Effects of regular exercise on anxiety, depression, and quality of life in maintenance hemodialysis patients

Randomized Controlled Trial of the Effect of an Exercise Rehabilitation Program on Symptom Burden in Maintenance Hemodialysis: A Clinical Research Protocol

Background

People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms.

Objective

The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis.

Design

Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial.

Setting

Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada.

Participants

Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150).

Intervention

Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention.

Control

Usual hemodialysis care (no exercise program).

Measurements

Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality.

Methods

Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution.

Limitations

The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted.

Conclusions

The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.

Exploring Preconceptions as Barriers to Peritoneal Dialysis Eligibility: A Global Scenario-Based Survey of Kidney Care Physicians

Introduction

Despite the growing number of patients requiring kidney replacement therapy (KRT), peritoneal dialysis (PD) is underutilized globally. A contributory factor may be clinician myths about its use. The aim of this study was to explore perceptions about PD initiation by clinicians according to various physical, social, and clinical characteristics of patients.

Methods

An online global survey (in English and Thai) was administered to ascertain nephrologists' and nephrology trainees' decisions on recommending PD as a treatment modality.

Results

A total of 645 participants (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% from high-income countries [HICs], 22% from upper middle-income countries [UMICs], 12% from lower middle-income countries, and 1% from low-income countries [LICs]) completed the survey. Of the respondents, 81% identified as attending physicians or consultants, and 19% identified as trainees or other. PD was recommended for most scenarios, including repeated exposures to heavy lifting, swimming (especially in a private pool and ocean), among patients with cirrhosis or cognitive impairment with available support, and those living with a pet if a physical separation can be achieved during PD. Certain abdominal surgeries were more acceptable to proceed with PD (hysterectomy, 90%) compared to others (hemicolectomy, 45%). Similar variation was noted for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; and ileostomies, 27%).

Conclusion

The probability of recommending PD in various scenarios was greater among clinicians from HICs, larger units, and consultants with more clinical experience. There is a disparity in recommending PD across various clinical scenarios driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.

Nine Months of Hybrid Intradialytic Exercise Training Improves Ejection Fraction and Cardiac Autonomic Nervous System Activity

Cardiovascular disease is the most common cause of death in hemodialysis (HD) patients. Intradialytic aerobic exercise training has a beneficial effect on cardiovascular system function and reduces mortality in HD patients. However, the impact of other forms of exercise on the cardiovascular system, such as hybrid exercise, is not clear. Briefly, hybrid exercise combines aerobic and strength training in the same session. The present study examined whether hybrid intradialytic exercise has long-term benefits on left ventricular function and structure and the autonomous nervous system in HD patients. In this single-group design, efficacy-based intervention, twelve stable HD patients (10M/2F, 56 ± 19 years) participated in a nine-month-long hybrid intradialytic training program. Both echocardiographic assessments of left ventricular function and structure and heart rate variability (HRV) were assessed pre, during and after the end of the HD session at baseline and after the nine-month intervention. Ejection Fraction (EF), both assessed before and at the end of the HD session, appeared to be significantly improved after the intervention period compared to the baseline values (48.7 ± 11.1 vs. 58.8 ± 6.5, p = 0.046 and 50.0 ± 13.4 vs. 56.1 ± 3.4, p = 0.054 respectively). Regarding HRV assessment, hybrid exercise training increased LF and decreased HF (p < 0.05). Both conventional Doppler and tissue Doppler imaging indices of diastolic function did not change after the intervention period (p > 0.05). In conclusion, long-term intradialytic hybrid exercise training was an effective non-pharmacological approach to improving EF and the cardiac autonomous nervous system in HD patients. Such exercise training programs could be incorporated into HD units to improve the patients’ cardiovascular health.

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).

Prevalence of depression and anxiety and their predictors among patients undergoing maintenance hemodialysis in Northern China: a cross-sectional study

OBJECTIVE

To investigate the prevalence of depression and anxiety in patients undergoing maintenance hemodialysis (MHD) in Hohhot, a large city on the northern border of China, and to identify independent risk factors for depression and anxiety in these patients.

METHODS

Patients receiving MHD for >3 months were enrolled in the four largest hemodialysis centers between September 2020 and December 2020. Depression and anxiety were assessed using the Zung self-rated depression scale (SDS) and Zung self-rated anxiety scale (SAS), respectively, with demographic and other data collected for logistic regression analyses.

RESULTS

Among 305 MHD patients included in this study, the prevalence of depression was 55.1%, including 27.5%, 21.0%, and 6.6% with mild, moderate and severe cases, respectively. The prevalence of anxiety was 25.9%, with 20.0%, 4.6%, and 1.3% having mild, moderate, and severe cases, respectively. An independent protective factor for depression was family income of ≥1415 US dollars/month relative to <157 US dollars/month (odds ratio [OR] 0.209, 95% confidence interval [CI] 0.065-0.673), and predictors of depression included ≥3 comorbidities (OR 18.527, 95% CI 1.674-205.028) and severe pruritus (OR 15.971, 95% CI 5.173-49.315). Independent predictors of anxiety included infrequent exercise (OR 3.289, 95% CI 1.411-7.664) and severe pruritus (OR 5.912, 95% CI 1.733-20.168). The correlation between depression and anxiety in these patients was significant (r_s = 0.775, p < 0.001).

CONCLUSION

MHD patients in Northern China had high prevalence rates of depression (55.1%) and anxiety (25.9%). Lower family income, more comorbidities, and a higher degree of pruritus were predictors of depression, while infrequent exercise and severe pruritus were predictors of anxiety. Depression correlated significantly with anxiety. Attention should be given to family income, comorbidity, exercise, and pruritus severity for improved management of depression and anxiety among MHD patients.

Malnutrition-Inflammation Score: A Valid Tool to Assess Nutritional Status in Patient with End-stage Renal Disease

Nutritional assessment is a basic and necessary process in the nutritional management of dialysis patients. Malnutrition is a prevalent complication in patients on maintenance hemodialysis (HD). The study aimed to evaluate its relationship with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess malnutrition inflammation score (MIS) in HD patients. In this descriptive-analytical study, 153 HD patients were selected with random sampling. All the patients were interviewed and the MIS of the patients was recorded. Evaluate the relationship of malnutrition with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess MIS in HD patients. Patients were followed up for 3 months. Data were analyzed with Chi-square and t-tests and Pearson correlation coefficient. A total of 153 patients were studied, 53 (34.64%) patients had good nutritional status and 100 (65.35%) patients had malnutrition. The mean of patients MIS score was 10.71 ± 5.14. Malnutrition rates in males and females were not significantly different. There was a positive and significant relationship between age and MIS score (P = 0.035). There was also a significant correlation between the level of education and MIS score (P = 0.042). The mean dialysis duration was 25.52 ± 2 6.27 months. There was a significant difference in the duration of dialysis in mild to severely malnourished patients (P = 0.002). A significant correlation between MIS score and the serum calcium and serum iron results (r = 0.402). The rise in serum prealbumin level was significantly greater at 3 months. MIS score is the best tool to assess nutritional status in patients with ESRD undergoing HD, because it can recognize various degrees of malnutrition that may remain undetected by a single laboratory assessment. The correlation between MIS score and age and dialysis period was significant.

Chronic kidney disease: prevalence and association with handgrip strength in a cross-sectional study

Background

Poor physical function is strongly associated with mortality and poor clinical outcomes in adults with chronic kidney disease (CKD). Handgrip strength (HGS) is an important index for physical function in the general population, and the association between HGS and CKD is worth investigating.

Methods

From September to November 2015, we conducted a cross-sectional study consisting of 10,407 participants in Jurong City, China. Age-related and sex-specific HGS percentile curves were constructed using the GAMLSS method. In addition, logistic regression was applied to estimate the association between HGS and the presence of CKD with odds ratios (ORs) and 95 % confidence intervals (CIs).

Results

Participants with low HGS tended to be older and were more likely to have CKD (8.73 %). Smoothed centile curves of HGS showed a similar shape in both sexes: participants peaked at approximately 20–35 years old and gradually decreased after the age of 50. In addition, independent of age and other factors, the decreased presence of CKD was significantly identified in individuals with moderate (OR: 0.64, 95 % CI: 0.49–0.83) and high HGS (OR: 0.37, 95 % CI: 0.23–0.58).

Conclusions

We concluded that HGS was significantly negatively associated with CKD in Chinese community-dwelling persons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02452-5.

Energy expenditure estimates in chronic kidney disease using a novel physical activity questionnaire

BACKGROUND

Physical activity (PA) levels are low in patients with advanced chronic kidney disease (CKD), and associate with increased morbidity and mortality. Reliable tools to assess PA in CKD are scarce. We aimed to develop and validate a novel PA questionnaire for use in CKD (CKD-PAQ).

METHODS

In phase 1, a prototype questionnaire was developed based on the validated Recent Physical Activity Questionnaire (RPAQ). Structured feedback on item relevance and clarity was obtained from 40 CKD patients. In phase 2, the questionnaire was refined in 3 iterations in a total of 226 CKD patients against 7-day accelerometer and RPAQ measurements. In phase 3, the definitive CKD-PAQ was compared with RPAQ in 523 CKD patients.

RESULTS

In the final iteration of phase 2, CKD-PAQ data were compared to accelerometer-derived and RPAQ data in 60 patients. Mean daily Metabolic Equivalent of Task (MET) and Total Energy Expenditure (TEE) levels were similar by all methods. Intraclass correlation coefficients showed fair agreement (MET) and good (TEE) between accelerometry and both CKD-PAQ and RPAQ. Agreement between questionnaires was excellent. For mean daily MET bias was 0.035 (SD 0.312) for CKD-PAQ and 0.018 (SD 0.326) for RPAQ. For TEE bias was 91 (SD 518) for CKD-PAQ and 44 (SD 548) kcal for RPAQ. Limits of agreement were wide for both parameters, with less dispersion of CKD-PAQ values. In phase 3, agreement between questionnaires was good (MET) and excellent (TEE). Bias of CKD-PAQ-derived mean daily MET from RPAQ-derived values was 0.031 (SD 0.193) with 95% limits of agreement -0.346 to 0.409. Corresponding values for TEE were 48 (SD 325) and -588 to 685 kcal/day. CKD-PAQ appeared to improve discrimination between low activity groups.

CONCLUSIONS

CKD-PAQ performs comparably to RPAQ though is shorter, easier to complete, may better capture low level activity and improve discrimination between low-activity groups.

Quality of life, depression, and anxiety of patients undergoing hemodialysis: Significant role of acceptance of the illness

OBJECTIVE

Routine dialysis is stressful. It has the possibility of leading to depression and anxiety and also reducing patients' quality of life. Despite these significant consequences, these comorbidities have been rarely studied among Indonesian patients. This study aims to examine the rate of depression, anxiety, and the role of acceptance of their illness on patients' quality of life.

METHOD

A total of 213 patients undergoing hemodialysis in three general hospitals in Aceh, Indonesia, were included in the study. The presence of depression, anxiety, and the quality of life of each patient was assessed using the hospital anxiety and depression scale and WHO quality of life-BREF questionnaires.

RESULTS

The prevalence of depression and anxiety was 46% and 30.5%, respectively. Depression was only associated with the presence of anxiety and the duration of hemodialysis. Anxiety was negatively associated with quality of life but positively associated with depression and the prescription of an anxiolytic. Overall quality of life was associated with age, body mass index, the presence of anxiety, and acceptance of the illness. Acceptance of the illness was also independently associated with almost every domain of patients' quality of life.

CONCLUSIONS

The rates of depression and anxiety among patients undergoing hemodialysis in the current study setting are relatively similar to the rates in other settings. Patients' acceptance of their illnesses is significantly associated with the occurrence of anxiety and quality of life. Therefore, health practitioners should help patients accept their illnesses and the administration of regular hemodialysis.

Application of Wearables to Facilitate Virtually Supervised Intradialytic Exercise for Reducing Depression Symptoms

Regular exercise can reduce depression. However, the uptake of exercise is limited in patients with end-stage renal disease undergoing hemodialysis. To address the gap, we designed a gamified non-weight-bearing intradialytic exercise program (exergame). The intradialytic exergame is virtually supervised based on its interactive feedback via wearable sensors attached on lower extremities. We examined the effectiveness of this program to reduce depression symptoms compared to nurse-supervised intradialytic exercise in 73 hemodialysis patients (age = 64.5 ± 8.7years, BMI = 31.6 ± 7.6kg/m²). Participants were randomized into an exergame group (EG) or a supervised exercise group (SG). Both groups received similar exercise tasks for 4 weeks, with three 30 min sessions per week, during hemodialysis treatment. Depression symptoms were assessed at baseline and the fourth week using the Center for Epidemiologic Studies Depression Scale. Both groups showed a significant reduction in depression score (37%, p < 0.001, Cohen's effect size d = 0.69 in EG vs. 41%, p < 0.001, d = 0.65 in SG) with no between-group difference for the observed effect (p > 0.050). The EG expressed a positive intradialytic exercise experience including fun, safety, and helpfulness of sensor feedback. Together, results suggested that the virtually supervised low-intensity intradialytic exergame is feasible during routine hemodialysis treatment. It also appears to be as effective as nurse-supervised intradialytic exercise to reduce depression symptoms, while reducing the burden of administrating exercise on dialysis clinics.

Aerobic exercise in adults with chronic kidney disease (CKD): a meta-analysis

PURPOSE

Patients with chronic kidney disease (CKD) are frail and have high risk of cardiovascular disease. This study was performed to assess the effects of aerobic exercise training in adults with CKD.

METHODS

MEDLINE, EMBASE, CENTRAL, Web of Science were searched up to December 2018 to identify eligible randomized controlled trials (RCTs) that studied aerobic exercise in adults with CKD. Primary outcomes include oxygen consumption at peak exercise (VO₂ peak), exercise capacity, blood pressure, heart rate, and health-related quality of life (HRQoL). Statistical analysis was performed using Review Manager 5.2.1 software.

RESULTS

Thirty-one trials, containing 1305 adults with CKD, were included. The most used aerobic exercise program was characterized as moderate intensity (15/31), 3 times/week frequency (22/31), 30 min duration (9/31) and 3 months follow-up (12/31). Significant improvement was observed in cardiorespiratory function (VO₂ peak) (P < 0.0001), exercise duration (P < 0.0001), HDL-C (P = 0.03) and pain (P = 0.007), physical role (P = 0.03), general health (P = 0.007) of HRQoL after aerobic exercise in patients with CKD. A marginal difference was observed in HR max (P = 0.07). However, no statistical difference was noticed in exercise capacity, blood pressure, resting heart rate, serum lipid and serum creatinine between aerobic training group and control. No subgroup differences were altered in all outcomes when studies were divided based on intensity of exercise training, the treatment of dialysis or the length of intervention.

CONCLUSIONS

Aerobic exercise training could benefit adult CKD patients in increasing cardiorespiratory function, exercise duration, HDL-C level and improve health quality of life.

Facilitators and Barriers to Exercise Influenced by Traditional Chinese Culture: A Qualitative Study of Chinese Patients Undergoing Hemodialysis

Introduction: Exercise is recommended for patients undergoing hemodialysis to decrease morbidity and mortality. However, their exercise level is lower than healthy people. Understanding reasons behind their sedentary lifestyle is required. Traditional Chinese culture may have a profound impact on patients’ perceptions of exercise, particularly with regard to the relationship of overwork and kidney function and family members’ attitudes toward patients’ participation in exercise. Therefore, we sought to explore the facilitators and barriers to exercise influenced by traditional Chinese culture. Methods: We conducted semistructured interviews with 44 Chinese patients residing in Nantong of Jiangsu Province undergoing hemodialysis, aged 25 to 77 years. Interview questions focused on their perceptions of, attitudes to, and experiences with exercise. Each interview was digitally recorded and lasted from 40 to 60 minutes. Conventional content analysis was used to understand facilitators and barriers to exercise within their experience and perceptions. Findings: We found that specific Chinese cultural health beliefs informed by traditional Chinese medicine strongly affected patients’ attitudes and behaviors toward exercise. Participants in this study tended to believe that overwork impairs kidney functions and viewed strenuous exercise as overwork. Although participants admitted the benefits of exercise, they rejected strenuous exercise and regarded nearly all modalities of exercise with or without facilities (except walking) as strenuous exercise. The most common barriers to exercise were lack of motivation, bad weather, negative attitudes of family members toward patients’ doing exercise, and insufficient exercise information resources. The most common facilitators found in this study were their increased physical well-being and confidence from exercise. Group exercise supported by family members and positive attitudes toward obtaining exercise information were also motivators. Discussion: Chinese patients undergoing hemodialysis reported more barriers than facilitators to exercise. Perceptions and attitudes toward exercise informed by traditional Chinese culture may be hidden barriers to exercising. Our findings indicated that culturally sensitive and patient-centered exercise interventions for Chinese patients are urgently needed.

Implementing a theory-based intradialytic exercise programme in practice: a quality improvement project

BACKGROUND

Research evidence outlines the benefits of intradialytic exercise (IDE), yet implementation into practice has been slow, ostensibly due to a lack of patient and staff engagement. The aim of this quality improvement project was to improve patient outcomes via the introduction of an IDE programme, evaluate patient uptake and sustainability and enhance the engagement of routine haemodialysis (HD) staff with the delivery of the IDE programme.

METHODS

We developed and refined an IDE programme, including interventions designed to increase patient and staff engagement that were based on the Theoretical Domains Framework (TDF), using a series of 'Plan, Do, Study, Act' (PDSA) cycles. The programme was introduced at two UK National Health Service HD units. Process measures included patient uptake, withdrawals, adherence and HD staff involvement. Outcome measures were patient-reported functional capacity, anxiety, depression and symptomology. All measures were collected over 12 months.

RESULTS

A total of 95 patients were enrolled in the IDE programme; 64 (75%) were still participating at 3 months, decreasing to 41 (48%) at 12 months. Adherence was high (78%) at 3 months, decreasing to 63% by 12 months. The provision of IDE by HD staff accounted for a mean of 2 (5%) sessions per 3-month time point. Patients displayed significant improvements in functional ability (P = 0.01) and a reduction in depression (P = 0.02) over 12 months, but the effects seen were limited to those who completed the programme.

CONCLUSIONS

A theory-based IDE programme is feasible and leads to improvement in functional capacity and depression. Sustaining IDE over time is complicated by high levels of patient withdrawal from the programme. Significant change at an organizational level is required to enhance sustainability by increasing HD staff engagement or access to professional exercise support.

Intradialytic Exercise: One Size Doesn't Fit All

Purpose: Hemodialysis patients commonly have impaired physical performance and mental health. We studied the effects of an intradialytic exercise program on these variables.

Methods: 27 patients (33% women; 68 ± 13 years) were enrolled in a 14-week intradialytic endurance-resistance training program (‘exercise’ group, 40 programmed sessions per patient); 40 hemodialysis patients (28% women; 68 ± 11 years) performing no exercise during the same time length were used as controls. Endpoints included physical performance (6-min walk test [6MWT], 10-repetition sit to stand [STS-10] and handgrip strength), emotional status (Beck’s depression inventory and State-Trait Anxiety Inventory), and mental and physical component scores of the short-from (SF)-12 Health Survey.

Results: There were no differences (p> 0.05) between groups at baseline for sex distribution, or mean age, body mass index and time spent on dialysis. Exercise benefits were observed for 6MWT (11 and −3% for the exercise and control groups, respectively; p < 0.001), STS-10 performance time (-22 and 6%; p < 0.001) and handgrip strength (4 and −4%; p < 0.02). No significant benefits (p> 0.05) were observed for emotional status endpoints or SF-12 component scores. Despite significant benefits on physical performance, the proportion of clinically meaningful responders was low (<50%). Responsiveness was dependent on baseline physical performance (p < 0.05) but not on age or sex (p > 0.05).

Conclusion: A 14-week intradialytic training program induced significant improvements on physical performance. However, the rate of clinically meaningful responders observed in the present study was low, being the level of responsiveness dependent on baseline physical status. Efforts to individualize exercise prescription are needed in clinical practice.

Depression in dialysis patients

Depression is the most common psychiatric illness in patients with end-stage renal disease (ESRD). The reported prevalence of depression in dialysis population varied from 22.8% (interview-based diagnosis) to 39.3% (self- or clinician-administered rating scales). Such differences were attributed to the overlapping symptoms of uraemia and depression. Systemic review and meta-analysis of observational studies showed that depression was a significant predictor of mortality in dialysis population. The optimal screening tool for depression in dialysis patients remains uncertain. The Beck Depression Inventory (BDI), Patient Health Questionnaire (PHQ) and Center for Epidemiologic Studies Depression Scale (CESD) have been validated for screening purposes. Patients who scored ≥14 using BDI should be referred to a psychiatrist for early evaluation. Structured Clinical Interview for DSM disorders (SCID) remains the gold standard for diagnosis. Non-pharmacological treatment options include cognitive behavioural therapy and exercise training programs. Although frequent haemodialysis may have beneficial effects on patients' physical and mental well-being, it cannot and should not be viewed as a treatment of depression. Selective serotonin reuptake inhibitors (SSRIs) are generally effective and safe in ESRD patients, but most studies were small, non-randomized and uncontrolled. The European Renal Best Practice (ERBP) guideline suggests a trial of SSRI for 8 to 12 weeks in dialysis patients who have moderate-major depression. The treatment effect should be re-evaluated after 12 weeks to avoid prolonging ineffective medication. This review will discuss the current understanding in the diagnosis and management of depression in dialysis patients.

Underdiagnosis of delirium on admission and prediction of patients who will develop delirium during their inpatient stay: a pilot study

INTRODUCTION

The study aimed to determine the prevalence and documentation of delirium among the elderly and if the Clock Drawing Test (CDT) can be used to predict which patients had delirium on admission and those who may develop delirium during their stay in acute medical wards.

METHODS

A single researcher performed the Mini-Mental State Examination (MMSE) and CDT on admission and discharge of 57 elderly adults at the National University Hospital, Singapore. Delirium was defined as a ≥ 3-point improvement or ≥ 2-point decline in MMSE scores from admission to discharge, where a fall denotes development of delirium and a rise denotes resolution. The case notes of the same patients were reviewed for documentation of delirium. All inpatients from two acute medical wards were examined. One CDT score and a pair of MMSE scores were collected from each patient.

RESULTS

A total of 57 patients (28 male, 29 female) were involved in the study. Their mean age was 76.0 ± 8.7 years. The prevalence of delirium based on MMSE scores was 40.4%; 16 patients had delirium on admission while seven developed delirium during their inpatient stay. However, delirium was documented in the case notes of only 7 (30%) of the 23 patients. CDT score was better than baseline MMSE score at predicting a decline in MMSE score.

CONCLUSION

The prevalence of delirium in the acute medical setting is high but underdiagnosed. The CDT may be a good screening tool to identify patients at risk of delirium during their inpatient stay. Baseline cognition screening should be performed in every elderly patient admitted to hospital.

Association between quality of life and anxiety, depression, physical activity and physical performance in maintenance hemodialysis patients

OBJECTIVE

Maintenance hemodialysis (MHD) patients often have impaired quality of life (QOL), anxiety, depression, and reduced daily physical activity (DPA) and physical performance. The contributions of these latter factors to reduced QOL in MHD are poorly understood. We examined the association of QOL with anxiety, depression, DPA, and physical performance.

METHODS

Seventy-two relatively healthy adult MHD patients, vintage ≥6 months, and 39 normals of similar age range and gender distribution were studied. QOL was assessed using the Kidney Disease Quality of Life-Short Form (KDQOL-SF). Anxiety and depression were each evaluated with two questionnaires. DPA and physical performance were assessed with a physical activity monitor, Human Activity Profile, and 6-minute walk, sit-to-stand, and stair-climbing tests.

RESULTS

Most KDQOL components were reduced in MHD patients versus normals. KDQOL components in patients were commonly inversely correlated with measures of anxiety and depression (P < 0.05) and were more reduced in patients with both anxiety and depression. KDQOL was often impaired in patients with either anxiety or depression. However, most KDQOL scores did not differ between patients and normals without anxiety or depression. DPA, Human Activity Profile, and physical performance often correlated with KDQOL scores in adjusted models, but after further adjustment for anxiety and depression, DPA, Human Activity Profile, and physical performance correlated less frequently with KDQOL scores. This reduction in significant correlations after adjustment for anxiety and depression was particularly pronounced for the association between KDQOL and DPA.

CONCLUSION

In relatively healthy MHD patients, KDQOL scores are usually decreased in those with anxiety and/or depression but are usually normal in those without anxiety or depression. Lower DPA in MHD patients with reduced KDQOL scores often appears to be associated with anxiety and depression. The relationship between QOL and physical performance appears to be less influenced by anxiety and/or depression. These data suggest that treatment of anxiety and depression in MHD patients may improve their QOL, DPA, and possibly physical performance.

How Can We Improve the Quality of Life of Dialysis Patients?

As medical advances are made in the care of persons with chronic illnesses including those with end-stage renal disease (ESRD), patients are not only experiencing increasing life expectancy but also bearing the burden of illness and treatment for a longer duration of time. With this in mind, it is increasingly important for health care providers to pay close attention to their individual patient's perceptions of their health, fitness, life satisfaction, and well-being. This assessment of Health-Related Quality of Life (HRQOL) also includes an evaluation of the patient's level of satisfaction with treatment, outcome, and health status, also taking into account their perspective on future prospects. In addition to improving patient-provider communication by helping in the identification and prioritization of problems, it is important to note that high HRQOL has been shown to be associated with better medical outcomes, including reduction in hospitalizations and death. In this review, we outline several validated tools that are used to quantitatively measure HRQOL in the ESRD population and incorporate these instruments in a review of specific, evidence-based measures by which we can measurably improve health-related quality of life in dialysis patients.

Increased Frontal Response May Underlie Decreased Tinnitus Severity

Objectives

The overall goal of the study was to identify functional and behavioral differences between individuals with higher tinnitus distress and individuals with lower tinnitus distress. Subsequent exploratory analyses were conducted to investigate the role physical activity may have on the observed results between high and low distress groups. The purpose of the experiment was to identify brain regions to be targeted in future intervention studies for tinnitus.

Design

A total of 32 individuals with varying levels of tinnitus severity were recruited from the Urbana-Champaign area. Volunteers were divided into higher tinnitus distress (HD) and lower tinnitus distress (LD) groups. Note that these groups also significantly differed based on physical activity level and were subsequently stratified into higher and lower physical activity level subgroups for exploratory analysis. While in a functional magnetic resonance imaging (fMRI) scanner, subjects listened to affective sounds classified as pleasant, neutral or unpleasant from the International Affective Digital Sounds database.

Results

The HD group recruited amygdala and parahippocampus to a greater extent than the LD group when listening to affective sounds. The LD group engaged frontal regions to a greater extent when listening to the affective stimuli compared to the HD group. Both higher physical activity level subgroups recruited more frontal regions, and both lower levels of physical activity subgroups recruited more limbic regions respectively.

Conclusion

Individuals with lower tinnitus distress may utilize frontal regions to better control their emotional response to affective sounds. Our analysis also suggests physical activity may contribute to lower tinnitus severity and greater engagement of the frontal cortices. We suggest that future intervention studies focus on changes in the function of limbic and frontal regions when evaluating the efficacy of treatment. Additionally, we recommend further investigation concerning the impact of physical activity level on tinnitus distress.

Aerobic training during hemodialysis improves body composition, muscle function, physical performance, and quality of life in chronic kidney disease patients

[Purpose] We assessed the influences of individualized aerobic training on body composition, knee joint muscle function, physical performance, and quality of life in chronic kidney disease patients. [Subjects] Ten chronic kidney disease patients undergoing dialysis. [Methods] Overall physical function and quality of life before and after 12 weeks of aerobic training were evaluated by body composition, the six-minute walk test, cardiopulmonary exercise tests, and Short Form 36-item questionnaire. [Results] The six-minute walk test distance increased significantly after 12 weeks aerobic training. Resting metabolic rate, lactate threshold, maximum oxygen uptake, and quality of life tended to increase after training. Post-training weight, muscle mass, body fat mass, fat percentage, body mass index, and peak torque of right and left knee extension and flexion did not change significantly. [Conclusion] Intra-dialytic training can a safe approach to maintain or improve physical performance and quality of life of chronic kidney disease patients undergoing hemodialysis without adverse events or negative cardiovascular responses. Aerobic training may prevent a decline in body composition and knee joint muscle function due to inactivity in chronic kidney disease patients. Clinically, aerobic training may initially be adapted to maintain overall physical function or improve quality of life in chronic kidney disease patients undergoing hemodialysis.

Predictors of anxiety and depression among women with vaginal bleeding referred to gynecology clinic during hajj 2011

Background:

One of the most important complications for women during hajj trip is menstruation and most commonly spotting, which is the second important problem. This complication would cause some problems in performing religious rites as the main purpose of the trip and on the other hand, it would lead to psychologic complications for women. Controlling psychologic complications of women during and after hajj is necessary.

Objectives:

The purpose to this study was to investigate predictors of anxiety and depression among the women with vaginal bleeding who were referred to Iranian clinic in Mecca and Medina in hajj 2011.

Patients and Methods:

In this cross-sectional study, 110 women with vaginal bleeding who were referred to gynecology clinic were enrolled. The Samples were selected by easy way method from all referrals on Tuesdays during hajj (October and November 2011). To evaluate the anxiety and depression signs, Hospital Anxiety and Depression Scale (HADS) questionnaire was employed. The analyses were performed using SPSS 17.0 through parametric methods.

Results:

Predictors of anxiety were observed in 22 women (20%). Moreover, 34 women (30.9%) were diagnosed from normal to abnormal, 3 (2.72%) had depression signs, and 22 (20%) showed symptoms of borderline symptoms of depression.

Conclusions:

Considering the high frequency of anxiety disorder among women with vaginal bleeding in hajj, gynecological consultation seems essential for women during Hajj.

Effect of Regular Exercise Program on Depression in Hemodialysis Patients

Background and Aim. Depression is the most common psychological disorder in hemodialysis patients which decreases their quality of life and increases the mortality. This study was conducted to assess the effect of regular exercise on depression in hemodialysis patients. Methods. In a randomized clinical trial, 51 hemodialysis patients were allocated in two groups. Beck Depression Inventory (BDI) scale was used to assessing depression rate in participants. Designed program was educated using poster and face-to-face methods for case group. Intervention was carried out three times a week for ten weeks. At the beginning and the end of the study, depression rate of the subjects was assessed. Data was analyzed by SPSS16 software and descriptive and inferential statistics. Findings. According to the results of this study, there were no differences between case and control groups in depression rate at the beginning of the study, but there was significant difference after intervention (P = 0.016). In the beginning of the study, the mean and SD of depression in case group were 23.8 ± 9.29 and reduced to 11.07 ± 12.64 at the end (P < 0.001). Conclusion. The regular exercise program could reduce the depression in hemodialysis patients; therefore it is suggested for training this program for hemodialysis patients. This trial is registered with Iranian Registry of Clinical Trial (IRCT) number IRCT201205159763N1.

Comorbidity influences multiple aspects of well-being of patients with ischemic heart disease

BACKGROUND

Comorbidity is prevalent among patients with Ischemic Heart Disease (IHD) and may influence patients' subjective and objective domains of well-being.

OBJECTIVES

We aimed to investigate the associations between comorbidity and different measures of well-being (i.e. health related quality of life, psychological distress, sleep quality, and dyadic adjustment) among patients with IHD.

METHODS

In this cross-sectional study, 796 outpatients with documented IHD were enrolled from an outpatient cardiology clinic in 2006. Comorbidity (Ifudu index), quality of life (SF36), psychological distress (Hospital Anxiety Depression Scale; HADS), sleep quality (Pittsburg Sleep Quality Index; PSQI), and dyadic adjustment quality (Revised Dyadic Adjustment Scale; RDAS) were measured. Associations between comorbidity and different measures of well-being were determined.

RESULTS

Significant correlations were found between comorbidity score and all measures of well-being. Comorbidity score was correlated with physical quality of life (r = -0.471, P < 0.001), mental quality of life (r = -0.447, P < 0.001), psychological distress (r = 0.344, P < 0.001), sleep quality (r = 0.358, P < 0.001), and dyadic adjustment (r = -0.201, P < 0.001).

CONCLUSIONS

This study showed a consistent pattern of associations between somatic comorbidities and multiple aspects of well-being among patients with IHD. Findings may increase cardiologists' interest to identify and treat somatic conditions among IHD patients.

Effects of progressive resistance training on body composition, physical fitness and quality of life of patients on hemodialysis

PURPOSE

To investigate the effect of progressive resistance training (PRT) on body composition, physical fitness, quality of life, lipid and nutritional profile of patients on hemodialysis (HD).

METHODS

A non equivalent comparison group pretest and posttest design study was used with 40 participants who were randomly assigned to the exercise group (20 participants) and the comparison group (20 participants). The exercise group received PRT for 30 minutes per session, 3 sessions a week, for 12 weeks, while the comparison group received usual care. The PRT consisted of upper and lower body exercises using elastic bands and sandbags. Outcome measures evaluated were: body composition, physical fitness, quality of life, and lipid profile.

RESULTS

Skeletal muscle mass, grip, leg muscle strength, and quality of life all improved significantly in the exercise group. Body fat rate, total cholesterol and triglyceride rate decreased significantly in the exercise group.

CONCLUSION

These results suggest that PRT improves body composition, physical fitness, quality of life, and lipid profile of patients on HD. PRT using elastic bands and sandbags can be utilized as part of a regular care plan for these patients.

Self-care ability in hemodialysis patients

INTRODUCTION

Considering the numerous physical and psychological problems in hemo-dialysis patients, they are dependent on others in some daily activities and in fact, they do not have full self-care ability. A few studies have ever been done, particularly in Iran, on self-care ability of hemodialysis patients. The present study aimed to determine self-care ability of these patients in addition to evaluate its association with some demo-graphic characteristics.

METHODS

This was a descriptive study in 2009 done in Marag-heh, Bonab and Miandoab Hospitals. The study population included 115 hemodialysis patients who were eligible. Data were collected using a combined and modified ques-tionnaire including demographic characteristics and self-care ability items.

RESULTS

Self-care ability was desirable in 78.3 percent of the patients. The highest desirable self-care ability in the study participants was related to vascular access (73%) and the highest undesirable self-care ability was related to follow the diet. There was a significant asso-ciation between self-care ability and some demographic characteristics including age, gender, marital status and employment status.

CONCLUSION

Hemodialysis patients did not have full self-care ability. It is necessary to enhance their knowledge about diet, complications of hemodialysis and preventive methods through accurate and permanent education so that they can increase their self-care ability.

Upper limb disability in hemodialysis patients: evaluation of contributing factors aside from amyloidosis

This cross-sectional case-control study evaluated upper limb muscle strength and shoulder mobility in hemodialysis (HD) patients with arteriovenous fistula or graft. Twenty-five adult patients on thrice-a-week HD treatment for 6 months at least, were selected for the study. In all the patients and control subjects, handgrip tests and tests of range of motion in the upper extremities were evaluated by physiotherapy tests. Patients on HD showed lower muscle strength than age and sex matched subjects without severe chronic kidney disease (right: 30.1 ± 11.6 vs 40.5 ± 15.1 kg, P < 0.001; left 29.1 ± 12.9 vs 40.7 ± 11.1 kg, P < 0.01), and a reduced range of shoulder mobility. The presence of fistula or graft was associated with a greater limitation of both active (74.0 ± 18.3 vs 85.2 ± 8.8 °, P < 0.01) and passive (82.2 ± 9.9 vs 87.2 ± 6.6 °, P < 0.05) extra-rotation than the contralateral limb, with a higher prevalence of impingement (72 vs 36%, P < 0.05). Muscle strength was related to albumin and inversely to age; whereas β(2) -microglobulin and CRP serum levels were associated with impairment of passive and active extra-rotation of the shoulder that was free from the fistula or graft. In summary, patients on HD have a reduced range of shoulder mobility and marked reduction of muscle strength. The abnormalities are more prevalent in upper limbs with fistula or grafts. The arteriovenous fistula or graft may worsen the disability of the patient's upper limbs presumably due to the obligate position required during the HD sessions. Proper pre- and post-dialysis exercise programs should be implemented to maintain mobility and strength of the upper limbs.

Exercise training for adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem. In the National Kidney Foundation Disease Outcomes Quality Initiative guidelines it is stressed that lifestyle issues such as physical activity should be seen as cornerstones of the therapy. The physical fitness in adults with CKD is so reduced that it impinges on ability and capacity to perform activities in everyday life and occupational tasks. An increasing number of studies have been published regarding health effects of various regular exercise programmes in adults with CKD and in renal transplant patients.

OBJECTIVES

We aimed to: 1) assess the effects of regular exercise in adults with CKD and kidney transplant patients; and 2) determine how the exercise programme should be designed (e.g. type, duration, intensity, frequency of exercise) to be able to affect physical fitness and functioning, level of physical activity, cardiovascular dimensions, nutrition, lipids, glucose metabolism, systemic inflammation, muscle morphology and morphometrics, dropout rates, compliance, adverse events and mortality.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, Biosis, Pedro, Amed, AgeLine, PsycINFO and KoreaMed. We also handsearched reference lists of review articles and included studies, conference proceeding's abstracts. There were no language restrictions.Date of last search: May 2010.

SELECTION CRITERIA

We included any randomised controlled trial (RCT) enrolling adults with CKD or kidney transplant recipients undergoing any type of physical exercise intervention undertaken for eight weeks or more. Studies using less than eight weeks exercise, those only recommending an increase in physical activity, and studies in which co-interventions are not applied or given to both groups were excluded.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study and data quality were performed independently by the two authors. Continuous outcome data are presented as standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

Forty-five studies, randomising 1863 participants were included in this review. Thirty two studies presented data that could be meta-analysed. Types of exercise training included cardiovascular training, mixed cardiovascular and resistance training, resistance-only training and yoga. Some studies used supervised exercise interventions and others used unsupervised interventions. Exercise intensity was classed as 'high' or 'low', duration of individual exercise sessions ranged from 20 minutes/session to 110 minutes/session, and study duration was from two to 18 months. Seventeen per cent of studies were classed as having an overall low risk of bias, 33% as moderate, and 49% as having a high risk of bias.The results shows that regular exercise significantly improved: 1) physical fitness (aerobic capacity, 24 studies, 847 participants: SMD -0.56, 95% CI -0.70 to -0.42; walking capacity, 7 studies, 191 participants: SMD -0.36, 95% CI-0.65 to -0.06); 2) cardiovascular dimensions (resting diastolic blood pressure, 11 studies, 419 participants: MD 2.32 mm Hg, 95% CI 0.59 to 4.05; resting systolic blood pressure, 9 studies, 347 participants: MD 6.08 mm Hg, 95% CI 2.15 to 10.12; heart rate, 11 studies, 229 participants: MD 6 bpm, 95% CI 10 to 2); 3) some nutritional parameters (albumin, 3 studies, 111 participants: MD -2.28 g/L, 95% CI -4.25 to -0.32; pre-albumin, 3 studies, 111 participants: MD - 44.02 mg/L, 95% CI -71.52 to -16.53; energy intake, 4 studies, 97 participants: SMD -0.47, 95% CI -0.88 to -0.05); and 4) health-related quality of life. Results also showed how exercise should be designed in order to optimise the effect. Other outcomes had insufficient evidence.

AUTHORS' CONCLUSIONS

There is evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. blood pressure and heart rate), health-related quality of life and some nutritional parameters in adults with CKD. Other outcomes had insufficient evidence due to the lack of data from RCTs. The design of the exercise intervention causes difference in effect size and should be considered when prescribing exercise with the aim of affecting a certain outcome. Future RCTs should focus more on the effects of resistance training interventions or mixed cardiovascular- and resistance training as these exercise types have not been studied as much as cardiovascular exercise.

Evidence of increased muscle atrophy and impaired quality of life parameters in patients with uremic restless legs syndrome

Background

Restless Legs Syndrome is a very common disorder in hemodialysis patients. Restless Legs Syndrome negatively affects quality of life; however it is not clear whether this is due to mental or physical parameters and whether an association exists between the syndrome and parameters affecting survival.

Methodοlogy/Principal Findings

Using the Restless Legs Syndrome criteria and the presence of Periodic Limb Movements in Sleep (PLMS/h >15), 70 clinically stable hemodialysis patients were assessed and divided into the RLS (n = 30) and non-RLS (n = 40) groups. Physical performance was evaluated by a battery of tests: body composition by dual energy X ray absorptiometry, muscle size and composition by computer tomography, while depression symptoms, perception of sleep quality and quality of life were assessed through validated questionnaires. In this cross sectional analysis, the RLS group showed evidence of thigh muscle atrophy compared to the non-RLS group. Sleep quality and depression score were found to be significantly impaired in the RLS group. The mental component of the quality of life questionnaire appeared significantly diminished in the RLS group, reducing thus the overall quality of life score. In contrast, there were no significant differences between groups in any of the physical performance tests, body and muscle composition.

Conclusions

The low level of quality of life reported by the HD patients with Restless Legs Syndrome seems to be due mainly to mental health and sleep related aspects. Increased evidence of muscle atrophy is also observed in the RLS group and possibly can be attributed to the lack of restorative sleep.

Sustaining a hemodialysis exercise program: a review

This article reviews the literature addressing exercise programs for dialysis patients to identify elements necessary for sustaining exercise programs in this population. Literature searches for publications (January 1980-February 2009) in Medline (OVID), PubMed, CINAHL (EBSCO), EBSCOhost EJS, ProQuest Central, Web of Science, Cochrane Library, Google Scholar, ScienceDirect, SpringerLink (Kluwer), and Wiley Interscience (Blackwell) were performed. Reference lists from relevant articles were hand-searched for further publications. Criteria for inclusion included full-text primary research and review articles focused on exercise for adult hemodialysis patients. One hundred and seventy one publications were found with a primary focus on exercise in hemodialysis. Of these, 28 primary research and 14 review articles addressed one or more aspects of sustainability of hemodialysis exercise programs. Factors contributing to sustainable exercise programs included: dedicated exercise professionals; encouragement to exercise intradialytically; dialysis and medical staff commitment; adequate physical requirements of equipment and space; interesting and stimulating; cost implications need to be addressed; exercise is not for everyone; requires individual prescription; and there is no age barrier to exercise on hemodialysis.

Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes

BACKGROUND

Levels of physical exercise among haemodialysis patients are low. Increased physical activity in this population has been associated with improved health-related quality of life (HRQoL) and survival. However, results of previous studies may not be applicable to the haemodialysis population as a whole. The present study provides the first description of international patterns of exercise frequency and its association with exercise programmes and clinical outcomes among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

METHODS

Data from a cross section of 20,920 DOPPS participants in 12 countries between 1996 and 2004 were analysed. Regular exercise was defined as exercise frequency equal to or more than once/week based on patient self-report. Linear mixed models and logistic regression assessed associations of exercise frequency with HRQoL and other psychosocial variables. Mortality risk was calculated in Cox proportional hazard models using patient-level (patient self-reported exercise frequency) and facility-level (the dialysis facility percentage of regular exercisers) predictors.

RESULTS

Regular exercise frequency varied widely across countries and across dialysis facilities within a country. Overall, 47.4% of participants were categorized as regular exercisers. The odds of regular exercise was 38% higher for patients from facilities offering exercise programmes (adjusted odds ratio = 1.38 [95% confidence interval: 1.03-1.84]; P = 0.03). Regular exercisers had higher HRQoL, physical functioning and sleep quality scores; reported fewer limitations in physical activities; and were less bothered by bodily pain or lack of appetite (P <or= 0.0001 for all). Regular exercise was also correlated with more positive patient affect and fewer depressive symptoms (P <or= 0.0001). In models extensively adjusted for demographics, comorbidities and socio-economic indicators, mortality risk was lower among regular exercisers (hazard ratio = 0.73 [0.69-0.78]; P < 0.0001) and at facilities with more regular exercisers (0.92 [0.89-0.94]; P < 0.0001 per 10% more regular exercisers).

CONCLUSIONS

Results from an international study of haemodialysis patients indicate that regular exercise is associated with better outcomes in this population and that patients at facilities offering exercise programmes have higher odds of exercising. Dialysis facility efforts to increase patient physical activity may be beneficial.

Exercise performance by hemodialysis patients: a review of the literature

Hemodialysis (HD) patients exhibit poor functional capacity and reduced quality of life as a result of the complications associated with end-stage renal disease (ESRD). A review of the literature indicates that regular physical activity can reduce the complications associated with ESRD by inducing adaptations in the cardiovascular, nervous, and musculoskeletal systems. In turn, this increases functional capacity and enhances quality of life in patients on HD. Hemodialysis patients can safely participate in a variety of exercise programs with minimal adverse effects. Intradialytic exercise programs that can incorporate aerobic and resistance exercise promote exercise adherence and should be encouraged on dialysis units.

Exercise and end-stage kidney disease: functional exercise capacity and cardiovascular outcomes

This review examined published reports of the impact of extradialytic and intradialytic exercise programs on physiologic aerobic exercise capacity, functional exercise endurance, and cardiovascular outcomes in individuals with ESKD. Studies spanning 30 years from the first published report of exercise in the ESKD population were reviewed. Studies conducted in the first half of the publication record focused on the efficacy of exercise training programs performed "off"-dialysis with respect to the modification of traditional cardiovascular risk factors, aerobic capacity, and its underlying determinants. In the latter half of the record, there had been a shift to include other client-centered goals such as physical function and quality of life. There is evidence that both intra- and extradialytic programs can significantly enhance aerobic exercise capacity, but moderate-intensity extradialytic programs may result in greater gains in those individuals who initially have extremely poor aerobic capacity. Functionally, substantive improvements in exercise endurance in excess of the minimum clinical significant difference can occur following either low- or moderate-intensity exercise regardless of the initial level of performance. Reductions in blood pressure and enhanced vascular functioning reported after predominantly intradialytic exercise programs suggest that either low- or moderate-intensity exercise programs can confer cardiovascular benefit. Regardless of prescription model, there was an overall lack of evidence regarding the impact of exercise-induced changes in exercise capacity, endurance, and cardiovascular function on a number of relevant health outcomes (survival, morbidity, and cardiovascular risk), and, more importantly, there is no evidence on the long-term impact of exercise and/or physical activity interventions on these health outcomes.

The Impact of Pre-Dialytic Endurance Training on Nutritional Status and Quality of Life in Stable Hemodialysis Patients (Sawada Study)

BACKGROUND

Protein-energy malnutrition and decreased quality of life (QOL) are common in hemodialysis (HD) patients. Although several studies have proved that regular exercise has beneficial effects, few control studies have shown the effects of exercise training on the nutritional status and QOL in HD patients.

METHODS

Fifty-five HD patients were recruited, and 22 of them were trained to exercise on an ergometer prior to dialysis three times a week for one year. Serum albumin levels, creatinine generation rate (CGR), and the Short Form 36 were assessed as outcome measures.

RESULTS

The serum albumin levels and CGR increased in the training group compared with baseline. The QOL scores also increased in half of the physical health and mental health dimensions in the training group.

CONCLUSION

These observations suggest that low-dose, long-term pre-dialytic endurance training might reverse the poor clinical outcome by improving the nutritional status and QOL in HD patients.

Development and psychometric evaluation of the Dialysis patient-perceived Exercise Benefits and Barriers Scale

BACKGROUND

Perceptions of exercise benefits and barriers affect exercise behavior. Because of the clinical course and treatment, dialysis patients differ from the general population in their perceptions of exercise benefits and barriers, especially the latter. At present, no valid instruments for assessing perceived exercise benefits and barriers in dialysis patients are available.

OBJECTIVES

Our goal was to develop and test the psychometric properties of the Dialysis patient-perceived Exercise Benefits and Barriers Scale (DPEBBS).

METHODS

A literature review and two focus groups were conducted to generate the initial item pool. An expert panel examined the content validity. Then, 269 Chinese hemodialysis patients were recruited by convenience sampling. Exploratory and confirmatory factor analyses were used to test construct validity. Finally, internal consistency and test-retest reliability were assessed.

RESULTS

The expert panel determined that the content validity index was satisfactory. The final 24-item scale consisted of six factors explaining 57% of the total variance in the data. Confirmative factor analysis supported the six-factor structure and a higher-order model. Cronbach's alpha was 0.87 for the total scale, and 0.84 for test-retest reliability.

CONCLUSION

The DPEBBS was a valid and reliable instrument for evaluating dialysis patients' perceived benefits and barriers to exercise. The application value of this scale remains to be investigated by increasing the sample size and evaluating patients undergoing different dialysis modalities and coming from different regions and cultural backgrounds.

Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients

OBJECTIVE

To assess the effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients.

SUBJECTS/PATIENTS

Thirty-five patients on haemodialysis, with a mean (SD) age of 48.8 (13.9) years, volunteered to participate in the study. They were randomized either to rehabilitation group (group A: 19 patients), following a 10-month intradialytic exercise training programme or to control group (group B: 14 patients). After the randomization, two of the patients, one of each group, withdrew from the study for reasons unrelated to exercise training.

METHOD

All patients at the beginning and the end of the study underwent clinical examination, laboratory tests and a treadmill exercise testing with spiroergometric study for the evaluation of their aerobic capacity (Vo(2peak)). A formal psychosocial assessment, which included affective (Beck Depression Inventory), health-related quality of life (Quality of Life Index, Living Questionnaire of Minnesota, Life Satisfaction Index and Short Form-36 questionnaire) and personality (Eysenck Personality Questionnaire) parameters, was evaluated at beginning and end of the study. The dose of erythropoietin was changed as needed, according to the level of the haemoglobin, aiming to keep it at 11 (2) g/dL during the study.

RESULTS

Baseline values were similar between the two groups. After training in group A, Vo(2peak) was increased by 21.1% (P<0.05) and exercise time by 23.6% (P<0.05). Moreover, group A showed a decrease in self-reported depression (Beck Depression Index) of 39.4% (P<0.001). In addition, trained patients demonstrated a significant improvement in Quality of Life Index (from 6.5 (1.8) to 9.0 (1.3), P<0.001) and Life Satisfaction Index (from 44.8 (8.6) to 53.0 (5.6), P<0.001), and an increase in the Physical Component Scale of the SF-36 (from 40.5 (5.6) to 44.5 (5.5), P<0.05), while the Mental Component Scale remained unchanged. Multiple regression analysis indicated that the improvement in quality of life depended on the participation in exercise programmes, the effects of training and the reduction in the level of depression. No changes were observed in Eysenck Personality Questionnaire by the end of the study, while all the above parameters remained almost unchanged in the controls.

CONCLUSION

The results demonstrated that intradialytic exercise training improves both physical functioning and psychological status in haemodialysis patients, leading to an improvement of patients' quality of life.

Exercise, learned helplessness, and the stress-resistant brain

Exercise can prevent the development of stress-related mood disorders, such as depression and anxiety. The underlying neurobiological mechanisms of this effect, however, remain unknown. Recently, researchers have used animal models to begin to elucidate the potential mechanisms underlying the protective effects of physical activity. Using the behavioral consequences of uncontrollable stress or "learned helplessness" as an animal analog of depression- and anxiety-like behaviors in rats, we are investigating factors that could be important for the antidepressant and anxiolytic properties of exercise (i.e., wheel running). The current review focuses on the following: (1) the effect of exercise on the behavioral consequences of uncontrollable stress and the implications of these effects on the specificity of the "learned helplessness" animal model; (2) the neurocircuitry of learned helplessness and the role of serotonin; and (3) exercise-associated neural adaptations and neural plasticity that may contribute to the stress-resistant brain. Identifying the mechanisms by which exercise prevents learned helplessness could shed light on the complex neurobiology of depression and anxiety and potentially lead to novel strategies for the prevention of stress-related mood disorders.

Anxiety and Depression Are Correlated With Higher Morbidity After Kidney Transplantation

BACKGROUND

Psychiatric comorbidities have been reported to be associated with low quality of life, but less attention has been paid to their impact on other morbidity measures. The aim of this study was to investigate the correlation of anxiety and depression with marital relation, sexual function, and sleep quality in kidney transplant recipients.

METHODS

In a cross-sectional study between 2005 and 2006, 88 kidney transplant recipients were divided into four groups according to their scores of anxiety and depression using Hospital Anxiety Depression Scale (HADS): group I(anx) (anxiety score <11; n=64); group II(anx) (anxiety score >or= 11; n=24); group I(dep) (depression score <11; n=68); and group II(dep) (depression score >or= 11; n=20). Morbidity measures including quality of life (Short Form-36), marital adjustment (Revised Dyadic Adjustment Scale), sexual relationship (Relationship and Sexuality Scale), and quality of sleep (Pittsburgh Sleep Quality Index) were separately compared between groups of anxious versus nonanxious and depressed versus nondepressed.

RESULTS

Group I(anx), compared with group II(anx), displayed a better state of mental health (48.80 +/- 7.14 vs. 44.45 +/- 7.80; P=.01), general health (49.36 +/- 12.77 vs. 42.91 +/- 16.67; P=.05), marital adjustment (55.13 +/- 8.01 vs. 48.35 +/- 16.62; P=.04), and lower sleep disturbance (1.36 +/- 0.62 vs. 1.66 +/- 0.63; P=.05). Group I(dep), compared with group II(dep), showed lower fatigue score (39.79 +/- 8.30 vs. 46.84 +/- 8.85; P=.002) and better sexual relationships (15.28 +/- 5.50 vs. 19.00 +/- 5.92; P=.03).

CONCLUSIONS

Screening for anxiety and depression in kidney transplant recipients is essential. Appropriate treatment of these prevalent psychiatric comorbidities may improve various aspects of patient well-being, including quality of life, sleep, marital relations, and sexual relationship.

Exercise in the end-stage renal disease population

Many of the known benefits of exercise in the general population are of particular relevance to the ESRD population. In addition, the poor physical functioning that is experienced by patients who are on dialysis is potentially addressable through exercise interventions. The study of exercise in the ESRD population dates back almost 30 yr, and numerous interventions, including aerobic training, resistance exercise training, and combined training programs, have reported beneficial effects. Recently, interventions during hemodialysis sessions have become more popular and have been shown to be safe. The risks of exercise in this population have not been rigorously studied, but there have been no reports of serious injury as a result of participation in an exercise training program. It is time that we incorporate exercise into the routine care of patients who are on dialysis, but identification of an optimal training regimen or regimens, according to patient characteristics or needs, is still needed to facilitate implementation of exercise programs.

Psychosocial interventions for depression in dialysis patients

BACKGROUND

Depression is the most common psychological problem in the dialysis population. The diagnosis of depression in dialysis patients is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects the physical, psychological and social well being of the dialysis population in several ways.

OBJECTIVES

The aim of this systematic review was to assess the effectiveness of psychosocial interventions in the treatment of depression in patients who are dialysed for end-stage renal disease.

SEARCH STRATEGY

A comprehensive search strategy was employed to identify all randomised controlled trials (RCTs) relevant to the treatment of depression in dialysis patients. The following databases were searched - MEDLINE (1966 - October 2003), EMBASE (1980 - October 2003), PsycINFO (1872 - October 2003) and The Cochrane Library (issue 3, 2003). Authors of potential studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.

SELECTION CRITERIA

RCTs comparing any psychosocial intervention with control intervention or no intervention in depressed dialysis patients.

DATA COLLECTION AND ANALYSIS

Data were to be abstracted by two investigators independently onto a standard form and entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (MD) for continuous data were to be calculated with 95% confidence intervals (CI).

MAIN RESULTS

Despite extensive searching, no RCTs were identified.

AUTHORS' CONCLUSIONS

Data were not available to draw conclusions about the effectiveness of psychosocial interventions in the treatment of depression in the chronic dialysis population, as we did not find any RCTs of psychosocial interventions to treat depression in dialysis patients. This review highlights the need for commencing and completing adequately powered RCTs to address the issue of psychosocial interventions for depression in dialysis patients.