Diagnostic utility of salivary creatinine and urea as non-invasive biomarkers in chronic kidney disease – A cross-sectional study

Background and aim: Children with chronic kidney disease (CKD) develop many metabolic changes in blood that often necessitate frequent biochemical analysis. Serum analysis is an invasive and painful procedure. It would be highly beneficial if a noninvasive alternative process to serum analysis in children were identified. Saliva can be collected noninvasively, repeatedly, and without the use of healthcare personnel. The aims of this study were to compare serum and salivary urea and creatinine levels in children with CKD and healthy controls, and to determine if salivary creatinine and urea levels can be used to diagnose CKD in children as accurately as serum creatinine and urea levels. Materials and methods: This case–control study included 35 children with CKD and 28 healthy children as controls. Saliva and blood samples were collected for measurement of urea and creatinine levels. The urea and creatinine levels in serum and saliva in the CKD and control groups were compared using the independent samples Mann–Whitney U test. Correlations between the serum and salivary urea and creatinine levels were determined using Pearson’s correlation coefficient. Receiver operating characteristic analysis was used to assess the diagnostic performance of salivary creatinine and cutoff values were identified. Results: In the CKD group, the mean salivary creatinine level was 0.45 mg/dL and the mean salivary urea level was 0.11 mg/dL, versus 28.83 mg/dL and 21.78 mg/dL, respectively, in the control group. Stage 4 and 5 CKD patients had a mean salivary urea level of 31.35 mg/dL, as compared to 17.78 mg/dL in the control group. Serum urea and creatinine, and salivary creatinine were significantly higher in the CKD patients (regardless of disease stage) than in the controls (p < .05). The salivary urea level was significantly higher in the stage 4 and 5 CKD patients than in the controls (p < .05). There was a positive correlation between serum and salivary creatinine. The area under the curve for salivary creatinine was 0.805. The cutoff value for salivary creatinine was 0.125 mg/dL, with a sensitivity of 82.9% and specificity of 78.6%. Conclusions: Based on the positive correlation between the serum and saliva creatinine levels observed in the present study, we think saliva analysis could be used as a noninvasive alternative to blood analysis for diagnosing CKD in children.

Serum urea and creatinine are most widely accepted parameters to assess Chronic Kidney Disease (CKD)status as well as to assess renal status in susceptible diabetic and hypertensive subjects. To assess and correlate the serum and salivary urea and creatinine levels of CKD, diabetes mellitus and hypertensive subjects. This cross-sectional study was done on 120 subjects involving 30 CKD, 30 diabetic, 30 hypertensive subjects and 30 healthy controls. After collection of saliva and blood samples, urea was analyzed by enzymatic calorimetric method and creatinine by Jaffe's method. Kruskal Wallis test and Mann Whitney U test were used for comparison between different groups and correlations between serum and salivary parameters were evaluated by applying Spearman's correlation test. The p-value <0.05 was considered statistically significant. The median serum and salivary urea and creatinine levels were highest in CKD group followed by diabetic, hypertensive groups and controls. The correlation coefficient for serum urea and salivary urea was 0.977 and for serum creatinine and salivary creatinine was 0.976, with p-value <0.001. This study showed that there is a significant positive relationship between salivary and serum urea and creatinine. Thus, salivary urea and creatinine levels can be used non-invasively to detect serum urea and creatinine levels respectively in renal disease and diabetic and hypertensive nephropathic cases.

To assess whether salivary urea and creatinine levels accurately reflect their serum levels in blood samples of adults to detect chronic kidney disease. A systematic review was conducted in eight electronic databases. The protocol was registered in PROSPERO. Only diagnostic test studies were included. The JBI critical appraisal tools assessed the risk of bias. A meta-analysis of proportions was performed. The GRADE tool assessed the quality of evidence and strength of recommendation across the studies included. Eight studies met the eligibility criteria and were included. Six studies assessed salivary urea, and six studies assessed salivary creatinine. All studies presented moderate risk of bias. The meta-analysis depicted an overall sensitivity of 93.3% (95% CI = 88.6; 97.9) for salivary creatinine levels and 87.5% (95% CI = 83.2; 91.8) for salivary urea levels, while the overall specificity was 87.1% (95% CI = 82.8; 91.3) and 83.2% (95% CI = 65.0; 101.4) for salivary creatinine and urea levels, respectively. The overall accuracy of salivary creatinine was 5.2 percentage points higher compared with salivary urea levels (90.8% vs. 85.6%). According to the GRADE tool, the analysed outcomes were classified as having low tomoderate level of certainty. Compared with blood samples, salivary urea and creatinine levels presented high diagnostic values for chronic kidney disease screening, but should not be considered equivalent to levels obtained from blood at stages three, four, or five of the disease. Chronic kidney disease patients could receive a clinically significant benefit from replacing blood with saliva for potentially monitoring renal function. Saliva collection presents greater simplicity, comfort, safety, and lower collection cost.

BackgroundFrequent venepuncture for monitoring of serum urea and creatinine in chronic kidney disease (CKD) patients on dialysis will result in venous damage and infection. In this research, we assessed the feasibility of utilizing salivary samples as a substitute for serum samples in determining the levels of urea and creatinine in patients with CKD undergoing dialysis.MethodsThe study participants included 50 patients diagnosed with CKD undergoing hemodialysis and an equal number of apparently healthy individuals. We measured the serum and salivary levels of urea and creatinine in normal subjects. CKD patients were also subjected to similar investigations both before and after hemodialysis.ResultsIn our study, we found that the mean value of salivary urea and creatinine are significantly elevated in the case group (salivary urea: 99.56 ± 43.28 mg/dL, salivary creatinine: 1.10 ± 0.83 mg/dL) as compared to the control group (salivary urea: 33.62 ± 23.84 mg/dL, salivary creatinine: 0.15±0.12 mg/dL, p value: <0.001). There was a statistically significant reduction in the mean value of salivary urea and creatinine in the post-dialysis sample (salivary urea: 45.06 ± 30.37 mg/dL, salivary creatinine: 0.43±0.44 mg/dL) compared to the pre-dialysis sample (salivary urea: 99.56 ± 43.28 mg/dL, salivary creatinine: 1.10 ± 0.83 mg/dL; p value: <0.001) in the case group. The salivary urea is significantly positively correlated with serum urea (r value: 0.366, p value: 0.009). But there is no significant correlation seen between salivary and serum creatinine. We have created a cut-off for salivary urea (52.5 mg/dL) to diagnose CKD which has a good sensitivity (84%) and specificity (78%).ConclusionThe results of our study suggest that the estimation of salivary urea and creatinine could serve as a non-invasive, alternative marker for the diagnosis of CKD, and benefit in risk-free monitoring of their progress before and after hemodialysis.

Introduction: Chronic Kidney Disease (CKD) has become an impending health concern due to the massive rise in the number of patients with diabetes mellitus and hypertension. Monitoring CKD patients typically requires regular invasive testing, and a simple diagnostic test that does not involve venipuncture would greatly benefit patients and healthcare professionals. Extensive research is being conducted to explore the use of saliva as a Non invasive tool for evaluation of systemic diseases like CKD. However, most of these studies have focused on End Stage Renal Disease (ESRD) patients. Aim: To investigate the correlation between salivary urea and creatinine levels and their serum counterparts in CKD patients and healthy controls. Additionally, the study aimed to assess the efficacy of salivary urea and creatinine compared to serum urea and creatinine in predicting CKD. Materials and Methods: The present cross-sectional study was conducted between January 2021 and July 2022 in the Department of Biochemistry, in collaboration with the Department of Medicine, at Heritage Institute of Medical Sciences in Varanasi, Uttar Pradesh, India. The study included a total of 60 participants: 30 CKD patients (stage 1-3) and 30 age-matched healthy controls. Serum and salivary urea were analysed using the Urease-Glutamate Dehydrogenase (GLDH) method, and creatinine was measured using the Modified Jaffe’s method on the Dirui-300B autoanalyser. Data were statistically analysed using Pearson’s correlation coefficient. The sensitivity, specificity, and Area Under the Curve (AUC) of salivary urea and creatinine were evaluated in comparison to their serum counterparts. Results: The participants consisted of 30 CKD patients with a mean age of 54.8±8.8 years and 30 age-matched healthy controls with a mean age of 52.42±8.4 years. A significant difference in salivary urea and creatinine levels was observed between the control and CKD groups. There was a strong and significant correlation (p-value &lt;0.01) between salivary creatinine and serum creatinine in both the control group (r-value=0.76) and the CKD group (r-value=0.82). Additionally, a strong and significant correlation (p-value &lt;0.01) was found between salivary urea and serum urea in the CKD group (r-value=0.63). However, the correlation between salivary and serum urea was not significant in the control group, with an r-value of 0.58 and a p-value of 0.24. Both salivary urea and creatinine demonstrated high sensitivity (90% and 89%, respectively), specificity (80% and 80%, respectively), and AUC (0.78 and 0.86, respectively) compared to their serum counterparts, validating their practical clinical utility. Conclusion: The concentration of urea and creatinine in saliva can reflect kidney damage and help monitor kidney function in CKD patients. Standardising the protocol for evaluation of salivary urea and creatinine and establishing a reference range will make it useful for screening for CKD.

Aim To evaluate and correlate the salivary urea and creatinine levels to the serum levels in smokeless tobacco (SLT) chewers. Materials and methods The present study included 60 subjects, 30 SLT chewers, and 30 controls aged between 20 years and 60 years. Serum and salivary urea and creatinine levels were estimated using Berthelot-urease method enzymatic colorimetric method and modified Jaffe's method, respectively. Results The mean salivary urea, mean serum, and salivary creatinine levels were higher in SLT chewers (33.77 ± 15.04, 0.76 ± 0.17, and 0.17 ± 0.07 mg/dL, respectively) than controls (32.3 ± 14.73, 0.67 ± 0.15, and 0.13 ± 0.05 mg/dL, respectively). Although serum and salivary urea showed a strongly positive correlation (r = 0.654, p &lt; 0.001**) among SLT chewers and controls, no correlation was noted for serum and salivary creatinine (r = 0.098, p = 0.606). Receiver operating curve (ROC) analysis revealed better sensitivity and specificity of serum and salivary creatinine than for urea among both SLT chewers and controls. Conclusion Salivary urea, serum, and salivary creatinine levels were higher among SLT chewers than controls showing that SLT can be nephrotoxic. Clinical significance Smokeless tobacco chewers can be assessed for early renal damage caused by the tobacco products using salivary parameters of urea and creatinine so that they can be counseled for the risk of renal diseases and referred appropriately. How to cite this article Basavarajappa S, Shahira. Do the Renal Function Parameters of Serum and Salivary Urea and Creatinine Alter in Smokeless Tobacco Chewers? A Case–Control Study. J Contemp Dent Pract 2020;21(11):1222–1228.

BackgroundMany metabolic changes develop in patients with chronic kidney disease which often necessitate frequent biochemical analysis of blood. Saliva analysis as an alternative to blood has many advantages. The aims of this study were to evaluate levels of salivary creatinine and urea in patients with chronic kidney disease in comparison to healthy individuals; to determine correlation between salivary creatinine/urea and blood creatinine/urea and to evaluate the diagnostic potential of saliva.MethodsA case control study, involving 50 patients with late stage chronic kidney disease and 49 healthy individuals as control. Blood and saliva samples were analyzed for urea and creatinine levels. Data are presented as median with interquartile range and compared using Independent Samples Mann Whitney U test. Correlation between plasma and salivary creatinine as well as urea was determined using Spearman’s correlation test. Receiver operating characteristics (ROC) analysis was done to determine the diagnostic ability of salivary creatinine and urea and cut-off values were established.ResultsMedian salivary creatinine levels were 2.60 mg/dl and 0.20 mg/dl while median salivary urea levels were 92.00 mg/dl and 20.50 mg/dl in patients with chronic kidney disease and controls respectively. Salivary levels of creatinine and urea were significantly elevated in chronic kidney disease patients (p < 0.001). In addition, there was positive correlation between blood and salivary creatinine as well as urea levels. Total areas under the curve for salivary creatinine and urea were 0.97 and 0.89 respectively. Cut-off values for salivary creatinine and urea were 0.55 mg/dl and 27.50 mg/dl respectively which gave sensitivity and specificity of 94 % and 85 % for creatinine; as well as 86 % and 93 % for urea.ConclusionsFindings of this study suggest that analysis of salivary creatinine and urea in patients with chronic kidney disease reflects their levels in blood. Hence, salivary creatinine and urea could be used as diagnostic biomarkers of chronic kidney disease.

Objectives: The aims of this case control study were to correlate the serum and salivary urea as well as creatinine levels; and to evaluate salivary urea and creatinine as noninvasive alternatives to serum for creatinine estimation in chronic kidney disease (CKD) patients.Methods: Blood and saliva samples were collected from 112 CKD patients and 108 subjects without CKD for quantitative analysis of urea and creatinine. Spearman’s correlation coefficients between salivary and serum urea as well as creatinine were obtained. Receiver operating characteristic analysis was done to assess the diagnostic tests of salivary urea and creatinine. Cut-off values were determined based on the best trade-off between the sensitivity and specificity for both salivary urea and creatinine.Results: Salivary urea and creatinine concentrations were significantly higher in CKD patients than those in control subjects; and increased by the stages of the severity of the disease. The positive correlation was significantly found between salivary and serum creatinine (r = 0.90) and between salivary and serum urea (r = 0.73). Area under the curve for salivary urea was 0.76 and a cut-off value of 14.25 mmol/L gave a sensitivity of 82.9% and specificity of 57.8%. Area under the curve for salivary creatinine was 0.92 and a cut-off value of 0.24 mg/dL gave a sensitivity of 86.5% and specificity of 87.2%.Conclusions: Both salivary urea and creatinine have a high capacity for serum creatinine estimation. Salivary urea and creatinine tests can be used as low-cost, easily accessible and noninvasive tools for screening, diagnosing, monitoring treatment outcomes and ascertaining prognosis of chronic kidney disease.

Introduction: Saliva has hundreds of components that may serve to detect systemic diseases or as evidence of exposure to various harmful substances, as well as provide biomarkers of health and disease status. Pilocarpine has effects on serum urea, creatinine and phosphorus in patients with chronic kidney disease (CKD) and patients with End Stage Renal Disease (ESRD) on hemodialysis. Pilocarpine is a parasympathomimetic drug used to induce hypersalivation. Parasympathetic stimulation leads to acetylcholine (ACh) release into the salivary acinar cells. ACh causes the salivary gland to release kallikrein, an enzyme that converts kininogen to lysyl-bradykinin. Lysyl-bradykinin acts upon blood vessels and capillaries of the salivary gland to generate vasodilation and increased capillary permeability respectively. The resulting increased blood flow to the acini allows production of more saliva. Aim of work: To determine the effects of expelling induced hyper salivation on serum Phosphorus, urea and creatinine levels in CKD and ESRD patients. Materials and Methods: It is a case control study which included 80 patients divided into Group A: 40 patients with End Stage Renal Disease on Hemodialysis for at least six months in Assiut University Hospital and Group B: 40 patients with Chronic Kidney Disease (stage 3,4) on conservative medical treatment. Both groups were complaining of hyperphosphatemia. Their ages ranged from 18 to 60 years old with mean age ± SD (51 ± 11) pilocarpine mouth washer (4% concentration, 5 ml pilocarpine which equals 13 mg, three times daily) is given for two months. Results:. After pilocarpine intake; there was a decrease in serum phosphorus level in CKD patients (33%) than those with ESRD (30%). But there was a decrease in serum creatinine level in ESRD patients (23%) than those with CKD patients (15%). The two groups had the same percentage of decrease in blood urea level (40%). In salivary measures after pilocarpine intake; one hundred percent increase in phosphorus excretion in both group but patients with ESRD showed more creatinine excretion compared to patients with CKD (84% vs. 60%). CKD patients had more urea excretion in saliva versus to patients with ESRD (100% and 55%) respectively. Conclusion: Pilocarpine has a role in improving hyperphosphatemia in CKD patients and ESRD patients, also pilocarpine led to decrease in serum urea and creatinine levels so it can be used as an adjuvant therapy in CKD and ESRD patients.

Serum urea levels are essential for the diagnosis of chronic kidney disease (CKD), as they are a measure of renal function. Salivary urea has been used as an alternative to serum urea in patients with CKD. To estimate serum urea levels and their correlation with salivary urea levels in order to validate the use of saliva as an alternative diagnostic tool for renal dysfunction. Thirty healthy individuals and 150 patients with CKD (30 from each CKD stage) were recruited for the study. Serum and salivary samples were collected to estimate the urea levels, and statistical analyses were performed. Statistically significant (P < 0.05) differences in the mean serum and salivary urea levels were observed between the healthy and each stage of the CKD group; significance at P < 0.05 was observed within the stages of CKD as well. Correlation analysis also showed significant differences between the serum and salivary urea levels at each stage of the disease. Receiver operating characteristic analysis revealed a higher area under the curve of 0.917 at a 95% confidence interval with a salivary urea cut-off of 28.25 mg/dl (sensitivity and specificity: 88% and 84%, respectively). The variability in salivary urea levels in the early and late stages suggests the use of salivary urea in the late stages of CKD. It is suggested that salivary urea levels may be used as an alternative to serum to assess and monitor the progression of renal impairment along with other standard renal function markers.

INTRODUCTION:Various metabolic changes were elaborated in patients with chronic kidney disease which often require biochemical analysis of blood regularly.Saliva analysis has many advantages as an alternative to blood analysis.OBJECTIVE: Evaluate levels of some parameters in saliva and serum including: urea, creatinine, calcium and phosphorus in children undergoing hemodialysis and to determine the correlation between saliva and serum regarding these parameters in order to evaluate salivary diagnostic potential. MATERIALS AND METHODS:A cross sectional analytical study was conducted on children undergoing hemodialysis in Alexandria University Children's Hospital (AUCH).A total of 20 patients were included in the present study of whom, 10 were boys (50%) and 10 were girls (50%) with a mean age 8.85 ± 2.74.Serum and salivary samples were collected from the participants for analysis.Serum tests including Urea, creatinine (Cr), calcium (Ca), phosphorus (P) and salivary tests including Urea, Cr, Ca and P were recorded in all subjects.RESULTS: There was significant a positive correlation (P <0.0001) between serum and salivary urea (r = 0.79), as well as between serum and salivary creatinine (r = 0.68).Besides, levels of phosphorus were significantly higher in saliva than in serum.However, levels of creatinine and calcium showed significantly lower levels in saliva compared to serum.CONCLUSION: Outcomes of this study found that analysis of salivary creatinine and urea in patients with chronic kidney disease mirrored their levels in serum.Consequently, salivary creatinine and urea levels could be used non-invasively to measure serum urea and creatinine levels respectively in patients with chronic kidney disease which may be helpful in monitoring of these patients.

Objective: The objective of this study was to evaluate serum urea, creatinine and hemoglobin level in chronic renal failure pre and post dialysis at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia.&#x0D; Methodology: Cross sectional study design was conducted From February to May 2017 to all chronic kidney failure patients Ethio-Egyptian Nephrology unit in SPHMMC Addis Ababa Ethiopia. 5 ml of the blood will be obtained from each patient before and after dialysis. Each sample was divided in to two; half of the blood was placed in tubes containing anticoagulant (EDTA) and half in clot activator tubes. Clotted blood was centrifuge to separate serum and used for the estimation of creatinine and urea. Non-clotted blood samples were used for complete blood count and hemoglobin in blood Analyzer Sysmax KX-21. Percentages of reduction in urea and creatinine values were calculated using the values of blood samples withdrawn from each patient before and after each hemodialysis sessions.&#x0D; Results: A total of 33 chronic kidney patients participated in this study. Out of this only 26 patients (78.79%) attend the dialysis unit for four months the rest either passed away or kidney transplantation done. The study population comprised 80.8% male and 19.2% female. Before the dialysis, 12 (46.2%) patients serum urea level was 101-122 mg/dl, however after dialysis, 14 (53.8%) patients had serum urea level were between 20 – 50.99 mg/dl and 11 (42.3%) patients had serum urea level were between 51 – 100 mg/dl. Most of the patients, (53.8%) undergoing hemodialysis serum creatinine level before dialysis were between 7.6 – 10.5 mg/dl. The majority of patients’ (42.3%), serum creatinine level after dialysis was between 3.0 – 3.92 mg/dl. The majority (73.1%) of the patient hemoglobin level was between 7.0 – 11.0 mg/dl and 23.1% of the patients were between 11.1 – 14.0 mg/dl. Patients with chronic kidney disease have high serum urea and creatinine level before hemodialysis.&#x0D; Conclusion: Hemodialysis decreases the burden of kidney in chronic kidney disease patients.

Background: Diabetes is a common cause of end-stage renal disease and nephropathy, which is characterized by abnormal renal function with reduction of glomerular filtration and rise in the level of serum urea and creatinine. Aims and Objectives: The aim of this study was to compare serum urea and creatinine levels in Type 1 and Type 2 diabetics and further correlate the serum creatinine and urea levels in both Type 1 and Type 2 diabetic subjects with duration of diabetes and glycosylated hemoglobin levels (HbA1c). Materials and Methods: Blood samples were collected and analyzed for serum urea and creatinine levels in diabetic subjects, both Type 1 and Type 2 attending diabetic clinic and non-diabetic subjects in a tertiary hospital. 72 male subjects in each group of age 35-55 years were selected for the study. Fasting, post-meal blood sugar levels, and HbA1c of all the subjects in the study were determined. Results were interpreted by one-way analysis of variance test. Association of serum urea and creatinine levels with HbA1c and duration of illness in all diabetic subjects was analyzed by applying Pearson’s correlation coefficient. Results: There was statistically significant increase in serum urea and creatinine levels in both Type 1 and Type 2 diabetic subjects compared to non-diabetic subjects. There was a correlation of levels of serum urea and creatinine with HbA1c levels and duration of diabetes in Type 1 diabetics but not with Type 2 diabetic study group. Conclusion: Serum urea and creatinine are simple and useful biomarkers which can serve as predictor tests for assessing kidney functions (nephropathy) in diabetic patients.

This study aimed to assess whether the reductions in serum urea and creatinine levels are different from the reductions in salivary urea and creatinine levels that occur after hemodialysis in chronic renal patients. The systematic review protocol was registered in the PROSPERO database. Eight databases were searched to identify pretest-posttest studies of chronic kidney disease patients undergoing hemodialysis, with no language or year restrictions. The JBI Critical Appraisal Tool was used to assess the risk of bias. Meta-analyses using random-effect models were conducted to compare salivary and serum correlations and to pooled mean and proportion differences from pre- to posthemodialysis urea and creatinine levels by subgroup analysis. The I2 test was used to assess heterogeneity, and a meta-regression was performed to statistically assess correlations and differences in the pooled effects pre- and postdialysis. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to assess the certainty of evidence. The search resulted in 1404 records, and only six studies (n = 252 participants) fulfilled the eligibility criteria and were included. The studies were published between 2013 and 2018. All studies showed a significant reduction in both salivary and serum urea/creatinine levels. All eligible studies presented a low risk of bias. The meta-analysis shows a moderate to high correlation between salivary and blood levels of urea (r: 0.79; 95% CI: 0.56-1.00) and creatinine (r: 0.64; 95%CI: 0.16-1.00), with a very low level of certainty. The reductions in salivary urea and creatinine levels are similar to and correlated with the reductions in blood urea and creatine levels after hemodialysis among chronic kidney disease patients.

In chronic kidney disease (CKD) toxins accumulate in the muscles and cause fatigue, mental impairment, and muscle dysfunction (cramps). Exercise results in the opening of capillaries thereby increasing blood flow and allowing greater movement of urea and creatinine from the tissues to the vascular compartment and subsequent removal through dialysis. An experimental study of 64 CKD patients (32 each in experimental and control group), six low-intensity intra-dialytic exercises (IDE) were implemented for experimental group using video demonstration at 90 min after initiation of hemodialysis (HD) repeated thrice at an interval of 10 mins. Pre- and post-HD serum urea, creatinine, and fatigue levels were assessed at baseline, two, four and six weeks. Fatigue was measured using FACIT scale. Significant difference was found between the control and experimental group in serum urea, creatinine and fatigue levels (P = 0.007, P = 0.001, P = 0.001) at six weeks post HD. The experimental group showed a significant decrease in creatinine levels from baseline to six weeks (P = 0.04). Ninety-seven percent of patients were compliant to low-intensity IDE with patients feeling better and comfortable along with decrease in felt fatigue levels. No significant association was found between duration of illness, duration of maintenance HD and comorbidities and serum urea, serum creatinine, and fatigue levels (P = 0.5, P = 0.21, P = 0.78). The present study shows low-intensity IDE when performed regularly, was effective in decreasing serum urea, creatinine, and fatigue levels of CKD patients undergoing HD with vital signs remaining within the normal range. No overt complications were reported; hence, the exercises were safe.