Effects of the inspiratory muscle training and aerobic training on respiratory and functional parameters, inflammatory biomarkers, redox status and quality of life in hemodialysis patients: A randomized clinical trial

Effects of inspiratory muscle training on dyspnea and lung capacity in patients with chronic kidney disease on hemodialysis: a systematic review and meta-analysis

INTRODUCTION

Inspiratory muscle training (IMT) is an alternative to improve the respiratory condition of hemodialysis (HD) patients with respiratory muscle weakness.

OBJECTIVE

To evaluate the effect of IMT on dyspnea and lung capacity in dialysis patients.

METHOD

A systematic review of randomized controlled trials (RCTs) which evaluated the effects of IMT in dialysis patients on the outcomes of dyspnea, lung capacity, respiratory muscle strength and dialysis effectiveness index (Kt/V) was conducted. The searches were conducted in February 2025 and were performed in the Medline/PubMed, Cochrane Library, LILACS, CINAHL, PEDro, Web of Science, Embase and Google Scholar databases. Study quality was assessed using the Cochrane RoB2 tool.

RESULTS

Six studies were analyzed (n = 210). One study showed an improvement in dyspnea [4.17   ±   0.58; 95%CI (0.0073-0.884); p = .022], and the meta-analyses found a mean difference of 0.34 L/min [95%CI (0.08-0.61); p = .010] in forced vital capacity (FVC) and 25.15 cmH2O [95%CI (17.05-33.24); p < .001] in maximum inspiratory pressure (MIP) in the IMT groups. There was no difference in Kt/V. Only one study showed a low risk of bias.

CONCLUSION

IMT in patients with CKD on HD improved dyspnea, FVC and MIP. Considering the low quality of the studies, new RCTs with greater methodological rigor are needed.

Multifactorial inspiratory muscle training and its impact on respiratory and functional parameters of patients with diabetic polyneuropathy-A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Diabetic polyneuropathy is a long-standing microvascular complication of diabetes that affects the postural control and functional mobility of patients. There are other microvascular complications, including pulmonary complications that reduce lung function. Multifactorial Inspiratory Muscle Training (IMT) can act as a home-based technique targeted to affect both these complications. This study aims to determine the effects of IMT on respiratory and functional parameters in diabetic polyneuropathy patients.

METHODS

This is a Pre-Test Post-Test Randomized Controlled Trial (NCT#04947163) with 62 diabetic polyneuropathy patients. Each was randomly assigned to the IMT or sham-IMT group. Both the groups performed OTAGO exercises , with the sham-IMT group performing IMT at 15% of baseline maximal inspiratory pressure (MIP), whereas IMT were trained at 50% of baseline MIP as an initial intensity, which was increased as per the tolerance of patients. Both groups performed training for 12 weeks. The study investigated diaphragmatic strength, pulmonary function, functional capacity through 6MWT, 30s sit to stand test and anterior trunk muscle endurance tested through sit up test as outcome variables. Data was analysed on SPSS v26 at the significance level of 0.0.5.

RESULTS

The IMT group significantly improved diaphragmatic strength, pulmonary function, 6MWT and anterior trunk muscle endurance when compared to the sham-IMT group.

CONCLUSION

The study concluded that home-based IMT can improve pulmonary parameters including diaphragmatic strength and lung function as well as functional parameters including functional capacity in patients with diabetic polyneuropathy. The study was registered at ClinicalTrials.gov, NCT#04947163.

Inspiratory Muscle Training in Patients Living With Chronic Kidney Disease and Receiving Hemodialysis: Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

People living with chronic kidney disease (CKD) and receiving hemodialysis (HD) have impaired respiratory muscle strength and endurance. The objective of this study was to systematically review the effects of inspiratory muscle training (IMT) on respiratory muscle strength, functional capacity, lung function, quality of life, endothelial function, and oxidative stress in people living with CKD and receiving HD.

METHODS

An electronic search was conducted from inception to June 2023. Randomized controlled trials that evaluated the effects of IMT on respiratory muscle strength, functional capacity, lung function, endothelial function, quality of life, or oxidative stress in adults living with CKD and receiving HD, compared with control, placebo IMT, or conventional physical therapy, were included.

RESULTS

Eight studies were included, totaling 246 people. The meta-analysis showed that IMT increased the maximum inspiratory pressure (MIP) by 22.53 cm H2O, the maximum expiratory pressure (MEP) by 19.54 cm H2O, and the distance covered in the 6-minute walk test by 77.63 m. Changes in lung function and quality of life were not observed. It was not possible to quantitatively analyze data on endothelial function and oxidative stress.

CONCLUSION

IMT improves MIP, MEP, and functional capacity in people living with CKD and receiving HD. IMT did not demonstrate significant results for lung function and quality of life. Effects on endothelial function and oxidative capacity remain uncertain.

IMPACT

Inspiratory muscle training improves MIP, MEP, and functional capacity in people living with CKD and receiving HD, compared with conventional physical therapy or controls or placebo intervention. Increases in functional capacity in this population are extremely important because of the relationship with the survival of these people.

Investigation of respiratory muscle strength and its influence on exercise capacity and quality of life in patients with idiopathic pulmonary fibrosis

BACKGROUND

Adequate respiratory muscle strength is required to meet the increased ventilatory demand during physical activities. However, it is not well known whether respiratory muscle strength is impaired in patients with idiopathic pulmonary fibrosis (IPF).

OBJECTIVES

This study aimed to investigate the relationship between respiratory muscle strength and exercise capacity, quality of life, physical activity level, and fatigue in IPF patients.

METHODS

The study comprised 30 individuals with idiopathic pulmonary fibrosis (IPF) and 30 healthy controls. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured to assess respiratory muscle strength. The International Physical Activity Questionnaire-Short Form, 6-minute walk test distance (6MWD), St George Respiratory Questionnaire (SGRQ), and Fatigue Severity Scale (FSS) were employed to evaluate physical activity level, exercise capacity, quality of life, and fatigue severity, respectively.

RESULTS

MIP (81±29 vs.73±20 cmH2O) and MEP (93±31 vs. 93±34 cmH2O) did not differ significantly between IPF patients and controls (p>0.05). In patients with IPF, MIP was significantly correlated with 6MWD (r=0.533), SGRQ (r=-0.428), and FSS (r=-0.433). Multivariate models including MIP, MEP, FEV1, FVC, and PA level explained 74% of the variance in the 6MWD (p<0.001), and MIP, FEV1, and PA level were independent predictors of the 6MWD, with FEV1 being the strongest predictor (β=0.659). Multivariate models predicting SGRQ revealed none of MIP, FEV1 or PA level was directly influencing the SGRQ score.

CONCLUSIONS

This study suggests that patients with IPF do not have respiratory muscle weakness. Inspiratory muscle strength has a direct influence on exercise capacity but an indirect effect on quality of life, probably by influencing exercise capacity.

Effects of different inspiratory muscle training protocols on functional exercise capacity and respiratory and peripheral muscle strength in patients with chronic kidney disease: a randomized study

BACKGROUND

Pathological changes were observed in the diaphragm due to abnormal renal function in chronic kidney disease (CKD). Inspiratory muscle training (IMT) has been suggested for patients with CKD; however, the most appropriate intensity for IMT has not been determined. Therefore, this study aimed to investigate the effects of different IMT protocols on respiratory muscle strength, quadriceps femoris muscle strength (QMS), handgrip muscle strength (HGS), functional exercise capacity, quality of life (QoL), pulmonary function, dyspnoea, fatigue, balance, and physical activity (PA) levels in patients with CKD.

METHODS

This randomized, controlled, single-blind study included 47 patients and they were divided into three groups: Group 1 (n = 15, IMT with 10% maximal inspiratory pressure (MIP)), Group 2 (n = 16, IMT with 30% MIP), and Group 3(n = 16; IMT with 60% MIP). MIP, maximal expiratory pressure (MEP), 6-min walking test (6-MWT), QMS, HGS, QoL, pulmonary function, dyspnoea, fatigue, balance, and PA levels were assessed before and after eight weeks of IMT.

RESULTS

Increases in MIP, %MIP, 6-MWT distance, and %6-MWT were significantly higher in Groups 2 and 3 than in Group 1 after IMT (p < 0.05). MEP, %MEP, FEF25-75%, QMS, HGS, and QoL significantly increased; dyspnoea and fatigue decreased in all groups (p < 0.05). FVC, PEF, and PA improved only in Group 2, and balance improved in Groups 1 and 2 (p < 0.05).

CONCLUSIONS

IMT with 30% and 60% MIP similarly improves inspiratory muscle strength and functional exercise capacity. IMT with 30% is more effective in increasing PA. IMT is a beneficial method to enhance peripheral and expiratory muscle strength, respiratory function, QoL and balance, and reduce dyspnoea and fatigue. IMT with %30 could be an option for patients with CKD who do not tolerate higher intensities.

TRIAL REGISTRATION

This study was retrospectively registered (NCT06401135, 06/05/2024).

Psychometrically validated questionnaires to measure the effects and benefits/barriers to physical exercise in hemodialysis patients: a systematic review

PURPOSE

To provide a critical assessment, summarize, and synthesize the evidence from studies using psychometrically validated questionnaires to assess the effects and benefits/barriers of physical exercise in hemodialysis patients.

METHODS

The search was performed on six electronic databases. It was conducted following the PRISMA statement and the PICO framework. The methodological quality was assessed using the MMAT. Were used the quality criteria for psychometric properties developed by Terwee et al.

RESULTS

Overall, 70 studies were included, and 39 questionnaires identified, evaluating 13 outcomes. The quality of the psychometric properties of the questionnaires was not always described; only 13 presented positive ratings on > =6/9 properties. The most assessed measure was criterion validity, and the least assessed criteria was responsiveness. The most outcome measured by these questionnaires was quality of life using SF-36, followed by psychological health using the BDI. The DPEBBS was the only instrument identified that assessed the benefits and barriers of exercise.

CONCLUSION

Quality of life and depression were the most frequent outcomes. Other measures contemplating physical, mental, cognitive performance, and especially of the perceptions benefits and barriers to exercise should be further investigated. We have clearly identified the need for more studies evaluating psychometric measures that have not been tested satisfactorily or hardly been tested at all.

The effects of inspiratory muscle training on balance and functional mobility: a systematic review

INTRODUCTION

Inspiratory muscle training (IMT) has been widely used in both healthy and diseased populations especially in older adults, and its effects have been proven not only on inspiratory muscle strength but also on dyspnea, exercise capacity, quality of life, and other health parameters.

AIM

This study aims to review the effects of IMT on balance and functional ability of healthy and diseased populations.

METHODS

A systematic literature search was conducted on MEDLINE, EMBASE, AMED, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomized control trials having participants > 18 years of age and having balance and functional mobility as primary or secondary outcomes were included. Two independent reviewers screened studies against the eligibility criteria, extracted the data, and assessed the quality of evidence. The protocol was prospectively registered on PROSPERO: CRD42021261652.

RESULTS

Ten studies were included in the review out of which eight had balance and six had functional mobility as an outcome measure. There was a significant improvement in balance of the participants after treatment with IMT, however the effect on functional mobility was inconclusive.

CONCLUSION

The review provided evidence of improvement in balance and functional mobility following inspiratory muscle training in both healthy and diseased adults. Future studies should be conducted to determine the optimal protocol and dosage of treatment.

Interventions for fatigue in people with kidney failure requiring dialysis

BACKGROUND

Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD).

OBJECTIVES

We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported.

AUTHORS' CONCLUSIONS

Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.

Does Exercising with the Use of Virtual Reality during Haemodialysis Have an Impact on Plasma Levels of Interleukin 1β, Interleukin 6, and Interleukin 8?

Cytokines are a group of fine proteins which play a key role in the regulation of various biological processes, including inflammatory reactions. Proinflammatory cytokines, such as interleukin 1β (IL-1β), interleukin 6 (IL-6), and interleukin 8 (IL-8), are produced in response to various stimuli, including infections, tissue damage, and oxidative stress. Virtual reality (VR) use during intradialytic exercises improves physical activity. The purpose of the study was to evaluate the relationship between exercising regularly with the use of virtual reality during haemodialysis and the levels of selected cytokines (Il-1, Il-6, Il-8). The study and the control groups consisted of end-stage renal disease patients who underwent haemodialysis as a renal replacement treatment. The study group comprised patients subject to haemodialysis as a renal replacement therapy who were to work out with the use of a prototype of the NefroVR system for 20 min when undergoing haemodialysis (HD). Statistical analyses utilised Statistica 13. The conducted research demonstrated that regular exercises with the use of virtual reality might be related to a decrease in inflammation in patients included in the chronic haemodialysis programme. It is key to encourage patients with end-stage renal disease treated with haemodialysis to exercise regularly because of the possibility of their proinflammatory parameters becoming reduced.

Inflammatory biomarkers at different stages of Sarcopenia in older women

In recent years, studies have found that Sarcopenia alters inflammatory biomarkers. However, the behavior of inflammatory biomarkers at different stages of Sarcopenia is not well understood. This study aimed to compare a broad panel of inflammatory biomarkers in older women at different stages of Sarcopenia. The study included 71 Brazilian community-dwelling older women. Muscle Strength was assessed by using handgrip strength (Jamar dynamometer). The Short Physical Performance Battery (SPPB) was performed to assess the physical performance, and body composition was assessed by DEXA. Sarcopenia was diagnosed and classified according to the EWGSOP2 criteria. Blood was drawn, and inflammatory biomarkers associated with Sarcopenia (IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, TNF, adiponectin, leptin, resistin, BDNF, sTNFr-1 and sTNFr-2) was analysed. After diagnosis and classification of sarcopenia, 45% of women did not present Sarcopenia (NS, N = 32), 23.9% were diagnosed with Sarcopenia Probable (SP, N = 17), 19,7% with Sarcopenia Confirmed (SC, N = 14), and 11.3% with Severe Sarcopenia (SS, N = 8). The analysis of inflammatory biomarkers revealed that the more advanced the stage of Sarcopenia, the higher the levels of BDNF, IL-8, sTNFr-1, and sTNFr-2. The assessment of BDNF, IL-8, sTNFr-1, and sTNFr-2 levels may be an adjuvant tool in diagnosis and severity classification of Sarcopenia in older Brazilian women.

Effect of breathing exercises on oxidative stress biomarkers in humans: A systematic review and meta-analysis

Background

Breathing exercises improve oxidative stress in healthy young adults and patients with diabetes, hypertension, and chronic obstructive pulmonary disease. Furthermore, the mechanism of respiratory intervention is controversial. Therefore, in this meta-analysis, we aimed to systematically evaluate the effects of breathing exercises on oxidative stress biomarkers in humans and provide evidence for the clinical application of breathing exercises.

Methods

The Embase, PubMed, Cochrane Library, Web of Science, CNKI, and WANFANG databases were searched for studies about the effects of breathing exercises on human oxidative stress levels, with no restraints regarding time, race, or language. The experimental group included various breathing exercises, and the outcome index included malondialdehyde, superoxide dismutase, and glutathione, nitric oxide, vitamin C, or total antioxidant capacity levels from a randomized controlled trial. Data were extracted by more than two authors and reviewed by one author.

Results

Ten studies were included from five countries. Data from patients with no disease, chronic obstructive pulmonary disease, hypertension, or diabetes were included. Participants who performed breathing exercises had greater changes in the included biomarkers than those who did not, suggesting that these biomarkers can be used to evaluate oxidative stress after respiratory interventions.

Conclusion

Breathing exercises increased SOD and GSH activities and decreased MDA content.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022337119, identifier CRD42022337119.

Effect of respiratory muscle training in patients with chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effect of respiratory muscle training on respiratory muscle strength, lung function, cardiopulmonary fitness, and quality of life for chronic kidney disease patients.

METHODS

PubMed, Embase, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials published randomized controlled trials that evaluated the effect of respiratory muscle training for chronic kidney disease patients from inception to December 2021, and rerun on September 2022. The quality of included studies was evaluated according to the Cochrane Collaboration's risk of bias tool-2. The outcomes were analyzed as mean differences with a fixed/random effect model. The strength of evidence was evaluated with the Grading of Recommendation, Assessment, Development, and Evaluation approach.

RESULTS

Eleven randomized controlled trials were included. All but two of the studies were in hemodialysis patients. The follow-up time range was 4 to 12 weeks. Compared to controls, respiratory muscle training significantly improved maximal expiratory pressure (mean difference = 17.36, p = 0.013), maximal inspiratory pressure (mean difference = 18.26, p = 0.002), forced expiratory volume at 1 second (mean difference = 0.20, p= 0.020), forced vital capacity (mean difference = 0.26, p = 0.008), but not for 6-minute walk test (mean difference = 39.85, p= 0.138).

CONCLUSIONS

As a non-pharmacological therapy, respiratory muscle training can effectively improve maximal expiratory pressure, maximal inspiratory pressure, forced expiratory volume at 1 second, and forced vital capacity in patients with chronic kidney disease and is safe for such populations.

Inspiratory-Expiratory Muscle Training Improved Respiratory Muscle Strength in Dialysis Patients: A Pilot Randomised Trial

End-stage kidney disease (ESKD) exposes patients to progressive physical deconditioning involving the respiratory muscles. The aim of this pilot randomized controlled trial was to determine the feasibility and effectiveness of low-intensity respiratory muscle training (RMT) learned at the hospital and performed at home. A group of ESKD patients (n = 22) were randomized into RMT or usual care (control group, CON) in a 1:1 ratio. The respiratory training was performed at home with an inspiratory-expiratory system for a total of 5 min of breathing exercises in a precise rhythm (8 breaths per minute) interspersed with 1 min of rest, two times per day on nondialysis days for a total of 4 weeks, with the air resistance progressively increasing. Outcome measures were carried out every 4 weeks for 3 consecutive months, with the training executed from the 5th to the 8th week. Primary outcomes were maximal inspiratory and expiratory pressure (MIP, MEP), while secondary outcomes were lung capacity (FEV1, FVC, MVV). Nineteen patients without baseline between-group differences completed the trial (T: n = 10; Age: 63 ± 10; Males: n = 12). Both MIP and MEP significantly improved at the end of training in the T group only, with a significant difference of MEP of 23 cmH₂O in favor of the RMT group (p = 0.008). No significant variations were obtained for FVC, FEV1 or MVV in either group, but there was a greater decreasing trend over time for the CON group, particularly for FVC (t = -2.00; p = 0.046). Low-fatiguing home-based RMT, with a simple device involving both inspiratory and expiratory muscles, may significantly increase respiratory muscle strength.

Effects of intradialytic inspiratory muscle training at different intensities on diaphragm thickness and functional capacity: clinical trial protocol in patients undergoing haemodialysis

INTRODUCTION

Patients with end-stage renal disease (ESRD) undergoing haemodialysis (HD) commonly present with a sedentary behaviour and reduced functional capacity, factors that can compromise their prognosis. Intradialytic inspiratory muscle training (IMT) can increase respiratory muscle strength and, consequently, improve functional capacity, besides being easy to apply, cheap and performed in a supervised setting. However, few studies show the effects of this type of training applied at different intensities in this population. This study aims to compare the effects of IMT at different intensities in adults with ESRD undergoing HD.

METHODS AND ANALYSIS

A randomised, double-blind, sham-controlled trial will be conducted on 36 subjects randomly allocated into three groups: IMT at intensities of 30% or 50% of maximal inspiratory pressure (intervention groups), or 10% of maximal inspiratory pressure (sham-IMT). All the interventions will be supervised and performed three times per week, for 12 weeks, totalling 36 sessions. The primary outcomes are the 6-minute walk test, diaphragm thickness and the response of VO₂peak post-intervention. Respiratory muscle strength, 24-hour ambulatory blood pressure measurement and the Kidney Disease Quality of Life 36-item short form survey will be evaluated as secondary outcomes.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committee of the Hospital de Clínicas de Porto Alegre (ID: 2020-0458). The results of this study will be disseminated by conference presentations and peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04660383.

Prevalence and predisposing factors for fatigue in patients with chronic renal disease undergoing hemodialysis: a cross-sectional study

BACKGROUND

Patients with chronic renal disease and undergoing hemodialysis are at a high risk for developing several complications. Fatigue is a common, troubling symptom that affects such patients and can contribute to unfavorable outcomes and high mortality.

OBJECTIVE

This cross-sectional study aimed to evaluate the prevalence of fatigue in Brazilian patients with chronic kidney disease undergoing hemodialysis and determine the predisposing factors for fatigue.

DESIGN AND SETTING

An observational, cross-sectional, descriptive study was conducted in two renal replacement therapy centers in the Greater ABC region of São Paulo.

METHODS

This study included 95 patients undergoing dialysis who were consecutively treated at two Brazilian renal replacement therapy centers between September 2019 and February 2020. The Chalder questionnaire was used to evaluate fatigue. Clinical, sociodemographic, and laboratory data of the patients were recorded, and the Short Form 36 Health Survey, Pittsburgh Sleep Quality Index, and Beck Depression Inventory were administered.

RESULTS

The prevalence of fatigue in patients undergoing hemodialysis was 51.6%. Fatigue was independently associated with lower quality of life in terms of physical and general health. Patients with fatigue had a higher incidence of depression (65.9% vs. 34.1%, P = 0.001) and worse sleep quality (59.1% vs. 49.9%; P = 0.027) than those without fatigue.

CONCLUSION

Prevalence of fatigue is high in patients undergoing hemodialysis and is directly related to physical and general health.

Measuring quality of life in trials including patients on haemodialysis: methodological issues surrounding the use of the Kidney Disease Quality of Life Questionnaire

BACKGROUND

Haemodialysis (HD) treatment causes a significant decrease in quality of life (QoL). When enrolled in a clinical trial, some patients are lost prior to follow-up because they die or they receive a kidney transplant. It is unclear how these patients are dealt with in the analysis of QoL data. There are questions surrounding the consistency of how QoL measures are used, reported and analysed.

METHODS

A systematic search of electronic databases for trials measuring QoL in HD patients using any variation of the Kidney Disease Quality of Life (KDQoL) Questionnaire was conducted. The review was conducted in Covidence version 2. Quantitative analysis was conducted in Stata version 16.

RESULTS

We included 61 trials in the review, of which 82% reported dropouts. The methods to account for missing data due to dropouts include imputation (7%) and complete case analysis (72%). Few trials (7%) conducted a sensitivity analysis to assess the impact of missing data on the study results. Single imputation techniques were used, but are only valid under strong assumptions regarding the type and pattern of missingness. There was inconsistency in the reporting of the KDQoL, with many articles (70%) amending the validated questionnaires or reporting only statistically significant results.

CONCLUSIONS

Missing data are not dealt with according to the missing data mechanism, which may lead to biased results. Inconsistency in the use of patient-reported outcome measures raises questions about the validity of these trials. Methodological issues in nephrology trials could be a contributing factor to why there are limited effective interventions to improve QoL in this patient group.

PROSPERO REGISTRATION

CRD42020223869.

The effect of breathing exercise on daytime sleepiness and fatigue among patients with obstructive sleep apnea syndrome

This study was conducted with randomized controlled and experimental design to examine the effect of breathing exercise on daytime sleepiness and fatigue on patients with obstructive sleep apnea syndrome. The first application was performed by teaching patients in the intervention group breathing exercises including diaphragmatic and pursed lip breathing via the face-to-face interview technique. Then, the researcher applied breathing exercises in the same patient group every morning/evening for 10-15 min and a total of 20-30 min for eight weeks via the online interview method. The data were collected via a questionnaire, Epworth sleepiness scale (ESS), and Piper Fatigue Scale (PFS). Chi-square, Student's t, Mann Whitney U, paired sample t-test, analysis of variance (ANOVA) and generalized estimating equations were used to assess the data. It was determined that PFS total mean score of the intervention group which was 6.15 ± 1.65 before the application decreased to 5.34 ± 1.94 in the eighth week (p> 0.05) and PFS total mean score of the control group which was 5.59 ± 1.76 before the application increased to 5.77 ± 1.81 in the eighth week (p> 0.05). ESS total mean score of the intervention group which was 12.13 ± 4.34 at the baseline decreased to 9.13 ± 4.71 in the eighth week (p> 0.05) and ESS total mean score of the control group which was 10.37 ± 2.77 at the baseline increased to 10.5 ± 2.85 in the eighth week (p> 0.05). It was concluded that breathing exercise performed in the intervention group decreased the fatigue and daytime sleepiness mean scores of the patients at the end of the fourth and eighth week. In addition, the group-time interaction was significant, which was associated with the intervention group.

Effect of Exercise on Inflammation in Hemodialysis Patients: A Systematic Review

BACKGROUND

In recent years, physical exercise has been investigated for its potential as a therapeutic tool in patients with end-stage renal disease (ESRD) undergoing hemodialysis maintenance treatment (HD). It has been shown that regular practice of moderate-intensity exercise can improve certain aspects of immune function and exert anti-inflammatory effects, having been associated with low levels of pro-inflammatory cytokines and high levels of anti-inflammatory cytokines.

PURPOSE

The aim of this review is to examine the studies carried out in this population that analyzed the effect of intradialytic exercise on the inflammatory state and evaluate which exercise modality is most effective.

METHODS

The search was carried out in the MEDLINE, CINAHL Web of Science and Cochrane Central Register of Controlled Trials databases from inception to June 2022. The PEDro scale was used to assess methodological quality, and the Cochrane Risk of Bias Tool and MINORS were used to evaluate the risk of bias. The quality of evidence was assessed with GRADE scale. The outcome measures were systemic inflammation biomarkers.

RESULTS

Mixed results were found in terms of improving inflammation biomarkers, such as CRP, IL-6 or TNFα, after exercise. Aerobic exercise seems to improve systemic inflammation when performed at medium intensity while resistance training produced better outcomes when performed at high intensity. However, some studies reported no differences after exercise and these results should be taken with caution.

CONCLUSIONS

The low quality of the evidence suggests that aerobic and resistance exercise during HD treatment improves systemic inflammation biomarkers in patients with ESRD. In any case, interventions that increase physical activity in patients with ESRD are of vital importance as sedentary behaviors are associated with mortality. More studies are needed to affirm solid conclusions and to make intervention parameters, such as modality, dose, intensity or duration, sufficiently clear.

Translational Potential of High-Resistance Inspiratory Muscle Strength Training

Age-associated cardiovascular (CV) dysfunction increases the risk for CV diseases. Aerobic exercise training can improve CV function, but only a minority of adults meet aerobic exercise guidelines. High-resistance inspiratory muscle strength training is a time-efficient lifestyle intervention that may promote adherence and improve CV function. However, further investigation is needed to translate inspiratory muscle strength training into the public health domain.

Time-efficient, high-resistance inspiratory muscle strength training for cardiovascular aging

Cardiovascular diseases (CVD) remain the leading cause of death in developed and developing societies and aging is the primary risk factor for CVD. Much of the increased risk of CVD in midlife/older adults (i.e., adults aged 50 years and older) is due to increases in blood pressure, vascular endothelial dysfunction and stiffening of the large elastic arteries. Aerobic exercise training is an effective lifestyle intervention to improve CV function and decrease CVD risk with aging. However, <40% of midlife/older adults meet guidelines for aerobic exercise, due to time availability-related barriers and other obstacles to adherence. Therefore, there is a need for new lifestyle interventions that not only improve CV function with aging but also promote adherence. High-resistance inspiratory muscle strength training (IMST) is an emerging, time-efficient (5 min/day) lifestyle intervention. Early research suggests high-resistance IMST may promote adherence, lower blood pressure and potentially improve vascular endothelial function. However, additional investigation will be required to more definitively establish high-resistance IMST as a healthy lifestyle intervention for CV aging. This review will summarize the current evidence on high-resistance IMST for improving CV function with aging and will identify key research gaps and future directions.

A systematic review of trials investigating the efficacy of exercise training for functional capacity and quality of life in chronic kidney disease patients

OBJECTIVE

To investigate the efficacy of exercise training on functional capacity and quality of life in chronic kidney disease.

DATA SOURCES

SCOPUS, CINAHL, Science Direct, Web of Science, MEDLINE, ProQuest, Physiotherapy Evidence Database (PEDRO), and Google Scholar databases were searched between 2010 and December 2020.

METHODS

Randomized controlled trials were included if they involved any types of exercise training (aerobic, resisted and respiratory ex.) conducted with chronic kidney disease patients. Three authors independently screened articles, extracted data, and assessed the methodological quality using PEDro scale, and two authors released any confliction. Modified Sackett Scale was used to determine the level of evidence for each outcome.

RESULTS

Out of 130 papers screened, 13 studies with 619 participants met the inclusion criteria. The frequency of the treatment ranged from three to four sessions per week for a period ranging from 8 to 24 weeks. According to the Pedro scale, the quality of studies ranged from good (three studies) to fair (ten studies). All included studies showed positive effects on the measured outcomes (functional capacity and quality of life in chronic kidney disease).

CONCLUSION

Exercise programs for chronic kidney disease patients provide beneficial clinical outcomes and optimize functional capacity and quality of life in those patients. Future studies still need to focus on high-quality evidence and studies evaluating the adverse effects of exercise.

Impact of inspiratory muscle training on diaphragmatic mobility and arterial blood gases in patients undergoing haemodialysis

Background/aims

Impairment of respiratory muscle function is common in patients with chronic kidney disease undergoing haemodialysis, and is manifested by decreased oxygenation and physical function. The purpose of this study was to analyse the impact of training with incentive spirometer on mobility of the diaphragm, arterial blood gases and functional capacity in patients with chronic kidney disease undergoing haemodialysis.

Methods

A pre–post research design was implemented. A total of 30 patients undergoing haemodialysis for chronic kidney disease received incentive spirometer training intradialysis three sessions a week for 8 weeks. Outcome measures were the amount of diaphragmatic mobility measured by ultrasonography, the levels of arterial partial pressure of oxygen, arterial partial pressure of carbon dioxide, oxygen saturation percentages and the distance walked in 6 minutes.

Results

Significant improvement from pre-treatment to post-treatment measurements occurred in all outcome measures, with P<0.05.

Conclusions

Incentive spirometer training should be recommended to be a part of daily routine of patients with chronic kidney disease who are undergoing haemodialysis to decrease respiratory and physical function impairments.

Breathing-based leg exercises during hemodialysis improve quality of life: A randomized controlled trial

OBJECTIVE

To evaluate the effect of a 12-week breathing-based leg exercises program on quality of life under stabilizing heart rate variability and reducing fatigue in regular hemodialysis patients.

DESIGN

Randomized controlled trial.

SETTING

A 94-bed hemodialysis department at a medical center in northern Taiwan.

PARTICIPANTS

Eighty-six patients with end-stage renal disease undergoing hemodialysis were recruited and randomly assigned to the ExBr or control groups.

INTERVENTIONS

The breathing-based leg exercises program comprised abdominal breathing and low-intensity leg exercise, including leg lifts, quadriceps femoris contraction and knee flexion, and lasted for 15 minutes at one time, three times a week for 12 weeks.

MAIN MEASURE

Data was collected by using the World Health Organization quality of life assessment-brief, physiological signal recorder for heart rate variability and hemodialysis-related fatigue scale at baseline and on Week 4, Week 8, and Week 12.

RESULTS

Average (standard deviation) age was 53.70 (10.04) years in the ExBr group and 61.19 (10.19) years in the control group. The linear mixed model with adjusted age, creatinine, heart rate variability and fatigue revealed that the ExBr group had significantly higher quality of life than did the control group (P = 0.01), especially on Week 12 (P = 0.04). Fatigue was significantly correlated with quality of life (P < 0.001).

CONCLUSION

This study supported the benefits of the continued breathing-based leg exercises during hemodialysis for at least 12 weeks, which improved the quality of life of patients with end-stage renal disease and did not affect the stability of their vital signs.

Effect of inspiratory muscle training on respiratory muscle strength and functional capacity in patients with type 2 diabetes mellitus: A randomized clinical trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) is usually associated with respiratory manifestations including inspiratory muscle weakness which affects exercise capacity. The present study aimed to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and exercise capacity in patients with Type 2 diabetes mellitus (T2DM).

METHODS

This was a randomized controlled trial in patients with type 2 diabetes mellitus with no previous cardiopulmonary or neuromuscular diseases. Patients had no back pain. Patients were randomized into interventional or placebo groups. Sniff nasal inspiratory pressure (SNIP), maximum inspiratory pressure (MIP), and six-minute walking test (6MWT) were measured at baseline and 8 weeks post incremental inspiratory muscle training.

RESULTS

At baseline, interventional and placebo groups were similar in age, body mass index, sex inspiratory muscle strength, and exercise capacity. After 8 weeks of incremental inspiratory muscle training at 40% of MIP, the interventional group had a significant increase in the SNIP (mean difference: 18.5 ± 5.30 cm H2O vs 2.8 ± 4.8 cm H2O) and MIP (mean difference: 19.4 ± 4.3 Vs 5.4 ± 3.6 cm H2O) compared to the placebo group, respectively. The interventional group showed improvement in the 6MWT (mean difference: 70 ± 29 m vs 34 ± 24 m) compared to the placebo group, P < .05.

CONCLUSION

Incremental inspiratory muscle training increased the diaphragm strength in patients with T2DM and improved exercise capacity.

The reliability and validity of the 30-seconds sit-to-stand test and its capacity for assessment of the functional status of hemodialysis patients

PURPOSE

To investigate the validity of the 30-seconds sit-to-stand test (STS-30) and its reliability in hemodialysis patients.

METHODS

Patients receiving hemodialysis treatment three times a week for at least six months were evaluated using STS-30, Incremental Shuttle Walking Test, and health-related quality of life by KDQOL-SF questionnaire. The data obtained from the Incremental Shuttle Walking Test were divided into tertiles, and the STS-30 results were compared among tertiles. The accuracy of the STS-30 to identify low exercise capacity was evaluated. A second STS-30 was performed after 6 to 8-weeks for the reliability analyses using Intraclass Correlation Coefficient (ICC). Minimal detectable change scores were calculated.

RESULTS

Sixty-three individuals (66.7% men) aged 48.3 years (95%CI 44.6-51.9) were evaluated. There were significant correlations between STS-30, exercise capacity (r = 0.72), and physical domains of health-related quality of life (0.30 ≤ r ≤ 0.51). Tertile 1 of the Incremental Shuttle Walking Test was different from tertiles 2 and 3 for STS-30 [difference of 3.4 repetitions (95%CI 1.5-5.4) and 4.7 repetitions (95%CI 2.8-6.7), respectively]. The value of 12 repetitions was the cut-off points for stratification of individuals with low exercise capacity. The STS-30 had a high test-retest reliability (ICC = 0.93) and the minimal detectable change was 2.1 repetitions.

CONCLUSION

The STS-30 is a reliable test, associated with exercise capacity and physical domains of health-related quality of life. Thus, is a valid method for functional evaluation in hemodialysis patients.

Effectiveness of inspiratory muscle training on respiratory fitness and breathlessness in chronic renal failure: A randomized control trial

BACKGROUND

People with chronic renal failure (CRF) show decreased respiratory fitness and poor quality of life (QOL). Exercise during hemodialysis has been suggested to improve the cardio-respiratory fitness. However, results of effects of respiratory muscle (RM) training on respiratory fitness and QOL are inconsistent. In addition, very few studies explored the association between inspiratory muscle (IM) training and sensation of breathlessness.

OBJECTIVES

To examine the effects of IM training in hemodialysis patients on respiratory fitness QOL and breathlessness.

METHOD

A randomized control trial with 50 CRF, who underwent hemodialysis (25 individuals in each group; IM training and sham group) was designed. Pulmonary function, RM strength, QOL (measured by Kidney Disease Quality of Life-36), and sensation of breathlessness were measured before and after an 8-week intervention.

RESULTS

Compared to the sham group, the IM strength increased in the intervention group after an 8-week program (Δ25.92 ± 8.73 cmH₂ O, p = 0.005). Significantly increased IM and forced vital capacity values in training groups was observed after an 8-week intervention (Δ12.44 ± 3.07 cmH₂ O and Δ0.097 ± 0.046 L, respectively), but not the sham group. Neither, the training group, nor the sham group were significantly different in the QOL. However, feeling of shortness of breath improved after the training program among inspiratory muscle training group, but not the sham group.

CONCLUSION

IM training during hemodialysis could lead to an improvement of respiratory fitness and reduce breathlessness in people with CRF who are receiving hemodialysis. However, QOL was not different after the training program. The study suggests that after 8-week intervention program, IM training (loading exercise) could improve IM strength, pulmonary function without any complications during the intervention program within 1-2 h.

Maximal inspiratory pressure is associated with health-related quality of life and is a reliable method for evaluation of patients on hemodialysis

OBJECTIVE

To evaluate the association between Maximal Inspiratory Pressure (MIP) and health-related quality of life (HRQoL) and to verify the reliability of the MIP in patients on hemodialysis.

METHODS

In a repeated-measures design, patients on hemodialysis performed MIP and specific HRQoL questionnaire (trial 1). The MIP was repeated after 6 to 8 weeks (trial 2) and reliability was assessed using Intra-class Correlation Coefficient. Standard Error of Measurement and Minimal Detectable Change scores were calculated.

RESULTS

Sixty-one individuals (68.9% men) were evaluated in trial 1. MIP was associated with specific domains "Symptoms" (r = 0.45; R² adjusted = 0.192) and the kidney disease component summary (r = 0.38; R² adjusted = 0.138). Regarding generic domains, the MIP was associated with "Physical Functioning" (r = 0.57; R² adjusted = 0.375) and Physical component summary (r = 0.47; R² adjusted = 0.258). Thirty-three patients were randomly selected to perform a second MIP test (trial 2). The Intra-class Correlation Coefficient was 0.94 (95%CI 0.88-0.97). By Bland-Altman analysis, the bias was 3.2 cmH2O, which represents a difference of 3.7%. The Standard Error of Measurement and Minimal Detectable Change for MIP were 5.9 cmH2O and 13.8 cmH2O, respectively.

CONCLUSION

The MIP is a reliable test, associated with physical domains of HRQoL in patients on hemodialysis. Thus, it is a useful method for respiratory evaluation in this population.

Chronic Influence of Inspiratory Muscle Training at Different Intensities on the Serum Metabolome

This study investigated the chronic effect of inspiratory muscle training (IMT) on the human serum metabolome in healthy male recreational cyclists. Using a randomized, parallel group design, twenty-eight participants were randomized to three IMT groups: low intensity (LI, n = 7); moderate intensity (MI, n = 10); and high intensity (HI, n = 11). The IMT was performed for 11 weeks. Another group of participants under the same conditions, who did not perform the IMT but participated in all procedures, was included as controls (CG, n = 6). Blood samples were collected one week before and after 11 weeks of IMT and analyzed for metabolite shifts using 1H NMR. Statistical analysis included a 4 (group) × 2 (time) repeated measures ANOVA using the general linear model (GLM), and multivariate principal component analysis (PCA). Untargeted metabolomics analysis of serum samples identified 22 metabolites, including amino acids, lipids, and tricarboxylic acid cycle intermediates. Metabolites shifts did not differ between groups, indicating that IMT at three intensity levels did not alter the serum metabolome relative to the control group. These results reveal novel insights into the metabolic effects of the IMT and are consistent with the results from other studies showing negligible chronic alterations in the serum metabolome in response to physical training.