Sports Medicine

, Volume 44, Issue 8, pp 1125–1138 | Cite as

Effect of Progressive Resistance Training on Measures of Skeletal Muscle Hypertrophy, Muscular Strength and Health-Related Quality of Life in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis

  • Birinder S. Cheema
  • Danwin Chan
  • Paul Fahey
  • Evan Atlantis
Systematic Review


Background and Objective

Skeletal muscle wasting resulting in reduced muscular strength and health-related quality of life (HR-QOL) is common in chronic kidney disease (CKD) and may be reversed with progressive resistance training (PRT). Therefore, we systematically assessed the effect of PRT on measures of skeletal muscle hypertrophy, muscular strength and HR-QOL in this cohort to inform clinical practice and guidelines.


We performed a systematic review and meta-analysis.

Inclusion Criteria

We included randomised controlled trials (RCTs) that investigated the independent effect of PRT (>6 weeks) on measures of skeletal muscle hypertrophy [muscle mass or cross-sectional area (CSA)], muscular strength and/or HR-QOL in adults with CKD.

Data Extraction and Analysis

The standardised mean difference (SMD) from each study was pooled to produce an overall estimate of effect and associated 95 % confidence interval (95 % CI) between treatment and control groups on primary outcomes.


Seven RCTs in 271 patients with Stage 3–5 CKD yielded seven studies on muscular strength (N = 249), six studies on total body muscle mass (N = 200) and six studies on HR-QOL (N = 223). PRT significantly improved standardised muscular strength [SMD 1.15 (95 % CI 0.80–1.49)] and HR-QOL [SMD 0.83 (95 % CI 0.51–1.16)], but not total body muscle mass [SMD 0.29 (95 % CI −0.27 to 0.86)] in our primary analysis. However, secondary analysis of six studies showed that PRT induced significant muscle hypertrophy of the lower extremities (leg mass, or mid-thigh or quadriceps CSA) [SMD 0.43 (95 % CI 0.11–0.76)], a pertinent analysis given that most studies implemented lower-body PRT only.


Robust evidence from RCTs indicates that PRT can induce skeletal muscle hypertrophy and increase muscular strength and HR-QOL outcomes in men and women with CKD. Therefore, clinical practice guidelines should be updated to inform clinicians on the benefits of PRT in this cohort.



BSC is the guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article. BSC, DC and EA conceived and designed the review, identified articles for inclusion and exclusion, extracted and interpreted the data and drafted the article. PF analysed and interpreted the data and revised the article. All authors have approved and read the final article. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors declare they have no competing interests. We sincerely thank Ms Katrina Chaudhary for her work in developing the database searches.

Conflict of interest


Supplementary material

40279_2014_176_MOESM1_ESM.docx (39 kb)
Supplementary material 1 (DOCX 39 kb)


  1. 1.
    USRDS: U.S. Renal Data System, USRDS 2009 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2011.Google Scholar
  2. 2.
    Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382(9888):260–72.PubMedCrossRefGoogle Scholar
  3. 3.
    El Nahas AM, Bello AK. Chronic kidney disease: the global challenge. Lancet. 2005;365(9456):331–40.CrossRefGoogle Scholar
  4. 4.
    Fouque D, Kalantar-Zadeh K, Kopple J, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int. 2008;73(4):391–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Kopple J. Pathophysiology of protein-energy wasting in chronic renal failure. J Nutr. 1999;129(1S Suppl):247S–51S.PubMedGoogle Scholar
  6. 6.
    Workeneh BT, Mitch WE. Review of muscle wasting associated with chronic kidney disease. Am J Clin Nutr. 2010;91(4):1128S–32S.PubMedCrossRefGoogle Scholar
  7. 7.
    Johansen KL, Chertow GM, Ng AV, et al. Physical activity levels in patients on hemodialysis and healthy sedentary controls. Kidney Int. 2000;57:2564–70.PubMedCrossRefGoogle Scholar
  8. 8.
    Caso G, Garlick P. Control of muscle protein kinetics by acid-base balance. Curr Opin Clin Nutr Metab Care. 2005;8(1):73–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Raj D, Zager P, Shah V, et al. Protein turnover and amino acid transport kinetics in end-stage renal disease. Am J Physiol Endocrinol Metab. 2004;286:E136–43.PubMedCrossRefGoogle Scholar
  10. 10.
    John SG, Sigrist MK, Taal MW, et al. Natural history of skeletal muscle mass changes in chronic kidney disease stage 4 and 5 patients: an observational study. PLoS One. 2013;8(5):e65372.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Cheema B, Abas H, Smith B, et al. Investigation of skeletal muscle quantity and quality in end-stage renal disease. Nephrology (Carlton). 2010;15:454–63.CrossRefGoogle Scholar
  12. 12.
    Johansen KL, Shubert T, Doyle J, et al. Muscular atrophy in patients receiving hemodialysis: effects on muscle strength, muscle quality, and physical function. Kidney Int. 2003;63:291–7.PubMedCrossRefGoogle Scholar
  13. 13.
    McClellan WM, Anson C, Birkeli K, et al. Functional status and quality of life: predictors of early mortality among patients entering treatment for end stage renal disease. J Clin Epidemiol. 1991;44(1):83–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Desmeules S, Levesque R, Jaussent I, et al. Creatine index and lean body mass are excellent predictors of long-term survival in haemodiafiltration patients. Nephrol Dial Transplant. 2004;19(5):1182–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Roshanravan B, Robinson-Cohen C, Patel KV, et al. Association between physical performance and all-cause mortality in CKD. J Am Soc Nephrol. 2013;24(5):822–30.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Knight EL, Ofsthun N, Teng M, et al. The association between mental health, physical function, and hemodialysis mortality. Kidney Int. 2003;63(5):1843–51.PubMedCrossRefGoogle Scholar
  17. 17.
    DeOreo P. Hemodialysis patient-assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance. Am J Kidney Dis. 1997;30(2):204–12.PubMedCrossRefGoogle Scholar
  18. 18.
    Lowrie EG, Curtin RB, LePain N, et al. Medical outcomes study short form-36: a consistent and powerful predictor of morbidity and mortality in dialysis patients. Am J Kidney Dis. 2003;41(6):1286–92.PubMedCrossRefGoogle Scholar
  19. 19.
    Fiatarone Singh M. Exercise comes of age: rationale and recommendations for a geriatric exercise prescription. J Gerontol A Biol Sci Med Sci. 2002;57A:M262–82.CrossRefGoogle Scholar
  20. 20.
    Cheema B, Fiatarone Singh M. Exercise training in patients receiving maintenance hemodialysis: a systematic review of clinical trials. Am J Nephrol. 2005;25:352–64.PubMedCrossRefGoogle Scholar
  21. 21.
    Cheema B, Smith B, Fiatarone Singh M. A rationale for intradialytic exercise training as standard clinical practice in end stage renal disease. Am J Kidney Dis. 2005;45:912–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Chan M, Cheema B, Fiatarone Singh M. Progressive resistance training and nutrition in renal failure. J Ren Nutr. 2007;17(1):84–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Cheema B, Chan D. Resistance training in chronic kidney disease. In: Ciccolo J, Kraemer W, editors. Resistance training for the prevention and treatment of chronic disease. Boca Raton: Taylor & Francis; 2014.Google Scholar
  24. 24.
    Smart N, Steele M. Exercise training in haemodialysis patients: a systematic review and meta-analysis. Nephrology (Carlton). 2011;16:626–32.Google Scholar
  25. 25.
    Smart NA, Williams AD, Levinger I, et al. Exercise and Sports Science Australia (ESSA) position statement on exercise and chronic kidney disease. J Sci Med Sport. 2013;21(13):005.Google Scholar
  26. 26.
    Johansen K, Painter P, Sakkas G, et al. Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized controlled trial. J Am Soc Nephrol. 2006;17:2307–14.PubMedCrossRefGoogle Scholar
  27. 27.
    Cheema B, Abas H, Smith B, et al. Progressive exercise for anabolism in kidney disease (PEAK): a randomized controlled trial of resistance training during hemodialysis. J Am Soc Nephrol. 2007;18(5):1594–601.PubMedCrossRefGoogle Scholar
  28. 28.
    Chen JL, Godfrey S, Ng TT, et al. Effect of intra-dialytic, low-intensity strength training on functional capacity in adult haemodialysis patients: a randomized pilot trial. Nephrol Dial Transplant. 2010;25(6):1936–43.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    de Lima MC, Cicotoste Cde L, Cardoso KDa S, et al. Effect of exercise performed during hemodialysis: strength versus aerobic. Ren Fail. 2013;35(5):697–704.PubMedCrossRefGoogle Scholar
  30. 30.
    Castaneda C, Gordon P, Uhlin K, et al. Resistance training to counteract the catabolism of a low-protein diet in patients with chronic renal insufficiency. A randomized, controlled trial. Ann Intern Med. 2001;135:965–76.PubMedCrossRefGoogle Scholar
  31. 31.
    Dong J, Sundell MB, Pupim LB, et al. The effect of resistance exercise to augment long-term benefits of intradialytic oral nutritional supplementation in chronic hemodialysis patients. J Ren Nutr. 2011;21(2):149–59.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Song WJ, Sohng KY. Effects of progressive resistance training on body composition, physical fitness and quality of life of patients on hemodialysis. J Korean Acad Nurs. 2012;42(7):947–56.PubMedCrossRefGoogle Scholar
  33. 33.
    Cheema B. Tackling the survival issue in end stage renal disease: Time to get physical on haemodialysis. Nephrology (Carlton). 2008;3(7):560–9.CrossRefGoogle Scholar
  34. 34.
    KDOQI clinical practice guideline for diabetes and CKD. 2012 update. Am J Kidney Dis. 2012;60(5):850–86.CrossRefGoogle Scholar
  35. 35.
    Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Trials. 2010;11:32.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.PubMedCrossRefGoogle Scholar
  37. 37.
    Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011.
  38. 38.
    Higgins J, Thompson S, Deeks J, et al. Measuring inconsistency in meta-analysis. BMJ. 2003;327(7414):557–60.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Higgins J, Thompson S. Quantifying heterogeneity in meta-analysis. Stat Med. 2002;21(11):1539–58.PubMedCrossRefGoogle Scholar
  40. 40.
    Eggers M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–63.CrossRefGoogle Scholar
  41. 41.
    Cheema B, Lassere M, Shnier R, et al. Rotator cuff tear in an elderly woman performing progressive resistance training: case report from a randomized controlled trial. J Phys Act Health. 2007;4(1):1–8.Google Scholar
  42. 42.
    Honda H, Qureshi A, Axelsson J, et al. Obese sarcopenia in patients with end-stage renal disease is associated with inflammation and increased mortality. Am J Clin Nutr. 2007;86(3):633–8.PubMedGoogle Scholar
  43. 43.
    Carrero JJ, Chmielewski M, Axelsson J, et al. Muscle atrophy, inflammation and clinical outcome in incident and prevalent dialysis patients. Clin Nutr. 2008;27(4):557–64.PubMedCrossRefGoogle Scholar
  44. 44.
    Chang YT, Wu HL, Guo HR, et al. Handgrip strength is an independent predictor of renal outcomes in patients with chronic kidney diseases. Nephrol Dial Transplant. 2011;26(11):3588–95.PubMedCrossRefGoogle Scholar
  45. 45.
    Kalantar-Zadeh K, Kopple JD, Block G, et al. Association among SF36 quality of life measures and nutrition, hospitalization, and mortality in hemodialysis. J Am Soc Nephrol. 2001;12(12):2797–806.PubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Birinder S. Cheema
    • 1
    • 2
  • Danwin Chan
    • 1
  • Paul Fahey
    • 1
  • Evan Atlantis
    • 3
    • 4
  1. 1.School of Science and HealthUniversity of Western SydneyPenrithAustralia
  2. 2.The National Institute of Complementary Medicine (NICM)University of Western SydneyCampbelltownAustralia
  3. 3.School of Nursing and MidwiferyUniversity of Western SydneyPenrithAustralia
  4. 4.School of MedicineUniversity of AdelaideAdelaideAustralia

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