Efficacy and safety of intradialytic exercise in haemodialysis patients: a systematic review and meta-analysis

Comparison of the efficacy of intradialytic core stabilization and aerobic exercises for hemodialysis patients: randomized controlled single-blind study

PURPOSE

This study was performed to investigate and compare the effects of intradialytic core stabilization and aerobic exercises on physical performance, fatigue, quality of life and dialysis adequacy.

MATERIALS AND METHODS

The study involved 39 individuals on hemodialysis randomized into two groups: aerobic exercise (AE, n = 20) and core stabilization (CSE, n = 19). Over 8 weeks, the AE group performed pedal ergometer exercises, while the CSE group performed 4-phase core stabilization exercises. Physical performance (five times sit to stand test, 2-min step test), quality of life (Kidney Disease Quality of Life-36; KDQOL-36), fatigue levels (Piper Fatigue Scale), and dialysis adequacy (Kt/V and URR) were assessed.

RESULTS

After training, a significant improvement was observed in the physical performance, fatigue levels, and some parameters of KDQOL-36 of the patients (p < 0.05). However, no significant changes were observed in dialysis adequacy indicators (Kt/V and URR) (p > 0.05). When the amount of development obtained in both treatment groups is compared, kidney disease burden only in the subparameter of KDQOL-36 was statistically significantly improved in the CSE group compared to the AE group (p < 0.05).

CONCLUSIONS

According to the results of the study, intradialytic core stabilization exercises appear to have similar effects to aerobic exercises and can be performed by HD patients.

The Effect of Intradialytic Aerobic Exercise on Dialysis Parameters and Fatigue in Hemodialysis Patients: A Non-randomized Interventional Study

Introduction Hemodialysis is the standard treatment for end-stage renal disease. However, patients receiving hemodialysis can become less active as a result of treatment, resulting in the accumulation of waste products. Intradialytic exercise improves the clearance of urea and creatinine by opening up vascular beds. Materials and methods We conducted a non-randomized interventional study to evaluate the effect of intradialytic aerobic exercise on dialysis parameters and fatigue among 295 hemodialysis patients selected through consecutive sampling (control group, n=147; experimental group, n=148) from two tertiary care centers. Baseline data on background variables and pre-test dialysis parameters (e.g., blood urea, creatinine, potassium, and hemoglobin levels) were assessed in both groups. Following connection to the hemodialysis machine, participants in the experimental group engaged in 15 minutes of intradialytic aerobic exercise per two hours of dialysis for a total of eight weeks, besides receiving routine care, compared to those in the control group. Post-test dialysis parameters were assessed for both groups at the end of the eighth week. The collected data were analyzed and tabulated using SPSS (IRB Inc., Armonk, New York). Results Intradialytic exercise led to significant improvements in post-test blood urea, creatinine, and fatigue in the experimental group (p<0.001). However, post-test serum potassium and hemoglobin levels remained relatively unchanged. Conclusion This study demonstrates the benefits of intra-dialytic aerobic exercise as a safe complementary therapy for a large population of dialysis patients, leading to better patient outcomes.

The role of exercise training on cardiovascular risk factors and heart disease in patients with chronic kidney disease G3-G5 and G5D: A Clinical Consensus Statement of the European Association of Preventive Cardiology (EAPC) of the ESC and the European Association of Rehabilitation in Chronic Kidney Disease (EURORECKD)

Cardiovascular (CV) morbidity and mortality is high in patients with chronic kidney disease (CKD). Most patients reveal a high prevalence of CV risk factors such as diabetes or arterial hypertension and many have manifest cardiovascular disease (CVD), such as coronary artery disease and chronic heart failure with an increased risk of clinical events including sudden cardiac death. Diabetes mellitus and hypertension contribute to the development of CKD and the prevalence of CKD is in the range of 20%-65% in diabetic and 30%-50% in hypertensive patients. Therefore, prevention and optimal treatment of CV risk factors and comorbidities are key strategies to reduce CV risk and improve survival in CKD. Beyond common CV risk factors, patients with CKD are often physically inactive and have low physical function leading to subsequent frailty with muscle fatigue and weakness, sarcopenia and increased risk of falling. Consequently, the economic health burden of CKD is high, requiring feasible strategies to counteract this vicious cycle. Regular physical activity and exercise training have been shown to be effective in improving risk factors, reducing CVD and reducing frailty and falls. Nonetheless, combining exercise training and a healthy lifestyle with pharmacological treatment is not frequently applied in clinical practice. For that reason, this Clinical Consensus Statement reviews the current literature and provides evidence-based data regarding the role of exercise training in reducing CV and overall burden in patients with CKD. The aim is to increase awareness among cardiologists, nephrologists, and health care professionals of the potential of exercise therapy in order to encourage implementation of exercise training in clinical practice, eventually reducing CV risk and disease, as well as reducing frailty in patients with CKD G3 to G5D.

Effect of Exercise on Fatigue in Patients Receiving Maintenance Hemodialysis Treatment: A Systematic Review and Network Meta-analysis

OBJECTIVE

This study aimed to evaluate the effect of different exercises for improving fatigue in maintenance hemodialysis patients.

DESIGN

PubMed, Embase, Web of Science, Cochrane, PEDro, CNKI, VIP, Wanfang data, CBM, and CINAHL were conducted from the establishment of the database to July 2023. We independently screened the literature, evaluated the quality, analyzed the data using Stata 15.0, and performed subgroup analysis on intervention time and exercise intervention adherence.

RESULTS

Twenty-three studies were analyzed, with 1867 patients and nine interventions. Based on the surface under cumulative ranking curves and pairwise comparisons effects, overall long-term, short-term, and exercise intervention adherence >90% effects have all presented that during dialysis aerobic-resistance combined exercise was ranked as the most effective compared with routine care (surface under cumulative ranking curves = 83.9%, standardized mean difference = -1.45, 95% CI = -2.23 to -0.67; surface under cumulative ranking curves = 85.9%, standardized mean difference = -1.38, 95% CI = -2.24 to -0.52; surface under cumulative ranking curves = 86.6%, standardized mean difference = -1.54, 95% CI = -2.58 to -0.49; surface under cumulative ranking curves = 83.6%, standardized mean difference = -1.45, 95% CI = -2.25 to -0.66, respectively), followed by interdialytic period muscle relaxation exercise, interdialytic period aerobic-resistance combined exercise, interdialytic period aerobic exercise, and interdialytic period Baduanjin.

CONCLUSIONS

Dialysis aerobic-resistance combined exercise may be considered in practice when resources allow. However, high-quality, multicenter, and large-sample randomized control trials must further verify this conclusion.

Comparison of intradialytic continuous and interval training on hemodynamics and dialysis adequacy: A crossover randomized controlled trial

AIM

Circulating blood volume (BV) during exercise changes depending on the intensity and duration, and post-exercise hypotension is observed after continuous exercise. We investigated the safety and efficacy of both interval and continuous IDE at anaerobic threshold (AT) levels with respect to hemodynamic stability and dialysis efficiency.

METHODS

In this crossover randomized controlled trial, 16 patients on haemodialysis were subjected to three trial arms, including non-IDE, interval-IDE, and continuous-IDE arms. Systolic blood pressure (SBP), BV, and ultraviolet absorbance - an indicator of dialysis efficiency - were continuously measured, and each change was compared between the three arms by two-way analysis of variance.

RESULTS

Continuous IDE decreased SBP from post-exercise to the end of dialysis compared with baseline (pre 142.8 ± 19.0 vs. post 127.5 ± 24.5 mmHg, p = .02), whereas interval IDE maintained better SBP levels post-exercise (pre 139.9 ± 17.1 vs. post 140.1 ± 15.8 mmHg, p = 1.0) than continuous IDE (non-IDE 133.2 ± 19.9 vs. interval 140.1 ± 15.8 vs. continuous 127.5 ± 24.5 mmHg, p = .04). Moreover, interval IDE caused less tiredness and few symptoms (p < .05), despite reaching higher intensity than continuous IDE (p = .001). The BV of each IDE arm decreased during exercise and recovered post-exercise to the same level as non-IDE. Ultraviolet absorbance was not different between each arm (p = .16).

CONCLUSION

AT-level interval IDE maintains better hemodynamic stability from post-exercise to the end of dialysis and may represent a novel approach that can be effectively performed with fewer symptoms.

Effect of Intradialytic Exercise on Cardiovascular Outcomes in Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

Key Points

Individuals receiving hemodialysis have high rates of cardiovascular disease not explained by traditional cardiovascular risk factors. Intradialytic exercise improves cardiovascular outcomes, including arterial resistance, BP, and heart rate variability. Clinicians should consider including intradialytic aerobic exercise programs in hemodialysis care to supplement broader treatment plans.

Background

Cardiovascular disease is the leading cause of death among people with kidney failure on hemodialysis, for whom improving cardiovascular health is a research priority. Intradialytic myocardial stunning is common and associated with adverse cardiovascular events. Intradialytic exercise may mitigate intradialytic myocardial stunning and improve cardiovascular structure and function. This systematic review investigated the effect of intradialytic exercise on cardiovascular outcomes in adults undergoing maintenance hemodialysis (PROSPERO CRD42018103118).

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE, Embase, Cochrane CENTRAL, SportDiscus, and PEDro databases from 1960 until June 2022, for randomized and nonrandomized studies investigating the effect of intradialytic exercise programs on objective cardiovascular outcomes, prespecified as primary or secondary outcomes. The primary outcome was arterial resistance.

Results

Of 10,837 references identified, 32 met eligibility criteria. These studies investigated the effect of intradialytic exercise on arterial resistance (eight studies), BP (20 studies), myocardial structure and function (seven studies), endothelial function (two studies), sympathetic overactivity (nine studies), biomarkers of cardiac injury (three studies), and cardiovascular hospitalization and mortality (two studies). Most studies used aerobic exercise as the intervention and usual care (no exercise) controls. Meta-analysis of intradialytic exercise versus usual care resulted in a statistically significant reduction in arterial resistance measured by pulse wave velocity with mean difference −1.63 m/s (95% confidence interval, −2.51 to −0.75). Meta-analyses for diastolic BP, left ventricular ejection fraction, and low-frequency/high-frequency ratio measure of heart rate variability also showed statistically significant improvements with exercise. There was no significant difference in change in systolic BP, augmentation index, and left ventricular mass index between groups.

Conclusions

Intradialytic exercise programming resulted in a clinically meaningful improvement to pulse wave velocity, a component of arterial resistance. Improvements in several physiologic measures of cardiovascular health, including diastolic BP, left ventricular ejection fraction, and heart rate variability measured by the low-frequency/high-frequency ratio were also observed. The effects of intradialytic exercise on major adverse cardiovascular events remains uncertain.

Home-based exercise in dialysis patients with end-stage renal disease: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Lack of exercise may reduce the quality of life, physical capability, and functional capability of dialysis patients. Home-based exercise seems to be a desirable form of low-cost intervention. But the effectiveness of this intervention in the dialysis population is still unclear. The purpose of this meta-analysis is to provide effective evidence to determine the impact of home-based exercise on functional capacity, physical capacity, muscular strength, biochemical parameters, and health-related quality of life among dialysis patients with end-stage renal disease (ESRD).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to May 2023, to identify potential randomized controlled trials (RCTs) assessing the effectiveness of home-based exercise in dialysis patients with ESRD. Two independent reviewers selected studies, extracted data, and assessed the risk of bias using the Cochrane tool. Evidence summary using fixed or random effects for meta-analysis.

RESULTS

Twelve RCTs including 1008 dialysis patients met the inclusion criteria. The meta-analysis showed significant effects of home-based exercise on physical capacity. Seven studies reported the results of the 6-min walking test, compared with short-term (0-3 months) home-based exercise (P = 0.76), long-term (3-6 months) interventions (P < 0.001) can significantly improve the results of the 6-min walking test. The results showed that home-based exercise did significantly improve patients' VO2 peak (P = 0.007). Compared with center-based exercise or usual care, home exercise did not significantly improve handgrip strength, quality of life or CRP and other biochemical parameters (P > 0.05).

CONCLUSION

The results showed that long-term home-based exercise can improve walking ability. In addition, home-based exercise had the benefit on the VO2 peak of ESRD patients receiving dialysis patients. However, there was no statistically significant difference in handgrip strength, health-related quality of life, CRP, and other biochemical parameters.

Logistic regression analysis of risk factors for hematoma after autologous arteriovenous fistula in hemodialysis patients

To determine the risk factors and nursing countermeasures for post-operative hematoma in hemodialysis patients with autogenous arteriovenous fistula by logistic regression analysis. A retrospective analysis of 240 chronic hemodialysis patients admitted to our hospital from January 2019 to October 2022 was performed. Physical and vascular examinations of the patients were performed by surgeons. Continuous care measures were implemented for all patients. The patient serum creatinine (Scr) and blood urea nitrogen (BUN) were measured on the day of inclusion and after the implementation of care measures. Self-management scales were used to analyze patients' self-management. Fatigue symptoms were assessed using the Fatigue Scale 14. The WHO Quality of Life Scale (WHOQOL-BREF score) was used to assess patients' quality of life. Self-Rating Depression Scale and Self-Rating Anxiety Scale (SAS) were used to assess negative affect. Treatment compliance was assessed according to 3 levels: complete compliance, compliance, and noncompliance. In all, 240 patients underwent 240 initial and 48 repeat procedures; 18 of the 240 patients experienced fistula failure, with an overall success rate of 92.5% (222/240). There were no significant differences in renal function, self-management, General Self-Efficacy Scale, fatigue symptom scores, and WHOQOL-BREF scores between the postoperative hematoma group and no-hematoma group before the continuous care. After continuous care, renal function, self-management, General Self-Efficacy Scale, fatigue symptom scores, and WHOQOL-BREF scores were better in the postoperative no-hematoma group than in the hematoma group, and the difference was statistically significant (P < .05). Logistic regression analysis of risk factors for postoperative hematoma showed that elevated Scr and BUN levels, decreased self-management and SAS scores and poor treatment compliance were independent risk factors for postoperative hematoma in hemodialysis patients with autologous arteriovenous fistulas (P < .05). Elevated Scr levels, elevated BUN levels, decreased self-management scores, decreased SAS scores, and poor treatment compliance were independent risk factors for postoperative hematoma in hemodialysis patients with autogenous arteriovenous fistulas. By providing continuous care to hemodialysis patients based on timing theory, the negative emotions can be alleviated and the self-efficacy, quality of life, and treatment compliance of the patients can be improved.

Differences in the purpose of exercise between hemodialysis patients who continued or dropped out of exercise programs: a multicenter cohort study

BACKGROUND

Selecting suitable exercise goals is crucial for fostering adherence to, and maintenance of, exercise therapy. We aimed to evaluate the variance in exercise objectives between individuals who continued and those who dropped out of a 6-month intradialytic exercise program by analyzing an open-ended questionnaire administered to patients undergoing hemodialysis.

METHODS

The study consisted of outpatients (n = 541; mean age, 70 years) undergoing maintenance hemodialysis, who had been informed of an intradialytic exercise program and voluntarily agreed to participate. The primary outcome was the exercise purpose. The difference in exercise purpose was quantitatively analyzed between the exercise continuation and dropout groups. A co-occurrence network was created and concepts were constructed. The basic attributes were compared using chi-squared and independent t-tests.

RESULTS

Over 6 months, 154 patients (28.5%) dropped out of the intradialytic exercise program. Concepts related to the goals of the program were: (1) physical function and condition, (2) addressing limitations, (3) maintaining daily life activities, and (4) physical condition recognition. Co-occurrence network analysis showed that the exercise continuation group established their objectives based on the health benefits of exercise, and proactively set goals rooted in comprehending their current issues and problems. The dropout group tended to perceive treatment passively as an extension of daily clinical practice, rather than actively formulating exercise objectives.

CONCLUSION

The exercise objectives of those who continued the exercise program differed from those who dropped out. Patients in the exercise continuation group set more affirmative and specific exercise objectives, whereas those in the dropout group set more passive and abstract exercise objectives.

The impact of aerobic exercise on health-related quality of life among patients undergoing maintenance hemodialysis

To investigate the effect of exercise on cardiopulmonary function and the life quality of maintenance hemodialysis patients. Eighty-four patients who underwent maintenance hemodialysis treatment for more than 3 months were randomly divided into experimental group and control group. The general data and nutritional indexes, including hemoglobin and plasma albumin, before and after the experiment. The differences in lung function, cardiac ultrasound, cardiopulmonary function, exercise endurance between the 2 groups before and after intervention were compared. The short form 36-item health survey (SF-36) and self-rating depression scale (SDS) were assessed. In our study, the experimental group had better Force vital capacity (FVC) and peak expiratory flow (PEF) after the intervention compared to the control group (P < .05). Anaerobic threshold and 6-minute walk test (6MWT) improved significantly in the experimental group (P < .05), and SF-36 showed better physical functioning, social functioning, general health, and vitality scores in the experimental group compared to the control group (P < .05). In addition, following 24 weeks of exercise, the Depression score of the exercise group showed a statistically significant improvement when compared to the control group (P < .05). After the intervention, hemoglobin improved significantly in the experimental group (P < .05). Intradialytic exercise can improve hemoglobin, Alb, pulmonary function, aerobic capacity, and exercise endurance in maintenance hemodialysis patients, so as to improve the quality of life, which is worthy of further promotion.

Effects of resistance training on patients with End-Stage Renal Disease: an umbrella review with meta-analysis of the pooled findings

OBJECTIVES

This umbrella review aimed to review the effects of resistance training on patients with end-stage renal disease and assess the methodological quality of the available literature.

METHODS

An umbrella review and meta-meta-analysis was performed. A systematic search was conducted until May 2022. Article selection, quality assessment, and risk of bias assessment were performed by two independent reviewers. The meta-meta-analyses were performed with a random-effects model and the summary statistics were presented in the form of a forest plot with a weighted compilation of all standardized mean differences and corresponding 95% confidence interval. Twenty-four reviews were eventually included. The protocol was registered in the international registry PROSPERO (CRD42022321702).

RESULTS

Resistance training showed positive effects on functional capacity (g = 0.614), aerobic capacity (g = 0.587), health-related quality of life (g = 0.429), and peak force (g = 0.621). Fifteen of the included studies (63%) presented low risk of bias, and the remaining studies (37%) showed unclear risk of bias.

CONCLUSION

Resistance training in patients undergoing hemodialysis is an intervention that shows positive results regarding physical and functional outcomes. The quality level of the literature is inconclusive, but the included studies present low risk of bias.

Effects of Different Exercises on Physical Function, Dialysis Adequacy, and Health-Related Quality of Life in Maintenance Hemodialysis Patients: A Systematic Review and Network Meta-Analysis

BACKGROUND

Clinical guidelines recommend exercise training for patients undergoing maintenance hemodialysis (MHD). However, the effectiveness of different types of exercise remains uncertain.

OBJECTIVES

The aims of the study were to compare and rank the effect of different types of exercise on walking capacity, cardiorespiratory fitness, dialysis adequacy, and health-related quality of life (HRQOL) in patients undergoing MHD.

METHODS

Eight databases (four English and four Chinese) were searched from inception to January 1, 2022. Randomized controlled trials evaluating the efficacy of different exercises for patients undergoing MHD were included. Two independent reviewers screened the literature, extracted data, assessed the risk of bias, and evaluated the certainty of evidence. A frequentist random-effect network meta-analysis was conducted.

RESULTS

Ninety trials with 4,084 participants comparing 15 types of exercise were included, reporting on the six-minute walking test (45 trials), peak oxygen uptake (22 trials), dialysis adequacy (30 trials), and HRQOL (23 trials). Network meta-analysis showed that the most effective intervention for walking capacity was intradialytic aerobic exercise combined with blood flow restriction with a mean difference and 95% confidence interval of 97.35 (11.89-182.81), for peak oxygen uptake it was non-intradialytic combined aerobic and resistance exercise with a value of 4.35 (2.25-6.44), for dialysis adequacy it was intradialytic combined aerobic and resistance exercise with a value of 0.17 (0.06-0.28), for the physical component summary of HRQOL it was intradialytic aerobic exercise with a value of 4.93 (2.31-7.54), and for the mental component summary of HRQOL it was non-intradialytic combined aerobic and resistance exercise with a value of 6.36 (0.45-12.27). Ultimately, intradialytic combined aerobic and resistance exercise could improve all the above outcomes compared to usual care.

CONCLUSIONS

This study concluded that intradialytic combined aerobic and resistance exercise is optimal for MHD patients due to its significant positive effects on multiple outcomes. Walking capacity can be further enhanced by combining blood flow restriction with exercise. For improving dialysis adequacy, intradialytic exercise proves to be more effective than non-intradialytic exercise. Further well-designed clinical trials are needed to investigate the effects of exercise with varying durations, intensities, and frequencies.

A Randomized Trial Examining the Impact of Timing of Intradialytic Cycling on Intradialytic Hypotension

Introduction

Intradialytic cycling is often performed during the first half of hemodialysis because of concerns regarding increased frequency of intradialytic hypotension (IDH) late in hemodialysis. This increases exercise program resource needs and limits utility of intradialytic cycling to treat dialysis-related symptoms.

Methods

This multicenter, randomized, crossover trial compared IDH rate when cycling during the first half versus the second half of hemodialysis in 98 adults on maintenance hemodialysis. Group A cycled during the first half of hemodialysis for 2 weeks and subsequently during the second half for 2 weeks. In group B, the cycling schedule was reversed. Blood pressure (BP) was measured every 15 minutes throughout hemodialysis. Primary outcome was IDH rate (systolic BP [SBP] decrease of >20 mm Hg or SBP <90 mm Hg). Secondary outcomes included symptomatic IDH rate and time to recover post hemodialysis. Data were analyzed using negative binomial and gamma distribution mixed regression.

Results

Mean age 64.7 (SD 12.0) and 64.7 (SD 14.2) years in group A (n = 52) and group B (n = 46), respectively. Proportions of females were 33% in group A and 43% in group B. Median time on hemodialysis was 4.1 (interquartile range [IQR] 2.5, 6.1]) years in group A and 3.9 years (IQR 2.5, 6.7) in group B. IDH rate per 100 hemodialysis hours (95% confidence interval [CI]) was 34.2 (26.4, 42.0) and 36.0 (28.9, 43.1) during early and late intradialytic cycling, respectively (P = 0.53). Timing of intradialytic cycling was not associated with symptomatic IDH (relative risk [RR]: 1.07 [0.75-1.53]) or time to recover post hemodialysis (odds ratio: 0.99 [0.79-1.23]).

Conclusion

We found no association between the rate of overall or symptomatic IDH and the timing of intradialytic cycling in patients enrolled in an intradialytic cycling program. Increased use of cycling late in hemodialysis may optimize intradialytic cycling program resource use and should be studied as a possible treatment for symptoms common in late hemodialysis.

Feasibility of randomized controlled trials and long-term implementation of interventions: Insights from a qualitative process evaluation of the PEDAL trial

Introduction

A multi-site randomized controlled trial was carried out between 2015 and 2019 to evaluate the impacts on quality of life of an intradialytic exercise programme for people living with chronic kidney disease. This included a qualitative process evaluation which gave valuable insights in relation to feasibility of the trial and of the intervention in the long-term. These can inform future clinical Trial design and evaluation studies.

Methods

A constructivist phenomenological approach underpinned face-to-face, semi-structured interviews. Purposive recruitment ensured inclusion of participants in different arms of the PEDAL Trial, providers with different roles and trial team members from seven Renal Units in five study regions. Following ethical review, those willing took part in one interview in the Renal Unit. Audio-recorded interviews were transcribed (intelligent verbatim) and inductively thematically analyzed.

Results

Participants (n = 65) (Intervention arm: 26% completed; 13% who did not; Usual care arm: 13%; 46% women; 54% men; mean age 60 year) and providers (n = 39) were interviewed (23% PEDAL Trial team members). Three themes emerged: (1) Implementing the Intervention; (2) Implementing the trial; and (3) Engagement of the clinical team. Explanatory theory named "the Ideal Scenario" was developed, illustrating complex interactions between different aspects of intervention and trial implementation with the clinical context. This describes characteristics likely to optimize trial feasibility and intervention sustainability in the long-term. Key aspects of this relate to careful integration of the trial within the clinical context to optimize promotion of the trial in the short-term and engagement and ownership in the long-term. Strong leadership in both the clinical and trial teams is crucial to ensure a proactive and empowering culture.

Conclusion

Novel explanatory theory is proposed with relevance for Implementation Science. The "Ideal Scenario" is provided to guide trialists in pre-emptive and ongoing risk analysis relating to trial feasibility and long-term intervention implementation. Alternative study designs should be explored to minimize the research-to-practice gap and optimize the likelihood of informative findings and long-term implementation. These might include Realist Randomized Controlled Trials and Hybrid Effectiveness-Implementation studies.

Effects of a Combined Intradialytic Exercise Training Program on Functional Capacity and Body Composition in Kidney Transplant Candidates

Chronic kidney disease (CKD) leads to gradual muscle mass loss, which is strongly associated with lower functional capacity, which limits a patient’s daily activities. The aim of the present study is to examine the effects of a 4-month intradialytic exercise program on the functional capacity and body composition of kidney transplant (KT) candidates. Twenty-nine male patients on hemodialysis (HD) waiting for a kidney transplant, with a mean age of 53.86 ± 9.56 years old and BMI 27.11 ± 5.55 kg/m2, were randomly assigned into the following two groups: A (nA = 15 HD patients), who followed a 4-month intradialytic exercise program combining aerobic and resistance training, with a supervised, progressively increasing workload, and B (nB = 14 HD patients), who continued to receive usual care. At baseline and the end of the study, the KT candidates underwent a 6-min walking distance (6-MWD), and a 10-repetition sit-to-stand test (10-STS) to access physical function, a handgrip strength (HGS) test to evaluate the muscle strength of the non-fistula hand. Moreover, the bioelectrical impedance analysis (BIA) was performed to assess body composition indices, such as body fat (BF), body fat mass index (BFMI), fat-free mass index (FFMI), body cell mass (BCM), basal metabolic rate (BMR), extracellular water (ECW), intracellular water (ICW), total body water (TBW) and phase angle (PhA). Following the exercise program, group A showed favorable improvements in HGS (from 26.59 ± 9.23 to 28.61 ± 9.58 kg, p < 0.05) and 6-MWD (from 427.07 ± 7.66 to 468.16 ± 11.39 m, p < 0.05). Intergroup results from 6-MWD showed a statistically significant difference (Δp = 0.04), at the end of the study. Moreover, group A results from BIA revealed a significant increase of BMR by 2.4% (p < 0.05), ECW by 3.6% (p = 0.01), ICW by 3.8% (p = 0.01), TBW by 4.1% (p = 0.01), lean mass by 2.7% (p = 0.01), and PhA by 13.3% (p = 0.04), while a reduction in BF by 5.0% (p = 0.01) and BFMI by 6.6% (p = 0.03) was also noticed. At the end of the study, group A showed statistical differences in BMR (Δp = 0.01), BMR/BW (Δp = 0.01), dry lean (Δp = 0.01), and PhA (Δp = 0.03), compared to the group B. Linear regression analysis in group A after training showed positive correlations between HGS and both PhA (r = 0.52, p = 0.04) and FFMI (r = 0.64, p = 0.01), and a strong negative correlation between 6-MWT and BF (r = −0.61, p = 0.01). In conclusion, a 4-month intradialytic exercise program can enhance body composition and some physical parameters in HD patients awaiting kidney transplantation.

The Efficacy of Short-Term Toe Resistance Training in Chronic Hemodialysis Patients with Type 2 Diabetes

Resistance training is effective in chronic hemodialysis patients with type 2 diabetes mellitus, but its effect on toe pinch force (TPF) is unknown. This study was a randomized controlled trial conducted at three hospitals to investigate the effect of short-term toe resistance training on TPF in chronic hemodialysis patients with type 2 diabetes. The patients were randomly allocated to intervention (performed aerobic exercise and four toe resistance training exercises) and control (performed aerobic exercise only) groups. After 2 weeks of exercise intervention program, evaluations of TPF and clinical parameters were performed. In addition, the rate of retention of exercise therapy was assessed 6 months after the exercise intervention program was completed. After the exercise intervention program, TPF was significantly higher in the intervention group than in the control group. The intervention group had a significantly higher rate of continuation of exercise therapy. Two weeks of toe resistance training significantly increased the TPF in chronic hemodialysis patients with type 2 diabetes. Toe resistance training was shown to be an effective training method for continuing exercise therapy. Toe resistance training is recommended in clinical practice for chronic hemodialysis patients with type 2 diabetes.

Does Intradialytic Group Exercise Programme Influence Patient-Reported Outcomes, Laboratory Parameters, and Anthropometric Parameters in Maintenance Hemodialysis Patients? A Single-Group Repeated-Measures Trial

BACKGROUND

Maintenance hemodialysis(MHD) patients often suffer from fatigue and are recommended to undertake physical activities. The optimal format of exercise rehabilitation for MHD patients remains uncertain despite demonstrated health benefits. This study aimed to evaluate the effectiveness of an intradialytic group exercise programme for MHD patients.

METHODS

This was a single-centre, single-group repeated-measures design study. The 12-week, three times per-week intradialytic group exercise programme was conducted for around 30 min during the first 2 hours of each dialysis session. Patient-reported outcomes including fatigue, anxiety, depression and health-related quality of life, laboratory parameters including haemoglobin, albumin, pre-albumin and hypersensitive C-reactive protein, and anthropometric parameters including triceps skinfold thickness, mid-upper arm circumference, mid-arm muscle circumference and handgrip strength, were measured at baseline, immediately post-intervention and 12-weeks post-intervention. The repeated-measures analysis of variance and Friedman test were used to compare the parametric and non-parametric data across time points, respectively.

RESULTS

Ninety patients were enrolled and 75 completed. Participants reported significant improvements across time points in fatigue (F = 10.19, p < 0.01), depression (F = 19.20, p < 0.001), health-related quality of life (F = 5.36, p = 0.006), haemoglobin (F = 3.43, p = 0.047), albumin (F = 4.42, p = 0.032), hypersensitive C-reactive protein (χ ² = 50.39, p < 0.001), pre-albumin (χ ² = 11.85, p = 0.003), triceps skinfold thickness (F = 25.03, p < 0.001), mid-upper arm circumference (F = 6.32, p = 0.005), mid-arm muscle circumference (F = 4.89, p = 0.02), and handgrip strength (F = 13.59, p < 0.001). Although the mean anxiety score tended to reduce, the difference across time points was nonsignificant (F = 1.33, p = 0.27).

CONCLUSION

The findings suggested that the intradialytic group exercise programme could improve MHD patients' fatigue, depression, health-related quality of life, nutritional status, and inflammation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000034394 (04/07/2020).

Hemodynamic Tolerance of Virtual Reality Intradialysis Exercise Performed during the Last 30 Minutes versus the Beginning of the Hemodialysis Session

Background: Exercise improves the physical function of people suffering from chronic kidney disease on hemodialysis (HD). Virtual reality is a new type of intradialysis exercise that has a positive impact on physical function. Intradialysis exercise is recommended during the first 2 h, but its safety in the last part of the dialysis session is unknown. Methods: This was a pilot sub-study of a clinical trial. Several hemodynamic control variables were recorded, including blood pressure, heart rate, and intradialytic hypotensive events. These variables were recorded during three different HD sessions, one HD session at rest, another HD session with exercise during the first two hours, and one HD session with exercise during the last 30 min of dialysis. The intradialysis virtual reality exercise was performed for a maximum of 30 min. Results: During exercise sessions, there was a significant increase in heart rate (6.65 (4.92, 8.39) bpm; p < 0.001) and systolic blood pressure (6.25 (0.04,12.47) mmHg; p < 0.05). There was no difference in hemodynamic control between the sessions with exercise during the first two hours and the sessions with exercise during the last 30 min. There was no association between intra-dialytic hypotensive events at rest (five events) or exercise at any point (two vs. one event(s), respectively). Conclusion: performing exercise with virtual reality at the end of a hemodialysis session is not associated with hemodynamic instability.

The impact of nurse-led nonpharmacological multidisciplinary holistic nursing care on fatigue patients receiving hemodialysis: a randomized, parallel-group, controlled trial

BACKGROUND

Fatigue is a symptom characterized by an elevated prevalence in patients undergoing hemodialysis, which may cause extreme mental and muscular debilitation, significantly influencing social interaction, life quality and well-being. However, the significance of fatigue to patients undergoing hemodialysis has not been recognized yet, and prevention and management of fatigue in this population have not been thoroughly investigated. Additionally, previous studies mainly focused on muscular fatigue, while mental fatigue has been seldom discussed. This study aims to investigate the interaction between nurses and multidisciplinary of nonpharmacological integrated care interventions (NICIs) and assess the impact of fatigue on patients undergoing hemodialysis.

METHODS

The integrative nonpharmacological care interventions in this study included walking, motivational interviewing (MI) and health education regarding behavioral self-management. A single-center randomized controlled trial was conducted in the dialysis center of the nephrological department in a tertiary affiliated hospital of medical university from January to June 2019. A total of 118 patients were selected and randomly divided into the intervention group (IG) and the control group (CG). Four patients dropped out during the study, and 114 patients were enrolled for the eventual analysis. The 60 patients in the IG received routine nursing combined with integrated care interventions, while the 54 patients in the CG received routine nursing only. This study lasted for six months.

RESULTS

The experimental group exhibited significant reductions of overall fatigue (2.26 vs. 0.48), mental fatigue (1.41 vs. 0.54), muscular fatigue (2.13 vs. 0.75), and some biochemical indicators (e.g., serum urea) (P<0.05), compared with the CG.

CONCLUSIONS

Nurses and multidisciplinary teams have been demonstrated to play a key role and interplay function in chronic disease management. Hence, the nurse-led multidisciplinary NICIs significantly alleviated total fatigue (muscular fatigue and mental fatigue) and improved other parameters.

TRIAL REGISTRATION

ChiCTR-IOR-16008621 (March 18, 2016).

The effectiveness of intradialytic exercise in ameliorating fatigue symptoms in patients with chronic kidney failure undergoing hemodialysis: A systematic literature review and meta-analysis

Objective

Hemodialysis in patients with chronic kidney failure is an intervention serving as an alternative to kidney transplantation. In 2019, chronic kidney failure became the world's 6th leading cause of death. In Indonesia, kidney failure has an increasing number of cases every year and is the 10th highest cause of death. According to basic health research in 2018, the prevalence of chronic kidney failure was 3.4%, and 19.3% of patients 15 years of age and older underwent hemodialysis. This study analyzed the effectiveness of intradialytic exercise in ameliorating fatigue symptoms in patients with chronic kidney failure undergoing hemodialysis, in terms of exercise type, duration, time, and frequency.

Methods

All appropriate and eligible full-text articles published between January 2010 and October 2021 were screened and extracted from the databases PubMed, Scopus, ProQuest, Science Direct, CrossRef, Google Scholar, and Garuda Database for Research and Technology. The articles were critically reviewed, and two independent authors reviewed the risk of bias by using the JBI form. Data analysis was performed qualitatively to obtain an overview of the characteristics of intradialytic exercise and quantitatively through meta-analysis.

Results

Intradialytic exercise was found to effectively decrease fatigue by 81% in the intervention group. The most significant effect sizes were as follows: type of intradialytic exercise: aerobic exercise (146%); duration of intradialytic exercise: >20 min (100%); time of intradialytic exercise: first 2 h (127%); and exercise frequency: <12 sessions (120%).

Conclusion

The characteristics of intradialytic exercise that are considered effective in ameliorating fatigue are aerobic exercise lasting >20 min and performed in the first 2 h of hemodialysis, with a frequency of <12 sessions.

Therapeutic effects of exercise interventions for patients with chronic kidney disease: an umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To conduct an overview of meta-analyses evaluating the impact of exercise interventions on improving health outcomes in patients with chronic kidney disease (CKD).

DESIGN

An umbrella review of systematic review and meta-analyses of intervention trials was performed.

DATA SOURCES

PubMed, Web of Science, Embase and the Cochrane Database of Systematic Reviews were searched from inception to 9 March 2021 for relevant articles.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible meta-analyses compared the effects of usual care with and without exercise in patients with CKD. Health outcomes included those related to cardiovascular risk factors, physical fitness, dialysis-related symptoms, dialysis adequacy and health-related quality of life. Systematic reviews and meta-analyses that included fewer than 3 RCTs or fewer than 100 participants were excluded from the analysis.

RESULTS

A total of 31 eligible systematic reviews and meta-analyses were included that assessed 120 outcomes. For physical fitness, there was a moderate effect size for cardiorespiratory fitness, muscle strength and body composition and small effect size for muscle endurance. The effect sizes for cardiovascular risk factors, dialysis-related symptoms and health-related quality of life outcomes were small. According to the Grading of Recommendations Assessment, Development and Evaluation framework, most outcomes were low or very low quality.

CONCLUSION

Exercise appears to be a safe way to affect concomitant cardiovascular risk factors, such as blood pressure, improve physical fitness and health-related quality of life and reduce dialysis-related symptoms in patients with CKD.

PROSPERO REGISTRATION NUMBER

CRD42020223591.

Bicycle ergometer exercise during hemodialysis and its impact on quality of life, aerobic fitness and dialysis adequacy: A pilot study

BACKGROUND

Chronic kidney disease patients on hemodialysis commonly have a worse quality of life (QoL) due to complications of the disease and dialysis procedure. Physical exercise has emerged as a strategy to improve this scenario. The objective of this study was to evaluate the effect of an intradialytic aerobic exercise program on QoL and aerobic fitness in hemodialysis patients.

MATERIAL AND METHODS

These are a secondary analysis of clinical trial data previously published in which hemodialysis patients were randomized into "bike group" (using an adapted exercise bicycle) or "control group" (usual care). The exercise sessions lasted 45 min (5 min of warm-up, 35 min of moderate-intensity and 5 min of cool-down) three times/week for three months. The QoL domains were assessed using the SF-36 QoL questionnaire. Aerobic fitness was evaluated using the 6-min walk test (6MWT). Circulating cytokines, biochemical parameters and Kt/V were also assessed.

RESULTS

Nine patients completed three months of exercise (5 men, 44 ± 11 years), and nine were in the control group (6 men, 44 ± 14 years). In the bike group, there was a trend to improve the physical role domain (p = 0.06) regarding QoL, an improvement in the 6MWT (p = 0.02), and in the Kt/V (p = 0.03) after three months. There was a positive correlation between the general health domain and Kt/V (r = 0.691; p = 0.003) and an inverse correlation between the physical functioning domain and plasma TNF-α levels (r = -0.514; p = 0.04).

CONCLUSIONS

12 weeks of intradialytic aerobic exercise was enough to benefit hemodialysis patients' quality of life, aerobic fitness, and quality of dialysis.

CLINICALTRIALS

gov id: NCT04375553.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

An equation to predict peak heart rate for prescribing exercise intensity in middle-aged to older patients requiring hemodialysis

PURPOSE

Exercise prescription based on a population-specific physiological response can help ensure safe and effective physical interventions. However, as a facile approach for exercise prescription in hemodialysis population that is based on their exercise capacity has not yet been established, the aim of our study was to develop a unique prediction formula for peak heart rate (HR) that can be used in this population.

METHODS

This cross-sectional study measured physical function and HR at peak exercise and anaerobic threshold (AT) during cardiopulmonary exercise tests in 126 individuals. Participants were randomly assigned to the development group (n = 78), whose data were used to calculate the prediction equation, or the validation group (n = 48).

RESULTS

The HR reserve in this population was significantly lower (0.44 ± 0.20%) and there was a large discrepancy between conventional age-predicted maximal HR and measured peak-HR values (R = 0.36). The average of the ratio between HR at AT point and peak HR was 85% (95% CI, 83.5%-86.4%). The peak-HR prediction equation was based on resting HR, presence of diabetes, physical dysfunction (gait speed < 1.0 m/s), and hypoalbuminemia (< 3.5 g/dL). It showed high prediction accuracy (R² [95%CI] = 0.71 [0.70-0.71]) with similar correlation coefficients between the development and validation groups (R = 0.82).

CONCLUSION

Aerobic exercise based on estimated peak HR < 85% obtained from the equation in this study may enable safe and effective physical intervention in this population.

Therapeutic Effects of Intradialytic Exercise on Life Quality of Patients with End-Stage Renal Disease: Study Protocol for a Randomized Control Trial

Background: Exercise training has positive effects on physical functions and could reduce a sedentary lifestyle for hemodialysis (HD) patients. Given that low-level physical activity increases morbidity and mortality, here, we aimed to determine the effects of an intradialytic exercise program delivered at different frequencies on HD patients in Taiwan. Methods: This study is a prospective, randomized control trial. An intradialytic exercise program will be arranged for patients after receiving their informed consent. Patients will be segregated at random into three groups as follows: (a) three times/week of intradialytic exercise training plus standard care maintenance of HD, (b) two times/week of intradialytic exercise training plus standard care maintenance of HD, or (c) standard care maintenance of HD. Subjects will be followed for 24 weeks. At three time points, 0, 12, and 24 weeks, the primary outcome, the Short-Form 36 score, will be measured. Additional secondary outcomes to be measured are the Beck depression inventory, 6 min walking test, sit-to-stand test, and anthropometric measures such as the body mass index, thigh circumference, and the proportion of fat in the body composition. Conclusions: There is emerging evidence in support of intradialytic exercise improving health-related quality of life for patients on HD. However, the difference in the therapeutic effects between three times per week and twice per week has never been determined. With this study, we anticipate to fill the knowledge gap in the exercise prescription among HD patients.

The Associations of Suspected COVID-19 Symptoms with Anxiety and Depression as Modified by Hemodialysis Dietary Knowledge: A Multi-Dialysis Center Study

During the COVID-19 pandemic, it is essential to evaluate hemodialysis patients’ dietary knowledge, especially among those with COVID-19 related symptoms, in order to identify appropriate strategies in managing their mental health. The study’s purposes were to test the psychometric properties of the hemodialysis dietary knowledge (HDK) scale, and to investigate the modifying impact of HDK on the associations of suspected COVID-19 symptoms (S-COVID-19-S) with anxiety and depression among hemodialysis patients. A cross-sectional study was conducted from July 2020 to March 2021 at eight hospitals across Vietnam. Data of 875 hemodialysis patients were analyzed, including socio-demographic, anxiety (the generalized anxiety disorder scale, GAD-7), depression (the patient health questionnaire, PHQ-9), S-COVID-19-S, HDK, health literacy, and digital healthy diet literacy. Confirmatory factor analysis (CFA) and logistic regression models were used to analyze the data. The HDK scale demonstrates the satisfactory construct validity with good model fit (Goodness of Fit Index, GFI = 0.96; Adjusted Goodness of Fit Index, AGFI = 0.90; Standardized Root Mean Square Residual, SRMR = 0.05; Root Mean Square Error of Approximation, RMSEA = 0.09; Normed Fit Index, NFI = 0.96; Comparative Fit Index, CFI = 0.96, and Parsimony goodness of Fit Index, PGFI = 0.43), criterion validity (as correlated with HL (r = 0.22, p < 0.01) and DDL (r = 0.19, p < 0.01), and reliability (Cronbach alpha = 0.70)). In the multivariate analysis, S-COVID-19-S was associated with a higher likelihood of anxiety (odds ratio, OR, 20.76; 95% confidence interval, 95%CI, 8.85, 48.70; p < 0.001) and depression (OR, 12.95; 95%CI, 6.67, 25.14, p < 0.001). A higher HDK score was associated with a lower likelihood of anxiety (OR, 0.70; 95%CI, 0.64, 0.77; p < 0.001) and depression (OR, 0.72; 95%CI, 0.66, 0.79; p < 0.001). In the interaction analysis, the negative impacts of S-COVID-19-S on anxiety and depression were mitigated by higher HDK scores (p < 0.001). In conclusion, HDK is a valid and reliable tool to measure dietary knowledge in hemodialysis patients. Higher HDK scores potentially protect patients with S-COVID-19-S from anxiety and depression during the pandemic.

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 intradialytic exercise on geriatric issues in older patients undergoing hemodialysis: a single-center non-randomized controlled study

PURPOSE

This study investigated the effect of 1 year of intradialytic exercise on older hemodialysis patients with geriatric issues.

METHODS

Forty-six patients aged ≥ 70 years were non-randomly assigned to two groups (exercise group: 27, control group: 19). Intradialytic exercise consisted of 30 min of aerobic exercise using a cycle ergometer, and resistance training comprising four exercises using an elastic tube three times per week for 1 year. Handgrip strength, leg extremity muscle strength, 10-m walk speed, short physical performance battery, serum albumin, Geriatric Nutritional Risk Index (GNRI), geriatric depression scale, frailty, and mobility were each assessed before and after the intervention.

RESULTS

The control group exhibited a significant reduction in handgrip strength, 10-m walking speed, serum albumin, and GNRI after intervention compared to baseline (p < 0.05). Conversely, no significant reductions were observed in the exercise group. The ΔGNRI (effect size, 0.69; 95% confidence interval [CI]  - 5.21, - 0.1; p < 0.05) and Δserum albumin (effect size, 0.72; 95% CI - 0.31, - 0.02; p < 0.05) before and after the intervention declined significantly less in the exercise group than in the control group. Other between-group values were not significantly different. The number of frail patients and patients requiring walking assistance exhibited no significant intra-group or between-group differences before and after the intervention.

CONCLUSION

Intradialytic exercise prevented the worsening of nutritional status and physical function in the exercise group compared to the control group. Exercise therapy during dialysis is an important aspect of patient care that helps prevent functional decline in older patients.

Exercise or physical activity-related adverse events in people receiving peritoneal dialysis: A systematic review

People receiving peritoneal dialysis (PD) may benefit from participation in exercise or physical activity. However, exercise therapy for people receiving PD is not typically included in routine care, in part, due to ongoing uncertainties about risk. The aim of this review was to systematically collate and explore data on adverse events experienced by people receiving PD while undertaking an exercise or physical activity intervention. Searches yielded 25 exercise or physical activity intervention studies involving people receiving PD. Of these 25 studies, 17 studies provided adverse event data and were included in the final review. No serious adverse events (e.g. death, hospitalisation) were found attributable to the intervention. From 50 reported adverse events during the intervention period, 32 were attributable to the exercise or physical activity intervention with most being musculoskeletal (e.g. muscle/joint pain, etc.) followed by fatigue. Most events were mild to moderate in severity and resolved by exercise programme modification, education, rest or medication. The results from this review did not uncover signals of harm for people receiving PD who engage in exercise with risk of adverse events appearing to be low, however, improved adverse events reporting and further interventional studies are required before robust guidelines can be produced.

Effect of Intradialytic Aerobic Exercise on Relative Blood Volume in Patients Undergoing Maintenance Hemodialysis

The purpose of this study was to investigate changes in the relative blood volume because of intradialytic exercise. Twenty patients undergoing hemodialysis (HD) were assigned randomly to exercise or control sessions as a first test by simple randomization. All participants were crossed over and participated in both tests. In the exercise test, each patient underwent 30 minutes of exercise using a cycle ergometer from the initiation of HD. The control session consisted of routine HD without exercise. The blood volume (ΔBV) reduction in both types of sessions was calculated from the area under the curve of the ΔBV (ΔBVAUC) from the initiation of HD to the end of exercise (During Ex), from the end of exercise to the end of HD (Post Ex), and during the entire HD session (Whole HD). The ΔBVAUC of Post Ex in the exercise test (44.9 ± 14.3%h) was significantly smaller than that in the control test (50.3 ± 14.3%h) (p < 0.05), although other parameters such as ΔBVAUC either in the entire HD session or during exercise training did not differ significantly between two groups. This result suggests that intradialytic exercise at the beginning of the HD sessions may be altered the ΔBV in the latter part of the session.

Effects of an additional resistance training intervention in hemodialysis patients performing long-term ergometer exercise during dialysis

[Purpose] To verify the effect of a 12-week additional resistance training intervention in patients on hemodialysis who had been performing supine ergometer exercises alone during dialysis. [Participants and Methods] Overall, 18 patients undergoing hemodialysis were included. A 12-week intervention with additional resistance training was conducted in hemodialysis patients who had been performing supine ergometer exercise for 30 min during dialysis for over >3 months. Physical function before and after the period of bicycle ergometer exercise alone and before and during the additional intervention was compared. Resistance training consisted of 1–3 sets per day of five different exercises for the large muscle groups of the upper and lower limbs. [Results] The results of the 6-min walk test improved significantly after the additional intervention. The average driving distance in the supine ergometer exercise during the additional intervention was identified as an associated factor. [Conclusion] The addition of the resistance training to long-term supine ergometer exercisers improved walking endurance. When supine ergometer exercise alone does not change physical function, the additional use of resistance training subsequently may have a positive effect on walking endurance.

Is It Safe for Hemodialysis Patients to Seek Gains with Less Pain? Acute Hemodynamic Response to Intradialytic Blood Flow Restriction Training

Considering that the hemodynamic safety is a major concern about intradialytic exercise with blood flow restriction, this analysis was performed to compare the blood pressure (BP) behavior during the first two hours of hemodialysis (HD) between sessions with no exercise (control group, CG), low/moderate intensity aerobic exercise with blood flow restriction (BFRE) and conventional aerobic exercise (AE). Adult patients with chronic kidney disease on HD at a university hospital were randomly assigned and submitted to a 12-week intradialytic training with BFRE or AE compared with the CG group. The main outcomes of this report were the change in systolic (SBP) and diastolic (DBP) BP during HD and the frequency of low BP (LBP) and high BP (HBP) episodes. A total of 6,074 BP measurements of 58 patients were analyzed. There was a larger decrease in BP in the exercise sessions compared with the control sessions, but with a similar magnitude in the BFRE and AE groups (effect size 0.49). There was a higher number of LBP in the BFRE group. The frequency of HBP was similar between the BFRE and the CG groups and lower in the AE group. Despite a greater number of mild LBP in BFRE patients, the BP change during the first two hours of HD was similar to that of patients in AE. Intradialytic aerobic exercise with blood flow restriction does not seem to be associated with a higher hemodynamic burden than conventional aerobic exercise.

Echocardiographic left ventricular hypertrophy and geometry in Chinese chronic hemodialysis patients: the prevalence and determinants

Background

To investigate the prevalence of left ventricular hypertrophy (LVH) and explore left ventricular geometry in maintenance hemodialysis (MHD) patients, and to explore the risk factors of LVH which is an important predictor of cardiovascular events.

Methods

The subjects were patients who are on MHD for more than 3 months in Peking University People's Hospital from March 2015 to February 2017. Demographic and clinical data were retrospectively collected. Left ventricular mass was measured by echocardiography. LVH is defined by Left ventricular mass index (LVMI) > 115 g/m² for men and > 95 g/m² in women. LVMI and relative wall thickness were used to determine left ventricular geometry. Logistic regression was used to analyze the risk factors of LVH.

Results

Altogether, 131 patients including 77 males were enrolled. The median age was 60 (47, 69) years, with a median dialysis vintage of 48 (18, 104) months. There were 80 patients with LVH, the prevalence rate was 61.1%, and 66.3% of them were moderate to severe LVH. We found that (1) most of the patients were concentric hypertrophy; (2) one-third of the patients were concentric remodeling; (3) only 4 cases with normal geometry. The pre-dialysis serum sodium level and time average pre-dialysis systolic blood pressure (SBP) were independent risk factors of LVH.

Conclusion

LVH is prevalent in MHD patients. Concentric hypertrophy and concentric remodeling are the most common geometric patterns. Attention should be paid to long-term pre-dialysis SBP management and pre-dialysis sodium control as they might be potentially modifiable risk factors for LVH.

Renal rehabilitation as a management strategy for physical frailty in CKD

An aging population and the increasing prevalence of lifestyle-related diseases have led to a worldwide increase in the rate of chronic kidney disease requiring renal replacement therapy. The mean age of individuals requiring dialysis therapy has been increasing, and Japanese patients are aging more rapidly than those in the USA and Europe. Patients undergoing renal replacement therapy are at increased risk of sarcopenia/frailty compared with people with normal kidney function due to comorbid burden, long-standing malnutrition, chronic inflammation, metabolic acidosis, anabolic resistance, hormonal changes, physical inactivity and amino acid loss via dialysis treatment in addition to aging. Sarcopenia and frailty are serious global health problems that can decrease access to kidney transplantation and lead to various adverse health outcomes, including functional dependence, hospitalizations and deaths in patients on dialysis treatment. However, sarcopenia/frailty fortunately is potentially modifiable by early identification of poor physical functioning, sustainment and enhancement of daily physical activity, and participation in exercise treatments. The Japanese Society of Renal Rehabilitation was established in 2011 and published a clinical practice guideline for “Renal Rehabilitation” targeting nondialysis-dependent and dialysis-dependent patients and renal transplant recipients, in 2019. The guideline emphasized the importance of physical management for patients with kidney diseases in addition to nutritional supports and anemia management. Kidney health professionals should manage sarcopenia and physical frailty as a part of routine clinical care for patients undergoing hemodialysis to improve poor physical functioning, functional dependence, decreased quality of life and poor prognosis.

Exercise training for adults undergoing maintenance dialysis

BACKGROUND

Dialysis treatments weigh heavily on patients' physical and psychosocial health. Multiple studies have assessed the potential for exercise training to improve outcomes in adults undergoing dialysis. However, uncertainties exist in its relevance and sustainable benefits for patient-important outcomes. This is an update of a review first published in 2011.

OBJECTIVES

To assess the benefits and safety of regular structured exercise training in adults undergoing dialysis on patient-important outcomes including death, cardiovascular events, fatigue, functional capacity, pain, and depression. We also aimed to define the optimal prescription of exercise in adults undergoing dialysis.

SEARCH METHODS

In this update, we conducted a systematic search of the Cochrane Kidney and Transplant Register of Studies up to 23 December 2020. The Register includes studies identified from CENTRAL, MEDLINE, EMBASE, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov as well as kidney-related journals and the proceedings of major kidney conferences.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of any structured exercise programs of eight weeks or more in adults undergoing maintenance dialysis compared to no exercise or sham exercise.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane risk of bias tool. Whenever appropriate, we performed random-effects meta-analyses of the mean difference in outcomes. The primary outcomes were death (any cause), cardiovascular events and fatigue. Secondary outcomes were health-related quality of life (HRQoL), depression, pain, functional capacity, blood pressure, adherence to the exercise program, and intervention-related adverse events.

MAIN RESULTS

We identified 89 studies involving 4291 randomised participants, of which 77 studies (3846 participants) contributed to the meta-analyses. Seven studies included adults undergoing peritoneal dialysis. Fifty-six studies reported aerobic exercise interventions, 21 resistance exercise interventions and 19 combined aerobic and resistance training within the same study arm. The interventions lasted from eight weeks to two years and most often took place thrice weekly during dialysis treatments. A single study reported death and no study reported long-term cardiovascular events. Five studies directly assessed fatigue, 46 reported HRQoL and 16 reported fatigue or pain through their assessment of HRQoL. Thirty-five studies assessed functional capacity, and 21 reported resting peripheral blood pressure. Twelve studies reported adherence to exercise sessions, and nine reported exercise-related adverse events. Overall, the quality of the included studies was low and blinding of the participants was generally not feasible due to the nature of the intervention. Exercise had uncertain effects on death, cardiovascular events, and the mental component of HRQoL due to the very low certainty of evidence. Compared with sham or no exercise, exercise training for two to 12 months may improve fatigue in adults undergoing dialysis, however, a meta-analysis could not be conducted. Any exercise training for two to 12 months may improve the physical component of HRQoL (17 studies, 656 participants: MD 4.12, 95% CI 1.88 to 6.37 points on 100 points-scale; I² = 49%; low certainty evidence). Any exercise training for two to 12 months probably improves depressive symptoms (10 studies, 441 participants: SMD -0.65, 95% CI -1.07 to -0.22; I² = 77%; moderate certainty evidence) and the magnitude of the effect may be greater when maintaining the exercise beyond four months (6 studies, 311 participants: SMD -0.30, 95% CI 0.14 to -0.74; I² = 71%). Any exercise training for three to 12 months may improve pain (15 studies, 872 participants: MD 5.28 95% CI -0.12 to 10.69 points on 100 points-scale; I² = 63%: low certainty evidence) however, the 95% CI indicates that exercise training may make little or no difference in the level of pain. Any exercise training for two to six months probably improves functional capacity as it increased the distance reached during six minutes of walking (19 studies, 827 participants: MD 49.91 metres, 95% CI 37.22 to 62.59; I² = 34%; moderate certainty evidence) and the number of sit-to-stand cycles performed in 30 seconds (MD 2.33 cycles, 95% CI 1.71 to 2.96; moderate certainty evidence). There was insufficient evidence to assess the safety of exercise training for adults undergoing maintenance dialysis. The results were similar for aerobic exercise, resistance exercise, and a combination of both aerobic and resistance exercise.

AUTHORS' CONCLUSIONS

It is uncertain whether exercise training improves death, cardiovascular events, or the mental component of HRQoL in adults undergoing maintenance dialysis. Exercise training probably improves depressive symptoms, particularly when the intervention is maintained beyond four months. Exercise training is also likely to improve functional capacity. Low certainty evidence suggested that exercise training may improve fatigue, the physical component of quality of life, and pain. The safety of exercise training for adults undergoing dialysis remains uncertain.

Physical Activity and Health-Related Quality of Life of Patients on Hemodialysis with Comorbidities: A Cross-Sectional Study

Patients on hemodialysis with multiple comorbidities have limited physical activity, resulting in poor health, low activity participation, and low quality of life. Accordingly, the nursing care provided to such patients should include regular physical activity training programs. Therefore, this cross-sectional descriptive study investigated whether patients on hemodialysis with and without comorbidities have different levels of physical activity and health-related quality of life (HRQoL); the correlations among the comorbidities, physical activity, and HRQoL of the two cohorts were also assessed. The 36-Item Short-Form Health Survey version 2 and International Physical Activity Questionnaire were employed to collect data from 120 patients on hemodialysis. An independent samples t-test and univariate and multivariate linear regression analyses were conducted. The overall HRQoL of patients with comorbidities was lower than that of patients without comorbidities (p = 0.008). Compared with patients who participated in low-intensity physical activity, the overall HRQoL of patients who participated in moderate-intensity physical activity was higher (p < 0.001). The overall HRQoL of patients with comorbidities who participated in low-intensity physical activity was lower than that of those who participated in moderate-intensity physical activity (p < 0.001). Moderate-intensity physical activity was correlated with higher HRQoL for patients with comorbidities. This finding supports the implementation of effective physical activity intervention measures. Furthermore, it supports the promotion of patient self-management and the implementation of regular exercise programs and lifestyle changes, and patients on hemodialysis can benefit from the future management of physical activities.

OUP accepted manuscript

Sarcopaenia is a highly prevalent condition in persons on haemodialysis (HD). In stable very elderly (75–95 years old) persons on chronic HD, we prospectively studied the European Working Group on Sarcopaenia in Older People (EWGSOP2) steps stability over time in 37 controls and their response to a 12-week intradialytic lower limb exercise programme in 23 persons. Overall dropout was 15% and the main cause for dropout was death (8%). Thus 33 controls and 18 exercise participants were evaluated at 12 weeks. In controls, comorbidity, nutrition, dependency and frailty scales, anthropometric assessments, EWGSOP2 step values and the prevalence of suspected, confirmed and severe sarcopaenia as assessed by EWGSOP2 remained stable. In contrast, in persons who completed the exercise programme, a significant improvement in the five times sit-to-stand (STS-5) test was noted at the end of the 12-week exercise programme (19.2 ± 4.9–15.9 ± 5.9 seconds; P = .001), consistent with the lower limb nature of the exercise programme, that persisted 12 weeks after completion of the programme. Exercise also improved the Fried frailty scale (1.7 ± 1.0–1.1 ± 0.6; P = .004). In conclusion, EWGSOP2 steps remain stable in stable very elderly persons on HD and STS-5 is responsive to a short-term intradialytic lower limb exercise programme. These results may help define EWGSOP2-based primary endpoints in future large-scale clinical trials assessing exercise interventions.

Profile of professionals working in intradialytic exercise programs in Brazil: a national survey

OBJECTIVE

This survey was designed to assess the profile of professionals working in intradialytic exercise programs (IEPs) in Brazil and reveal the motivators and barriers they face.

METHODS

The survey was sent to physiotherapists and exercise physiologists working in IEPs in Brazil. Phone interviews and electronic forms were used to collect the answers to the survey questionnaire.

RESULTS

Forty-one of the 261 included dialysis centers had IEPs; 44 professionals answered the questionnaire over the phone and 26 used the electronic form to do it. A total of 70 professionals (mean age 33.4±7.4 years; 84.3% physiotherapists) answered the questionnaire. Resistance training was the preferred mode of therapy. Most of the IEPs were connected to research and were paid for by private health insurance. The desire to work in a different field (30.0%) and lack of resources (31.4%) were the most prevalent motivator and barrier cited by IEP professionals working in dialysis centers, respectively.

CONCLUSION

The majority of the few professionals that work in IEPs in Brazil are physiotherapists. Lack of resources was the most commonly reported barrier faced by survey respondents.

The effect of intradialytic exercise on inflammatory markers in hemodialysis patients

Background

Chronic low-grade inflammation is a feature of chronic kidney disease associated with increased risk of multiple morbidities and mortalities. Hemodialysis (HD) patients lead a sedentary life style which may aggravate their inflammatory state and practicing exercise may improve this condition. The aim of this work was to study the effect of intradialytic exercise (IDE) on inflammatory markers in HD patients.

Results

This prospective cohort study included 40 HD patients, divided into 2 groups: exercise group completed IDE for 3 months and non-exercise group matched in age and sex as controls. At baseline, there was no difference between both groups regarding physical performance assessed using short physical performance battery test (SPBT) or inflammatory markers C-reactive protein (CRP) and interleukin 6 (IL-6) P > 0.05. After 3 months, SPBT significantly improved in exercise group (P < 0.001). Also, both serum CRP and IL-6 levels showed significant decrease in exercise group compared to baseline (P < 0.001), while no similar change was noticed in non-exercise group.

Conclusions

Regular intradialytic aerobic exercise program can improve physical function and inflammation in hemodialysis patients. Further studies on larger number of patients are warranted.

Effects of intradialytic exercise on health-related quality of life in patients undergoing maintenance haemodialysis: a systematic review and meta-analysis

PURPOSE

To summarize the current evidence regarding the effectiveness of intradialytic exercise (IDE) on the health-related quality of life (HRQOL) of patients undergoing maintenance haemodialysis.

METHODS

Five English databases (PubMed, EMBASE, Cochrane Library, Web of Science, and ScienceDirect) and four Chinese databases (VIP, WAN FANG, CNKI, CBM) were comprehensively searched from their inception to 18 March 2021. This study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Two independent reviewers selected the papers and extracted the details of each study therein. Only randomized controlled trials were included. The risk of bias tool version 2.0 was used to evaluate the risk of bias of the included studies. A random-effects meta-analysis was conducted to pool the effect size.

RESULTS

Thirty-three eligible studies with 1481 participants were included. For the generic HRQOL, assessed by the Medical Outcomes Study Short-Form survey, IDE significantly improved most domains and the physical component summary compared with the control group. Furthermore, aerobic exercise alone significantly improved more domains compared to resistance exercise, combined aerobic and resistance exercise, and other types of exercise. Regarding the kidney-specific HRQOL, IDE improved three of eleven domains, including the symptom/problem list, the effect of kidney disease, and the quality of social interaction. No significant effect was found on other domains of kidney-specific HRQOL.

CONCLUSION

Intradialytic exercise could benefit patients undergoing haemodialysis in improving most domains of generic HRQOL, but the effect on most domains of kidney-specific HRQOL is insufficient.

Association between the transtheoretical model approach and sustained intradialytic pedaling exercise: A retrospective cohort study

The transtheoretical model (TTM) is a promising approach to the promotion of behavior change, but it remains to be established whether there is an association between the TTM approach and intradialytic exercise among patients on hemodialysis (HD) with low motivation to exercise in a real-world setting.This retrospective cohort study, conducted in a regional hospital in Japan, included adult outpatients receiving HD 3 times per week who had never participated in intradialytic pedaling exercise despite the encouragement of the HD personnel. Patients were divided into 2 groups according to HD weekday. Patients undergoing HD on Tuesday, Thursday, and Saturday were encouraged by the HD unit team to exercise during HD based on the TTM (exposure group) and those receiving HD on Monday, Wednesday, and Friday were encouraged to exercise as usual (control group). The primary outcome was sustained intradialytic exercise using a leg ergometer, defined as a total of 72 sessions of 30-minute pedaling exercise (duration of at least 6 months).Overall, 85 patients were included in the analysis (mean age: 67.1 ± 11.9 years, 22% female). Of 33 patients in the exposure group, 10 (30%) maintained intradialytic exercise, compared with 2 of 52 patients (4%) in the control group. Log-binomial regression models with stabilized inverse probability of treatment weighting showed a significant association between the TTM approach and sustained intradialytic exercise (adjusted risk ratio 9.23 [95% confidence interval 2.13-40.00]). There were no exercise-related cardiovascular events.Among patients with low motivation to exercise during HD, use of the TTM approach in clinical practice was associated with sustained intradialytic exercise compared with usual care.

Effect of blood volume change related to intensity of intradialytic aerobic exercise on hemodialysis adequacy: a pilot study

PURPOSE

Intradialytic exercise may improve dialysis efficiency; however, the association between changes in blood volume (BV) related to exercise intensity and solute removal kinetics remains unknown. We herein investigated the relationship between changes in BV with exercise and removal of solute molecules during hemodialysis.

METHODS

Each of the 21 hemodialysis patients underwent cardiopulmonary exercise test to measure anaerobic threshold (AT). According to the exercise intensity, patients were classified into two groups, the low group (n = 12), whose intensity was below the AT, and the high group (n = 9), whose intensity was at the AT level. Each patient completed two trial arms of resting and discontinuous exercise dialysis sessions in a randomized manner.

RESULTS

The change in BV with the exercise dialysis session in the high group decreased during exercise (p = 0.028) and remained decreased after exercise (p = 0.016), compared with the low group. In the low group, compared with routine sessions, the removal of potassium (p = 0.030), phosphate (p = 0.024), and urea nitrogen (p = 0.065) increased during exercise, but the total removal of these solutes did not change. In the high group, the removal of phosphate (p < 0.001) and urea nitrogen (p = 0.018) after exercise and even total phosphate (p = 0.027) decreased.

CONCLUSION

These findings suggest that the removal of small solute molecules is improved during exercise in intradialytic low-intensity exercise with no change in BV, and decreased after exercise in high-intensity exercise with a decrease in BV.

CLINICAL TRIALS REGISTRY

Trial retrospectively registered at the UMIN Clinical Trials Registry: study number UMIN000038629 (Registration date: September 7, 2019).

Motivation, Barriers, and Suggestions for Intradialytic Exercise-A Qualitative Study among Patients and Nurses

Background: Intradialytic exercise is an effective intervention to reduce morbidity and mortality and increase quality of life among patients with chronic kidney disease undergoing dialysis. However, implementing and sustaining it in clinical practice has proved challenging. To identify how to best design an effective and sustainable intervention in clinical practice, we aimed to explore hemodialysis patients’ and nurses’ attitudes towards intradialytic exercise, including their motivation, anticipated barriers, and suggestions for the design of a proposed exercise program. Methods: Data were collected through qualitative semistructured interviews with patients and focus group interviews with nurses and analyzed inductively with content analysis. Results: Overall, patients’ and nurses’ attitudes towards intradialytic exercise were positive. Patients were motivated by their expectations about perceived benefits, such as improved quality of life and reduced musculoskeletal pain. Their main concern was triggering dialysis machine alarms and disturbing nurses. Nurses were more skeptical of intradialytic exercise and concerned about patient safety. Patients and nurses had several ideas on how to design a safe and motivating intradialytic exercise intervention. Conclusion: The analysis of patients’ and nurses’ experiences and attitudes generated recommendations for an intradialytic exercise program. Recommendations include individually tailored programs that are safe and that patients can do independently, continuous collaboration between patients, nurses, physicians, and physiotherapists, and educating nurses about the benefits and safety of intradialytic exercise.

Effects of Intradialytic Exercise on Dialytic Parameters, Health-Related Quality of Life, and Depression Status in Hemodialysis Patients: A Randomized Controlled Trial

Exercise is fundamentally important in managing chronic diseases and improving health-related quality of life (HRQL). However, whether intradialytic exercise is safe through assessment of changes in dialytic parameters and has a positive impact on HRQL and depression status of hemodialysis patients requires further research with diverse racial and cultural populations to identify. This study aimed to evaluate the effects of intradialytic exercise on dialytic parameters, HRQL, and depression status in hemodialysis patients. A randomized controlled trial was conducted at a medical center in Northern Taiwan. Sixty-four hemodialysis patients were recruited using stratified random sampling. Participants were randomized into an experimental group (EG, n = 32) or a control group (CG, n = 32). The EG received a 12-week intradialytic exercise program while the CG maintained their usual lifestyles. Dialytic parameters, HRQL, and depression status were collected at baseline and at 12 weeks. The results indicated no differences in the dialytic parameters from the baseline between both groups. However, the EG had increased HRQL (ß = 22.6, p < 0.001) and reduced depression status (ß = −7.5, p = 0.02) at 12 weeks compared to the CG. Therefore, a 12-week intradialytic exercise regime is safe and effective in improving HRQL and reducing depression status for hemodialysis patients.

Cluster Randomized Controlled Trial on the Effects of 12 Months of Combined Exercise Training during Hemodialysis in Patients with Chronic Kidney Disease-Study Protocol of the Dialysis Training Therapy (DiaTT) Trial

Patients with chronic kidney disease (CKD) on hemodialysis (HD) experience treatment-related immobility and physical deconditioning, which is responsible for an increased risk of frailty and a high burden of multi-morbidity. Exercise has been shown to counteract this vicious cycle; however, its effectiveness has only been investigated in small cohorts. Therefore, the objective of the Dialysis Training Therapy (DiaTT) trial will be to assess the effects of a 12-month intradialytic exercise program on physical functioning, frailty and health economics in a large cohort of HD patients in a real-world setting. DiaTT will be a prospective, cluster-randomized (1:1), controlled, multi-center, interventional clinical trial across 28 dialysis units, aiming at the recruitment of >1100 CKD patients on HD. The intervention group will receive 12 months’ intradialytic exercise (combined aerobic and resistance training), whereas the usual care group will not receive intervention. The primary endpoint will be a change on the sit-to-stand test (STS60) result between baseline and 12 months. Secondary endpoints will include physical functioning, frailty, quality of life, 3-point MACE, hospitalizations, survival, quality of HD, health literacy and health care costs. By including almost as many patients as previously investigated in smaller trials, DiaTT will be the largest randomized, controlled trial assessing frailty, quality of life and mortality in the field of nephrology.

Addressing feasibility challenges to delivering intradialytic exercise interventions: A theory-informed qualitative study

BACKGROUND

Intradialytic exercise (IDE) may improve physical function and health-related quality of life. However, incorporating IDE into standard hemodialysis care has been slow due to feasibility challenges. We conducted a multicenter qualitative feasibility study to identify potential barriers and enablers to IDE and generate potential solutions to these factors.

METHODS

We conducted 43 semi-structured interviews with healthcare providers and patients across twelve hospitals in Ontario, Canada. We used the Theoretical Domains Framework and directed content analysis to analyze the data.

RESULTS

We identified eight relevant domains (knowledge, skills, beliefs about consequences, beliefs about capabilities, environmental context and resources, goals, social/professional role and identity, and social influences) represented by three overarching categories: 1) Knowledge, skills and expectations: lack of staff expertise to oversee exercise, uncertainty regarding exercise risks, benefits, and patient interest, lack of knowledge regarding exercise eligibility; 2) Human, material and logistical resources: staff concerns regarding workload, perception that exercise professionals should supervise IDE; space, equipment, and scheduling conflict concerns; 3) Social dynamics of the unit: local champions and patient stories contribute to IDE sustainability.We developed a list of actionable solutions by mapping barriers and enablers to behavior change techniques. We also developed a feasibility checklist of 47 questions identifying key factors to address prior to IDE launch.

CONCLUSIONS

Evidence-based solutions to identified barriers and enablers to IDE and a feasibility checklist may help recruit and support units, staff, and patients and address key challenges to the delivery of IDE in diverse clinical and research settings.