Italian Study Looks at the Effects of Exercise in Renal Transplant Recipients

A review of evidence-based results headed up by Giulio Romano, MD and Professor of Nephrology at Misericordia University Hospital, hoped to discover whether or not it is possible to reduce cardiovascular risk and influence graft (kidney) survival of renal transplant recipients (RTRs) other than pharmacologically. The idea came about because, even after a successful kidney transplant, the RTR continues suffering from the consequences of the illness accompanying kidney failure, uremia. And because RTRs already carry the burden of administering a large drug regimen, it becomes very important, the authors say, to introduce "non-pharmacological" therapies to end the medication madness. As you may have guessed, based on the URL of this blog, the "non-pharmacological" therapy in question is exercise.

Romano, Eric Lorenzon, and Domenico Montanaro (the paper's other two contributors) point out many studies have shown over the last twenty years that physical training can improve graft function, work capacity and quality of life, as well as reduce cardiovascular risk. Sadly, a large number of RTRs report low exercise rates. The reasons are varied. Some believe it is because of the fear of injuring the transplanted kidney and/or the transplant professionals' silence (read: ignorance) regarding the benefits of exercise. Other reasons may include an overly protective attitude of family and friends or are simply the result of a lack of structural support (something I strive to at least contribute to through this blog). Lastly, some patients of culturally and ethnically diverse backgrounds may not place a great deal of importance on exercise and self-maintenance.

Measured against the general population, renal patients are at an increased risk of having a cardiovascular event. With a mortality rate 10 to 20 times higher than the at-large population, cardiovascular events remain the major cause of death in kidney patients. The main cause of this elevated risk is accelerated atherosclerosis, which is a chronic inflammatory response in the walls of arteries. The threat of accelerated atherosclerosis continues into post-transplantation and is, in fact, the most important late complication for all organ recipients, representing the main cause of death in RTRs. What are the major risk factors associated with the development of atherosclerosis? High plasma cholesterol levels, high blood pressure, diabetes mellitus, smoking, and a sedentary lifestyle.

Romano et al note that because elevated levels of IL-6 represent a trigger factor of inflammation, they may significantly contribute to the cardiovascular risk of RTRs. Exercise, it has been shown, reduces the levels of IL-6 in RTRs. One note of caution, however, is that overtraining (i.e., strenuous exercise) actually increases IL-6 production. Therefore, the authors advocate RTRs perform an "appropriate level" of exercise consisting of 30-45 minutes of aerobics (walking or cycling) three or more times per week. So while an exercise regimen that is too intense may be bad, moderate exercise is good. When participating in what is considered to be an appropriate amount of exercise, physical strength in RTRs improve while IL-6 levels are reduced. The net biological effect, the authors say, is overwhelmingly positive.

A few other highlights of the review of the evidence-based results include:

• Greater physical activity is a statistically significant predictor of improved graft function over a one-year period, based on glomerular filtration rate. The authors believe that exercise leads to improved cardiovascular function, which likely improves perfusion and oxygen delivery to the grafted kidney.
• Exercise reduces the dependence on blood pressure medication for lung and kidney transplant recipients.
• Patients with advanced chronic kidney disease have lower cardiorespiratory fitness that remains reduced by 30% post-transplant, when compared against age and gender matched control subjects. Exercise improves cardiorespiratory fitness and muscle strength in RTRs.
• Homocysteine is a factor related to a higher prevalence of cardiovascular disease. It remains elevated in RTRs versus the general population, but physical activity may significantly lower the levels of this amino acid.
• Anxiety and depression are common among the RTR population and contribute to an increased cardiovascular risk. Exercise can reduce anxiety and depression in this group.

The authors conclude that an appropriate amount of exercise is a useful, safe, and non-pharmacological contribution to the transplant patient's treatment through the reduced risk of cardiovascular disease, the improvement of the grafted kidney's function, the increase of energetic metabolism, and an improved quality of life.

And regardless of the type we choose, the authors state that physical training can always yield remarkable health benefits. Yet despite all the positives outcomes associated with physical activity, most RTRs do not meet established minimum exercise guidelines. They call on the professional transplant community to consider exercise not as merely an assistant or luxury accessory, but as an integral part of the complex treatment of RTRs.

This article was published in the World Journal of Transplantation and can be accessed at:

http://www.wjgnet.com/2220-3230/full/v2/i4/46.htm

Please share and help get the word out!

Study: Being Physically Active at Work Does Not Sufficiently Fend Off Hypertension

According to a new study referenced in the National Kidney Foundation's blog, The Pressure Point, "recreational exercise for four hours each week was linked to a 19 percent lower risk of developing high blood pressure. But the health benefit did not extend to those who had similar levels of physical activity during the course of their work. They had the same high blood pressure risk as those in less physically taxing jobs."

At first glance, this didn't make much sense to me. But there is a logical explanation behind this finding. In our free time, we are the masters of the exercises we perform. We determine the type, length, and intensity of our workouts. We have the freedom to substitute, modify, and sometimes even walk away from our planned activities. On the job, we're usually more restricted in our familiar, repetitive movements. Our sessions and pace are frequently dictated by forces beyond our control, and oftentimes we're working under a deadline or quota system.  All of these factors can result in increased stress levels, leading to high blood pressure.

Another point worth mentioning is that, generally speaking, physical activity performed in the workplace emphasizes the upper body, and this can raise blood pressure, particularly if strenuous and repetitive. This is in contrast to lower body exercise (e.g. swimming, running), which promotes cardiovascular health and lower blood pressure.

Read the entire piece by Dr. George L. Bakris by following the link below: 

http://nkfpressurepoint.wordpress.com/2013/10/25/physical-activity-and-high-blood-pressure-risk-does-it-matter-where-you-exercise/

Some Side Effects of Prednisone That We Need to Know

I found this article about prednisone at http://www.cssassociation.org/, which is a site devoted to Churg Strauss Syndrome, a rare systemic autoimmune disease. The article is written by osteopathic physician Carol Kavanaugh and provides useful information for anyone currently taking prednisone.

Prednisone Part Two

This is the second in a series of articles written to address some of the metabolic problems one can encounter with the use of prednisone (a mainstay drug for most of us). Metabolism is defined as the chemical changes in living cells by which energy is provided for vital processes and activities and new material is assimilated.

In this article, I want to focus primarily on glucose metabloism and insulin resistance and a bit on weight and structural changes to the body on steroids.The next article will be a continuation of metabolic issues and we will discuss issues with lipid disorders provokes by both prednisone and vasculitis itself.

First of all, prednisone has many striking effects on the boday habitus (or body form). From the onset of taking the medicine a process of catabolism starts (catabolism is the breakdown of muscle). This is most striking in the quadriceps (thigh muscles), buttocks, and shoulder girdle (shoulder muscles and muscles in the upper arm). Many people on long term steroids develop very thin arms and legs. In contrast to this fat deposition and redistribution occur in strange places. Fat deposition occurs in the cheeks and temple area giving the classic moon face or the Charlie Brown face as I like to call it. Deposition occurs strongly across the trucal area (truncal obesity) and the upper thoracic area causing the proverbial 'buffalo hump'. The changes in the skin can cause striae or stretch marks. These changes in appearance altogether are known as a 'cushinoid appearance', referring to the classic appearance of a person with Cushings disease. Cushings disease is caused when the adrenal gland overproduces cortisol (prednisone like substance). The taking of steroids by mouth or by injection simulate the appearance of someone with Cushing's disease but when it is created by taking the medicine is it known as Cushings syndrome.

This process of breakdown of muscle and buildup of fat in unusual places is out of the control of the person taking the medicine. It is dose related and the higher the dose the more marked the body changes are. Some people are more resistant to these changes than others while some people are very sensitive to prednisone and even small doses cause marked changes in appearance. Remember, prednisone is a pro-obesity drug (it causes obesity).

One of the next things to occur is the process of insulin resistance. Again, some people are more sensitive to this process than others but almost all of us develop this to one degree or another. Insulin resistance is actually a precursor or forerunner to Type 2 diabetes.

Insulin resistance is defined as the following:

truncal obesity (fat deposition in the trunk area of the body)

hypertriglyceridemia (elevation of a type of blood fat)

increased BMI or body mass index (weight and height used to calculate and is more sensitive in measuring obesity than just weight alone)

increased waist to hip ratio_ (people with insulin resistance have more of an apple appearance than of a pear)

hypertension ( high blood pressure)

high serum insulin

A person with insulin resistance may not have every one of the criteria but usually have at least three. This process of insulin resistance is sometimes called Syndrome X. The significance of this syndrome is a) the propensity of developing full blown diabetes and 2) the striking increase of cardiovascular disease. Heart disease and cardiovascular disease start in this phase, long before the diagnosis of diabetes has been made or before blood sugars are ever abnormal.

Generally a person spends about ten years with insulin resistance prior to the development of diabetes, but this varies markedly. Steroids or prednisone intake markedly enhances insulin resistance and may speed up the progression to type 2 diabetes.

So what is this insulin resistance exactly? If you can envision little insulin molecules floating around in the blood stream, ready to bind to insulin receptors on the surface of the cells of the body. When they are able to bind then glucose is able to be taken up by the cells and processed for energy. In insuline resistance, the receptors on the cells are fewer in number and don't work as well. You can think of insulin and receptors like a lock and key mechanism. If there is no lock for this key to turn then things don't work. The body tries to compensate by increasing the amount of insulin in the body to help bind to the faulty and decreased number of receptors. Increased insulin levels help to start of the cascade of vascular disease and heart disease. This process occurs long before the glucose (blood sugar ) levels rise to an abnormal level.

Okay, now what do I do? I have to take medication to control my disease, the medicine is causing other problems - what do I do from here? First of all, just as in diabetes, weight loss and careful eating need to be the cornerstone of treatment. A diabetic type diet, limited in calories, fat and saturated fat and low in simple sugars and sweets needs to be started. Examples of foods that need to be avoided include desserts, sugary foods, soft drinks and limited in fruit juices. Fried foods, cheeses and marbled red meat need to be eaten sparingly. An increase in fiber intake is also helpful. Exercise, to the extent that you are able, is also encouraged. The advice of a dietician may be in order.

There is one study out there looking at the intake of chromium supplements to enhance sensitivity to insulin. Glucophage (metformin) may be taken even if the blood sugar is not elevated or only infrequently elevated. This is an excellent medicine to help control the process of insulin resistance. Actos and Avandia are other meds that can be use to help combat the process as well.

Get your physician to evaluate you for insulin resistance and formulate a strategy for you to help treat it. Rheumatologists are not always the ideal doctors (no offense to any rheumatologist) to treat this as it is not really the focus of their specialty training. If they are uncomfortable or uninterested ask your internist, family doctor or an endocrinologist for assistance. These type of doctors can also help treat any accompanying lipid disorders that may arise in conjucntion with Churg Strauss Syndrome and prednisone or steroid administration.

In the next article , I will discuss more on lipid disorders and vasculitis. None of these recommendations in this article are meant as a substitute for appropriate clinical exam (doctor exam) and evaluation.

God bless all of you and take care.

Carol Kavanaugh D.O.

CKD Patients' Risk For Heart Disease As High As Heart Attack Survivors?

Kidney disease may be as harmful to heart as heart attack

Updated: Jun 20, 2012 12:20 PM CDT

TUESDAY, June 19 (HealthDay News) -- People with chronic kidney disease may have the same level of risk for coronary heart disease as people who have previously had a heart attack, a new study suggests.

It has long been known that chronic kidney disease patients are at increased risk for heart attacks, but this is the first study to show that their risk for heart disease may be as high as heart attack survivors.

For the study, researchers compared the incidence of heart attacks and death among 1.3 million people in Canada with chronic kidney disease, diabetes, previous heart attack or a combination of these risk factors.

The risk of heart attack among people with chronic kidney disease, diabetes or both was comparable to that of people who previously had a heart attack, found lead researcher Dr. Marcello Tonelli, of the University of Alberta, and colleagues.

The findings, published online June 19 in the journal The Lancet, suggest that kidney disease could be used to help identify people at risk for coronary heart disease.

"Our research suggests that there is a strong case for considering chronic kidney disease to be a coronary heart disease risk equivalent, meaning people with chronic kidney disease are at a comparable risk of coronary events to those who have previously had a heart attack," Tonelli said in a journal news release.

"Chronic kidney disease patients have substantially higher rates of death from heart disease after a heart attack than the general population, which emphasizes the potential value of preventing coronary events through drug treatment and lifestyle interventions," Tonelli said. "The rate of death from heart disease among people with chronic kidney disease was similar to or higher than the rate of death among people with diabetes -- in whom the value of preventive treatments is well known."

The study findings need to be interpreted with caution, George Bakris, of the University of Chicago, noted in an accompanying editorial. Although the study was large, there was no information about patients' medication use or other factors such as blood pressure.

Because of this, the results do not "support classification of chronic kidney disease as a coronary heart disease risk equivalent," Bakris wrote in the editorial.

Prednisone's Effect on Exercise Capacity in the Kidney Transplant Recipient

A 2003 study published in Kidney International, the official journal of the International Society of Nephrology, concludes that prednisone may contribute to lower spontaneous improvements in exercise capacity, possibly by limiting increases in muscle strength. The researchers further conclude that the low exercise capacity found in all transplant recipients, whether taking prednisone or not, at one year post-transplant suggests a need for patient exercise training to optimize physical functioning.

The basis for the study was that although exercise capacity increases significantly after transplantation, over time it does not further improve and patients remain low compared to normal levels. Suspicious that prednisone may be to blame in the debilitating process, the researchers studied cardiorespiratory fitness, muscle strength, and body composition in two groups of transplant patients - one group in which prednisone was included in the immunosuppression therapy and one group in which it was not. Testing was performed at 3 and 12 months post-transplant, and the 12 month data was compared to 15 normal sedentary controls.

The results showed the non-prednisone group had greater gains in cardiorespiratory fitness and muscle strength. In fact, the study said there were significant gains in cardiorespiratory fitness and muscle strength in those patients not taking prednisone. Patients taking prednisone showed actual deterioration. However, researchers cautioned that all patients remained low in peak oxygen uptake compared to the sedentary normal controls. The sedentary normal controls achieved 96% (+/-18%) of their age-predicted maximal capacity, compared to only 67% in the patients at 1 year post-transplant.

Heart rates in both study groups at 1 year post-transplant were significantly lower than the sedentary controls. Patients' maximal heart rates registered only 75% - 85% of age predicted maximal heart rates, while the controls (who took no meds that affected heart rates) came in at 98%. Further, the Respiratory Exchange Ratio, which is a physiologic indicator of maximal effort, was significantly lower in all patients at 1 year compared to the controls, suggesting, the authors say, a muscle metabolic limitation to higher levels of exercise among the patients.

The researchers determined that prednisone is not the cause for increased body fat following transplant, as both groups had a greater fat mass than the controls at 1 year, even when controlling for gender differences between the groups. Finally, the patients not on prednisone had significantly larger muscle fiber size (type IIX, for those of you scoring at home) than those taking prednisone.

So there you have it - further evidence of how truly important aerobic and strength exercise is for our continued good health, especially for those of us taking prednisone. For more details on the study and its results, please click here.

Hate to Exercise? Do it Anyway

If you're a kidney transplant patient who doesn't like to exercise, you must read this short article now. Here's the gist of it:

Dutch researchers took a physical health assessment of 540 kidney transplant recipients between 2001 and 2003 and monitored their physical activity levels until 2007. They discovered there were 260 patients, or 48%, who did not meet guidelines for minimum requirements of physical activity and that 79 patients, or 14.6%, were completely inactive. During the study period, 81 patients died, including 37 who suffered heart-related deaths. As you've probably guessed, the death rate was higher among those who participated in lower levels of physical activity. Below are a few more detailed findings from the study, as reported in the article.

Cardiovascular deaths occurred in:

• 11.7% of inactive patients
• 7.2% of moderately active patients
• 1.7% of active patients

Death rates from any cause occurred in:

• 24.4% of inactive patients
• 15.0% of moderately active patients
• 5.6% of active patients

We transplant recipients must exercise on a regular basis; there is simply no question about it. This is particularly true for those of us taking prednisone (as I will cover in an upcoming post). I include both cardiorespiratory and strength training in my exercise regimen. This is of vital importance, as patients like me are more susceptible to cardiovascular disease and osteoporosis. Remember, kidney transplant recipients are 4-6 times more likely to die from cardiovascular causes than are people in the general population. So even if you hate to exercise, do it anyway.

Interval Training: Less Time, More Benefit

Because kidney transplant recipients are 4-6 times more likely to die from cardiovascular disease than are people in the general population, I want to ensure my cardio training delivers maximal health benefits. Interval training is a style of aerobic exercise which is gaining popularity, partially because it provides a superior workout for the heart. It is so effective, in fact, that some people are significantly reducing - or completely eliminating - their traditional slow and steady cardio routines.

A study published in the Journal of Applied Physiology in 2007 found that interval training, which alternates between short rounds of high- and low-intensity exercise, increased the ability of the heart and lungs to supply oxygen to working muscles by 13 percent. This, according to the American College of Sports Medicine, represents an increase in heart efficiency over and above what can be achieved with slow and steady exercise. And maintaining cardiovascular efficiency is a matter of life and death: According to Men's Health, a study published in the New England Journal of Medicine found that men whose heart rates took longer than 60 seconds to decrease 25 beats had a 2.2 times greater risk of sudden death from a heart attack than those who recovered quicker.

Furthermore, interval training may be more effective than traditional cardio at reducing blood pressure. In a Wall Street Journal article from earlier this year, Katherine Hobson reported that in a randomized study of 88 patients with hypertension, the Norweigan University of Science and Technology found that "high-intensity interval training reduced blood pressure more than a steady workout regimen." Putting its official seal of approval on interval training, Hobson noted that the Canadian Association of Cardiac Rehabilitation believes "there is 'compelling evidence' that high-intensity interval training can lead to improvements in aerobic capacity, functional status and quality of life, and that it can be used as an alternative to traditional continuous training."

In the YouTube video linked below, the Mayo Clinic discusses the advantages of interval training. One noteworthy nugget found in the video is that 20 minutes of interval training will burn the same amount of calories as 30 minutes of sustained exercise. This is surely great news to all of us short on free time. Quite certainly it won't kill (because it never can be killed, it seems), but it definitely maims, the time-honored 'I'm-too-busy-to-exercise' excuse.  


http://www.youtube.com/embed/I1B1IIZjd2Y?rel=0