Brazilian nephrologist’s knowledge of intradialytic exercise: a national survey

Nephrologists' lack of knowledge regarding the benefits of intradialytic exercise (IE) may result in patients not being adequately instructed to participate in exercise programs and to become more active. To evaluate the knowledge of Brazilian nephrologists regarding guidance and importance of IE for patients with chronic kidney disease. This was a cross-sectional survey of 16 items administered to Brazilian nephrologists actively registered with the Brazilian Nephrology Society. A total of 262 nephrologists participated in the study. Most of the participants were from the southeast region (n = 124, 47.3%). Additionally, 140 nephrologists (53.4%) had more than 11 years of experience. Notably, 172 nephrologists (65.5%) reported that they had not received information about the importance of IE during their formal training. Nephrologists endorsing exercise during the intradialytic period (OR = 2.00, p = 0.03) perceive its impact on their patients (OR = 6.21, p = 0.01). With an increase in years of nephrology training, there was a decreased likelihood of being informed about IE (OR = 0.13, p < 0.01). The willingness to provide exercise guidance for CKD patients is associated with nephrologists' perception of the impact of exercise (OR 7.07, p = 0.01). Most nephrologists were not knowledgeable about IE, those who were knowledgeable were more likely to recommend it, and those with more years of experience tended to be less knowledgeable about IE. Having this knowledge seems to have the potential to reduce barriers that affect the practice of IE.

Background Dialysis patients are at a high risk of sarcopenia. To prevent sarcopenia in these patients, exercise programs, especially during dialysis sessions, have recently been used. However, the long-term effects of intradialytic exercise on body composition, physical function, and dialysis adequacy have not been fully elucidated. Methods Fourteen dialysis patients were divided into an ergometer group (n = 8), with intradialytic exercise using an ergometer and the non-ergometer group (n = 6) without intradialytic exercise. Bioimpedance analysis for measuring body composition and physical function tests were performed during the one-year study period. Results There were no patient dropouts from the study. Ergometer exercise increased the percentage change in skeletal muscle mass (non-ergometer 2.01%±2.93% vs. ergometer 6.27%±2.12%, p = 0.005), leg muscle mass (5.85%±12.88% vs. 15.39%±8.78%, p = 0.073), bone mineral content (4.50%±6.18% vs. 9.69%±1.77%, p = 0.036), and decreased the percentage change in body fat percentage (-4.46%±16.30% vs. -14.24%±6.86%, p = 0.098). Lower limb physical function mildly improved, and Kt/V changed to a positive value in the ergometer group. Conclusions One-year intradialytic ergometer exercise increased lower limb muscle mass and bone mineral content, and decreased body fat percentage in dialysis patients. Additionally, it mildly increased physical function and Kt/V. Therefore, intradialytic ergometer exercise could be a promising and sustainable intervention program for improving body composition, physical activity, and dialysis adequacy.

Introduction: Despite ongoing advancements in dialysis techniques, patients undergoing this treatment often experience impaired physical performance. Intradialytic exercise has shown potential in improving dialysis adequacy, biochemical markers (calcium and phosphorus), and quality of life for these patients. Objectives: This study aimed to investigate the effect of intradialytic exercise on various factors including dialysis efficacy, biochemical markers, quality of life, and physical performance among individuals undergoing hemodialysis. Patients and Methods: A single-center randomized clinical trial was conducted to investigate the effects of a 6-month exercise program on 30 end-stage renal disease patients who were receiving hemodialysis (HD) treatment for at least six months. The patients were randomly assigned to either the experimental group (n = 16) or the control group (n = 14). The experimental group received a 30-minute intradialytic exercise session three times a week, during the first 2 hour of HD. Blood samples were collected at baseline, as well as at the end of six months of the exercise program, for biochemical measurements. Additionally, the sit-to-stand 10 (STS-10) test and KDQOL-36 scale were completed at the beginning and end of the study to assess the participants’ quality of life. Results: There were no significant differences between the control and intervention groups in baseline demographic and biochemical characteristics. The results of the STS-10 test showed a noteworthy increase in muscle strength at the end of six months for the exercise group (P&lt;0.05). The prescribed intradialytic exercise led to an improvement in Kt/V and C-reactive protein (CRP) levels, although the improvement was not statistically significant (P=0.06). No significant changes were observed in biochemical parameters and the level of quality of life between the two groups after six months (P&gt;0.05). Conclusion: It can be concluded that an intradialytic exercise program is a safe and effective complementary intervention, with the potential for improvement in physical ability. Trial Registration: The trial protocol was approved by the Iranian Registry of Clinical Trials (identifier: IRCT20080916001256N2; https:// en.irct.ir/trial/43662; Ethical code: IR.MUMS.MEDICAL.REC.1399.110).

A Comparison of Aerobic Exercise and Resistance Training in Patients With and Without Chronic Kidney Disease

The mortality of dialysis patients treated with high-volume online hemodiafiltration (OL-HDF) is better than hemodialysis, but is still higher than healthy population. Low daily physical activity increases cardiovascular mortality. Addition of intradialytic exercise (IDX) program might improve physical activity and health status in OL-HDF patients. This pilot open-labeled randomized-controlled trial was conducted to evaluate the effects of IDX on physical activity and other clinical parameters in OL-HDF patients. Twelve OL-HDF patients were randomized into control (n = 6) or IDX (n = 6) groups. The subjects in IDX group were trained to exercise using a cycle ergometer for 60min during each OL-HDF session. Physical activity measured as daily step count using a wrist-worn triaxial accelerometer, physical fitness, or cardiorespiratory fitness assessed by VO2max and other physical performance tests, lean body mass determined by the Dual-energy X-ray absorptiometry (DXA), quality of life (QOL), and various parameters were compared between baseline and 6months. The baseline physical activity status was comparable. Following 6-month IDX, the physical activity was significantly improved in IDX group [+ 1048.79 (+ 741.50, + 2792.54) vs. -362.06 (-1626.82, -167.47) steps/day, p = 0.01], while physical fitness and QOL were unchanged. The lean body mass parameters were preserved in the IDX group while seemed to decrease in the control group. Serum albumin was significantly increased in the IDX group (p = 0.01). The hemoglobin changes were significantly better (p = 0.01) and the erythropoietin resistance index was significantly lower in the IDX group (p = 0.03). Phosphate reduction was significantly greater in the IDX group (p = 0.04). IDX could improve physical activity and other metabolic parameters in OL-HDF patients and these might contribute to further improvement in clinical and survival outcomes. ClinicalTrials.gov Registration: NCT03353844.

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

Background: Chronic Kidney Disease (CKD) patients undergoing maintenance hemodialysis (MHD) are often physically deconditioned due to multiple factors such as uremic toxins, malnutrition, and physical inactivity. Which leads to muscle weakness, reduced exercise tolerance, and physical frailty. Hence, quality of life is significantly impaired. Intradialytic exercise, which involves physical activity during dialysis, can be a viable intervention to address these challenges. Purpose: To evaluate the effect of intradialytic Lower Limb (LL) resisted exercise on muscle strength, exercise capacity, and quality of life in patients with CKD on MHD. Method: 4 patients (3 male and 1 female, age 20-29 years) of CKD on MHD were on dialysis for more than 12 months and had no contraindications to exercise. Pre- and post-assessment were taken with 1- Repetition maximum (1-RM), 6-min Walk Test (6-MWT), Hand Grip Strength (HGS), Bioelectrical Impedance Analysis (BIA), and Kidney Disease and Quality of Life Instrument-36 (KDQOL-36). Patients performed a structured intradialytic exercise program during their hemodialysis, focused on lower limb strength using a weight cuff [Load- 65%-75% of 1-RM, Frequency- 2 times/week, 3-4 sets of 10-15 repetitions, Duration- 6 weeks]. Result: 6 weeks of intradialytic LL-resisted exercise resulted in notable improvement in muscle strength in terms of 1-RM, exercise capacity in terms of 6-MWT, and quality of life (KDQOL-36) in patients with CKD on MHD Conclusion: This case series shows that intradialytic LL-resisted exercise is a promising intervention for improving muscle strength, exercise capacity, and Quality of Life (QoL) in patients with CKD on MHD. Keywords: Intradialytic exercise, Muscle strength, Exercise capacity, Quality of life, CKD, Case series.

The C-C chemokine receptor type 5 (CCR5) plays a role in the immunopathogenesis of chronic kidney disease (CKD). Exercise has anti-inflammatory properties that may contribute to the rehabilitation of CKD patients. To date, the impact of the intradialytic exercise on CCR5 expression in monocytes and lymphocytes of CKD patients is unknown. We aimed to evaluate the effects of an acute intradialytic moderate-intensity exercise on CD4+CCR5+ T-cells and CD14+CCR5+ monocytes of elderly individuals with Chronic Kidney Disease (CKD). Eight CKD elderly patients performed a single bout of 20 min intradialytic exercise and a control hemodialysis (HD) session. Blood samples were collected at baseline, during and immediately after the trials. HD therapy increased the peripheral frequency of CD4+CCR5+ T-cells. The systemic CCL5 levels and the peripheral CD14+CCR5+ proportions increased during and after HD therapy. No significant alterations in CD4+CCR5+ and CD14+CCR5+ proportions or CCL5 levels were identified in CKD patients during and after intradialytic exercise. A negative correlation between the peripheral frequency of CD14+CCR5+ and the creatinine levels was identified in the intradialytic exercise session. A single moderate-intensity intradialytic exercise imposes an immunomodulatory impact in CKD elderly patients, preventing an excessive inflammatory response induced by hemodialysis.

Background: End Stage Renal Disease (ESRD) patients undergoing hemodialysis (HD) tend to be less active, experience decreased exercise capacity, and have poor physical function when compared to the general population. Decreased lower extremity physical performance in ESRD is associated with an increased risk of death. Intradialytic exercise is the most feasible option and intradialytic exercise programs are mostly aerobic exercise. This study aims to determine the effect of low-intensity intradialytic aerobic exercise using a cycle ergometer on lower extremity muscle strength with a 30 second sit to stand test in patients with ESRD undergoing HD. Method: This study is a quasi-experimental design with a pre and post-test randomized control group. The research is performed in the Hemodialysis Installation of Dr. Soetomo General Academic Hospital Surabaya from March to June 2021. From the total of 30 ESRD patients undergoing HD randomly assigned to either treatment or control group, 2 subjects dropped out, leaving 28 ESRD patients. The treatment group received light-intensity intradialytic aerobic exercise with a cycle ergometer, performed during the first two hours of HD, twice weekly, for 12 weeks. The 30-second sit-to-stand (30 STS) test was evaluated at baseline and after 12 weeks in both groups. The data were analyzed in the SPSS package program. Result: There was no significant difference between of 30 STS results for both groups at baseline. There was a significant increase in the mean of 30 STS results before and after the intervention in the treatment group with a large effect. Conclusion: Low-intensity intradialytic aerobic exercise using a cycle ergometer for 12 weeks in ESRD patients undergoing hemodialysis increases lower extremity muscle strength.

Background and Aims Frailty prevalence is notably high among older hemodialysis patients, correlating with poorer prognoses. Prior smaller-scale studies have underscored the benefits of various exercise interventions in individuals with Chronic Kidney Disease and those receiving dialysis treatments. Addressing frailty in older hemodialysis patients by exercise therapy is crucial for healthcare professionals aiming to enhance patient outcomes. Despite this, a standardized exercise therapy protocol for this demographic has not been broadly implemented in clinical practice. Our study sought to evaluate the impact of intradialytic resistance exercise programs on the prognosis of frail individuals undergoing hemodialysis. Method This retrospective, multicenter, non-randomized clinical trial encompassed 2006 participants (mean age 70.1±11.7 years) from 17 outpatient clinics within the Kaikoukai Medical Group. Enrollment spanned from April to December 2018, with patients stratified according to baseline frailty levels, determined by the Japanese Frailty Criteria for the Diagnosis of Frailty in the Elderly. In this study, patients meeting the criteria for frailty or pre-frailty, as defined by the Japanese Criteria for Health and Social Services (J-CHS), were collectively classified as 'frail’. Participants were invited to join a voluntary exercise program during dialysis, which included stretching and four types of resistance exercises using elastic tubes. The cohort was divided into four groups based on their frailty status and participation in the exercise program. Patient outcomes were monitored until either death or the study's conclusion in December 2021. Kaplan-Meier and log-rank analyses were utilized to assess prognostic differences among the groups, with significance levels adjusted using the Bonferroni correction. Ethical approval was granted by the Nagoya Kyoritsu Hospital's ethical committee. Results The study comprised 112 non-frail exercising, 398 frail exercising, 205 non-frail non-exercising, and 1287 frail non-exercising patients. Over the study period (median 25 months), mortality was recorded in 338 (16.9%) patients, including 8 (7.1%) non-frail exercising, 50 (12.6%) frail exercising, 16 (7.8%) non-frail non-exercising, and 264 (20.5%) frail non-exercising participants. Prognostic analysis revealed that the frail non-exercising group had a significantly poorer prognosis than both the non-frail exercising and non-frail non-exercising groups, as well as the frail exercising group (p&amp;lt;0.05). Conclusion This investigation is pioneering in establishing a link between intradialytic resistance exercise interventions and prognosis in frail patients. The findings indicate that, although frail patients inherently face a more challenging prognosis, participation in intradialytic exercise can yield substantial improvements. Therefore, clinicians are encouraged to advocate for exercise therapy as a means to enhance prognosis in frail patients undergoing hemodialysis.

BackgroundDepression is associated with morbidity, death, diminished quality of life, decreased longevity, and even suicidal ideation in hemodialysis patients. Intra-dialytic exercise is considered as integral component of the clinical care management of hemodialysis patients as it improves hemodialysis effectiveness, reducing systemic inflammation, increasing exercise tolerance, decreasing depression and improving quality of life. The objective of this study was to assess the effect of intra-dialytic physical exercise on depression and physical activity in prevalent hemodialysis patients. This prospective cohort research comprised 50 hemodialysis patients maintained on regular hemodialysis 3 times/week with duration since starting dialysis (1–5 years), not practicing any previous physical activity, suffering from depressive symptoms, not maintained on antidepressants and separated into two groups: group I underwent intra-dialytic exercise for 3 months and group II was matched in age and gender but did not undertake any exercise.ResultsHamilton depression rating scale was significantly decreased in group I after completing the exercise program compared to baseline (P = 0.000), while there was no significant change in group II. Serum tumor necrosis factor alpha significantly decreased in group I compared to baseline (P = 0.000), while there was no significant change in group II. A positive correlation was found between serum tumor necrosis factor alpha and Hamilton depression rating scale (r = 0.676), (P = 0.000). Physical activity tests; 6-min walk test, rapid assessment of physical activity and peak volume of oxygen consumption were significantly improved in group I compared to baseline (P = 0.000), while there was no statistically significant difference in group II. Serum phosphorus and parathyroid hormone levels were significantly decreased in group I compared to baseline (P < 0.01), while urea reduction ratio was significantly increased in group I compared to baseline (P = 0.000), but there was no significant change in group II.ConclusionsIntra-dialysis exercise can improve depression and physical performance in hemodialysis patients. As positive correlation was found between serum tumor necrosis factor alpha and Hamilton depression rating scale, so tumor necrosis factor alpha may be considered as marker of depression in hemodialysis patients. Intra-dialytic exercise can improve dialysis efficacy by improving urea reduction ratio.

Background: Hemodialysis is an ongoing process where patients experience complications such as hypotension, muscle cramps, fatigue and nausea during the procedure. Aim: To evaluate the effect of implementing intradialytic hemodialysis exercises program on fatigue and leg cramps. Subjects and methods: Pre/posttest was utilized in this study. it was conducted in dialysis unit at Sohag University Hospital, A sample of 60 patients who undergoing hemodialysis with fistula (peripheral vascular access), with age 18-65 years old. four tools were used: Tool(I): Structured Interview Questionnaire sheet, Tool (II):Cramp questionnaire chart and visual analogue scale : Pre/post test (after 2 months) Tool (III) : Fatigue severity scale and Tool (IV): Intradialytic exercise. Results. The mean age of the patients was 43.80± 12.089(range 18- 65). More than half of patients (58.3%) experienced muscle cramps in both the legs. As regard muscle involved in cramps, majority of patients(83.3 %) experienced muscle cramps in gastrocnemius muscle. Conclusion: The findings of the study revealed that there were statistical significance differences as regard cramps questionnaire chart, visual analogue scale and fatigue severity scale pre &post intradialytic exercises. Recommendations: Intradialytic exercises can be adapted as a procedure to the patients undergoing hemodialysis.

IntroductionWhether clinically implementable exercise interventions in people receiving hemodialysis (HD) therapy improve health-related quality of life (HRQoL) remains unknown. The PrEscription of intraDialytic exercise to improve quAlity of Life (PEDAL) study evaluated the clinical benefit and cost-effectiveness of a 6-month intradialytic exercise program.MethodsIn a multicenter, single-blinded, randomized, controlled trial, people receiving HD were randomly assigned to (i) intradialytic exercise training (exercise intervention group [EX]) and (ii) usual care (control group [CON]). Primary outcome was change in Kidney Disease Quality of Life Short-Form Physical Component Summary (KDQOL-SF 1.3 PCS) from baseline to 6 months. Cost-effectiveness was determined using health economic analysis; physiological impairment was evaluated by peak oxygen uptake; and harms were recorded.ResultsWe randomized 379 participants; 335 and 243 patients (EX n = 127; CON n = 116) completed baseline and 6-month assessments, respectively. Mean difference in change PCS from baseline to 6 months between EX and CON was 2.4 (95% confidence interval [CI]: −0.1 to 4.8) arbitrary units (P = 0.055); no improvements were observed in peak oxygen uptake or secondary outcome measures. Participants in the intervention group had poor compliance (47%) and poor adherence (18%) to the exercise prescription. Cost of delivering intervention ranged from US$598 to US$1092 per participant per year. The number of participants with harms was similar between EX (n = 69) and CON (n = 56). A primary limitation was the lack of an attention CON. Many patients also withdrew from the study or were too unwell to complete all physiological outcome assessments.ConclusionsA 6-month intradialytic aerobic exercise program was not clinically beneficial in improving HRQoL as delivered to this cohort of deconditioned patients on HD.

Intradialytic exercise (ID) programs are effective and safe for hemodialysis (HD) patients to avoid functional deterioration. However, exercise is not routinely undertaken in most HD units, and we do not know if home-based (HB) programs are as effective as ID programs. The purpose of this study was to compare the effects of 16 weeks of ID exercise versus a HB exercise program for HD patients. A total of 46 patients were randomly assigned to the ID group (n = 24) or HB group (n = 22). They completed a 16-week combined exercise program 3 times/week. We measured physical activity level, physical functioning, depression level, and health-related quality of life at baseline and after 16 weeks. A significant time effect was found in both groups for the physical activity level (p = 0.012). There was also a significant group–time interaction effect for the one-leg standing test (OLST) (p = 0.049) and a significant time effect for the Short Physical Performance Battery (p = 0.013), timed up-and-go test (p = 0.005), sit-to-stand-10 (p = 0.027), right and left hand handgrip (p = 0.044, p < 0.001), one-heel left leg raise (p = 0.019), and 6-minute walking (p = 0.006), depression (p = 0.017). HRQoL remained unchanged. There was no difference between the two interventions on the tested outcomes (besides OLST). Both interventions were associated with positive changes of the physical activity levels and physical function.

BACKGROUND The benefits of exercise for vascular and physical health in patients on chronic hemodialysis (CHD) are controversial. This study evaluated the outcomes of an intradialytic aerobic exercise program on carotid-femoral pulse wave velocity (cfPWV, an index of arterial stiffness), gait speed, and a sit-to-stand test in patients with CHD. MATERIAL AND METHODS A total of 114 CHD patients were randomly assigned to the exercise or the control (regular care) group. Patients performed intradialytic cycling exercises (3 sessions/week for 12 months) for 20 minutes in a supine position and the exercise protocol was set at a low-to-moderate intensity, defined as activities eliciting 3 to 5.9 metabolic equivalents. Data on cfPWV, gait speed, and the 5-times sit-to-stand test were collected. cfPWV was determined from the time taken for the arterial pulse to propagate from the carotid to the femoral artery and were compared between the 2 groups. RESULTS Arterial stiffness was improved, as evidenced by a significant decrease in cfPWV, in the exercise group compared to the control group (p<0.001). Generalized estimating equations analysis revealed a reduction in cfPWV at 6 and 12 months after the exercise intervention (p<0.001). Gait speed was significantly faster in the exercise group than in the control group (p=0.019). No exercise-related adverse events were reported. Results of 5-times sit-to-stand and body composition did not differ significantly between the 2 study groups. CONCLUSIONS Intradialytic cycling exercise significantly improved cfPWV and gait speed in CHD patients during the 12-month study period.