Preamble

Guidance for Patient Rehabilitation Implementation

Authors: Wang Tingting, Lin Zehua, Ma Yingchun
Source: Chinese General Practice

Abstract

This article provides comprehensive guidance and recommendations for the implementation of rehabilitation for patients, aiming to offer clinical practitioners and rehabilitation specialists a standardized framework for practice. By integrating current evidence-based medical principles with clinical experience, the authors outline key strategies for optimizing patient recovery outcomes across various stages of the rehabilitation process.

Introduction

Rehabilitation medicine plays a critical role in the modern healthcare system, focusing not only on the recovery of physical functions but also on the improvement of the patient's overall quality of life. As the prevalence of chronic diseases and age-related functional impairments increases, the demand for structured, effective rehabilitation guidance has become more pressing. This paper synthesizes current methodologies to provide actionable insights for healthcare providers.

Core Principles of Rehabilitation Implementation

The implementation of rehabilitation must adhere to several fundamental principles to ensure safety and efficacy. First, the rehabilitation plan must be individualized, taking into account the patient's specific diagnosis, comorbidities, and personal goals. Second, a multidisciplinary team (MDT) approach is essential, involving physicians, physical therapists, occupational therapists, and nursing staff to provide holistic care.

Assessment and Goal Setting

Before initiating any rehabilitation program, a thorough baseline assessment is mandatory. This includes:
- Functional Evaluation: Utilizing standardized scales to measure mobility, strength, and activities of daily living (ADL).
- Psychosocial Assessment: Evaluating the patient's mental health status and social support system, which significantly influence rehabilitation adherence.
- Risk Stratification: Identifying potential contraindications or risks associated with specific physical interventions.

Goals should follow the SMART criteria (Specific, Measurable, Achievable, Relevant, and Time-bound). Short-term goals focus on immediate functional gains, while long-term goals aim for community reintegration and the prevention of secondary complications.

Implementation Strategies

The actual execution of the rehabilitation plan requires precise monitoring and adjustment. Key components include:
1. Exercise Prescription: Tailoring the intensity, frequency, and duration of physical activity to the patient's tolerance levels.
2. Patient Education: Empowering patients and their families with knowledge regarding the recovery process, which enhances compliance and self-management.
3. Technological Integration: Leveraging modern tools such as wearable devices and telerehabilitation to monitor progress and provide remote guidance.

Conclusion

Effective rehabilitation

School of Rehabilitation Medicine, Capital Medical University, Beijing 100068, China

According to data released by the National Bureau of Statistics, at the end of 2023, the population aged 60 and over in China reached 296 million, accounting for 21.1% of the total population. Within this demographic, the population aged 65 and over reached 216 million, representing 15.4% of the national total. Projections indicate that by 2050, the total number of elderly individuals aged 60 and over in China will reach 430 million, while those aged 65 and over will reach 320 million \cite{1-2}. Reports indicate that the prevalence of multimorbidity among the elderly in different regions of China ranges from 47.5% to 75%. Clinically, these individuals are susceptible to acute kidney injury (AKI), and some patients may progress to chronic kidney disease or even require renal replacement therapy. Patients with acute kidney injury in geriatric comorbidities (AKI-GC) suffer from various functional impairments. Early and timely intervention with rehabilitation therapy can enhance patients' quality of life and improve clinical outcomes. As China's elderly population continues to rise, the demand for rehabilitation services among AKI-GC patients has surged. Consequently, there is an urgent need to establish standardized rehabilitation service protocols for AKI-GC patients to guide clinical and rehabilitation professionals in providing better rehabilitation management for this population.

1 Scope

Rehabilitation Service Standards for Elderly Patients with Comorbidity and Acute Kidney Injury (AKI-GC)

This specification defines the standard terminology, definitions, basic requirements, assessment methods, and rehabilitation implementation protocols for rehabilitation services provided to patients with Elderly Comorbidity and Acute Kidney Injury (AKI-GC). It is intended for use by clinicians, rehabilitation therapists, nursing staff, and relevant multidisciplinary teams across various levels of medical institutions—including general hospitals, specialized rehabilitation hospitals, and geriatric hospitals—to guide both inpatient and outpatient rehabilitation services for AKI-GC patients.

These standards are applicable to patients aged 60 years or older who meet the criteria for geriatric comorbidities combined with acute kidney injury.

Rehabilitation Service Standards for Elderly Patients with Comorbidity and Acute Kidney Injury
Chinese Association of Rehabilitation Medicine, Renal Rehabilitation Professional Committee

100068 Beijing, School of Rehabilitation Medicine, Capital Medical University

Specification of Rehabilitation Service for Elderly Patients with Comorbidity Complicated with Acute Kidney Injury

Committee on Kidney Disease Rehabilitation, Chinese Association of Rehabilitation Medicine
Kidney Disease Rehabilitation Center, Beijing Boai Hospital, China Rehabilitation Research Center
Chief Physician: MA Yingchun

Abstract

In clinical practice, it is highly prevalent for elderly individuals with multiple coexisting chronic conditions (also known as "geriatric comorbidities") to develop acute kidney injury (AKI). Early and timely intervention through rehabilitation therapy can significantly enhance patients' quality of life and improve clinical outcomes. This specification is intended to provide guidance for clinical and rehabilitation specialists in managing elderly patients with comorbidities complicated by acute kidney injury.

【Keywords】 Comorbidity; Acute Kidney Injury; Rehabilitation Services; Specification; Group Standard

【CLC Number】 R 36; R 692.5
【Document Code】 A

Introduction

The occurrence of acute kidney injury (AKI) in the context of geriatric comorbidities is a frequent clinical challenge. Given the physiological vulnerability and complex medical profiles of elderly patients, the onset of AKI often leads to a rapid decline in physical function and a high risk of adverse outcomes. Integrating rehabilitation services into the acute and sub-acute management phases is essential. This document establishes a standardized framework for rehabilitation services tailored to this specific population, aiming to bridge the gap between intensive clinical treatment and functional recovery.

1. Clinical Context and Rationale

Elderly patients often present with a cluster of chronic diseases, including hypertension, diabetes, and cardiovascular disorders. When AKI is superimposed on these conditions, the complexity of care increases exponentially. Rehabilitation in this context is not merely an adjunct therapy but a core component of comprehensive care. The primary goals are to prevent the complications of immobility, preserve residual renal function, and facilitate the restoration of activities of daily living (ADL).

2. Assessment and Evaluation

Before initiating rehabilitation, a multidisciplinary assessment is mandatory. This includes:
- Renal Function Monitoring: Tracking serum creatinine, urine output, and electrolyte balance.
- Comorbidity Profiling: Evaluating the stability of concurrent chronic conditions.
- Functional Status: Assessing baseline mobility, muscle strength, and cognitive function.
- Risk Stratification: Identifying potential contraindications to physical activity during the acute phase of AKI.

3. Rehabilitation Interventions

Rehabilitation services should be phased according to the patient's clinical stability:
- Early Mobilization: Implementing passive range-of-motion exercises and bedside sitting as soon as hemodynamic stability is achieved.
- Therapeutic Exercise: Gradually introducing resistance and aerobic training tailored to the patient's tolerance levels to counteract sarcopenia.
- Nutritional Support: Coordinating with dietitians to ensure adequate protein and caloric intake while managing metabolic wastes.
- Psychosocial Support: Addressing the psychological

Abstract

Acute kidney injury (AKI) on the basis of multimorbidity (also known as “geriatric comorbidity”) in elderly individuals is very common in clinical practice. Early and timely intervention with rehabilitation treatment can improve the quality of life and clinical prognosis of patients. This guideline aims to guide clinical and rehabilitation experts to provide guidance for the implementation of rehabilitation for elderly patients with comorbidity and AKI.

Key words: Comorbidities; Acute kidney injury; Rehabilitation services; Standards; Group standards

WANG T T, LIN Z H, MA Y C, et al. Specification of rehabilitation service for elderly patients with comorbidity complicated with acute kidney injury [J]. Chinese General Practice, 2025. [Epub ahead of print] Editorial Office of Chinese General Practice. This is an open access article under the CC BY-NC-ND 4.0 license.

Rehabilitation Intervention Protocols for Patients with Acute Kidney Injury: Covering Critical Care in the ICU, General Ward Hospitalization, and Post-Discharge Recovery

Acute Kidney Injury (AKI) is a clinical syndrome characterized by a rapid decline in renal function, often leading to significant morbidity and mortality. For patients surviving the initial insult, the recovery process is complex and requires a structured approach to rehabilitation. This protocol outlines comprehensive intervention strategies across three distinct phases: the critical care period in the Intensive Care Unit (ICU), the stabilization period in the general ward, and the long-term recovery period following hospital discharge.

1. Rehabilitation During the ICU Critical Phase

In the ICU, the primary goal of rehabilitation is to prevent the complications of prolonged immobilization and "ICU-acquired weakness" while managing the metabolic instability associated with AKI. Early mobilization is a cornerstone of this phase, provided the patient meets hemodynamic stability criteria.

Interventions should focus on passive and active range-of-motion exercises to maintain joint integrity and prevent muscle atrophy. For patients undergoing Renal Replacement Therapy (RRT), rehabilitation timing must be carefully coordinated. Studies suggest that low-intensity bedside cycling or passive stretching during RRT is feasible and may improve local blood flow, potentially enhancing the efficiency of solute clearance. Monitoring vital signs, fluid balance, and electrolyte levels is mandatory before and during any physical intervention to ensure patient safety.

2. Rehabilitation During the General Ward Hospitalization Phase

As patients transition from the ICU to the general ward, the focus shifts toward restoring functional independence and optimizing nutritional status. AKI often results in significant protein-energy wasting; therefore, a personalized nutritional plan—balancing adequate protein intake for muscle recovery with the necessary restrictions to manage residual renal dysfunction—is essential.

Physical therapy in this phase should progress from assisted transfers to independent ambulation. Resistance training can be introduced to counteract the sarcopenia often observed following an acute renal event. Additionally, clinicians should prioritize "nephroprotective" education, teaching patients to avoid nephrotoxic agents (such as certain NSAIDs or contrast media) and to maintain adequate hydration. This period serves as a critical window for multidisciplinary coordination between nephrologists, physiotherapists, and dietitians to prepare the patient for a safe transition to the home environment.

3. Post-Discharge Recovery and Long-term Management

The recovery phase following hospital discharge is vital for preventing the progression of AKI to Chronic Kidney Disease (CKD). Rehabilitation protocols in the outpatient setting emphasize

2 Normative References

The following documents contain provisions which, through normative reference in this text, constitute indispensable provisions of this document.

• GB 24436, General safety requirements for rehabilitation training devices;
• GB/T 42195-2022, Specification for assessment of abilities of older adults;
• Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for Acute Kidney Injury.

3 Terms and Definitions

The following terms and definitions apply to this document. Geriatric multimorbidity refers to the simultaneous occurrence of two or more health conditions in a single elderly individual (including organic diseases, psychological issues, and other problems affecting the health of the elderly) that persist for one year or longer \cite{8-9}. Acute Kidney Injury (AKI) is a clinical syndrome characterized by a rapid decline in renal function over a short period due to various etiologies. It manifests as a decrease in the glomerular filtration rate (GFR), accompanied by the retention of nitrogenous waste products such as creatinine and urea nitrogen, as well as disturbances in fluid, electrolyte, and acid-base balance; severe cases may lead to multi-system complications. According to the 2012 KDIGO Clinical Practice Guidelines, AKI can be diagnosed if any of the following criteria are met: (1) an increase in serum creatinine (SCr) by $\ge 0.3$ mg/dL ($\ge 26.5$ $\mu$mol/L) within 48 hours; (2) a known or presumed increase in SCr to $\ge 1.5$ times the baseline within the prior 7 days; or (3) a urine output of $< 0.5$ mL/kg/h for $\ge 6$ hours.

The staging criteria for renal function in patients with AKI and geriatric multimorbidity (AKI-GC) are presented in Table 1 [TABLE:1].

Serum Creatinine Criteria

Stage 1: An absolute increase in SCr $\ge 0.3$ mg/dL ($\ge 26.5$ $\mu$mol/L) or 1.5 to 1.9 times the baseline value, or a urine output of $< 0.5$ mL/kg/h for 6 to 12 hours.

Stage 2: SCr 2.0 to 2.9 times the baseline value, or a urine output of $< 0.5$ mL/kg/h for $\ge 12$ hours.

Stage 3: An increase in SCr to $\ge 4$ mg/dL ($\ge 353.6$ $\mu$mol/L) or more than 3.0 times the baseline value, or a urine output of $< 0.3$ mL/kg/h for $\ge 24$ hours or anuria for $\ge 12$ hours.

4.1.1 Establishing a Multidisciplinary Integrated Clinical and Rehabilitation Collaborative Group

A multidisciplinary team (MDT) was established, comprising nephrologists, geriatricians, cardiologists, orthopedists, nutritionists, psychiatrists, rehabilitation therapists, pharmacists, and specialized nurses. This collaborative platform integrates clinical medical care, patient education, health counseling, dietary management, exercise training, psychological intervention, and rehabilitative nursing. By leveraging team synergy, the platform facilitates the implementation of comprehensive, holistic interventions.

4.1.2 Personnel Qualifications

Professionals should hold nationally recognized vocational qualifications and have completed at least six months of specialized training in rehabilitation. In centers lacking dedicated rehabilitation physicians or therapists, nephrologists and/or nursing staff should undergo relevant rehabilitation training and obtain the necessary certifications.

4.1.3 Personnel Allocation

For institutions that are currently unable to recruit qualified professional personnel in the short term, it is recommended to establish collaborative partnerships with rehabilitation institutions that meet the necessary requirements. Within the institution, the ratio of rehabilitation intervention personnel to patients should be no less than 1:10.

4.2.1 Functional Assessment Tools

Basic equipment: Height and weight scale, measuring tape, stopwatch, handgrip dynamometer, sphygmomanometer, finger-clip pulse oximeter, Activities of Daily Living (ADL) scale, Quality of Life (QoL) scale, and psychological function assessment scales.

Standard equipment: Geriatric rehabilitation assessment and training system, cardiopulmonary exercise testing (CPET) system, muscle strength assessment and training system, multi-joint isokinetic training and assessment system, body composition analyzer, and static/dynamic balance assessment system.

4.2.2 Common Equipment for Exercise Rehabilitation

Basic equipment: Training mats or yoga mats, foot pedals, dumbbells, sandbags, resistance bands, balance balls, stationary bikes, exercise treadmills, recumbent rehabilitation pedaling bikes, pedometers, or fitness trackers.

Standard equipment: In-hospital exercise software management systems, telemetric exercise ECG monitoring systems, and rehabilitation training equipment (including electric rehabilitation beds, four-limb coordinated training devices, active and passive training devices for upper and lower limbs, core muscle strength training equipment, balance function training equipment, and occupational therapy equipment such as comprehensive hand function training systems), as well as psychological and cognitive rehabilitation training systems. All rehabilitation training equipment must comply with the requirements of GB 24436.

4.2.3 Emergency Equipment

Basic equipment: Cardiac defibrillator, emergency cart equipped with routine emergency medications (including epinephrine, nitroglycerin, dopamine, atropine, etc.), oxygen supply facilities, sphygmomanometers, and electrocardiographs (ECG). Standard equipment: cardiac monitors.

5.1.1 Pre-rehabilitation Assessment

Assessment is a critical component of the clinical management of patients with Acute Kidney Injury-related Geriatric Comorbidity (AKI-GC). The evaluation process should be integrated throughout the entire duration of the patient's diagnosis and treatment. By implementing a continuous cycle of "assessment $\rightarrow$ rehabilitation $\rightarrow$ re-assessment $\rightarrow$ adjustment of the rehabilitation plan $\rightarrow$ further rehabilitation," clinicians can ensure the ongoing improvement and optimization of the quality of rehabilitation therapy for AKI-GC patients.

5.1.2 Clinical Indicator Assessment

5.1.2.1 Medical History: This includes systemic symptoms (such as fever, cough, chest tightness, chest pain, abdominal discomfort, dizziness, headache, urinary frequency, urgency, dysuria, and low back pain); recording of 24-hour fluid intake and output; past medical history (including cardiovascular and cerebrovascular diseases, pulmonary diseases, hypertension, diabetes, tumors, bone and joint abnormalities, and diabetic foot); medication-related history (current and past medications, drug allergies, etc.); previous surgical history; lifestyle and exercise habits; and family history.

5.1.2.2 Physical Examination: This includes height, body weight, waist circumference, blood pressure, heart rate, thoracic and abdominal examinations, lumbar spine assessment, muscle strength and range of motion of the limbs and joints, and peripheral arterial pulses.

5.1.2.3 Laboratory Examinations: These include complete blood count (CBC), urinalysis, blood biochemistry, inflammatory markers, coagulation function, glycated hemoglobin (HbA1c), and B-type natriuretic peptide (BNP).

5.1.2.4 Auxiliary Examinations: These include electrocardiography (ECG), abdominal ultrasound, urinary system ultrasound, post-void residual volume ultrasound, echocardiography, chest CT, and body composition analysis.

5.1.3 Functional Impairment Assessment

5.1.3.1 In accordance with the requirements of GB/T 42195-2022, the functional capacity levels of elderly individuals should be classified, and a capacity assessment report should be generated and maintained in either paper or electronic format.

5.1.3.2 Exercise capacity assessment: Exercise capacity is evaluated using the 6-minute walk test (6MWT), the Timed Up and Go (TUG) test, and the Short Physical Performance Battery (SPPB) protocol.

5.1.3.3 Psychological and cognitive function assessment: Psychological function is assessed using the Hamilton Anxiety/Depression Scale or the Self-Rating Anxiety/Depression Scale. Cognitive function is evaluated using the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA).

5.1.3.4 Activities of Daily Living (ADL) and Quality of Life assessment: Commonly used scales include the Barthel Index, the Functional Independence Measure (FIM), the Functional Activities Questionnaire (FAQ), and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

5.2 Implementation of the Rehabilitation Program

5.2.1 Principles of the rehabilitation program: To facilitate the recovery process for patients with Acute Kidney Injury (AKI) following Geriatric Comorbidity (GC), rehabilitation should be initiated early, timely, and comprehensively. Rehabilitation goals should be established, and phased programs should be developed for the intensive care unit (ICU) critical stage, the general ward hospitalization stage, and the post-discharge recovery stage. Individualized rehabilitation plans must be tailored to the patient based on factors such as age, comorbidities, functional impairments, family support, and educational level.

5.2.2 Determining Rehabilitation Goals

5.2.2.1 During the critical care phase in the ICU, the primary objectives are to maintain systemic physiological functions, promote the recovery of renal function, and ameliorate impairments across physical, psychological, and cognitive domains.

5.2.2.2 During the general ward hospitalization phase, the objectives shift toward facilitating the continued recovery of renal function, preventing and managing complications, and reducing functional dependency.

5.2.2.3 During the post-discharge recovery phase, the objectives are centered on enhancing the patient's quality of life and supporting their successful reintegration into family and social environments.

5.2.3 Rehabilitation Program for AKI-GC Patients in the ICU Critical Phase

5.2.3.1 Critically ill patients with AKI-GC who have no contraindications should receive at least passive rehabilitation therapy. For conscious patients capable of cooperation, it is recommended to transition gradually from combined passive and active rehabilitation to active exercise rehabilitation. Concurrently, rational nutritional strategies should be implemented alongside psychological, cognitive, and speech rehabilitation, as well as rehabilitative nursing, to minimize functional impairment and functional dependence.

5.2.3.2 Timing of Rehabilitation Intervention: Rehabilitation intervention may commence once hemodynamic and respiratory functions have stabilized \cite{13-14}. The recommended criteria are as follows: (1) heart rate 50–120 beats/min; (2) systolic blood pressure 100–160 mmHg (1 mmHg = 0.133 kPa) or mean arterial pressure 65–110 mmHg; (3) respiratory rate $\leq 30$ breaths/min, oxygen saturation $\geq 90\%$, fraction of inspired oxygen ($FiO_2$) $\leq 60\%$, and positive end-expiratory pressure $\leq 10$ cm$H_2O$; (4) during the life-support maintenance phase, support with low-dose vasoactive drugs, such as dopamine $\leq 10$ $\mu$g·kg$^{-1}$·min$^{-1}$ or norepinephrine/epinephrine $\leq 0.1$ $\mu$g·kg$^{-1}$·min$^{-1}$.

Timing of rehabilitation during renal replacement therapy \cite{15-16}: For hemodialysis, rehabilitation should be scheduled 1–2 hours after starting the treatment; for continuous renal replacement therapy (CRRT), rehabilitation should be scheduled 4–6 hours after initiation; for peritoneal dialysis, rehabilitation should occur when the volume of dialysate in the abdomen is $< 500$ mL or during the "dry" phase.

5.2.3.3 Rehabilitation Interventions: A progressive approach from passive to active modalities should be adopted \cite{17-18}. Passive interventions include: passive joint range-of-motion exercises, stretching, functional positioning, tilt-table training, passive bedside cycling, and neuromuscular electrical stimulation. For conscious and cooperative patients, combined active rehabilitation is recommended, including: respiratory training, swallowing training, bedside resistance exercise, active bedside cycling, supine gymnastics, bedside sitting/standing balance training, bedside weight-shift training, assisted walking, functional electrical stimulation (FES), and active exercise combined with FES-assisted circulation.

5.2.3.4 Precautions for Rehabilitation Therapy. (1) Principles of exercise rehabilitation: Start at low intensity, progress gradually, and maintain consistency. When bedbound patients require postural changes, a gradual increase in the angle of passive sitting should be used to avoid orthostatic hypotension, with careful attention paid to protecting vascular access.

(2) Exercise Prescription: Exercise prescriptions should be individualized following the FITT-VP principles: frequency (F), intensity (I), time (T), type (T), volume (V), and progression (P) \cite{7, 19}. For critically ill patients, an exercise intensity corresponding to a Borg Rating of Perceived Exertion (RPE) of 11–13, with a frequency of 1–2 sessions per day and 1–3 sets per session, is most appropriate.

(3) Rehabilitation should be implemented under close monitoring of blood pressure, heart rate, and oxygen saturation. Proper education before exercise, guidance and supervision during exercise, and monitoring of vital signs after exercise are essential to guard against exercise-related adverse events.

(4) Contraindications for exercise rehabilitation: These include uncontrolled hypertension or hypotension, uncorrected acute left heart failure and/or New York Heart Association (NYHA) Class IV chronic heart failure, potentially fatal arrhythmias (including sustained ventricular tachycardia), recent myocardial infarction, unstable angina, severe pericardial effusion, active liver disease, uncontrolled diabetes, severe cerebrovascular disease, peripheral vascular disease, persistent pre-dialysis hyperkalemia, and/or severe metabolic acidosis.

5.2.3.5 Nutritional Strategies: After assessing energy and protein requirements, a caloric intake of 20–30 kcal·kg$^{-1}$·d$^{-1}$ is recommended. In the early stage, low-calorie nutrition should be provided, not exceeding 70% of energy expenditure (EE), followed by a gradual increase to 80%–100% of EE to avoid both underfeeding and overfeeding. For protein intake in AKI-GC patients during critical illness, the recommended protocols are as follows: for patients not receiving renal replacement therapy, start at 0.8–1.0 g·kg$^{-1}$·d$^{-1}$ and gradually increase to 1.3 g·kg$^{-1}$·d$^{-1}$ as tolerated; for patients receiving conventional intermittent renal replacement therapy, 1.0–1.5 g·kg$^{-1}$·d$^{-1}$; and for patients receiving continuous renal replacement therapy or those in a hypermetabolic state, 1.5–1.7 g·kg$^{-1}$·d$^{-1}$.

5.2.3.6 Rehabilitative Nursing: Rehabilitative nursing should be strengthened for bedbound patients, including posture management, prone position sputum drainage, swallowing and dietary care, artificial airway management, and bladder management.

5.2.3.7 Psychological Rehabilitation: Full attention should be paid to the patient's psychological changes and feelings. For conscious patients, rehabilitation goals should be negotiated and agreed upon with the patient to ensure cooperation. When patients cannot actively participate in goal setting, family members or caregivers should be encouraged to participate in the joint formulation and assistance of the rehabilitation management plan for AKI-GC patients. Psychological rehabilitation measures include pharmacological intervention, cognitive behavioral therapy, and music therapy.

5.2.4 Rehabilitation Program for AKI-GC Patients During General Ward Hospitalization

5.2.4.1 Education: Educational content includes daily dietary management for AKI-GC patients, fluid intake and output management, and self-management of AKI comorbidities and complications. It also covers the benefits, risks, and implementation methods of renal rehabilitation, precautions for renal function assessment, psychological adjustment and counseling during rehabilitation, and the utilization of family and social support.

5.2.4.2 Rehabilitation Therapeutic Measures: These measures encompass passive joint range of motion, stretching exercises, proper positioning (reflex-inhibiting postures), tilt-table training, respiratory training, and swallowing training. Additional interventions include bedside resistance exercises, active and passive bedside cycling, isokinetic muscle strength training, supine and standing calisthenics, bedside sitting/standing balance training, and bedside center-of-gravity transfer training. Furthermore, assisted walking, activities of daily living (ADL) training, fine motor hand function training, intermittent pneumatic compression therapy, infrared thermal radiation phototherapy, functional electrical stimulation (FES), active exercise combined with FES-assisted circulation, and psychological, cognitive, speech, and music rehabilitation are utilized.

5.2.4.3 Exercise Rehabilitation Prescription: The basic components of exercise rehabilitation should include a warm-up, the primary exercise session, and a cool-down or stretching phase. Early-stage exercise rehabilitation should combine active and passive movements, with an emphasis on encouraging active participation. Exercise intensity should be maintained at a Borg Rating of Perceived Exertion (RPE) of 11–13. The exercise prescription is developed according to the FITT-VP principles (Frequency, Intensity, Time, Type, Volume, and Progression) as referenced in the Expert Consensus on Exercise Rehabilitation for Adult Patients with Chronic Kidney Disease in China, as shown in [TABLE:2].

5.2.4.4 Nutritional Management: In patients with AKI-GC, the amino acid conversion rate increases over time during the recovery phase and continues into the later stages; therefore, protein intake should be gradually increased to 1.3 g/kg. The optimal energy-to-nitrogen ratio during the AKI process has not yet been definitively established. Meanwhile, electrolyte changes should be closely monitored.

5.2.4.5 Psychological Rehabilitation: Clinicians should employ effective communication skills during doctor-patient interactions to proactively establish a positive therapeutic relationship, ensuring that patients actively cooperate with their rehabilitation treatment. For patients with concurrent psychological dysfunction, group interventions may be employed in addition to pharmacological treatment. This format allows patients to provide mutual support, participate in collective training, and freely exchange information, thereby reigniting their interest in life and facilitating the restoration of their social roles and functions.

5.2.5 Rehabilitation Program for AKI-GC Patients During Post-Discharge Recovery Phase

5.2.5.1 Rehabilitation Principles: Unsupervised outpatient rehabilitation primarily encourages patients to progressively increase their activities of daily living. Outpatient exercise prescriptions should be simple, safe, and sustainable for long-term adherence, with sessions lasting 20–60 minutes, performed 3–5 times per week.

5.2.5.2 Education: To ensure the safety of outpatient rehabilitation, patients and their families must receive exercise-related education before a prescription is issued. This includes instructing patients on how to use the Borg Rating of Perceived Exertion (RPE) scale to determine exercise intensity, understanding safety precautions, and clarifying the supportive, supervisory, and guiding roles of family members during rehabilitation.

5.2.5.3 Outpatient Exercise Rehabilitation Workflow: Blood pressure and pulse should be measured prior to exercise. The exercise venue should be flat and free of obstacles, and sessions should ideally take place 1–2 hours after meals. Patients should begin with 5–10 minutes of warm-up exercises to allow the joints, ligaments, and muscles to adapt, followed by the formal exercise phase. The formal exercise should last at least 20 minutes; if the patient cannot sustain this duration, they may exercise for 5–10 minutes, rest for 3–5 minutes, and then resume. As cardiorespiratory endurance improves, the duration and intensity should be gradually increased to a moderate level. Finally, 5–10 minutes of cool-down exercises should be performed. Resistance training sessions should be separated by at least one day. Recommended exercises include seated leg extensions, semi-recumbent hip flexion, supine straight leg raises, and standing calf raises. Initially, patients should work against their own body weight, gradually progressing to external resistance using elastic bands, sandbags, or dumbbells. Flexibility training should ideally be performed daily. Additionally, patients with AKI-GC may engage in balance training (such as Baduanjin, Tai Chi, or Yoga) 2–3 times per week to reduce the risk of falls. Heart rate and blood pressure should be measured 3–5 minutes after the conclusion of the exercise.

5.2.5.4 Safety Precautions for Outpatient Exercise Rehabilitation: (1) Exercise should be suspended during acute metabolic complications such as severe hypoglycemia or diabetic ketoacidosis; (2) Patients with diabetes or a tendency toward hypoglycemia should monitor finger-prick blood glucose before, during, and after exercise, and keep high-glycemic-index foods readily available; (3) Swimming and weight-bearing exercises should be avoided in the presence of open wounds or unhealed ulcers; (4) Patients should be instructed on how to avoid the Valsalva maneuver, particularly during resistance training; (5) Doctors must be notified if the patient experiences persistent hypotension or other discomfort; (6) Doctors must be notified if blood pressure rises significantly during exercise (systolic blood pressure $\geq 180$ mmHg); (7) The following symptoms post-exercise indicate excessive intensity, requiring a physician to adjust the exercise plan: Persistent fatigue, nausea, or dyspnea; severe fatigue that does not resolve; insomnia; muscle or joint pain that interferes with daily activities; and significant chest tightness or chest pain.

5.2.5.5 Supervision: The implementation of exercise rehabilitation for AKI-GC patients should be monitored through exercise diaries, pedometers, or family accompaniment to encourage patient confidence in their training regimen.

6.1 Assessment Content

Establish a robust and scientific evaluation mechanism for personnel and operations. The assessment criteria can be categorized into three primary indicators: organizational management, operational management, and work effectiveness.

6.1.1 Organizational Management

Organizational management primarily assesses the structural development of the rehabilitation institution. This includes evaluating whether the Multi-Disciplinary Team (MDT) has been established with clearly defined roles and responsibilities, the comprehensiveness of rehabilitation service regulations, the adequacy of staffing levels, and the qualification rates of professional training programs.

Exercise Rehabilitation Prescription for AKI-GC Patients During Hospitalization in the General Ward

Flexibility and Mobility Training

Intensity (I):
Training should be maintained at a Borg Rating of Perceived Exertion (RPE) of 11–13, corresponding to 50%–80% of maximum oxygen consumption ($\text{VO}_{2}\text{max}$).

Type (T):
Exercises should consist of regular, rhythmic, and continuous periodic movements involving large muscle groups. Examples include calisthenics, walking, or supine-position exercises.

Volume (V):
The target energy expenditure is at least 500–1,000 kcal/week, or a step count of no less than 7,000 steps/day. While smaller volumes of exercise may still provide clinical benefits, there is currently a lack of evidence to determine the minimum recommended dose.

Progression (P):
Training should begin at a low intensity, with a gradual and systematic increase in duration, frequency, and intensity. This progressive approach is designed to reach exercise goals while minimizing the risk of adverse events.

6.1.2 Business Management

This section primarily evaluates the completion of rehabilitation service indicators within the institution. Key metrics include the standardization and timeliness of rehabilitation assessments, as well as the implementation rate of individualized rehabilitation treatment plans.

6.1.3 Work Effectiveness

This section primarily assesses the actual outcomes of rehabilitation services, including:

The outcome measures for patients with Acute Kidney Injury (AKI) and Geriatric Comorbidity (GC) include the renal function recovery rate (such as the proportion of patients showing improvement in AKI staging) and the improvement rate of functional impairments (such as the proportion of patients with increased scores on the Short Physical Performance Battery [SPPB] and the Mini-Mental State Examination [MMSE]). Additionally, the evaluation incorporates levels of satisfaction reported by both patients and their families.

Core Evaluation Metrics

In the field of machine learning and deep learning, selecting appropriate evaluation metrics is crucial for accurately assessing model performance. These metrics provide quantitative measures of how well a model generalizes to unseen data and guide the optimization process during training.

Classification Metrics

For classification tasks, the most fundamental metrics are derived from the confusion matrix, which tracks true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN).

• Accuracy: The ratio of correctly predicted observations to the total observations. While intuitive, it can be misleading in cases of class imbalance.
• Precision: The ratio of correctly predicted positive observations to the total predicted positives. It answers the question: "Of all instances labeled as positive, how many were actually positive?"
• Recall (Sensitivity): The ratio of correctly predicted positive observations to all actual positives. It measures the model's ability to find all relevant cases within a dataset.
• F1-Score: The harmonic mean of Precision and Recall. This metric is particularly useful when seeking a balance between Precision and Recall, especially in the presence of uneven class distributions.
• ROC-AUC: The Area Under the Receiver Operating Characteristic curve. It represents the model's ability to discriminate between classes across various threshold settings.

Regression Metrics

In regression analysis, evaluation metrics focus on the residual difference between predicted continuous values and actual ground truth.

• Mean Squared Error (MSE): The average of the squares of the errors. It penalizes larger errors more heavily due to the squaring operation.
• Root Mean Squared Error (RMSE): The square root of the MSE, which brings the metric back to the same units as the target variable.
• Mean Absolute Error (MAE): The average of the absolute differences between predictions and actual values, providing a linear representation of error magnitude.
• R-squared ($R^2$): The coefficient of determination, which indicates the proportion of the variance in the dependent variable that is predictable from the independent variables.

Specialized Metrics

Depending on the specific domain, other specialized metrics may be employed. In natural language processing, metrics such as BLEU or ROUGE are standard for translation and summarization tasks. In computer vision, Mean Average Precision (mAP) and Intersection over Union (IoU) are critical for object detection and segmentation. Selecting the correct core evaluation metric ensures that the model's performance aligns with the practical requirements of the task.

6.2.1 Rehabilitation Standardized Management Rate

Rehabilitation Standardized Management Rate = (Number of patients who completed rehabilitation assessment and intervention according to standards / Total number of AKI-GC patients managed within the year) $\times 100\%$.

6.2.2 Functional Improvement Rate

Functional Improvement Rate = (Number of patients whose exercise capacity or cognitive function improved compared to baseline at follow-up / Total number of AKI-GC patients managed within the year) $\times 100\%$.

6.2.3 Patient Satisfaction Rate

Patient Satisfaction Rate = (Number of patients satisfied with rehabilitation services / Total number of patients participating in the survey) $\times 100\%$.

6.3.1 Multi-dimensional Assessment

The standardization of rehabilitation services is evaluated through various methods, including on-site inspections, medical record audits, and equipment verification. Information systems are utilized to extract critical data, such as rehabilitation assessments and treatment records. Furthermore, independent organizations are commissioned to conduct patient satisfaction surveys or facilitate expert peer reviews.

6.3.2 Dynamic Feedback and Improvement

Assessment results are summarized quarterly to form analysis reports and provide feedback to the team; targeted improvement plans are developed for identified weaknesses, and personnel training is enhanced or operational processes are optimized.

6.4.1 Standardized Process

Develop a unified assessment manual, clarify scoring standards, and form a quality control group to periodically review the accuracy of the assessment results.

6.4.2 Expert Participation

Establish a review panel composed of experts from nephrology, rehabilitation, and geriatrics, and conduct pre-assessment training for all reviewers to ensure consistency in evaluation standards.

6.4.3 Continuous Improvement Mechanism

Establish channels for complaints and suggestions to promptly handle patient feedback, and publish assessment results regularly to incentivize improvements in service quality. Training for all muscle groups and tendons is recommended at least 2–3 times per week. Effective methods include static stretching, dynamic stretching, ballistic stretching, and proprioceptive neuromuscular facilitation (PNF).

This guideline systematically constructs a full-cycle rehabilitation service system for patients with Acute Kidney Injury in Geriatric Comorbidities (AKI-GC). It defines core principles of multidisciplinary collaboration, phased rehabilitation, and individualized intervention, covering rehabilitation assessment, exercise prescription, nutritional support, psychological intervention, and rehabilitation nursing. Furthermore, it establishes scientific evaluation and quality control mechanisms. The formulation and implementation of this guideline will promote the standardization and normalization of rehabilitation services for elderly patients with comorbidities and acute kidney injury, providing an important practical framework for the comprehensive management of AKI within the context of China's aging population.

Lead Drafting Units: Kidney Disease Rehabilitation Center of Beijing Bo'ai Hospital, China Rehabilitation Research Center; Renal Rehabilitation Professional Committee of the Chinese Association of Rehabilitation Medicine.

Lead Authors: Wang Tingting, Lin Zehua, Ma Yingchun (Kidney Disease Rehabilitation Center, Beijing Bo'ai Hospital, China Rehabilitation Research Center); Ao Qiangguo (Department of Nephrology, Second Medical Center of the Chinese People's Liberation Army General Hospital); Bai Yun (Department of Geriatric Nephrology, The First Affiliated Hospital of Nanjing Medical University); Bian Xueyan (Department of Nephrology, Ningbo First Hospital); Cao Pengyu (Department of Nephrology, The Third Affiliated Hospital of Nanjing University); Chen Guanglei (Beidaihe Rehabilitation and Recuperation Center of the PLA Joint Logistic Support Force); Chen Jing (Department of Geriatrics, Zhongnan Hospital of Wuhan University); Chen Limeng (Department of Nephrology, Peking Union Medical College Hospital); Chen Ling (Department of Geriatrics, Zhongnan Hospital of Wuhan University); Chen Menghua (Department of Nephrology, General Hospital of Ningxia Medical University); Chen Yuqing (Department of Nephrology, Peking University First Hospital); Cheng Qingli (Department of Nephrology, Second Medical Center of the Chinese People's Liberation Army General Hospital); Gan Liangying (Department of Nephrology, Peking University People's Hospital); Gao Ping (Department of Nephrology, Zhongnan Hospital of Wuhan University); Guo Minghao (Kidney Disease Hospital, The First Affiliated Hospital of Xinxiang Medical University); Guo Qi (School of Rehabilitation Medicine, Shanghai University of Medicine and Health Sciences); He Qiang (Zhejiang Provincial Hospital of Traditional Chinese Medicine); Hu Zhao (Department of Nephrology, Qilu Hospital of Shandong University); Hui Haipeng (Department of Cardiology, First Medical Center of the Chinese People's Liberation Army General Hospital).

Exercise Prescription Parameters:
- Frequency: Start at 2 sessions/week, gradually increasing to 3–5 sessions/week for aerobic exercise; start at 2 non-consecutive sessions/week, increasing to 3 sessions/week for resistance training. Flexibility training should occur at least 2–3 times per week, involving 8–12 major muscle groups.
- Intensity: 5–10 repetitions at 50%–60% of 1-RM for resistance; stretching should reach a state of tension or slight discomfort. Training for all major muscle groups is recommended, utilizing multi-joint movements and simultaneous agonist/antagonist training. Activities may include bodyweight resistance or the use of tools such as elastic bands and dumbbells.
- Time (T): 10–30 minutes for aerobic sessions. While there is no definitive evidence for an optimal duration for resistance sets, static stretches should be held for 10–30 seconds, though elderly individuals may benefit more from 30–60 seconds.
- Volume: Complete 5–10 repetitions per set, starting with 1 set and gradually increasing to 2–4 sets. The total duration for each flexibility exercise should be 60 seconds.
- Progression: Begin with a low exercise load and progressively increase resistance, repetitions per set, and/or frequency to reach exercise goals while minimizing the risk of adverse events.
Note: 1-RM (One-Repetition Maximum) refers to the maximum load that can be tolerated for a single repetition of a resistance exercise performed with correct technique.

Chinese General Practice

Additional Contributors: Jiang Hongli (Department of Blood Purification, First Affiliated Hospital of Xi'an Jiaotong University); Jiang Xia (Department of Nephrology, Nantong Second People's Hospital); Li Guisen (Department of Nephrology, Sichuan Provincial People's Hospital); Li Guiying (Department of Nephrology, Affiliated Hospital of Hebei University of Engineering); Li Han (Department of Nephrology, Beijing Chaoyang Hospital, Capital Medical University); Li Hong (Blood Purification Center, Hainan General Hospital); Li Yancun (Department of Nephrology, Beijing Daxing District Integrated Traditional Chinese and Western Medicine Hospital); Ma Yingchun (Department of Nephrology, Beijing Bo'ai Hospital, China Rehabilitation Research Center); Mao Huijuan (Department of Nephrology, Jiangsu Province Hospital); Pei Huaying (Department of Nephrology, Second Hospital of Hebei Medical University); Peng Hongying (Department of Nephrology, Baiyun Hospital Affiliated to Guizhou Medical University); Shen Lin (Department of Geriatric Cardiovascular Medicine, Qilu Hospital of Shandong University); Shen Ying (Department of Nephrology, The First People's Hospital of Yunnan Province); Su Haihua (Department of Endocrinology and Nephrology, CNOOC Bohai Oilfield Hospital, Peking University Healthcare); Sun Fuyun (Department of Nephrology, Cangzhou Central Hospital); Tang Ying (Department of Nephrology, Third Affiliated Hospital of Southern Medical University); Tian Na (Department of Nephrology, General Hospital of Ningxia Medical University); Wang Caili (Department of Nephrology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology); Wang Jiaying (Department of Nephrology, Suzhou Science and Technology City Hospital); Wang Jing (Department of Nephrology, Luohu District Traditional Chinese Medicine Hospital, Shenzhen); Wang Song (Department of Nephrology, Peking University Third Hospital); Xia Peng (Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences); Xie Ying (Department of Rehabilitation Medicine, Beijing Friendship Hospital, Capital Medical University); Xing Guangqun (Department of Nephrology, West Coast Campus, Affiliated Hospital of Qingdao University); Xu Jinsheng (Department of Nephrology, Fourth Hospital of Hebei Medical University); Yang Zhenhua (Department of Nephrology, First Affiliated Hospital of Guangxi Medical University); Yao Li (Department of Nephrology, First Affiliated Hospital of China Medical University); Ye Wenling (Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences); Yong Zhenzhu (Department of Geriatric Nephrology, The First Affiliated Hospital of Nanjing Medical University); Yu Chen (Department of Nephrology, Tongji Hospital Affiliated to Tongji University); Zhang Aihua (Department of Nephrology, Xuanwu Hospital, Capital Medical University); Zhang Dongliang (Department of Nephrology, Beijing Jishuitan Hospital); Zhang Guojuan (Department of Nephrology, Beijing Tongren Hospital, Capital Medical University); Zhang Xinzhou (Department of Nephrology, Shenzhen People's Hospital); Zhang Yue (Department of Nephrology, Peking University Shenzhen Hospital); Zhao Ban (Department of Nephrology, Beijing Hospital); Zhao Jiahui (Department of Nephrology, Second Medical Center of the Chinese People's Liberation Army General Hospital); Zhao Weihong (Department of Geriatric Nephrology, The First Affiliated Hospital of Nanjing Medical University); Zhao Xiaoyi (Department of Nephrology, Affiliated Hospital of Chifeng University, Inner Mongolia); Zhao Yingying (Department of Nephrology, Rheumatology and Immunology, Second Affiliated Hospital of Zhengzhou University); Zhao Zhanzheng (Department of Nephrology, First Affiliated Hospital of Zhengzhou University); Zhong Aimin (Department of Nephrology, Jiangxi Provincial People's Hospital); Zhong Hongbin (Department of Nephrology, Xiamen Fifth Hospital); Zhou Yun (Department of Nephrology, First Hospital of Shanxi Medical University).

The authors declare no conflicts of interest.

References

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Chinese Expert Consensus on the Management of Multimorbidity in Older Adults (2023)

Zhu Minglei, Liu Xiaohong, Dong Birong, et al.
Chinese Journal of Clinical Healthcare, 2023, 26(5): 577-584.

1. Introduction

With the intensification of global population aging, the health of older adults has become a significant public health challenge. Multimorbidity, defined as the co-existence of two or more chronic conditions in a single individual, is highly prevalent among the elderly population. Unlike single-disease models, multimorbidity involves complex interactions between diseases, treatments, and psychosocial factors, often leading to polypharmacy, functional decline, reduced quality of life, and increased healthcare costs. To standardize the clinical management of older patients with multimorbidity in China, this expert consensus was developed based on the latest international guidelines and clinical evidence, tailored to the specific characteristics of the Chinese healthcare system.

2. Definition and Epidemiology of Multimorbidity

Multimorbidity in older adults refers to the simultaneous presence of two or more chronic medical conditions in an individual aged 60 years or older. These conditions include not only traditional chronic non-communicable diseases (such as hypertension, diabetes, and coronary heart disease) but also geriatric syndromes (such as frailty, sarcopenia, and cognitive impairment), infectious diseases with chronic courses (such as HIV/AIDS or hepatitis), and mental health disorders.

Epidemiological data indicate that the prevalence of multimorbidity increases significantly with age. In China, studies suggest that over 70% of adults aged 60 and older suffer from multimorbidity. The complexity of these cases necessitates a shift from a disease-centered medical model to a patient-centered, integrated care model.

3. Core Principles of Management

The management of multimorbidity in older adults should adhere to the following core principles:

1. Patient-Centered Care: Management plans must prioritize the patient's personal goals, preferences, and values. Decisions should be made through a shared decision-making process involving the patient, their family, and a multidisciplinary team.
2. Holistic Assessment: Beyond diagnosing specific diseases, clinicians must conduct a Comprehensive Geriatric Assessment (CGA) to evaluate physical function, cognition, psychological state, and social support.
3. Prioritization of Interventions: In the presence of multiple conditions, interventions should focus on those that most significantly impact the patient's quality of life and functional independence.

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Multidisciplinary Decision-Making Model for Declining Exercise Capacity in Older Adults

Geriatrics Branch of the Chinese Medical Association

Introduction

As the global population ages, maintaining physical function and independence in older adults has become a critical public health priority. Exercise capacity is a vital indicator of health status and quality of life in the elderly. A decline in exercise capacity is not merely a natural consequence of aging but is often a precursor to frailty, disability, and increased mortality. Given the complex interplay of physiological, psychological, and social factors contributing to this decline, a multidisciplinary approach is essential for effective assessment and intervention. This consensus document outlines a multidisciplinary decision-making model designed to standardize the clinical management of declining exercise capacity in older adults.

1. Definition and Clinical Significance

Exercise capacity refers to an individual's ability to perform physical activities that require aerobic metabolism, muscular strength, and coordination. In older adults, a decline in this capacity is characterized by reduced walking speed, diminished muscle strength, and decreased endurance.

Clinically, monitoring exercise capacity allows for the early identification of "pre-frail" states. Early intervention can delay the onset of functional dependence, reduce the incidence of falls, and alleviate the burden on healthcare systems. Therefore, establishing a systematic decision-making model is paramount for geriatric care.

2. The Multidisciplinary Team (MDT) Composition

Effective management of exercise capacity requires a coordinated effort from various specialists. The core multidisciplinary team should include:

• Geriatricians: To manage comorbidities, polypharmacy, and overall health coordination.
• Rehabilitation Physicians and Physical Therapists: To design and supervise individualized exercise prescriptions and physical therapy.
• Nutritionists: To address malnutrition and sarcopenia through dietary optimization.
• Psychologists/Psychiatrists: To manage depression, anxiety, and cognitive impairment that may hinder physical activity.
• Nurses and Social Workers: To provide patient education, monitor adherence, and address social determinants of health.

3. Assessment Framework

The decision-making process begins with a comprehensive geriatric assessment (CGA). This multidimensional diagnostic process determines an older person's medical, psychological, and functional capabilities.

3.1 Physical Function Assessment

Standardized tools should be used to quantify exercise capacity:
- Gait Speed: Often measured over a 4-meter or 6-meter distance.
- Handgrip Strength: A reliable measure of overall muscle strength.

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(Received: 2025-06-18; Revised: 2025-09-01) (Editor: JIA Meng-meng)