Body composition and exercise intolerance in renal transplant patients: the response to exercise training Eugénie van den Ham
Consequences of malnutrition in HD patients Involuntary weight loss Fat mass Fat-free mass (muscle mass) Muscle weakness and exercise intolerance Physical activity Quality of life Mortality risk
? Effects of successful renal transplantation on nutritional state and physical performance? Factors influencing nutritional state and physical performance in renal transplant patients? Chapter 2 t/m 7
Changes in weight (kg) Changes in body weight after renal transplantation 8,0 7,0 # * p < 0.001 (baseline) # p < 0.001 (12 months) 6,0 5,0 4,0 * 3,0 2,0 1,0 0,0 0 12 24 36 48 60-1,0-2,0 Time after RTx (months) Chapter 2
? Changes in body composition after successful renal transplantation? Techniques to assess body composition in renal transplant patients? Chapter 3, 4, 5, 6
Methods to assess body composition Isotope dilution techniques Anthropometry Dual energy x-ray absorptiometry (DEXA) Multi-frequency bio-electrical impedance spectroscopy (MF-BIA) Chapter 3
Validation MF-BIA in RTx patients MF-BIA Isotope dilution Water compartments (TBW and ECW) MF-BIA DEXA Fat and fat-free mass Anthropometry Chapter 3
MF-BIA in RTx patients Method agreement MF-BIA - isotope dilution TBW: ICC = 0.94 suitable ECW: ICC = 0.84 not satisfactory Method agreement MF-BIA - DEXA FM and FFM: ICC = 0.88 questionable Chapter 3
Changes in body composition in the first six months after transplantation t = 0 t = 3 m t = 6 m p Weight (kg) 77.4 ± 13.2 78.9 ± 11.1 81.4 ± 9.9 + 4.0 0.02 Fat mass (kg) 21.4 ± 9.7 22.8 ± 8.7 24.6 ± 8.8 + 3.2 0.03 Fat-free mass (kg) 52.8 ± 10.7 52.8 ± 10.4 53.6 ± 9.8 + 0.8 0.15 Fat-free mass = indicator muscle mass Chapter 4
Body composition in renal transplant patients (longer-term) Percentage body fat males: 24 % (ideal 15-20 %) females: 38 % (ideal 20-25 %) Waist-hip circumference males: 12 % > 1.00 females: 66 % > 0.80!! Chapter 6
Nutritional state after renal transplantation Body weight Fat mass (truncal fat) Cardiovascular disease Graft survival Patient survival
? Which factors are involved in changes in body weight and body composition after renal transplantation? Chapter 2, 5 en 6
Potential factors Prednisolone Dietary pattern Physical inactivity Chapter 2, 5 en 6
Physical inactivity Physical activity preventing weight gain Physical activity level muscle mass and fat mass accumulation adipose tissue in upper, central body regions Renal transplant patients? Chapter 6
Factors body composition Prednisolone Nutrient intake Physical activity - - + physical activity fat mass and muscle mass Chapter 2, 5 en 6
? Effects of succesful renal transplantation on physical performance? Determinants of physical functioning and performance in renal transplant patients? Chapter 7
Physical performance Skeletal muscle strength - quadriceps femoris (Cybex) - specific muscle groups (fitness equipment) Exercise capacity - Wpeak and VO 2 peak (symptom-limited graded cycle-ergometry) Renal transplant patients Hemodialysis patients Healthy, sedentary controls Chapter 7
Strength (nm) Wpeak (Watt) Muscle strength and exercise capacity 150 120 Quadriceps strength (Cybex) p < 0.01 225 200 175 Peak work load (Cycle-ergometry) p < 0.01 90 150 125 60 30 100 75 50 25 0 RTx HD CON RTx HD CON 0 RTx = renal transplant HD = hemodialysis CON = controls Chapter 7
Determinants of exercise capacity in RTx patients Skeletal muscle strength + Physical activity level + Chapter 7
Physical activity level RTx patients Low physical activity levels Adverse effects body composition Strongly reduced exercise capacity
? Effects of exercise training on - body composition? - skeletal muscle strength and exercise capacity? - quality of life? Comparison of the response to exercise training in - renal transplant patients - hemodialysis patients - healthy controls Chapter 8
Hypotheses Training improves - body composition - skeletal muscle strength - quality of life Response to training dialysis patients < renal transplant patients< controls Multiple catabolic factors uremia dialysis treatment itself chronic inflammation oxidative stress Subnormale renal function Mostly using corticosteroids Chapter 8
Design of the study medical examination baseline training program 12 weeks post-training t = 0 t = 1 t = 6 t = 13 t = 14 time (weeks) body composition exercise capacity muscle strength quality of life muscle biopsy Chapter 8
Training program I standardized, 12 weeks lasting training program 2 supervised sessions (2 hrs each) per week each session endurance training (30 min) - cycle-ergometry and treadmill walking dynamic strength training (30 min) - alternating resistance or strength-endurance training break (30 min) alternating swimming or gymnastics (30 min) mixed groups of renal patients and controls Chapter 8
Training program II intensity endurance training: 50 % Wmax 75 % Wmax strength training: - resistance 50 % Pmax 60 % Pmax, 1x 10 3x 10 - strength-endurance 25 % Pmax 35 % Pmax, 1x 30 3x 30 after 6 weeks of training: measurement of Wmax en Pmax training intensity adjusted constant relative training intensity
Training Endurance training Dynamic strength training Gymnastics Swimming Chapter 8
Effects of training in RTx and HD patients no changes in body composition exercise capacity and skeletal muscle strength (20-25%) quality of life proportion type I MyHC isoforms, proportion type IIa MyHC isoforms trend for an increase in HAD enzyme activity, suggesting an improvement in fatty acid oxidation Chapter 8
Quadriceps (Nm) Arm- and dorsal muscles (kg) Wpeak (Watt) VO2peak (ml/min/kg BW) Changes in exercise capacity and skeletal muscle strength after exercise training 250 P time < 0.001; P time * group = 0.735 30 P time = 0.004; P time * group = 0.285 200 28 150 26 100 24 50 22 0 baseline 12 w eeks 20 baseline 12 w eeks 140 P time = 0.001; P time * group = 0.369 60 P time < 0.001; P time * group = 0.953 130 50 120 40 110 100 90 80 baseline 12 w eeks 30 20 10 0 baseline 12 w eeks RTx HD Control
MyHC type IIb/x (%) HAD (U / mg protein) MyHC type I (%) MyHC type IIa (%) Changes in skeletal muscle fiber type distribution and HAD activity after exercise training 40 P time < 0.001; P time * group = 0.773 60 P time = 0.036; P time * group = 0.646 30 20 50 10 40 0 baseline 12 w eeks 30 baseline 12 w eeks 40 P time = 0.173; P time * group = 0.566 50 P time = 0.052; P time * group = 0.997 30 40 20 10 30 20 10 RTx HD 0 baseline 12 w eeks 0 baseline 12 w eeks Control
Response to training - No significant differences in the functional response and the intrinsic changes in skeletal muscle between RTx patients, HD patients and controls - Disease-specific factors do not appear to affect the response to exercise training
Exercise training has to be considered as part of the routine treatment of renal transplant and hemodialysis patients!