We propose several recommendations aimed to increase the promotion of physical activity in kidney transplant recipients. First, we recommend exercise regimens tailored to the needs and resources of the individual. Such an exercise regimen would be based on patients’ clinical status, prior exercise activity, and capability. Health care professionals can tailor their counseling of patients according to recommendations; provide written materials about physical activity; refer patients to physical therapists, exercise facilities, or other outside providers to increase physical activity; and provide exercise training programs and equipment for use in-center. This tailored approach is necessary to address unique clinical concerns, personal considerations, and cultural values patients place on physical activity.
Granted, some kidney recipients have comorbidities that challenge their ability to exercise. Nevertheless, the literature of physical activity with older adults with specific chronic conditions is extensively researched. There is a general consensus36
that individuals with such specific chronic conditions as heart disease, chronic obstructive pulmonary disease, and arthritis are capable of exercise and benefit from participation (Prohaska et al, unpublished data). Based on recent studies (Prohaska et al, unpublished data),36
even older adults with chronic health problems can engage in low-intensity activity. Unfortunately, there is very little research on the effects of exercise on transplant recipients with multiple chronic illnesses.
We recommend the development of evidence-based guidelines on physical activity to assist transplant professionals and nephrologists in counseling kidney recipients as a routine part of patient management. Opportune teaching moments for health care professionals to promote exercise with kidney transplant recipients would occur both before transplantation and routinely afterward. Others have argued for transplant professionals to provide kidney transplant recipients with detailed instruction on exercise regimens before hospital discharge after transplantation.27
Emphasis can be placed on how exercise directly improves health outcomes by reducing the risk for transplant-related comorbidities.
Second, collaboration between transplant and cardiac departments is necessary to effectively tailor exercise regimens to various groups within this patient population. Patients can be grouped according to risk profiles and undergo levels of cardiac rehabilitation as part of a coordinated multidisciplinary approach to patient management. Cardiac rehabilitation is especially essential for patients requiring retransplantation. A high body mass index poses a risk factor for cardiovascular problems, which in turn jeopardize subsequent transplantations. Counseling should address misperceptions and beliefs held by kidney transplant recipients about the value of exercise for their health. Such counseling may serve to encourage patients to increase their physical activity levels. Obtaining reimbursement for this collaboration, as well as potential liability for adverse events pursuant to referral for exercise training, remain challenges that need to be addressed. However, reimbursement may be more likely to be provided given the increasing emphasis that ESRD policymakers are placing on quality improvement strategies to improve the functional status and outcomes of patients with ESRD.37
To minimize concerns about liability, nephrologists should learn about exercise, provide recommendations within the bounds of their knowledge, monitor patients’ exercise programs, and/or refer patients to more knowledgeable providers, such as physical therapists, cardiologists, and rehabilitation physicians, when appropriate.
Last, we recommend a line of research that investigates the impact of exercise on health outcomes among kidney transplant recipients. The same set of research questions concerning physical activity raised for heart transplant recipients could be applied to kidney transplant recipients: “(i) how would chronic immune suppression alter recommendations [regarding physical activity] because of their adverse effects on renal function, glucose metabolism and bone mineralization?; and (ii) what safety precautions should be in place to assure risk free participation?”29, p 267
Such research could help identify precisely what kinds of exercise programs are best suited to kidney recipients5
and how transplant longevity is affected by exercise. Research should be conducted that documents the utility of physical activity for kidney transplant patients, especially noting the health benefits and protective benefits in the context of the disease. Because transplant recipients are a heterogeneous group, research also should inquire into the extent to which subgroups based on, for example, age, comorbidities, or years with transplantation, have activity recommendations beyond basic guidelines for all kidney recipients. Not knowing what constitutes a safe level of exercise for kidney transplant patients undermines appropriate health promotion efforts. Such a line of research could then foster evidence-based recommendations for exercise about the type, level, intensity, and duration of the exercise and recommendations on determining base level and gradual progression of the exercise program.
Research to date suggests that exercise is likely to be beneficial and should be promoted among kidney transplant recipients. Health professionals may refer to recently developed principles of exercising for patients with ESRD and &
model exercise training program38
for ways to manage kidney transplant recipients’ exercise regimens. Posttransplantation exercise regimens should be assessed and managed on an ongoing basis to optimize kidney recipients’ physical functioning and minimize the risk for CVD. New motivational techniques may be needed for promoting physical activity among kidney recipients.
In conclusion, there is a strong argument for exercise to be part of the posttransplantation medical regimen in kidney transplant recipients. The patient, physician, and health care system all have a role in incorporating exercise into routine patient management. Aerobic exercise is necessary to reduce the risks for CVD, minimize osteoporosis, and facilitate weight loss, whereas strength-based exercise is necessary to minimize sarcopenia. To foster this health change, we must reward the counseling by physicians, the behavior in patients, and the system for promoting it. Finally, research must be done to investigate the specific impacts of exercise on graft and patient outcomes among kidney recipients to provide more effective physical activity counseling and devise evidence-based recommendations.