ObjectivesFor people with end-stage renal disease requiring haemodialysis, exercise can improve aspects of quality of life (QoL). However, the relative benefits and risks of different types of exercise in this population are unknown. Therefore, this pilot study aimed to evaluate the feasibility of a main study evaluating the efficacy of cycling and resistance exercise each performed during the haemodialysis treatment on QoL.MethodsIn this factorial (2×2) pilot trial, 31 haemodialysis patients were randomised to cycling, resistance, cycling and resistance, or an attention control. Feasibility was defined a priori by criteria on recruitment, fidelity to the protocol and patient response to the intervention. To better understand feasibility, we conducted interviews with dialysis unit staff and trial participants. As secondary outcomes, we estimated the main effect of cycling and weights each compared with control on QoL, physical function and strength.FindingsWe exceeded the target accrual of 28 participants over 12 weeks. Irrespective of exercise group allocation, adherence was high; of the 1038 training sessions offered, 87% were initiated and over 80% of exercise sessions were performed as per protocol. Progression based on perceived exertion, individual instruction and interactions with the kinesiologist facilitated acceptability across exercise groups. Using an attention control, measures of contamination and attrition were low. Important barriers to unit staff readiness for the intervention were initial safety and workflow concerns, unit workload and onerous data collection. Secondary outcomes were not statistically significant. Adverse events were low and did not increase with a higher volume of exercise.ConclusionsThe main study is feasible with minor modifications. In addition to practical assistance, involvement from unit staff could increase patient participation and improve trial implementation. Strategies to increase acceptability of the intervention for staff include improving workflow integration and using a prestudy demonstration phase to introduce the intervention.Trial registration numberNCT02234232. Results
Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.
Despite having good intentions, hemodialysis (HD) clinics often fail to sustain exercise programs that they initiate. There are many reasons for this, including a lack of funding, inadequate training of the clinic staff, a lack of exercise professionals to manage the program or train the staff, and the many challenges inherent to exercising a patient population with multiple comorbid diseases. Despite these barriers, there are several outstanding examples of successful exercise programs in HD clinics throughout the world. The aim of this manuscript is to review the characteristics of four successfully sustained HD exercise programs in Portugal, Canada, Mexico, and Germany. We describe the unique approaches they have used to fund and manage their programs, the varied exercise prescriptions they incorporate, the unique challenges they face, and discuss the benefits they have seen. While the programs differ in many regards, a consistent theme is that they each have substantial and committed support from the entire clinic staff, including the nephrologists, administration, nurses, dietitians, and technicians. This suggests that exercise programs in HD clinics can be successfully implemented and sustained provided significant effort is made to foster a culture of physical activity throughout the clinic.
Introduction
Remaining physically active is important to patients undertaking dialysis, however, clinical recommendations regarding exercise type, timing, intensity, and safety precautions vary. The purpose of this scoping review was to analyse and summarise recommendations for physical activity and exercise for people undertaking dialysis and identify areas that require further research or clarification.
Materials and methods
A scoping review of literature from five bibliographic databases (Medline, Scopus, Web of Science, CINAHL, and SPORTDiscus) was conducted. Eligible articles included consensus guidelines, position statements, reviews, or clinical practice guidelines that included specific physical activity and exercise recommendations for people undertaking dialysis. Key search terms included "kidney disease" OR "kidney failure" OR "chronic kidney disease" OR "end stage kidney disease" AND guideline* OR consensus OR "position statement" OR prescription OR statement AND exercise OR "physical activity". Hand searching for relevant articles in all first twenty quartile 1 journals listed on SCImago under ‘medicine—nephrology’ and ‘physical therapy, sports therapy and rehabilitation’ using the terms ‘exercise and dialysis’ was undertaken. Finally, home pages of key societies and professional organisations in the field of sports medicine and nephrology were searched.
Results
The systematic search strategy identified 19 articles met the inclusion criteria. Two were specific to pediatric dialysis and three to peritoneal dialysis. Whilst many publications provided recommendations on aerobic exercise, progressive resistance training and flexibility, few provided explicit guidance. Recommendations for the intensity, duration and frequency of aerobic and resistance training varied. Discrepancies or gaps in guidance about precautions, contraindications, termination criteria, progression, and access site precautions were also apparent.
Conclusion
Future guidelines should include specific guidance regarding physical activity, safety precautions, and timing and intensity of exercise for individuals who undertake dialysis. Collaborative multidisciplinary guideline development and appropriate exercise counselling may lead to increased participation in physical activity and exercise and facilitate better patient outcomes.
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