Version July 2025
INTRODUCTION —
Patients with advanced chronic kidney disease (CKD), particularly those on dialysis, often suffer from physical deconditioning and muscle weakness; the latter is sometimes referred to as “uremic myopathy.” Physical deconditioning increases morbidity and mortality among patients on dialysis but may be prevented or treated by exercise.
This topic reviews the pathophysiology of deconditioning among patients with CKD. The beneficial effects of exercise are discussed, and exercise recommendations are provided, for patients with nondialysis CKD and those on dialysis. The effects of a sedentary lifestyle and the effects of exercise in the general adult population are discussed elsewhere:
●(See "The benefits and risks of aerobic exercise".)
●(See "Physical activity and exercise in older adults".)
●(See "Obesity in adults: Role of physical activity and exercise".)
EPIDEMIOLOGY —
Physical deconditioning and muscle weakness are considered common in patients with advanced CKD, given the obvious decline in physical function observed in many patients [1,2]. However, the prevalence of a specific pathophysiological process directly attributable to impaired kidney function is not well defined [3]. Estimates of physical inactivity, which is both a cause and consequence of deconditioning, and sarcopenia among patients with CKD are presented below:
●Physical inactivity is common in patients with CKD, particularly those on dialysis [4-8]. In a study of 134 patients on maintenance dialysis, a wearable device measured steps, activity-related energy expenditure, and physical activity level for five days; 86 patients (64 percent) had physical activity parameters consistent with a sedentary or low active lifestyle [5]. In a study of individuals with nondialysis CKD who participated in the United States National Health and Nutrition Examination Survey (NHANES), only 55 percent spent at least 150 minutes per week engaged in moderate aerobic activity or at least 75 minutes per week engaged in vigorous aerobic activity [4], which is the minimum level of physical activity recommended by the World Health Organization.
●Sarcopenia (ie, decreased muscle mass with decreased function/mobility) is also common in patients with advanced CKD [9-11]. In one study including 330 patients on dialysis, sarcopenia was present in 20 percent, decreased muscle mass alone was present in 24 percent, and decreased muscle strength was present in 15 percent [9]. In a meta-analysis that included over 42000 patients with CKD, the prevalence of sarcopenia was approximately 26 percent for patients on dialysis and 3 percent for patients not on dialysis [10].
PATHOPHYSIOLOGY —
In patients with CKD, comorbid illnesses such as diabetes mellitus, poor nutrition, and peripheral vascular disease play an important role in physical deconditioning. However, CKD-specific factors also contribute to impairment of physical function and sarcopenia. These factors include inflammation and accumulation of reactive oxygen species that result in mitochondrial uncoupling and impaired muscle repair [12-14], as well as deficiencies of erythropoietin, vitamin D, and androgens:
●Mitochondrial uncoupling – Studies have suggested that there is a decrease in mitochondrial efficiency in CKD that is characterized by a decline in adenosine triphosphate (ATP) production per unit of oxygen consumption (ie, mitochondrial uncoupling) [15,16]. Mitochondrial uncoupling may occur prior to the functional decline in exercise tolerance and endurance [17]. The initial cause of mitochondrial uncoupling is not known but may be related to increased oxidative stress as the glomerular filtration rate (GFR) declines [18].
●Erythropoietin deficiency – Erythropoietin deficiency may contribute to muscle weakness, but it is not clear whether this is because the resulting anemia causes a decrease in oxygen delivery to muscle and/or contributes to inactivity and deconditioning or whether erythropoietin has direct effects on muscle.
The correction of anemia with erythropoietin improves endurance and strength in patients with CKD [19]. In an early study, the correction of anemia with erythropoietin to a target hemoglobin of 11 g/dL in 11 previously transfusion-dependent patients on dialysis resulted in a 10 to 30 percent increase in arm and leg muscle strength in three months, although this improvement still left the patients significantly less strong than healthy controls [20].
Muscle structure improves with erythropoietin treatment. In one study, muscle biopsies performed before and after correction of anemia showed an improvement in the diameter of muscle fibers and a reduction in structural abnormalities after partial correction of anemia [21]. These changes would be expected to produce an increase in both muscle strength and performance and are most probably a consequence of an increase in muscle oxygen delivery. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Hyporesponse to erythropoiesis-stimulating agents (ESAs) in chronic kidney disease".)
That erythropoietin may have a direct effect on muscle (ie, that is unrelated to anemia) is suggested by the fact that the correction of anemia with transfusion in nonuremic patients (who would not be expected to have a decrease in endogenous erythropoietin levels) does not appear to improve muscle function [22].
●Androgen deficiency – Both male and female patients with CKD have decreased androgen production. (See "Causes of primary hypogonadism in males", section on 'Chronic kidney disease'.)
Androgen deficiency likely contributes to muscle impairment. Prior to the availability of recombinant erythropoietin, androgen therapy was used to treat anemia in some patients on hemodialysis [23,24], and, in one study, the androgen, nandrolone decanoate, was noted to increase muscle mass [24,25]. This agent was subsequently shown to improve body composition and muscle strength [26,27]. In one study, 79 patients were randomly assigned in a 2x2 factorial fashion to anabolic steroid administration and resistance exercise training [27]. Nandrolone administration increased lean body mass and quadriceps muscle size, while exercise increased muscle size alone.
●Vitamin D deficiency – Vitamin D deficiency has been associated with myopathies of various causes including statin-induced and vitamin D-dependent rickets [28-30]. In several reports, supplementation with appropriate doses of vitamin D as ergocalciferol improved muscle function [28-30]. (See "Etiology and treatment of calcipenic rickets in children" and "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Skeletal changes'.)
●Secondary hyperparathyroidism – Myopathy has been reported in patients with both primary [31-34] and secondary hyperparathyroidism [35,36]. The myopathy associated with primary hyperparathyroidism has been shown to be reversible with reduction in parathyroid hormone (PTH) suggesting causality [32,34]. However, it is difficult to distinguish effects of PTH from those of vitamin D deficiency and uremia in published reports of secondary hyperparathyroidism [35,36].
●Carnitine deficiency – Some studies demonstrated that L-carnitine supplementation improved muscle strength but not endurance [37,38]. However, when muscle metabolism and function were assessed by magnetic resonance or near-infrared spectroscopy, L-carnitine supplementation for 16 weeks in patients receiving maintenance hemodialysis showed no effect [39].
●Dialysis access – The dialysis access may have effects on local muscle function and physical activity. A forearm hemodialysis access likely affects the function of both large and fine motor skills in the affected arm [40]. A hemodialysis access or peritoneal dialysis catheter may also decrease patient activity for fear of harming the access or catheter. Although restrictions are often placed upon patients with various access types (eg, swimming and heavy lifting with peritoneal catheters; lifting with the vascular access arm; heavy perspiration or swimming with a hemodialysis catheter; etc), these recommendations are largely based on anecdotal practices.
●Other factors – Other factors that may contribute to physical deconditioning or muscle weakness in some patients include orthostatic hypotension after dialysis, steroid myopathy, hypokalemia, and malnutrition. These factors are generally recognized to be associated with decreased physical function. (See "Glucocorticoid-induced myopathy".)
CLINICAL PRESENTATION —
The physical deconditioning associated with advanced CKD has the following manifestations and characteristics:
●Decreased endurance and exercise capacity.
●Easy fatigability.
●A normal physical examination except for weakness (and sometimes wasting) of both proximal and distal muscles [3,41].
●Greater severity with lower glomerular filtration rate (GFR) [42]. The most severe cases have been described among patients on dialysis [3,43].
Diagnostic tests are not routinely performed in clinical practice. However, in studies of deconditioned patients on dialysis, electromyographic studies and muscle enzyme serum levels are generally normal [3], and muscle imaging studies [43,44] and muscle biopsies [3,45] sometimes show atrophy.
SURVEILLANCE —
We assess functional limitations in most patients on dialysis and in patients with nondialysis CKD whose symptoms appear out of proportion to their comorbid illness. Assessing physical performance and self-reported functional limitation (defined by restrictions in basic activities such as ambulation and climbing stairs) may identify patients at risk for further functional decline and increased mortality [9,12], provides a baseline to gauge response to prescribed exercise regimens (see 'Management' below), and may motivate patients to adhere to prescribed exercise.
The questions and physical performance tests we use to assess functional and mobility limitations are detailed below:
●Questions – We ask the following questions:
•Do you have difficulty walking a quarter of a mile (two to three city blocks) or climbing 10 steps?
•Have you changed the way you walk a quarter of a mile or how often you do this because of a physical condition?
●Physical performance tests – Physical performance may be objectively quantitated. There are multiple tests of physical function that are simple to administer and are commonly used in the non-CKD population [46]. We use tests of gait speed or a timed up-and-go test:
•To measure gait speed, the patient walks at their usual speed over 3 meters and is allowed to stop and rest as necessary. Walking speed <0.8 m/s has been associated with increased mortality in patients with CKD [47].
•For the timed up-and-go test, the patient must stand from a fully seated position and walk 4 meters; time ≥4 seconds is associated with increased mortality in CKD.
Other commonly used tests include the six-minute walk test, which many transplant centers use as a screening criterion for suitability for kidney transplantation (see "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient"). Additional metrics, such as smaller step length [48] and reduced grip strength [49], have been proposed to assess a variety of functional limitations in patients with kidney disease.
MANAGEMENT —
Our approach to preventing and treating physical deconditioning in patients with CKD includes optimal treatment of vitamin D deficiency and anemia, adequate nutrition, and prescription of an exercise regimen.
General measures for all patients
Treat vitamin D deficiency — We measure 25-hydroxyvitamin D and treat vitamin D deficiency according to standards set for the general population (see "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment"). The restoration of vitamin D levels has been shown to reduce muscle weakness in case reports [28-30]. (See 'Pathophysiology' above.)
However, a randomized controlled trial did not show a beneficial effect of cholecalciferol on muscle strength and functional capacity among patients on hemodialysis [50]. Sixty individuals were randomly assigned to receive either oral cholecalciferol, 50,000 international units, or placebo weekly for eight weeks and then monthly for four months. At six months, there was no difference between groups in muscle strength, functional capacity, or health-related quality of life, despite higher values of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D.
We treat secondary hyperparathyroidism, but not specifically to improve muscle weakness. The treatment of secondary hyperparathyroidism is discussed elsewhere:
●(See "Management of secondary hyperparathyroidism in adult patients on dialysis".)
Treat anemia — We carefully monitor for the development of iron deficiency and anemia and treat to accepted thresholds for patients with CKD. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Treatment of anemia in patients on dialysis".)
Erythropoiesis-stimulating agents (ESAs) are generally not given until the hemoglobin is <10 g/dL for patients with CKD not on dialysis. However, we are attentive to possible symptoms of anemia in younger patients who have CKD with few comorbidities, whose symptoms of anemia may occur at higher hemoglobin levels (particularly if the patient is trying to maintain the recommended active lifestyle). For such patients, we may initiate ESAs at hemoglobin levels of 10 g/dL or even higher after discussing potential risks and benefits with each patient. (See "Treatment of anemia in nondialysis chronic kidney disease", section on 'Indications and contraindications'.)
Adequate protein intake — Adequate protein intake is important to maintain muscle mass. Our approach to protein intake varies by dialysis status:
●For patients with nondialysis CKD who do not have nephrotic syndrome, we suggest a modest protein intake restriction of approximately 0.8 g/kg. This level of protein intake is generally well tolerated and does not lead to malnutrition in patients with CΚD. (See "Dietary recommendations for patients with nondialysis chronic kidney disease", section on 'Protein intake'.)
●For patients on dialysis, inadequate protein intake is common. A nutritionist should be involved in the care of patients on dialysis to monitor and encourage protein intake. Protein intake among patients on dialysis is discussed elsewhere:
•(See "Nutritional status and protein intake in patients on peritoneal dialysis".)
•(See "Protein intake in patients on maintenance hemodialysis".)
•(See "Nutritional status and protein intake in patients on peritoneal dialysis".)
Exercise as first-line therapy — We counsel all patients with CKD, including those on dialysis, to maintain an active lifestyle. Multiple studies have shown that exercise improves the physical performance and muscular function of patients with CKD [51-56].
Optimal exercise dose — Patients with CKD should follow recommendations for aerobic exercise, muscle strengthening, flexibility, and balance that exist for the general population (see "Physical activity and exercise in older adults", section on 'Overview of physical activity components'). Specific exercise goals, and an intradialytic exercise program to help meet those goals, are discussed below:
●Exercise goals – All patients with CKD, including those on dialysis, should be encouraged to participate in an exercise program after appropriate screening for medical limitations. The amount of exercise depends upon patient capability. For those who are capable, we advise patients to follow recommendations for the general public: at least 150 minutes per week of moderate aerobic activity or at least 75 minutes per week of vigorous aerobic physical activity, with additional resistance training as appropriate [57]. A concrete plan to help achieve this target would be walking a minimum of 4000 steps daily [58], an approach that has shown positive effects in a randomized trial, even with older patients [54,59]. (See "Physical activity and exercise in older adults", section on 'Overview of physical activity components'.)
●Intradialytic exercise – Exercise during hemodialysis is a powerful tool for achieving weekly exercise targets. Some dialysis centers, including ours, have offered basic stationary cycling in the treatment chair during hemodialysis. Improvement in physical function occurs within 12 weeks of this simple program, although only approximately 20 percent of patients participate regularly [60].
Patients with frailty — Patients on dialysis are frequently deconditioned and frail. Although functionally limited or frail individuals may never be able to meet minimum recommended activity levels, even modest activity and muscle strengthening can positively impact functional limitations [61,62]. While all elements of the physical activity recommendations should be incorporated into an activity plan, the adage "start low and go slow" should be kept in mind. It is acceptable to begin a baseline physical activity recommendation of walking for five minutes twice a day as a starting point. The key is to identify a set of activities the patient feels capable of doing, therefore incorporating the concept of self-efficacy into the physical activity recommendation [63]. Further discussion of exercise among frail or functionally limited patients is elsewhere. (See "Physical activity and exercise in older adults", section on 'Functionally limited or frail'.)
Dialysis-related limitations — Almost all patients on dialysis can engage safely in at least some exercise. Dialysis-specific issues related to exercise are addressed below:
●Hemodialysis – Some clinicians have been reluctant to permit exercise during the latter portions of the dialysis session (see 'Optimal exercise dose' above) due to a concern that physical activity near the end of dialysis might precipitate intradialytic hypotension. However, this concern is unfounded for most patients. In a crossover trial in which 98 patients on hemodialysis were randomly assigned to two sequential two-week intradialytic cycling regimens that occurred either during the first or second half of the dialysis session, the timing of intradialytic cycling had no appreciable effect on the rate or severity of intradialytic hypotension [64].
●Peritoneal dialysis – Concerns about exercise for patients on peritoneal dialysis include abdominal discomfort and potential catheter problems.
•Occasionally, patients will state that the presence of dialysis fluid limits their activity due to abdominal discomfort. For these patients, we drain the abdomen for one to two hours during their period of physical activity.
•Some patients may have concerns that exercise can lead to peritoneal dialysis catheter problems (eg, exit-site infections, leaks, pulling trauma) or the development of abdominal hernias that complicate the peritoneal dialysis regimen. However, none of these issues were observed in a systematic review that included 17 exercise or physical intervention studies of patients on peritoneal dialysis [65].
Benefits of exercise
Preserving physical function and strength — A number of studies have shown that exercise helps to preserve or improve physical capacity, muscle function, and muscle mass among patients with nondialysis and dialysis CKD [52,53,66-79]. Three meta-analyses of randomized trials showed improvements in physical function and muscle strength with exercise [52,53,79], regardless of type, intensity, length of intervention, or stage of CKD [52].
In a representative trial, 296 patients on dialysis were randomly assigned to six months of a walking exercise program or usual physical activity [54]. At six months, patients in the exercise group experienced improvements in measured physical performance compared with baseline (as determined by six-minute walking test distance and five-times sit-to-stand test time), whereas those in the usual activity group did not. In addition, patients in the walking exercise group, compared with those in the usual physical activity group, had lower rates of hospitalization (35 versus 57 hospitalizations per 100 person-years, respectively) and improved cognitive and social interaction scores on the Kidney Disease Quality of Life Short Form (KDQOL-SF) questionnaire. A subsequent observational study of these trial participants found that those in the exercise group had a superior performance in the six-minute walking test, but not in the sit-to-stand test or in the KDQOL-SF score, compared with the control group up to 12 months after the end of the exercise intervention [80].
Slowing of GFR decline — Multiple studies have suggested that exercise slows the decline in kidney function and reduces the risk of requiring dialysis [81-84]. The best data are from a randomized, controlled trial that compared the effects of a three-times-weekly exercise regimen (including both resistance and aerobic training) to usual care among 20 patients (17 men) who had a rate of decline in estimated glomerular filtration rate (eGFR) of 2.9 mL/min/1.73 m2 per year for 12 months prior to intervention [81]. In the group undergoing exercise, the mean change in eGFR was -9.7±7.2 mL/min/1.73 m2 during the year prior to intervention and -3.8±2.8 mL/min/1.73 m2 per year in the year during which they performed exercise. At 12 months, compared with the control group, the mean rate of change in eGFR was lower in the exercise group, with a mean difference between groups of 7.8±3.0 mL/min/1.73 m2 (95% CI, 1.1-13.5). There was no difference between groups in the absolute eGFRs at 12 months.
Longer-term data are limited to observational studies. A longitudinal cohort study compared physical activity, quantitated using the Four-Week Physical Activity History Questionnaire, with longitudinal measurement of eGFR at a median follow-up of 3.7 years [82]. Individuals who reported over 150 minutes of physical activity per week had a slower decline in eGFR compared with inactive individuals (-6.2 versus -9.6 percent per year, respectively). At a median follow-up of 3.7 years, each 60-minute increment in weekly activity was associated with a 0.5 percent slower decline in kidney function in adjusted analysis.
Cardiovascular benefit — The ill effects of sedentary lifestyle on cardiovascular disease and mortality are well accepted, and a benefit of exercise has been suggested by observational studies [85]. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease", section on 'Benefits of exercise'.)
A few studies have examined the association between survival and exercise in patients on dialysis [83,86,87].
●In an analysis of observational data for 2507 patients from the United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Study (Wave 2), decreased mortality was associated in patients who exercised two to three and four to five times per week [86]. However, for unclear reasons, daily exercise provided no survival benefit.
●In one study of 6363 patients from China, walking was associated with decreased mortality in patients with CKD not on dialysis [83]. Compared with those who reported not walking at all (frequency = 0), the adjusted hazard ratios (HRs) were 0.83, 0.72, 0.42, and 0.41 for patients who walked one to two, three to four, five to six, and seven or more times per week, respectively.
●In an analysis of data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), in which 5763 participants were classified into increasing levels of physical activity, aerobic activity was associated with decreased mortality [87]. The adjusted HR for death for very active participants compared with never or rarely active participants was 0.60 (95% CI 0.47-0.77).
Aerobic activity was also associated with increased health-related quality of life and decreased depression in this study.
●In a small trial in which 74 patients on hemodialysis were randomly assigned to 60 minutes of intradialytic exercise thrice weekly for six months or to usual care, one-year survival was higher in the exercise group [88]. However, participants in the exercise group were younger and were less likely to have diabetes than participants in the control group.
Other benefits — Other benefits of exercise include improvements in restless leg syndrome and sleep quality [89], improved quality of life in general [79], more social interaction as assessed by the KDQOL-SF questionnaire [53,54], and, potentially, better cognitive function [90,91].
Second-line therapies — Despite optimal treatment of vitamin D deficiency and anemia, adequate nutrition, and three months or more of a prescribed exercise regimen (see 'General measures for all patients' above and 'Exercise as first-line therapy' above), some patients with advanced CKD will have persistent and debilitating weakness. We refer such patients to a physical therapist or an exercise physiologist, though no high-quality data has demonstrated that physical therapy benefits this patient population. In addition, we also treat select patients on dialysis with testosterone replacement therapy:
Testosterone treatment in select patients — In all male patients on dialysis with persistent and debilitating weakness and no contraindication to androgen therapy, we evaluate for testosterone deficiency and, if present, we treat with testosterone replacement therapy for three months and reassess muscle strength. If the patient demonstrates an improvement in muscle strength, we continue testosterone therapy indefinitely. If the patient demonstrates no improvement in muscle strength and has no other indications for androgen therapy, we discontinue testosterone. Details on the diagnosis and treatment of testosterone deficiency are presented separately. (See "Clinical features and diagnosis of male hypogonadism" and "Testosterone treatment of male hypogonadism".)
In female patients, we do not routinely evaluate for testosterone deficiency. The role of androgen therapy in women is limited to the treatment of postmenopausal women with a diagnosis of female sexual interest/arousal disorder.
Our approach to the evaluation and treatment of androgen deficiency in this setting is based on the high prevalence of hypogonadism among patients on dialysis and is consistent with Endocrine Society guidelines [92]. However, there are no high-quality data demonstrating that testosterone replacement therapy benefits this patient population.
Other treatments — Other treatments have been studied as therapies for CKD-associated deconditioning and weakness. However, we do not advocate their use because of insufficient data and/or side effects.
●L-carnitine – In patients on dialysis with persistent and debilitating muscle weakness, some clinicians administer a three- to six-month trial of intravenous (IV) L-carnitine supplementation (1000 mg at hemodialysis three times weekly). However, the use of IV L-carnitine in patients on hemodialysis remains controversial [93,94]. The biochemical diagnosis of carnitine deficiency is difficult since nearly all patients on dialysis have abnormalities in serum carnitine levels, and no study has demonstrated a correlation between various blood carnitine measurements and muscle function.
●Growth hormone – We do not give growth hormone. Although the anabolic effects of recombinant human growth hormone (rhGH) have been reported in many muscle-wasting conditions, including CKD [93], there are little data that show a sustained improvement in physical function and strength with rhGH administration. One placebo-controlled study of 20 patients reported increased handgrip strength and anabolic effects with subcutaneous rhGH at 66.7 mcg/kg thrice weekly following hemodialysis [94]. A phase III, international, multicenter trial of over 2000 patients on hemodialysis was terminated early due to slow recruitment but showed no improvement in grip strength or walking capacity in the 695 patients who received at least one dose of study medication [95].
PROGNOSIS —
Decreased muscle strength, an important component of physical deconditioning, is associated with increased mortality. This was best shown in an observational study including 330 patients on dialysis, 29 percent of whom died over a follow-up of five years [9]. Patients with decreased strength had increased mortality risk even if muscle mass was normal (hazard ratio [HR] 1.98, 95% CI 1.01-3.87). Decreased muscle mass in the absence of decreased strength did not increase mortality in this study. This suggests that a functional assessment may provide prognostic information beyond that provided by assessment of muscle mass. (See 'Surveillance' above.)
Decreased strength and endurance also are important components of frailty, which is highly prevalent among older patients on dialysis [96,97]. Among patients on dialysis, frailty has been associated with increased mortality [97-103] and increased fractures [104,105], as well as decreased quality of life [106].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic kidney disease in adults" and "Society guideline links: Dialysis".)
SUMMARY AND RECOMMENDATIONS
●Overview – Patients with advanced chronic kidney disease (CKD), particularly those on dialysis, often have significant muscle weakness and lack of endurance. This often results in progressive deconditioning and increases morbidity and mortality. (See 'Introduction' above and 'Epidemiology' above and 'Prognosis' above.)
●Pathophysiology – In patients with CKD, comorbid illnesses such as diabetes mellitus, poor nutrition, and peripheral vascular disease play an important role in physical deconditioning. However, CKD-specific factors also contribute to impairment of physical function and sarcopenia. These factors include inflammation and accumulation of reactive oxygen species that result in mitochondrial uncoupling and impaired muscle repair, as well as deficiencies of erythropoietin, vitamin D, and androgens. (See 'Pathophysiology' above.)
●Surveillance – We assess functional limitations in most patients on dialysis and in patients with nondialysis CKD whose symptoms appear out of proportion to their comorbid illness. Assessing physical performance and self-reported functional limitation may identify patients at risk for further functional decline and increased mortality, provides a baseline to gauge response to prescribed exercise regimens, and may motivate patients to adhere to prescribed exercise. (See 'Surveillance' above.)
●Management – Our approach to preventing and treating physical deconditioning in patients with CKD includes optimal treatment of vitamin D deficiency and anemia, adequate nutrition, and prescription of an exercise regimen. (See 'General measures for all patients' above.)
•Exercise as first-line therapy – Patients with CKD, including those on dialysis, should follow recommendations for exercise that exist for the general population. However, the amount of exercise depends upon patient capability. Exercise during hemodialysis is a powerful tool for achieving weekly exercise targets. (See 'Optimal exercise dose' above and 'Patients with frailty' above.)
-Almost all patients on dialysis can engage safely in at least some exercise. Most dialysis-related concerns about exercise are either unfounded or can be overcome. (See 'Dialysis-related limitations' above.)
-Exercise has numerous benefits including potential preservation of kidney function in patients with CKD not on dialysis and possible cardiovascular and survival benefits. (See 'Benefits of exercise' above.)
•Second-line therapies – Despite optimal management, some patients with advanced CKD will have persistent and debilitating weakness. We refer such patients to a physical therapist or an exercise physiologist. In addition, for male patients on dialysis, we evaluate for testosterone deficiency. For male patients on dialysis with persistent weakness and low serum testosterone levels, we suggest testosterone replacement therapy (Grade 2C). We do not administer testosterone to patients who have contraindications to androgen therapy, and we discontinue testosterone after three months if the patient demonstrates no improvement in muscle strength. (See 'Testosterone treatment in select patients' above.)
