Management of Patients with Chronic Renal Failure

Role of Physical Therapy

PAULA J. GRAY

Chronic renal failure can lead to multiple medical and physical problems requir-
ing physical therapy treatment. The purpose of this article is to provide an
understanding of the medical treatment and the complications of chronic renal
failure. Medically, patients with chronic renal failure are treated by hemodialysis,
by peritoneal dialysis, or with a kidney transplant. The physical therapy man-
agement of the patient on dialysis and that of the patient with a kidney transplant
differs as to the extent and aggressiveness of the program. Providing the proper
physical therapy program for patients with chronic renal failure is often a
challenge because of such complications as congestive heart failure and periph-
eral neuropathies. Physical therapy is a necessary part of the rehabilitation of
the patient with chronic renal failure.

Key Words: Renal failure, Kidney transplant, Rehabilitation, Physical therapy.

A new and challenging area of patient care for the
physical therapist is the physical rehabilitation of
patients with chronic renal failure (CRF). The pur-
pose of this paper is to review the pathophysiology of
CRF and to describe the rehabilitative management
of both the patient undergoing dialysis and the patient
who has had a renal transplant.
The functional unit of the kidney, the nephron, is
composed of the glomerulus and the proximal and
distal tubules. Filtration, secretion, and reabsorption
take place in the nephron.
The kidney regulates the volume and chemical
composition of blood and extracellular fluid. Other
kidney functions include secretion of erythropoietin
(a hormone that induces the marrow to produce red
blood cells) and renin (a substance that affects blood
pressure control) and conversion of vitamin D to its
active form.1'2
Chronic renal failure is a condition in which the
kidneys are no longer functioning as a result of
progressive destruction of the nephron. The most
common causes of CRF are chronic glomerulone-
phritis (CGN), chronic pyelonephritis, nephrosclero-
sis, and polycystic disease.1, 3
Miss Gray was Clinical Supervisor, Department of Physical Ther-
apy, Hahnemann Medical College and Hospital, Philadelphia, PA,
when this article was written. She is now Assistant Chief, Physical
Therapy, University of Maryland Hospital, Baltimore, MD 21210
(USA).
This article was submitted September 2, 1980, and accepted June
19, 1981.
Chronic glomerulonephritis results from any dis-
ease that damages the glomeruli. Chronic pyelone-
phritis is a chronic inflammatory disease of the kid-
ney. Nephrosclerosis is a disease secondary to hyper-
tension that causes sclerotic lesions of the renal arter-
ies and arterioles. These sclerotic lesions may lead to
ischemia and death of the renal tissue. Polycystic
disease is a hereditary disorder in which large cysts
develop in the kidneys and destroy surrounding neph-
rons by compression.3
MEDICAL MANAGEMENT
When CRF occurs, the kidney is unable to perform
its normal functions, metabolic end products, such as
urea, build up in the bloodstream, and the patient
develops uremia. The clinical manifestations of ure-
mia vary with the medical condition of the patient
and include gastrointestinal upset, decreased mental
concentration, apathy, lethargy, confusion and in-
creased irritability, peripheral neuropathy, dermato-
logical changes, generalized itching of the skin, ane-
mia, weakness, and changes in cardiovascular func-
tion.1 The cardiovascular system can be affected by
hypertension, congestive heart failure, cardiac hyper-
trophy, coronary artery disease, and pericarditis.4
Without medical intervention, such as renal dialysis
or renal transplantation, the prognosis for the patient
with CRF is poor. If the patient is treated with

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 dialysis, the clinical symptoms should improve, and
the patient is usually able to return to work or home-
making activities. Most patients with CRF are able to
lead comparatively normal lives punctuated by main-
tenance dialysis treatments three times each week.
Some patients, however, do not respond as well to
treatment and continue to exhibit problems as a result
of uremia. These patients often require physical ther-
apy as described in the physical therapy management
in dialysis section.
According to Mabee and associates, a majority of
patients with CRF return to work or homemaking
after successful transplantation.5 About one-third, of
these patients, however, reported functioning below
pre-illness levels.6 The kidney transplant may be re-
jected by an immune response, in which case the
patient is weak from the surgery and bedrest and
depressed because of the rejection.6 These patients
are candidates for physical therapy programs to in-
crease endurance and strength. The physical therapy
program offered in the physical therapy management
in transplant section must be modified to accommo-
date any secondary problems such as rejection.
Renal Dialysis
Peritoneal dialysis (PD) and hemodialysis (HD)
are the two forms of dialysis used to treat CRF. The
PD involves the insertion of a catheter into the peri-
toneal cavity. The Tenckhoff catheter is commonly
used. One or two liters of dialysate, a fluid composed
of electrolytes, buffer, and water, enters the cavity
through the catheter. The dialysate remains in the
cavity for a specified period of time, usually ranging
from 15 to 45 minutes, before being drained into a
collecting bag. This process continues for a long
period of time, usually 36 to 48 hours. Maintenance
PD is performed three to five times each week and
during PD the patient must remain in bed or in a
chair. Continuous ambulatory peritoneal dialysis is a
relatively new technique in which the patient carries
on daily living while being dialyzed.7
Maintenance PD is indicated when arteries can not
tolerate a hemodialysis vascular access, while the
patient is waiting for the permanent hemodialysis
vascular access, or when the patient prefers this
method of treatment.
Hemodialysis uses a blood circuit to connect the
patient to a dialysis machine called a hemodialyzer.
A vascular access is surgically implanted, usually in
an upper extremity. The most common vascular ac-
cess is an internal arteriovenous fistula, an anasto-
mosis created between an artery and a vein. The
radial artery and cephalic vein are used most often.
An arteriovenous graft involves the interposition of
material, such as bovine heterographs or Dacron
grafts, between the patient's artery and vein. An
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external arteriovenous shunt is used temporarily
while the internal fistula or graft is maturing. Matu-
ration takes from four to six weeks during which time
the fistula or graft gradually adapts to the increased
volumes of blood, and the venous walls thicken ade-
quately for repeated puncture. The graft or fistula is
permanent, although it may be removed if compli-
cations occur, such as clotting or infection.8
Renal Transplant
A renal transplant was first successfully performed
in the 1950s.9 Patients may receive a kidney transplant
(an allograft) from a living related donor or from a
cadaver. The tissues are carefully matched to mini-
mize rejection. Matching is a process in which blood
of one patient is tested for compatability with that of
a potential donor. The best match is a kidney from a
sibling, the second best match is a kidney from a
parent. Living related donor kidneys function better
than cadaveric kidneys; there is an 80 to 85 percent
survival rate for patients with living donor transplants
and a 40 to 50 percent survival rate for those with
cadaveric transplants.10 The risk of rejection is sig-
nificantly higher with cadaveric kidneys than with
kidneys from living related donors.
Kidney transplant survival rates vary. One study
reported patient survival rates of 92 percent at one
year and 84 percent at five years.11 Of the grafts, 79
percent were functioning after one year and 64 per-
cent were functioning after five years. Survival rate is
affected by many factors including age, race, duration
on dialysis before transplant, presence of diabetes,
and tissue match.
PHYSICAL THERAPY MANAGEMENT
For the patient who is on dialysis or who has had
a renal transplant, progression of an exercise program
or determination of an activity level is done empiri-
cally by the physical therapist. The progression, there-
fore, is highly variable and depends upon the individ-
ual patient. The general responses the physical ther-
apist should monitor are the patient's vital signs such
as pulse rate, breathing rate, and blood pressure.
However, further research is needed to determine the
specific responses for progression of the patient with
chronic renal failure.
Dialysis
Patients on PD or HD who are lethargic and have
had prolonged bedrest should be seen daily for a
physical therapy program. Clinically, the patients
may demonstrate contractures, distal edema, disuse
atrophy, and decubiti. Patients on PD or HD are
subject to a number of well-known cardiovascular
PHYSICAL THERAPY
 risk factors such as hypertensive heart failure, cardio-
myopathy, vascular calcifications, pericarditis, car-
diac tamponade, and cardiac arrest caused by electro-
lyte imbalance and uremic cardiomyopathy.4
Short-term goals for patients on dialysis include
preventing contractures, disuse atrophy, and decubiti;
increasing strength, mobility, and endurance; and
decreasing edema.
Long-term goals vary, but one primary goal is
increasing mobility enough to enable the patient to
perform activities of daily living (ADL) and to travel
to a dialysis center.
A treatment plan should include proper bed posi-
tioning and mobility training, exercises for general
conditioning, ambulation training, and ADL training.
Proper bed positioning for a patient with severe
uremia aids in preventing decubiti and contractures
and in decreasing edema. Patients should be in each
of the following positions for up to two hours: on left
side, on right side, supine, and prone if tolerated. The
heels should be protected from pressure while the
patient is supine. A pillow should be placed between
the knees and behind the back while the patient is
side lying.
Bed mobility training assists in achieving short-
term goals, especially preventing contractures and
decubiti. The patient should be encouraged to roll
from side to side and be taught to sit up from the
supine position. An overhead trapeze is often a useful
aid for the patient to increase his mobility in bed. The
patient should be instructed in proper transfer tech-
niques.
The patient must be encouraged to stay out of bed
as much as possible in order to increase gradually
sitting tolerance. The legs should be elevated to pre-
vent dependent edema while the patient is sitting in
a chair.
General conditioning exercise prevents disuse atro-
phy and increases strength, mobility, and endurance.
Such exercises can prepare the patient for more ad-
vanced activities such as transfers and walking.
Patients may begin walking in the parallel bars or
with a walker. In some cases, the therapist may decide
that the patient does not need an assistive device at
all. The level of ambulation a patient reaches is
dependent on many factors including age, medical
condition, mental status, and physical disabilities.
Some patients may not be able to walk and should,
therefore, be assessed as wheelchair candidates.
Transplantation
Physical therapy should begin within a few days
after the transplant when the patient is medically
stable. There is always a possibility of an acute rejec-
tion, and this is most common 7 to 10 days after
transplant. The clinical features of rejection are fever,
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graft tenderness, oliguria, rising blood levels of cre-
atinine, and hypertension.9
The amount of physical therapy required to reha-
bilitate the patient with a transplant depends to a
large extent on the patient's medical condition before
the transplant. The patient with a recent diagnosis of
renal failure will probably have fewer problems than
the patient who has been on dialysis for several
months while waiting for a transplant to become
available. This is because the clinical manifestations
of the former have not yet become severe, while the
latter may have developed complications such as
weakness or cardiac problems. Diabetic patients with
renal transplantations often have additional compli-
cations such as peripheral neuropathies or amputa-
tions.
The short-term goals for a patient after a kidney
transplant include increasing general muscle strength
and endurance, and determining that the patient can
walk independently on level surfaces and stairs.
The long-term goal for a patient after a kidney
transplant is to regain maximal functional capacity,
including return to work.
A suggested patient program would consist of ac-
tive exercises,6 riding a stationary bicycle (with regu-
lar increases in duration and mileage), walking to
increase speed (using a stop watch), walking to in-
crease endurance (with regular increases in distance),
and stair climbing (with increases in the number of
flights).
COMPLICATIONS
The patient's ability to participate in a physical
therapy program may be directly affected by the
many complications common to CRF. The compli-
cations encountered most often are peripheral neu-
ropathy (uremic or diabetic), congestive heart failure,
myocardial infarction, cerebrovascular accident, am-
putation, encephalopathy, organic brain syndrome,
aseptic necrosis of the hip, and osteodystrophy with
possible fractures.
Peripheral neuropathies in the patient with CRF
are usually bilateral. Both sensory and motor modal-
ities may be affected, with sensory disturbances in a
stocking or glove distribution. Burning feet and "rest-
less legs" are common complaints associated with
dialysis and uremic neuropathy.11 These neuropathies
may show improvement with dialysis, and often will
disappear after transplant, unless permanent damage
has occurred. If an orthosis is needed, sensation as
well as the fluctuating volume of the foot should be
considered and assessed.
During treatment, the physical therapist should be
aware of the site of the patient's vascular access. A
vibration, called a "thrill," caused by the high volume
of blood from the artery rushing into the smaller vein,
can be felt over the area. Direct pressure should at no
175
 time be applied to the access, including when assisting
the patient to stand or during progressive resistive
exercises. It is contraindicated to take blood pressure
in the extremity with the vascular access.
Blood flow is decreased distal to the vascular access.
The result is a decreased ability to dissipate heat
adequately. Extreme caution must be used, therefore,
when applying heat to the extremity with the vascular
access.
Lack of motivation is perhaps the major problem
encountered in the rehabilitation of a patient with
CRF. This is, of course, not true with every patient,
REFERENCES
1. Chyatte S (ed): Rehabilitation in Chronic Renal Failure. Bal-
timore, MD, Williams & Wilkins Co, 1979, pp 1-15
2. Stark JL: Bun/creatinine: Your keys to kidney function.
Nursing 80:33-38, 1980
3. Guyton AC: Textbook of Medical Physiology, ed 5. Philadel-
phia, PA, WB Saunders Co, 1976, pp 438-445
4. Nik-Aktar B, Khonsari H, Hesabi A, et al: Uremic cardiomy-
opathy in hemodialysis patients. Angiology 29:758-763,
1978
5. Mabee MS, Tilney NL, Vineyard GC, et al: Rehabilitation
profile of kidney transplant patients. Am J Surg 136(5):614-
617, 1978
6. Sachs B: Renal Transplantation: A Nursing Perspective.
Flushing, NY, Medical Examination Publishing Congress,
1977
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but many patients become dependent and manifest
signs of uremia such as decreased mental concentra-
tion, apathy, and lethargy. These patients need to be
motivated to get out of bed and increase their mobil-
ity.
The patient with CRF who is treated with PD, HD,
or transplant is a challenging and interesting patient.
The existence of multiple medical problems, many of
them physical, indicates that physical therapy is a
necessary part of this patient's total rehabilitation.
The physical therapist should become an integral part
of the CRF patient care team.
7. Popovich RP, Monarie JW, Nolph KD, et al: Continuous
ambulatory peritoneal dialysis. Ann Intern Med 88:449-455,
1978
8. Irwin BC: Hemodialysis means vascular access .. . and the
right kind of nursing care. Nursing 79:49-53, 1979
9. Forland M (ed): Nephrology: A Review of Clinical Nephrology.
Garden City, NY, Medical Examination Publishing Co Inc,
1977, pp 422-424
10. Pfaff WW, Morehead RA, Fennell RS, et al: The role of
various risk factors in living related donor renal transplant
success. Ann Surg 191:617-625, 1980
11. Callaghan NC: Restless legs syndrome in uremic neuropathy.
Neurology 16:359-361, 1966
PHYSICAL THERAPY