Abstracts
Introduction:
Chronic kidney disease (CKD) infers directly in functional capacity, independence and therefore quality of life (QOL).
Objective:
To compare the physical fitness and quality of life of patients with chronic kidney disease submitted on hemodialysis (G1) and predialysis treatment (G2).
Methods:
A cross-sectional study, 54 patients with CKD, 27 of the G1 group (58.15 ± 10.84 years), 27 of G2 group (62.04 ± 16.56 years). There were cardiovascular risk factors, anthropometric measurements, respiratory muscle strength was measured by the inspiratory pressure (MIP) and expiratory (MEP) maximum measured in the manometer, six-minute walk (TC6'), cardiopulmonary exercise test, sit and stand one minute test (TSL1') and the Short-Form Questionary (SF-36) to assess QOL. The patients presented disease of stage between 2 and 5. It was applied the Kolmogorov-Smirnov normality test and used the t (Student) test or the U (Mann Whitney) test to compare the means of quantitative variables and the chi-square Pearson test and Fisher's exact test for qualitative variables. Pearson's or Spearman's test was used to identify correlations.
Results:
No statistically significant difference was found between G1 and G2 in VO2peak (p = 0,259) in TC6' (p = 0,433) in the MIPmáx (p = 0,158) and found only in the MEPmáx (p = 0,024) to G1. The scores of the SF-36 in both groups showed a worse health status as evidenced by the low score in scores for QOL.
Conclusion:
Patients with CKD had reduced functional capacity and QOL, and hemodialysis, statistically, didn't have showed negative repercussions when compared with pre-dialysis patients.
health evaluation; hemodialysis, home; quality of life; renal dialysis
Introdução:
A doença renal crônica (DRC) interfere diretamente na capacidade funcional, na independência e, consequentemente, na qualidade de vida (QV).
Objetivo:
Comparar a capacidade funcional e a qualidade de vida de doentes renais crônicos em hemodiálise (G1) e pré-dialíticos (G2).
Métodos:
Estudo transversal descritivo, 54 pacientes com DRC, 27 do G1 (58,15 ± 10,84 anos) e 27 do G2 (62,04 ± 16,56 anos). Verificaramse os fatores de risco cardiovasculares, medidas antropométricas, força muscular respiratória verificada por meio da pressão inspiratória (PImax) e expiratória (PEmax) máximas, teste de caminhada de seis minutos (TC6'), teste cardiopulmonar de exercício, teste de sentar e levantar de um minuto (TSL1') e o Short-Form Questionary (SF-36) para avaliar a QV. Os pacientes apresentavam estadiamento da doença entre 2 a 5. Realizou-se o teste de normalidade Kolmogorov-Smirnov e utilizou-se o teste t (Student) ou o teste U (Mann Whitney) para a comparação das médias das variáveis quantitativas e o teste de Quiquadrado de Pearson e exato de Fischer para as variáveis qualitativas. Para identificar as correlações, foi utilizado o teste de Pearson ou de Spearman.
Resultados:
Não foi encontrada diferença estatisticamente significativa entre G1 e G2, no VO2pico (p = 0,259), no TC6' (p = 0,433), na PImax (p = 0,158) e somente foi encontrada diferença na PEmax (p = 0,024) para G1. Os escores do questionário SF-36 mostram em ambos os grupos um pior estado de saúde evidenciada pela pontuação baixa nos escores de QV.
Conclusão:
Os pacientes com DRC apresentaram reduzida capacidade funcional e QV, sendo que a hemodiálise não demonstrou estatisticamente ter repercussão negativa quando comparados com os pacientes pré-dialíticos.
avaliação em saúde; diálise renal; hemodiálise no domicílio; qualidade de vida
Introduction
The increase in chronic degenerative diseases has placed chronic kidney diseases
(CKD) as one of the greatest challenges of public health, which is considered both a
social and an economic problem worldwide, associated with numerous comorbidities and
high public health costs.11 Heiwe S, Clyne N, Dahlgren MA. Living with chronic renal failure:
patients' experiences of their physical and functional capacity. Physiother Res Int
2003;8:167-77. DOI: http://dx.doi.org/10.1002/pri.287
http://dx.doi.org/10.1002/pri.287...
,22 Locatelli F, Vecchio LD, Pozzoni P. The importance of early detection of
chronic kidney disease. Nephrol Dial Transplant 2002;17:2-7. DOI:
http://dx.doi.org/10.1093/ndt/17.suppl_11.2
http://dx.doi.org/10.1093/ndt/17.suppl_1...
Thus, surveillance is paramount to avoid
increasing this endemic situation because the clinical expression of chronic diseases
usually occurs after long exposure to risk factors and living with the silent disease
yet undiagnosed.33 Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic
diseases: overcoming impediments to prevention and control. JAMA 2004;291:2616-22.
PMID: 15173153 DOI: http://dx.doi.org/10.1001/jama.291.21.2616
http://dx.doi.org/10.1001/jama.291.21.26...
Patients with chronic kidney disease have enjoyed an increase in survival, due to the
use of kidney replacement therapies.44 Goldberg AP, Geltman EM, Gavin JR 3rd, Carney RM, Hagberg JM, Delmez JA,
et al. Exercise training reduces coronary risk and effectively rehabilitates
hemodialysis patients. Nephron 1986;42:311-6. PMID: 3960242 DOI:
http://dx.doi.org/10.1159/000183694
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The
kidney replacement therapy of choice is a successful kidney transplant; however,
hemodialysis and peritoneal dialysis have similar outcomes and represents the most
used treatment.55 Medeiros RH, Pinent CEC, Meyer F. Aptidão física de indivíduo com doença
renal crônica. J Bras Nefrol 2002;24:81-7. Despite this, studies have
shown the negative impact the disease and the treatment have on the cardiorespiratory
and musculoskeletal systems and the very quality of life (QOL) of patients;66 Adams GR, Vaziri ND. Skeletal muscle dysfunction in chronic renal
failure: effects of exercise. Am J Physiol Renal Physiol
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(KDQOL-SF). Rev Assoc Med Bras 2003;49:375-81. DOI:
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9 Schardong TJ, Lukrafka JL, Garcia VD. Avaliação da função pulmonar e da
qualidade de vida em pacientes com doença renal crônica submetidos à hemodiálise. J
Bras Nefrol 2008;30:40-7.-1010 Kolewaski CD, Mullally MC, Parsons TL, Paterson ML, Toffelmire EB,
King-VanVlack CE. Quality of life and exercise rehabilitation in end stage renal
disease. CANNT J 2005;15:22-9. thus impacting their physical and mental health,11 Heiwe S, Clyne N, Dahlgren MA. Living with chronic renal failure:
patients' experiences of their physical and functional capacity. Physiother Res Int
2003;8:167-77. DOI: http://dx.doi.org/10.1002/pri.287
http://dx.doi.org/10.1002/pri.287...
,1111 Floyd M, Ayyar DR, Barwick DD, Hudgson P, Weightman D. Myopathy in
chronic renal failure. Q J Med 1974;43:509-24. their
activities,1212 Kouidi E, Albani M, Natsis K, Megalopoulos A, Gigis P, Guiba-Tziampiri
O, et al. The effects of exercise training on muscle atrophy in haemodialysis
patients. Nephrol Dial Transplant 1998;13:685-99. DOI:
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an integrated point of view. Am J Kidney Dis 1998;32:834-41. DOI:
http://dx.doi.org/10.1016/S0272-6386(98)70148-9
http://dx.doi.org/10.1016/S0272-6386(98)...
independence, overall well-being and social
interaction.1414 Meo SA, Al-Drees AM, Arif M, Shah FA, Al-Rubean K. Assessment of
respiratory muscles endurance in diabetic patients. Saudi Med J
2006;27:223-6. This causes reduced
functional capacity and reduced muscle strength in these patients.1111 Floyd M, Ayyar DR, Barwick DD, Hudgson P, Weightman D. Myopathy in
chronic renal failure. Q J Med 1974;43:509-24.,1515 Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle
training in patients with heart failure and inspiratory muscle weakness: a randomized
trial. J Am Coll Cardiol 2006;47:757-63. DOI:
http://dx.doi.org/10.1016/j.jacc.2005.09.052
http://dx.doi.org/10.1016/j.jacc.2005.09...
16 Ramirez-Sarmiento A, Orozco-Levi M, Guell R, Barreiro E, Hernandez N,
Mota S, et al. Inspiratory muscle training in patients with chronic obstructive
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-1818 Quintanilla AP, Sahgal V. Uremic myopathy. Int J Artif Organs
1984;7:239-42. Several studies
have shown that respiratory muscle function may be impaired in heart failure
(HF),1515 Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle
training in patients with heart failure and inspiratory muscle weakness: a randomized
trial. J Am Coll Cardiol 2006;47:757-63. DOI:
http://dx.doi.org/10.1016/j.jacc.2005.09.052
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in diabetics,1414 Meo SA, Al-Drees AM, Arif M, Shah FA, Al-Rubean K. Assessment of
respiratory muscles endurance in diabetic patients. Saudi Med J
2006;27:223-6.,1919 Wanke T, Formanek D, Auinger M, Popp W, Zwick H, Irsigler K. Inspiratory
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mellitus. Am Rev Respir Dis 1991;143:97-100. DOI:
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in
chronic obstructive pulmonary disease (COPD)1616 Ramirez-Sarmiento A, Orozco-Levi M, Guell R, Barreiro E, Hernandez N,
Mota S, et al. Inspiratory muscle training in patients with chronic obstructive
pulmonary disease: structural adaptation and physiologic outcomes. Am J Respir Crit
Care Med 2002;166:1491-7. DOI:
http://dx.doi.org/10.1164/rccm.200202-075OC
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,1717 Kunikoshita LN, Silva YP, Silva TLP, Costa D, Jamami M. Efeitos de três
programas de fisioterapia respiratória (PFR) em portadores de DPOC. Rev Bras Fisioter
2006;10:449-55. DOI:
http://dx.doi.org/10.1590/S1413-35552006000400014
http://dx.doi.org/10.1590/S1413-35552006...
and in individuals
with CKD1111 Floyd M, Ayyar DR, Barwick DD, Hudgson P, Weightman D. Myopathy in
chronic renal failure. Q J Med 1974;43:509-24.,1818 Quintanilla AP, Sahgal V. Uremic myopathy. Int J Artif Organs
1984;7:239-42. already in regular hemodialysis.
Studies have also shown that CKD patients on hemodialysis develop physical
changes,99 Schardong TJ, Lukrafka JL, Garcia VD. Avaliação da função pulmonar e da
qualidade de vida em pacientes com doença renal crônica submetidos à hemodiálise. J
Bras Nefrol 2008;30:40-7.,2020 Menezes Junior CAV, Guia MJ, Perão KA, Santos E. Repercussões da doença
renal crônica e da hemodiálise na função pulmonar: uma revisão bibliográfica. Rev
UNILUS Ensino Pesqui. 2013;10:21-4.,2121 Cury JL, Brunetto AF, Aydos RD. Efeitos negativos da insuficiência renal
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2010;14:91-8. DOI: http://dx.doi.org/10.1590/S1413-35552010005000008
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and the
same is observed in patients with CKD undergoing renal transplantation;2222 Ferrari RS, Schaan CW, Cerutti K, Menedes J, Garcia CD, Monteiro MB, et
al. Avaliação da capacidade funcional e pulmonar em pacientes pediátricos
transplantados renais. J Bras Nefrol 2013;35:35-41. DOI:
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and those patients not yet on dialysis.2323 Coelho CC, Aquino ES, Lara KL, Peres TM, Barja PR, Lima EM. Repercussões
da insuficiência renal crônica na capacidade de exercício, estado nutricional, função
pulmonar e musculatura respiratória de crianças e adolescentes. Rev Bras Fisioter
2008;12:1-6. DOI: http://dx.doi.org/10.1590/S1413-35552008000100002
http://dx.doi.org/10.1590/S1413-35552008...
Thus, this study aims to compare the
functional capacity and quality of life of chronic kidney failure patients on
hemodialysis (G1) and pre-dialysis patients (G2).
Methods
This study was characterized as descriptive and cross-sectional, in which there were differences in the profile of CKD patients in pre-dialysis phase compared to those undergoing hemodialysis treatment. The study was designed in accordance with the Guidelines and Norms Regulating Research Involving Human Subjects, according to the National Council of Health (CNS) No. 466/11; and it approved by the Ethics Committee of the Regional University of the Northwest of Rio Grande do Sul on the advice embodied No. 187.1/2011.
The study included patients in pre-dialysis CKD and in hemodialysis, of both genders, over 18 years of age, clinically stable and with medical authorization allowing the performance of physical tests. The study excluded patients with associated chronic obstructive pulmonary disease, congestive heart failure, infectious diseases, those unable to understand and perform the test procedures, those who did not sign the consent form, and those who did not complete the assessment protocol or could not be contacted.
Assessment Protocol
The subjects’ information was collected from an interview and direct examination. We collected data regarding risk factors, anthropometric measurements, respiratory muscle strength, six minutes walking test (6MWT), cardiopulmonary exercise test (CPT), muscular endurance of the lower limbs and quality of life. The patients had disease stages between 2 and 5 and we did not analyze the variables by disease stage. Upon starting the study, the participants were submitted to an assessment protocol, as described below.
Risk factors and anthropometric measures
We investigated CKD cause, risk factors for cardiovascular disease (physical
inactivity, diabetes mellitus, smoking, alcohol consumption,
hypertension, age higher than 60 years). We also measured the subjects’ weight
(kg), height (cm), body mass index (BMI = weight/height22 Locatelli F, Vecchio LD, Pozzoni P. The importance of early detection of
chronic kidney disease. Nephrol Dial Transplant 2002;17:2-7. DOI:
http://dx.doi.org/10.1093/ndt/17.suppl_11.2
http://dx.doi.org/10.1093/ndt/17.suppl_1...
), abdominal (AC: cm) and hip (HC cm) circumferences.2424 American College of Sports Medicine. Manual do ACSM para avaliação da
aptidão física relacionada à saúde. Rio de Janeiro: Guanabara Koogan;
2006.
Respiratory muscle strength (RMS)
We used a pressure transducer (MVD-500 V.1.1 Microhard System, Globalmed, Porto
Alegre, Brazil), to assess inspiratory and expiratory muscle function, determining
the maximal inspiratory pressure (MIP) and maximum expiratory pressure (MEP )
carried out according to the study from Dall’Ago et al.1515 Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle
training in patients with heart failure and inspiratory muscle weakness: a randomized
trial. J Am Coll Cardiol 2006;47:757-63. DOI:
http://dx.doi.org/10.1016/j.jacc.2005.09.052
http://dx.doi.org/10.1016/j.jacc.2005.09...
and the expected value was calculated based
on the paper by Neder et al.2525 Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung
function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J
Med Biol Res 1999;32:719-27. DOI:
http://dx.doi.org/10.1590/S0100-879X1999000600007
http://dx.doi.org/10.1590/S0100-879X1999...
Sumaximal functional capacity (SFC)
Submaximal functional capacity evaluation was carried out through the six-minute
walk test (6MWT), according to the recommendations of the American Thoracic
Society (ATS),2626 ATS Committee on Proficiency Standards for Clinical Pulmonary Function
Laboratories. ATS statement: guidelines for the sixminute walk test. Am J Respir Crit
Care Med 2002;166:111-7. in which we measured the
longest distance the individual was able to cover within a six-minute walking
interval and we calculated the predicted distance walked.2727 Enright PL, Sherril DL. Reference equations for the six-minute walk in
healthy adults. Am J Respir Crit Care Med 1998;158:1384-7. DOI:
http://dx.doi.org/10.1164/ajrccm.158.5.9710086
http://dx.doi.org/10.1164/ajrccm.158.5.9...
Cardiopulmonary exercise testing
The cardiopulmonary exercise test (CPET) or maximal incremental exercise test was
performed on a treadmill (Imbrasport Porto Alegre, Brazil), with a ramp protocol
(initial speed of 1 km/h and end speed of 6 km/h; initial slope of 0% and 10%
final slope) and the exhaled gases were analyzed every 20 seconds through a gas
analyzer (Total Metabolic Analysis System, TEEM 100, Aero Sport, Ann Arbor,
Michigan). Arterial blood pressure (ABP) was measured every 3 minutes with a
sphygmomanometer. Heart rate (HR) was determined through the R-R interval using a
12-lead electrocardiogram. The cardiopulmonary test variables were calculated as
described by Dall’Ago et al.1515 Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle
training in patients with heart failure and inspiratory muscle weakness: a randomized
trial. J Am Coll Cardiol 2006;47:757-63. DOI:
http://dx.doi.org/10.1016/j.jacc.2005.09.052
http://dx.doi.org/10.1016/j.jacc.2005.09...
In short, peak VO2 was defined as the highest value
reached during the test for 20 seconds, and the peak circulatory power was
calculated as the product of peak VO2 and peak systolic pressure.1515 Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle
training in patients with heart failure and inspiratory muscle weakness: a randomized
trial. J Am Coll Cardiol 2006;47:757-63. DOI:
http://dx.doi.org/10.1016/j.jacc.2005.09.052
http://dx.doi.org/10.1016/j.jacc.2005.09...
Oxygen consumption recovery kinetics was
evaluated as the time required for 50% decrease from the peak VO2
(T1/2 peak VO2) and calculated using the minimum squares
mathematical model according to Dall’Ago et al.1515 Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle
training in patients with heart failure and inspiratory muscle weakness: a randomized
trial. J Am Coll Cardiol 2006;47:757-63. DOI:
http://dx.doi.org/10.1016/j.jacc.2005.09.052
http://dx.doi.org/10.1016/j.jacc.2005.09...
All patients continued with the medication
commonly prescribed by the doctor to perform the CPET.
Lower limbs muscular strength
We used the one-minute sitting and standing test (1’SST), in which the individual was asked to sit in a chair with his back resting on the seat, then get up without using the arms, extending the knees and then sit again with his back against the chair. The patient should stand up the most times possible within a minute.
Quality of life (QOL)
To measure QoL we used the Medical Outcomes Study 36-Item short- Form Health Survey (SF36). This questionnaire is a generic tool used to broadly and completely assess quality of life. It consists of 36 items encompassing eight dimensions, namely: functional capacity (ten items); physical aspects (two items); emotional aspects (three items); pain (two items), general health (five items); vitality (four items); social aspects (two items); mental health (five items) and one further question comparing current health status and that of a year ago, which is extremely important for understanding the patient’s disease. This instrument assesses both negative aspects (disease) as the positive aspects (wellbeing); it yields a final score from 0 to 100, where zero corresponds to the worst general health status and 100 to the best state of health.2828 Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR: Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol 1999;39:143-50.
Statistical analysis
Data was processed in the SPSS statistical package (version 18.0, Chicago, IL, USA). The descriptive analysis is presented as mean ± standard deviation, relative and absolute frequency. For quantitative variables we used the Kolmogorov-Smirnov normality test and also the t test (Student) or the U test (Mann Whitney) to compare the means. For qualitative variables, we used the Pearson’s chi-square and Fisher’s exact tests. To correlate variables we used the Pearson’s test or the Spearman’s. A p value ≤ 0.05 was considered significant.
Results
From a total of 121 patients with CKD who underwent hemodialysis in a hemodialysis unit in the interior of Rio Grande do Sul state, 27 patients were enrolled in the study. Of the 121 patients, 15 did not complete the assessment; four were bedridden; 1 was visually impaired; 2 were hospitalized; 32 refused to participate in the study and 40 patients were out of reach; thus, 27 patients entered the study. Of the 60 patients with pre-dialysis CKD, 8 did not complete the evaluation; 3 were bedridden; 1 hospitalized; 5 refused to participate in the study and 16 patients could not be reached. Thus, the total sample comprised 54 patients with CKD, who made up two groups, G1: CKD patients undergoing hemodialysis and G2: patients in pre-dialysis CKD (Table 1).
Age and gender characteristics were similar in both groups. Our analysis regarding the mean anthropometric, weight, height, BMI, WC and HC variables, also yielded similar values; however, when we ranked the patients according to BMI, there was a statistically significant difference between classes, with more overweight and obesity in the group submitted to hemodialysis and low weight only seen in patients who did not undergo hemodialysis (59.3%). CKD etiology was predominantly diabetes and hypertension (Table 1).
Chronic renal failure patients had changes in respiratory muscle strength in both
groups, both MIP and the MEP; however, this reduction was more representative in MIP
(70.23% of predicted). Comparing both groups, we noticed that the patients submitted
to hemodialysis already had weak respiratory muscles (MIP ≤ 70%
predicted),1313 Bergström J, Lindholm B. Malnutrition, cardiac disease, and mortality:
an integrated point of view. Am J Kidney Dis 1998;32:834-41. DOI:
http://dx.doi.org/10.1016/S0272-6386(98)70148-9
http://dx.doi.org/10.1016/S0272-6386(98)...
as well as MEP, a
statistically significant difference (p = 0.024) (Table 2). In the functional capacity analysis,
we noticed that there were no significant differences in both groups, both in
distance traveled as in lower limbs muscle endurance (1'SST) (Table 2).
Respiratory muscle strength, submaximal functional capacity and lower limb muscle strength for G1 and G2 groups
There was no correlation between MIP and the distance covered on the six-minute walk test (r = 0.189/p = 0.171), sit up test (r = 0.041/p = 0.768), VO2max (r = 0.197/p = 0.170 ) and duration of hemodialysis (r = -0.195/p = 0.329). There was a significant correlation (p < 0.001) between the 6MWD 'with VO2max (Figure 1).
Correlation between 6’WT and peak VO2. 6’WT: distance of the 6 minute walk test; Peak VO2: Peak of oxygen consumption.
Table 3 shows the results of cardiopulmonary exercise testing between G1 and G2. In both groups we had low values at peak exercise, in the submaximal ventilatory response and in the kinetics of gas exchange recovery. However, the peak VO2 value and the gas exchange recovery kinetics of pre-dialysis patients were higher, although not statistically significant.
The SF-36 quality of life questionnaire yielded low scores in both groups, and there were no statistically significant differences between the groups, except for the mental health dimension in G1 (Table 4).
Discussion
In this study, we noticed that CKD patients undergoing hemodialysis had inspiratory muscle weakness (IPmax ≤ 70% predicted). Regardless of the group, all had reduced submaximal and maximal functional capacities, demonstrated by the decrease in distance walked in the 6MWT and peak VO2 obtained from the cardiopulmonary exercise testing, respectively.
We found a decrease in respiratory muscle strength (MIP and MEP) in both groups, but
with a higher impact on the group already on hemodialysis. This result corroborates
the findings from Bohannon et al.2929 Bohannon RW, Hull D, Palmeri D. Muscle strength impairments and gait
performance deficits in kidney transplantation candidates. Am J Kidney Dis
1994;24:480-5. DOI: http://dx.doi.org/10.1016/S0272-6386(12)80905-X
http://dx.doi.org/10.1016/S0272-6386(12)...
and Kettner-Melsheimer et al.,3030 Kettner-Melsheimer A, Weiss M, Huber W. Physical work capacity in
chronic renal disease. Int J Art Organs 1987;10:23-30. which confirmed 30% to 40% muscle strength reduction in
patients undergoing dialysis, when compared with individuals not receiving
dialysis.
The reduced functional capacity observed in this study is also described in this
population by other papers.2323 Coelho CC, Aquino ES, Lara KL, Peres TM, Barja PR, Lima EM. Repercussões
da insuficiência renal crônica na capacidade de exercício, estado nutricional, função
pulmonar e musculatura respiratória de crianças e adolescentes. Rev Bras Fisioter
2008;12:1-6. DOI: http://dx.doi.org/10.1590/S1413-35552008000100002
http://dx.doi.org/10.1590/S1413-35552008...
,3131 Jatobá JPC, Amaro WF, Andrade APA, Cardoso FPF, Monteiro AMH, Oliveira
MAM. Avaliação da função pulmonar, força muscular respiratória e teste de caminhada
de seis minutos em pacientes portadores de doença renal crônica em hemodiálise. J
Bras Nefrol 2008;30:280-7.,3232 Moreira PR, Plentz R, Aguirre M, Barros E. Avaliação da capacidade
aeróbia de pacientes em hemodialise. Rev Bras Med Esport 1997;3:1-5. Coelho et al.2323 Coelho CC, Aquino ES, Lara KL, Peres TM, Barja PR, Lima EM. Repercussões
da insuficiência renal crônica na capacidade de exercício, estado nutricional, função
pulmonar e musculatura respiratória de crianças e adolescentes. Rev Bras Fisioter
2008;12:1-6. DOI: http://dx.doi.org/10.1590/S1413-35552008000100002
http://dx.doi.org/10.1590/S1413-35552008...
demonstrated that children and adolescents with CKD undergoing conservative treatment
may present significantly impaired functional capacity, respiratory musculature and
nutritional status. Similarly, Jatoba et al.,3131 Jatobá JPC, Amaro WF, Andrade APA, Cardoso FPF, Monteiro AMH, Oliveira
MAM. Avaliação da função pulmonar, força muscular respiratória e teste de caminhada
de seis minutos em pacientes portadores de doença renal crônica em hemodiálise. J
Bras Nefrol 2008;30:280-7. evaluated 27 patients with CKD, found significant and directly
proportional impairment in ventilatory muscle capacity, with effect and functional
impairment in physical performance by significantly reducing the walking distance
compared to the predicted values; a reduction of 38.2% in MIP and 29% in MEP compared
to the predicted values. The study by Moreira et al.3232 Moreira PR, Plentz R, Aguirre M, Barros E. Avaliação da capacidade
aeróbia de pacientes em hemodialise. Rev Bras Med Esport 1997;3:1-5. reported that patients who underwent CPET
obtained aerobic capacity corresponding to half of that obtained by normal subjects.
Only 16% of patients would have aerobic capacity equivalent to sedentary healthy
individuals. In their study, they further reinforce that low physical performance -
which explains the low rates of social rehabilitation, and these hemodialysis
patients would have improved their QOL if subjected to a physical rehabilitation
program.
Whether in hemodialysis or not, the patients in this study had a low test time and
peak VO2 below 20 ml/kg/min, with no statistical difference between the
groups. Sietsema et al.3333 Sietsema KE, Amato A, Adler SG, Bass EP. Exercise capacity as a
predictor of survival among ambulatory patients with endstage renal disease. Kidney
Int 2004;65:719-24. DOI:
http://dx.doi.org/10.1111/j.1523-1755.2004.00411.x
http://dx.doi.org/10.1111/j.1523-1755.20...
reported that peak VO2 values higher than 17.5 ml/min/Kg are a strong and
important predictor of survival for CKD patients, demonstrating that exercise
capacity assessment is essential when monitoring individuals with CKD. Within this
analysis, patients who did not undergo hemodialysis have strong survival predictor,
unlike those already in hemodialysis.
CKD Patients on hemodialysis had reduced functional capacity, which can hinder the performance of basic activities, leisure, work and social life, thus reducing their quality of life. In this study, both groups had impaired health status showed by low quality of life scores.3434 Barbosa LMM, Andrade Júnior MP, Bastos KA. Preditores de qualidade de vida em pacientes com doença renal crônica em hemodiálise. J Bras Nefrol 2007;29:222-9. Hemodialysis alone did not change the worsening in quality of life scores; it is rather a possibility of life for these patients. This fact highlights the importance of adopting measures to improve the quality of life of these patients as soon as diagnosed with CKD, when hemodialysis is still not required.
The questionnaire domains that had the lowest values in both groups were functional capacity and the physical aspect. We noticed that patients who are not in hemodialysis, because of their awareness of disease progression, worsening of their disease and a possible inclusion in hemodialysis -which can change their whole lives - can explain their already poor quality of life and compromise their mental health. Even before hemodialysis, CKD is a disease that hinders physical health, often because of the associated comorbidities, anemia, etc.
Barbosa et al.3434 Barbosa LMM, Andrade Júnior MP, Bastos KA. Preditores de qualidade de
vida em pacientes com doença renal crônica em hemodiálise. J Bras Nefrol
2007;29:222-9. showed a
significant lowering in the quality of life of CKD patients under HD, especially with
regards to the physical aspect, which is consistent with the results of other
Brazilian studies3535 Castro M, Caiuby AVS, Draibe AS, Canziani MEF. Qualidade de vida de
pacientes com insuficiência renal crônica em hemodiálise avaliada através do
instrumento genérico SF- 36. Rev Assoc Med Bras 2003;49:245-9. DOI:
http://dx.doi.org/10.1590/S0104-42302003000300025
http://dx.doi.org/10.1590/S0104-42302003...
,3636 Santos PR. Correlação entre marcadores laboratoriais e nível de
qualidade de vida em renais crônicos hemodialisados. J Bras Nefrol
2005;27:70-5. using the same instrument of measurement, in
which there is a predominance of better scores regarding the mental component (AS, AE
and SM) and worst regarding the physical component (especially AF) in patients with
CKD undergoing regular HD. It should be noted that in this study, mental health in
group 1 (hemodialysis) was more impaired because it was effectively the only quality
of life aspect with statistical significance between the groups.
According to Mittal et al.,3737 Mittal SK, Ahern L, Flaster E, Maesaka JK, Fishbane S. Selfassessed
physical and mental function of hemodialysis patients. Nephrol Dial Transplant
2001;16:1387-94. DOI: http://dx.doi.org/10.1093/ndt/16.7.1387
http://dx.doi.org/10.1093/ndt/16.7.1387...
CKD impacts QOL more intensely than other chronic diseases such as heart failure,
chronic obstructive pulmonary disease and rheumatoid arthritis. Note that physical
aspects and functional capacity are the individual’s perception of the results in
relation to their QOL and these are in agreement with the findings from the physical
assessment obtained by the 6MWT and cardiopulmonary exercise testing. Together with
this, these patients have cardiovascular risk factors, regardless of the groups. This
confirms the need to propose to these patients physical and psychological
interventions as a therapeutic treatment that can reverse or ameliorate this
worsening in physical and mental states in CKD. Thus, the physical therapy that works
with different types of diseases, both in hospitals as in outpatient wards, may help
in the treatment of these aspects in these individuals improving their physical
performance.
Conclusion
Through these analyses, we noticed that in both groups there was a reduction in functional capacity and quality of life. Therefore, patients who do not require hemodialysis treatment have also shown a reduction in their physical condition and quality of life. This reinforces the need for physical rehabilitation, in which physical therapy plays a key role to reverse or ameliorate the physical condition of these patients.
It should be noted that this study is limited by its small sample size; it was carried out in a single center; the analysis did not consider CKD stage, we did not have information on the drugs used by the patients - which can have a direct impact on their functional capacity and on test results, such as beta-blockers. Therefore, a prospective study, following the same patients from their conservative treatment all the way to HD would show us the impact of the disease throughout its evolution.
-
To the financial aid granted by the Foundation for Research Support of Rio Grande do Sul State (Fapergs); to the National Council of Scientific and Technological Development (CNPq) and the Regional State University of the Northwest of Rio Grande do Sul (UNIJUÍ) through Scientific Initiation scholarships.
Acknowledgement
To the support granted by the Foundation for Research Support of Rio Grande do Sul State (Fapergs); the National Council of Scientific and Technological Development (CNPq) and the Rio Grande do Sul Northwest Regional State University (UNIJUÍ) through scientific initiation scholarships.
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Publication Dates
-
Publication in this collection
Jan-Mar 2015
History
-
Received
20 Mar 2013 -
Accepted
28 July 2014