed with healthy fats, B vitamins, magnesium, copper, iron and manganese.

One ounce (28 grams) of macadamia nuts contains (46):

• Sodium: 1.4 mg
• Potassium: 103 mg
• Phosphorus: 53 mg

Radishes are crunchy vegetables that make a healthy addition to a renal diet.

This is because they are very low in potassium and phosphorus but high in many other important nutrients.

Radishes are a great source of vitamin C, an antioxidant that has been shown to decrease the risk of heart disease and cataracts (47Trusted Source, 48Trusted Source).

Additionally, their peppery taste makes a flavorful addition to low-sodium dishes.

A half cup (58 grams) of sliced radishes contains (49):

• Sodium: 23 mg
• Potassium: 135 mg
• Phosphorus: 12 mg

Turnips are kidney-friendly and make an excellent replacement for vegetables that are higher in potassium like potatoes and winter squash.

These root vegetables are loaded with fiber and nutrients like vitamin C, vitamin B6, manganese and calcium.

They can be roasted or boiled and mashed for a healthy side dish that works well for a renal diet.

A half cup (78 grams) of cooked turnips contains (50):

• Sodium: 12.5 mg
• Potassium: 138 mg
• Phosphorus: 20 mg

Many tropical fruits like oranges, bananas and kiwis are very high in potassium.

Luckily, pineapple makes a sweet, low-potassium alternative for those with kidneys problems.

Plus, pineapple is rich in fiber, B vitamins, manganese and bromelain, an enzyme that helps reduce inflammation (51).

One cup (165 grams) of pineapple chunks contains (52):

• Sodium: 2 mg
• Potassium: 180 mg
• Phosphorus: 13 mg

Cranberries benefit both the urinary tract and kidneys.

These tiny, tart fruits contain phytonutrients called A-type proanthocyanidins, which prevent bacteria from sticking to the lining of the urinary tract and bladder, thus preventing infection (53, 54Trusted Source).

This is helpful for those with kidney disease, as they have an increased risk of urinary tract infections (55).

Cranberries can be eaten dried, cooked, fresh or as a juice. They are very low in potassium, phosphorus and sodium.

One cup (100 grams) of fresh cranberries contains (56):

• Sodium: 2 mg
• Potassium: 85 mg
• Phosphorus: 13 mg

Shiitake mushrooms are a savory ingredient that can be used as a plant-based meat substitute for those on a renal diet who need to limit protein.

They are an excellent source of B vitamins, copper, manganese and selenium.

In addition, they provide a good amount of plant-based protein and dietary fiber.

Shiitake mushrooms are lower in potassium than portobello and white button mushrooms, making them a smart choice for those following a renal diet (57, 58).

One cup (145 grams) of cooked shiitake mushroom contains (59):

• Sodium: 6 mg
• Potassium: 170 mg
• Phosphorus: 42 mg

The kidney-friendly foods above are excellent choices for people following a renal diet.

Remember to always discuss your food choices with your healthcare provider to ensure that you are following the best diet for your individual needs.

Dietary restrictions vary depending on the type and level of kidney damage, as well as the medical interventions in place, such as medications or dialysis treatment.

While following a renal diet can feel restrictive at times, there are plenty of delicious foods that fit into a healthy, well-balanced and kidney-friendly meal plan.

Credit

Healthline.com

A

Management of Adolescent Obesity

Shawn Riser Taylor, PharmD, CDEAssistant Professor of PharmacyWingate University School of PharmacyHendersonville, North CarolinaDavid S. Taylor, PharmDStaff PharmacistIngles MarketsBlack Mountain, North Carolina 18-23 minutes

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US Pharm. 2015;40(5):35-38.

ABSTRACT: The etiology of adolescent obesity relates to both genetic makeup and environmental factors such as increased consumption of high-energy foods and decreased physical activity. Prevention of obesity during childhood is supported by numerous philanthropic efforts in the United States; however, primary preventive measures often are not implemented appropriately, resulting in adolescent obesity. Secondary and tertiary prevention strategies facilitated by a multidisciplinary healthcare team incorporate structured behavioral interventions to prevent adult obesity. Beyond nonpharmacologic therapies, evidence supports the use of pharmacologic agents and surgical procedures for adolescent obesity management in certain populations.

According to the CDC, approximately 12.7 million children and adolescents in the United States are obese, totaling 17% of the population aged 2 to 19 years.¹ As with adult obesity, risk factors for childhood obesity include race, age, and social class.^2-4 In addition, parental factors such as education level and income have been noted to impact the prevalence of childhood obesity.Complications secondary to adolescent obesity, including hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), align with those of adult obesity; however, these complications may yield higher mortality outcomes, owing to the younger age at onset and the limited use of pharmacologic and surgical methods in this population.⁵ This review article aims to summarize the etiology, diagnosis, prevention, and treatment of adolescent obesity.

Etiology

The cause of adolescent obesity is regarded as multifaceted, given the numerous components that increase a child’s risk of developing the condition. First, there is a known genetic link, as described in a study of twins with heritability estimates between 0.5 and 0.9.⁶ Accounting for a much larger proportion of cases is the number of environmental factors in the adolescent’s home. In one report, children aged <3 years being raised by obese parent(s) were more likely to become obese, which reflects an environmental, not genetic, etiology.⁷ Additionally, variables outside the home—e.g., increased availability of high-energy foods and sugar-filled beverages at school, minimal advertising of healthful foods, lack of required physical activity at school, larger portion sizes, and more time looking at screens—have contributed to the current rates of adolescent obesity in the U.S.^8-16 These factors can present challenges for any child regardless of social status, but children of low-income families often face further barriers to achieving a healthy lifestyle, including the lack of safe areas for physical activity and the expense of healthful food choices.^14,17

Diagnosis

The diagnosis of obesity in the adolescent population is determined by BMI.⁵ In children aged 2 to 18 years, cutoff BMI points of ≥95th percentile and ≥99th percentile per adolescent age correspond to obesity and severe obesity, respectively. Because measurements of weight and height are easily obtainable, most healthcare providers should feel proficient in assessing for adolescent obesity. Beyond diagnosis, depending upon the severity of the obesity, behavioral, pharmacologic, and surgical interventions may be necessary from numerous supporters, including healthcare providers.

Methods

For this review, a systematic search was conducted via PubMed to identify literature reports relating to obesity in the adolescent population. Medical Subject Headings (MeSH) included “obesity,” “adolescent,” “pediatric,” and “child.” Initial results were limited to clinical trials from 2004 to the present that were conducted in human subjects and written in English. Applicable guidelines and further relevant trials were identified from the initial retrieved primary literature search.

Nonpharmacologic Prevention and Treatment

The importance of preventing adolescent obesity through lifestyle modification is well documented and supported by billions of dollars of research in the U.S. Many health-focused philanthropies, such as the Robert Wood Johnson Foundation, develop and maintain programs to slow or reverse progression of overweight or obesity in childhood.¹⁸ Behaviors that increase the risk of obesity are often easily identified, but persuading the whole family to change these behaviors remains a challenge, given that the promotion of excess energy consumption is ubiquitous in today’s society.¹⁹

The Academy of Nutrition and Dietetics (A.N.D.) classifies pediatric overweight and obesity prevention into primary, secondary, and tertiary strategies. Primary prevention measures are designed to prevent adolescent obesity, and secondary and tertiary prevention measures are designed to prevent progression of adolescent obesity to adult obesity.²⁰ Primary prevention incorporates a lifestyle or system-level approach for all adolescents, regardless of weight. In this strategy, the adolescent’s environment is evaluated for possible attributing risk factors, and programs on general topics such as healthy eating and physical activity are promoted. These interventions are generally widespread and available to the entire population via family-, school-, and community-based programs. The Expert Committee recommendations report regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity endorses the application of motivational interviewing or the stages of change theory, which takes into account the individual’s readiness to change.⁵ This strategy also allows the provider to assess the willingness and understanding of the adolescent and his or her family and to provide incentives.^5,21,22 The A.N.D. endorses incorporation of both physical activity and nutritional interventions, since the combination of measures has been proven effective in improving adolescent adiposity, whereas using a single intervention is less beneficial.²⁰

The secondary prevention strategy centers on the overweight or obese adolescent as an individual, and incorporates a structured interventional method of change.²⁰ In the tertiary prevention stage, which is the most intensive strategy, management of overweight or obesity with pharmacologic therapies or bariatric surgical procedures may be considered. A multidisciplinary intervention team, including a provider and a dietitian or clinician who can provide nutritional education, should be implemented in the secondary and tertiary prevention stages. No matter which prevention strategy is indicated, participation of the adolescent and anyone who has an influence on the adolescent’s behavior via multifaceted behavioral modification measures is recommended.

Pharmacologic Management

Several pharmacologic agents are FDA-approved for weight management. Orlistat, a lipase inhibitor that directly affects fat absorption, is the only pharmacologic agent approved for the treatment of obesity in the adolescent population.²³ Specifically, the 120-mg prescription strength is approved, not the OTC formulation, owing to the need for provider monitoring.

Chanoine and colleagues conducted the largest study detailing the benefit and tolerability of orlistat in an adolescent population also receiving dietary and exercise counseling.²⁴ The adolescents, with a mean age of 13 years and a BMI of 35.4 kg/m², were randomized to receive orlistat 120 mg three times daily with meals or placebo for 52 weeks. Significant improvements in body weight (BW), waist circumference, BMI, and diastolic blood pressure were seen in adolescents taking orlistat versus those given placebo. Additionally, significantly more adolescents taking orlistat achieved at least 5% and 10% total BW reduction—which coincides with T2DM risk reduction occurrence in an adult population—compared with placebo (19% and 11%, respectively, P = .03; 9.5% and 3.3%, respectively, P = .01).²⁵ Adverse effects (AEs) associated with orlistat therapy, mostly gastrointestinal (GI), were consistent with phase III studies conducted in adults; however, these AEs occurred more often in adolescents than in subjects in manufacturer reports. The greater risk of GI AEs in adolescents compared with adults could be related to greater receptiveness and adherence to recommended dietary modifications on the part of adults. Discontinuation of therapy because of an AE was greater in the placebo group than in the orlistat group. To date, there is no literature regarding use of orlistat beyond 1 year in adolescents; however, data in adults demonstrate safety with long-term use.

Five glucagon-like peptide-1 (GLP-1) agonists are FDA-approved for management of T2DM in adults; one of these, liraglutide, is also approved for weight management.²³ Based on their efficacy and relative tolerability, GLP-1 agonists have been proposed as a viable pharmacologic agent for weight management in adolescents. The longest trial evaluating the use of GLP-1 agonist therapy in obese adolescents, a crossover pilot study conducted by Kelly and colleagues, investigated the safety and efficacy of exenatide titrated to 10 mcg twice daily over 6 months in 11 adolescents (mean age 12 years and BMI 36.7 kg/m²).²⁶ BMI, BW, insulin, and beta-cell function were significantly improved in the exenatide group versus controls (–0.9 vs. 0.84 kg/m², P = .01; –0.99 vs. 2.97 kg, P = .017; –1.62 vs. 6 mU/L, P = .017; 14.5 vs. –1.16, P = .034, respectively). All AEs were considered mild, and the AE most commonly reported was nausea, followed by vomiting and headache. Further research is needed prior to approval of GLP-1 agonists to manage adolescent obesity; however, there is currently no evidence to suggest that the tolerability, pharmacology, and pharmacokinetics of exenatide in adolescents differ from those in adults.

There is little primary literature evaluating the use of other weight-management medications approved by the FDA for use in adults, such as phentermine, phentermine plus topiramate, bupropion plus naltrexone, and lorcaserin. A study of the use of topiramate for reducing migraine occurrence in adolescents (mean age 14 years) revealed an approximate rate of AEs of 30%, with cognitive decline constituting the majority of AEs.²⁷ Given the AE profile of phentermine-containing products, use is not recommended in adolescents aged <16 years.²³ Overall, evidence regarding the pharmacologic weight management of adolescent obesity is limited. Orlistat is the only FDA-approved agent recommended for use in adolescents, and exenatide has shown promise with regard to efficacy; however, more safety data are needed.

Surgical Management

For adolescents diagnosed with severe obesity who have failed weight-management interventions despite organized multidisciplinary means or pharmacologic management, bariatric surgery is an option.^28,29 The bariatric surgical procedures most commonly performed in obese adolescents are the Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and vertical sleeve gastrectomy (VSG). RYGB yields the greatest weight loss; however, LAGB is being increasingly performed in adolescents because of its shorter overall hospital stay and operating time.²⁹ Third-party coverage of any type of bariatric surgery in adolescents is rare because the procedures are FDA-approved for use in adults only.³⁰

In 2013, a meta-analysis of 23 trials evaluated the safety and efficacy of RYGB, LABG, VSG, and biliopancreatic diversion in 637 patients with mean ages of 6 to 18 years at enrollment.³¹ Mean BMI was reduced by 17.2, 10.5, and 14.5 kg/m² following RYGB, LAGB, and VSG, respectively, 1 year post surgery. Complications were less likely following LAGB compared with RYGB in adolescents; however, LAGB recipients often required additional surgery.

Following publication of the Teen-Longitudinal Assessment of Bariatric Surgery study (the largest trial evaluating the safety of bariatric surgery in adolescents), VSG gained popularity, as it was shown to pose less risk of major postsurgery complications compared with RYGB and LAGB.³²

Despite short-term data showing marked weight loss and projected comorbidity improvement with bariatric surgery, the procedures remain a last resort for adolescent obesity management, owing to financial burden, lack of FDA approval, postsurgical AEs, and absence of long-term safety and efficacy data. In addition, behavioral approaches to managing weight have been shown more effective in adolescents compared with adults, which suggests that more invasive procedures, such as bariatric surgery, may not be necessary for the desired weight-loss outcome.⁷ In summary, the use of bariatric procedures in adolescents with a BMI ≥99th percentile for age has been documented to be relatively safe and effective over the last two decades, and this option may be considered if the adolescent and the family are in agreement.³²

Conclusion

Pharmacists in clinical and community practice settings can be instrumental in the management of adolescent obesity. Clinical pharmacists, who frequently are responsible for educating patients about obesity-related comorbidities, such as T2DM and hypertension, should provide nutritional education, as applicable, to both the adolescent and his or her family. Community pharmacists should be prudent when counseling about weight-management medications in order to ensure adherence and thereby maximize benefit achievement, given that the incidence of drug AEs may be greater in adolescents compared with adults. All healthcare providers can be influential in the prevention and management of adolescent obesity. This responsibility extends beyond the pharmacist, and a multidisciplinary team of providers should be involved in order to improve outcomes, mainly the prevention of adult obesity and comorbidity.

REFERENCES

1. CDC. Prevalence of childhood obesity in the United States, 2011-2012. www.cdc.gov/obesity/data/childhood.html. Accessed March 31, 2015.
2. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.
3. Gordon-Larsen P, Adair LS, Popkin BM. The relationship of ethnicity, socioeconomic factors, and overweight in US adolescents. Obes Res. 2003;11:121-129.
4. Miech RA, Kumanyika SK, Stettler N, et al. Trends in the association of poverty with overweight among US adolescents, 1971-2004. JAMA. 2006;295:2385-2393.
5. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.
6. Maes HH, Neale MC, Eaves LJ. Genetic and environmental factors in relative body weight and human adiposity. Behav Genet. 1997;27:325-351.
7. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869-873.
8. CDC. Children’s food environment state indicator report, 2011. www.cdc.gov/obesity/downloads/childrensfoodenvironment.pdf. Accessed March 31, 2015.
9. Committee on Food Marketing and the Diets of Children and Youth. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: National Academies Press; 2005.
10. Office of Child Care. Pathways and partnerships for child care excellence. www.acf.hhs.gov/sites/default/files/occ/pathways_partnerships_v1_0.pdf. Accessed March 31, 2015.
11. Kaphingst KM, Story M. Child care as an untapped setting for obesity prevention: state child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States. Prev Chronic Disease. 2009;6:1-13.
12. U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. www.health.gov/paguidelines/pdf/paguide.pdf. Accessed March 31, 2015.
13. Youth Risk Behavior Surveillance System. Trends in the prevalence of physical activity and sedentary behaviors national YRBS: 1991–2011. www.cdc.gov/HealthyYouth/yrbs/pdf/us_physical_trend_yrbs.pdf. Accessed March 31, 2015.
14. CDC. State Indicator Report on Physical Activity, 2010. Atlanta, GA: U.S. Department of Health and Human Services; 2010.
15. Johnson L, Mander AP, Jones LR, et al. A prospective analysis of dietary energy density at age 5 and 7 years and fatness at 9 years among UK children. Int J Obes (Lond). 2008;32:586-593.
16. Johnson L, Mander AP, Jones LR, et al. Energy-dense, low-fiber, high-fat dietary pattern is associated with increased fatness in childhood. Am J Clin Nutr. 2008;87:846-854.
17. Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36:74-81.
18. Robert Wood Johnson Foundation. Our topics. www.rwjf.org/en/our-topics.html. Accessed March 31, 2015.
19. Davis MM, Gance-Cleveland B, Hassink S, et al. Recommendations for prevention of childhood obesity. Pediatrics. 2007;120(suppl 4):S229-S253.
20. Hoelscher DM, Kirk S, Ritchie L, et al. Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity. J Acad Nutr Diet. 2013;113:1375-1394.
21. Prochaska JO, DiClemente CC. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, IL: Dorsey Press; 1991.
22. Rhee KE, De Lago CW, Arscott-Mills T, et al. Factors associated with parental readiness to make changes for overweight children. Pediatrics. 2005;116:e94-e101.
23. Lexi-Drugs [subscription database]. Orlistat. Hudson, OH: Lexi-Comp, Inc; 2015.
24. Chanoine JP, Hampl S, Jensen C, et al. Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial. JAMA. 2005;293:2873-2883.
25. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
26. Kelly AS, Metzig AM, Rudser KD, et al. Exenatide as a weight-loss therapy in extreme pediatric obesity: a randomized, controlled pilot study. Obesity (Silver Spring).2012;20:364-370.
27. Cruz MJ, Valencia I, Legido A, et al. Efficacy and tolerability of topiramate in pediatric migraine. Pediatr Neurol. 2009;41:167-170.
28. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114:217-223.
29. Zitsman JL, Inge TH, Reichard KW, et al. Pediatric and adolescent obesity: management, options for surgery, and outcomes. J Pediatr Surg. 2014;49:491-494.
30. Strain GW, Gagner M, Pomp A, et al. Comparison of weight loss and body composition changes with four surgical procedures. Surg Obes Relat Dis. 2009;5:582-587.
31. Black JA, White B, Viner RM, Simmons RK. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obes Rev. 2013;14:634-644.
32. Inge TH, Zeller MH, Jenkins TM, et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. JAMA Pediatr. 2014;168:47-53.