Awareness of exercise importance, information sources, and adherence in predialysis chronic kidney disease: a nationwide web-based cross-sectional study

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Rhee This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8205156/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Feb, 2026 Read the published version in BMC Nephrology → Version 1 posted 11 You are reading this latest preprint version Abstract Background Physical activity (PA) and exercise are key in the non-pharmacological management of chronic kidney disease (CKD). However, patient awareness, information sources, and adherence to advice are not well-established. Herein, we quantified the awareness of the importance of PA and exercise, identified information sources, described receipt of advice and adherence, and explored factors associated with poor adherence. Methods We conducted a nationwide web-based survey of adults with predialysis CKD in Japan. Inclusion criteria included being of age ≥ 50 years, physician-diagnosed CKD, no prior/active receipt of dialysis or transplant, ability to report recent serum creatinine or estimated glomerular filtration rates, and independence in activities of daily living. Questionnaires assessed awareness of importance (four-level scale), information sources, receipt of advice from healthcare professionals (yes/no), and adherence among recipients. Frailty was measured using the Kihon Checklist. Among recipients of exercise advice, correlates of poor adherence were examined using a modified Poisson regression with robust variance. Results Of the 312 respondents, 285 met the inclusion criteria. Awareness of the importance of PA/exercise was very or moderately evident in 72.7% of respondents, and diet awareness was similarly evident in 85.3%. Physicians (70.1%) and online articles (33.3%) were the most common information sources; physical therapists were rarely cited (4.4%). Overall, 71.6% of respondents reported receiving PA/exercise advice: 12.3% almost completely adhered, 51.0% mostly adhered, 31.9% did not adhere adequately, and 4.9% were unsure how to follow the advice. Frailty was independently associated with poor adherence. Conclusions In predialysis CKD, awareness of exercise lags behind that of diet, information sources are physician-centered, and adherence to advice is often suboptimal, particularly in patients with frailty. These findings reveal a gap in implementation and underscore the need to standardize structured clinical advice and monitoring, integrate exercise professionals into kidney care teams, and provide tailored support for frail patients. Chronic kidney disease Exercise Physical activity Awareness Adherence Frailty Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Physical activity (PA) and exercise are central components of non-pharmacological management of patients with chronic kidney disease (CKD). Historically, exercise has been discouraged in patients with CKD due to concerns that it might worsen kidney function and increase proteinuria, and exercise restriction has been regarded as standard of care 1 . However, recent evidence supports regular PA and exercise as safe and beneficial for patients with CKD, with salutary effects on kidney function, cardiovascular risk, physical and cognitive function, and health-related quality of life 2 – 8 . In light of this, clinical guidelines and statements worldwide now recommend PA and exercise for patients with CKD 9 – 12 , reflecting a paradigm shift from historical exercise restrictions to active prescriptions. Despite a robust evidence base, patient awareness of the importance of PA and exercise remains insufficient. Although most nephrology healthcare providers consider PA counseling beneficial within their scope of practice, such advice is not routinely provided in clinical practice 13 , 14 , consequently limiting the opportunities for patients to learn about the importance of PA and exercise. Moreover, even when patients recognize its importance, the sources from which they obtain information, whether from healthcare professionals, family or peers, mass media, or digital resources, remain poorly defined. To effectively promote the role of PA and exercise in CKD care, it is essential to better understand patient awareness and their information sources. In addition, data on the number of patients with CKD who reported having received exercise advice and the extent of their self-reported adherence are limited. Access to dedicated PA and exercise programs remains outside the standards of care for most kidney services globally 15 . In Japan, few facilities within the national health insurance system have been developed to provide exercise guidance for patients with predialysis CKD, and the involvement of exercise professionals, such as physical therapists, remains uncommon 16 . Nevertheless, clinicians and/or other healthcare professionals may still provide exercise advice as part of routine care even without specific reimbursement. However, the proportion of patients who report receiving such advice at the national level is unknown. Moreover, adherence is not routinely assessed among recipients who receive advice, and patient-level characteristics associated with low self-reported adherence remain poorly defined. To address these gaps, in this study we 1) described the prevalence of receipt of self-reported exercise advice and adherence, and 2) evaluated patient characteristics associated with poor adherence. This study pursued three objectives: (1) To quantify patients’ awareness of the importance of PA and exercise in CKD care and delineate the sources from which they obtain such information; (2) To describe the prevalence of self-reported receipt of PA/exercise advice from healthcare professionals and subsequent adherence; and (3) To identify patient characteristics associated with poor adherence. The findings of this study have important implications for CKD care and will inform dissemination strategies to raise awareness of the importance of PA and exercise. Furthermore, this study supports the tailoring of exercise counseling and interventions for patients at risk of poor adherence. Methods Study Population This was a nationwide web-based cross-sectional study that recruited participants through convenience sampling across Japan using an online research agency. A total of 312 predialysis CKD participants completed an online survey in February 2024. The inclusion criteria were as follows: age ≥ 50 years, diagnosed with CKD by a physician, no prior or active receipt of dialysis or kidney transplantation, ability to provide estimated glomerular filtration rate (eGFR) or serum creatinine values from recent blood test results conducted during clinic visits, and ability to perform activities of daily living (ADL) independently (e.g., eating, grooming, walking, climbing stairs, and dressing). The reason for including patients age ≥ 50 years was to capture not only older adults, but also middle-aged patients, as vulnerability and psychosocial challenges can begin during this time frame. A previous study involving patients with predialysis CKD with a mean age of 52 years reported a 16% prevalence of frailty 17 , supporting the relevance of this age group. Participants were excluded if they could not provide blood test results from the past year or if their eGFR was ≥ 90 mL/min/1.73 m 2 . Demographic and clinical characteristics We collected data on demographic and clinical characteristics, including age, sex, body mass index, eGFR, comorbidities such as diabetes mellitus (DM) and cerebral/cardiovascular disease (CVD), education level (≤9 years, 10-12 years, or ≥13 years), and employment status (employed, never employed, or retired). eGFR was calculated from serum creatinine levels using an equation developed for Japanese subjects 18 . CKD stages G2, G3a, G3b, G4, and G5 were defined as eGFR values of 60–89, 45–59, 30–44, 15–29, and <15 mL/min/1.73m 2 , respectively 19 . Frailty status was assessed using the Kihon Checklist (KCL), a self-reported survey consisting of 25 yes/no questions related to instrumental ADL’s, physical function, nutrition, oral function, homebound status, cognitive function, and depressive symptoms 20 . Based on a previous study 20 , a KCL score of ≥ 8 points was considered as having frailty. Study questionnaire Patients were administered a study questionnaire that was comprised of the following questions: Awareness of the importance of PA and exercise in CKD care Participants were asked, “How aware are you of the importance of PA and exercise in CKD care?” Responses included “Very aware”, “Moderately aware”, “Not very aware”, or “Not at all aware.” For comparison, the same question was also asked regarding dietary management. Sources of information on the importance of PA and exercise Participants who answered “Very aware” or “Moderately aware” were further asked, “Where did you obtain information about the importance of PA and exercise?” Multiple responses were allowed with the following options: physicians, nurses, pharmacists, dietitians, physical therapists, other healthcare professionals, care managers, friends or family, TV/radio, books/magazines, newspapers, online articles, and social media. Experience of receiving exercise advice Participants were asked, “Have you received exercise or PA advice from healthcare professionals?” with the response options of “Yes” or “No.” Adherence to received exercise advice Participants who answered “Yes” to the question on experience of receiving exercise advice were asked, “How closely do you follow the instructions you were given?” Response options were: “Almost completely adhere,” “Mostly adhere,” “Do not adhere adequately,” and “Unsure how to follow.” Poor adherence was defined as responding “Do not adhere adequately” or “Unsure how to follow.” Statistical analysis Descriptive statistics were used to summarize the participant characteristics. Continuous variables were presented as means with standard deviations or medians with interquartile ranges, as appropriate, and categorical variables were presented as numbers and percentages. Factors associated with poor adherence to exercise advice among participants who had received instructions were examined using modified Poisson regression with robust variance estimation to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). Poisson regression was selected since the prevalence of poor adherence exceeded 10%, the threshold above which the odds ratios from logistic regression may substantially overestimate the corresponding risk ratios 21,22 . Both the unadjusted and adjusted models were constructed. Variables included in the adjusted model were age, sex, eGFR, DM, CVD, education, employment status, and frailty status. All statistical analyses were conducted using Stata/SE version 19.0 for Mac (Stata Corp., College Station, TX, USA). Results Participant selection process and demographic/clinical characteristics Of the 312 participants with CKD who completed the online survey, 27 were excluded: 26 were unable to provide blood test results from within the past year, and one had an eGFR ≥ 90 mL/min/1.73 m 2 . A total of 285 participants were included in the final analysis (Fig. 1 ). The demographic and clinical characteristics of the participants are presented in Table 1 . The mean ± SD age of participants was 67.9 ± 7.8 years, and 249 (87.4%) were males. The mean ± SD eGFR was 40.7 ± 16.7 mL/min/1.73m 2, and the distribution of CKD stages was as follows: G2, 34 (11.9%); G3a, 84 (29.4%); G3b, 91 (31.9%); G4, 54 (19.0%); and G5, 22 (7.7%). A total of 214 participants (75.1%) were classified as robust, while 71 (24.9%) were identified as frail. Table 1 Demographic and clinical characteristics of participants Overall (n = 285) Age, years (mean ± SD) 67.9 ± 7.8 Sex, male (n [%]) 249 (87.4) BMI, kg/m 2 (mean ± SD) 23.3 ± 3.4 eGFR, mL/min/1.73m 2 (mean ± SD) 40.7 ± 16.7 CKD stage (n [%]) G2 34 (11.9) G3a 84 (29.4) G3b 91 (31.9) G4 54 (19.0) G5 22 (7.7) Comorbidities (n [%]) Diabetes Mellitus 57 (20.0) CVD 46 (16.1) Education (n [%]) ≤ 9 years 4 (1.4) 10–12 years 82 (28.8) ≥ 13 years 199 (69.8) Living alone (n [%]) 24 (8.4) Current employed (n [%]) 129 (45.3) KCL total score, points (median [IQR]) 4.0 (2.0–7.0) Frailty status (n [%]) Robust 214 (75.1) Frailty 71 (24.9) SD, standard deviation; IQR, interquartile range; BMI, body mass index; eGFR, estimated glomerular filtration rate; CKD, chronic kidney disease; CVD, cerebral/cardiovascular disease; KCL, Kihon Checklist. Awareness of PA and exercise in CKD care and sources of information The levels of awareness regarding the importance of PA and exercise in CKD care are outlined in Fig. 2 . Seventy participants (24.6%) reported being “very aware,” 137 (48.1%) were “moderately aware,” 73 (25.6%) were “not very aware,” and five (1.8%) were “not at all aware.” Regarding dietary management, 118 (41.4%) reported being “very aware,” 125 (43.9%) were “moderately aware,” 37 (13.0%) were “not very aware,” and five (1.8%) were “not at all aware.” The sources of information regarding the importance of PA and exercise are shown in Fig. 3 . The most common sources were physicians (70.1%), online articles (33.3%), and books/magazines (16.9%), followed by TV/radio (13.0%), dietitians (10.6%), nurses (10.1%), newspaper (8.2%), friends/family (4.8%), physical therapists (4.4%), pharmacists (2.9%), social media (2.4%), other healthcare professionals (1.3%), and other sources (1.9%). Care managers were not reported as sources by any of the participants. Self-report receipt of exercise advice and adherence level Of the 285 participants, 204 (71.6%) reported having received PA or exercise advice from healthcare professionals, whereas 81 (28.4%) did not (Fig. 4 A). Among those who had received advice (n = 204), 25 (12.3%) reported “almost complete adherence to the instructions,” 104 (51.0%) responded that they “mostly adhere,” 65 (31.9%) responded that they “do not adhere adequately,” and 10 (4.9%) were “unsure how to follow the instructions” (Fig. 4 B). Factors associated with poor adherence to exercise advice In the modified Poisson regression analysis (Table 2 ), frailty was significantly associated with poor adherence to exercise advice in both the unadjusted model (prevalence ratio [PR], 1.81; 95% confidence interval [CI], 1.28–2.55; p = 0.001) and the adjusted model (adjusted PR, 1.63; 95% CI, 1.14–2.32; p = 0.007). No other factors were significantly associated with poor patient adherence. Table 2 Factors associated with poor adherence to exercise advice among participants reporting receipt of advice: a modified Poisson regression analysis Factors Reference Category Unadjusted Adjusted PR 95% CI p PR 95% CI p Sex Male Female 0.77 0.40–1.48 0.44 0.66 0.36–1.24 0.20 Age per-1 year increase – 0.98 0.95–1.00 0.07 0.97 0.95–1.00 0.05 eGFR per-1 mL/min/1.73m 2 increase – 0.99 0.99–1.01 0.81 1.00 0.99–1.01 0.83 Diabetes Mellitus No Yes 1.33 0.91–1.93 0.14 1.22 0.84–1.77 0.30 CVD No Yes 0.76 0.42–1.36 0.36 0.81 0.46–1.42 0.46 Education ≤ 9 years 10–12 years 1.32 0.26–6.75 0.74 1.45 0.36–5.89 0.60 ≥ 13 years 1.01 0.20–5.13 0.99 1.13 0.28–4.51 0.87 Current employed No Yes 1.03 0.72–1.48 0.86 0.91 0.61–1.34 0.63 Frailty Non frailty Frailty 1.81 1.28–2.55 0.001 1.63 1.14–2.32 0.007 PR, prevalence ratio; CI, confidence interval; eGFR, estimated glomerular filtration rate; CVD, cerebral/cardiovascular disease. Poor adherence (outcome) was defined as responding “Do not adequately” or “Unsure how to follow” to the question, “How closely do you follow the instructions you were given?” (n = 75) among the participants who received advice on exercise or physical activity from healthcare professionals. The adjusted model included all the variables listed in the table. Discussion In this cross-sectional study of participants with predialysis CKD, we characterized patients’ awareness of the importance of PA and exercise, identified their information sources for these areas, and described the self-reported receipt of exercise advice from healthcare professionals and subsequent adherence. Three principal findings were identified in this study. First, awareness of the importance of PA/exercise was, overall moderate to high, although lower than awareness of dietary management. Second, physicians were the dominant information source (70.1%), with online articles also frequently cited (33.3%); physical therapists, as exercise professionals, were rarely cited (4.4%). Third, while 71.6% of participants reported receiving exercise advice from healthcare professionals, more than one-third of recipients of exercise advice reported poor adherence or uncertainty regarding how to follow instructions. Notably, frailty was independently associated with poor self-reported adherence. Patient awareness of the importance of PA and exercise in CKD care lags behind awareness of dietary management. Moreover, information sources remain largely physician-centered, with limited involvement from other healthcare professionals. In our sample, 72.7% were “very/moderately” aware of PA and exercise versus 85.3% for diet. Physicians were the dominant source (70.1%), whereas physical therapists, as exercise professionals, were rarely cited (4.4%). Physician visits remain the primary channel for dissemination; however, outpatient time constraints and variability in exercise prescription knowledge (e.g., frequency, intensity, time, type, volume, and progression [FITT-VP] principles) may limit the specificity and consistency of messages delivered in routine care. Consistent with this, a survey of nephrologists reported that barriers to providing exercise advice included competing priorities, time constraints, limited knowledge of specific exercise prescriptions, and concerns that patients would not follow the advice of non-exercise experts 13 . Accordingly, greater involvement of exercise professionals, such as physical therapists, is warranted. In practice, multidisciplinary care that includes physical therapists has been associated with a more favorable prognosis 23 , and integrating exercise professionals into kidney care teams is recommended 24 , 25 . However, in current practice, partly owing to reimbursement constraints, the participation of exercise professionals, such as physical therapists, in kidney care teams, remains limited 16 , 26 . Collectively, policy actions to embed exercise professionals within kidney care teams are needed to enhance the dissemination of the importance of PA and exercise. Online articles were identified as an information source by 33.3% of participants, second only to physicians. Online articles are increasingly recognized for their capacity to deliver PA/exercise information and support large populations in a potentially equitable and cost-effective manner 25 , 27 . Accordingly, online articles are useful channels for raising awareness regarding the importance of PA and exercise. However, variability in information quality and readability, and the risk of misinformation and commercial bias remain a concern 28 – 31 ; therefore, quality assurance and equity safeguards are essential. From an implementation standpoint, it is vital to signpost patients with easy-to-understand, professionally vetted online resources endorsed by academic societies and healthcare institutions (e.g., Kidney Beam 32 and My Kidneys and Me 33,34 ). Additional accommodations are needed for older adults, patients with limited health/digital literacy, and those without access to digital devices or the internet; hence, providing paper-based materials and other low-barrier formats may be essential. Accordingly, online resources should be leveraged while ensuring quality and equity to promote awareness of the importance of PA and exercise and support exercise advice. Despite relatively high rates of exercise advice, adherence remained suboptimal, potentially indicating a gap between counseling and sustained behavior. In this study, 71.6% of participants reported receiving PA and exercise advice from healthcare professionals, yet among recipients of this advice, 36.8% reported poor adherence or were unsure how to follow the instructions. Several factors may contribute to this gap, including limited specificity and/or individualization of advice (e.g., lack of explicit FITT-VP parameters and written plans) 25 , 35 , insufficient follow-up 36 , and outpatient time constraints 36 . Notably, the subgroup that was “unsure how to follow” suggested comprehension and implementation barriers rather than motivation alone, underscoring the need for clear, brief, and progressive prescriptions, safety guidance, and preference-aligned activities. Therefore, standardizing brief, structured exercise advice during clinic visits, with scheduled follow-ups, and referrals to exercise professionals (e.g., physical therapists), may help improve adherence and close the gap between counseling and sustained behavior change. Frailty was associated with poor adherence to the exercise advice, necessitating targeted implementation efforts in this group. Symptoms and circumstances commonly observed in patients with frailty, including reduced exercise tolerance 37 , fatigue 38 , fear of falling 39 , cognitive decline 40 , psychological distress 41 , and limited social support 42 , can hinder the translation of understanding to the initiation and sustained practice of exercise. These features indicate that in-clinic advice, followed by unsupervised home exercises, may be insufficient for patients with frailty. Implementation should be personalized in both mode and setting and guided by the assessment of physical, cognitive, psychological, and social functions, including exercise-related risks. When feasible, supervised or semi-supervised options should be offered through community resources (e.g., municipal classes, senior centers, and walking groups). Supplementing clinic-based advice with digital remote engagement and caregiver or peer support may be helpful for patients with frailty. Accordingly, patients with frailty require individualized, supported pathways rather than advice alone to initiate and sustain exercise. This study has several strengths. First, we sampled participants across almost all prefectures in Japan, reducing single-center bias. Second, by evaluating the awareness of PA and exercise alongside dietary management, we contextualized the relative awareness gap. Third, we quantified the information sources and distinguished advice receipt from adherence, thereby clarifying the translation gap between counselling and exercise adherence. However, the significant limitations of this study warrant consideration. First, its cross-sectional design precluded causal inferences, including the directionality of the association between adherence to exercise advice and frailty. Second, the receipt of exercise advice and adherence were assessed by participant self-report; we did not capture the content or dose of counseling or objective measures of exercise behavior. Frailty was assessed using the KCL self-report instrument. Given these measurement constraints, residual confounding factors cannot be excluded. Future studies should document the counseling delivered and verify exercise implementation and functional status using objective measures. Third, using a web-based survey might have introduced sampling bias, as participants with higher digital literacy are likely overrepresented and may not reflect the broader CKD population. Moreover, the sample was predominantly male, further limiting generalizability. Conclusions This nationwide web-based cross-sectional survey of participants with predialysis CKD revealed that the patients’ awareness of the importance of PA and exercise was moderate, lagging behind their awareness of diet. Information sources were mainly from physicians and online articles, whereas physical therapists were rarely cited. Most participants reported receiving exercise advice from healthcare professionals; however, adherence was often poor, and frailty was associated with non-adherence. These findings highlight an implementation gap. Providing standardized, structured clinical advice with scheduled follow-up, integrating exercise professionals into kidney care teams, and using high-quality online resources may help convert counseling into sustained exercise in CKD care. Particularly, patients with frailty are likely to struggle with adherence. Additional support and personalized delivery, including supervised community management, may be essential. Declarations Ethics approval and consent to participate This study was conducted in accordance with the guidelines of the Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of the Graduate School of Rehabilitation Science, Osaka Metropolitan University (approval number: 2023 − 129). All participants provided electronic informed consent before starting the web-based survey. Consent for publication Not applicable. Competing interests The authors have no relevant conflicts of interest to declare. Funding This study was supported by a grant from the Osaka Kidney Foundation (OK24-0005). Author Contribution Y.O.: Conceptualization; Methodology; Investigation; Formal analysis; Data curation; Visualization; Writing– original draft; Project administration.C.R.: Supervision; Writing–review and editing.All authors approved the final version of the manuscript. Acknowledgements Not applicable. Data Availability The data used in the current study are not publicly available but can be obtained from the corresponding author upon reasonable request. References Japan Diabetes Society. Diabetes Treatment Guide 2012–2013. Bunkodo; 2012. Shlipak MG, Sheshadri A, Hsu FC, et al. Effect of structured, moderate exercise on kidney function decline in sedentary older adults: An ancillary analysis of the LIFE study randomized clinical trial. JAMA Intern Med. 2022;182(6):650–9. Zhang L, Wang Y, Xiong L, Luo Y, Huang Z, Yi B. 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Lightfoot CJ, Wilkinson TJ, Song Y, Burton JO, Smith AC. Perceptions of exercise benefits and barriers: the influence on physical activity behaviour in individuals undergoing haemodialysis and peritoneal dialysis. J Nephrol. 2021;34(6):1961–71. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Feb, 2026 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 27 Jan, 2026 Reviews received at journal 22 Jan, 2026 Reviews received at journal 08 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 04 Jan, 2026 Reviewers agreed at journal 04 Jan, 2026 Reviewers agreed at journal 01 Jan, 2026 Reviewers invited by journal 07 Dec, 2025 Editor assigned by journal 26 Nov, 2025 Submission checks completed at journal 26 Nov, 2025 First submitted to journal 25 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8205156","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":557744375,"identity":"03e690c0-ff8f-4a3f-ad54-2f3a6b9b9582","order_by":0,"name":"Yuhei Otobe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqklEQVRIiWNgGAWjYHACNgaGChibhzgNQC1nSNbC2EaKq/jlm489+DjPJtrgAPPDDwwydwhrkWxjSzecuS0td8MBNmMJBp5nhLUYHOMxk+bddhiohcEM6JfDRGr5Owekhf0bCVoYG0BaeIi0RbItLd2w51ha7szDPMUSCcT4hZ/58LEHP2pscvuOt2/88LGHiBBDAGYgTuw5QIoWMPhBupZRMApGwSgY/gAAafg3whUYmL8AAAAASUVORK5CYII=","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":true,"prefix":"","firstName":"Yuhei","middleName":"","lastName":"Otobe","suffix":""},{"id":557744376,"identity":"1138e70f-4bc7-49cb-8eda-4797aeaab434","order_by":1,"name":"Connie M. Rhee","email":"","orcid":"","institution":"University of California Los Angeles","correspondingAuthor":false,"prefix":"","firstName":"Connie","middleName":"M.","lastName":"Rhee","suffix":""}],"badges":[],"createdAt":"2025-11-25 16:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8205156/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8205156/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-026-04850-z","type":"published","date":"2026-02-26T15:59:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":98106902,"identity":"d5d57dac-9925-48f2-93b7-ce04f5d2a7f3","added_by":"auto","created_at":"2025-12-13 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00:19:47","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111783,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8205156/v1/c2714af8e493c2ed7af72001.html"},{"id":98430113,"identity":"11984765-49d0-4ca9-af57-43152813cd53","added_by":"auto","created_at":"2025-12-17 16:44:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":206721,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram of the participant selection process.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8205156/v1/7606a396937589f2d47cd481.jpg"},{"id":98106893,"identity":"d51aef07-87a1-4547-9163-ec45a627d3f1","added_by":"auto","created_at":"2025-12-13 00:19:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":650909,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAwareness of the importance of physical activity and exercise in CKD care.\u003c/strong\u003eParticipants were asked, “How aware are you of the importance of physical activity and exercise in CKD care?.”\u003c/p\u003e","description":"","filename":"Figure12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8205156/v1/b6a93535fa2f9d2b88ecd2e4.jpg"},{"id":98430300,"identity":"a2131375-8afa-468f-ab8b-6c7e700b7be4","added_by":"auto","created_at":"2025-12-17 16:45:07","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":181463,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSources of information on the importance of physical activity and exercise.\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eMultiple answers were allowed for this question. Data are from participants who answered, “Moderately aware” or “Very aware” (n = 207) in response to the question, “How aware are you of the importance of physical activity and exercise in CKD care?.”\u003c/p\u003e","description":"","filename":"Figure13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8205156/v1/258d2ca323dae5573154c043.jpg"},{"id":98430967,"identity":"d6113c86-e881-4f07-b2e0-e3991164b222","added_by":"auto","created_at":"2025-12-17 16:46:33","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":624294,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSelf-reported receipt of exercise advice and adherence level.\u003c/strong\u003e A. Receipt of exercise advice. B. Adherence to received exercise guidance\u003c/p\u003e\n\u003cp\u003eNote: A: All participants (n = 285) were asked, “Have you received exercise or physical activity advice from healthcare professionals?” B: Among participants who reported receiving exercise advice (n = 204), we asked, “How closely do you follow the instructions you were given?”\u003c/p\u003e","description":"","filename":"Figure14.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8205156/v1/a18fdde81f667c306d9f9346.jpg"},{"id":103766122,"identity":"4aff40f5-c2b9-457c-ab40-403b4fa1ea2b","added_by":"auto","created_at":"2026-03-02 16:12:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2629473,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8205156/v1/52d0b53c-f30e-43c7-924d-db64cc001a03.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Awareness of exercise importance, information sources, and adherence in predialysis chronic kidney disease: a nationwide web-based cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003ePhysical activity (PA) and exercise are central components of non-pharmacological management of patients with chronic kidney disease (CKD). Historically, exercise has been discouraged in patients with CKD due to concerns that it might worsen kidney function and increase proteinuria, and exercise restriction has been regarded as standard of care\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. However, recent evidence supports regular PA and exercise as safe and beneficial for patients with CKD, with salutary effects on kidney function, cardiovascular risk, physical and cognitive function, and health-related quality of life\u003csup\u003e\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. In light of this, clinical guidelines and statements worldwide now recommend PA and exercise for patients with CKD\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, reflecting a paradigm shift from historical exercise restrictions to active prescriptions.\u003c/p\u003e\u003cp\u003eDespite a robust evidence base, patient awareness of the importance of PA and exercise remains insufficient. Although most nephrology healthcare providers consider PA counseling beneficial within their scope of practice, such advice is not routinely provided in clinical practice\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, consequently limiting the opportunities for patients to learn about the importance of PA and exercise. Moreover, even when patients recognize its importance, the sources from which they obtain information, whether from healthcare professionals, family or peers, mass media, or digital resources, remain poorly defined. To effectively promote the role of PA and exercise in CKD care, it is essential to better understand patient awareness and their information sources.\u003c/p\u003e\u003cp\u003eIn addition, data on the number of patients with CKD who reported having received exercise advice and the extent of their self-reported adherence are limited. Access to dedicated PA and exercise programs remains outside the standards of care for most kidney services globally\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn Japan, few facilities within the national health insurance system have been developed to provide exercise guidance for patients with predialysis CKD, and the involvement of exercise professionals, such as physical therapists, remains uncommon\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Nevertheless, clinicians and/or other healthcare professionals may still provide exercise advice as part of routine care even without specific reimbursement. However, the proportion of patients who report receiving such advice at the national level is unknown. Moreover, adherence is not routinely assessed among recipients who receive advice, and patient-level characteristics associated with low self-reported adherence remain poorly defined. To address these gaps, in this study we 1) described the prevalence of receipt of self-reported exercise advice and adherence, and 2) evaluated patient characteristics associated with poor adherence.\u003c/p\u003e\u003cp\u003eThis study pursued three objectives: (1) To quantify patients\u0026rsquo; awareness of the importance of PA and exercise in CKD care and delineate the sources from which they obtain such information; (2) To describe the prevalence of self-reported receipt of PA/exercise advice from healthcare professionals and subsequent adherence; and (3) To identify patient characteristics associated with poor adherence. The findings of this study have important implications for CKD care and will inform dissemination strategies to raise awareness of the importance of PA and exercise. Furthermore, this study supports the tailoring of exercise counseling and interventions for patients at risk of poor adherence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a nationwide web-based cross-sectional study that recruited participants through convenience sampling across Japan using an online research agency. A total of 312 predialysis CKD participants completed an online survey in February 2024. The inclusion criteria were as follows: age ≥ 50 years, diagnosed with CKD by a physician, no prior or active receipt of dialysis or kidney transplantation, ability to provide estimated glomerular filtration rate (eGFR) or serum creatinine values from recent blood test results conducted during clinic visits, and ability to perform activities of daily living (ADL) independently (e.g., eating, grooming, walking, climbing stairs, and dressing). The reason for including patients age ≥ 50 years was to capture not only older adults, but also middle-aged patients, as vulnerability and psychosocial challenges can begin during this time frame. A previous study involving patients with predialysis CKD with a mean age of 52 years reported a 16% prevalence of frailty\u003csup\u003e17\u003c/sup\u003e, supporting the relevance of this age group. Participants were excluded if they could not provide blood test results from the past year or if their eGFR was ≥ 90 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic and clinical characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe collected data on demographic and clinical characteristics, including age, sex, body mass index, eGFR, comorbidities such as diabetes mellitus (DM) and cerebral/cardiovascular disease (CVD), education level (≤9 years, 10-12 years, or ≥13 years), and employment status (employed, never employed, or retired). eGFR was calculated from serum creatinine levels using an equation developed for Japanese subjects\u003csup\u003e18\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCKD stages G2, G3a, G3b, G4, and G5 were defined as eGFR values of 60–89, 45–59, 30–44, 15–29, and \u0026lt;15 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e, respectively\u003csup\u003e19\u003c/sup\u003e. Frailty status was assessed using the\u0026nbsp;Kihon Checklist (KCL), a self-reported survey consisting of 25 yes/no questions related to instrumental ADL’s, physical function, nutrition, oral function,\u0026nbsp;homebound status, cognitive function, and\u0026nbsp;depressive symptoms\u003csup\u003e20\u003c/sup\u003e. Based on a previous study\u003csup\u003e20\u003c/sup\u003e, a KCL score of ≥ 8 points was considered as having frailty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were administered a study questionnaire that was comprised of the following questions:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eAwareness of the importance of PA and exercise in CKD care\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eParticipants were asked, “How aware are you of the importance of PA and exercise in CKD care?” Responses included “Very aware”, “Moderately aware”, “Not very aware”, or “Not at all aware.” For comparison, the same question was also asked regarding dietary management.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eSources of information on the importance of PA and exercise\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eParticipants who answered “Very aware” or “Moderately aware” were further asked, “Where did you obtain information about the importance of PA and exercise?” Multiple responses were allowed with the following options: physicians, nurses, pharmacists, dietitians, physical therapists, other healthcare professionals, care managers, friends or family, TV/radio, books/magazines, newspapers, online articles, and social media.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eExperience of receiving exercise advice\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eParticipants were asked, “Have you received exercise or PA advice from healthcare professionals?” with the response options of “Yes” or “No.”\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eAdherence to received exercise advice\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eParticipants who answered “Yes” to the question on experience of receiving exercise advice were asked, “How closely do you follow the instructions you were given?” Response options were: “Almost completely adhere,” “Mostly adhere,” “Do not adhere adequately,” and “Unsure how to follow.” Poor adherence was defined as responding “Do not adhere adequately” or “Unsure how to follow.”\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to summarize the participant characteristics. Continuous variables were presented as means with standard deviations or medians with interquartile ranges, as appropriate, and categorical variables were presented as numbers and percentages.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Factors associated with poor adherence to exercise advice among participants who had received instructions were examined using modified Poisson regression with robust variance estimation to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). Poisson regression was selected since the prevalence of poor adherence exceeded 10%, the threshold above which the odds ratios from logistic regression may substantially overestimate the corresponding risk ratios\u003csup\u003e21,22\u003c/sup\u003e. Both the unadjusted and adjusted models were constructed. Variables included in the adjusted model were age, sex, eGFR, DM, CVD, education, employment status, and frailty status. All statistical analyses were conducted using Stata/SE version 19.0 for Mac (Stata Corp., College Station, TX, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eParticipant selection process and demographic/clinical characteristics\u003c/h2\u003e\u003cp\u003eOf the 312 participants with CKD who completed the online survey, 27 were excluded: 26 were unable to provide blood test results from within the past year, and one had an eGFR\u0026thinsp;\u0026ge;\u0026thinsp;90 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e. A total of 285 participants were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The demographic and clinical characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD age of participants was 67.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years, and 249 (87.4%) were males. The mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD eGFR was 40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 mL/min/1.73m\u003csup\u003e2,\u003c/sup\u003e and the distribution of CKD stages was as follows: G2, 34 (11.9%); G3a, 84 (29.4%); G3b, 91 (31.9%); G4, 54 (19.0%); and G5, 22 (7.7%). A total of 214 participants (75.1%) were classified as robust, while 71 (24.9%) were identified as frail.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and clinical characteristics of participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;285)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, male (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e249 (87.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eeGFR, mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCKD stage (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (11.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG3a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84 (29.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG3b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91 (31.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54 (19.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (7.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCVD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (16.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;9 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (1.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82 (28.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;13 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199 (69.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving alone (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (8.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent employed (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129 (45.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKCL total score, points (median [IQR])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.0 (2.0\u0026ndash;7.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrailty status (n [%])\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRobust\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e214 (75.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrailty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (24.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eSD, standard deviation; IQR, interquartile range; BMI, body mass index; eGFR, estimated glomerular filtration rate; CKD, chronic kidney disease; CVD, cerebral/cardiovascular disease; KCL, Kihon Checklist.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAwareness of PA and exercise in CKD care and sources of information\u003c/h3\u003e\n\u003cp\u003eThe levels of awareness regarding the importance of PA and exercise in CKD care are outlined in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Seventy participants (24.6%) reported being \u0026ldquo;very aware,\u0026rdquo; 137 (48.1%) were \u0026ldquo;moderately aware,\u0026rdquo; 73 (25.6%) were \u0026ldquo;not very aware,\u0026rdquo; and five (1.8%) were \u0026ldquo;not at all aware.\u0026rdquo; Regarding dietary management, 118 (41.4%) reported being \u0026ldquo;very aware,\u0026rdquo; 125 (43.9%) were \u0026ldquo;moderately aware,\u0026rdquo; 37 (13.0%) were \u0026ldquo;not very aware,\u0026rdquo; and five (1.8%) were \u0026ldquo;not at all aware.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe sources of information regarding the importance of PA and exercise are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The most common sources were physicians (70.1%), online articles (33.3%), and books/magazines (16.9%), followed by TV/radio (13.0%), dietitians (10.6%), nurses (10.1%), newspaper (8.2%), friends/family (4.8%), physical therapists (4.4%), pharmacists (2.9%), social media (2.4%), other healthcare professionals (1.3%), and other sources (1.9%). Care managers were not reported as sources by any of the participants.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eSelf-report receipt of exercise advice and adherence level\u003c/h3\u003e\n\u003cp\u003eOf the 285 participants, 204 (71.6%) reported having received PA or exercise advice from healthcare professionals, whereas 81 (28.4%) did not (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). Among those who had received advice (n\u0026thinsp;=\u0026thinsp;204), 25 (12.3%) reported \u0026ldquo;almost complete adherence to the instructions,\u0026rdquo; 104 (51.0%) responded that they \u0026ldquo;mostly adhere,\u0026rdquo; 65 (31.9%) responded that they \u0026ldquo;do not adhere adequately,\u0026rdquo; and 10 (4.9%) were \u0026ldquo;unsure how to follow the instructions\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with poor adherence to exercise advice\u003c/h2\u003e\u003cp\u003eIn the modified Poisson regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), frailty was significantly associated with poor adherence to exercise advice in both the unadjusted model (prevalence ratio [PR], 1.81; 95% confidence interval [CI], 1.28\u0026ndash;2.55; p\u0026thinsp;=\u0026thinsp;0.001) and the adjusted model (adjusted PR, 1.63; 95% CI, 1.14\u0026ndash;2.32; p\u0026thinsp;=\u0026thinsp;0.007). No other factors were significantly associated with poor patient adherence.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with poor adherence to exercise advice among participants reporting receipt of advice: a modified Poisson regression analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eUnadjusted\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003eAdjusted\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.40\u0026ndash;1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.36\u0026ndash;1.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eper-1 year increase\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.95\u0026ndash;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.95\u0026ndash;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eeGFR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eper-1 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e increase\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.99\u0026ndash;1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.99\u0026ndash;1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.91\u0026ndash;1.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.84\u0026ndash;1.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCVD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.42\u0026ndash;1.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.46\u0026ndash;1.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;9 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u0026ndash;12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.26\u0026ndash;6.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.36\u0026ndash;5.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;13 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.20\u0026ndash;5.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.28\u0026ndash;4.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.72\u0026ndash;1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.61\u0026ndash;1.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrailty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon frailty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrailty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.28\u0026ndash;2.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1.14\u0026ndash;2.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003ePR, prevalence ratio; CI, confidence interval; eGFR, estimated glomerular filtration rate; CVD, cerebral/cardiovascular disease.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003ePoor adherence (outcome) was defined as responding \u0026ldquo;Do not adequately\u0026rdquo; or \u0026ldquo;Unsure how to follow\u0026rdquo; to the question, \u0026ldquo;How closely do you follow the instructions you were given?\u0026rdquo; (n\u0026thinsp;=\u0026thinsp;75) among the participants who received advice on exercise or physical activity from healthcare professionals. The adjusted model included all the variables listed in the table.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this cross-sectional study of participants with predialysis CKD, we characterized patients\u0026rsquo; awareness of the importance of PA and exercise, identified their information sources for these areas, and described the self-reported receipt of exercise advice from healthcare professionals and subsequent adherence. Three principal findings were identified in this study. First, awareness of the importance of PA/exercise was, overall moderate to high, although lower than awareness of dietary management. Second, physicians were the dominant information source (70.1%), with online articles also frequently cited (33.3%); physical therapists, as exercise professionals, were rarely cited (4.4%). Third, while 71.6% of participants reported receiving exercise advice from healthcare professionals, more than one-third of recipients of exercise advice reported poor adherence or uncertainty regarding how to follow instructions. Notably, frailty was independently associated with poor self-reported adherence.\u003c/p\u003e\u003cp\u003ePatient awareness of the importance of PA and exercise in CKD care lags behind awareness of dietary management. Moreover, information sources remain largely physician-centered, with limited involvement from other healthcare professionals. In our sample, 72.7% were \u0026ldquo;very/moderately\u0026rdquo; aware of PA and exercise versus 85.3% for diet. Physicians were the dominant source (70.1%), whereas physical therapists, as exercise professionals, were rarely cited (4.4%). Physician visits remain the primary channel for dissemination; however, outpatient time constraints and variability in exercise prescription knowledge (e.g., frequency, intensity, time, type, volume, and progression [FITT-VP] principles) may limit the specificity and consistency of messages delivered in routine care. Consistent with this, a survey of nephrologists reported that barriers to providing exercise advice included competing priorities, time constraints, limited knowledge of specific exercise prescriptions, and concerns that patients would not follow the advice of non-exercise experts\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Accordingly, greater involvement of exercise professionals, such as physical therapists, is warranted.\u003c/p\u003e\u003cp\u003eIn practice, multidisciplinary care that includes physical therapists has been associated with a more favorable prognosis\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, and integrating exercise professionals into kidney care teams is recommended\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. However, in current practice, partly owing to reimbursement constraints, the participation of exercise professionals, such as physical therapists, in kidney care teams, remains limited\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Collectively, policy actions to embed exercise professionals within kidney care teams are needed to enhance the dissemination of the importance of PA and exercise.\u003c/p\u003e\u003cp\u003eOnline articles were identified as an information source by 33.3% of participants, second only to physicians. Online articles are increasingly recognized for their capacity to deliver PA/exercise information and support large populations in a potentially equitable and cost-effective manner\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Accordingly, online articles are useful channels for raising awareness regarding the importance of PA and exercise. However, variability in information quality and readability, and the risk of misinformation and commercial bias remain a concern\u003csup\u003e\u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e; therefore, quality assurance and equity safeguards are essential. From an implementation standpoint, it is vital to signpost patients with easy-to-understand, professionally vetted online resources endorsed by academic societies and healthcare institutions (e.g., Kidney Beam\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e and My Kidneys and Me\u003csup\u003e33,34\u003c/sup\u003e). Additional accommodations are needed for older adults, patients with limited health/digital literacy, and those without access to digital devices or the internet; hence, providing paper-based materials and other low-barrier formats may be essential. Accordingly, online resources should be leveraged while ensuring quality and equity to promote awareness of the importance of PA and exercise and support exercise advice.\u003c/p\u003e\u003cp\u003eDespite relatively high rates of exercise advice, adherence remained suboptimal, potentially indicating a gap between counseling and sustained behavior. In this study, 71.6% of participants reported receiving PA and exercise advice from healthcare professionals, yet among recipients of this advice, 36.8% reported poor adherence or were unsure how to follow the instructions. Several factors may contribute to this gap, including limited specificity and/or individualization of advice (e.g., lack of explicit FITT-VP parameters and written plans)\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, insufficient follow-up\u003csup\u003e36\u003c/sup\u003e, and outpatient time constraints\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Notably, the subgroup that was \u0026ldquo;unsure how to follow\u0026rdquo; suggested comprehension and implementation barriers rather than motivation alone, underscoring the need for clear, brief, and progressive prescriptions, safety guidance, and preference-aligned activities. Therefore, standardizing brief, structured exercise advice during clinic visits, with scheduled follow-ups, and referrals to exercise professionals (e.g., physical therapists), may help improve adherence and close the gap between counseling and sustained behavior change.\u003c/p\u003e\u003cp\u003eFrailty was associated with poor adherence to the exercise advice, necessitating targeted implementation efforts in this group. Symptoms and circumstances commonly observed in patients with frailty, including reduced exercise tolerance\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, fatigue\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e, fear of falling\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e, cognitive decline\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e, psychological distress\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, and limited social support\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e, can hinder the translation of understanding to the initiation and sustained practice of exercise. These features indicate that in-clinic advice, followed by unsupervised home exercises, may be insufficient for patients with frailty. Implementation should be personalized in both mode and setting and guided by the assessment of physical, cognitive, psychological, and social functions, including exercise-related risks. When feasible, supervised or semi-supervised options should be offered through community resources (e.g., municipal classes, senior centers, and walking groups). Supplementing clinic-based advice with digital remote engagement and caregiver or peer support may be helpful for patients with frailty. Accordingly, patients with frailty require individualized, supported pathways rather than advice alone to initiate and sustain exercise.\u003c/p\u003e\u003cp\u003eThis study has several strengths. First, we sampled participants across almost all prefectures in Japan, reducing single-center bias. Second, by evaluating the awareness of PA and exercise alongside dietary management, we contextualized the relative awareness gap. Third, we quantified the information sources and distinguished advice receipt from adherence, thereby clarifying the translation gap between counselling and exercise adherence.\u003c/p\u003e\u003cp\u003eHowever, the significant limitations of this study warrant consideration. First, its cross-sectional design precluded causal inferences, including the directionality of the association between adherence to exercise advice and frailty. Second, the receipt of exercise advice and adherence were assessed by participant self-report; we did not capture the content or dose of counseling or objective measures of exercise behavior. Frailty was assessed using the KCL self-report instrument. Given these measurement constraints, residual confounding factors cannot be excluded. Future studies should document the counseling delivered and verify exercise implementation and functional status using objective measures. Third, using a web-based survey might have introduced sampling bias, as participants with higher digital literacy are likely overrepresented and may not reflect the broader CKD population. Moreover, the sample was predominantly male, further limiting generalizability.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis nationwide web-based cross-sectional survey of participants with predialysis CKD revealed that the patients\u0026rsquo; awareness of the importance of PA and exercise was moderate, lagging behind their awareness of diet. Information sources were mainly from physicians and online articles, whereas physical therapists were rarely cited. Most participants reported receiving exercise advice from healthcare professionals; however, adherence was often poor, and frailty was associated with non-adherence. These findings highlight an implementation gap. Providing standardized, structured clinical advice with scheduled follow-up, integrating exercise professionals into kidney care teams, and using high-quality online resources may help convert counseling into sustained exercise in CKD care. Particularly, patients with frailty are likely to struggle with adherence. Additional support and personalized delivery, including supervised community management, may be essential.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study was conducted in accordance with the guidelines of the Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of the Graduate School of Rehabilitation Science, Osaka Metropolitan University (approval number: 2023\u0026thinsp;\u0026minus;\u0026thinsp;129). All participants provided electronic informed consent before starting the web-based survey.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors have no relevant conflicts of interest to declare.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was supported by a grant from the Osaka Kidney Foundation (OK24-0005).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.O.: Conceptualization; Methodology; Investigation; Formal analysis; Data curation; Visualization; Writing\u0026ndash; original draft; Project administration.C.R.: Supervision; Writing\u0026ndash;review and editing.All authors approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used in the current study are not publicly available but can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJapan Diabetes Society. Diabetes Treatment Guide 2012\u0026ndash;2013. Bunkodo; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShlipak MG, Sheshadri A, Hsu FC, et al. Effect of structured, moderate exercise on kidney function decline in sedentary older adults: An ancillary analysis of the LIFE study randomized clinical trial. JAMA Intern Med. 2022;182(6):650\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang L, Wang Y, Xiong L, Luo Y, Huang Z, Yi B. Exercise therapy improves eGFR, and reduces blood pressure and BMI in non-dialysis CKD patients: evidence from a meta-analysis. BMC Nephrol. 2019;20(1):398.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTasaki H, Kosugi T, Eriguchi M et al. Impact of exercise on all-cause and cardiovascular mortality in non-dialysis chronic kidney disease: the Japan specific health checkups (J-SHC) study. \u003cem\u003eHypertens Res\u003c/em\u003e. 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Aerobic exercise in adults with chronic kidney disease (CKD): a meta-analysis. Int Urol Nephrol. 2019;51(10):1787\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamagata K, Hoshino J, Sugiyama H et al. Clinical practice guideline for renal rehabilitation: systematic reviews and recommendations of exercise therapies in patients with kidney diseases. Ren Replace Ther. 2019;5(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaker LA, March DS, Wilkinson TJ, et al. Clinical practice guideline exercise and lifestyle in chronic kidney disease. BMC Nephrol. 2022;23(1):75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBattaglia Y, Baciga F, Bulighin F, et al. Physical activity and exercise in chronic kidney disease: consensus statements from the Physical Exercise Working Group of the Italian Society of Nephrology. J Nephrol. 2024;37(7):1735\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKouidi E, Hanssen H, Anding-Rost K, et al. The role of exercise training on cardiovascular risk factors and heart disease in patients with chronic kidney disease G3-G5 and G5D: a Clinical Consensus Statement of the European Association of Preventive Cardiology of the ESC and the European Association of Rehabilitation in Chronic Kidney Disease. Eur J Prev Cardiol. 2024;31(12):1493\u0026ndash;515.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaryana AA, Krishnasamy R, Bohm C, et al. Physical activity for people with chronic kidney disease: an international survey of nephrologist practice patterns and research priorities. BMJ Open. 2019;9(12):e032322.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSilva LC, Marinho P\u0026Eacute;M. Knowledge among nephrologists about the importance of exercise in the intradialytic period. J Phys Ther Sci. 2015;27(9):2991\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBohm C, Bennett P, Lambert K, et al. Advancing exercise science for better health outcomes across the spectrum of chronic kidney disease. J Ren Nutr. 2023;33(6S):S103\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHirano Y, Kono K, Takahashi R et al. Participation of Physical Therapists in Medical Fee-Based Dialysis-PreventionInterventions: A Nationwide Survey in Japan. Clin Exp Nephrol. Published online September 19, 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDelgado C, Grimes BA, Glidden DV, Shlipak M, Sarnak MJ, Johansen KL. Association of Frailty based on self-reported physical function with directly measured kidney function and mortality. BMC Nephrol. 2015;16(1):203.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsuo S, Imai E, Horio M, et al. 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JAMA. 1998;280(19):1690.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbe M, Hatta T, Imamura Y, Sakurada T, Kaname S. Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study. Clin Exp Nephrol. 2023;27(6):528\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBennett PN, Kohzuki M, Bohm C, et al. Global policy barriers and enablers to exercise and physical activity in kidney care. J Ren Nutr. 2022;32(4):441\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilkinson TJ, Tarca B, Lightfoot CJ, et al. Prescribing physical activity and exercise for people with CKD: A practical guide by the global renal exercise network. Clin J Am Soc Nephrol. 2025;20(6):876\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHiraki K, Matsumoto D, Mori K, Hayashi H, Kawabe N, Igaki M. A survey of physical therapist involvement for patients with diabetic nephropathy: a questionnaire study of members of the Japanese Society of Physical Therapy for Diabetes Mellitus [in Japanese]. J Jpn Diabetes Soc. 2019;62(3):178\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLetton ME, Trần TB, Flower S, et al. Digital physical activity and exercise interventions for people living with chronic kidney disease: A systematic review of health outcomes and feasibility. J Med Syst. 2024;48(1):63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuarez-Lledo V, Alvarez-Galvez J. Prevalence of health misinformation on social media: Systematic review. J Med Internet Res. 2021;23(1):e17187.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Y, McKee M, Torbica A, Stuckler D. Systematic literature review on the spread of health-related misinformation on social media. Soc Sci Med. 2019;240(112552):112552.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDaraz L, Morrow AS, Ponce OJ, et al. Readability of online health information: A meta-narrative systematic review. Am J Med Qual. 2018;33(5):487\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHelou V, Mouzahem F, Makarem A, et al. Conflict of interest and funding in health communication on social media: a systematic review. BMJ Open. 2023;13(8):e072258.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreenwood SA, Young HML, Briggs J, et al. Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): a multicentre, randomised controlled trial in the UK. Lancet Digit Health. 2024;6(1):e23\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLightfoot CJ, Wilkinson TJ, Hadjiconstantinou M, et al. The codevelopment of My Kidneys \u0026amp; Me: A digital self-management program for people with chronic kidney disease. J Med Internet Res. 2022;24(11):e39657.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLightfoot CJ, Wilkinson TJ, Sohansoha GK, et al. The effects digital health intervention patient activation chronic kidney disease. npj Digit Med. 2024;7:318.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am J Public Health. 1998;88(2):288\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlbert FA, Crowe MJ, Malau-Aduli AEO, Malau-Aduli BS. Functionality of Physical Activity Referral Schemes (PARS): A systematic review. Front Public Health. 2020;8:257.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim JC, Shapiro BB, Zhang M, et al. Daily physical activity and physical function in adult maintenance hemodialysis patients. J Cachexia Sarcopenia Muscle. 2014;5(3):209\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHannan M, Bronas UG. Barriers to exercise for patients with renal disease: an integrative review. J Nephrol. 2017;30(6):729\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShirai N, Yamamoto S, Osawa Y et al. Fear of falling and physical activity in hemodialysis patients: a pilot study. Ren Replace Ther. 2021;7(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheshadri A, Kittiskulnam P, Delgado C, Sudore RL, Lai JC, Johansen KL. Association of cognitive function screening results with adherence and performance in a pedometer-based intervention. Am J Nephrol. 2021;52(5):420\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCardol CK, Meuleman Y, van Middendorp H, et al. Psychological distress and self-management in CKD: A cross-sectional study. Kidney Med. 2023;5(10):100712.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLightfoot CJ, Wilkinson TJ, Song Y, Burton JO, Smith AC. Perceptions of exercise benefits and barriers: the influence on physical activity behaviour in individuals undergoing haemodialysis and peritoneal dialysis. J Nephrol. 2021;34(6):1961\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic kidney disease, Exercise, Physical activity, Awareness, Adherence, Frailty","lastPublishedDoi":"10.21203/rs.3.rs-8205156/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8205156/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePhysical activity (PA) and exercise are key in the non-pharmacological management of chronic kidney disease (CKD). However, patient awareness, information sources, and adherence to advice are not well-established. Herein, we quantified the awareness of the importance of PA and exercise, identified information sources, described receipt of advice and adherence, and explored factors associated with poor adherence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a nationwide web-based survey of adults with predialysis CKD in Japan. Inclusion criteria included being of age\u0026thinsp;\u0026ge;\u0026thinsp;50 years, physician-diagnosed CKD, no prior/active receipt of dialysis or transplant, ability to report recent serum creatinine or estimated glomerular filtration rates, and independence in activities of daily living. Questionnaires assessed awareness of importance (four-level scale), information sources, receipt of advice from healthcare professionals (yes/no), and adherence among recipients. Frailty was measured using the Kihon Checklist. Among recipients of exercise advice, correlates of poor adherence were examined using a modified Poisson regression with robust variance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf the 312 respondents, 285 met the inclusion criteria. Awareness of the importance of PA/exercise was very or moderately evident in 72.7% of respondents, and diet awareness was similarly evident in 85.3%. Physicians (70.1%) and online articles (33.3%) were the most common information sources; physical therapists were rarely cited (4.4%). Overall, 71.6% of respondents reported receiving PA/exercise advice: 12.3% almost completely adhered, 51.0% mostly adhered, 31.9% did not adhere adequately, and 4.9% were unsure how to follow the advice. Frailty was independently associated with poor adherence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eIn predialysis CKD, awareness of exercise lags behind that of diet, information sources are physician-centered, and adherence to advice is often suboptimal, particularly in patients with frailty. These findings reveal a gap in implementation and underscore the need to standardize structured clinical advice and monitoring, integrate exercise professionals into kidney care teams, and provide tailored support for frail patients.\u003c/p\u003e","manuscriptTitle":"Awareness of exercise importance, information sources, and adherence in predialysis chronic kidney disease: a nationwide web-based cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-13 00:19:42","doi":"10.21203/rs.3.rs-8205156/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-27T10:23:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T18:51:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-09T03:03:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98977104055382170355312391103765254909","date":"2026-01-05T21:34:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98086668052800260589704842227579799281","date":"2026-01-05T01:34:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179947986068019451243089121524157010927","date":"2026-01-04T20:24:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82968679806237061935942132818573836904","date":"2026-01-01T11:04:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-07T13:48:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-26T11:01:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-26T11:00:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-11-25T15:36:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c4bf3213-9f8a-42b4-9534-9a59a1f853a4","owner":[],"postedDate":"December 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:08:21+00:00","versionOfRecord":{"articleIdentity":"rs-8205156","link":"https://doi.org/10.1186/s12882-026-04850-z","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2026-02-26 15:59:28","publishedOnDateReadable":"February 26th, 2026"},"versionCreatedAt":"2025-12-13 00:19:42","video":"","vorDoi":"10.1186/s12882-026-04850-z","vorDoiUrl":"https://doi.org/10.1186/s12882-026-04850-z","workflowStages":[]},"version":"v1","identity":"rs-8205156","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8205156","identity":"rs-8205156","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}