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Objective: People with nondialysis-dependent chronic kidney disease (CKD) and renal transplant recipients (RTRs) have compromised physical function and reduced physical activity (PA) levels. Whilst established in healthy older adults and other chronic diseases, this association remains underexplored in CKD. We aimed to review the existing research investigating poor physical function and PA with clinical outcome in nondialysis CKD. Data sources: Electronic databases (PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials) were searched until December 2017 for cohort studies reporting objective or subjective measures of PA and physical function and the associations with adverse clinical outcomes and all-cause mortality in patients with nondialysis CKD stages 1-5 and RTRs. The protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42016039060). Review methods: Study quality was assessed using the Newcastle-Ottawa Scale and the Agency for Healthcare and Research Quality (AHRQ) standards. Results: A total of 29 studies were included; 12 reporting on physical function and 17 on PA. Only eight studies were conducted with RTRs. The majority were classified as 'good' according to the AHRQ standards. Although not appropriate for meta-analysis due to variance in the outcome measures reported, a coherent pattern was seen with higher mortality rates or prevalence of adverse clinical events associated with lower PA and physical function levels, irrespective of the measurement tool used. Sources of bias included incomplete description of participant flow through the study and over reliance on self-report measures. Conclusions: In nondialysis CKD, survival rates correlate with greater PA and physical function levels. Further trials are required to investigate causality and the effectiveness of physical function and PA interventions in improving outcomes. Future work should identify standard assessment protocols for PA and physical function.

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9 Shuman W'1P. The Fpoor quality of early evaluations of MNIR imaging: a reply.

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Thrombocytopenia is unusual in sickle cell disease. We present the case of a child with homozygous sickle cell disease who experienced life-threatening thrombocytopenia during a prolonged and disabling vasoocclusive episode. Irreversibly sickled cells were conspicuously absent from the peripheral blood at presentation and during the subsequent protracted illness. These observations illustrate the pathophysiology of the intravascular events during vasoocclusive crisis and provide indirect evidence for the consumption of both platelets and irreversibly sickled cells at sites of infarction.

Chronic Kidney Disease (CKD) is a long-term progressive condition affecting 10-15% of people. The overlap of diabetes, hypertension and CKD in an aging population means that prevalence will only increase. CKD increases the risk of all-cause mortality, secondary to the elevated cardiovascular risk. It also significantly affects the patients' ability to engage in functional activities and their quality of life. The evidence base suggests that exercise has the capacity to improve symptom burden, functional ability and mental health. The majority of the patient population are pre-dialysis yet previous research has concentrated on dialysing patients. This review will focus on the patient group not requiring renal replacement therapy (non-RRT) as this is an area where further work is urgently needed. A large majority of people with CKD tend to be inactive despite emerging guidelines emphasising the positive effect of exercise for both people with chronic disease and healthy populations. This paper will review the evidence to support exercise to improve outcomes and quality of life and report on common barriers that patients experience and advocate the need for supported exercise interventions to help patients become more active and gain the potential resultant health benefits.

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