Exercise During Hemodialysis in Patients With Chronic Kidney Failure
- In chronic hemodialysis patients, a 12-month intradialytic exercise program with endurance and strength components resulted in improved sit-to-stand test and 6-minute walk test results, as compared with usual care.
- Patients participating in intradialytic exercise spent fewer days in the hospital than usual care patients (median days per patient, 2 vs. 5; p = 0.036).
What are the clinical effects of combined endurance and resistance exercise during chronic hemodialysis?
The DiaTT (Dialysis Training Therapy) trial was a cluster randomized controlled trial conducted at 21 German hemodialysis centers, examining the clinical effects of a 12-month, thrice-weekly intradialytic exercise intervention incorporating resistance and endurance training (30 minutes of each per session). A semi-recumbent bicycle ergometer, programmed to maintain target heart rate, was used for endurance exercise. Recumbent resistance exercises, supervised by trainers, were performed with elastic bands, exercise balls, and dumbbells. Intensity of all exercises was progressively increased and reassessed every 3 months. During the SARS-CoV-2 pandemic, study personnel were temporarily unable to enter dialysis units, and patients received instructions for a substitute home exercise program. The primary outcome was the change in the 60-second sit-to-stand test (STS60 – i.e., number of sit-to-stand repetitions within 60 seconds) between baseline and 12 months.
A total of 1,211 patients underwent randomization, and 917 (mean age 65.9 years, 38.9% female) were included in the full analysis. In the intervention group, mean STS60 repetitions improved significantly from 16.2 to 19.2, while they declined from 16.2 to 14.7 in the usual care group (adjusted group difference, 3.85 repetitions; 95% confidence interval [CI], 2.22-5.48; p < 0.0001). The intervention group performed better in the 6-minute walk test (adjusted group difference, 37.5 m; 95% CI, 14.7-60.4) but not in the grip strength test. With regard to quality of life, physical health and vitality subscores on the 36-item Short Form Health Survey improved in the intervention group. Median hospital days per patient were 2 in the intervention group and 5 in the usual care group (p = 0.036). Mortality and serious adverse events leading to discontinuation of dialysis did not differ between groups.
This 12-month intradialytic exercise program, incorporating endurance and strength training, improved measures of physical functioning and quality of life in chronic hemodialysis patients as compared with usual care. Intervention patients also spent fewer days in the hospital.
Frailty is a pervasive problem in the chronic dialysis population. This relatively straightforward exercise intervention resulted in gains in physical functioning and quality of life, with a concomitant reduction in hospital days. Feasibility and patient acceptance of this type of intervention should be evaluated in a US population. Hospital savings could potentially offset startup costs (equipment and staff training) for intradialytic exercise programs. For patients with concomitant end-stage kidney disease and heart disease, cardiac rehabilitation attendance can be logistically challenging, and further study is needed to understand if intradialytic exercise could provide substantial benefits to patients who cannot attend traditional rehabilitation programs.
Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Sports and Exercise Cardiology, Exercise, Sports and Exercise and ECG and Stress Testing
Keywords: Cardiac Rehabilitation, Dialysis, Endurance Training, Exercise, Frailty, Geriatrics, Kidney Failure, Chronic, Metabolic Syndrome, Patient Admission, Primary Prevention, Secondary Prevention, Quality of Life, Renal Dialysis, SARS-CoV-2, Walk Test
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