Exercise interventions for improving objective physical function in patients with end-stage kidney disease on dialysis: a systematic review and meta-analysis

Systemic inflammation in midlife is associated with late-life functional limitations

Systemic inflammation generally coexists with functional limitations that seriously affect quality of life. This study aimed to investigate the association between systemic inflammation in midlife and the risk of functional limitations in late-life. A total of 10,044 participants with an average age of 53.9 ± 5.7 years at baseline were included in a cohort study. At the last follow-up, the prevalence of impaired activities of daily living (ADLs), instrumental activities of daily living (IADLs), and lower extremity function (LEF) was 14.7%, 21.6%, and 50.3%, respectively. The values of four inflammatory biomarkers were used to calculate the inflammation composite score. Compared with the participants in the lowest quartile of the inflammation composite score (Q1), those in the highest quartile (Q4) exhibited an odds ratio (OR) of 1.589 and a 95% confidence interval (CI) of 1.335-1.892 for impaired ADLs, an OR of 1.426 and a 95% CI of 1.228-1.657 for impaired IADLs, and an OR of 1.728 and a 95% CI of 1.526-1.957 for impaired LEF. The association between systemic inflammation and functional limitations was partly mediated by cardiac and brain function. The present study provides evidence that systemic inflammation in midlife is associated with a higher risk of late-life functional limitations. Protecting vital organ functions in midlife may have a positive impact on reducing the risk of future functional limitations.Trial registration: www.clinicaltrials.gov ; Unique identifier: NCT00005131.

Physical exercise in haemodialysis patients: which type of exercise is more convenient?

Randomized intra-haemodialysis and home-based exercise trials have demonstrated similar efficacy in improving physical performance, particularly in increasing walking distance. During dialysis sessions, patients can engage in structured, supervised activities such as cycling or resistance exercises, ensuring safety and immediate feedback from healthcare professionals. This structured nature can significantly enhance adherence, making exercise a regular part of the patient's treatment schedule. Home-based exercise offers flexibility and convenience. Patients can incorporate activities like walking, stretching or using resistance bands into their daily lives. This flexibility allows patients to exercise at their own pace and according to their preferences, fostering independence and self-management. By continuing physical activity at home, patients can maintain continuity in their exercise regimen, which is crucial for long-term health benefits. Combining both intra-haemodialysis and home-based exercises has the potential to improve overall adherence to exercise programs. Strategies such as patient education, customized plans, monitoring and feedback, and support systems can help combine these two exercise types. By integrating these two modalities, healthcare providers can create a comprehensive and balanced exercise regimen that enhances adherence, promotes independence and maximizes health benefits for dialysis patients, fostering long-term health and well-being through sustained physical activity. However, this dual approach, which caters to both the need for medical supervision and the desire for personal autonomy, has yet to be tested in randomized trials.

Beyond sarcopenia: frailty in chronic haemodialysis patients

Background

Frailty, characterized by vulnerability, reduced reserves and increased susceptibility to severe events, is a significant concern in chronic haemodialysis (HD) patients. Sarcopenia, corresponding to the progressive loss of muscle mass and strength, may contribute to frailty by reducing functional capacity, mobility and autonomy. However, consensus lacks on the optimal bedside frailty index for chronic HD patients. This study investigated the influence of frailty on chronic HD patient survival and explored the associated factors.

Methods

A total of 135 patients were enrolled from January to April 2019 and then followed up prospectively until April 2022. At inclusion, frailty was assessed by the Timed Up and Go (TUG) and Short Physical Performance Battery (SPPB) tests including gait speed, standing balance and lower limb muscle strength.

Results

From a total of 114 prevalent chronic HD patients (66% men, age 67.6 ± 15.1 years), 30 died during the follow-up period of 23.7 months (range 16.8-34.3). Deceased patients were older, had more comorbidities and a higher sarcopenia prevalence (P < .05). The TUG and SPPB test scores were significantly reduced in patients who had died [SPPB total score: 7.2 ± 3.3 versus 9.4 ± 2.5; TUG time 8.7 ± 5.8 versus 13.8 ± 10.5 (P < .05)]. Multivariate analysis showed that a higher SPPB score (total value >9) was associated with a lower mortality risk [hazard ratio 0.83 (95% confidence interval 0.74-0.92); P < .03). Each component of the SPPB test was also associated with mortality in univariate analysis, but only the SPPB balance test remained protective against mortality in multivariate analysis. Older age, lower handgrip strength and lower protein catabolic rate were associated with SPPB total scores <9, SPPB balance score and TUG time >10 s.

Conclusions

Screening for frailty is crucial in chronic HD patients, and incorporating SPPB, especially the balance test, provides valuable insights. Diminished muscle strength and inadequate protein intake negatively influence the SPPB score and balance in chronic HD patients. Effective identification and management of frailty can therefore improve outcomes.

CLINICAL TRIAL REGISTRATION ClinicalTrialsgov

NCT03845452.

Development and internal validation of a clinical prediction model to predict independence in daily living at discharge for patients with heart failure: analysis using a Japanese national inpatient database real-world dataset

PURPOSE

To develop a clinical prediction model (CPM) to predict independence in activities of daily living (ADLs) in patients with heart failure.

SUBJECTS AND METHODS

We collected the data of the individuals who were admitted and rehabilitated for heart failure from January 2017 to June 2022 from Japan's Diagnosis Procedure Combination database. We assessed the subjects' ADLs at discharge using the Barthel Index and classified them into independence, partial-independence, and total-dependence groups based on their ADLs at discharge. Two CPMs (an independence model and a partial-independence model) were developed by a binomial logistic regression analysis. The predictors included subject characteristics, treatment, and post-hospitalization disease onset. The CPMs' accuracy was validated by the area under the curve (AUC). Internal validation was performed using the bootstrap method. The final CPM is presented in a nomogram.

RESULTS

We included 96,753 patients whose ADLs could be traced at discharge. The independence model had a 0.73 mean AUC and a 1.0 slope at bootstrapping. We thus developed a simplified model using nomograms, which also showed adequate predictive accuracy in the independence model. The partial-independence model had a 0.65 AUC and inadequate predictive accuracy.

CONCLUSIONS

The independence model of ADLs in patients with heart failure is a useful CPM.

The impact of malnutrition on the effectiveness of intradialytic exercise in hemodialysis patients: amulticenter cohort study

PURPOSE

Low physical function can be effectively improved via intradialytic exercise. However, the association between the effects of intradialytic exercise on physical function and malnutrition severity has not been studied extensively. This study aimed to investigate the impact of nutritional status severity on physical function in patients undergoing hemodialysis with low physical function to whom intradialytic exercise was prescribed.

METHODS

The participants were patients with decreased mobility [walking speed < 1.0 m/s and/or Short Physical Performance Battery (SPPB) < 12] who had been undergoing hemodialysis thrice a week for 6 months and performing intradialytic exercise program. Patients were divided into groups based on the Geriatric Nutritional Risk Index (GNRI) [Non-malnutrition group (GNRI > 98), Gentle/slim malnutrition group (GNRI ≤ 98, GNRI ≥ 92), Mild malnutrition group (GNRI < 92, GNRI ≥ 82), Severe malnutrition group (GNRI < 82)]. The primary outcomes were Grip strength, isometric knee extension strength (IKES), SPPB, and 10-m walking speed measured at baseline and at 6 months. Statistical analyses were performed using a linear mixed-effects model with the intention-to-treat analysis, including within-group analysis and between-group comparison.

RESULTS

A total of 805 participants were included in the study. Within-group comparisons showed significantly improved IKES, 10-m walking speed, and SPPB improved, except in the Severe malnutrition group. Grip strength significantly improved in the Gentle/slim and mild malnutrition groups. Between-group comparison with controls showed that the improvement in Grip strength was significantly bigger in the Gentle/slim malnutrition group [0.98 (0.15 to 1.82) kg] than in the non-malnutrition group. However, IKES in the Severe malnutrition group [- 5.14 (- 9.18 to - 1.10) %] less significantly improve than that in the non-malnutrition group. No significant differences were found in the other indices.

CONCLUSION

In patients with severe malnutrition, the changes in IKES scores resulting from Intradialytic exercise were significantly smaller than those observed in non-malnourished patients. Therefore, it is necessary to initiate suitable nutritional and exercise therapy based on the severity of malnutrition.

Effect of exercise training on functional capacity, muscle strength, exercise capacity, dialysis efficacy and quality of life in children and adolescents with chronic kidney disease: a systematic review and meta-analysis

PURPOSE

To synthesize the effect of exercise training on functional capacity, muscle strength, exercise capacity, dialysis efficacy, and quality of life (QOL) in children and adolescents with CKD.

METHODS

PubMed/Medline, Scopus, PEDro, Web of Science, CINAHL, Cochrane, and Embase were searched from inception to September 30, 2023. Randomized control trials (RCTs) and clinical trials that assessed the effect of exercise training programs on functional capacity, muscle strength, exercise capacity, dialysis efficacy, and QOL in children and adolescents with CKD were included. Random effect model and meta-regression were used for the meta-analysis.

RESULTS

Four clinical trials and three RCTs were included. The results showed that exercise training improves strength, but meta-analysis did not show a significant effect of exercise on functional capacity (WMD: 1.02; 95% CI: - 0.14 to 2.18; p = 0.083) and QOL (WMD: 8.00; 95% CI: - 3.90 to 19.91; p = 0.187). Subgroup analysis revealed that more than 25 sessions and 45 min per session of intervention, a PEDro score of more than 5, and being younger than 12 years of age had a large effect on functional capacity and QOL results. Due to the limited number of studies that reported the effect of exercise on dialysis efficacy and exercise capacity, the findings were inconclusive.

CONCLUSION

Exercise training could benefit children and adolescents with CKD by increasing their strength. Longer exercise interventions may be beneficial for improving functional capacity and QOL. Future well-designed RCTs should overcome the existing limitations using adequate sample sizes and longer exercise durations.

Efficacy of resistance exercise during hemodialysis on improving lower limb muscle strength in patients with chronic kidney disease: a meta-analysis of randomized clinical trials

INTRODUCTION

Patients with chronic kidney disease (CKD) on hemodialysis (HD) have muscle weakness in addition to a high risk of falls, motor impairment and immobilization.

OBJECTIVE

To conduct a systematic review with meta-analysis of randomized clinical trials regarding the effectiveness of resistance exercises on muscle strengthening and lower limb endurance in patients with CKD on HD.

METHODOLOGY

The study was conducted in the PubMed, EMBASE, SciELO, LILACS and Cochrane databases, without linguistic restrictions or year of publication.

RESULTS

Of the 824 studies found, only 6 were included for analysis. Studies were allocated to some concern or high risk of bias regarding the reporting of outcomes. The low quality of outcome evidence can mainly be observed due to the severe level of inconsistency owing to the high degree of heterogeneity. A significant reduction in heterogeneity was observed after the sensitivity analysis, demonstrating an improvement in the muscle strength of the lower limbs (p = .002).

CONCLUSION

It is concluded that most studies demonstrate benefits in carrying out resistance training programs in increasing muscle strength of the lower limbs, however, it is necessary that randomized clinical trials (RCTs) with greater methodological rigor are performed to confirm these findings.

Investigating the relationship between FRailty And Quality of LIfe in patients with heart faiLure and CKD (FRAIL study)

AIMS

Patients with chronic kidney disease (CKD) or heart failure (HF) are disproportionally affected by frailty, an independent predictor of morbidity. The prevalence of frailty and its impact on quality of life (QoL) in a unique population of patients with both CKD and HF (CKD-HF) is unclear. The aim of this study was to investigate the association between frailty and QoL in patients with CKD-HF.

METHODS AND RESULTS

Patients were identified from a tertiary care cardiorenal clinic. Eligible patients had CKD-HF with a stable estimated glomerular filtration rate of <60 mL/min/1.732. Data were collected from each participant at one point in time using surveys delivered by study personnel between 14 July 2022 and 31 March 2023. Frailty was defined as Modified Frailty Phenotype (MFP) score ≥3. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to assess QoL. Demographic data were retrospectively collected from electronic patient records. Demographics and QoL were compared between frail and non-frail cohorts using Pearson's R and Student's t-test (two-tailed, alpha-priori = 0.05). One hundred five participants consented, and 103 completed the questionnaires in full. Amongst the 103 participants, 49.5% (n = 51) were frail. Frailty was related to sex (P = 0.021) and medication count (P = 0.007), however not to other clinical measures, including estimated glomerular filtration rate (P = 0.437) and ejection fraction (P = 0.911). Frail patients reported poorer QoL across physical functioning (P < 0.001), general health (P < 0.001), bodily pain (P = 0.004), social functioning (P < 0.001), and energy levels (P < 0.001), however not emotional wellbeing (P = 0.058); 51.5% cited 'better quality of life' as their healthcare priority, over longer survival (23.3%) or avoiding hospital admissions (22.3%). This was consistent across frail and non-frail groups.

CONCLUSIONS

A large proportion of CKD-HF patients are frail, regardless of disease severity, and more susceptible to significantly poorer QoL across physical and social domains. Improving QoL is the priority of patients across both frail and non-frail cohorts, further emphasizing the need for prompt recognition of frailty as well as possible intervention and prevention.

Modifiable Physical Factors That Influence Physical Function for People Receiving Peritoneal Dialysis

Introduction

People receiving peritoneal dialysis experience physical function decline, impairing their ability to complete everyday activities, leading to poorer quality of life. Physical factors, including cardiorespiratory fitness, muscle strength, physical activity, and sedentary behavior are associated with physical function. However, little is known about this relationship, or temporal changes of these factors in this cohort. This study aimed to explore modifiable physical factors that are associated with physical function, identify which factor has the strongest influence, and explore temporal changes.

Methods

Adults receiving peritoneal dialysis underwent objective and self-reported physical function, cardiorespiratory fitness, muscle strength, physical activity and sedentary behavior assessments 3 times over a 12-month observation period (at baseline, 6 months, and 12 months).

Results

Eighty-two participants underwent assessments. All modifiable physical factors were predominantly moderate to strongly associated with physical function at baseline. Cardiorespiratory fitness had the strongest and most consistent influence with every meter conferring a 0.08-unit (P < 0.01) and 0.01-unit (P < 0.05) increase in self-report and objective physical function score, respectively. Temporal changes were observed for modifiable physical factors with significant mean changes in cardiorespiratory fitness (-9.8%), quadricep strength (-5%), moderate-to-vigorous (-25.9%) and total (-16.2%) physical activity, and sedentary behavior (+7.1%).

Conclusion

The results of this study indicate that cardiorespiratory fitness could be routinely monitored to detect risk of physical function decline and targeted through intervention to enhance physical function for people receiving peritoneal dialysis. Nevertheless, all factors should be considered when designing interventions to mitigate temporal changes and induce the numerous health benefits offered by being physically active.

Association of kidney function with physical performance: the Maastricht study

BACKGROUND

Kidney failure has been associated with decreased physical capacity, although evidence regarding the physical performance of individuals with earlier stages of chronic kidney disease (CKD) remains limited.

METHODS

Cross-sectional data were derived from the prospective, population-based Maastricht Study. Multivariate linear regression models were fitted to assess the association of estimated glomerular filtration rate (eGFR) and albuminuria categories with physical performance test outcomes.

RESULTS

Overall, 7396 participants were included. Compared to eGFR 60-90 ml/min/1.73 m2, values < 60 ml/min/1.73 m2 were associated with significantly shorter 6-min walk distance (β: - 13.04 m, 95% confidence intervals-CI - 19.95; - 6.13), worse timed chair rise stand test time (β: 0.91 s, 95% CI 0.36; 1.47), lower maximal grip (β: - 0.83 kg, 95% CI - 1.50; - 0.15) and elbow flexion (β: - 3.64 Nm, 95% CI - 7.11; - 0.16) strength. Additionally, eGFR > 90 ml/min/1.73 m2 was linked to significantly shorter 6-min walk distance (β: - 6.13 m, 95% CI - 9.44; - 2.82). Urinary albumin excretion > 30 mg/24 h was associated with shorter 6-min walk distance (β: - 12.48 m, 95% CI - 18.28; - 6.68), worse timed chair rise stand test time (β: 0.51 s, 95% CI 0.11; 1.06), lower maximal grip (β: - 1.34 kg, 95% CI - 1.91; - 0.76) and elbow flexion strength (β: - 3.31 Nm, 95% CI - 5.80; - 0.82).

CONCLUSIONS

Reduced eGFR and higher albuminuria levels were associated with worse physical performance, especially shorter 6-min walk distance and lower muscle strength. The relationship between eGFR and physical function was non-linear, with also high eGFR values being associated with worse performance, especially in the six-minute walk test.

Psychometrically validated questionnaires to measure the effects and benefits/barriers to physical exercise in hemodialysis patients: a systematic review

PURPOSE

To provide a critical assessment, summarize, and synthesize the evidence from studies using psychometrically validated questionnaires to assess the effects and benefits/barriers of physical exercise in hemodialysis patients.

METHODS

The search was performed on six electronic databases. It was conducted following the PRISMA statement and the PICO framework. The methodological quality was assessed using the MMAT. Were used the quality criteria for psychometric properties developed by Terwee et al.

RESULTS

Overall, 70 studies were included, and 39 questionnaires identified, evaluating 13 outcomes. The quality of the psychometric properties of the questionnaires was not always described; only 13 presented positive ratings on > =6/9 properties. The most assessed measure was criterion validity, and the least assessed criteria was responsiveness. The most outcome measured by these questionnaires was quality of life using SF-36, followed by psychological health using the BDI. The DPEBBS was the only instrument identified that assessed the benefits and barriers of exercise.

CONCLUSION

Quality of life and depression were the most frequent outcomes. Other measures contemplating physical, mental, cognitive performance, and especially of the perceptions benefits and barriers to exercise should be further investigated. We have clearly identified the need for more studies evaluating psychometric measures that have not been tested satisfactorily or hardly been tested at all.

Effects of upper limbs' neuromuscular electrical stimulation (NMES) superimposed to voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise, in muscle strength, functional capacity and quality of life of adult patients with CKD: a randomized clinical trial protocol

OBJECTIVE

To investigate the effects of unilateral upper limbs' (ULM) neuromuscular electrical stimulation (NMES) superimposed on a voluntary contraction added to a protocol of intradialytic leg cycle ergometer exercise on muscle strength, functional capacity and quality of life of adult patients with chronic kidney disease (CKD).

METHODS

This randomized controlled clinical trial will be carried out at a Brazilian University Hospital. The patients will be evaluated and randomly allocated to an intervention group (i.e., unilateral NMES on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min) or a control group (i.e., unilateral NMES-Sham on the upper limb without hemodialysis fistula for 20 min and leg cycle ergometer for 30 min). The patients will be treated for 8 weeks, with three weekly treatment sessions totaling 24 sessions.

MEASUREMENTS

ULM muscle strength, functional capacity, quality of life and also the feasibility, safety and patient adherence to the exercise protocol. All physical measurements will be collected by trained researchers before treatment (week 0) and at the end of treatment (week 9), always in the second hemodialysis session of the week. It will be used in an intention-to-treat analysis.

RESULTS/CONCLUSIONS

The outcomes of this clinical trial protocol may help to know the possible benefits of unilateral ULM' NMES superimposed on a voluntary contraction added to a protocol of leg cycle ergometer for patients with CKD and to aid clinical decisions about future implementation or not of this technique (NMES) in intradialytic physical training programs.

Factors associated with improved health-related quality of life due to improvements in physical function and dialysis-related symptoms following intradialytic exercise in outpatients undergoing haemodialysis

PURPOSE

Exercise therapy is a crucial intervention for improving health-related quality of life (HRQOL) in patients undergoing haemodialysis. However, factors that improve HRQOL by improving physical function and dialysis-related symptoms remain unknown. This study aimed to examine the physical function parameters and dialysis-related symptoms that improve HRQOL following intradialytic exercise.

METHODS

This multicentre cohort study included 596 patients who participated in an intradialytic exercise program three times per week for a period of 6 months, which comprised of stretching and resistance training. EuroQol 5 dimensions 5-level (EQ5D-5L), grip strength, isometric knee extension strength, 10-m walking speed, Short Physical Performance Battery (SPPB), and improvement in dialysis-related symptoms were measured at the baseline and post-intervention. A linear mixed model was used to analyse the effects of improved physical function and dialysis-related symptoms on improvements in EQ5D-5L.

RESULTS

As a physical function index affecting ΔEQ5D-5L, only SPPB showed a significant increase in ΔEQ5D-5L compared with the non-improved group [difference in ΔEQ5D-5L, 0.05 (0.004 to 0.092) point; p < 0.05]). In addition, dialysis-related symptoms with Improved physical conditions [difference in ΔEQ5D-5L, 0.07 (0.02 to 0.13) point] and an Extended walking distance [difference in ΔEQ5D-5L was 0.07 (0.01 to 0.12) point] significantly influenced ΔEQ5D-5L (p < 0.05, both).

CONCLUSIONS

The improvements observed in the SPPB scores and self-percieved physical fitness and ambulation range, attributable to intradialytic exercise, may potentially improve HRQOL.

Exercise for patients with chronic kidney disease: from cells to systems to function

Chronic kidney disease (CKD) is among the leading causes of death and disability, affecting an estimated 800 million adults globally. The underlying pathophysiology of CKD is complex creating challenges to its management. Primary risk factors for the development and progression of CKD include diabetes mellitus, hypertension, age, obesity, diet, inflammation, and physical inactivity. The high prevalence of diabetes and hypertension in patients with CKD increases the risk for secondary consequences such as cardiovascular disease and peripheral neuropathy. Moreover, the increased prevalence of obesity and chronic levels of systemic inflammation in CKD have downstream effects on critical cellular functions regulating homeostasis. The combination of these factors results in the deterioration of health and functional capacity in those living with CKD. Exercise offers protective benefits for the maintenance of health and function with age, even in the presence of CKD. Despite accumulating data supporting the implementation of exercise for the promotion of health and function in patients with CKD, a thorough description of the responses and adaptations to exercise at the cellular, system, and whole body levels is currently lacking. Therefore, the purpose of this review is to provide an up-to-date comprehensive review of the effects of exercise training on vascular endothelial progenitor cells at the cellular level; cardiovascular, musculoskeletal, and neural factors at the system level; and physical function, frailty, and fatigability at the whole body level in patients with CKD.

Digital health interventions to promote healthy lifestyle in hemodialysis patients: an interventional pilot study

Low physical activity has been associated with poor prognosis in hemodialysis (HD) patients. Interventions to maintain healthy lifestyle in this population are important to reduce mortality. This study aimed to evaluate the effectiveness of digital health interventions (DHIs) for improving the physical activity and health-related quality of life (HRQoL) in HD patients. The 24-week prospective study enrolled 31 clinically stable HD patients. All participants were assigned home exercises and provided with wearable devices. Dietary and exercise information was uploaded to a health management platform. Suggestions about diet and exercise were provided, and a social media group was created. Physical performance testing was performed at baseline and during weeks 4, 8, 12, 16 and 24. HRQoL and nutritional status were evaluated. A total of 25 participants completed the study. After the interventions, the daily step count increased 1658 steps. The 10-time-repeated sit-to-stand test reduced by 4.4 s, the sit-to-stand transfers in 60 s increased 12 repetitions, the distance of six-minute walk test (6MWT) increased by 55.4 m. The mental health components and burden of kidney disease of the Kidney Disease Quality of Life survey, and subjective global assessment (SGA) scores improved. By Spearman correlation, the monthly step count correlated positively with 6MWT and SGA. DHIs that combined wearable devices, a health management platform, and social media could strengthen physical activity and improve the HRQoL and nutrition of maintenance HD patients. The results outline a new model to promote healthy lifestyle behaviors in HD patients.

The phase angle cut-off point capable of discriminating hemodialysis patients with reduced exercise tolerance: a cross-sectional study

BACKGROUND

Phase angle (PhA) is a prognostic marker of all-cause mortality in chronic kidney disease. However, no study has investigated this marker as a predictor of exercise intolerance in hemodialysis (HD) patients. The aim of this study was to determine a cut-off point for the PhA capable of discriminating HD patients with reduced exercise tolerance.

METHODS

Thirty-one patients (80.6% men, median age 69 years) were included. The evaluations were performed on three different days, before the HD session. The outcomes evaluated were: biochemical markers, inflammatory and nutritional status, body composition, peripheral muscle strength and exercise tolerance. Performance ≤50% of the predicted value in the six-minute step test (6MST) was defined as reduced exercise tolerance.

RESULTS

Patients presented an average of 67.6 steps (50.5% of predicted) in the 6MST. Fifteen patients (48.4%) were classified with reduced exercise tolerance. The receiver operating characteristic curve indicated a cut-off point of 3.73° for the PhA (sensitivity = 87%, specificity = 81%, and area under the curve = 0.88 [95% CI: 0.76-1.00]; p < 0.001). Patients with reduced exercise tolerance had worse inflammatory and nutritional status, lower PhA and greater impairment of peripheral muscle strength.

CONCLUSION

The cut-off point of 3.73° for the PhA is sensitive and specific to discriminate HD patients with reduced exercise tolerance.

TRIAL REGISTRATION

This study was registered in the Clinical Trials database (no. NCT03779126, date of first registration 19/12/2018).

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.

The effects of exercise training interventions on depression in hemodialysis patients

Purpose

Depression considerably influences the clinical outcomes, treatment compliance, quality of life, and mortality of hemodialysis patients. Exercise plays a beneficial role in depressive patients, but its quantitative effects remain elusive. This study aimed to summarize the effects of exercise training on depression in patients with end-stage renal disease undergoing hemodialysis.

Methods

The PUBMED, EMBASE, and Cochrane Library databases were systematically searched from inception to April 2023 to identify published articles reporting the effect of exercise training on the depression level of patients with End-Stage Renal Disease undergoing hemodialysis. Data were extracted from the included studies using predefined data fields by two independent researchers. The Cochrane Handbook for Systematic Reviews of Interventions and Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies were employed for quality evaluation.

Results

A total of 22 studies enrolling 1,059 patients who participated in exercise interventions were included. Hemodialysis patients exhibited superior outcomes with intradialytic exercise (SMD = -0.80, 95% CI: -1.10 to -0.49) and lower levels of depression following aerobic exercise (SMD = -0.93, 95%CI: -1.32 to -0.55) compared to combined exercise (c - 0.85, 95% CI: -1.29 to -0.41) and resistance exercise (SMD = -0.40, 95%CI: -0.96 to 0.17). Regarding exercise duration, patients manifested lower depression levels when engaging in exercise activities for a duration exceeding 6 months (SMD = -0.92, 95% CI: -1.67 to -0.17). Concerning the duration of a single exercise session, the most significant improvement was noted when the exercise duration exceeded 60 min (SMD = -1.47, 95% CI: -1.87 to -1.06).

Conclusion

Our study determined that exercise can alleviate depression symptoms in hemodialysis patients. This study established the varying impacts of different exercise parameters on the reduction of depression levels in hemodialysis patients and is anticipated to lay a theoretical reference for clinicians and nurses to devise tailored exercise strategies for interventions in patients with depression.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, with registration number CRD42023434181.

Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): a multicentre, randomised controlled trial in the UK

BACKGROUND

Remote digital health interventions to enhance physical activity provide a potential solution to improve the sedentary behaviour, physical inactivity, and poor health-related quality of life that are typical of chronic conditions, particularly for people with chronic kidney disease. However, there is a need for high-quality evidence to support implementation in clinical practice. The Kidney BEAM trial evaluated the clinical effect of a 12-week physical activity digital health intervention on health-related quality of life.

METHODS

In a single-blind, randomised controlled trial conducted at 11 centres in the UK, adult participants (aged ≥18 years) with chronic kidney disease were recruited and randomly assigned (1:1) to the Kidney BEAM physical activity digital health intervention or a waiting list control group. Randomisation was performed with a web-based system, in randomly permuted blocks of six. Outcome assessors were masked to treatment allocation. The primary outcome was the difference in the Kidney Disease Quality of Life Short Form version 1.3 Mental Component Summary (KDQoL-SF1.3 MCS) between baseline and 12 weeks. The trial was powered to detect a clinically meaningful difference of 3 arbitrary units (AU) in KDQoL-SF1.3 MCS. Outcomes were analysed by an intention-to-treat approach using an analysis of covariance model, with baseline measures and age as covariates. The trial was registered with ClinicalTrials.gov, NCT04872933.

FINDINGS

Between May 6, 2021, and Oct 30, 2022, 1102 individuals were assessed for eligibility, of whom 340 participants were enrolled and randomly assigned to the Kidney BEAM intervention group (n=173) or the waiting list control group (n=167). 268 participants completed the trial (112 in the Kidney BEAM group and 156 in the waiting list control group). All 340 randomly assigned participants were included in the intention-to treat population. At 12 weeks, there was a significant improvement in KDQoL-SF.13 MCS score in the Kidney BEAM group (from mean 44·6 AU [SD 10·8] at baseline to 47·0 AU [10·6] at 12 weeks) compared with the waiting list control group (from 46·1 AU [10·5] to 45·0 AU [10·1]; between-group difference of 3·1 AU [95% CI 1·8-4·4]; p<0·0001).

INTERPRETATION

The Kidney BEAM physical activity platform is an efficacious digital health intervention to improve mental health-related quality of life in patients with chronic kidney disease. These findings could facilitate the incorporation of remote digital health interventions into clinical practice and offer a potential intervention worthy of investigation in other chronic conditions.

FUNDING

Kidney Research UK.

Nutritional Considerations for Patients With Renal Failure Undergoing Sleeve Gastrectomy

Obesity is highly prevalent in patients with renal disease, as it contributes to or accelerates the progression of kidney disease and is frequently a barrier to kidney transplantation. Patients with renal disease have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG), as the safest, most effective, and long-lasting weight loss option to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with renal disease undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with renal disease seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre and post-SG.

Age-associated effects of intradialytic exercise on physical function and nutritional status in patients receiving ambulatory hemodialysis: A multicenter cohort study

INTRODUCTION

Intradialytic exercise is essential for improving physical function for older patients. This study aimed to examine the relationship between the effects of exercise therapy and aging.

METHODS

This multicenter cohort study included 1176 patients aged 40-89 years, who participated in an intradialytic exercise program, comprising stretching and resistance training, three times per week for 12 months. Isometric knee extension strength (IKES), 10-m walking speed, Short Physical Performance Battery (SPPB), and Geriatric Nutritional Risk Index (GNRI) were measured at baseline and after 12 months. The patients were divided according to age as follows: 40-59, 60-69, 70-79, and 80-89 years. A linear mixed-effects model examined the improvement within-group and between-control differences, as the 40-59 age group was the control group.

FINDINGS

The 40-59, 60-69, 70-79, and 80-89 age groups comprised 180, 317, 466, and 213 participants, respectively. Within-group differences, all the age groups significantly improved IKES and SPPB. The 10-m walking speed [0.02 (0.02) m/s] and GNRI [0.38 (0.33)] did not improved only in the 80-89 age group despite other age groups significantly improved. Between-control differences, IKES of the 70-79 age group [-0.24 (-0.42 to -0.06) %] was significantly lower improvement than control. GNRI of all the older groups were significantly smaller improvement than control (p < 0.05).

DISCUSSION

The older group demonstrated difficulty in improving walking ability and nutritional status compared with the younger groups. Clinicians need to consider the difference in effectiveness due to age and prescribe intradialytic exercises accordingly.

Combining exercise and nutrition in chronic kidney disease and dialysis: Can we learn from the performance nutrition of athletes?

The benefits of exercise interventions in individuals with chronic kidney disease have been widely reviewed; however, exercise has not yet been incorporated into routine clinical practice. In athletic populations, the goals of exercise training are to improve a specific aspect of physical performance such as strength or endurance, to ultimately optimize physical performance. This contrasts with many chronic kidney disease exercise studies where the goals are more aligned to a minimal effect, such as prevention of decline in physical function, frailty or protein energy wasting (PEW), weight loss for cardiovascular disease risk reduction, and risk minimization for mortality. In athletic populations, there are common targeted nutrition strategies used to optimize physical performance. In this review, we consider the evidence for and potential benefits of targeted nutrition strategies to complement well-designed exercise interventions to improve physical performance in people with chronic kidney disease and dialysis. Overall, we found a small number of studies using targeted protein supplementation in combination with a variety of exercise protocols; however, results were mixed. Future studies in people with chronic kidney disease should optimize acute (pre, during, and postexercise) and chronic nutritional status, utilizing targeted nutrition interventions proven in athletes to have benefit.

Effects of intradialytic exercise on functional capacity in patients with end-stage chronic kidney disease: a systematic review and meta-analysis

The study aimed to investigate the effect of intradialytic exercise training programmes on the submaximal functional capacity of patients with kidney failure. We searched for randomized clinical trials that assessed submaximal functional capacity using the 6-min walk test (6 MWT) in adult patients on maintenance haemodialysis submitted to intradialytic physical training. The search was performed on 15 October 2021, in different databases. Random-effect, multivariate meta-regression adjusted for multiplicity were performed to examine the relationship between exercise effect and covariates. Intradialytic physical exercise induced greater changes in 6MWT distance (k = 18; n = 1,458; WMD: 37.0; 95% CI 29.3; 50.6 metres) than control groups, with substantial heterogeneity (I2 = 78.3%). Aerobic, strength, and combined exercise promoted an average increase of 48.7 (95%CI 30.9; 66.4 metres), 16.9 (95%CI 7.6; 26.3 metres), and 75.8 (95%CI 55.1; 96.6 metres) metres, respectively. Strength training resulted in inferior gains in 6MWT distance compared to aerobic training (WMD: -25.0; 95%CI: -49.1; -0.9). Intervention length shorter than 11 weeks (WMD: 37.0; 95%CI: -5.4; 79.3 metres) did not induce greater changes in 6MWT compared to control groups. There was a positive response in submaximal functional capacity to intradialytic training in kidney failure patients on maintenance haemodialysis.

Prevention of Cardiovascular Events in Patients With Chronic Kidney Disease

OBJECTIVE

To examine the evidence base for lifestyle and pharmacologic interventions to reduce the risk of cardiovascular events in patients with chronic kidney disease, with an emphasis on reporting available data in distinct subtypes.

DATA SOURCES

A PubMed search (origin to February 2023) was conducted and references for selected studies were reviewed to identify additional articles. Search terms included chronic kidney disease, major adverse cardiovascular events, and heart failure hospitalization.

STUDY SELECTION AND DATA ANALYSIS

English language studies reporting cardiovascular outcomes data in patients with chronic kidney disease were included.

DATA SYNTHESIS

Much of the data on interventions to prevent cardiovascular events in patients with chronic kidney disease are derived from observational studies or subgroup analyses of trials of broader populations. Some common recommendations, such as weight loss, may be harmful in certain patients. Others may only offer benefits in subgroups, such as those with albuminuria. Newer agents, such as SGLT2 inhibitors and finerenone, have clearer evidence of cardiovascular benefit, but these may also apply only to specific subgroups.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Given the prevalence of chronic kidney disease and its attendant cardiovascular risk, it is important to understand which interventions offer the greatest benefit.

CONCLUSIONS

Patients diagnosed with chronic kidney disease have markedly increased risk of cardiovascular events, including myocardial infarction, stroke, heart failure, and cardiovascular death. However, until recently, there were few cardiovascular outcome studies that targeted enrollment specifically to those patients. Certain drugs now have shown benefits to cardiovascular end points in this population.

Frailty and Adverse Outcomes After SARS-CoV-2 Infection in Elderly Patients on Maintenance Hemodialysis: A Cohort Study

Purpose

Frailty is an important geriatric syndrome associated with aging and adverse events, especially in patients with severe infection. To help guide prognosis for elderly patients undergoing maintenance hemodialysis (MHD) who experience acute infection, this study investigated whether baseline (pre-infection) frailty may be associated with adverse outcomes in elderly patients undergoing MHD who suffer SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection.

Patients and Methods

Patients (aged ≥60 y) receiving MHD had been assessed for overall frailty and the 5 frailty components based on the Fried Frailty Phenotype scale within 3 months prior to SARS-CoV-2 infection.

Results

There were 59 and 98 patients in the frail and non-frail groups, respectively. Three months after SARS-CoV-2 infection, 21 (13.4%) and 45 (28.7%) patients had died or were in hospital. The multivariate COX proportional risk model suggested that the all-cause mortality rate in patients judged overall frail or with low activity was significantly higher compared with that of the non-frail (P = 0.049; 0.003). The multivariate logistic regression analysis showed that hospitalization 3 months after SARS-CoV-2 infection was associated with both overall frailty and low activity (OR 2.276, 95% CI: 1.034-5.010, P = 0.041; OR 2.809, 95% CI: 1.311-6.020, P = 0.008, respectively).

Conclusion

Overall frailty and specifically low activity were significantly associated with all-cause mortality and hospitalization in this elderly MHD population after SARS-CoV-2 infection. Early assessment of frailty and effective interventions are recommended to improve the prognosis of patients receiving MHD who are at higher risk of acute infection.

A Comprehensive Exercise (COMEX) Intervention to Optimize Exercise Participation for Improving Patient-Centered Outcomes and Physical Functioning in Patients Receiving Hemodialysis: Development and Pilot Testing

Rationale & Objective

To address the need for an intradialytic exercise program that is easily delivered in clinical setting, engaging and scalable, we developed a novel COMprehensive EXercise (COMEX) program based on input from patients receiving hemodialysis (HD), dialysis staff members and nephrologists. The objective of this study was to determine the feasibility, safety, and acceptance of COMEX during HD.

Study Design

Single-arm prospective pilot feasibility study.

Setting & Participants

Seventeen patients receiving in-center HD.

Intervention

Three-month participation in the COMEX program, which included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components.

Outcomes

Data on recruitment, adherence, safety and acceptability were collected. Additional assessments were performed to evaluate changes in physical functioning, patient-reported symptoms, and objectively measured sleep and physical activity. We also examined the feasibility of obtaining skeletal muscle biopsies and blood samples to explore molecular mechanisms of muscle atrophy and to assess platelet mitochondrial function and adaptation to exercise during HD.

Results

Thirteen of the 17 (76%) participants completed the 3-month intervention. The mean participant age was 63.6 ± 15.1 years. In total, 46% of participants were males, and 55% were White. The mean body mass index was 38.7 ± 11.6 kg/m2. There were no reported adverse effects, and the adherence rate to exercise sessions was high with 88% of the sessions completed. Patient satisfaction was high, as 100% of the patients would recommend the program to other dialysis patients. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples.

Limitations

Small sample size, lack of an onsite exercise professional, and technological issues with telemedicine behavioral motivation.

Conclusions

The COMEX intradialytic exercise intervention is safe and acceptable to patients, and outcome measures were feasible to obtain. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.

Funding Source

This work is supported by pilot award from P30 DK079307 (PI, Jhamb).

Trial Registration

ClinicalTrials.gov, NCT03055299.

Plain-Language Summary

We tested a new COMprehensive EXercise (COMEX) program to deliver exercise during dialysis. This 3-month program included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components. Our study shows COMEX was feasible, had high satisfaction and adherence, and was safe. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.

Examining the safety and effectiveness of a 4-week supervised exercise intervention in the treatment of frailty in patients with chronic kidney disease

Background

The optimal duration of antifrailty interventions and how best to deliver them to patients with chronic kidney disease (CKD) is unknown. The aim of this study was to examine the safety, feasibility and preliminary efficacy of a 4-week supervised exercise intervention on frailty in patients with CKD.

Methods

We conducted a prospective feasibility study involving patients with ≥stage 3 CKD (1 patient with stage 3 CKD, 7 patients with stage 4 CKD and 17 patients with stage 5 CKD) who were either frail or prefrail according to the physical frailty phenotype and/or had a Short Physical Performance Battery (SPPB) score ≤10. The exercise intervention consisted of two supervised outpatient sessions per week for 4 weeks (eight total sessions). Frailty and other study measures were assessed at baseline and after 4 weeks of exercise.

Results

Of the 34 participants who completed the baseline assessment and were included in the analyses, 25 (73.5%) completed the 4-week assessment. Overall, 64.0% of patients were on dialysis and 64.0% had diabetes mellitus. After 4 weeks of exercise, frailty prevalence, total SPPB scores and energy/fatigue scores improved. No adverse study-related outcomes were reported.

Conclusions

The 4 weeks of supervised exercise was safe, was associated with an excellent completion rate and improved frailty parameters in CKD patients with CKD. This study provides important preliminary data for a future larger prospective randomized study.

Clinical Trialgov

registration: NCT03535584.

Home-based exercise in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The impact of home-based exercise on physical performance and quality of life (QoL) in patients on maintenance dialysis has not yet been fully established.

METHODS

We searched four large electronic databases to identify randomized controlled trials (RCTs) reporting the impact of home-based exercise interventions vs. usual care or intradialytic exercise interventions, on physical performance and QoL in patients on dialysis. The meta-analysis was performed using fixed effects modeling.

RESULTS

We included 12 unique RCTs involving 791 patients of various ages on maintenance dialysis. Home-based exercise interventions were associated with an improvement of walking speed at the 6 Minutes Walking Test [6MWT; nine RCTs; pooled weighted mean differences (WMD): 33.7 m, 95% confidence interval (CI) 22.8-44.5; P < 0.001; I2 = 0%) and in aerobic capacity as assessed by the peak oxygen consumption (VO2 peak; 3 RCTs; pooled WMD: 2.04 ml/kg/min, 95% CI 0.25-3.83; P = 0.03; I2 = 0%). They were also associated with improved QoL, as assessed by the Short Form (36) Health (SF-36) score. Stratifying the RCTs by control groups, no significant difference was found between home-based exercise and intradialytic exercise interventions. Funnel plots did not reveal any significant publication bias.

CONCLUSIONS

Our systematic review and meta-analysis showed that home-based exercise interventions for 3-6 months were associated with significant improvements in physical performance in patients on maintenance dialysis. However, further RCTs with a longer follow-up should be conducted to assess the safety, adherence, feasibility, and effects on QoL of home-based exercise programs in dialysis patients.

Constipation in Patients With Chronic Kidney Disease

Constipation is a frequent symptom in patients with chronic kidney disease (CKD). This review outlines the mechanisms and management of constipation in patients with CKD from a physician's perspective. Common causes of constipation in patients with CKD include concomitant medications, low dietary fiber intake, water-restricted diet, lack of physical activity, altered gut microbiota, and reduced gastrointestinal motility. Constipation has a negative impact on overall health, and, in particular, the presence of constipation has been associated with worsening kidney function and increased risk of developing advanced stages of CKD. Although lifestyle and dietary modifications may not always be practical for patients with CKD, they are recommended because they are beneficial as they lower mortality in patients with CKD. The use of laxatives containing magnesium salts, bulking agents, and osmotic laxatives may have insufficient efficacy and may be associated with adverse effects. In contrast, lactulose and lubiprostone have been shown to exhibit reno-protective effects. Linaclotide and plecanatide have very limited systemic absorption and appear safe in patients with CKD. Tenapanor reduces paracellular intestinal phosphate absorption in addition to blocking sodium uptake by enterocytes, and provides additional benefit in patients patients with CKD who have hyperphosphatemia and constipation. Prucalopride leads to improvements in bowel function and constipation-related symptoms in cases in which response to conventional laxatives are inadequate. However, the dose of prucalopride should be reduced to 1 mg once daily for patients with CKD. In conclusion, there are important advances on the impact and treatment of constipation in patients with CKD.

Delivering Personalized, Goal-Directed Care to Older Patients Receiving Peritoneal Dialysis

Background

An aging population living with chronic kidney disease and progressing to kidney failure, subsequently receiving peritoneal dialysis (PD) is growing. A significant proportion of these patients are also living with multi-morbidities and some degree of frailty. Recent practice recommendations from the International Society of Peritoneal Dialysis advocate for high-quality, goal-directed PD prescription, and the Standardized Outcomes of Nephrology-PD initiative emphasized the need for an individualized, goal-based care approach in all patients receiving PD treatment. In older patients, this approach to PD care is even more important. A frailty screening assessment, followed by a comprehensive geriatric assessment (CGA) prior to PD initiation and when dictated by change in relevant circumstances is paramount in tailoring PD care and prescription according to the needs, life goals, as well as clinical status of older patients with kidney failure.

Summary

Our review aimed to summarize the different dimensions to be taken into account when delivering PD care to the older patient - from frailty screening and CGA in older patients receiving PD to employing a personalized, goal-directed PD prescription strategy, to preserving residual kidney function, optimizing blood pressure (BP) control, and managing anemia, to addressing symptom burden, to managing nutritional intake and promoting physical exercise, and to explore telehealth opportunities for the older PD population.

Key Messages

What matters most to older PD patients may not be simply extending survival, but more importantly, to be living comfortably on PD treatment with minimal symptom burden in a home environment and to minimize treatment complications.

Muscle Strength and Biochemical Markers as Predictors of Depression in Hemodialysis Patients: A Cross-Sectional Study

Patients with chronic renal failure, many of which treated with hemodialysis, present a high prevalence of impaired muscle strength which suggest that muscle mass parameters may be used as markers for changes in muscle in these patients. Measurement of handgrip strength (HGS) is a common, simple, and quick measure of muscle function an indicator of overall muscle strength which has been associated with physical activity and several anthropometric traits. Intercellular adhesion molecule-1 (ICAM-1) and insulin-like growth factor-1 (IGF-1) are biochemical markers associated with inflammatory processes which are a common consequence of dialysis. Additionally, hemodialysis patients frequently present signs of malnutrition and depression. This cross-sectional study aimed to evaluate if muscle and biochemical markers could be used to predict the risk of depression in hemodialysis patients. Several anthropometric parameters, nutrient intake, depression state and the serum levels of ICAM-1 and IGF-1 were determined and Pearson's correlation coefficient and/or Spearman's correlation coefficient were used to test the correlation between them. Our results do not show a correlation between HGF, IGF-1 and ICAM-1 with the depression status of the patients, but mid-arm muscle circumference (MAMC) was statistically and positively correlated with depression. Additionally, ICAM-1 levels were negatively correlated with HGS, MAMC, and IGF-1. Overall, the results of the present study suggest that HGS may be used as an indicator of cardiovascular diseases and MAMC may be a good predictor of the level of depression in hemodialysis patients, although further studies are required.

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.

Exercise during Hemodialysis in Patients with Chronic Kidney Failure

BACKGROUND: Patients with kidney failure undergoing hemodialysis experience physical deconditioning and multimorbidity. Exercise interventions may mitigate this outcome, but their clinical role is unclear. METHODS: This multicenter, cluster randomized controlled trial evaluated combined endurance and resistance exercise training during hemodialysis versus usual care in chronic kidney failure. It assessed physical functioning, quality of life, hospitalizations, and overall survival. The primary outcome was the change in the 60-second sit-to-stand test (STS60) between baseline and 12 months. RESULTS: A total of 1211 patients underwent randomization, 917 (65.9±14.4 years; 38.9% female) of whom were included in the full analysis (exercise intervention, n=446; usual care, n=471). At 12 months, the STS60 repetitions improved from 16.2±7.6 to 19.2±9.1 in the exercise group but declined from 16.2±7.1 to 14.7±7.9 in the usual care group (group difference, 3.85 repetitions; 95% confidence interval [CI], 2.22 to 5.48; P<0.0001). The timed up-and-go test (−1.1 seconds; 95% CI, −1.9 to −0.3) and the 6-minute walk test (37.5 m; 95% CI, 14.7 to 60.4) also differed in the exercise group versus usual care group. The physical summary score and vitality subscale of the quality of life questionnaire (i.e., the 36-item Short Form Health Survey) differed in the exercise group versus usual care group, but the other subscales did not change. Adverse events during dialysis sessions were similar in both groups. Median days spent in the hospital annually were 2 in the exercise group and 5 in the usual care group. Mortality and dialysis-specific adverse events were not affected. CONCLUSIONS: Twelve months of intradialytic exercise in patients with kidney failure significantly improved the STS60 compared with usual care. (Funded by the Innovation Fund, Federal Joint Committee; ClinicalTrials.gov number, NCT03885102.)

The Impact of Intradialytic Cognitive and Physical Training Program on the Physical and Cognitive Abilities in End-Stage Kidney Disease Patients: A Randomized Clinical Controlled Trial

BACKGROUND

Hemodialysis (HD) patients have lower cognitive functioning and reduced physical fitness than age-matched healthy individuals. Clinicians typically do not recognize the declining cognitive performance in these patients; therefore, cognitive impairment is greatly underestimated and not appropriately treated. This study aimed to evaluate the impact on cognitive function of combining cognitive training with physical exercise and physical performance in HD patients.

METHODS

Using a randomized, single-blinded control design, forty-four HD patients were recruited and randomly assigned to either an intradialytic physical exercise and cognitive training program (EXP group; n = 22; 54% male; 65.7 ± 9.7 years; 77.1 ± 21.9 kg; body mass index 26.8 ± 6.0) or a standard care control group (CON group; n = 21; 77% male; 67.2 ± 12.5 years; 74.2 ± 14.3 kg; body mass index 25.9 ± 3.8). The EXP group performed intradialytic cycling and cognitive training three days per week for 12 weeks. Study outcomes were assessed by the Symbol Digit Modalities Test (SDMT), Montreal Cognitive Assessment (MoCA), 10-repetition sit-to-stand test (10-STS), handgrip strength test (HGS), and stork balance test.

RESULTS

The results showed a significant time*group interaction effect for SDMT (p < 0.001; η2 = 0.267) and MoCA (p < 0.001; η2 = 0.266). Moreover, no significant interaction was observed for 10-STS, HGS, and stork balance test (p > 0.05).

CONCLUSIONS

Our findings suggest that incorporating intradialytic cognitive and physical exercise training could help to improve the functional status of HD patients. The innovative, nonpharmacological, bimodal intervention is cost-effective, safe, and easy to implement during the intradialytic period and offers a potential impact on patients' quality of life and well-being.

Clinical features and molecular mechanism of muscle wasting in end stage renal disease

Muscle wasting in end-stage renal disease (ESRD) is an escalating issue due to the increasing global prevalence of ESRD and its significant clinical impact, including a close association with elevated mortality risk. The phenomenon of muscle wasting in ESRD, which exceeds the rate of muscle loss observed in the normal aging process, arises from multifactorial processes. This review paper aims to provide a comprehensive understanding of muscle wasting in ESRD, covering its epidemiology, underlying molecular mechanisms, and current and emerging therapeutic interventions. It delves into the assessment techniques for muscle mass and function, before exploring the intricate metabolic and molecular pathways that lead to muscle atrophy in ESRD patients. We further discuss various strategies to mitigate muscle wasting, including nutritional, pharmacological, exercise, and physical modalities intervention. This review seeks to provide a solid foundation for future research in this area, fostering a deeper understanding of muscle wasting in ESRD, and paving the way for the development of novel strategies to improve patient outcomes. [BMB Reports 2023; 56(8): 426-438].

Combined aerobic and resistance exercise in maintenance hemodialysis patients: A meta-analysis

Exercise brings many benefits to patients undergoing maintenance hemodialysis (MHD), but the effect of combined aerobic and resistance exercise remains unclear. English and Chinese databases (PubMed, Cochrane Library, Embase, Web of Science, CNKI, VIP, Wan Fang, and CBM) were searched from inception to January 2023 to retrieve qualified randomized controlled trials. The literature selection, data extraction, and risk of bias assessment of included studies were conducted independently by two reviewers. Meta-analysis was performed using RevMan 5.3 software. A total of 23 studies with 1214 participants were included, and 17 of the interventions were conducted during dialysis. Results showed that combined aerobic and resistance exercise (CARE) improved the peak oxygen uptake, six-minute walking test, 60 s sit-to-stand test (STS), 30 s STS, dialysis adequacy, five (out of eight) domains and physical component summary of health-related quality of life (HRQOL) measured by the Medical Outcomes Study Short Form-36, blood pressure, and hemoglobin for MHD patients compared with usual care. No significant changes were found in the mental component summary of HRQOL, C-reactive protein, creatinine, potassium, sodium, calcium, and phosphate. Subgroup analysis showed that intradialytic CARE ameliorated more outcomes, except for handgrip strength and hemoglobin, than non-intradialytic ones. CARE is an effective way to improve physical function, aerobic capacity, dialysis adequacy, and HRQOL for MHD patients. Strategies should be implemented by clinicians and policymakers to motivate patients to do more exercise. Well-designed clinical trials are warranted to explore the effectiveness of non-intradialytic CARE.

Digital health technology to support care and improve outcomes of chronic kidney disease patients: as a case illustration, the Withings toolkit health sensing tools

Cardiovascular disease (CVD) is a major burden in dialysis-dependent chronic kidney disease (CKD5D) patients. Several factors contribute to this vulnerability including traditional risk factors such as age, gender, life style and comorbidities, and non-traditional ones as part of dialysis-induced systemic stress. In this context, it appears of utmost importance to bring a closer attention to CVD monitoring in caring for CKD5D patients to ensure early and appropriate intervention for improving their outcomes. Interestingly, new home-used, self-operated, connected medical devices offer convenient and new tools for monitoring in a fully automated and ambulatory mode CKD5D patients during the interdialytic period. Sensoring devices are installed with WiFi or Bluetooth. Some devices are also available in a cellular version such as the Withings Remote Patient Monitoring (RPM) solution. These devices analyze the data and upload the results to Withings HDS (Hybrid data security) platform servers. Data visualization can be viewed by the patient using the Withings Health Mate application on a smartphone, or with a web interface. Health Care Professionals (HCP) can also visualize patient data via the Withings web-based RPM interface. In this narrative essay, we analyze the clinical potential of pervasive wearable sensors for monitoring ambulatory dialysis patients and provide an assessment of such toolkit digital medical health devices currently available on the market. These devices offer a fully automated, unobtrusive and remote monitoring of main vital functions in ambulatory subjects. These unique features provide a multidimensional assessment of ambulatory CKD5D patients covering most physiologic functionalities, detecting unexpected disorders (i.e., volume overload, arrhythmias, sleep disorders) and allowing physicians to judge patient's response to treatment and recommendations. In the future, the wider availability of such pervasive health sensing and digital technology to monitor patients at an affordable cost price will improve the personalized management of CKD5D patients, so potentially resulting in improvements in patient quality of life and survival.

The effect of intradialytic exercise on dialysis patient survival: a randomized controlled trial

BACKGROUND

Patients with kidney failure have a high mortality rate. This study aimed to evaluate the effect of intradialytic exercise on survival in patients receiving hemodialysis (HD).

METHODS

In this randomized controlled trial conducted in a HD center in Iran, adult patients receiving chronic HD were randomized to intradialytic exercise (60 min) in the second hour of thrice weekly dialysis for 6 months (intervention) or no intradialytic exercise (control). The primary outcome was survival rate at 12 months. Secondary outcomes were serum albumin, hemoglobin, hematocrit, red blood cell count, serum calcium, serum phosphorous, parathyroid hormone, physical function (6-min walk test) and nutritional status (Geriatric Nutritional Risk Index) during the first 6 months. The trial follow-up period was 12 months.

RESULTS

The study included 74 participants (44 males) with an age average of 64 ± 12 years old and a dialysis history of 27 ± 12 months, randomized to intervention (n = 37) or control (n = 37). Compared with controls, 1-year survival was higher in the intervention group (94% vs 73%, P = 0.01). The hazard ratio in univariate analysis in intervention group was 0.17 (95% CI 0.04-0.8; P = 0.02) compared to that in control group. During the 6-month intervention period, significant between-group changes were observed in all secondary outcomes between the intervention and control groups.

CONCLUSION

Intradialytic exercise performed for at least 60 min during thrice weekly dialysis sessions improves survival in adult patients receiving HD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04898608. Retrospectively registered on 24/05/2021. Registered trial name: The Effect of Intradialytic Exercise on Dialysis Patients Survival.

Accelerated Vascular Aging in Chronic Kidney Disease: The Potential for Novel Therapies

The pathophysiology of vascular disease is linked to accelerated biological aging and a combination of genetic, lifestyle, biological, and environmental risk factors. Within the scenario of uncontrolled artery wall aging processes, CKD (chronic kidney disease) stands out as a valid model for detailed structural, functional, and molecular studies of this process. The cardiorenal syndrome relates to the detrimental bidirectional interplay between the kidney and the cardiovascular system. In addition to established risk factors, this group of patients is subjected to a plethora of other emerging vascular risk factors, such as inflammation, oxidative stress, mitochondrial dysfunction, vitamin K deficiency, cellular senescence, somatic mutations, epigenetic modifications, and increased apoptosis. A better understanding of the molecular mechanisms through which the uremic milieu triggers and maintains early vascular aging processes, has provided important new clues on inflammatory pathways and emerging risk factors alike, and to the altered behavior of cells in the arterial wall. Advances in the understanding of the biology of uremic early vascular aging opens avenues to novel pharmacological and nutritional therapeutic interventions. Such strategies hold promise to improve future prevention and treatment of early vascular aging not only in CKD but also in the elderly general population.

Nine Months of Hybrid Intradialytic Exercise Training Improves Ejection Fraction and Cardiac Autonomic Nervous System Activity

Cardiovascular disease is the most common cause of death in hemodialysis (HD) patients. Intradialytic aerobic exercise training has a beneficial effect on cardiovascular system function and reduces mortality in HD patients. However, the impact of other forms of exercise on the cardiovascular system, such as hybrid exercise, is not clear. Briefly, hybrid exercise combines aerobic and strength training in the same session. The present study examined whether hybrid intradialytic exercise has long-term benefits on left ventricular function and structure and the autonomous nervous system in HD patients. In this single-group design, efficacy-based intervention, twelve stable HD patients (10M/2F, 56 ± 19 years) participated in a nine-month-long hybrid intradialytic training program. Both echocardiographic assessments of left ventricular function and structure and heart rate variability (HRV) were assessed pre, during and after the end of the HD session at baseline and after the nine-month intervention. Ejection Fraction (EF), both assessed before and at the end of the HD session, appeared to be significantly improved after the intervention period compared to the baseline values (48.7 ± 11.1 vs. 58.8 ± 6.5, p = 0.046 and 50.0 ± 13.4 vs. 56.1 ± 3.4, p = 0.054 respectively). Regarding HRV assessment, hybrid exercise training increased LF and decreased HF (p < 0.05). Both conventional Doppler and tissue Doppler imaging indices of diastolic function did not change after the intervention period (p > 0.05). In conclusion, long-term intradialytic hybrid exercise training was an effective non-pharmacological approach to improving EF and the cardiac autonomous nervous system in HD patients. Such exercise training programs could be incorporated into HD units to improve the patients’ cardiovascular health.

Exploring patients' experiences of the impact of dialysis therapies on quality of life and wellbeing

BACKGROUND

When people with chronic kidney disease reach kidney failure, renal replacement therapy is usually required to improve symptoms and maintain life. Although in-centre haemodialysis is most commonly used for this purpose, other forms of dialysis are available, including home haemodialysis and peritoneal dialysis.

OBJECTIVES

We aimed to explore the experiences of adults living with chronic kidney disease who were either approaching the need for dialysis or had reached kidney failure and were receiving a form of dialysis. In particular, we explored how different forms of dialysis affect their quality of life, wellbeing, and physical activity.

METHODS

Individual semistructured interviews were conducted with 40 adults with kidney failure, comprising four groups (n = 10 each): those receiving in-centre haemodialysis, home haemodialysis or peritoneal dialysis, or predialysis. Interviews were transcribed verbatim, thematically analysed, and then composite vignettes were subsequently developed to present a rich narrative of the collective experiences of each group.

FINDINGS

Compared with adults who were predialysis, quality of life and wellbeing improved upon initiation of their home haemodialysis or peritoneal dialysis. Conversely, minimal improvement was perceived by those receiving in-centre haemodialysis. Low physical activity was reported across all four groups, although those receiving home haemodialysis and peritoneal dialysis reported a greater desire and ability to be physically active than those in-centre.

CONCLUSION

These findings highlight that dialysis modalities not requiring regular hospital attendance (i.e., home haemodialysis and peritoneal dialysis) improve independence, quality of life, wellbeing, and can facilitate a more physically active lifestyle.

A novel health behaviour intervention to promote adherence in kidney failure

BACKGROUND

Health behaviour adherence is associated with improved survival in kidney failure (KF); however, most patients with KF do not adhere to one or more health behaviours. Existing health behaviour interventions have significant limitations and do not focus on psychological factors that are associated with adherence and health.

OBJECTIVES

To examine the feasibility, acceptability, and preliminary efficacy of a 12-week, phone-delivered, positive psychology-motivational interviewing (MI) intervention to promote psychological well-being and adherence in KF.

DESIGN

Single-arm, proof-of-concept trial (N = 10).

PARTICIPANTS

Participants were adults with KF undergoing haemodialysis and reporting suboptimal adherence to physical activity, diet, and/or medications. Participants attended weekly phone sessions with a study trainer, completed weekly positive psychology exercises (focused on gratitude, strengths, and meaning), and worked towards physical activity, diet, and/or medication goals.

MEASUREMENTS

Feasibility was measured by the percentage of sessions completed, while acceptability was assessed through participant ratings of positive psychology and MI session ease and utility (0-10 Likert scales). We explored the intervention's impact on psychological outcomes and health behaviour adherence using validated scales and accelerometers.

RESULTS

Participants completed 78% of sessions and rated the program's components as easy to complete (positive psychology: 8.7 ± 1.5; MI: 8.3 ± 2.0) and subjectively helpful (positive psychology: 8.8 ± 1.2; MI: 8.8 ± 1.6). The intervention led to promising but nonsignificant improvements in psychological and adherence measures.

CONCLUSIONS

This 12-week, phone-delivered program was feasible, well-accepted, and associated with nonsignificant improvements health behaviour adherence, highlighting the need for a larger efficacy trial.

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.

Effect of intradialytic exercises (IDE) on maximal oxygen consumption and quality of life undergoing hemodialysis in Indian population—a pilot study

Background

End stage renal disease (ESRD) is emerging as a major health issues across developing countries with limited access and awareness about the importance of exercises in daily life. People on prolong hemodialysis has difficulty in performing their activities of daily living (ADL). Loss of muscle mass is inevitable among patients on hemodialysis that leads to morbidity and mortality. Exercise is feasible during dialysis and can enhance quality of life. Increase in aerobic endurance by various combined protocol of aerobic and resistive exercises can improve compliance to regular exercise that underlines the theme of present study.

Methods

A total of 31 participants were recruited during November 2019 to February 2020, after screening of 65 participants for selection criteria from Indraprastha Apollo Hospital’s dialysis unit. The average age of the participants was 52.36 ± 11.56 years. A single-blinded, pre-test–post-test quasi-experimental clinical trial for intradialytic exercise program involving lower limb ergometer and resistance training for lower limbs and non-fistula hand for 24 sessions, in 3 months, twice a week was conducted.

Results

The exercise program was well tolerated and all patients completed it. Aerobic and resistance intradialytic exercises (IDE) had a positive effect on maximal oxygen consumption (VO2 Max), quality of life (SF 36), and sleep quality (PSQI). IDE showed statistically significant difference from pre- to post-intervention for maximal oxygen consumption, quality of life boosting their sleep quality.

Conclusions

IDE found to benefit the patient and results showed a significant improvement in maximal oxygen consumption, sleep quality, quality of life and fatigue over a span of 12 weeks.

Trial registration

CTRI, CTRI/2019/08/020848. Registered on 22 August 2019.

Mortality and Quality of Life with Chronic Kidney Disease: A Five-Year Cohort Study with a Sample Initially Receiving Peritoneal Dialysis

The quality of life, morbidity and mortality of people receiving renal replacement therapy is affected both by the renal disease itself and its treatment. The therapy that best improves renal function and quality of life is transplantation. Objectives: To study the quality of life, morbidity and mortality of people receiving renal replacement therapy over a five-year period. Design: A longitudinal multicentre study of a cohort of people with chronic kidney disease. Methods: Patients from the Girona health area receiving peritoneal dialysis were studied, gathering data on sociodemographic and clinical variables through an ad hoc questionnaire, quality of life using the SF-36 questionnaire, and social support with the MOS scale. Results: Mortality was 47.2%. Physical functioning was the variable that worsened most in comparison with the first measurement (p = 0.035). Those receiving peritoneal dialysis (p = 0.068) and transplant recipients (p = 0.083) had a better general health perception. The social functioning of transplant recipients improved (p = 0.008). Conclusions: People with chronic kidney disease had a high level of mortality. The dimension of physical functioning worsens over the years. Haemodialysis is the therapy that most negatively effects general health perception. Kidney transplantation has a positive effect on the dimensions of energy/vitality, social functioning and general health perception.

Palliative rehabilitation in end-stage renal failure

Background

In end-stage chronic kidney disease (CKD), patients experience disabilities stemming from organ failure. These can be worsened by symptoms and complications of underlying cause(s), and the conditions associated with the CKD. There is a dearth of literature regarding palliative rehabilitation in end-stage CKD. Our case highlights the complex medical and rehabilitative issues that such patients face.

Case presentation

A 64-year-old male had end-stage CKD and declined dialysis. After sustaining a myocardial infarction, he suffered a posterior circulation stroke the following month. Whilst undergoing stroke rehabilitation, his progress was further hampered by symptoms of kidney failure. The patient underwent interdisciplinary rehabilitation for 29 days. Goal-setting was performed with the patient and family to allow contextualization to the patient’s stage of disease, beliefs and environment. Care-giver training was provided to facilitate discharge back home. He demonstrated improvements in physical endurance and function. His Functional Independence Measure score improved from 51 to 82. He outlived his prognosis of 3–6 months and demised 15 months after discharge.

Conclusions

In end-stage CKD without renal replacement therapy, rehabilitation and palliative care efforts align to enhance quality of life, in the face of unlikely cure. While palliative care provides symptom management and supportive care, rehabilitation safeguards physical endurance and ability. It is in the hope of doing so, independence and thence, self-esteem, can be maintained. Future research should explore the benefits of palliative rehabilitation in renal failure.

The effect of regular aerobic exercise on renal function in patients with CKD: A systematic review and meta-analysis

Objective: To evaluate the effect of regular aerobic exercise on the improvement of renal function in patients with chronic kidney disease through meta-analysis and to provide targeted exercise recommendations for patients with CKD.

Methods: PubMed, Web of Science, EBSCO, China National Knowledge Infrastructure (CNKI), and other databases were searched, and randomized controlled trials on the effects of regular aerobic exercise on renal function-related indexes in patients with CKD were collected according to the inclusion and exclusion criteria. The methodological quality of the included literature was evaluated using the Cochrane evaluation tool second generation, and statistical analysis was performed using R analysis software.

Results: A total of 12 randomized controlled trials (RCTs) with a total of patients with CKD were included, and the results of the meta-analysis showed that regular aerobic exercise significantly improved the estimated glomerular filtration rate SMD = 0.65, 95% CI [0.30, 1.00], serum creatinine SMD = -0.63, 95% CI [-0.86, -0.40], 24-h urine protein volume in patients with CKD SMD = -0.41, 95% CI [-0.70, -0.11], and serum urea nitrogen SMD = -0.66, 95% CI [-1.20, -0.12]. Single exercise session longer than 30 min significantly improved the estimated glomerular filtration rate in CKD patients (p < 0.01), and walking and running as exercise modalities significantly improved CKD patients’ SCr levels were significantly improved by walking and running as exercise modalities (p < 0.05), and the improvement effect was not significant when cycling was selected as an exercise modality.

Conclusion: Regular aerobic exercise has a significant effect on the estimated glomerular filtration rate, serum creatinine, 24-h urine protein amount, and blood urea nitrogen in CKD patients. Aerobic exercise with a single exercise duration longer than 30 min has a more significant effect on the estimated glomerular filtration rate, and aerobic exercise by walking or running can more effectively improve the serum creatinine in CKD patients.

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.

Long-Term Effect of Physical Exercise on the Risk for Hospitalization and Death in Dialysis Patients: A Post-Trial Long-Term Observational Study

BACKGROUND AND OBJECTIVES

In the EXerCise Introduction to Enhance Performance in Dialysis (EXCITE) trial, a simple, personalized 6-month walking exercise program at home during the day off of dialysis improved the functional status and the risk for hospitalization in patients with kidney failure. In this post-trial observational study, we tested whether the same intervention was associated with a lower long-term risk of death or hospitalization (combined end point) during a follow-up extended up to 36 months.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In total, 227 patients (exercise, n=104; control, n=123) completed the 6-month trial and entered the post-trial observational study. Data were analyzed by unadjusted and adjusted Cox regression analyses and Bayesian analysis.

RESULTS

In the long-term observation (up to 36 months), 134 events were recorded (eight deaths not preceded by hospitalization and 126 hospitalizations, which were followed by death in 38 cases). The long-term risk for hospitalization or death was 29% lower (hazard ratio, 0.71; 95% confidence interval, 0.50 to 1.00), and in an analysis stratified by adherence to the walking exercise program during the 6-month trial, the subgroup with high adherence (>60% of prescribed sessions) had a 45% lower risk as compared with the control group (hazard ratio, 0.55; 95% confidence interval, 0.35 to 0.87). A Bayesian analysis showed that the posterior probability of a hazard ratio of 0.71 (95% confidence interval, 0.50 to 1.00) for the risk of the composite outcome observed in the post-trial observational study was 93% under the conservative prior and 97% under the optimistic prior. Sensitivity analyses restricted to the risk of hospitalization only or censoring patients at the time of transplantation fully confirmed these findings.

CONCLUSIONS

A simple, personalized, home-based, low-intensity exercise program was associated with a lower risk of hospitalization.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

EXerCise Introduction to Enhance Performance in Dialysis (EXCITE), NCT01255969.