Can you tell me the best way to combat the muscle wastage that accompanies CKD?
Does optimal dialysis treat muscle wastage once a patient progresses to CKD5?
Does a strength training program ever effectively combat this problem?
Thank you!
Dear MooseMum
In 4 words … exercise, yes and yes.
Exercise is crucial for dialysis patients.
The team of my friend and colleague up the highway (Peter Kerr) showed nicely that both time and exercise during dialysis mobilises and improves phosphate removal … See http://www.ncbi.nlm.nih.gov/pubmed/14712431
Note this combines exercise with that key component of optimal dialysis … time!
See their paper …
Am J Kidney Dis. 2004 Jan;43(1):85-9. Vaithilingam I, Polkinghorne KR, Atkins RC, Kerr PG. Department of Nephrology, Monash Medical Centre, Clayton, Vic, Australia. TITLE: Time and exercise improve phosphate removal in hemodialysis patients. BACKGROUND: Control of serum phosphate remains a difficult clinical issue in most hemodialysis (HD) patients. This study examines 2 nonpharmacological approaches to improving phosphate control in HD patients. METHODS: First, 9 stable HD patients underwent dialysis in random fashion for either 4 hours 3 times weekly or 5 hours 3 times weekly. Adjustments were made to blood flow rates such that Kt/V was the same for all sessions, thus allowing independent assessment of the influence of time. The primary end point was weekly dialysate phosphate removal. In the second study, 12 different patients underwent an exercise program in which they pedaled a bicycle ergometer either immediately before or during dialysis. Again, weekly dialysate phosphate removal was measured. RESULTS: In the time study, urea reduction ratio (69% +/- 0.02% versus 68% +/- 0.07, 4 versus 5 hours) and weekly urea removal were no different between the 2 groups. However, weekly phosphate removal (3,007 +/- 641 versus 3,400 +/- 647 mg; P < 0.02) significantly improved with longer dialysis duration. Serum phosphate levels improved, but did not reach statistical significance in this short-term study. In the exercise study, weekly phosphate removal improved with exercise, but did not reach significance (2,741 +/- 715 [no exercise] versus 2,917 +/- 833 [exercise predialysis] versus 2,992 +/- 852 mg [exercise during dialysis]; P = 0.055), although comparing only exercise during dialysis with no exercise reached significance (P = 0.02). There was no significant difference in serum phosphate levels. CONCLUSION: Both increased dialysis time and exercise result in increased dialytic removal of phosphate and could be expected in the long term to improve phosphate control.
The same applies to the interdialytic period … a fitter and stronger dialysis patient = a better dialysis experience (if you have to have one!) …
Just see the story of Shad Ireland http://www.aakp.org/aakp-library/Shad-Ireland/
or …
Visit Shad at his Facebook … he’s a true inspiration … http://www.facebook.com/pages/Shad-Ireland/137596180680
As for optimal dialsis treating muscle wastage on dialysis … The same (above) applies and the answer is ‘yes’.
Ditto for strength training … though I would avoid the high protein supplements that some peddle with strength training.
Never, never, pass up the chance (or be afraid) to be as fit as you can be, to be well exercised and strong.
Though I now speak with tongue firmly in my cheek - as you will doubtlessly pick up on - I have often thought we should have one of those ‘airport’ moving footpaths installed at the ‘out’ door of all dialysis facilities … the direction of ‘roll’ being inwards! This would mean that in order to exit the facility and get home after dialysis, all patients would have to walk (ie: exercise) against the direction of the pathway, just to get out of the unit and go home. This would be one way to ensure all facility-based patients got some exercise at least 3 times a week!
Exercise will benefit you in so many ways. To borrow the Nike slogan … “JUST DO IT”
I’ve taken daily exercise for years, swimming in the summer, snowshoeing in the winter and walking on all other occasions with cycling thrown in. Daily exercise in some form is essential for my mental health, and it is probably more important for my overall wellbeing now than it has ever been. My biggest struggle with CKD has been psychological, and daily exercise helps me in that regard, so I have no real reason to give it up. CKD brings with it a certain feeling of loss of control. You do all that you can to stay well. CKD is hard work, and for some of us, despite all of the money, time, effort and resolve we put into trying to stay healthy, our bodies let us down and remind us that we can’t control everything. But any small thing that CAN be done is welcomed, and if taking a walk each day or training with moderate weights can help us reclaim some small modicum of control, I’m in!
Your reply made me realize that there must be some correlation between muscle wastage and phosphate clearance…is that right? I wasn’t entirely sure what exactly it was about CKD that causes wastage…it’s the poor control of serum phosphate?
Hi Moosemom, Im here waiting with ya for the answer to this. 
DH’s stature has changed a lot and we are working hard to help his mustles firm up. He is really active but no spacific exercises so im hoping to find more out with answers to ‘your’ question.
iboswife, I may be overthinking this as is my wont, but I wonder if it is worth finding a personal trainer who is medically certified or who is knowledgeable enough to put together a program to address this specific problem in renal patients. Do abdominal exercises hurt PD patients? Do people with AV fistulas need to be careful how they perform certain movements? Or is just being generally physically active enough? These are the exciting things I think about while on my daily walk! haha
I would think a personal trainer would be wonderful. I would love DH to have one and I would think that as long as I asked that his fistula arm was left out of the ‘equasion’ that all exercise would be great. I know that he’s not suppose to lift to much or put pressure on it so that would have to be expressed strongly!! I laugh at your ‘overthinking’… I overthink and ‘what if’ every single part of this D stuff. It’s just so important to me that i let it get the best of my stressability. (geesh, i cant think of words im trying to use to explain myself but they are just not with me this eve)
You and I have “overthinking” down to a fine art! Instead of “overthinking”, I prefer to think of it as “extreme educating”. It does probably mean, though, that we are too easily stressed out, but then again, if we felt like we didn’t know what the heck was going on, we’d be doubly stressed! (PS…who cares if we’re “overthinking”? Others can wallow in their ignorance, but not us!!)
Oh moosemom, you gave me a very hearty laugh (of which it kind of takes a lot to break sound out of me like that! lol) I LOVE your “extreme educating” and it is very true!! Im stressed trying to learn it all, but i’d be worse im sure, if i was to sit and know theres the knowledge out there and im not searching for it. You have been a great friend it all this, and i appreciate all i’ve learned from you
Soooo, off to someore digging My efforts these days are mustle tone, and albumin, as we’ve conquered our ‘flipping’ of A needle issue. We are now NON flippers…lol
You both crack me up…And Here I thought I was the only over thinker… I was waiting for many good answers on Muscle Wasteing. I have read this paper and I have had further questions…
Here is a good read…
http://www.renalandurologynews.com/protein-energy-wasting-could-impair-wound-healing/article/192733/
now that I have been on Dialysis for over a year now… This lab for the first time I am low on protein and I have been losing weight lately… I think its mostly muscle… I have been trying to find more information on how to treat protien loss…
Trying to balance our chemistries is very difficult and challenging… I hope someone can bring more light on the subject … There are many well informed people on the site…
it is funny to find others ‘like you’ isnt it… 
I surely hope others join this and help us out. I will say that we have ordered ‘liquacell’ to try to help boost DH’s albumin. He really eats good and has good appitite, but that is his only number that is comming in low and its a vERY important one… We do his testing in another 2 weeks and he will have been on it for a month by then so we shall see. They offered Nepro as well, but we figure we should try one thing at a time so if its going good, we’ll be able to pinpoint better. Hubby has been on D for almost 2 years now, and nxStage for just nearly 3 months of that. Somehting that’s kind of weard to me is that his albumin has gone down in this time and im wondering if he’s getting too much D now… Geesh, i wish i knew all, and could just fix it… Ok, now back to digging again…lol Oh, and thank you for that article!! very very interesting!
There is no doubt about it, each question you ask is (1) good, (2) way more complex than you could imagine (3) will wear my fingers and my years away!
My 1st answer was perhaps too glib … that ‘exercise is the answer’ … though, in part, it really is … at least from a practical stand point – it is certainly by far and away the most useful and contributory thing that you can do!
But, the possible causes of muscle atrophy (wasting) and dysfunction (not working as well) or in as sustained a fashion as they should (faster fatigue) or as effectively as they should (a lack power) … these are many, varied and complex. While I cannot possibly address them all, some include:
Damage to muscle due to altered blood flow (perfusion) … as might occur (and perhaps especially so) while on dialysis – and here hemodialysis may be ‘worse’ than peritoneal dialysis as hemodialysis imposes an obligatory perfusion insult every time as the circulating blood volume and the ‘goodies’ levels are acutely altered by dialysis within the circulation. As a result of these circulatory changes, these effects then have a snowball response backwards into the tissues and organs.
Alterations in the delivery of the ‘goodies’ that muscle needs to function well … as might occur with anaemia (a feature of most CKD and itself with many causes) … among which effects are (but which are not restricted to) …
[ul]
[li]a lack of EPO production,
[/li][li]subtle changes in iron transport and storage due to the up-regulation (the turning-on) of a hormone called hepcidin,
[/li][li]low level chronic blood loss
[/li][li]and possibly vitamin deficiencies in under-replaced dialysis
[/li][/ul]
… just to name some … or as occur with the changes in some of the necessary ‘goodies’ for normal muscle function (like those that may result from a reduced uptake of fatty acids, or of glucose or (as above) of oxygen.
Muscle function is all about making energy … energy that allows the muscle to contract and create the power that is needed for movement. This power generation process depends on the ‘cracking’ of a phosphate-dependent substance called ATP (adenosine tri-phosphate) into lower levels of phosphated adenosine … (ADP (di-phosphate) and AMP (mono-phosphate) … with each ‘cracking’ releasing a little parcel of energy.
Yes … phosphate is intimately in there … so, why then do we try so hard in dialysis patients to remove it? Well, firstly, CKD patients tend to ‘drown’ in phosphate – literally … and secondly, it then gets into all the wrong places where it does far more harm than good. So … it’s not the phosphate that is used for muscle function (eg: ATP) that is the problem in CKD, it’s the phosphate load that is in all the wrong bits that is the real problem.
We also know that a substance necessary for normal muscle function – carnitine – is often in a state of metabolic ‘imbalance’ in the mitochondria of the muscle cells of patients with CKD … mitochondria are the little energy powerhouses that drive each and every one of our cells. Carnitine is essential for oxidizing (breaking down) nutrient fatty acids to produce energy. It gets out of whack, often wildy so, and is a growing area of interest in research .
You see … our muscles need the right oxygen and fat and glucose delivery orders, they need the right balance of the energy-makers within the cells … without this, they don’t get the right recipe from which to make energy. Its a matter of balance. Think of making a cake … get all the ingredients wrong, omit some, over-supply others … and the cake will be awful. So, too, for muscles.
The muscles need ‘ingredients’ for proper energy production. That energy is delivered by the blood stream as it carries the building blocks that are needed to make that energy in the sites (like the mitochondria of muscle cells) where energy is created.
Our blood stream needs our gut to absorb the right building blocks that are needed for energy production … without that absorption, those building blocks cant get into the blood stream in the first place.
Our diets need to have the right ‘mix’ of those things we need to ‘optimally’ absorb, then optimally deliver to the places (like muscle cells) where we create the energy we need.
In CKD … diet can be crappy – the wrong foods and the wrong mix – and often, in poorly dialysed people (the majority), the appetite is poor to begin with … etc etc …
In CKD … gut absorption is altered … things can ‘interfere’ with absorption (like hepcidin does with iron absorption), or like binders do … or gut ‘perfusion’ (blood flow) may be altered – especially by and following dialysis.
In CKD … the circulation can be less then optimal (that word keeps cropping up in my answers, doesn’t it) as the heart struggles and the blood vessels clamp down. This ‘constriction’ of blood vessels leads to an increase in capillary (small blood vessel) resistance and even poorer ‘goody’ delivery.
In CKD … the ‘goody’ mix isn’t so good any more – we eat (or absorb) the wrong fats, the wrong sugars, we have (or we develop) a disordered responsiveness to insulin … there is a state known as ‘insulin resistance’ where there is a ‘block’ to sugar transport into cells due to a resistance to the normal action of insulin (and this is not just in the diabetic patients either) … oh, it just gets more and more complicated.
In CKD … we know that normal, stable potassium and magnesium levels are awfully important for normal muscle function and especially for normal function of the neuro-muscular junction … the junctions between each minute nerve fibre and the muscle cell it innervates (links to the nervous system and, ultimately, to the brain) … and muscles need to be ‘told’ to contract, ultimately, by the brain … but if the ‘telling’ is disrupted, the response will be too! Neuromuscular function can be (is) disrupted in CKD … in part, but not wholly so, by the fluctuations in potassium and magnesium that are so much part and parcel of CKD and especially haemodialysis.
Then in CKD … there are abnormalities in the oxidative function of muscle cells … this refers to the actual utlisation of oxygen by the muscle cells and, as if to add insult to injury, there can also be an accumulation of some of the nastier end-products of cell oxygen use … stuff called reactive oxygen species, super-oxide and its cousins, uncles and aunts … yukky stuff that once made, needs to be cleared away and neutralized but which, in CKD, kind-of isn’t.
Normal kidneys clear away the acids that are made during normal cellular and bodily function but, these tend to accumulate in CKD – causing what is called a metabolic acidosis. Acidosis is a bad, bad milieu (environment) for normal muscle cells (indeed, all cells) to function in.
Drugs (like steroids) can play a negative role, too, in muscle function. The list of drugs that can interact and stymie muscles is legion … and I won’t open that box. I’d be here for ever. That’s something to discuss with your nephrologist if you are concerned.
Then, there are some really nasty liitle critters called – collectively – pro-inflammatory cytokines. Cytokines are chemicals that cells often make when they feel stressed, angry or sad. There are essential cytokines, but there are harmful ones, too. These can be released by a muscle cell when it is stressed, angry or sad – as you can now imagine that by now they well might be!
The whole cytokine story is so complicated that I wont try to open that box either … and don’t ask me to … that is too hard to do without lapsing into total incomprehensible language.
In this environment, physical exercise is harder, less ‘easy’ to undertake, and, as a result, muscles lose further ‘tone’ and ‘oomph’. Not feeling so ‘oomphy’, it is easy for the CKD patient to become a couch potato … what’s more, it takes for ever to recover after bad dialysis!
Yes … I know it all sounds a bit grim … but the trick is to give your muscles the BEST environment and training you possibly can - and from as early as you can.
Eat well.
Exercise.
Get the best dialysis you can.
Control weight and avoid the ‘bad’ foods we all tend to eat when we ‘can’t be bothered’
… so, be bothered.
Good diet, good exercise, a good circulation (the latter dependent on both of the former), good dialysis, good anaemia control, a good iron status, an un-inflammed environment (which means, among other things, ensuring good water with which to make the dialysate solution - often this is not so ‘chipper’ in the US system as a whole) … all and more … and you will be giving your muscles the best chance of responding to the exercise you give them.
… and that, in turn, will keep you as healthy you can be kept in the difficult environment that any CKD patient will always be trapped within.
No … you cant be dealt a different hand … but you can vastly improve the hand you have been dealt by wise drawing from the pack …
I didn’t mean for you to have to write another book, Dr. Agar! But I’m glad you did. All of this is hard enough, but for me personally, understanding WHY it is hard makes me feel better. It makes me appreciate how hard my body is having to work to keep me upright, and it makes me want to help it as much as I can.
I daresay most of us live in less than optimal (that word…) conditions. No one has a perfectly working body in a perfectly pure environment. Our food and water are tainted, we breathe foul air, we live in big cities with germy people, we travel in steel and metal carriages that can crash and burn at a moment’s notice. So you are right…we can vastly improve the hand we have been dealt because no hand is always a winner.
I appreciate once again the time and effort it must have taken to write that missive. I know you have other things to do, that you have little free time. But this is the price you must pay if you want educated renal patients! haha!
[QUOTE=iboswife;20913]Oh moosemom, you gave me a very hearty laugh (of which it kind of takes a lot to break sound out of me like that! lol) I LOVE your “extreme educating” and it is very true!! Im stressed trying to learn it all, but i’d be worse im sure, if i was to sit and know theres the knowledge out there and im not searching for it. You have been a great friend it all this, and i appreciate all i’ve learned from you
Soooo, off to someore digging My efforts these days are mustle tone, and albumin, as we’ve conquered our ‘flipping’ of A needle issue. We are now NON flippers…lol[/QUOTE]
I’m going to be coming to you for advice in the future, so you do all the digging you can! Be warned!!!
… from your last post, MooseMum (damn … I am an Aussie … I should try to get that right and do the ‘Mom’ thing) … you said … "But this is the price you must pay if you want educated renal patients! "
Its a price I pay with pleasure … would there were more of you to seek answers, challenge perceptions, argue entrenched thought (much wrong) … Oh, and there I sound a bit like the people you are warned that you should avoid on the internet who offer ill-directed advice. I hope I am never accused of that - but, again, that ends up in the eye of the beholder!
Hopefully Dori and her team will vouch for my main-streamedness … even if I have a ‘bent’ to longer hour, ‘extended’ versions of dialysis. Would that more of your country -men and -women did
Ask away.
It is a pleasure to try to help … for as I answer you, others (may) read.
Would that I could be resourced to do this as a full-time exercise.