Effects of exercise programs on physical function and activity levels in patients undergoing hemodialysis. A randomized controlled trial

Effect of perioperative rehabilitation exercise on postoperative outcomes in patients aged ≥65 years undergoing gastrointestinal surgery: A multicenter randomized controlled trial

STUDY OBJECTIVES

This study aimed to assess the effect of perioperative rehabilitation exercise, initiated shortly after hospital admission, on postoperative outcomes in elderly patients.

DESIGN

A prospective, multicenter, randomized, controlled, open-label, and assessor-blinded clinical trial.

SETTING

Hospital wards.

PATIENTS

Elderly patients (≥65 years, n = 160) scheduled for gastrointestinal surgery between June 2021 and November 2022 were enrolled and randomly assigned to the intervention or control group.

INTERVENTIONS

Patients were divided into two groups base on whether they had received a specific type of exercise program initiated after hospital admission and continued until 30 days after surgery.

MEASUREMENTS

The primary outcome was the Comprehensive Complications Index (CCI) measured at 30 days after surgery. Secondary outcomes were the rate of complications, number of complications, patient satisfaction, hospital readmission, postoperative length of stay, gastrointestinal function recovery, postoperative quality of life and psychological status. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted.

MAIN RESULTS

ITT analysis showed a significantly lower 30-day CCI in the intervention group (β: -6.31; 95 % Confidence Interval [CI], -11.26 to -1.37, P = 0.013). Compared to controls, the intervention group had a decreased rate of hospital readmission (Odds Ratio: 0.00; 95 % CI, 0.00 to 0.32, P = 0.022), less number of complications (β: -0.57; 95 % CI, -1.03 to -0.11, P = 0.016), as well as lower rate of postoperative anxiety (β: -0.74; 95 % CI, -1.42 to -0.06, P = 0.033) and depression scores (β: -1.13; 95 % CI, -0.97 to -1.30, P = 0.008). Additionally, the intervention group reported higher satisfaction (β: 0.98; 95 % CI, 0.33 to 1.64, P = 0.004) and Euro quality of life-Visual Analogue Scale scores (β: 8.88; 95 % CI, 2.48 to 15.28, P = 0.007). Similar results were found in the PP analysis.

CONCLUSION

Perioperative rehabilitation exercise has a positive impact on postoperative complications, quality of life and psychological well-being in elderly patients undergoing gastrointestinal surgery, even when implemented after hospital admission.

Physical activity and exercise in chronic kidney disease: consensus statements from the Physical Exercise Working Group of the Italian Society of Nephrology

The Italian Society of Nephrology has tasked its Working Group on Physical Exercise with developing a consensus statement document on physical activity and exercise in patients with chronic kidney disease (CKD). This paper consists of 16 points that were discussed, and approved using the mini-Delphi method by 15 members of the working group. Each statement is based on a comprehensive review of the literature, clinical experience, and expert opinions. Overall, the statements affirm that regular physical activity and exercise training offer numerous benefits to CKD patients, including improved physical function, enhanced cardiometabolic and neuromuscular function, cognitive benefits, and an overall improvement in quality of life. Furthermore, exercise may provide nephroprotection and reduce mortality. These advantages are observed across all CKD stages, whether on conservative therapy or kidney replacement therapy (hemodialysis or peritoneal dialysis), and in kidney transplant recipients. Moreover, when physical activity and exercise training are implemented with appropriate precautions, they are safe in CKD patients. Gradual physical activity and customized exercise programs should be tailored to the patient's exercise tolerance, potentially enhancing compliance. Clinicians are encouraged to use a series of questionnaires and tests to assess the patient's level of physical activity and performance. However, exercise and physical activity are poorly implemented in clinical practice due to many barriers related to patients and healthcare staff. Overcoming these barriers requires the proactive role of the nephrologists, who should actively incorporate exercise training and promote physical activity within routine care plans. Adopting a multidisciplinary team approach, which includes nephrologists, nurses, exercise professionals, and dietitians, is crucial for providing comprehensive rehabilitation for CKD patients. Integrating new technologies and remote check ups could further enhance the effectiveness of these interventions.

Supervised Versus Unsupervised Exercise for the Improvement of Physical Function and Well-Being Outcomes in Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Unsupervised exercise intervention (UNSUP) appears to be a practical and beneficial strategy for older adults, although its feasibility and effectiveness compared to supervised exercise intervention (SUP) remains unknown. We aimed to compare the safety, attendance/adherence rates, and effectiveness of SUP versus UNSUP on physical function and well-being outcomes in older adults.

METHODS

A systematic search was conducted in PubMed, Web of Science, CINAHL, SPORTDiscus, and APA PsycINFO up to September 2022 for randomized controlled trials comparing SUP versus UNSUP in older adults (≥ 60 years). Safety and attendance/adherence rates were registered as indicators of feasibility, and meta-analyses were performed for physical function and well-being outcomes. Sub-analyses were performed for those studies that applied a similar intervention in both groups and for those studies where participants performed ≥ 66% of the sessions in the assigned condition.

RESULTS

Thirty-four studies were included (n = 2830). No serious adverse events were reported, with similar attendance rates (81%) for both SUP and UNSUP. Compared with UNSUP, SUP induced significant higher benefits on knee extension strength (standardized mean difference (SMD) = 0.18, p = 0.002), sit-to-stand test (STS, SMD = 0.25, p = 0.050), timed-up-and-go test (TUG, SMD = 0.21, p = 0.035), usual gait speed (SMD = 0.29, p = 0.026), lean mass (mean difference = 1.05 kg, p < 0.001) and health-related quality of life (HRQoL, SMD = 0.21, p = 0.035), albeit only knee extension strength remained significant in sensitivity analyses. Sub-analyses revealed superior benefits of SUP on knee extension strength when only considering those studies that applied a similar intervention in both SUP and UNSUP groups. However, no significant benefits were found for the remaining outcomes. Beneficial effects of SUP over UNSUP were also observed for knee extension strength, STS, functional reach test, TUG, usual gait speed, lean mass, and HRQoL when separately analyzing those studies in which participants performed ≥ 66% of the sessions in the assigned condition.

CONCLUSIONS

Current evidence suggests that both SUP and UNSUP programs are safe and could exert benefits on physical function and HRQoL. However, despite being associated with similar attendance rates, SUP might offer some additional benefits, although further high-quality research (i.e., accounting for confounding factors such as presence of supervised sessions in UNSUP or vice versa, as well as equating the exercise dose) is necessary to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42022326420.

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.

The role of supervision and motivation during exercise on physical and mental health in older adults: a study protocol for a randomized controlled trial (PRO-Training project)

BACKGROUND

Although supervised exercise is frequently recommended for older adults, its superiority over unsupervised exercise remains uncertain. Furthermore, whether motivational techniques could help to enhance the effectiveness of the latter remains to be elucidated. The present randomized controlled trial aims to determine the role of supervision and motivational strategies on the safety, adherence, efficacy, and cost-effectiveness of different exercise programs for improving physical and mental health in older adults.

METHODS

Participants (n = 120, aged 60-75 years) will be randomly allocated into five groups: 1-Control (CON), 2-Supervised exercise without motivational intervention (SUP), 3- Supervised exercise with motivational intervention (SUP +), 4- Unsupervised exercise without motivational intervention (UNSUP) and 5- Unsupervised exercise with motivational intervention (UNSUP +). Over 24 weeks, all exercise groups will participate in a multicomponent exercise program three times/week (performed in group classes at a center for SUP and SUP + , or home without supervision but with the help of a mobile app for UNSUP and UNSUP +), while the CON group will maintain their usual lifestyle. The motivational intervention (for SUP + and UNSUP + groups) will be based on the self-determination theory, including strategies such as phone calls, interactive workshops, motivational messages, informative infographics and videos. Primary outcomes will include safety, adherence, costs, and lower-body muscular function using a leg press machine. Secondary outcomes will include upper-body muscular function, physical and cardiorespiratory function, blood pressure and heart rate, body composition, health-related quality of life, cognitive performance, anxiety, depression, physical activity levels, sleep and sedentarism, biochemical markers, motivators and barriers to exercise. Assessments will be conducted at baseline, mid-intervention (i.e., week 13), at the end of the intervention (i.e., week 25), and 24 weeks later (i.e., week 49).

DISCUSSION

The findings of this trial might provide valuable insights into the role of supervision and motivational strategies on the effectiveness of exercise programs for older adults. Additionally, the study could contribute to developing cost-effective interventions, supporting the design of future public policies for healthy aging.

TRIAL REGISTRATION

NCT05619250. Registered 16 November 2022.

Physical exercise in kidney disease: A commonly undervalued treatment modality

BACKGROUND

Physical inactivity has been identified as a risk factor for multiple disorders and a strong association exists between chronic kidney disease (CKD) and a sedentary lifestyle. Even though physical activity is crucial in the development and progression of disease, the general focus of the current medical practice is the pharmacological perspective of diseases with inadequate emphasis on lifestyle intervention.

METHODS

In this narrative review we explain the pathophysiological mechanisms underlying the beneficial effects of physical exercise on CKD in addition to discussing the clinical studies and trials centred on physical exercise in patients with CKD.

RESULTS

Physical activity influences several pathophysiological mechanisms including inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism. While exercise can initially induce stress responses like inflammation and oxidative stress, long-term physical activity leads to protective countermeasures and overall improved health. Trials in pre-dialysis CKD patients show that exercise can lead to reductions in body weight, inflammation markers and fasting plasma glucose. Furthermore, it improves patients' functional capacity, cardiorespiratory fitness and quality of life. The effects of exercise on kidney function have been inconsistent in these trials. In haemodialysis, peritoneal dialysis and kidney transplant patients exercise interventions improve cardiorespiratory fitness, walking capacity and quality of life. Combined training shows the best performance to increase peak oxygen uptake in haemodialysis patients. In kidney transplant recipients, exercise improves walking performance, quality of life and potentially arterial stiffness. However, exercise does not affect glucose metabolism, serum cholesterol and inflammation biomarkers. Long-term, adequately powered trials are needed to determine the long-term feasibility, and effects on quality of life and major clinical outcomes, including mortality and cardiovascular risk, in all CKD stages and particularly in kidney transplant patients, a scarcely investigated population.

CONCLUSION

Physical exercise plays a crucial role in ameliorating inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism, and contributes significantly to the quality of life for patients with CKD, irrespective of the treatment and stage. Its direct impact on kidney function remains uncertain. Further extensive, long-term trials to conclusively determine the effect of exercise on major clinical outcomes such as mortality and cardiovascular risk remain a research priority.

Emerging Preventive Strategies in Chronic Kidney Disease: Recent Evidence and Gaps in Knowledge

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is increasingly prevalent worldwide and is associated with increased cardiovascular risk. New therapeutic options to slow CKD progression and reduce cardiovascular morbidity and mortality have recently emerged. This review highlights recent evidence and gaps in knowledge in emerging CKD preventive strategies.

RECENT FINDINGS

EMPA-Kidney trial found that empagliflozin, a sodium-glucose co-transporter 2 inhibitor (SGLT2i) led to 28% lower risk of progression of kidney disease or death from cardiovascular causes, compared to placebo. This reinforced the previous findings from DAPA-CKD and CREDENCE trials and led to inclusion of SGLT2i as the cornerstone of CKD preventive therapy in both diabetic and non-diabetic CKD. Finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, slowed diabetic kidney disease progression by 23% compared to placebo in a pool analysis of FIDELIO-DKD and FIGARO-DKD trials. Non-pharmacological interventions, including low protein diet, and early CKD detection and risk stratification strategies based on novel biomarkers have also gained momentum. Ongoing efforts to explore the wealth of molecular mechanisms in CKD, added to integrative omics modeling are well posed to lead to novel therapeutic targets in kidney care. While breakthrough pharmacological interventions continue to improve outcomes in CKD, the heterogeneity of kidney diseases warrants additional investigation. Further research into specific kidney disease mechanisms will facilitate the identification of patient populations most likely to benefit from targeted interventions.

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.

Interventions to increase physical activity level in patients with whole spectrum chronic kidney disease: a systematic review and meta-analysis

Background: Little is known about effective interventions to increase physical activity levels in this population. This systematic review and meta-analysis evaluated the effectiveness of different interventions for physical activity levels in whole-spectrum CKD patients.Methods: In this systematic review and meta-analysis, PubMed, Embase, and Web of Science were searched from inception to December 2022, with an update in March 2023. Studies of clinical interventions based on assessing physical activity outcomes (e.g., daily steps, time spent doing physical activity) in patients with whole-spectrum CKD were included. The pooled effect size was calculated using a restricted maximum likelihood method and reported as a standardized mean difference (SMD) with 95% confidence interval (95% CI).Results: The systematic review included 2,156 participants (59.9 ± 8.7 years) from 35 studies. Interventions aimed at modifying physical activity were associated with significantly higher physical activity levels in patients with CKD (SMD = 0.22; 95% CI: 0.08 to 0.36; I2 = 55%). Exercise-based interventions and real-time step feedback increased physical activity by 0.26 (95% CI: 0.07 to 0.45; I2 = 59%) and 0.36 (95% CI: 0.12 to 0.60; I2 = 0%) standard deviations, respectively. Effect sizes did not vary by disease stage or study duration; however, there was evidence of small study or publication bias for the primary analysis.Conclusion: In this systematic review and meta-analysis, intervention strategies aimed at modifying physical activity were associated with significantly increased physical activity levels in patients with whole-spectrum CKD.

Game-based intradialytic non-weight-bearing exercise training on gait speed and balance in older adults with diabetes: a single-blind randomized controlled trial

Older adults with diabetes receiving hemodialysis have impaired gait speed and balance compared to the general population, which have been associated with increased risks of falls and mortality. This study evaluated the effectiveness of a game-based intradialytic exercise training program (iExergame) on improving gait speed and balance. This was a single-blind randomized controlled trial. The intervention group (IG) received iExergame training using real-time audiovisual feedback with wearable inertial sensors. The control group (CG) received conventional training without any technology. Both trainings were intradialytic, non-weight-bearing, and used ankle range of motion. Gait and balance parameters were collected at baseline and 4-week follow-up. Data from 70 adults (age 64.2 ± 9.0 years) were analyzed. Compared to the CG, the IG showed greater changes between baseline and 4-week follow-up in several parameters. Gait parameters included faster speeds and longer stride lengths, particularly during dual task walking (p < 0.050). Balance parameters included reductions in center of mass (p = 0.004), ankle (p < 0.001), and hip (p = 0.010) sways during semi-tandem stance, particularly in users of assistive devices. iExergame training could improve gait speed and balance in this population and might be an option to increase intradialytic exercise adherence while reducing burdens of exercise administration.

A dataset of the effects of therapeutic exercise programs on physical function in patients undergoing hemodialysis

The dataset presented in this article belongs to a randomized controlled trial, conducted between November 2015 and May 2016, where therapeutic exercise interventions were implemented in patients with End-Stage Renal Diseases undergoing hemodialysis. The intervention was carried out at the Hospital de Manises, in Manises (Spain). Participants performed a 16-week exercise program either during dialysis (intradialytic) or at home, combining resistance and aerobic training. Tests were assessed prior to the dialysis session, and include several dimensions of the patient's functional status, such as functional capacity, physical performance, balance, lower limb strength and endurance, and handgrip strength. Data was collected prior to and after the implementation of an intervention. The dataset contains the raw data obtained in this data collection. The analysis consisted in the improvement of these outcomes when a therapeutic exercise intervention is implemented. Further analysis could potentially include the stratification of the sample in several subgroups according to demographic characteristics of the participants, according to levels of compliance to the intervention and according to even more specific changes within the tests performed. For instance, the improvement of the overall assessment of the Short Performance Physical Battery Test might differ from the improvement of any of the components that build this "battery" of tests, such as gait speed, balance, or the Sit-to stand-to sit 5 tests.

The Effectiveness of an Online Learning Strategy on Changing Physical Activity Counseling Practice in Nurses

BACKGROUND

Nurses may be well poised for providing physical activity guidance and support to patients.

PURPOSE

The purposes of this study were to examine the effectiveness of a concise, evidence based online learning modules strategy (OLMS) for improving nurses' physical activity counselling.

METHODS

68 nurses were randomly assigned to either an OLMS group or control group. The OLMS group completed a series of six online learning modules aimed at improving physical activity counselling practice.

RESULTS

The OLMS group, compared to the control group, showed a trend for improvement in Physical Activity Counselling Practice (p = .063) after controlling for baseline values, and significant improvement in (a) Self-efficacy for Physical Activity Counselling (p = .001), (b) Knowledge of Physical Activity Guidelines, (p = .031), and (c) Perceived Benefits of Physical Activity Counselling (p = .014) over the course of the intervention. No significant change was found for Barriers for Providing Physical Activity Counselling (p > .05).

CONCLUSIONS

The OLMS tested may be an effective means for improving self-efficacy, knowledge, and perceived benefits of physical activity counselling, suggesting the utility of online learning strategies for improving nurses' physical activity counselling practice. Given barriers to providing physical activity counselling were not affected by the intervention, future interventions and policy change could target these barriers specifically in order to give nurses more tools and time for reaching patients and addressing physical activity counselling in practice.

Hierarchical multiple regression investigating factors associated with depressive symptoms in the middle-aged and elderly undergoing haemodialysis

BACKGROUND

Depressive moods are commonly seen in patients who receive haemodialysis. This can cause a lack of compliance in their treatment procedures and increase the rate of hospitalization. This study aimed to investigate the relationship between social support and degree of depression in middle-aged and elderly patients undergoing haemodialysis and the predictors of depressive symptoms.

METHODS

A cross-sectional correlational study was designed with a structured questionnaire survey. Patients over 40 years of age were included from five haemodialysis centres. Measures embraced a demographic and clinical characteristics questionnaire, the Centre for Epidemiologic Studies Depression Scale, and the Personal Resource Questionnaire 2000. Statistical analysis was performed using hierarchical multiple regression analysis.

RESULTS

A total of 179 patients over 40 years of age were included from five haemodialysis centres in the analysis. The mean CES-D score was 19.0(12.3); the majority of participants (60.3%) had a CES-D score ≥ 15, indicating likely depressive status. The mean PRQ2000 score was 75.7(15.9). The proportional mean of the PRQ2000 was 72.11%, indicating moderate social support for participants in this study. Data disclosed that marital status, number of comorbidities, exercise behaviour, and social support could significantly predict depressive symptoms; total explanatory variance was 31.3%.

CONCLUSION

Health care professionals should identify those at high risk of depressive symptoms when they provide care to the middle-aged and elderly patients undergoing haemodialysis. These findings may lead to greater insights into the nursing and rehabilitative care of patients treated by chronic maintenance haemodialysis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

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].

Physical Inactivity: A Modifiable Risk Factor for Morbidity and Mortality in Kidney Transplantation

In patients with chronic kidney disease, sedentary behavior is widely recognized as a significant risk factor for cardiovascular disease, diabetes, obesity, osteoporosis, cancer, and depression. Nevertheless, the real impact of physical inactivity on the health of kidney transplant (KT) recipients remains uncertain. Over the last decade, there has been a renewed interest in exploring the effects of regular physical exercise on transplant-related outcomes. There is now mounting evidence that physical activity may reduce the burden of cardiovascular risk factors, preserve allograft function, minimize immunosuppression requirement, and ameliorate the quality of life of KT recipients. Many positive feedbacks can be detected in the early stages of the interventions and with a minimal exercise load. Despite these encouraging results, the perceived role of physical activity in the management of KT candidates and recipients is often underrated. The majority of trials on exercise training are small, relatively short, and focused on surrogate outcomes. While waiting for larger studies with longer follow-up, these statistical limitations should not discourage patients and doctors from initiating exercise and progressively increasing intensity and duration. This narrative review summarizes current knowledge about the deleterious effects of physical inactivity after KT. The benefits of regular physical exercise are also outlined.