The Rehabilitation Role in Chronic Kidney and End Stage Renal Disease
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.
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 . 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 . The association with functional limitation has been observed not only in patients with ESRD  and moderate-severe CKD (mean GFR 25 ml/min/1.73 m2) , but also in subjects with milder CKD (mean GFR 50 ml/min/1.73 m2 ) . 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 . 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 . 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 . 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 , can be applied to patients with HD . Benefits associated with exercise training are improved peak VO2, cardiac function, quality of life, and sympatho-adrenal activity . Significant improvements in lean body mass, quadriceps muscle area, knee extension, hip abduction and flexion strength have been also reported . 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 . 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 . 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 . Only 13% of subjects after one year of HD maintain stable functionality . 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  and more recently, a patient centered intervention rather than disease treatment has been proposed . 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 . 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 . 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 .
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.
The author of this article confirm that there are no conflicts to state.
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