Background and Objective: Hemodialysis (HD) patients are more inactive, leading to poor functional capacity and quality of life; this may be reversed with intradi

Intradialytic exercise in hemodialysis patients: a systematic review and meta-analysis.

Regular physical activity is associated with an increased quality of life and reduced morbidity and mortality in the general population and in patients with chronic kidney disease (CKD). Physical activity, cardiorespiratory fitness, and muscle mass decrease even in the early stages of CKD, and continue to decrease with disease progression; notably, full recovery is generally not achieved with transplantation. The combined effects of uraemia and physical inactivity drive the loss of muscle mass. Regular physical activity benefits cardiometabolic, neuromuscular and cognitive function across all stages of CKD, and therefore provides an approach to address the multimorbidity of the CKD population. Interestingly, maintenance of muscle health is associated with renoprotective effects. Despite evidence of its benefits, physical activity and exercise management are not routinely addressed in the care of these patients. Although studies defining the optimum frequency, duration and intensity of physical activity are lacking, evidence from related fields can guide practical approaches to the care of patients with renal disease. Optimization of metabolic and nutritional status alongside promotion of physical activity is recommended. Behavioural approaches are now recognized as crucial in helping patients to adopt lifestyle changes and might prove valuable in integrating physical activity into renal care.

Physical inactivity: A risk factor and target for intervention in renal care

Chronic kidney disease (CKD) is a public health problem. Although physical activity is essential for the prevention and treatment of most chronic diseases, exercise is rarely prescribed for CKD patients. The objective of the study was to search for and appraise evidence on the effectiveness of exercise interventions on health endpoints in CKD patients. A systematic review was performed of randomized clinical trials (RCTs) designed to compare exercise with usual care regarding effects on the health of CKD patients. MEDLINE, EMBASE, Cochrane Central, Clinical Trials registry, and proceedings of major nephrology conference databases were searched, using terms defined according to the PICO (Patient, Intervention, Comparison and Outcome) methodology. RCTs were independently evaluated by two reviewers. A total of 5489 studies were assessed for eligibility, of which 59 fulfilled inclusion criteria. Most of them included small samples, lasted from 8 to 24 weeks and applied aerobic exercises. Three studies included only kidney transplant patients, and nine included pre-dialysis patients. The remaining RCTs allocated hemodialysis patients. The outcome measures included quality of life, physical fitness, muscular strength, heart rate variability, inflammatory and nutritional markers and progression of CKD. Most of the trials had high risk of bias. The strongest evidence is for the effects of aerobic exercise on improving physical fitness, muscular strength and quality of life in dialysis patients. The benefits of exercise in dialysis patients are well established, supporting the prescription of physical activity in their regular treatment. RCTs including patients in earlier stages of CKD and after kidney transplantation are urgently required, as well as studies assessing long-term outcomes. The best exercise protocol for CKD patients also remains to be established.

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Effects of exercise in the whole spectrum of chronic kidney disease: a systematic review.

Since the 19th century, many studies have enlightened the role of inflammation in atherosclerosis, changing our perception of “vessel plaque due to oxidized lipoproteins”, similar to a “rusted pipe”, towards a disease with involvement of many cell types and cytokines with more complex mechanisms. Although “physical activity” and “physical exercise” are two terms with some differences in meaning, compared to sedentary lifestyle, active people have lower cardiovascular risk and lower inflammatory markers. Activities of skeletal muscle reveal “myokines” which have roles in both the immune system and adipose tissue metabolism. In vitro and ex-vivo studies have shown beneficial effects of exercise on inflammation markers. Meanwhile in clinical studies, some conflicting results suggested that type of activity, exercise duration, body composition, gender, race and age may modulate anti-inflammatory effects of physical exercise. Medical data on patients with inflammatory diseases have shown beneficial effects of exercise on disease activity scores, patient well-being and inflammatory markers. Although the most beneficial type of activity and the most relevant patient group for anti-inflammatory benefits are still not clear, studies in elderly and adult people generally support anti-inflammatory effects of physical activity and moderate exercise could be advised to patients with cardiovascular risk such as patients with metabolic syndrome.

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Impact of physical activity on inflammation: effects on cardiovascular disease risk and other inflammatory conditions.

Aims and objectives
To determine the efficacy and safety of intradialytic exercises for haemodialysis patients, this study conducted a systematic review and meta-analysis of randomised controlled trials.

Background
Patients receiving haemodialysis have poor physical function, psychological status and quality of life than the general population. Exercise training may improve these parameters for haemodialysis patients.

Design
Systemic review was performed, and a meta-analysis was conducted.

Methods
Medline, PubMed, Cochrane Central Register of Controlled Trials, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature and Airiti Library were systematically searched for studies up to January 2015. In addition, the reference lists of eligible studies and relevant reviews were assessed.

Results
Seventeen studies with a total of 651 participants were included. Compared with no resistance exercise, nonexercise and walks at home, intradialytic exercises significantly improved the peak oxygen consumption (SMD = 0·50, 95% CI: 0·26–0·74), haemoglobin (SMD = 0·34, 95% CI: 0·13–0·55), depression (SMD = −0·80, 95% CI: −1·10 to −0·50) and physical component of the quality of life (SMD = 0·46, 95% CI: 0·20–0·73). Intradialytic exercises are safe with no adverse events. However, significant improvements were not observed in the albumin level and mental component of the quality of life.

Conclusions
The study results facilitate selecting intradialytic exercise that improves and provides safety with respect to the peak oxygen consumption, haemoglobin, depression and physical component of the quality of life. Furthermore, regular exercise should be considered a crucial therapeutic modality for patients undergoing haemodialysis.

Relevance to clinical practice
This study suggests that performing intradialytic exercises for 30 minutes per session three times a week for at least ≥8 weeks is beneficial. Regular exercise should be considered as a crucial therapeutic modality of managing patients undergoing haemodialysis, thus guiding in clinical practice.

Effects of intradialytic exercise on the physical function, depression and quality of life for haemodialysis patients: a systematic review and meta-analysis of randomised controlled trials.

Physical function limitation is a common disorder in chronic hemodialysis (HD) patients, relating to increased morbidity and mortality. The aim of this study was to determine the effects of aerobic and resistance trainings on blood lipids and inflammation status in HD patients. Out of 30 volunteer males who had been undergoing conventional maintenance HD within an HD unit in Tehran, 21 subjects were enrolled. They were randomly assigned into aerobic exercise group – resistance training group undergoing an 8-week intradialytic exercise program (three times/week) and control group (n = 7, each). Training program consisted of 10-30 min stationary cycling at an intensity of 12–16 out of 20 at the rate of perceived exertion (RPE) of Borg scale in aerobic group and using ankle weights for knee extension, hip abduction and flexions at an intensity of 15–17 out of 20 at the RPE of Borg scale in resistance group. Fasting blood samples for serum biochemistry were drawn at baseline and 8 weeks. The age, HD duration, and physical activity score were 51.6±18.9yrs; 25.1±13.9 mo, and 19.2±7.6, respectively. Diabetes mellitus (43%), hypertension (28%), and obstructive uropathy (14%) were the most common underlying diseases. Aerobic and resistance exercises were correlated with serum creatinine (P 0.05). Both intradialytic aerobic and resistance exercises showed beneficial effects on inflammation status without any influences on serum lipid levels probably due to short duration of the study which was not accompanied with body weight changes. Solute removal had no change during exercise programs. There is a need for more investigation on the role of exercise in HD patients.

L Shegarfy

Papers

Effects of aerobic exercise and resistance training on lipid profiles and inflammation status in patients on maintenance hemodialysis.