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 care¹. 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 globally¹⁵.

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 uncommon¹⁶. 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.

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 subjects¹⁸.

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/1.73m², respectively¹⁹. 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 symptoms²⁰. Based on a previous study²⁰, a KCL score of ≥ 8 points was considered as having frailty.

Patients were administered a study questionnaire that was comprised of the following questions:

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.

Of the 285 participants, 204 (71.6%) reported having received PA or exercise advice from healthcare professionals, whereas 81 (28.4%) did not (Fig. 4A). 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. 4B).

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 experts¹³. 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 prognosis²³, 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 Beam³² 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-up³⁶, and outpatient time constraints³⁶. 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 tolerance³⁷, fatigue³⁸, fear of falling³⁹, cognitive decline⁴⁰, psychological distress⁴¹, and limited social support⁴², 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.

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.