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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 92-98

Aerobic exercises along with resisted training to prevent postrenal transplant complications in renal transplant recipient: A single-subject design


1 Department of Cardiopulmonary, C.U. Shah Physiotherapy College, Surendranagar, Gujarat, India
2 Department of Nephrology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharastara, India
3 Department of Neurology, C.U. Shah Physiotherapy College, Surendranagar, Gujarat, India
4 Department of Medicine, C.U. Shah Medical College, Surendranagar, Gujarat, India

Date of Web Publication12-Sep-2017

Correspondence Address:
Jani Chaitsi Kiritkumar
C. U. Shah Physiotherapy College, Dudhrej Road, Surendranagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_4_17

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  Abstract 

Background: Renal transplantation has become moderately accepted and successful due to advancement in overall management. However, long-term complications of renal transplantation still post new challenges. Pharmacologic treatment along with “appropriate level” of exercise helps to prevent long-term complications. This study reports the efficacy of appropriate level of aerobic exercises along with resisted training to prevent post-renal transplant complications in a single case of renal transplant recipient. Methods: This single- subject experimental study design consist of A1, B1, A2, B2 and A3 phases which include either of aerobic exercise, aerobic exercise with resisted training or home programme. Visual analysis and 2SD- band method was used to analyze serum creatinine, postprandial blood sugar, blood pressure, VO2 max and amount of medicines required to renal transplant recipient. Results: A favorable changes were noted among the specific variables even after longtime, when combined aerobic exercises with resisted training were given. Conclusion: This case study shows that Aerobic exercises with resisted training are effective to prevent post renal transplant complications among renal transplant recipient within two years of transplantation, which could not be generalized but provides impetus to further research.

Keywords: Aerobic exercises, renal transplant recipient, postrenal transplant complication, renal transplantation, strengthening exercises


How to cite this article:
Kiritkumar JC, Vora HD, Surbala L, Vekariya R. Aerobic exercises along with resisted training to prevent postrenal transplant complications in renal transplant recipient: A single-subject design. Indian J Transplant 2017;11:92-8

How to cite this URL:
Kiritkumar JC, Vora HD, Surbala L, Vekariya R. Aerobic exercises along with resisted training to prevent postrenal transplant complications in renal transplant recipient: A single-subject design. Indian J Transplant [serial online] 2017 [cited 2019 Mar 20];11:92-8. Available from: http://www.ijtonline.in/text.asp?2017/11/2/92/214389


  Introduction Top


In last two decades, renal, heart, liver and lung transplantations have become common, successful and progressively improved, among which renal transplantation is the most frequent.[1] Although the number of successful transplantations increases, new challenges have arisen in the management of long-term complications of transplantation.[2] Even successfully transplanted renal transplant recipients (RTRs) suffer from hypertension (HTN), coronary artery diseases, skin cancers, diabetes, bone diseases, and various infections. Survival is compromised by an increased cardiovascular risk.[3],[4],[5],[6] The cardiovascular events are represented as one of the major causes of death among RTRs.[1],[3],[5],[7] Incidence and prevalence rate of cardiovascular disease (CVD) are four to six times higher in RTRs compared to the general population.[8] Among RTRs, dyslipidemia, HTN, obesity, chronic allograft nephropathy, anemia, muscle wasting, and use of immunosuppressive drugs commonly coexist as long-term complications.[3],[8],[9],[10]

Pharmacological treatments alone cannot efficiently reduce all cardiovascular risks. It also does not efficiently improve work capacity and quality of life including biological and psychological problems. Furthermore, immunosuppressive drugs have their own side effects such as excessive weight gain, HTN, dyslipidemia, and muscle wasting.[3],[4],[5] Moreover, after a successful renal transplantation, 83% of RTRs have a tendency that does not go back to work due to depression such as complex phenomenon and this type of sedentary lifestyle is also one of the risk factors for CVD.[4],[9],[11] Incorporating “nonpharmacological” therapies such as physical training which are able to reverse this trend is very important.[3] Physical training can increase flexibility, reduce systemic resistance and cardiovascular risk, improve endurance, work capacity, quality of life, and graft function over a 1-year period.[1],[2],[3],[4],[5],[12] After transplantation, cardiorespiratory fitness is found to be reduced by 30% compared to general population, which can be improved through the exercises.[3]

According to Surgeon General's report and few other studies, an “appropriate level” of physical training is a beneficial and safe modality of treatment. They also emphasized to the nephrologists to consider exercise as one of the integral parts of whole treatment regimes in RTRs.[3],[12],[13] One of the studies found a detrimental effect of strenuous exercises and hence, recommended to find out an appropriate level of moderate exercise with its type, intensity, duration, gradual progression, and determined impact of exercise on health outcomes to assist transplant professionals and nephrologists in counseling RTRs.[3] As per our knowledge, a precise exercise program of aerobic exercise with resisted training for RTR's has not yet been documented. Hence, the purpose of the case study was to investigate the efficacy of appropriate aerobic exercises with resistance training in preventing postrenal transplant complications such as HTN, chronic allograft nephropathy, and new-onset diabetes after transplantation (NODAT). The findings of our case study can provide impetus to a well-established protocol which could be followed in clinical practice for RTRs.


  Methods Top


Procedure

The single-subject experimental design was conducted on postrenal-transplanted subject. The case study was modified into multiple treatment A1-B1-A2-B2-A3 types designed instead of simple ABA design to evaluate an effect of variation in treatment and recovery phase.[14] On a first visit of the subject, a primary assessment was taken, and then, the first four baseline data (baseline phase-A1) were collected within a period of 2 weeks. Last data were collected just before initiation of treatment. All other phases (B1: aerobic phase, A2: recovery phase, B2: combined phase, and A3: follow-up phase) are described in [Table 1]. All the data related to the study were collected four times at the completion of all phases. The procedure of the case study was explained in detail to the subject before acquiring the signed informed consent. The Institutional Ethical Committee approved the study.
Table 1: Phase-wise application of intervention program

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  Case Report Top


A 58-year-old male, who had worked in a government office as a clerk, presented at our institute with complaints of shortness of breath while walking 15–20 steps on a level surface and reduced work capacity. He underwent living donor (wife) renal transplantation before 2 months. He was a nonsmoker and a known case of HTN for 14 years and had NODAT. He was diagnosed with urinary tract infection when he presented with an acute onset of colicky pain. The subject was first diagnosed with bilateral renal calculi (confirmed with radiological findings) after 3 years which was managed pharmacologically. In the subsequent years, the subject had multiple appointments, investigations, and management strategies under a guidance of a nephrologist as listed in [Table 2].
Table 2: Sequential events of medical and surgical history of condition

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In the subsequent years, he complained of having mild dyspnea during routine work, weakness, fatigue, and weight gain of 4–5 kg within 2 months. However, he ignored the complaints. However, after 2 months, dyspnea at rest was present with pitiable pedal edema extending up to the knees (bilateral). On consulting the nephrologist, he was diagnosed with chronic kidney disease (CKD) stage 4-National kidney disease-chronic tubule interstitial disease with abnormal laboratory findings (serum creatinine-5 mg/dl, estimated glomerular filtration rate [GFR]-23 mL/min/1.73 m2). Gradually, the subject progressed to end-stage kidney disease (serum creatinine: 19 mg/dl, estimated GFR <15 ml/min/1.73 m2). The nephrologist advised him maintenance hemodialysis, and for the same, arteriovenous fistula was created. Unfortunately, the fistula was unsuccessful and a temporary venous catheter was placed in the right internal jugular vein and maintenance hemodialysis was started on a thrice-weekly basis. A planned live allograft renal transplantation (willingly given left kidney by his wife) was performed after HLA typing and negative Centers for Disease Control and Prevention cross match 2 months after maintenance hemodialysis. The subject was monitored in the intensive care unit for 4 days before he was transferred to the ward. He was discharged after 6 days with a complication of NODAT.

He was advised rest for a month, with plenty of fluids, proper nutritional supply, prescribed medications (immunosuppressant, corticosteroids, antihypertensive, and antidiabetics) and advised for routine laboratory investigations which include complete blood count, serum creatinine, serum glucose, and uric acid at every week for 2 months which were evaluated by the nephrologist which showed a normal recovery. The subject was advised to continue the laboratory investigations for every 15 days and was referred to a nearby physician. He was also advised for postoperative physical therapy rehabilitation for his complaints of breathlessness after walking few steps, weakness, and fatigue for an early return to the job.

When the subject came to our physical therapy department, his body mass index (BMI) was 27.50 kg/m2, modified medical research council dyspnea scale was Grade 3, reduced chest expansion at all three sites, used accessory muscles, and had no adherent, nonpainful scar on right side of the lower abdomen (21 cm long and 2 cm in width). In fatigue severity scale, he scored 55 indicating greater fatigue severity. Borg scale was scored 9 following 6-min walk test, which is severe breathlessness. His pulmonary function test (PFT) showed reduced forced vital capacity and forced expiratory volume 1 indicative of the restrictive condition. He came with two-dimensional echo report, which was done after 1 month of operation suggested a normal internal dimension of all four valves, normal movement of walls, and left ventricular ejection fraction 60%. He consulted nephrologist every month till today, and during his visit, no graft rejection or any other related complaints were noted.

Outcome measures

Serum creatinine was taken as one of the very sensitive outcome measures to indicate renal function.[1] Systolic and diastolic blood pressure (SBP and DBP) and postprandial blood sugar (PP2BS) were used to measure the complications of HTN and NODAT.[8],[13] VO2 max was also used to measure the work capacity.[3],[15] Physical exercise is found to have an influence on the effectiveness of drugs and hence vice versa.[16] Dosage of medications was also monitored for any variation during the study. SF36 was also taken to evaluate health-related quality of life. White blood cell count (WBC) was an indicator of infection, one of the common causes of morbidity and mortality following transplantation.[7],[9],[16] Hemoglobin (Hb) level is commonly affected after transplantation.[3],[7],[9],[14],[15] PFT values and Borg scale of breathlessness were taken to evaluate pulmonary functions.[12],[15] BMI affected by immunosuppressant was taken as one of the outcome measures.[15],[17],[18] These all outcome measures are either subjective measurement or expensive and noticeable changes among readings may take longer time so were not included for statistical analysis.

Data analysis

The results of all the outcome measures were presented in graphical form for visual analysis and statistically analyzed to determine the effects of aerobic exercises with resisted training on post-RTR. Effects of medicines were clearly distinguishable, so analyzed by only traditional visual analysis method. SYSTAT computer package (version 11, SYSTAT software Inc., Chicago, Illinois) was used to analyze the data. Statistical analysis was performed to evaluate the effectiveness of treatment by utilizing two standard deviations (2-SDs) band method, which is sensitive to changes in variability across the treatment phases of a single-subject design. If at least two successive data point fall outside the bounds of 2-SD range, it indicates a significant change in parameters occurred across any two phases.[17],[18]


  Results Top


The figures show visual analysis of the changes in all the parameters among A1, B1, A2, B2, and A3 phases, with numbers referring to weeks. The change in level was noted by comparing the mean levels of data points in baseline phase (serum creatinine = 1.75, PP2BS = 304.5, SBP = 179, DBP = 94.5, VO2 max = 26.25) with aerobic phase (serum creatinine = 0.95, PP2BS = 192.5, SBP = 148.5, DBP = 88.25, VO2 max = 33.37) suggesting changes in all these parameters after application of intervention. Although changes also noted during the recovery phase (serum creatinine = 1.47, PP2BS = 226.7, SBP = 157, DBP = 91.5, VO2 max = 29.12) while comparing with aerobic phase and between recovery phase and combined phase (serum creatinine = 0.82, PP2BS = 132.5, SBP = 128.5, DBP = 81, VO2 max = 38.75) shown difference between effect of cessation of treatment and intervention. However, there was no noticeable change between combined phase and follow-up phase (serum creatinine = 0.92, PP2BS = 140.2, SBP = 133, DBP = 83.5, VO2 max = 37) [Graph 1],[Graph 2],[Graph 3],[Graph 4].



The trend for baseline phase and recovery phase of serum creatinine, PP2BS, SBP, and DBP was accelerating and for VO2 max was stable. These were indicated that during the baseline phase and recovery phase, either value was increased or remained constant. The decelerating changes in the trend were noted during aerobic, combined, and follow-up phases of serum creatinine, PP2BS, and SBP, which shows a reduction in the values during the treatment phase and effects remain almost similar even during follow-up phase. The DBP trend was stable during the aerobic phase which indicated no change during this phase, but this was decelerating (decreased values) during combined and follow-up phases. The trend of VO2 max, during aerobic, combined, and follow-up phases, was accelerating. Figures suggested a reduction in variability of data during aerobic, combined, and follow-up phases suggesting that collected data during these phases were much more stable [Graph 1],[Graph 2],[Graph 3],[Graph 4]. The analysis by 2-SD band method revealed that at least two successive data points fall outside the indicator line during aerobic, combined, and follow-up phases suggesting statistically significant changes in the values of serum creatinine, PP2BS, SBP, VO2 max, and also in DBP except in aerobic phase.

Visual analysis on the dosage of the drugs shows less variability in all data with changes of level in prednisolone during the phases (baseline phase = 20, aerobic phase = 11.87, recovery phase = 3.7, combined phase = 2.5, follow-up phase = 2.5 mg), tacrolimus (baseline phase = 6.37, aerobic phase = 6, recovery phase = 4.62, combined phase = 2.87, follow-up phase = 2.5 mg), and mycophenolate mofetil (baseline phase = 2000 aerobic phase = 2000, recovery phase = 1750, combined phase = 1000, follow up phase = 1000 mg), indicating a gradual reduction in the need of corticosteroids and immunosuppressant. The changed level of the sum of HTN drugs according to phases was minimal (baseline phase = 57.8, while in aerobic phase, recovery phase, combined phase, follow-up phase = 55.3) which indicates the constant need of antihypertensive drugs though blood pressure was gradually normalized [Graph 3] and [Graph 5]. The mean value study of glipizide indicated that during aerobic phase, need of drugs decreases compare to baseline phase, which again increased during the recovery phase and decreased in combined phase (baseline phase = 1000, aerobic phase = 687.5, recovery phase = 875, combined phase = 500). Graphical presentation was not shown for glipizide during follow-up phase. The trends for all the drugs during all the phases were either stable or decelerating [Graph 5] and [Graph 6].



Results of other outcome measures were SF36 (baseline phase = 47 follow-up phase = 68) WBC (baseline phase = 12300 follow-up phase = 8520/cu mm), Hb (baseline phase = 10.4 follow-up phase = 14.1 g %), and BMI (baseline phase = 28.5 follow-up phase = 26.64 kg/m2).


  Discussion Top


The study was a single-subject design, which was worthy for evaluating an in-depth management and response of an individual subject with renal transplantation. Resisted training was proved beneficial when combined with aerobic exercises on CKD and end-stage renal disease.[12],[19],[20] To the best of our knowledge, this was not yet implemented over RTR's. Hence, we investigated the efficacy of aerobic exercise with resisted training in preventing postrenal transplant complications. The results of the single-case study indicate that appropriate, regular, and supervised aerobic exercises with resisted training protocol can reduce postrenal transplant complications by normalizing posttransplant drug-induced hyperglycemia, HTN, and improving work capacity. Stable serum creatinine level indicates that there was not any episode of graft rejection. At the end of the treatment program, requirement of immunosuppressant drugs was reduced as per transplant protocol, which is also pointing toward the absence of any graft rejection in 2-year span.[1],[3],[12],[13],[14],[19],[20]

Posttransplant complications and mortality among RTR's are highly influenced by physical inactivity. Researchers have suggested the need for intervention studies to investigate the long-term effects of physical activity.[6],[8],[11] In our study, the first phase consisted of aerobic exercise, which showed improvement in symptoms within 2 months; however, the effect was not sustained after 2 months of cessation of the intervention. Hence, in the second combined phase, resisted exercises were included along with aerobic exercises for 6 months and a follow-up of 1 year after the cessation of the interventions was evaluated to know the actual effectiveness of interventions.

When the combined phase intervention was modified and resisted training was included for 6 months, it resulted in promising improvement in all outcomes and was in accordance with other studies.[1],[3],[6],[12],[13],[19],[20],[21],[22],[23],[24] VO2 max during the baseline phase and recovery phase was stable but showed improvement in aerobic phase with further improvement during combined phase. In follow-up phase, all the values of these variables remain almost similar to combined phase even after 1-year cessation of interventions, indicating the long-term success of this protocol.[12],[13]

Prednisolone, tacrolimus, and mycophenolate mofetil were either immunosuppressant or corticosteroids routinely used after transplantation and have their own side effects.[5] Results show that the requirement of these drugs also was gradually decreased as per transplant protocol, though during this period, any sign of graft rejection was not seen.[3],[4],[5] The need for antihypertensive drugs remains the same in all the phases. However, BP was normalized with the same dosage of the drug.[12] The requirement of glipizide for controlling hyperglycemia was also reduced during combined phase and hence subsequently quitted in follow-up phase from his treatment regime. This can be considered as a positive sign of exercise intervention, additional to drug therapy.[10] Results of other outcome measures such as SF36, WBC, and Hb level indicate improvement, which was in accordance with the result of other studies.[10],[15],[17],[25]

Combined aerobic exercises and resisted training show better improvement not only over the symptoms but also over the factors, which are responsible for causing after transplant complications. Furthermore, the valuable effects of the exercise interventions are that all the positive changes sustained even after 1-year cessation of the supervised intervention. The objective of our study was fulfilled by the interventions, which is worthwhile and is feasible to follow in clinical practice. However, there is a requirement to apply the interventions over a large group of RTR's as the results of our study were acquired from a single-case design. Further study can be aimed at investigating the effects and its mechanism of action on interleukin, homocysteine, CD4+ to CD8+ level, IgG, IgM level that can strongly prove the effect of exercise on late complications of renal transplantation, especially over graft rejection.[3]


  Conclusion Top


The result of the study shows that aerobic exercises with resisted training intervention are capable of not only improved but also maintained the overall health of RTR's and prevent long-term posttransplantation complications. Based on the overall result, we can conclude that prescribed dosage of aerobic exercise with resisted training is effective to prevent postrenal transplant complications among RTR after 2 years of transplantation. Although single-subject limits the generalization of its result, the study would provide a direction for further randomized clinical trials.

Acknowledgments

We extend our sincere thanks to the valuable subject.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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