DOI Number: 10.5958/0976-5506.2019.01910.

Role of Physiotherapy Post Renal Transplantation -

A Case Report

CharithaMatta1, PetetiSairam1, P Kamalanathan2, A Sankarganesh3, R Padmanaban4

MPT Students, 2Associate Professor, 3Assistant Professor, 4Professor and Head, Department of Nephrology,
1

SRM Institute of Science and Technology, Kattankulathur

Abstract
Introduction: Physiotherapy is widely used in the renal transplant intensive care unit to minimize post-
operative respiratory and musculoskeletal complications. Patients undergoing kidney allotransplants need help
in recovery. Improvement of health status after the intervention depends in large measure on cooperation of
the therapeutic team. For many physiotherapists, rehabilitation after transplantation becomes a problem with
such patients, and there is very sparely available data in the literature about methods for encouraging patients
to exercise. Hence this study was taken. Objective: To assess the changes in, pulmonary, physiological and
renal outcome in patient with renal transplant. Methodology: A case of chronic kidney disease was reported
to SRM General Hospital, Chennai and planned for renal transplant, post operatively patient complaints of
pain over lower abdomen and right side while moving around the bed and during sitting. Patient underwent
physiotherapy for 2weeks in SRM General Hospital and followed up for three months. Physiotherapy
Intervention program including chest physiotherapy, early mobilization and therapeutic exercises was given
following which physiological parameters, hemoglobin and renal profile. Results: The improvement in
physiological parameters and hemoglobin. There has been a modest improvement in vo2 max. Conclusion:
An individualized post renal transplant physiotherapy intervention improved pulmonary and physiological
outcomes than renal outcomes in renal transplant.

Keywords: post renal transplantation, physiotherapy, exercise, Vo2max, MET.

Introduction risk [3-6] The cardiovascular events are represented as

In last two decades, renal, heart, liver and lung
transplantations have become common, successful
and progressively improved, among which renal
transplantation is the most frequent.[1] Although the
number of successful transplantations increases, new
challenges have arisen in the management of long-term
complications of transplantation.[2] Even successfully
transplanted renal transplant recipients (RTRs) suffer
from hypertension (HTN), coronary artery diseases, skin
cancers, diabetes, bone diseases, and various infections.
Survival is compromised by an increased cardiovascular
Corresponding author:
P.Kamalanathan,
Associate Professor, SRM Institute of Science and
Technology, Kattankulathur
Email Id: Kamalanathan.p@ktr.srmuniv.ac.in
one of the major causes of death among RTRs.[1,3,5,7]
Incidence and prevalence rate of cardiovascular disease
(CVD) are four to six times higher in RTRs compared to
the general population.[8] Among RTRs, HTN, obesity,
anemia, muscle wasting, and use of immunosuppressive
drugs commonly coexist as long-term complications.[3,8-
10]
Pharmacological treatments alone cannot efficiently
reduce all cardiovascular risks. It also does not efficiently
improve work capacity and quality of life including
biological and psychological problems. Furthermore,
immunosuppressive drugs have their own side effects
such as excessive weight gain, HTN, dyslipidemia, and
muscle wasting.[3-5] Moreover, after a successful renal
transplantation, 83% of RTRs have a tendency that does
not go back to work due to depression such as complex
phenomenon and this type of sedentary lifestyle is also
 Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8
one of the risk factors for CVD.[4,9,11] Incorporating “non-
pharmacological” therapies such as physical training
which are able to reverse this trend is very important.[3]
Methodology
This is a single case report to analyze role of
Physical therapy intervention on physiological outcome
in a patient with renal transplantation the study was
conducted at SRM medical college hospital and research
institute Chennai, the subject was taken from a surgical
intensive care unit.
Case Report
A 44-year-old male, presented at our institute with
complaints of abdominal pain, shortness of breath while
walking 15–20 steps on a level surface and reduced work
capacity. He was investigated and diagnosed to have End
stage renal disease with haemodialysis and underwent
living donor (wife) renal transplantation on 24th October
2017. He was a nonsmoker and a known case of HTN for
10 years. He was diagnosed with chronic kidney disease.
In the subsequent years, he complained of having mild
dyspnea during routine work, weakness, fatigue, and
weight gain of 4–5 kg within 2 months. However, he
ignored the complaints.
However, after 2 months, dyspnea at rest was
present with pitting pedal edema extending up to the
knees (bilateral). On consulting the nephrologist, he was
diagnosed with chronic kidney disease (CKD) stage 4
with abnormal laboratory findings (serum creatinine‑5
mg/dl, estimated glomerular filtration rate [GFR]-23
mL/min/1.73 m2). Gradually, the subject progressed to
end stage kidney disease (serum creatinine: 19 mg/dl,
estimated GFR <15 ml/min/1.73 m2). A planned live
allograft renal transplantation (willingly given kidney by
his wife) was performed after HLA typing and negative
Centers for Disease Control and Prevention cross match.
The subject was monitored in the intensive care unit
for 15 days before he was transferred to the ward. He
was discharged after 6 days in ward advised for routine
laboratory investigations which include complete blood
count, serum creatinine, serum glucose, and BUN at
every week for 2 month.
Physiotherapy Intervention
Procedure:
The ICU patients who referred for physiotherapy
373
were included for the study after obtaining informed
consent from the patient / patient care taker.
In the institutional setup from day 1 of post operation
to 15 days of post operation, patient underwent various
aerobic and anaerobic exercises include Day 1st-5th Deep
breathing exercises, Chest expansion exercises, Chest
physiotherapy(percussion), Ankle and Toe movements,
Alternate leg slides, Incentive spirometry (600cc/sec),
Patient made to sit with support. On 5th day patient made
to walk with in the ICU (4 rounds) (RPE 10) , These
exercises are followed for Frequency: 6 days/week,
Intensity: 10 RPE, Time: 30 min/session. From Day 6th-
10th the exercises were progressed based on the patients
exercise capacity AROM and Strengthening exercises to
bilateral upper and lower limbs, Deep breathing exercises,
Chest expansion exercises, Chest physiotherapy
(percussion), Incentive spirometry(1200cc/sec), patient
Made to walk around the ICU (6 rounds)(RPE 13). Day
11th-15thAROM and Strengthening exercises to bilateral
upper and lower limbs, Deep breathing exercises, Chest
expansion exercises, Incentive spirometry (1200cc/sec)
with 10 sec hold ,patient made to walk around the ICU
for (7rounds) RPE 13 Routine Chest physiotherapy
continued, active exercise to bilateral upper and lower
limbs, pelvic bridging exercise, Along with patient made
high sitting, sit to stand, walking was given.
In the community based session patient performed a
series of aerobic exercises and resisted exercises based
on his exercise capacities by self monitoring the Target
heart rate (THR) initially up to 50% and progressing to
55 to 60% .From Day 16th – 60thChest care continued,
limb care such as stretching, Active range of motion to
right upper and lower limb, Strengthening Active range
of motion exercise bilateral upper and lower limb. Day
61st – 90thlimb care such as stretching, Active range of
motion to right upper and lower limb, Strengthening
Active range of motion exercise bilateral upper and
lower limb, cycling activities done, ambulation
done 15 – 30 minutes RPE 13. Day 91st – 120th
strengthening exercises, Active range of motion to right
upper and lower limb, Strengthening Active range of
motion exercise bilateral upper and lower limb. Cycling
activities, ambulation for more than 30 min.
Reassessment
Before the discharge from on the hospital on
December 23rdpatient was made to perform six minute
374 Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8

walk test which shows a pre test values of Respiratory

rate -24 breaths /min, Heart rate -85beats /min, Resting
blood pressure – 130/80 mm of hg and the post test
values were Respiratory rate -28 breaths /min, Heart
rate -92beats /min, Resting blood pressure – 140/90mm
of hg ,Number of laps covered – 6, Distance covered –
360meters, MET -2.5, VO2 max-8.1ml/kg/min.

Patient was made to repeat six minute walk test after Graph 1: Day wise changes in Blood, Creatinine, Hemoglobin
6 weeks of community training on February 15th pre test showing improvement in Haemoglobin levels.
values was Respiratory rate -24 breaths /min, Heart rate
-85beats /min, Resting blood pressure – 120/80mm of hg
and the post test values were Respiratory rate -26 breaths
/min, Heart rate -90beats /min, Resting blood pressure –
130/90mm of hg, Number of laps covered – 8, Distance
covered – 420meters. MET – 3.5, VO2 max- 10ml/kg/
min.

Data Analysis
Graph 2 : Changes showing increase in MET with duration
The changes in the parameters were noted for of exercise
everyday and the physiological outcomes in a post
renal transplantation patient receiving chest and limb
physiotherapy were analyzed after the data was taken
from day of physiotherapy received to till discharge.

Results
The purpose of this case study was to present the
effects of Role of physical therapy intervention on
patient with
Graph 3 : Changes showing increase in vo2 max with increase
in exercise
renal transplantation patient tolerated the
prescribed interventions very well. Regular physical Discussion
exercise improves exercise capacity and quality of life
The study was a single-subject design, which
(GaniyuSokunbi et al).The positive results of exercise
was worthy for evaluating physiological outcome
Capacity, our results support the efficacy and need and response of an individual subject with renal
for Physiotherapy intervention for this patient. However transplantation. Resisted training was proved beneficial
the hemoglobin level showed improvement in following when combined with aerobic exercises on CKD and end-
physical therapy. stage renal disease. We investigated the efficacy of aerobic
exercise with resisted training in preventing post renal
Table 1: Day wise changes in Blood, Creatinine, transplant complications. The results of the single-case
Hemoglobin. study indicate that appropriate, regular, and supervised
aerobic exercises with resisted training protocol can
Day BUN Creatinine Hemoglobin
reduce post renal transplant complications and improving
1-5 34 1.2 11.5
work capacity. The changes in renal parameters were
6-10 36 1.2 12.0
insignificant which indicates the potential benefits of
11-15 38 1.2 12.8
physiotherapy in improving the physiological outcomes
16-60 43 1.2 12.8
in renal transplant are independent of improvement in
61-90 48 1.4 13.6
renal parameters [10, 12] Post transplant complications and
90-120 51 1.4 15.7 mortality among RTR’s are highly influenced by physical
 Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8
inactivity. Researchers have suggested the need for
intervention studies to investigate the long-term effects
of physical activity [6, 8, 11] In our study, the Institutional
phase consisted of aerobic exercise, which showed
improvement in symptoms within 15 days; however,
the effect was not sustained after 15 days of cessation
of the intervention. Hence, in the community phase,
progressive resisted exercises were included along with
aerobic exercises for 4 months under telecommunication
and self monitoring the Target Heart Rate (THR)
initialing from 50% and progressing to 55-60%.
In addition, the concept of the breathing exercise has
changed over the years and only recently includes active
upper and lower limb exercises, supervised walking, and
the use of steps. These latter changes in body position,
as well as breathing exercises, In the present study,
the patient performed upper and lower limb exercises
combined with breathing exercises and used training
loads of 1kg to 3kg. However, there is no consensus
regarding the weight of the training load, the number of
series, and the frequency of the exercise protocol, each
of which could have been insufficient and could have
influenced our results.
VO2 max during the institutional phase was stable
and community phase showed improvement in aerobic
phase along with resisted phase. During this period, any
sign of graft rejection was not seen [3-5] Results of other
outcome measures Hb level indicate improvement, which
was in accordance with the result of other studies[10,15,17,25]
Combined aerobic exercises and resisted training show
better improvement not only over the symptoms but also
over the factors, which are responsible for causing after
transplant complications. The objective of our study was
fulfilled by the interventions, which is worthwhile and is
feasible to follow in clinical practice. However, there is a
requirement to apply the interventions over a large group
of RTR’s as the results of our study were acquired from
a single-case design.
The limitations of this study was first single case
study, second long term follow up was not considered,
third in community phase patient was not under therapist
supervision (telecommunication was done).
Further study can be aimed at large sample population,
long term follow up, community rehabilitation phase
under therapist supervision, investigating the effect of
exercise on late complications of renal transplantation.
375
Conclusion
This case report shows that aerobic exercises
with resisted training intervention are capable of not
only improving and maintaining the overall health of
RTR’s and prevent post transplantation complications.
Physical therapy intervention also has definite role in
improving quality of walking and exercise performance
in patient with post renal transplantation. On other
hand physiotherapy plays no role in improving renal
parameters. However this needs to be verified in larger
sample before generalization of these finding.
Source of Funding- Self
Conflict of Interest – Nil
Ethical Clearance – Not applicable for –A case
Report
References
1. Dennis L, Anthony S, Dan L, Eugene B, Stephen
L, Larry J. Harrison’s Principles of Internal
Medicine. 16th ed. New York: McGraw‑Hill;
2005.
2. GaniyuSokunbi 2017, Exercise and Rehabilitation
Needs for Kidney Transplantation
3. Romano G, Lorenzon E, Montanaro D. Effects
of exercise in renal transplant recipients. World J
Transplant 2012;2:46‑50.
4. Braddom RL. Physical Medicine and
Rehabilitation. New Jersey: Saunders; 2007. p.
1433‑51.
5. Bottomley MJ, Harden PN. Update on the long-
term complications of renal transplantation. Br
Med Bull. 2013; 106:117-34.
6. Lubrano R, Tancredi G, Bellelli E, Gentile I,
Scateni S, Masciangelo R, et al. Influence of
physical activity on cardiorespiratory fitness in
children after renal transplantation. Nephrol Dial
Transplant. 2012;27:1677-81.
7. Djamali A, Samaniego M, Muth B, Muehrer
R, Hofmann RM, Pirsch J, et al. Medical care
of kidney transplant recipients after the first
posttransplant year. Clin J Am SocNephrol
2006;1:623-40.
8. Zelle DM, Corpeleijn E, Stolk RP, de Greef MH,
Gans RO, van derHeide JJ, et al. Low physical
376 Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8
activity and risk of cardiovascular andall‑cause
mortality in renal transplant recipients. Clin J Am
SocNephrol 2011;6:898‑905.
9. Levey AS, Coresh J, Balk E, Kausz AT, Levin A,
Steffes MW, et al. National kidney foundation
practice guidelines for chronic kidney disease:
Evaluation, classification, and stratification. Ann
Intern Med 2003;139:137‑47.
10. Gordon EJ, Prohaska T, Siminoff LA, Minich PJ,
Sehgal AR. Needed: Tailored exercise regimens
for kidney transplant recipients. Am J Kidney Dis
2005;45:769‑74.
11. Rosas SE, Reese PP, Huan Y, Doria C, Cochetti
PT, Doyle A, et al. Pretransplant physical activity
predicts all‑cause mortality in kidney transplant
recipients. Am J Nephrol 2012;35:17‑23.
12. Kutner NG. 2013. Kidney disorders: end
stage renal disease/dialysis. In: JH Stone, M
Blouin, editors. International Encyclopedia of
Rehabilitation.[Last accessed on 2017 May 20.].
13. Painter PL, Hector L, Ray K, Lynes L, Dibble
S, Paul SM, et al. A randomized trial of exercise
training after renal transplantation. Transplantation
2002;74:42‑8.
14. Rafael J. The Practice of Research in Social Work.
3rd ed. Thousand Oaks, CA: SAGE Publications;
2005.
15. Carolyn K, Lynn A. Therapeutic Exercise.
Philadelphia: F.A. Davis Company; 2007. p.
231‑50.
16. Ramesh KV, Ashok Sheney K. Pharmacology for
Physiotherapist. 1st ed. Delhi: Jaypee Brothers;
2005.
17. Nourbakhsh MR, Ottenbacher KJ. The statistical
analysis of single‑subject data: A comparative
examination. PhysTher 1994;74:768‑76.
18. Savenkov A, Wu S, Neal D. Testing for efficacy
in single‑subject trials with intervention analysis.
Stat Med 2010:1‑7.
19. Afshar R, Shegarfy L, Shavandi N, Sanavi S.
Effects of aerobic exercise and resistance training
on lipid profiles and inflammation status in
patients on maintenance hemodialysis. Indian J
Nephrol 2010;20:185‑9.
20. Moinuddin I, Leehey DJ. A comparison of aerobic
exercise and resistance training in patients with
and without chronic kidney disease.Adv Chronic
Kidney Dis 2008;15:83‑96.
21. Miller TD, Squires RW, Gau GT, Ilstrup DM,
Frohnert PP, Sterioff S, et al. Graded exercise
testing and training after renal transplantation: A
preliminary study. Mayo ClinProc 1987;62:773‑7.
22. Johansen KL. Exercise and chronic kidney
disease: Current recommendations. Sports Med
2005;35:485‑99.
23. Kouidi E, Vergoulas G, Anifanti M, Deligiannis
A. A randomized controlled trial of exercise
training on cardiovascular and autonomic function
among renal transplant recipients. Nephrol Dial
Transplant 2013;28:1294‑305.
24. Kouidi E, Vergoulas G, Anifanti M, Deligiannis
A. Skeletal muscle limits the exercise tolerance
of renal transplant recipients: Effects of a
graded exercise training program. Nephrol Dial
Transplant 2013;28:1294‑305.
25. Nahid B, Samaneh F The effect of six months
of aerobic training on renal function markers in
untrained middle‑aged women. Int J Sport Std
2013;3:218‑24.
26. Ellen A.Hillegass, H.Steven Sadowsky Essentials
of cardiopulmonary physical therapy 2nd edition