VCU Research in Action: Offering a leg up to patients with chronic kidney disease

Carol Bourne had just moved to Richmond in 2019 when she received a call from back in Lansing, Michigan. It wasn't good news.

"My doctor called me from Michigan and said that my kidneys had failed completely," said Bourne, who had relocated to Virginia to be closer to family after a months-long hospitalization for an unrelated illness. "He said, 'Go see a doctor immediately.' And before I knew it, I was on dialysis."

Bourne, who is retired from a career in public relations, immediately went on hemodialysis for about a year, spending hours each week connected to a machine that replaced her kidneys' function by filtering her blood outside of her body. She then advanced to home dialysis for about year.

"And while I was doing that, I had been going back and forth to the doctor at VCU," she said. "And I came across a brochure for the Renal Rehab clinic."

At one of her appointments at VCU Health's Division of Nephrology, Bourne learned about a program that promised to improve her health - and her chances of getting a new kidney. Reflecting Virginia Commonwealth University's multidisciplinary approach to real-world problems, the Renal Rehab program bridges the MCV Campus and the Monroe Park Campus. And the foundation on which it is built - the field of exercise physiology - is rooted in VCU research that starts at the cellular level en route to transforming whole-body health care.

A huge population of patients

Almost everyone is born with two kidneys, which sit on each side of the abdomen and remove waste and excess fluid from the body through urine. When the kidneys fail, most commonly due to unmanaged diabetes or high blood pressure, waste and fluid begin to build up in the body. That can lead to symptoms like nausea, swelling, muscle cramps and brain fog, and eventually to death if not treated.

The are five stages of renal, or kidney, disease, but many people don't know that their kidneys have failed until they've reached the final stages. The ultimate treatment option for many patients with end-stage or chronic kidney disease - which affects 1 in 7 U.S. adults - is a kidney transplant.

Most patients with chronic or end-stage kidney disease wait years for a transplant, spending hours each week connected to dialysis machines, either at home or at dialysis centers. But many other patients simply aren't eligible for a transplant, because they're too frail to undergo the surgery.

That's where Renal Rehab steps in. The program, run by Danielle Kirkman, Ph.D., of the Department of Kinesiology and Health Sciences in VCU's College of Humanities and Sciences, aims to help patients with chronic kidney disease both prepare for transplant surgery and recover afterward through what may seem like a simple solution. It is based on the field of exercise physiology, which works to improve a chronic, underlying medical condition through exercise.

"These patients are really frail," Kirkman said. "They are usually receiving dialysis and need a transplant, but because they're older or frailer, they have a higher chance of not getting access to a kidney transplant."

That's what happened to Bourne, who like many patients was referred to Renal Rehab by her VCU Health care team. Kirkman developed the program alongside Jason M. Kidd, M.D.; Gaurav Gupta, M.D.; Dhiren Kumar, M.D.; and Anna Vinnikova, M.D., of VCU Health's Hume-Lee Transplant Center and the Division of Nephrology.

"As a younger person, I was a dancer. So, I was very active," Bourne said. "But as I got older, I did less and less of that. So, by the time I had my kidney failure, I was pretty sedentary."

For patients like Bourne, reversing frailty on their own is an almost insurmountable task. Many physicians will simply recommend that patients exercise, Kirkman said, but those patients often feel generally unwell, and they may not know how to work out safely given their medical condition.

"Just going down to the local Gold's Gym could be pretty intimidating," she said.

Brittany Barton, a recent VCU health and movement sciences master's program graduate, runs through exercises with Carol Bourne. (Jonathan Mehring, Enterprise Marketing and Communications)

From the lab to the patient

Renal Rehab, which has offered its programs to the Richmond community free of charge, started in 2021 to serve all patients with chronic kidney disease. Since then, Kirkman said, she has mostly worked with patients about to undergo, or in recovery from, a transplant.

Patients come in several times each week to complete their individually tailored exercise program, assisted by undergraduate and graduate students who coach patients through workouts and monitor their blood sugar and blood pressure. The program also includes nutrition counseling.

Although Kirkman works directly with patients, her lab's work begins at a smaller scale - a much smaller scale. To find out why exercise is so beneficial to the cardiovascular health of patients with chronic kidney disease, Kirkman and her students also run experiments at the cellular level.

Our blood vessels, which include our arteries, veins and capillaries, are lined with cells. In Kirkman's lab, the researchers expose those cells to toxins and other waste products that occur at high levels in people with chronic kidney disease, as well as to the blood plasma of patients with the disease. The researchers then observe negative changes in the cells, which helps them better understand what may be happening in the blood vessels of patients with chronic kidney disease.

The researchers also want to find out how exercise can guard against the negative impacts of the condition. When we exercise, blood flow increases inside of our vessels in order to move oxygen and nutrients to the working muscles. That increase in flow stimulates our blood vessel cells, leading to beneficial processes that improve our overall health and guard against disease. In the lab, Kirkman's team simulates that increase in blood flow to observe changes to the toxin-drenched blood vessel cells.

This research could ultimately help Kirkman's team optimize their exercise program. So far, both Kirkman's lab and patient-focused work have shown that exercise can reduce frailty in pre-transplant patients with chronic and end-stage kidney disease.

Kirkman and her VCU Health collaborators have also been studying how the prehab program has helped transplant recipients recover faster after surgery: How many days do they spend in the hospital after surgery? How many infections do they get?

Additionally, Kirkman's lab recently started working with VCU's Stravitz-Sanyal Institute for Liver Disease and Metabolic Health to set up a similar program for patients with liver disease and liver transplant recipients.

Undergraduate student Selah Porter works in the lab. "Every patient we have is so self-driven and really prioritizing their health and strength," she said. (Jonathan Mehring, Enterprise Marketing and Communications)

Building strength - and seeking coverage

On the surface, Renal Rehab is set up much like a typical cardiovascular and weight training workout: Patients who come into the clinic ride exercise bikes, lift weights and twist medicine balls, among many other standard exercises.

"Our goal as exercise physiologists is to build up [patients'] strength, to get them to where they want to be and need to be," said Brittany Barton of Sheltering Arms, who worked with Renal Rehab patients, including Bourne, while completing her master's degree in health and movement sciences at VCU.

But the program is more than a standard gym session, and patients benefit beyond just getting in better shape. Patients with kidney disease are at an extremely high risk of cardiovascular disease, and many experience muscle wasting and decreased bone health alongside concurrent diseases like diabetes, hypertension and obesity. Exercise can help stall or reverse those negative health outcomes.

"There are some safety aspects with chronic disease that you have to be aware of, that patients might not initially know about if they're just going to the gym themselves," Kirkman said. "Our goal is to help the patients recognize these aspects so that they feel confident to exercise safely in their community."

Renal Rehab is searching for funding before it can once again recruit new patients, but the researchers have kept tracking the progress of their former patients. That could help the program clear its highest hurdle yet: convincing health insurance companies to pay for the treatment.

"Part of our long-term goal is to provide a case that there is a really important need for this in a clinical setting, and to have third-party payers reimburse for these services," said Kirkman, pointing to similar exercise programs that are generally reimbursed for patients referred to cardiac and pulmonary rehab.

That could make all the difference to patients like Bourne. She participated in Renal Rehab both before and after her transplant, and the program has helped her feel her best in six years. She also has kept her progress going by working out at the local YMCA.

"It's really done wonders for me. It's better than any other program I've ever been in, and I would recommend it highly," Bourne said. "And I just don't know why it's not available to everybody, because it really is a lifesaving and life-affirming kind of program."

Beyond the exercise training, she is grateful for the supportive social atmosphere.

"Dr. Kirkman has been really, really great at building community. It's very nurturing. It's such a hospitable and wonderful place," Bourne said. "For people who have been chronically sick for a long time, it makes a huge difference, just getting out and working with people who are very caring and knowledgeable about what they're doing."

The Renal Rehab program collaborates with partners across VCU and VCU Health. Alexander Lucas, Ph.D., a researcher with VCU Pauley Heart Center and an associate professor in the Department of Social and Behavior Sciences in the School of Public Health, contributes to behavior change counseling. Additional VCU Health partners include professor and nephrologist Jason M. Kidd, M.D., professor and transplant nephrologist Gaurav Gupta, M.D., associate professor and transplant nephrologist Dhiren Kumar, M.D., and associate professor and nephrologist Anna Vinnikova, M.D., all in the Department of Internal Medicine, as well as Leana Yancey, M.S.N., the kidney and pancreas transplant program manager at the Hume-Lee Transplant Center. VCU Health kidney patients can speak to their care teams for more information or for a referral to Renal Rehab program.