Comparative efficacy of different exercise modalities on renal function and glycemic control in patients with non-dialysis diabetic kidney disease: a systematic review and network meta-analysis

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Abstract

OBJECTIVE: To evaluate the comparative efficacy and safety of structured exercise modalities on renal function and glycemic control in non-dialysis diabetic kidney disease (DKD). DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Six databases (PubMed, Embase, Cochrane CENTRAL, Web of Science, CNKI, Wanfang) were searched from inception to July 15, 2026. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized controlled trials (RCTs) evaluating structured exercise (aerobic, resistance, combined, or mind-body) versus usual care or an active comparator in adults with non-dialysis DKD (duration ≥4 weeks). OUTCOME MEASURES: Renal endpoints were estimated glomerular filtration rate (eGFR) and urinary albumin excretion (UAE); glycemic endpoints were glycated hemoglobin (HbA1c) and fasting blood glucose (FBG). RESULTS: Twenty RCTs (1,746 patients) were included. Compared with usual care, resistance training (RT) was the sole modality significantly increasing eGFR (mean difference [MD] 11.36 mL/min/1.73 m², 95% CI 4.47 to 18.25; low certainty) and outperforming aerobic training (MD 8.61, 2.22 to 15.00). Mind-body exercise (MBE) was the only intervention significantly reducing UAE (standardized mean difference -1.41, -2.67 to -0.16; low certainty). For glycemic regulation, RT (MD -1.65%), aerobic training (MD -1.07%), and combined training (CT; MD -0.70%) significantly lowered HbA1c (all low certainty). Significant FBG reductions occurred only with RT (MD -1.78 mmol/L; low certainty) and CT (MD -1.71 mmol/L; moderate certainty). In sensitivity analyses, RT's eGFR benefit lost significance after excluding high-risk trials (MD 8.24, -1.17 to 17.64), and CT's HbA1c reduction was attenuated in pure-exercise models (MD -0.60%, -1.39 to 0.19). Subgroup analyses showed CT uniquely sustained FBG reductions across short-term (≤12 weeks: MD -1.50) and longer-term (>12 weeks: MD -2.39) regimens. Structured safety was monitored in only five trials (25.0%): three reported mild, transient events without serious harm, while two explicitly declared zero adverse events. Thus, current evidence is insufficient to draw definitive conclusions regarding comparative safety. CONCLUSIONS: Structured exercise confers distinct adaptations in non-dialysis DKD. Combined training provides a reliable foundation for sustained glycemic management, while mind-body exercise represents a viable strategy for albuminuria. Resistance training's apparent renal benefit warrants caution due to fragility against bias. Prescriptions should be individualized rather than seeking a single optimal modality. Given the sparse monitoring of adverse events, comparative clinical safety cannot be definitively established and mandates routine surveillance. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420261489091.

Abstract as published, via PubMed.