Feasibility and effectiveness of pre-emptive rehabilitation in persons approaching dialysis (PREHAB)

Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review

Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.

Implementing a resistance training programme for patients on short daily haemodialysis: A feasibility study

BACKGROUND

Kidney failure patients receiving haemodialysis experience protein-energy wasting, muscle mass loss and physical function impairment. Intradialytic exercise interventions seem to modify these features, but they are often not implemented as a clinical routine.

OBJECTIVE

To investigate the feasibility of implementing a supervised intradialytic resistance training programme as a clinical routine for patients receiving short daily haemodialysis.

DESIGN

A prospective longitudinal study.

PARTICIPANTS

Eighteen patients in a supervised intradialytic resistance training programme for 8 months.

MEASUREMENTS

It consisted of a warm-up, lower- and upper-limb resistance exercises and a cool-down. Patients performed the resistance training during the first half of haemodialysis, twice a week, supervised by exercise physiologists and physiotherapists. The feasibility was assessed by the total and partial adherences, the reasons for refusing or for not exercising and the intradialytic complications.

RESULTS

From a total of 953 potential exercise sessions, 759 were performed, with a 79.6% adherence rate. In the first 9 weeks, the adherence rate was 86.6% and the lowest rate was in the 19-27 weeks (73.5%). The main intradialytic complication during exercise sessions was hypotension (n = 31; 4.1%). The highest number of complications was reported during the first 9 weeks (n = 27; 9.1%). The main reasons for refusing or for not performing the intradialytic exercise sessions were clinical complications previous to exercise time (n = 63; 32.5%) and self-reported indisposition (n = 62; 32.0%).

CONCLUSIONS

The intradialytic resistance training programme, supervised by exercise physiologists and physiotherapists, had very low complications, achieved a high long-term adherence rate and showed to be feasible as a clinical routine for patients receiving short daily haemodialysis.

Effect of Resistance Exercise Plus Cholecalciferol on Nutritional Status Indicators in Adults With Stage 4 Chronic Kidney Disease

OBJECTIVE

Decreased serum concentrations of 25-hydroxyvitamin D (25(OH)D) affect people with chronic kidney disease (CKD); lower concentrations of 25(OH)D have been associated with decrease in nutritional status indicators. On the other hand, muscle resistance exercise has improved the nutritional status of patients with CKD.The aim of this study was to evaluate the effect of resistance exercise and dietary supplementation with cholecalciferol on nutritional status indicators in adults with stage 4 CKD.

METHODS

Patients with an estimated glomerular filtration rate between 15 and 29 mL/min/1.73 m² in an open-label clinical trial were followed for 12 weeks. The intervention group received exercise resistance training sessions three times per week with oral cholecalciferol supplementation each day. The control group only received standard medical care. The outcomes were anthropometric measurements, handgrip strength, and bioelectrical impedance analysis.

RESULTS

Thirty-nine patients of a median age of 48 (36-52) years had an estimated glomerular filtration rate of 21.8 ± 6.5 mL/min/1.73 m². A total of 57.5% of the patients were women. In 41% of the patients, the etiology of CKD was diabetes. After 12 weeks, in the intervention group, the adherence to the resistance training was 77%, and the adherence to the supplementation with cholecalciferol was 96.2%. Significant improvements in 25(OH)D serum concentrations and in handgrip strength were detected in the intervention group (P < .05). In the control group, a decrease in 25(OH)D serum concentrations and a loss in handgrip strength were observed, although the difference was not statistically significant. Anthropometrics and biochemical and dietary indicators, but not bioelectrical impedance data, exhibited changes.

CONCLUSION

Supplementation with cholecalciferol improves serum concentrations of 25(OH)D and, when combined with resistance exercise, improved muscle function as measured by handgrip strength in a study of patients with CKD not on dialysis.