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      Prognostic value of the six-minute walk test in end-stage renal disease life expectancy: a prospective cohort study

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          Abstract

          OBJECTIVES:

          The six-minute walk test has been widely used to evaluate functional capacity and predict mortality in several populations. Thus, the aim of this study was to evaluate the prognostic value of the six-minute walk test for the life expectancy of end-stage renal disease patients.

          METHODS:

          Patients over 18 years old who underwent hemodialysis for at least six months were included. Patients with hemodynamic instability, smoking, chronic obstructive pulmonary disease, physical incapacity and acute myocardial stroke in the preceding three months were excluded.

          RESULTS:

          Fifty-two patients (54% males; 36±11 years old) were followed for 144 months. The distance walked in the six-minute walk test was a survival predictor for end-stage renal disease patients. In the multivariate analysis, for each 100 meters walked with a 100-meter increment, the hazard ratio was 0.53, with a 95% confidence interval of 0.37-0.74. There was a positive correlation between the distance walked in the six-minute walk test and peak oxygen consumption (r = 0.508). In the multivariate analysis, each year of dialysis treatment represented a 10% increase in death probability; in the severity index analysis, each point on the scale represented an 11% increase in the death risk.

          CONCLUSIONS:

          We observed that survival increased approximately 5% for every 100 meters walked in the six-minute walk test, demonstrating that the test is a viable option for evaluating the functional capacity in patients with end-stage renal disease.

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          The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure.

          Cycle and treadmill exercise tests are unsuitable for elderly, frail and severely limited patients with heart failure and may not reflect capacity to undertake day-to-day activities. Walking tests have proved useful as measures of outcome for patients with chronic lung disease. To investigate the potential value of the 6-minute walk as an objective measure of exercise capacity in patients with chronic heart failure, the test was administered six times over 12 weeks to 18 patients with chronic heart failure and 25 with chronic lung disease. The subjects also underwent cycle ergometer testing, and their functional status was evaluated by means of conventional measures. The walking test proved highly acceptable to the patients, and stable, reproducible results were achieved after the first two walks. The results correlated with the conventional measures of functional status and exercise capacity. The authors conclude that the 6-minute walk is a useful measure of functional exercise capacity and a suitable measure of outcome for clinical trials in patients with chronic heart failure.
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            Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing.

            The six-minute walk test is a submaximal exercise test that can be performed even by a patient with heart failure not tolerating maximal exercise testing. To elucidate the clinical significance and prognostic value of the six-minute walk test in patients with primary pulmonary hypertension (PPH), we sought (1) to assess the relation between distance walked during the six-minute walk test and exercise capacity determined by maximal cardiopulmonary exercise testing, and (2) to investigate the prognostic value of the six-minute walk test in comparison with other noninvasive parameters. The six-minute walk test was performed in 43 patients with PPH, together with echocardiography, right heart catheterization, and measurement of plasma epinephrine and norepinephrine. Symptom-limited cardiopulmonary exercise testing was performed in a subsample of patients (n = 27). Distance walked in 6 min was significantly shorter in patients with PPH than in age- and sex-matched healthy subjects (297 +/- 188 versus 655 +/- 91 m, p < 0. 001). The distance significantly decreased in proportion to the severity of New York Heart Association functional class. The distance walked correlated modestly with baseline cardiac output (r = 0.48, p < 0.05) and total pulmonary resistance (r = -0.49, p < 0. 05), but not significantly with mean pulmonary arterial pressure. In contrast, the distance walked correlated strongly with peak V O(2) (r = 0.70, p < 0.001), oxygen pulse (r = 0.57, p < 0.01), and V E-VCO(2) slope (r = -0.66, p < 0.001) determined by cardiopulmonary exercise testing. During a mean follow-up period of 21 +/- 16 mo, 12 patients died of cardiopulmonary causes. Among noninvasive parameters including clinical, echocardiographic, and neurohumoral parameters, only the distance walked in 6 min was independently related to mortality in PPH by multivariate analysis. Patients walking < 332 m had a significantly lower survival rate than those walking farther, assessed by Kaplan-Meier survival curves (log-rank test, p < 0.01). These results suggest that the six-minute walk test, a submaximal exercise test, reflects exercise capacity determined by maximal cardiopulmonary exercise testing in patients with PPH, and it is the distance walked in 6 min that has a strong, independent association with mortality.
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              Exercise capacity as a predictor of survival among ambulatory patients with end-stage renal disease.

              Exercise capacity is reduced in end-stage renal disease (ESRD). Exercise requires the integrated function of multiple vital organs, and low exercise capacity is an independent predictor of mortality in a number of clinical populations. We analyzed the value of exercise capacity, characterized as peak oxygen uptake (VO2), for predicting survival in a cohort of 175 hemodialysis patients over a median follow-up of 39 months. Survival status was determined for 175 ESRD patients who had participated in previous studies for which peak VO2 and other clinical data had been determined. Chi-square and Kaplan-Meier survival analyses were performed, and a minimal model of factors related to mortality was developed by Cox multiple regression. There were 23 deaths during the follow-up period. Peak VO2 (>17.5 mL/min/kg) was a powerful predictor of survival (P= 0.009 by Kaplan-Meier). Age (<65 years), dialysis vintage (<39 months), pulse pressure (<54 mm Hg), and absence of diagnoses of diabetes or heart failure were also associated with better survival on univariate analyses. On multivariate analysis peak VO2 contributed significantly to the minimal explanatory model relating clinical variables to mortality (overall chi2= 25.5, P= 0.00001). Among these ambulatory ESRD patients, peak VO2 was a stronger predictor of survival than many traditional prognostic variables, some of which are subject to ceiling effects. Exercise capacity may thus provide incremental prognostic information concerning healthier ESRD patients. Because peak VO2 may be modified by exercise training, the potential of exercise as an intervention to improve survival is suggested.
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                Author and article information

                Journal
                Clinics (Sao Paulo)
                Clinics (Sao Paulo)
                Clinics
                Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
                1807-5932
                1980-5322
                June 2012
                : 67
                : 6
                : 581-586
                Affiliations
                [I ]University Foundation of Cardiology, Institute of Cardiology of Rio Grande do Sul, Porto Alegre/RS, Brazil.
                [II ]University of Cruz Alta – UNICRUZ, Cruz Alta/RS, Brazil.
                [III ]Federal University of Rio Grande – FURG, Institute of Biological Sciences, Rio Grande/RS, Brazil.
                [IV ]Federal University of Santa Maria - UFSM, Physiotherapy and Rehabilitation Department, Santa Maria/RS, Brazil.
                [V ]Federal University of Health Sciences of Porto Alegre – UFCSPA, Physiotherapy Department, Porto Alegre/RS, Brazil.
                Author notes

                Kohl LM and Signori LU designed the study, analyzed the data and wrote the paper. Plentz RDM designed the study, analyzed the data, wrote the paper and had primary responsibility for the final content. Silva AMV and Lukrafka TJ analyzed the data. Ribeiro RA analyzed the data and wrote the paper. Moreira PR wrote the paper. All the authors conducted the research, read and approved the final manuscript.

                E-mail: roplentz@ 123456yahoo.com.br Tel.: 55 51 3303-8833
                Article
                cln_67p581
                10.6061/clinics/2012(06)06
                3370308
                22760895
                badb18dc-120e-49dd-a5bd-8f041ff03915
                Copyright © 2012 Hospital das Clínicas da FMUSP

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 26 December 2011
                : 30 January 2012
                : 22 February 2012
                Page count
                Pages: 6
                Categories
                Clinical Science

                Medicine
                exercise test,prognosis,kidney failure, chronic,survival analysis
                Medicine
                exercise test, prognosis, kidney failure, chronic, survival analysis

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