Combining intra‐dialytic exercise and nutritional supplementation in malnourished older haemodialysis patients: Towards better quality of life and autonomy

Abstract

Protein-energy wasting (PEW), defined as a loss of body protein mass and fuel reserves, is a powerful predictor of adverse outcomes in haemodialysis (HD) patients. Robust arguments suggest that intra-dialytic exercise, combined with oral/parenteral nutrition, enhances the effect of nutritional interventions in HD patients. This pilot randomized controlled trial investigated the feasibility and the effects of a 6 month intra-dialytic cycling program combined to a nutritional support on PEW, physical functioning (gait, balance, muscle strength) and quality of life (QoL) in older HD patients (mean age 69.7 ± 14.2 years).Twenty-one patients fulfilling diagnostic criteria of PEW were randomly assigned to Nutrition-Exercise group (GN-Ex , n = 10) or Nutrition group (GN , n = 11). Both groups received nutritional supplements in order to reach recommended protein and energy intake goals. In addition GN-Ex completed a cycling program. No significant difference between groups was found in the number of patients having reached remission of PEW. Likewise, no change was observed in serum-albumin, -prealbumin, C-reactive protein, body mass index, lean- and fat-tissue index, or quadriceps force. Interestingly, we found positive effects of exercise on physical function and QoL for the GN-Ex , as evidenced by a significant improvement in the 6-min walk test (+22%), the absence of decline in balance (unlike the GN ), and a noteworthy increase in QoL (+53%). Combining intra-dialytic exercise and nutrition in HD patients is feasible, and well accepted, improves physical function and QoL but it appears not to have the potential to reverse PEW.

Clinical practice guideline for renal rehabilitation: systematic reviews and recommendations of exercise therapies in patients with kidney diseases

“…The Dietary Recommendations for Chronic Dialysis Patients published by the Japanese Society for Dialysis Therapy 2014 also recommend an energy intake of 30-35 kcal/kg and protein intake of 0.9-1.2 g/kg [42]. However, a study demonstrated that the physical function and QOL were significantly improved in patients with PEW by a combination of nutritional and exercise therapies compared with nutritional therapy alone [43], thus nutritional and exercise therapies are complementary to each other.…”

“…4) (Fig. 6) [43,69,[71][72][73][74][75][76], and Kt/V (MD 0.07, 95% CI 0.01-0.14) ( Fig. 7) [43,66,67,71,[77][78][79].…”

“…6) [43,69,[71][72][73][74][75][76], and Kt/V (MD 0.07, 95% CI 0.01-0.14) ( Fig. 7) [43,66,67,71,[77][78][79]. However, no statistically significant difference was noted in muscle strength [69,70,[76][77][78][79][80], muscle mass [68,71], albumin [43,58,71,75,77,79,81,82], or CRP [43,82,83], while they were all improved.…”

Rehabilitation nutrition support for a hemodialysis patient with protein-energy wasting and sarcopenic dysphagia: a case report

“…Nutritional therapies such as enteral nutrition, parenteral nutrition, and oral nutritional supplementation can be used to treat PEW [1]. A list of these studies, along with their reported nutritional outcomes, is provided in Table 1 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. The studies designed to establish the benefits of nutritional supplementation on the long-term improvements in overall nutritional status in hemodialysis patients with PEW have yielded encouraging results.…”

Let's programme exercise during haemodialysis (intradialytic exercise) into the care plan for patients, regardless of age

“…One reason may be the age of patients with ESRD, a vulnerable population at high risk of mortality. Now more than ever, whether for paediatric patients4 or older patients (>65 years of age),5 let's challenge this intrinsic reluctance by advocating intradialytic exercise programmes as part of the standard care for patients receiving dialysis.…”