Podcast Episodes

Exercise Before Dialysis Onset: A Healthy Start?


Christopher Springmann: This is an encore presentation of NephTalk from Satellite Healthcare.

CS: You're suggesting that people become depressed, discouraged, and sedentary, not necessarily in that order? Am I exaggerating here?

Dr. Shuchi Anand MD: Once they start dialysis? No, you're not exaggerating. We know that 50 percent of patients on dialysis can barely walk a block.

CS: Really?

SA: Yes. If we can catch them before they have to go through that insult, we're really hoping that we can keep them in a positive cycle, where they have more self-efficacy. They have more confidence in their physical and mental capacity.

CS : That's Dr. Shuchi Anand, MD, who received a Satellite Healthcare research grant, inspired by provocative questions, like: What would happen if we, as nephrologists, intervened early in the patients chronic kidney disease journey before they started dialysis, by prescribing an exercise program? Would that better prepare patients for the physical, social and emotional challenges of the dialysis experience and ultimately make them healthier candidates for a transplant?

Dr. Anand, will be joined by several of her investigators, including fellow Stanford Medicine nephrologist Dr. Susan Ziolkowski, MD; and co-principal investigator Dr. Felipe Lobelo, MD, a medical epidemiologist at Emory University in Atlanta, Georgia, who's also working with a diverse groups of patients, including a significant African-American population.

CS: Thank you very much for joining us today on NephTalk. It is a joy to have you here.

SA: Thank you for having us.

CS: Let's talk about a grant that you received from Satellite Healthcare. The objective of that grant is to determine if a group-based technology enabled exercise intervention is acceptable to nephrologists and patients with advanced kidney disease.

What does all of that mean? How would you translate that for the audience?

SA: What that means is that we want to work with patients who have advanced kidney disease and get them into group-based exercise programs, and the objective of the grant is to figure out how to do that, what works, what doesn't, when we try to get patients with kidney disease moving.

CS: Could, or will this grant benefit Satellite Healthcare patients, perhaps their families while adding to a center's effectiveness. Let's start with a patient. How will this benefit the patient beyond where they are now?

SA: What we know is that patients who have kidney disease are very physically inactive, and that's partly due to the comorbidities that they have.

CS: What is a co-morbidity?

SA: Partly due to the diseases that they have, in addition to kidney disease, like diabetes or high blood pressure, sometimes heart disease. The weight of all of these diseases weighs on them physically, it affects their muscle mass. It affects their ability to move and it weighs on them mentally, too. And our goal with this study is to acknowledge the burden of all the diseases that can run together with kidney disease and still try to get people to exercise to get them feeling better, but also to get them stronger, in the long term, should help them withstand dialysis better, and if they're looking for a kidney transplant; hopefully, they will have better outcomes related to kidney transplant if they move and build up their muscle strength and the reserve.

Joining Dr. Anand is Dr. Susan Ziolkowski, M.D., a nephrologist from Stanford University. What is your role in this grant?

SZ: I joined onto this project about a little over a year ago now. And I've been helping with all aspects of the study, from patient recruitment to doing some of the measurements on the study participants, working on some of the papers, and things like that that we are starting to write and planning to write.

SA: Susan, tell us a little bit about why you're interested in this work.

SZ: I'm right now actually in my fourth year of fellowship at Stanford, and I've been working on a bunch of different research projects there, mainly on obesity and muscle mass and patients with chronic kidney disease.

CS: Dr. Anand, how is it beneficial? How would you categorize, how would you categorize those benefits?

SA: What we know is that for everyone who starts to move and exercise that we improve their mood. We improve their muscle mass, and we improve their overall health, particularly their cardiovascular health, and most patients with kidney disease have a high burden of cardiovascular disease. But what we don't know, and what we would like to investigate and would hope to determine further is whether it can also potentially affect their kidney health in that in can potentially help them feel better despite having kidney disease and, therefore, maybe push off the start of hemodialysis.

We're recording patients before they start dialysis, so they have advanced kidney disease, so likelihood that they'll start dialysis is high, but we're recruiting patients before they are routinely dialyzing three times a week, so they're motivated to try to delay that, and we are finding that when we talk to patients they are highly motivated in participating in exercise because they want to, either, improve their kidney health, or at least stabilize and not progress further fast.

CS: Would it be accurate it to say that these patients are more than just a little bit concerned about their ongoing health and their enthusiasm, in great part, or in some part, at least, is based on that?

SA: Yes. I mean, it's a looming threat in their mind; right, being on dialysis or needing a kidney transplant. It's going to change their life. They know it. And so, they want to, either, be prepared for that, or try to delay that for as long as possible, and their doctors, thanks to some of the work that were doing in clinics, where were asking about what their routine exercise is like, and because nephrologists are getting increasingly aware of the importance of the physical activity, are recommending that they increase their exercise levels during their clinic visits. So, they know what they have to do. They're just trying to find a way to do that while acknowledging their physical symptoms and their mental symptoms.

CS: Dr. Ziolkowski, how do you find patients, pre-dialysis patients?

SZ: We're recruiting patients now just from the Santa Clara Valley Medical System, And so, we're recruiting them from the renal care center, which is the nephrology clinic there. We want to kind of catch them almost as close to starting dialysis as possible, but, like I said, not already on dialysis.

CS: Dr. Anand, do these patients communicate via social media? Or do you encourage that?

SA: So, we are in the process of forming our first exercise group here at Santa Clara Valley, and they're going to have a WhatsApp communication. And we have a personal trainer, so an exercise professional who's trained, who Dr. Lobelo and myself trained in the issues, the medical issues related to kidney disease.

CS: And, joining us today from Emory University in Atlanta, Georgia, is Investigator Felipe Lobelo. What has your experience been with your patient population in Atlanta, Georgia? Do they have similar enthusiasm for joining this study?

FL: Yes. We have seen a lot of enthusiasm at the Emory Nephrology Clinic. We have recruited, so far, close to 20 patients, and they are incredibly excited about the opportunity to exercise with a fitness professional, the opportunity to meet older patients that are going through the same disease process, and simply the fact that our clinic is offering something different.

CS: Felipe, do you find that these patients get together and chat and, in effect, compare notes about their experience, and, therefore, bond in a very unique way?

FL: Absolutely. That's one of the aspects of the intervention that we knew from previous research, this component of social dynamics within the group is very important for them to get engaged with the intervention and also keep coming. We've also created a group chat so that

they can post pictures about what they do, what they eat, how many steps they've taken per day, or provide encouragement and support for each other.

CS: So, peer pressure is really crucial. However, my understanding is that these participants are asked to wear a Garmin device.

SA: That's right.

CS: Is it like a wristwatch?

SA: It's like a Fitbit, but its a Garmin device and it tracks steps and it tracks activity. And this goes back to your earlier question of how we're going to track it adherence.

CS: So, can people access their own information, in addition to having it relayed to you?

SA: Right. Yes.

CS: Is it sent to you on a nightly basis?

SA: It's a continual syncing process.

CS: Oh, really?

SA: So then the personal trainer or slash/exercise professional that we have is actually meant to provide them feedback while they're actively in the exercise program.

CS: Is this happening right now as we speak?

SA: Yes.

CS: It sounds, Felipe, that you all are experiencing the Law of Unintended Consequences, and that isn't necessarily a negative. In fact, that's really a good thing. What you're discussing here, is a very positive indication already early on in your study.

FL: So, yes. We are happy to see these unintended consequences because the main outcome is to have these patients increase their activity levels and their functional capacity. And, whether they engage because they want to improve their health or because they're making new friends and they have social support or because they enjoy the healthy competition with the wearable devices, and the communications with the group chat, as long as they engage we are happy with seeing these different pathways that each of the patients, as an individual, takes to get there.

CS: Dr. Ziolkowski, what has surprised you about what you have learned so far?

SZ: Our goal is to get obviously as many patients as we can, but were aiming for about 32 total. So far, weve recruited 14. So, recruitment kind of comes in spurts. I think what's surprised me the most is definitely of the patients that we've recruited, like Dr. Anand had said earlier, they're so motivated, and they're so excited to be in the study.

CS: So, being proactive as a patient, Dr. Anand, is really crucial, and it gives people, let's be honest, hope-

SA: Yes, exactly.

CS: - and a sense of purpose and mission perhaps.

SA: It gives them something to do for their own health aside from taking medications and coming to the doctor's visits. There's something that they can do positively that will improve their health. And, especially in the context of a looming dialysis situation. That really helps improve mood and physical capacity, were hoping.

CS: You're suggesting that people become depressed, discouraged, and sedentary, not necessarily in that order? Am I exaggerating here?

SA: Once they start dialysis? No, you're not exaggerating. We know that 50 percent of patients on dialysis can barely walk a block.

CS: Really?

SA: Yes. If we can catch them before they have to go through that insult, were really hoping that we can keep them in a positive cycle, where they have more self-efficacy, they have more confidence in their physical and mental capacity.

CS: You're also providing them with a social network.

SA : Right. And they'll have shared experiences during this intervention period. Some of them will undergo surgery to get a dialysis access placed, and that will be a shared experience

that the group can discuss and help them through potentially. And some of the symptoms that they experience, which other people may not quite understand.

CS: And so much of it is new for the patient.

SZ : Exactly. Yes. And so, if they talk to other kidney patients and see that they're all having similar symptoms, they might think to bring up to their nephrologist, and the nephrologist might be able to do something about it. The chronic kidney disease patients are very isolated, and it's great that they can get to know one another and experience some of the trials and tribulations and the issues and everything ongoing in these couple of months and years ahead, get to know one another and get the support.

CS: And the Exercise Is Medicine initiative or framework was developed by the American College of Sports Medicine, to integrate exercise as a clinical tool with patients who have chronic disease. Do you ultimately envision in your wildest dreams, Dr. Anand, that this will be just an everyday component of the prescription that a nephrologist writes?

SA: That would be fantastic. And some practices do that for patients with pre-diabetes, for example. There will be a prescription written for exercise and because those programs have been shown to be so effective, patients will lose weight and then remit. Their pre-diabetes will disappear. And although we don't expect something of that magnitude with patients with kidney disease, we hope that we can get some measurable benefits that then make it make sense that a routine clinical practice incorporates exercise, and provides an easy method for patients to plug into exercise.

CS: What does a grant like this mean to you, in terms of your professional growth and where you would like to be in the future?

SA: Like, Susan, when I was training in fellowship, I had my eyes opened about the level of physical inactivity and sedentariness and how much that can impact patient's health when they have kidney disease and that is worked on from epidemiology and observational data. This project is enabling us to do something about that, which is fantastic, beyond my usual clinic lectures, which, I'm particularly aware as Susan is particularly aware because we have studied this about the importance of physical activity. So, we incorporate it in our clinical practice in terms of when we counsel patients. But beyond that, I'm able to offer them a way to start, to get the ball rolling, and that's fantastic. And another thing, when you talked about the unintended consequences, I think this doing this work really makes me a better doctor. I get to talk to

patients in a non-clinical setting. I get to understand their whole life experience in a much larger range.

CS: And a level of engagement with people and their family members, too, whom can be very positively influenced by the patient's proactive efforts to take care of themselves, which ultimately becomes their legacy.

SA: Yes. We hope so.

SZ: We haven't had much exposure to family members yet, however, it's certainly yes, I'm sure if a husband starts exercising three times a week, the wife might get motivated, too. So, again, another unintended consequence, but we could be really improving the health for, you know, a much larger sector of the community than just the kidney patients.

CS: I would like to thank you all today for joining us on NephTalk.

SZ: Thank you.

FL: Awesome.

SA: Thank you for hosting us.