By Jens Goebel, MD & Lena Riley, RN

Tyke was born with a rare condition gradually destroying his kidneys, which required a kidney transplant at the age of two. Tyke is 11 years old, has good transplant function and leads an active life – mostly no different from any other child of his age. In fact, this life includes a large number of activities, such as soccer and basketball, keeping him so busy that occasionally his parents will get a phone call or letter from Tyke’s transplant center reminding them to keep his regular check-up appointments.

One issue discussed at these visits was whether it is dangerous for Tyke’s transplanted kidney if he participates in sports. Other related questions are how risky it might have been for him to play sports while on dialysis or if he would have been born with only one kidney. The answer to these questions is “Just Do It!,” and this article is intended to clarify this answer, to discuss possible risks associated with sports participation of children with kidney disease and outline some useful precautions and restrictions along these lines.

Generally, it is critical to remember a healthy and active lifestyle, while recommended for everyone, is especially important for kidney disease patients. Many kidney diseases and any long-term reduction in kidney function promotes damage to the heart and blood vessels and thus increases risk for high blood pressure, heart attack and stroke. For example, it has been shown young adults on dialysis have a 100 to 1000 times higher likelihood of experiencing such a complication than healthy peers. While unhealthy kidneys are responsible for a large proportion of this risk, some prescribed treatments also contribute. Steroids, used for a number of kidney diseases and after transplantation, have unfavorable effects on the heart and blood vessels, as do some other anti-rejection medicines required after transplantation, such as cyclosporine and Tacrolimus. Therefore, it is not surprising that transplant patients, even with normal kidney function, still have a substantially increased risk for cardiovascular disease. While this risk is less than that of dialysis patients, cardiovascular disease – not infection or cancer as might be expected with anti-rejection treatment that suppresses the immune system – is the main cause of death of kidney transplant patients.

These medical aspects should be enough to convince kidney patients of all ages and their families to lead a healthy lifestyle and pay special attention to diet and weight control, as well as regular exercise and other lifestyle aspects, such as avoidance of smoking and alcohol. However, there are additional, non-medical reasons to support sports participation of children with kidney disease. All the way through the course of chronic kidney disease (CKD), dialysis and after transplantation, the medical needs of these children mandate a variety of restrictions to “normal” childhood. There may be dietary restrictions, medications, clinic visits, frequent as are trips to the hemodialysis facility and hospital admissions may cause additional significant disruptions. Sports, in contrast, are an excellent “normal” activity for children with kidney disease and offer potentially immense social and developmental benefits.

Youth Sport Participation with a Single “Own” Kidney or a Kidney Transplant

Some children are born with only one kidney, or two kidneys with one functioning minimally or not at all. Others may require removal of one kidney (e.g. because of a tumor) and some will receive a transplanted kidney because their own kidney or kidneys stopped working completely or almost completely. In these situations, patients are left with only one kidney working enough to keep them off dialysis or from requiring a (or another) kidney transplant. These essentially single (solitary) kidneys can be in a normal (orthotopic) position, i.e. embedded deep in the flank underneath layers of muscles and protected by the overlying ribs. They can also be located somewhere else (ectopic), oftentimes in the pelvic area and thus not protected by ribs. Typically, transplants are rather close to the skin surface of the lower abdomen above the groin. While ectopic solitary kidneys and transplants would thus appear to be at greater risk for an injury during sports participation, such participation is generally not prohibited. However, certain contact sports are often discouraged, including football, wrestling, martial arts, fast-pitch baseball and snowboarding. Due to their generally high physical nature, these sports may pose comparably high risks for kidney injury. At the very least, specific protective shielding should be worn if patients insist on participating in these sports and detailed advice along these lines is available from pediatric urology and nephrology care providers. Shielding is also encouraged for sports like basketball or soccer, while swimming, running and similar sports are strongly encouraged without any specific protection.

To put the risk posed by sports participation further into perspective, it should be pointed out that most cases of trauma to solitary kidneys results from accidents involving motor vehicles or falls from activities unrelated to sports. It could even be argued that wearing protective shielding, while driving in a car might be much more effective than protection during sports participation. Most solitary injured kidneys may be saved with appropriate medical treatment.

Youth Sport Participation with CKD and/or High Blood Pressure

As long as children with CKD feel up to participating in sports, they should not be discouraged. One important issue is high blood pressure, which is often associated with CKD. Because blood pressure will increase during athletic and other physical activity, it needs to be well controlled before participation in sports, especially those associated with rather profound rises in blood pressure, such as weightlifting. Again, individual advice is available at each individual’s care center. Another important aspect is that kidney diseases going along with high urine output (polyuric kidney failure), due to inability of the kidneys to concentrate the urine and retain salts pose an increased risk of dehydration during strenuous physical activity. For these patients, especially generous intake of fluids before, during and after sports is critical.

Youth Sport Participation on Dialysis

Being on dialysis should generally not preclude sports participation. In fact, physical exercise is so important for patients with end-stage renal disease (ESRD) that some hemodialysis centers have experimented with offering treadmills for patients to use during treatment sessions. Depending on the dialysis access (peritoneal catheter or central line exiting the skin versus skin-covered shunt or graft), individual precautions and restrictions apply and the dialysis providers can give detailed advice along these lines.

Generally, the presence of kidney disease should be mentioned when children sign up for sports. Furthermore, parents, together with teachers and coaches, should communicate with their children’s kidney care providers to develop an individualized approach to each child’s sport participation.

We would like to conclude by pointing out exceptional examples illustrating it is possible to participate in athletic activities despite having CKD. First, the regularly held U.S. and World Transplant Games not only displays athletic achievements possible for patients with transplants, but also increases public awareness of organ donation and transplant-related issues. Second, there are now two professional basketball players, Sean Elliott and Alonzo Mourning, who developed kidney disease requiring a transplant and have since returned to play. Whether Tyke, the youngster featured in the introduction to this article, will progress that far remains to be seen, but we would certainly be more than willing to schedule most of his check-ups in the off-season.

Jens Goebel, MD, is associate professor of pediatrics in the pediatric nephrology division and medical director of kidney transplantation at Cincinnati Children’s Hospital.

Lena Riley, RN, is a pediatric nurse with extensive specialty experience in pediatric urology and nephrology. She is currently performing urodynamic studies of children seen in the pediatric urology clinic at Cincinnati Children’s Hospital.

This article originally appeared in the March 2005 issue of aakpRENALIFE, Vol. 20, No. 5.

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