Comparative efficacy of exercise modalities for general risk factors, renal function, and physical function in non-dialysis chronic kidney disease patients: a systematic review and network meta-analysis

Figures & data

Figure 1. The PRISMA flow diagram for search and selection processes of the meta-analysis.

Table 1. Basic characteristics of included randomized controlled trials.

References	Country	CKD stages	Sample (T/C)	Age (T/C, years old)	Intervention		Outcomes
					T	C
[18]	Japan	–	23/23	61.5 ± 11.2/58.9 ± 14.5	CBT + CT	CT	1,2,4,5,6
[21]	USA	3b–4	30/38	68.4 ± 6.6/67.2 ± 8.3	CBT + CT	CT	10,11
[19]	Brazil	–	19/19	57.94 ± 2.74/58.07 ± 5.22	RT + CT	CT	1,2,3,5,6,7,8,10
[22]	China	–	43/43	51.11 ± 4.32/51.62 ± 4.36	CBT + CT	AT	1,5,6,10
[20]	China	1–4	36/36	58.32 ± 5.61/57.18 ± 5.13	CBT + CT	AT	1,2,4,11
[23]	Brazil	2	30/30	58 ± 9/57 ± 6	RT + CT	CT	1,4,5,6
[27]	Japan	3–4	27/26	78.4 ± 6.4/78.1 ± 7.4	CBT + CT	CT	1,2
[25]	Brazil	2	35/35	58.09 ± 6.26/57.60 ± 5.22	RT + CT	CT	1,4
[28]	Japan	4	23/23	–	CBT + CT	CT	4
[24]	Brazil	2	35/35	58 ± 6/58 ± 5	RT + CT	CT	1,2,3
[26]	China	1–4	42/42	59.32 ± 3.26/59.28 ± 3.28	CBT + CT	CT	2,3
[29]	China	–	67/68	70.71 ± 7.56/72.51 ± 6.89	AT + CT	CT	1,2,5,6
[30]	Australia	3–4	56/57	58.8 ± 9.7/62.1 ± 8.6	AT + CT	CT	4,5,6,11
[31]	USA	3–5	16/15	55 ± 13/62 ± 9	AT + CT	CT	5,6,11
[33]	Brazil	3–4	76/74	65 ± 1.2/65.1 ± 1.3	CBT + CT	CT	1,5,6,7
[32]	Brazil	3–4	(13/12)/15	(56.3 ± 7.9/56 ± 8.3)/54.3 ± 8.7	AT + CT	CT	1,3,4,5,6,10,11
[35]	UK	3–5	20/21	63 (51–69)/63 (58–71)	CBT + CT	AT	5,6,11
[34]	China	2–3	20/20/20	(47.5 ± 5.6/51.6 ± 6.1)/49.2 ± 6.3	AT + CT / CBT + CT	CT	1,2,10
[41]	China	2–3	35/35	50.89 ± 4.78/50.91 ± 3.69	AT + CT	CT	2,3,11
[38]	China	Early stage	30/30	48.3 ± 10.7/49.1 ± 9.3	RT + CT	AT	1,2,7,8
[40]	China	1–3	42/42	–	AT + CT	CT	10
[39]	USA	3	28/23	–	AT + CT	CT	1,4,7,8,11
[37]	Japan	3–4	18/18	69.0 ± 6.8/67.8 ± 6.9	CBT + CT	CT	1
[36]	USA	3	25/21	58 ± 8/57.1 ± 9	AT + CT	CT	5,6
[42]	USA	2–4	18/18	65.4 ± 8.7/66.6 ± 7.5	CBT + CT	CT	1,4,5,6,7,8,10,11
[43]	China	2–3	29/29/29	(48.50 ± 3.51/48.21 ± 3.62)/48.00 ± 3.62	AT + CT/CBT + CT	CT	1,2,3,5,6,7,8
[46]	Australia	3–4	36/36	60.2 ± 9.7/62 ± 8.4	CBT + CT	CT	1,2,4,5,6,7,10
[45]	UK	3–4	10/10	53.58 ± 13.5/53.3 ± 12.9	CBT + CT	CT	1,4,5,6,7,11
[44]	Brazil	3–4	14/15	55.9 ± 7.7/54.3 ± 8.7	AT + CT	CT	1,2,4,5,6,10,11
[47]	Belgium	3–4	25/23	51.5 ± 11.8/54.7 ± 14.1	AT + CT	CT	1,4,5,6,7,11
[49]	USA	3	28/23	58 ± 8/57.1 ± 9	AT + CT	CT	4,5,6,11
[50]	China	–	11/10	69.5 ± 6.9/68.4 ± 8.7	AT + CT	CT	1,2,5,6,7,8
[48]	Brazil	3–4	(10/9)/10	(52.1 ± 11.4/50.8 ± 7.7)/53.4 ± 9.6	AT + CT	CT	1,4,10,11
[51]	UK	2–4	14/11	57.5 ± 11.5/52.5 ± 10.6	AT + CT	CT	1,3,4,5,6,7,11
[52]	USA	2–4	10/11	57.5 ± 11.5/52.5 ± 10.6	CBT + CT	CT	2,4,11
[53]	Canada	3–4	10/10	64 ± 13.33/72.5 ± 14.81	AT + CT	CT	11

CKD: chronic kidney disease; T: exercise therapy group; C: control group; AT: aerobic exercise therapy; RT: resistance exercise therapy; CBT: combined (Resistance-Aerobic) exercise therapy; CT: conventional therapy; 1: eGFR; 2: Scr; 3: 24hUTP; 4: BMI; 5: SBP; 6: DBP; 7: TC; 8: TG; 9: HbA1c; 10: 6MWT; 11: VO₂ peak

Table 2. The specific details of the interventions.

References	Intervention
	ET	Intensity	Exercise duration	Frequency (time/week)	Period (week)
[18]	CBT	AT: 40–60% of peak heart rate; 11–13 on the Borg Rating of perceived exertion scale; RT: at 70% of one repetition maximum	AT: 30 min; RT: 1 set of 10 repetitions	3 (AT), 2 (RT)	24
[21]	CBT	AT: 50–60% of heart rate reserve, increased over 7 weeks for a goal of 70–80% of heart rate reserve; RT: Borg 15–16	AT: 20 min, increased over 7 weeks for a goal of 40 min; RT: 10 min	3 (AT), 2 (RT)	48
[19]	RT	–	–	3–4	22
[22]	CBT	AT:60–80% of heart rate reserve, RT: -	AT: 40 min, RT: 40 min	3 (AT), 3 (RT)	12
	AT	60–80% of heart rate reserve	40 min	6
[20]	CBT	Adjusted to the patient’s tolerance level	AT: 30 min, RT: 10–30 min	4–5	24
	AT		30 min	2	24
[23]	RT	First 8 weeks, 50% RM, next 8 weeks, 60% RM, last 8 weeks, and 70% RM	First 8 weeks, 1–3 sets of 12 repetitions, next 8 weeks, 2–3 sets of 10 repetitions, last 8 weeks, and 3 sets of 8 repetitions	3	24
[27]	CBT	Moderate	60 min	3	24
[25]	RT	50–70% RM	60 min	3	24
[28]	CBT	AT: 40–60% peak heart rate, RT: 70% RM	–	3 (AT), 2 (RT)	24
[24]	RT	First 8 weeks, 50% RM, next 8 weeks, 60% RM, last 8 weeks, and 70% RM	First 2 months, 3 sets of 12 repetitions, next 2 months, 3 sets of 10 repetitions, last 2 months, and 3 sets of 8 repetitions	3	24
[26]	CBT	Adjusted to the patient’s tolerance level	AT: 20–30 min, RT: 20–30 min	–	12
[29]	AT	Moderate	–	3	48
[30]	AT	Borg 11–13	75 min	2	48
[31]	AT	60–85% heart rate reserve	45 min	3	12
[33]	CBT	Controlled using the Borg	60 min	3	16
[32]	AT	Moderate	30 min with increments of 10 min every 4 weeks until week 8	3	24
[35]	CBT	AT: 70–80% Heart rate maximum; RT: 70% RM	AT: 20–30 min; RT: 3 sets of 12–15 repetitions	3 (AT), 2 (RT)	12
	AT	70–80% Heart rate maximum	30 min
[34]	AT	50% VO2 peak	30min	3	12
	CBT	AT: 50% VO2 peak; RT: Borg 12–13	AT: 30 min, RT: 4 sets of 10 repetitions
[41]	AT	50% VO2 peak	30 min	3	12
[38]	RT	Adjusted to the patient’s tolerance level	30 min	3	24
	AT
[40]	AT	Moderate	20–30 min	3	12
[39]	AT	50–60% VO2 peak	55 min	3	16
[37]	CBT	Moderate	AT: 30 min, RT: 20–30 repetitions	3	48
[36]	AT	50–60% VO2 peak	55 min	3	16
[42]	CBT	Moderate and hard	60 min	3	52
[43]	AT	50% VO2 peak	30 min	3	12
	CBT	AT: 50% VO2 peak, RT: Borg 12–13	AT: 30 min, RT:4 sets of 10 repetitions	3	12
[46]	CBT	Moderate	AT: 30 min; RT: 3 sets of 10–15 repetitions of 6–8 functional resistance exercises	–	48
[45]	CBT	AT: 80% heart rate reserve, RT: 80% RM	AT: 20–40 min; RT: 2–3 sets of 8–10 repetitions	3	48
[44]	AT	40–60% VO2 peak	30–60 min	3	12
[47]	AT	90% of the heart rate achieved at the anaerobic threshold	40 min	3	12
[49]	AT	50–60% VO2 peak	55 min	3	16
[50]	AT	moderate	30 min	3–5	12
[48]	AT	40–60% VO2 peak	30 min, increment of 10 min every 4 weeks	3	12
[51]	AT	50–60% VO2 peak	45 min	3	48
[52]	CBT	AT: 50–60% VO2 peak; RT: based upon the individual’s fitness level and tolerance	AT: 55 min, RT: 1–3 sets of 10–12 repetitions	3 (AT), 2 (RT)	48
[53]	AT	Borg 12–15	60 min	3	48

ET: exercise therapy; AT: aerobic exercise therapy; RT: resistance exercise therapy; CBT: combined (Resistance-Aerobic) exercise therapy; CT: conventional therapy; RM: one-repetition maximum

Figure 2. Results of risk of bias graphs.

Figure 3. Network diagrams of comparisons on different outcomes of treatments in different groups of non dialysis chronic kidney disease patients. A: eGFR; B: Scr; C: 24hUTP; D: BMI; E: SBP; F: DBP; G: TC; H: TG; I: HbA1c; J: 6MWT; K: VO₂ peak; AT: aerobic exercise therapy; RT: resistance exercise therapy; CBT: combined (Resistance-Aerobic) exercise therapy; CT: conventional therapy.

Figure 4. Pooled estimates of the network meta-analysis. A: eGFR; B: Scr; C: 24hUTP; D: BMI; E: SBP; F: DBP; G: TC; H: TG; I: HbA1c; J: 6MWT; K: VO₂ peak; AT: aerobic exercise therapy; RT: resistance exercise therapy; CBT: combined (Resistance-Aerobic) exercise therapy; CT: conventional therapy.

Figure 5. Surface under the cumulative ranking area for outcomes. A: eGFR; B: Scr; C: 24hUTP; D: BMI; E: SBP; F: DBP; G: TC; H: TG; I: HbA1c; J: 6MWT; K: VO₂ peak; AT: aerobic exercise therapy; RT: resistance exercise therapy; CBT: combined (Resistance-Aerobic) exercise therapy; CT: conventional therapy.

Figure 6. Risk of bias funnel chart. A: eGFR; B: Scr; C: 24hUTP; D: BMI; E: SBP; F: DBP; G: TC; H: TG; I: HbA1c; J: 6MWT; K: VO₂ peak; AT: aerobic exercise therapy; RT: resistance exercise therapy; CBT: combined (Resistance-Aerobic) exercise therapy; CT: conventional therapy.

Data availability statement

The original data involved in this study can be requested by contacting the corresponding author (MZ) or the first author.