Approximately one-quarter of people living with chronic kidney disease (CKD) are affected by symptoms of depression, and this statistic is even higher in patients on dialysis (1). The prevalence of pervasive symptoms of anxiety is similar (2, 3), and early neuro-cognitive decline is common (4). Importantly, the presence of mental health disorders is associated with poorer patient outcomes (5). Prescription of appropriate pharmacotherapy for mental health conditions is low in patients with CKD (6), and given the pharmacokinetics of the drugs, their effectiveness in CKD is likely to be reduced.
In the general population, there are clear relationships between exercise behaviors and mental health burden (7); it is commonly espoused that physical activity and exercise are good for mental health. Exact definitions vary, but physical activity can be defined as “any bodily movement produced by skeletal muscles that results in energy expenditure,” whereas exercise is a subcategory of physical activity that is planned, structured, and usually repetitive with at least one goal related to improving or maintaining a physical fitness component (8). The term “exercise” tends to be associated with formal exercise training or activities, such as going to the gym, running, or bike riding, with the aim of becoming fitter or stronger. For many patients who are physically deconditioned or unfit, these activities or environments are incredibly off-putting, yet structured programs of exercise have often been the focus of rehabilitation programs in patients with CKD. Indeed, our research group showed that a structured program of intradialytic cycling led to prognostically important improvements in cardiac structure and function (9). As important as these findings are, just as important is the lack of effect that the program had on health-related quality of life or measures of depression and anxiety—findings that were corroborated by the PEDAL (Prescription of Intradialytic Exercise to Improve Quality of Life) study (10). Neither of these studies made patients feel better and had no effect on mental health or well-being.
For mental well-being, formal exercise may not be the answer. Instead, we need to think and talk about how we can support patients to become more physically active. Physical activity regimens can be more easily personalized to fit in with patients’ lives and what they enjoy doing, without the targets or pressure of a formal program and physiologic testing. We can be confident that if people can achieve close to 150 minutes of moderate to vigorous physical activity each week, then health outcomes will likely improve (11); it really does not matter how this is achieved. Results from the Kidney BEAM trial support this view. The study showed that for patients with CKD, on dialysis, and who underwent a transplant, engagement with a personalized program of exercise and activity, in a way that was convenient for them, led to important improvements in health-related quality of life and mental well-being (12).
This is the message that we need to convey to our patients. If we as clinicians can support them to become more physically active in a sustainable and enjoyable way, they will likely experience improvements in their mental well-being, and their physical health outcomes should improve.
Footnotes
References
- 1.↑
Palmer S, et al. Prevalence of depression in chronic kidney disease: Systematic review and meta-analysis of observational studies. Kidney Int 2013; 84:179–191. doi: 10.1038/ki.2013.77
- 2.↑
Lee YJ, et al. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. Int J Clin Pract 67; 2013:363–368. doi: 10.1111/ijcp.12020
- 3.↑
Feroze U, et al. Anxiety and depression in maintenance dialysis patients: Preliminary data of a cross-sectional study and brief literature review. J Ren Nutr 2012; 22:207–210. doi: 10.1053/j.jrn.2011.10.009
- 4.↑
Bugnicourt JM, et al. Cognitive disorders and dementia in CKD: The neglected kidney-brain axis. J Am Soc Nephrol 2013; 24:353–363. doi: 10.1681/ASN.2012050536
- 5.↑
Chiang HH, et al. Increased risk of progression to dialysis or death in CKD patients with depressive symptoms: A prospective 3-year follow-up cohort study. J Psychosom Res 2015; 79:228–232. doi: 10.1016/j.jpsychores.2015.01.009
- 6.↑
Fischer MJ, et al.; CRIC Study Group Investigators. Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC studies. Am J Kidney Dis 2012; 60:27–38. doi: 10.1053/j.ajkd.2011.12.033
- 7.↑
Chekroud SR, et al. Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: A cross-sectional study. Lancet Psychiatry 2018; 5:739–746. doi: 10.1016/S2215-0366(18)30227-X
- 8.↑
Caspersen CJ, et al. Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Rep 1985; 100:126–131. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424733/pdf/pubhealthrep00100-0016.pdf
- 9.↑
Graham-Brown MPM, et al. A randomized controlled trial to investigate the effects of intra-dialytic cycling on left ventricular mass. Kidney Int 2021; 99:1478–1486. doi: 10.1016/j.kint.2021.02.027
- 10.↑
Greenwood SA, et al. Randomized trial—Prescription of Intradialytic Exercise to Improve Quality of Life in patients receiving hemodialysis. Kidney Int Rep 2021; 6:2159–2170. doi: 10.1016/j.ekir.2021.05.034
- 11.↑
Dos Santos M, et al. Association of the “weekend warrior” and other leisure-time physical activity patterns with all-cause and cause-specific mortality: A nationwide cohort study. JAMA Intern Med 2022; 182:840–848. doi: 10.1001/jamainternmed.2022.2488
- 12.↑
Greenwood SA, et al. Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): A multicentre, randomised controlled trial in the UK. Lancet Digit Health 2024; 6:e23–e32. doi: 10.1016/S2589-7500(23)00204-2
