[Effects of aerobic exercise during haemodialysis in patients with chronic renal disease: a literature review]

Effect of Intradialytic Exercise on Cardiovascular Outcomes in Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

Key Points

Individuals receiving hemodialysis have high rates of cardiovascular disease not explained by traditional cardiovascular risk factors. Intradialytic exercise improves cardiovascular outcomes, including arterial resistance, BP, and heart rate variability. Clinicians should consider including intradialytic aerobic exercise programs in hemodialysis care to supplement broader treatment plans.

Background

Cardiovascular disease is the leading cause of death among people with kidney failure on hemodialysis, for whom improving cardiovascular health is a research priority. Intradialytic myocardial stunning is common and associated with adverse cardiovascular events. Intradialytic exercise may mitigate intradialytic myocardial stunning and improve cardiovascular structure and function. This systematic review investigated the effect of intradialytic exercise on cardiovascular outcomes in adults undergoing maintenance hemodialysis (PROSPERO CRD42018103118).

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE, Embase, Cochrane CENTRAL, SportDiscus, and PEDro databases from 1960 until June 2022, for randomized and nonrandomized studies investigating the effect of intradialytic exercise programs on objective cardiovascular outcomes, prespecified as primary or secondary outcomes. The primary outcome was arterial resistance.

Results

Of 10,837 references identified, 32 met eligibility criteria. These studies investigated the effect of intradialytic exercise on arterial resistance (eight studies), BP (20 studies), myocardial structure and function (seven studies), endothelial function (two studies), sympathetic overactivity (nine studies), biomarkers of cardiac injury (three studies), and cardiovascular hospitalization and mortality (two studies). Most studies used aerobic exercise as the intervention and usual care (no exercise) controls. Meta-analysis of intradialytic exercise versus usual care resulted in a statistically significant reduction in arterial resistance measured by pulse wave velocity with mean difference −1.63 m/s (95% confidence interval, −2.51 to −0.75). Meta-analyses for diastolic BP, left ventricular ejection fraction, and low-frequency/high-frequency ratio measure of heart rate variability also showed statistically significant improvements with exercise. There was no significant difference in change in systolic BP, augmentation index, and left ventricular mass index between groups.

Conclusions

Intradialytic exercise programming resulted in a clinically meaningful improvement to pulse wave velocity, a component of arterial resistance. Improvements in several physiologic measures of cardiovascular health, including diastolic BP, left ventricular ejection fraction, and heart rate variability measured by the low-frequency/high-frequency ratio were also observed. The effects of intradialytic exercise on major adverse cardiovascular events remains uncertain.

The impact of nurse-led nonpharmacological multidisciplinary holistic nursing care on fatigue patients receiving hemodialysis: a randomized, parallel-group, controlled trial

BACKGROUND

Fatigue is a symptom characterized by an elevated prevalence in patients undergoing hemodialysis, which may cause extreme mental and muscular debilitation, significantly influencing social interaction, life quality and well-being. However, the significance of fatigue to patients undergoing hemodialysis has not been recognized yet, and prevention and management of fatigue in this population have not been thoroughly investigated. Additionally, previous studies mainly focused on muscular fatigue, while mental fatigue has been seldom discussed. This study aims to investigate the interaction between nurses and multidisciplinary of nonpharmacological integrated care interventions (NICIs) and assess the impact of fatigue on patients undergoing hemodialysis.

METHODS

The integrative nonpharmacological care interventions in this study included walking, motivational interviewing (MI) and health education regarding behavioral self-management. A single-center randomized controlled trial was conducted in the dialysis center of the nephrological department in a tertiary affiliated hospital of medical university from January to June 2019. A total of 118 patients were selected and randomly divided into the intervention group (IG) and the control group (CG). Four patients dropped out during the study, and 114 patients were enrolled for the eventual analysis. The 60 patients in the IG received routine nursing combined with integrated care interventions, while the 54 patients in the CG received routine nursing only. This study lasted for six months.

RESULTS

The experimental group exhibited significant reductions of overall fatigue (2.26 vs. 0.48), mental fatigue (1.41 vs. 0.54), muscular fatigue (2.13 vs. 0.75), and some biochemical indicators (e.g., serum urea) (P<0.05), compared with the CG.

CONCLUSIONS

Nurses and multidisciplinary teams have been demonstrated to play a key role and interplay function in chronic disease management. Hence, the nurse-led multidisciplinary NICIs significantly alleviated total fatigue (muscular fatigue and mental fatigue) and improved other parameters.

TRIAL REGISTRATION

ChiCTR-IOR-16008621 (March 18, 2016).

Effects of upper limb exercise programs on the arteriovenous fistula in patients on hemodialysis: A systematic review and meta-analysis

BACKGROUND

The arteriovenous fistula (AVF) is a commonly used vascular access for chronic kidney disease (CKD) patients; exercise interventions may boost its maturation and help in its maintenance. A systematic review and meta-analysis of clinical trials on the effects of upper limb exercise programs on the AVF was conducted.

METHODS

The primary outcomes were draining vein diameter (DVD) and draining vein blood flow rate (DVBFR), and secondary outcomes were handgrip strength (HGS) and brachial artery flow rate (BAFR). Quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

Four studies met the inclusion criteria. When compared to usual care groups, the experimental groups did not improve DVD (mean difference [MD] 0.23, confidence interval [CI] -0.20-0.65). There were significant differences in DVBFR (mL/min) according to the fixed-effect model (MD 141.13, CI 36.84-245.42). HGS (kg) was significantly different between groups (MD 2.95, CI 0.55-5.35), but BAFR (mL/min) was not (MD 91.65, CI -94.72-278.01).

CONCLUSIONS

Although exercise programs did not improve DVD and BAFR, they increased muscle strength and DVBFR. Therefore, experimental exercise programs should be emphasized for AVF maturation and maintenance.Research Registry number: reviewregistry924.

Knowledge of physiotherapists working in adult ICU on contraindications to mobilization

Abstract Introduction: Mobilization is an effective therapy to combat the deleterious effects of immobility, but not all patients are in a condition to be moved; thus, knowledge about contraindication criteria is fundamental. Objective: To evaluate the knowledge of physiotherapists working in adult ICUs on contraindications to the mobilization of critical patients. Method: This was a cross-sectional study in which a survey was applied to physiotherapists working in an adult ICU in the city of Recife. Results: Out of the 36 criteria presented, only five were considered contraindication criteria. Clinical parameters were those that obtained higher frequency for not being considered criteria for contraindication, nor were there observed differences in the relation between the time of working in the ICU. Conclusion: Most physiotherapists did not consider the criteria presented as contraindications to mobilization, so that professional training in mobilization practices and the creation of protocols are necessary.

Is aerobic exercise training during hemodialysis a reliable intervention for autonomic dysfunction in individuals with chronic kidney disease? A prospective longitudinal clinical trial

Introduction

Physical exercises help in the rehabilitation and recovery of various diseases. Cardiovascular and hypertension problems are the main causes of people being affected by kidney problems, which as a consequence, affects the heart rate variability (HRV) of the individual. Physical activity developed in a well-planned and thorough way can be a component in the treatment of this problem.

Objective

We aimed to evaluate the effects of aerobic exercise intervention during hemodialysis on autonomic heart rate regulation in individuals with chronic kidney disease (CKD).

Methods

This was a longitudinal trial conducted in 19 CKD patients. The patients underwent three weekly sessions of aerobic exercise during hemodialysis for 30 mins for 12 weeks (three months).

Results

HRV was analyzed before and after the protocol training. Linear indices of HRV were not different between before and after the protocol training. Nonlinear HRV analysis indicated reduced values of determinism (p=0008, Cohen's d=0.82) and entropy (p=003, Cohen's d=0.84) after the training protocol.

Conclusion

In conclusion, aerobic exercise training during hemodialysis did not improve autonomic control of heart rate in CKD patients.

Effects of inspiratory muscle training on pulmonary functions and muscle strength in sedentary hemodialysis patients

[Purpose] This study was conducted to evaluate the effect of Inspiratory Muscle Trainer (IMT) on respiratory muscle strength and pulmonary functions. [Subjects and Methods] Fifteen sedentary unemployed patients were recruited from both genders who received regular hemodialysis sessions from at least three months. Those patients received Threshold IMT program for 12 weeks. Pulmonary functions and respiratory muscle strength in form of (PImax) and (PEmax) were measured by electronic spirometry and digital pressure vacuum meter respectively. Additionally oxygen saturation was measured by Finger pulse oximeter. All measurements were performed before and at the end of the treatment program after 12 weeks. [Results] The results of this study revealed significant improvement in FVC%, FEV1%, PEF%, PImax and PEmax after three months of treatment by using inspiratory muscle trainer while no significant difference was recorded regarding to FEV1/FVC% ratio and SpO₂. [Conclusion] Inspiratory muscle trainer is an effective therapeutic technique to improve respiratory muscle strength and pulmonary functions in patients undergoing hemodialysis.

Comparison between two physiotherapy protocols for patients with chronic kidney disease on dialysis

[Purpose] To compare the effects of two physiotherapy protocols for chronic kidney disease patients on dialysis. [Subjects and Methods] This is a prospective, randomized study, in chronic kidney disease patients 18 years of age or older on dialysis. Sessions for each group (were conducted three times per week for a total of 10 sessions), during hemodialysis. Respiratory muscle strength (maximal inspiratory and expiratory pressure), peak expiratory flow, and peripheral muscle strength were evaluated. The study group received motor and respiratory physiotherapy, and the control group received motor physiotherapy alone. [Results] We observed a significant increase in the maximal inspiratory pressure in the study group in the 5th and 10th sessions and in the maximal expiratory pressure in the 1st session, peak flow in the 1st and 10th sessions, and dynamometry in the 10th session. In the control group, there was a significant decrease in maximal inspiratory pressure in the 5th and 10th sessions, and in maximal expiratory pressure in the 10th session, peak flow in the 5th and 10th sessions, and dynamometry in the 5th session. [Conclusion] Implementation of motor physiotherapy combined with respiratory physiotherapy may have contributed to the improvement of the variables analyzed in the study group.

Physical exercise modifies the functional capacity of elderly patients on hemodialysis

Abstract Introduction Patients on hemodialysis (HD) improve functional capacity after physical training. However, little is discussed about these effects in elderly patients, since these are usually excluded of studies, due to their physical disabilities and other deficits. Objective To analyze the effects of aerobic and resistance training in the functional capacity of elderly patients submitted to HD. Methods Studied participants were 15 patients, of both genders, and aged over 60 years. Aerobic and resistance training was carried out during the hemodialysis session, three times per week, during four months. Patients were distributed into control (CG) and experimental (EG) groups. Functional capacity was assessed by six-minute walk (6MW), sit-to-stand (STS) and respiratory muscle strength tests. Results After the physical training, EG presented a significant increase in the distance covered in 6MW (Z = 2.521, p < .012), respiratory muscle strength (inspiratory pressure: Z = 2.533, p < .011; expiratory pressure: Z = 2.536, p < .011); and in number of STS repetitions (2.54; p <.001). Conclusion The training modified the functional capacity of the HD patients, contributing to their rehabilitation.

Attitudes and perceptions of patients on the kidney transplant waiting list toward mobile health-delivered physical activity programs

CONTEXT

Dialysis patients' lifestyles are associated with low levels of physical activity, increasing the chances of being removed from kidney waiting lists or dying while awaiting transplant because of increased cardiovascular risk factors and deteriorating health conditions. Personalized mobile health (mHealth) delivered programs may support their engagement in healthier lifestyles, maintain transplant eligibility, and reduce premature mortality.

OBJECTIVE

To explore barriers and perceptions of physical activity behaviors and gauge interest in using mHealth in a physical activity wellness program for dialysis patients on the kidney transplant waiting list.

PARTICIPANTS AND DESIGN

In-depth key informant interviews were conducted with 22 randomly selected dialysis patients during dialysis treatment in an urban Southeastern coastal city. A theory-guided community-based participatory research approach was used to develop the interview content. Constructivist grounded theory guided the data analysis using NVIVO 10 (QSR Int). The 32-item checklist from the Consolidated Criteria for Reporting Qualitative Studies was used in the qualitative reporting.

RESULTS

Dialysis patients had a mean age of 46 (SD, 10.7) years, 45% were female, and 82% were African American. Their mean duration on transplant waiting lists was 6.7 (SD 4.3) years, and 73% owned smartphones. After saturation was reached, predominant themes included (1) physical activity was perceived as optional, (2) social support both encouraged and limited physical activity, (3) chronic stress and coping influenced physical activity, (4) spirituality provided strength to engage in physical activity, (5) self-care management practices varied considerably, and (6) high interest (95%) for using mHealth to promote physical activity was found. Patients preferred their home and neighborhood environments to intradialytic settings for engaging in physical activity.

Physical activity level and depressive symptoms in patients undergoing hemodialysis: a cross-sectional study

This study aimed to evaluate the association between the presence of depressive symptoms and physical activity level (PAL) in patients with chronic kidney disease undergoing hemodialysis (HD). Cross-sectional study comprising 101 patients on HD, mean age 47.4±12.5 years. Sociodemographic data, economic, clinical, assessment of depressive symptoms (Beck Depression Scale - BDI), PAL (International Physical Activity Questionnaire - IPAQ), guidance for performing physical activity (PA) and time of HD. The prevalence of sedentary and depressive symptoms was 79.2% and 39.6%, respectively. Depressive symptoms were observed in 47.5% of sedentary patients (χ2=10.029, p=0.002), the ratio of prevalence of these symptoms five times higher in this group. 68.3% of patients on HD received no guidance for PA. Under 49 months of hemodialysis treatment, 63.8% of sedentary (χ2=3.011, p=0.083) and 57.5% of patients with depressive symptoms (χ2=0.100, p=0.752) already had these features. Although little is known about the relationship between depression and PA among patients undergoing HD, this study found that depressive symptoms were more prevalent among inactive. The results of this study demonstrate that patients undergoing HD have low PAL, relative presence of depressive symptoms and high lack of guidance on PA.