Physical activity and exercise recommendations for people receiving dialysis: A scoping review

Perceptions of healthcare providers on benefits, risks and barriers regarding intradialytic exercise among haemodialysis patients

PURPOSE

Clinical guidelines call for the inclusion of exercise interventions in every patient's dialysis session, but these recommendations are rarely adopted. Healthcare providers play a key role in this. Therefore, the aim of this study was to explore how healthcare providers perceive the benefits, risks and barriers of intradialytic exercise (IDE).

METHODS

We conducted 21 individual, semi-structured interviews with 11 nurses, 5 nephrologists, 3 training assistants and 2 managers from two dialysis centres in Slovakia. Verbatim transcripts of digitally recorded interviews were thematically analysed using MAXQDA®.

RESULTS

Participants reported the benefits of IDE as improvements in patients' physical and psychosocial functioning, independence and self-efficacy, clinical profile and quality of therapy. As risks of IDE, they most frequently reported exercise-related damage to vascular access, insufficient individualization of training and musculoskeletal injuries. The presence of psychological problems among patients was reported as a major barrier for initiating and maintaining patients' exercise. Other reported barriers included limitations in financial and personnel resources of haemodialysis care.

CONCLUSIONS

Safe and sustainable implementation of IDE, which might improve a patient's well-being, need to be prescribed in alignment with the patient's clinical profile, be delivered individually according to the patient's characteristics and requires adjustments in the available resources.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Validity and reliability of Persian version of Low Physical Activity Questionnaire (LoPAQ)

BACKGROUND

The Low Physical Activity Questionnaire (LoPAQ) was specifically developed to measure the low activity level observed in extremely inactive hemodialysis (HD) patients. This study aims to evaluate reliability and validity of Persian version of the LoPAQ.

METHODS

This study was a cross sectional study, conducted in three HD centers in Iran. The LoPAQ was translated into Persian. After cultural adaptions, it was filled out by 120 HD patiens. Convergent validity, was evaluated by calculating the correlations among the Persian version of the LoPAQ and Persian version of the Community Healthy Adults Model Program for Seniors (CHAMPS) questionnaire, physical function scale of the SF-36 and physical function (Short Physical Performance Battery (SPPB) test) using Spearman's correlation coefficients. The test-retest reliability was analyzed using the intraclass correlation coefficient (ICC).

RESULTS

In total, 109 patients completed all of the questionnaires, took part in physical performance tests and had valid data. Their mean age was 64 ± 11 years, with a dialysis history of 31 ± 10 months. For total calories, there was a strong correlation between the Persian version of the LoPAQ and CHAMPS-measured physical activity (rho = 0.85, p < 0.001). In addition, the higher physical activity level reported by Persian version of the LoPAQ was also correlated with better self-reported physical function (rho = 0.7, p < 0.001) and better physical performance (rho = 0.67, p < 0.001). The ICC ranged from 0.65 to 0.78, indicating strong reliability.

CONCLUSION

The assessment of the validity and reliability of the Persian version of the questionnaire confirmed its suitability for evaluating the level of physical activity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05930964, Registered on 05/07/2023. Registered trial name: Validity and Reliability of Persian Version of Low Physical Activity Questionnaire (LoPAQ).

Barriers and Facilitators to Exercise in Older Adults Awaiting Kidney Transplantation and Their Care Partners

Rationale & Objective

Despite guidelines calling to improve physical activity in older adults, and evidence suggesting that prekidney transplant physical function is highly associated with posttransplant outcomes, only a small percentage of older patients treated with dialysis are engaged in structured exercise. We sought to elucidate barriers and facilitators of exercise among older adults treated with dialysis awaiting transplant and their care partners.

Study Design

Individual, in-depth, cognitive interviews were conducted separately for patients and care partners through secure web-conferencing.

Setting & Participants

Twenty-three patients (≥50 years of age, treated with dialysis from the University of San Francisco kidney transplantation clinic, with a short physical performance battery of ≤10) and their care partners.

Analytical Approach

All audio interviews were transcribed verbatim. Three investigators independently coded data and performed qualitative thematic content. The interview guide was updated iteratively based on the Capability Opportunity Motivation Behavior model.

Results

Patients' median age was 60 years (57 ± 63.5) and care partners' median ages was 57 years (49.5 ± 65.5). Thirty-nine percent of patients and 78% of care partners were female, 39% of patients and 30% of care partners self-identified as African American, and 47% of dyads were spouse or partner relationships. Major themes for barriers to pretransplant exercise included lack of understanding of an appropriate regimen, physical impairments, dialysis schedules, and safety concerns. Major facilitators included having individualized or structured exercise programs, increasing social support for patients and care partners, and motivation to regain independence or functionality or to promote successful transplantation.

Limitations

Participants geographically limited to Northern California.

Conclusions

Although patients and care partners report numerous barriers to pretransplant exercise and activity, they also reported many facilitators. An individualized, structured, home-based exercise program could circumvent many of the reported barriers and allow older patients to improve pretransplant physical function.

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.

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.

Lifestyle Interventions, Kidney Disease Progression, and Quality of Life: A Systematic Review and Meta-analysis

Rationale & Objective

Poor dietary patterns and low physical activity levels are important lifestyle-related factors that contribute to negative health outcomes in individuals with chronic kidney disease (CKD). Previous systematic reviews have not explicitly focused on these lifestyle factors, nor undertaken meta-analyses of any effects. We aimed to evaluate the effect of lifestyle interventions (such as diet, exercise, and other lifestyle-related interventions) on the risk factors for and progression of CKD and the quality of life.

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

Individuals aged 16 years or older with CKD stages 1 to 5 not requiring kidney replacement therapy.

Selection Criteria for Studies

Randomized controlled trials of interventions.

Data Extraction

Kidney function, albuminuria, creatinine, systolic blood pressure, diastolic blood pressure, body weight, glucose control, and quality of life.

Analytical Approach

A random-effects meta-analysis with evidence certainty assessed using GRADE.

Results

Seventy-eight records describing 68 studies were included. Twenty-four studies (35%) were dietary interventions, 23 (34%) exercise, 9 (13%) behavioral, 1 (2%) hydration, and 11 (16%) multiple component. Lifestyle interventions resulted in significant improvements in creatinine (weighted mean difference [WMD], -0.43 mg/dL; 95% CI, -0.74 to -0.11; P = 0.008); 24-hour albuminuria (WMD, -53 mg/24 h; 95% CI, -56 to -50; P < 0.001); systolic blood pressure (WMD, -4.5 mm Hg; 95% CI, -6.7 to -2.4; P < 0.001); diastolic blood pressure (WMD, -2.2 mm Hg; 95% CI, -3.7 to -0.8; P = 0.003); and body weight (WMD, -1.1 kg; 95% CI, -2.0 to -0.1; P = 0.025). Lifestyle interventions did not result in significant changes in the estimated glomerular filtration rate (0.9 mL/min/1.73 m²; 95% CI, -0.6 to 2.3; P = 0.251). However, narrative synthesis indicated that lifestyle intervention resulted in improvements in the quality of life.

Limitations

Certainty of the evidence was rated very low for most outcomes, primarily owing to the risk of bias and inconsistency. No meta-analysis was possible for quality-of-life outcomes because of variations in measurement tools.

Conclusions

Lifestyle interventions seem to positively affect some risk factors for progression of CKD and quality of life.

Effects of intradialytic inspiratory muscle training at different intensities on diaphragm thickness and functional capacity: clinical trial protocol in patients undergoing haemodialysis

INTRODUCTION

Patients with end-stage renal disease (ESRD) undergoing haemodialysis (HD) commonly present with a sedentary behaviour and reduced functional capacity, factors that can compromise their prognosis. Intradialytic inspiratory muscle training (IMT) can increase respiratory muscle strength and, consequently, improve functional capacity, besides being easy to apply, cheap and performed in a supervised setting. However, few studies show the effects of this type of training applied at different intensities in this population. This study aims to compare the effects of IMT at different intensities in adults with ESRD undergoing HD.

METHODS AND ANALYSIS

A randomised, double-blind, sham-controlled trial will be conducted on 36 subjects randomly allocated into three groups: IMT at intensities of 30% or 50% of maximal inspiratory pressure (intervention groups), or 10% of maximal inspiratory pressure (sham-IMT). All the interventions will be supervised and performed three times per week, for 12 weeks, totalling 36 sessions. The primary outcomes are the 6-minute walk test, diaphragm thickness and the response of VO₂peak post-intervention. Respiratory muscle strength, 24-hour ambulatory blood pressure measurement and the Kidney Disease Quality of Life 36-item short form survey will be evaluated as secondary outcomes.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committee of the Hospital de Clínicas de Porto Alegre (ID: 2020-0458). The results of this study will be disseminated by conference presentations and peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04660383.

A blended e-health intervention for improving functional capacity in elderly patients on haemodialysis: A feasibility study

Introduction

Physical exercise showed to be beneficial for frail older adults on haemodialysis (HD). However, there are several obstacles hindering the regular practice of exercise, such as transportation difficulties, lack of time, fatigue and comorbidities. E-health in this regard has many potential advantages and could be useful for motivating HD patients to increase their level of physical activity. The aim of this study was to evaluate the feasibility of a blended e-health intervention for elderly HD patients who individually exercise at home while under remote supervision of a physiotherapist.

Material and methods

Patients over 60 years of age with sufficient cognitive and motoric resources to perform a simple physical test battery and to use a tablet-computer were recruited from four HD outpatient facilities. Following baseline assessment at home, the participants were visited by a physiotherapist (PT). The PT set an individual exercise programme and explained how to use the web-based interface. During the 12 weeks of training, the PTs remotely supervised the patients' progress. At 12 weeks follow-up a second assessment took place.

Results

Twenty-two patients were recruited to participate in the study. Seven patients dropped out of the blended programme and 15 patients concluded the programme. The average training frequency of the 15 participants concluding the study was 1.5 times a week [range 0.2-5.8]. The duration of a training session was between 20 and 40 min. The usability of the system was deemed positive. Regarding the efficacy of the intervention, no significant improvement of any measured parameter was found, and effect sizes were small to medium.

Conclusion

A blended e-health intervention supported by a web-based application for exercising at home under remote supervision of a PT is feasible in a HD population including older patients. However, before planning a randomized controlled trial, strategies to increase the recruitment rate and the adherence to such a blended intervention should be further developed, e.g., to improve the recruitment procedures and lower the expectable drop-out rate. Furthermore, the dosage of the blended programme should be adapted to the patients' physical performance levels in future trials.The study was registered on the website clinicaltrials.gov with ID NCT04076488.

The optimal exercise modality and intensity for hemodialysis patients incorporating Bayesian network meta-analysis and systematic review

Background: Physical inactivity is highly prevalent in patients with hemodialysis, and a large body of evidence reported the positive effect of different exercise modalities on their health outcomes. However, the effective dosage of exercise for hemodialysis patients still requires verification.

Objective: We aimed to determine the most effective exercise intensity and modality for improvements in physical function, blood pressure control, dialysis adequacy, and health-related quality of life for hemodialysis patients.

Design: Systematic review with network meta-analysis of randomized trials.

Data sources: Five electronic databases (PubMed, EMBASE, Web of Science, Cochrane CENTRAL, and Scopus) were searched for randomized controlled trials. Data extraction and quality appraisal were conducted by two authors independently. Data were analyzed by the R (version.3.6.2) and the Stata (version.15.0).

Result: We included 1893 patients involving four exercise modalities and six exercise intensities. Combined training (aerobic exercise plus resistance exercise) has been the top-ranking exercise modality for improving the 6-min walk test (6MWT) (surface under the cumulative ranking curve analysis (SUCRA) score, 90.63), systolic blood pressure control (SUCRA score, 77.35), and diastolic pressure control (SUCRA score, 90.56). Moreover, the top-ranking exercise intensity was moderate–vigorous for 6MWT (SUCRA score, 82.36), systolic blood pressure (SUCRA score, 77.43), and diastolic blood pressure (SUCRA score, 83.75). Regarding dialysis adequacy and health-related quality of life, we found no exercise modality or intensity superior to the placebo.

Conclusion: This network meta-analysis indicated that combined training and moderate–vigorous intensity might be the most effective interventions to improve 6MWT and blood pressure control. This finding helps further guide clinical exercise prescriptions for hemodialysis patients.

Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021268535].