Exercise in renal transplant recipients: a qualitative exploration

BACKGROUND. Cardiovascular disease (CVD) is a major cause of mortality in renal transplant recipients (RTRs). Calculators of CVD risk vastly underestimate risk in this population suggesting unique factors beyond that of the traditional causes. It is well known that physical activity is highly beneficial in reducing the risk of CVD in the general population and in many individual disease states. However, research in RTRs is severely limited and only around one in five are sufficiently active for health (as defined by meeting the national physical activity guidelines of 150 minutes of moderate intensity exercise per week). Recent literature has also alluded to exercise being ‘anti-inflammatory’ which may have a direct benefit to combat the excess inflammation in RTRs brought about by many factors including daily immunosuppressive medication. A recent abundance of literature around high intensity interval training (HIIT) has revealed a novel and time efficient method to reduce CVD risk. This area is un-researched in RTRs but large-scale efficacy trials are expensive and labour intensive. Therefore, more needs to be known about RTRs’ general exercise attitudes and behaviours as well as their perspectives and experiences of HIIT before definitive trials are completed. AIM. The aim of this research was to explore RTRs’ perceptions and experiences of exercise, in particular HIIT. This was with the intention to inform future efficacy trials in this population. On this basis, three research questions were addressed: (1) What are the past and current behaviours and attitudes towards exercise in RTRs? (2) What are the perceptions and/or experiences of high intensity interval training in RTRs? (3) Is there readiness to participate in high intensity interval training in RTRs? METHOD. Thirteen RTRs (8 males; mean [±SD]; age 53 [±13] years; eGFR 53 [±21] mL/min/1.73m2) were recruited and completed semi-structured one-to-one interviews at University Hospitals of Leicester NHS Trust. All RTRs were eligible if their renal transplant was completed more than 12 weeks prior to interview and their consultant considered them to have no major contraindications to exercise. All interviews were audio recorded, transcribed verbatim, and subject to framework analysis in order to identify and report emerging themes. FINDINGS. Past and current attitudes and behaviours towards exercise. Several internal and external influencers of exercise behaviour were identified in this study. The physiological and psychological benefits of exercise were important to participants, as was exercise preference. Outdoor exercise and walking were popular with participants and for some, exercise was driven by an internal need which stemmed from a desire to look after the new organ and/or feelings of guilt. There was some anxiety from participants around exercise causing harm to the new kidney. This was paired with a significant lack of specific exercise guidance and support from healthcare providers; exercise was not seen as a priority of the National Health Service (NHS) although the importance of the healthcare provider on influencing exercise behaviours was identified. Social interaction was extremely important eliciting motivation to exercise. Whether it was with family, friends, or new people, participants perceived an increased self-confidence to exercise. Perceptions and experiences of, and readiness to participate in, HIIT. Overall, participants had a good knowledge of HIIT and were open to participation. Acknowledgement of superior benefits to cardiovascular, mental, and general health as well as the lower time commitment were all motivators for participation. There were some heightened concerns around damaging the kidney and ‘knowing your limits’ which link back to the lack of exercise guidance and support identified in the previous section. Personalisation, doctor’s approval, and supervision were all important factors in the participant’s decision to take part in HIIT. DISCUSSION. The exercise barriers and potential barriers to HIIT identified in this study, in general, stem from an overall lack of specific exercise support and guidance given to RTRs as part of post-transplant care. Participants identified the need for guidance, which was written, prescriptive, or fully supervised depending on levels of self-confidence towards exercise. For healthcare providers to be confident in counselling patients about exercise, there is a pressing need for evidence-based guidelines, which do not exist in current clinical practice guides. Despite the known benefits of HIIT, and the potential to improve prevalent cardiovascular risk factors in RTRs, there are currently no studies reporting results of HIIT interventions in this population. This study provides evidence that HIIT would be, in principle, largely accepted by RTRs. However, there are several considerations also identified in the present study which would be essential to the success of any future efficacy trial.