Next Article in Journal
Genetic Variability of HUPRA Syndrome—A Case Report
Previous Article in Journal
The Role of L-Carnitine in Kidney Disease and Related Metabolic Dysfunctions
Previous Article in Special Issue
Effects of Diet and Exercise on Metabolic Parameters and Health in Moderate to Advanced Kidney Disease
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:

The Importance of Lifestyle Interventions in the Prevention and Treatment of Chronic Kidney Disease

Ellen M. Castle
Sharlene A. Greenwood
2 and
Roman-Ulrich Müller
Physiotherapy Division, Department of Health Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK
King’s College Hospital NHS Foundation Trust, Therapies Department, London SE5 9RS, UK
Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
Author to whom correspondence should be addressed.
Kidney Dial. 2023, 3(2), 192-195;
Submission received: 30 March 2023 / Accepted: 3 April 2023 / Published: 10 April 2023
(This article belongs to the Special Issue Lifestyle Interventions to Prevent Kidney Diseases)
Chronic kidney disease (CKD) is a global health problem, with a prevalence of approximately 13.4% worldwide [1]. Not only is CKD an independent risk factor for Cardiovascular disease (CVD) [2], it is associated with global mortality and morbidity [3]. Whilst the detection and treatment of CKD has improved over recent years, there is a strong need for preventative care [3]. Over the last few decades, strategies to prevent and treat CKD have largely focused on pharmacological interventions. However, while this approach has provided answers for individual disease settings, the general problem of CKD remains. Non-pharmacological treatments, such as Lifestyle interventions (including dietary recommendations and physical exercise) have been shown to harbour potential for beneficial effects on kidney health and the resulting co-morbidities [4]. The aim of the Special Issue on “Lifestyle interventions in Kidney Health and Disease” was to provide an overview on the current knowledge in this field and an outlook towards new research questions. Increasing awareness of lifestyle interventions and creating a setting in which these can be efficiently studied in clinical trials could facilitate future implementation into clinical practice and improvement in outcomes for people living with CKD. This Special Issue included 14 peer-reviewed publications reviewing dietary, exercise, and other non-pharmacological interventions in people living with CKD. The work received a lot of attention, as indicated by three publications being among the top read publications in Kidney & Dialysis in November 2022 ( accessed on 10 March 2023). The key messages from this Special Issue will be summarised below.
In ADPKD, animal experiments have shown potential of ketogenic dietary interventions ameliorating disease progression [5] and first data in humans point towards potential translatability of this approach [6,7]. In this Special Issue, Bruen et al. [8] provide a first insight into a potential tailored dietary intervention that may enable the implementation of ketogenic dietary interventions in real life in the future. This aspect is complemented by recent evidence on the role of weight reduction in ADPKD. Steele and Nowak [9] facilitate further exploration by providing an overview of available data, adding insight into potential mechanisms, and offering suggestions for future research. Ramos et al. [10] explore the evidence regarding the pathophysiology, assessment and treatment of constipation in people living with CKD.
Metabolic abnormalities associated with CKD including inflammation, dyslipidaemia, and oxidative stress, and are considered major factors contributing to disease progression and cardiovascular comorbidity. The review by Ertuglu and Ikizler [11] provides a summary of the current knowledge regarding how diet and exercise may impact on metabolic endpoints in CKD and suggests future interventions that may improve CKD-associated outcomes. The commentary by Artemis Simopoulos [12] extends on these thoughts by elaborating on the role of healthy dietary patterns in preventing inflammation. Such dietary patterns, including DASH- and Mediterranean diets, may become important to prevent loss of kidney function and further research is warranted.
Physical activity and exercise are recommended for people across all stages of CKD [13,14]. To facilitate tailored exercise interventions, the correct assessment tools are required. In this Special Issue, Koufaki [15] suggests physical function outcomes that are key for assessment and implementation into clinical practice for people living with CKD. There is a growing need and interest for patient-reported outcomes, such as the Participant’s Activation Measure (PAM) [16]. Lightfoot et al. [17] provide a review of patient activation and self-management, their interactions, and the importance of these concepts for self-management interventions for people living with CKD.
Frailty is an emerging area of research in CKD [18]. Mayes et al. [19] provide a review of the evidence addressing the assessment of frailty in people living with CKD, and the non-pharmacological management strategies to address frailty.
A recent systematic review and practice guideline suggests exercise in pre-dialysis candidates may contribute to improvements in blood pressure, physical function and capacity, functional limitations, and health-related quality of life [14]. Davies et al. [20] summarize and explore the evidence regarding exercising training and delaying kidney function and decline in individuals with CKD who are non-dialysis dependant. The pathophysiology, potential risk factors, how exercise may play a role in kidney function, and the need for future research are presented [20]. However, the authors acknowledge that there is no known harm associated with exercise in pre-dialysis candidates, the importance of individualised exercise prescription and the potential benefits of exercise on other health outcomes, such as quality of life [20].
Recent evidence regarding intra-dialytic cycling (IDC) has sparked debate within the CKD community [21,22,23]. In this Special Issue, King et al. [24] provide an up-to-date summary of the evidence reviewing IDC for those receiving haemodialysis (HD) and explore the concerns and benefits of this treatment approach. The authors urge the renal community to consider IDC not as an individual intervention, but as a component within a comprehensive patient-centred intervention [24].
Recent international guidelines for physical activity for people receiving Peritoneal dialysis (PD) have been published [13]. Despite the guidelines, and feasibility studies suggesting exercise can be safe in people receiving PD, there is low uptake [25]. The review by Lyasere et al. [25] further explores exercise for people living with PD by reviewing the benefits and limitations of the current evidence, providing clinician and patient insights, and potential steps for future research.
Evidence suggests exercise and access to weight management support should be recommended for people following a kidney transplant [14,26]. Whilst weight gain is a significant issue for new kidney transplant recipients, there is no recommended intervention designed to prevent adverse weight gain from occurring [27]. The systematic review and meta-analysis by Castle et al. [28] explore the effects of exercise interventions, dietary interventions and combined interventions on body weight and body mass index in people following a kidney transplant.
Behavioural change techniques are recommended to facilitate physical activity and dietary interventions [29]. In this Special Issue, Leunis et al. [30] explore physical activity behaviour in solid organ transplant recipients. The authors draw on the Behaviour Change Wheel [31] to propose physical activity behaviour change interventions for solid organ transplant candidates [30].
The perspective statement contributed by Tess Harris [32] provides the crucial patient perspective and clearly underlines the lack of lifestyle counselling in routine clinical care. This shortcoming, together with a lack of focus on patient-relevant outcomes, and the need for tools measuring these outcomes, will be topics requiring special attention in the future.


Lifestyle interventions to optimise diet, physical activity, exercise, and non-pharmacological interventions are crucial in the prevention and treatment of CKD. The challenge remains in how to deliver these potential kidney-specific solutions without a trained workforce in place. Novel ways to implement lifestyle interventions at scale, and pragmatically deliver them in routine clinical practice, should be the focus of further research and implementation projects. This will require coherent stakeholder engagement (e.g., patients, healthcare providers, researchers, and policy-makers) and a commitment from research funding schemes to support real-world implementation studies in this field.


Roman-Ulrich Müller received funding from the Ministry of Science North Rhine-Westphalia (Nachwuchsgruppen.NRW 2015–2021), the Marga and Walter Boll Foundation, the PKD Foundation and the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany’s Excellence Strategy—CECAD, EXC 2030–390661388 as well as DFG MU 3629/6-1 and DFG DI 1501/9.

Conflicts of Interest

The Dept. II of Internal Medicine (University Hospital Cologne) received research funding from Otsuka Pharmaceuticals and Thermo Fisher Scientific. RUM is member of the scientific advisory board of Santa Barbara Nutrients. There are no other conflicts of interest.


  1. Lv, J.-C.; Zhang, L.-X. Prevalence and Disease Burden of Chronic Kidney Disease; Springer: Singapore, 2019; Volume 1165. [Google Scholar] [CrossRef]
  2. Sarnak, M.J.; Levey, A.S.; Schoolwerth, A.C.; Coresh, J.; Culleton, B.; Hamm, L.L.; McCullough, P.A.; Kasiske, B.L.; Kelepouris, E.; Klag, M.J.; et al. 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. [Google Scholar] [CrossRef] [PubMed]
  3. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020, 395, 709–733. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  4. Estruch, R.; Ros, E.; Salas-Salvadó, J.; Covas, M.-I.; Corella, D.; Arós, F.; Gómez-Gracia, E.; Ruiz-Gutiérrez, V.; Fiol, M.; Lapetra, J.; et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. N. Engl. J. Med. 2018, 378, e34. [Google Scholar] [CrossRef] [PubMed]
  5. Torres, J.A.; Kruger, S.L.; Broderick, C.; Amarlkhagva, T.; Agrawal, S.; Dodam, J.R.; Mrug, M.; Lyons, L.A.; Weimbs, T. Ketosis Ameliorates Renal Cyst Growth in Polycystic Kidney Disease. Cell Metab. 2019, 30, 1007–1023.e5. [Google Scholar] [CrossRef]
  6. Strubl, S.; Oehm, S.; Torres, J.A.; Grundmann, F.; Haratani, J.; Decker, M.; Vuong, S.; Kaur Bhandal, A.; Methot, N.; Haynie-Cion, R.; et al. Ketogenic dietary interventions in autosomal dominant polycystic kidney disease—A retrospective case series study: First insights into feasibility, safety and effects. Clin. Kidney J. 2022, 15, 1079–1092. [Google Scholar] [CrossRef]
  7. Oehm, S.; Steinke, K.; Schmidt, J.; Arjune, S.; Todorova, P.; Lindemann, C.; Wöstmann, F.; Meyer, F.; Siedek, F.; Weimbs, T.; et al. RESET-PKD: A pilot trial on short-term ketogenic interventions in autosomal dominant polycystic kidney disease. Nephrol. Dial. Transplant. 2022, gfac311. [Google Scholar] [CrossRef] [PubMed]
  8. Bruen, D.M.; Kingaard, J.J.; Munits, M.; Paimanta, C.S.; Torres, J.A.; Saville, J.; Weimbs, T. Ren.Nu, a Dietary Program for Individuals with Autosomal-Dominant Polycystic Kidney Disease Implementing a Sustainable, Plant-Focused, Kidney-Safe, Ketogenic Approach with Avoidance of Renal Stressors. Kidney Dial. 2022, 2, 183–203. [Google Scholar] [CrossRef]
  9. Steele, C.; Nowak, K. Obesity, Weight Loss, Lifestyle Interventions, and Autosomal Dominant Polycystic Kidney Disease. Kidney Dial. 2022, 2, 106–122. [Google Scholar] [CrossRef]
  10. Ramos, C.I.; Nerbass, F.B.; Cuppari, L. Constipation in Chronic Kidney Disease: It Is Time to Bridge the Gap. Kidney Dial. 2022, 2, 221–233. [Google Scholar] [CrossRef]
  11. Ertuglu, L.A.; Ikizler, T.A. Effect of Diet and Exercise on Metabolic Parameters and Health in Moderate to Advanced Kidney Disease. Kidney Dial. 2022, 2, 330–345. [Google Scholar] [CrossRef]
  12. Simopoulos, A.P. Dietary Changes and Their Influence in the Development of Kidney Disease. Kidney Dial. 2022, 2, 131–137. [Google Scholar] [CrossRef]
  13. Bennett, P.N.; Bohm, C.; Harasemiw, O.; Brown, L.; Gabrys, I.; Jegatheesan, D.; Johnson, D.W.; Lambert, K.; Lightfoot, C.J.; MacRae, J.; et al. Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations. Perit. Dial. Int. 2022, 42, 8–24. [Google Scholar] [CrossRef] [PubMed]
  14. Baker, L.; March, D.S.; Wilkinson, T.J.; Billany, R.E.; Bishop, N.C.; Castle, E.M.; Chilcot, J.; Davies, M.D.; Graham-Brown, M.P.M.; Greenwood, S.A.; et al. Renal Association Clinical Practice Guideline. Exercise and Lifestyle in Chronic Kidney Disease 2021; The Renal Association: Bristol, UK, 2021. [Google Scholar]
  15. Koufaki, P. Assessment of Function Limitations in People with Chronic Kidney Disease for Implementation in Clinical Practice. Kidney Dial. 2022, 2, 234–244. [Google Scholar] [CrossRef]
  16. Hibbard, J.H.; Mahoney, E.R.; Stockard, J.; Tusler, M. Development and testing of a short form of the patient activation measure. Health Serv. Res. 2005, 40, 1918–1930. [Google Scholar] [CrossRef] [Green Version]
  17. Lightfoot, C.J.; Nair, D.; Bennett, P.N.; Smith, A.C.; Griffin, A.D.; Warren, M.; Wilkinson, T.J. Patient Activation: The Cornerstone of Effective Self-Management in Chronic Kidney Disease? Kidney Dial. 2022, 2, 91–105. [Google Scholar] [CrossRef]
  18. Chowdhury, R.; Peel, N.M.; Krosch, M.; Hubbard, R.E. Frailty and chronic kidney disease: A systematic review. Arch. Gerontol. Geriatr. 2017, 68, 135–142. [Google Scholar] [CrossRef] [Green Version]
  19. Mayes, J.; Young, H.M.L.; Blacklock, R.M.; Lightfoot, C.J.; Chilcot, J.; Nixon, A.C. Targeted Non-Pharmacological Interventions for People Living with Frailty and Chronic Kidney Disease. Kidney Dial. 2022, 2, 245–261. [Google Scholar] [CrossRef]
  20. Davies, M.; Sandoo, A.; Macdonald, J. The Role of Exercise Training in Delaying Kidney Function Decline in Non-Dialysis-Dependent Chronic Kidney Disease. Kidney Dial. 2022, 2, 262–286. [Google Scholar] [CrossRef]
  21. Graham-Brown, M.P.M.; March, D.S.; Young, R.; Highton, P.J.; Young, H.M.L.; Churchward, D.R.; Dungey, M.; Stensel, D.J.; Bishop, N.C.; Brunskill, N.J.; et al. A randomized controlled trial to investigate the effects of intra-dialytic cycling on left ventricular mass. Kidney Int. 2021, 99, 1478–1486. [Google Scholar] [CrossRef]
  22. Young, H.M.L.; March, D.S.; Highton, P.J.; Graham-Brown, M.; Churchward, D.C.; Grantham, C.; Goodliffe, S.; Jones, W.; Cheung, M.M.; Greenwood, S.A.; et al. Exercise for people living with frailty and receiving haemodialysis: A mixed-methods randomised controlled feasibility study. BMJ Open 2020, 10, e041227. [Google Scholar] [CrossRef]
  23. Greenwood, S.A.; Koufaki, P.; Macdonald, J.H.; Bulley, C.; Bhandari, S.; Burton, J.O.; Dasgupta, I.; Farrington, K.; Ford, I.; Kalra, P.A.; et al. Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: The PEDAL RCT. Health Technol. Assess. 2021, 25, 1–52. [Google Scholar] [CrossRef] [PubMed]
  24. King, A.C.; Wilund, K.R. Next Steps for Intradialytic Cycling Research. Kidney Dial. 2022, 2, 287–295. [Google Scholar] [CrossRef]
  25. Iyasere, O.; Young, H.M.L.; Burton, J.O. Peritoneal Dialysis and the Role of Exercise Training Interventions. Kidney Dial. 2022, 2, 57–67. [Google Scholar] [CrossRef]
  26. Wilkinson, T.J.; Bishop, N.C.; Billany, R.E.; Lightfoot, C.J.; Castle, E.M.; Smith, A.C.; Greenwood, S.A. The effect of exercise training interventions in adult kidney transplant recipients: A systematic review and meta-analysis of randomised control trials. Phys. Ther. Rev. 2022, 27, 114–134. [Google Scholar] [CrossRef]
  27. Castle, E.M.; Greenwood, J.; Chilcot, J.; Greenwood, S.A. Usability and experience testing to refine an online intervention to prevent weight gain in new kidney transplant recipients. Br. J. Health Psychol. 2020, 26, 232–255. [Google Scholar] [CrossRef]
  28. Castle, E.M.; McBride, E.; Greenwood, J.; Bramham, K.; Chilcot, J.; Greenwood, S.A. Do Exercise, Physical Activity, Dietetic, or Combined Interventions Improve Body Weight in New Kidney Transplant Recipients? A Narrative Systematic Review and Meta-Analysis. Kidney Dial. 2021, 1, 100–120. [Google Scholar] [CrossRef]
  29. Michie, S.; Ashford, S.; Sniehotta, F.F.; Dombrowski, S.U.; Bishop, A.; French, D.P. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychol. Health 2011, 26, 1479–1498. [Google Scholar] [CrossRef]
  30. Leunis, S.; Vandecruys, M.; Cornelissen, V.; Van Craenenbroeck, A.H.; De Geest, S.; Monbaliu, D.; De Smet, S. Physical Activity Behaviour in Solid Organ Transplant Recipients: Proposal of Theory-Driven Physical Activity Interventions. Kidney Dial. 2022, 2, 298–329. [Google Scholar] [CrossRef]
  31. Michie, S.; Atkins, L.; West, R. The Behaviour Change Wheel. A Guide to Designing Interventions; Silverback Publishing: Sutton, UK, 2014. [Google Scholar]
  32. Harris, T. Lifestyle Interventions in Improving Health Outcomes and Enabling People to Live Well with Kidney Disease. Kidney Dial. 2022, 2, 204–208. [Google Scholar] [CrossRef]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Castle, E.M.; Greenwood, S.A.; Müller, R.-U. The Importance of Lifestyle Interventions in the Prevention and Treatment of Chronic Kidney Disease. Kidney Dial. 2023, 3, 192-195.

AMA Style

Castle EM, Greenwood SA, Müller R-U. The Importance of Lifestyle Interventions in the Prevention and Treatment of Chronic Kidney Disease. Kidney and Dialysis. 2023; 3(2):192-195.

Chicago/Turabian Style

Castle, Ellen M., Sharlene A. Greenwood, and Roman-Ulrich Müller. 2023. "The Importance of Lifestyle Interventions in the Prevention and Treatment of Chronic Kidney Disease" Kidney and Dialysis 3, no. 2: 192-195.

Article Metrics

Back to TopTop