Background/Aims: Although the effect of exercise on health is well established, nephrologists seldom consider physical activity in the treatment of chronic kidney disease (CKD) or CKD in the presence of diabetes mellitus (DM/CKD). The aim of the present study was to analyze the benefits of leisure-time physical activity (LTPA) in DM/CKD. Methods: A total of 445,075 adult participants who underwent a medical screening program between 1996 and 2008 were prospectively recruited. Of these, 7,863 DM/CKD subjects were identified. Each participant was categorized according to LTPA level (a product of duration and intensity) as inactive, low-active or fully active. Hazard ratios (HRs) for mortality risk were calculated. Results: Fully active LTPA was associated with lower odds of DM/CKD development and lower risk of mortality among patients with DM/CKD in a dose-response relationship. The fully active and low-active DM/CKD groups had a 26% (HR 0.74, 95% CI 0.66-0.85) and 13% (HR 0.87, 95% CI 0.75-1.01) lower risk of all-cause mortality, respectively, in comparison to the inactive group. The association of exercise with mortality rate reduction was more pronounced among DM/CKD subjects (mortality rate reduction of 446.5 per 100,000 person-years) than among subjects with diabetes alone or CKD alone. Conclusion: Exercise, at the recommended level or more, is associated not only with lower odds of DM/CKD but also with a 26% lower mortality risk among DM/CKD patients. Nephrologists should encourage all DM/CKD subjects to be physically active.

de Boer IH, Rue TC, Hall YN, Heagerty PJ, Weiss NS, Himmelfarb J: Temporal trends in the prevalence of diabetic kidney disease in the United States. JAMA 2011;305:2532-2539.
Shaw JE, Sicree RA, Zimmet PZ: Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010;87:4-14.
Afkarian M, Sachs MC, Kestenbaum B, Hirsch IB, Tuttle KR, Himmelfarb J, de Boer IH: Kidney disease and increased mortality risk in type 2 diabetes. J Am Soc Nephrol 2013;24:302-308.
Groop PH, Thomas MC, Moran JL, Waden J, Thorn LM, Makinen VP, Rosengard-Barlund M, Saraheimo M, Hietala K, Heikkila O, Forsblom C: The presence and severity of chronic kidney disease predicts all-cause mortality in type 1 diabetes. Diabetes 2009;58:1651-1658.
Ninomiya T, Perkovic V, de Galan BE, Zoungas S, Pillai A, Jardine M, Patel A, Cass A, Neal B, Poulter N, Mogensen CE, Cooper M, Marre M, Williams B, Hamet P, Mancia G, Woodward M, Macmahon S, Chalmers J: Albuminuria and kidney function independently predict cardiovascular and renal outcomes in diabetes. J Am Soc Nephrol 2009;20:1813-1821.
So WY, Kong AP, Ma RC, Ozaki R, Szeto CC, Chan NN, Ng V, Ho CS, Lam CW, Chow CC, Cockram CS, Chan JC, Tong PC: Glomerular filtration rate, cardiorenal end points, and all-cause mortality in type 2 diabetic patients. Diabetes Care 2006;29:2046-2052.
Whaley-Connell A, Pavey BS, McCullough PA, Saab G, Li S, McFarlane SI, Chen SC, Vassalotti JA, Collins AJ, Bakris G, Sowers JR: Dysglycemia predicts cardiovascular and kidney disease in the Kidney Early Evaluation Program. J Clin Hypertens (Greenwich) 2010;12:51-58.
Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998;317:703-713.
Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright AD, Turner RC, Holman RR: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;321:412-419.
Bakris GL: Recognition, pathogenesis, and treatment of different stages of nephropathy in patients with type 2 diabetes mellitus. Mayo Clin Proc 2011;86:444-456.
Atkins RC, Zimmet P: Diabetic kidney disease: act now or pay later. Kidney Int 2010;77:375-377.
Angermayr L, Melchart D, Linde K: Multifactorial lifestyle interventions in the primary and secondary prevention of cardiovascular disease and type 2 diabetes mellitus - a systematic review of randomized controlled trials. Ann Behav Med 2010;40:49-64.
Balducci S, Zanuso S, Nicolucci A, De Feo P, Cavallo S, Cardelli P, Fallucca S, Alessi E, Fallucca F, Pugliese G: Effect of an intensive exercise intervention strategy on modifiable cardiovascular risk factors in subjects with type 2 diabetes mellitus: a randomized controlled trial: the Italian Diabetes and Exercise Study (IDES). Arch Intern Med 2010;170:1794-1803.
Hu G, Jousilahti P, Barengo NC, Qiao Q, Lakka TA, Tuomilehto J: Physical activity, cardiovascular risk factors, and mortality among Finnish adults with diabetes. Diabetes Care 2005;28:799-805.
de Groot M, Doyle T, Kushnick M, Shubrook J, Merrill J, Rabideau E, Schwartz F: Can lifestyle interventions do more than reduce diabetes risk? Treating depression in adults with type 2 diabetes with exercise and cognitive behavioral therapy. Curr Diab Rep 2012;12:157-166.
Beddhu S, Baird BC, Zitterkoph J, Neilson J, Greene T: Physical activity and mortality in chronic kidney disease (NHANES III). Clin J Am Soc Nephrol 2009;4:1901-1906.
Hawkins MS, Sevick MA, Richardson CR, Fried LF, Arena VC, Kriska AM: Association between physical activity and kidney function: National Health and Nutrition Examination Survey. Med Sci Sports Exerc 2011;43:1457-1464.
Heiwe S, Jacobson SH: Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev 2011;10:CD003236.
Johansen KL, Painter P: Exercise in individuals with CKD. Am J Kidney Dis 2012;59:126-134.
Pechter U, Ots M, Mesikepp S, Zilmer K, Kullissaar T, Vihalemm T, Zilmer M, Maaroos J: Beneficial effects of water-based exercise in patients with chronic kidney disease. Int J Rehabil Res 2003;26:153-156.
Robinson ES, Fisher ND, Forman JP, Curhan GC: Physical activity and albuminuria. Am J Epidemiol 2010;171:515-521.
Robinson-Cohen C, Katz R, Mozaffarian D, Dalrymple LS, de Boer I, Sarnak M, Shlipak M, Siscovick D, Kestenbaum B: Physical activity and rapid decline in kidney function among older adults. Arch Intern Med 2009;169:2116-2123.
Stengel B, Tarver-Carr ME, Powe NR, Eberhardt MS, Brancati FL: Lifestyle factors, obesity and the risk of chronic kidney disease. Epidemiology 2003;14:479-487.
Leehey DJ, Moinuddin I, Bast JP, Qureshi S, Jelinek CS, Cooper C, Edwards LC, Smith BM, Collins EG: Aerobic exercise in obese diabetic patients with chronic kidney disease: a randomized and controlled pilot study. Cardiovasc Diabetol 2009;8:62.
Myers GL Miller WG, Coresh J, Fleming J, Greenberg N, Greene T, Hostetter T, Levey AS, Panteghini M, Welch M, Eckfeldt JH; National Kidney Disease Education Program Laboratory Working Group: Recommendations for improving serum creatinine measurement: a report from the Laboratory Working Group of the National Kidney Disease Education Program. Clin Chem 2006;52:5-18.
National Kidney Foundation: K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-S266.
Wen CP, Wai JP, Tsai MK, Yang YC, Cheng TY, Lee MC, Chan HT, Tsao CK, Tsai SP, Wu X: Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011;378:1244-1253.
Carlson SA, Fulton JE, Schoenborn CA, Loustalot F: Trend and prevalence estimates based on the 2008 Physical Activity Guidelines for Americans. Am J Prev Med 2010;39:305-313.
Chen JL, Lerner D, Ruthazer R, Castaneda-Sceppa C, Levey AS: Association of physical activity with mortality in chronic kidney disease. J Nephrol 2008;21:243-252.
O'Hare AM, Tawney K, Bacchetti P, Johansen KL: Decreased survival among sedentary patients undergoing dialysis: results from the Dialysis Morbidity and Mortality Study Wave 2. Am J Kidney Dis 2003;41:447-454.
Stack AG, Molony DA, Rives T, Tyson J, Murthy BV: Association of physical activity with mortality in the US dialysis population. Am J Kidney Dis 2005;45:690-701.
Tentori F, Elder SJ, Thumma J, Pisoni RL, Bommer J, Fissell RB, Fukuhara S, Jadoul M, Keen ML, Saran R, Ramirez SP, Robinson BM: Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes. Nephrol Dial Transplant 2010;25:3050-3062.
Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, McCullough PA, Kasiske BL, Kelepouris E, Klag MJ, Parfrey P, Pfeffer M, Raij L, Spinosa DJ, Wilson PW: Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003;108:2154-2169.
Tseng CH: Mortality and causes of death in a national sample of diabetic patients in Taiwan. Diabetes Care 2004;27:1605-1609.
Sun G, Kashyap SR: Cancer risk in type 2 diabetes mellitus: metabolic links and therapeutic considerations. J Nutr Metab 2011;2011:708183.
Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-1350.
Johansen KL: Exercise in the end-stage renal disease population. J Am Soc Nephrol 2007;18:1845-1854.
Johansen KL, Sakkas GK, Doyle J, Shubert T, Dudley RA: Exercise counseling practices among nephrologists caring for patients on dialysis. Am J Kidney Dis 2003;41:171-178.
Delgado C, Johansen KL: Deficient counseling on physical activity among nephrologists. Nephron Clin Pract 2010;116:c330-c336.
Wen CP, Cheng TY, Tsai MK, Chang YC, Chan HT, Tsai SP, Chiang PH, Hsu CC, Sung PK, Hsu YH, Wen SF: All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan. Lancet 2008;371:2173-2182.
Matsushita K, van der Velde M, Astor BC, Woodward M, Levey AS, de Jong PE, Coresh J, Gansevoort RT: Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet 2010;375:2073-2081.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.