Recommendations for implementation of physical training guidelines for patients undergoing chronic hemodialysis
Keywords:Exercise therapy, Renal hemodialysis, Renal insufficiency, Chronic, Frailty, Quality of life
The exponential growth in the prevalence of chronic kidney disease (CKD) is currently one of the greatest public health challenges worldwide, with a high economic impact at the health level and on the quality of life of affected patients. In countries with a low organ donation rate, hemodialysis is the renal replacement treatment par excellence. Although hemodialysis improves patient survival, in the medium and long term it generates a series of consequences and pathophysiological adaptations that gradually cause a significant reduction in general physical function, affecting daily activities and quality of life. The evidence of the beneficial effects of exercise in patients with any stage of chronic kidney disease, including those on dialysis therapy, is well known. Different types of physical training programs have shown to significantly improve the physical function of patients. The positive impact on clinical aspects such as mental health, hemodialysis efficacy as well as associated healthcare costs is significant. In Latin American countries, these programs are still at a very incipient level of development. The present work is a review of recommendations that should be considered for the implementation of a physical training program for patients on chronic hemodialysis.
FundingNephrology Chilean Society, Chile.
Allen, K. L., Miskulin, D., Yan, G., Dwyer, J. T., Frydrych, A., Leung, J., … Hemodialysis (HEMO) Study Group. (2002). Association of nutritional markers with physical and mental health status in prevalent hemodialysis patients from the HEMO study. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation, 12(3), 160-169. https://doi.org/10.1053/jren.2002.33512
American College Sports Medicine. (2014). ACSM's Guidelines for Exercise Testing and Prescription, EEUU, Wolter Kluwer Health.
Andrade, F. P., Rezende, P. de S., Ferreira, T. de S., Borba, G. C., Müller, A. M., & Rovedder, P. M. E. (2019). Effects of intradialytic exercise on cardiopulmonary capacity in chronic kidney disease: systematic review and meta-analysis of randomized clinical trials. Scientific Reports, 9(1), 1-7. https://doi.org/10.1038/s41598-019-54953-x
Aucella, F., Gesuete, A., & Battaglia, Y. (2014). A "Nephrological" Approach to Physical Activity. Kidney and Blood Pressure Research, 39(2-3), 189-196. https://doi.org/10.1159/000355796
Aucella, F., Valente, G. L., & Catizone, L. (2014). The Role of Physical Activity in the CKD Setting. Kidney and Blood Pressure Research, 39(2-3), 97-106. https://doi.org/10.1159/000355783
C J Caspersen, K E Powell, & Christenson., G. M. (1985). Physical Activity, Exercise, and Physical Fitness: Definitions and Distinctions for Health-Related Research Synopsis. Public Health Rep, 100(2), 126-131.
Capitanini, A., Lange, S., D'Alessandro, C., Salotti, E., Tavolaro, A., Baronti, M. E., … Cupisti, A. (2014). Dialysis Exercise Team: The Way to Sustain Exercise Programs in Hemodialysis Patients. Kidney and Blood Pressure Research, 39(2-3), 129-133. https://doi.org/10.1159/000355787
Carlos Jorquera, A., & Jorge Cancino, L. (2012). Ejercicio, Obesidad y Sindrome Metabólico. Revista Médica Clínica Las Condes, 23(3), 227-235. https://doi.org/10.1016/S0716-8640(12)70305-X
Carney, E. F. (2015). Prevention: Intensive exercise associated with reduced risk of diabetic nephropathy in patients with type 1 diabetes mellitus. Nature Reviews Nephrology, 11(4), 198-198. https://doi.org/10.1038/nrneph.2015.17
Cheema, B. S., Chan, D., Fahey, P., & Atlantis, E. (2014). Effect of progressive resistance training on measures of skeletal muscle hypertrophy, muscular strength and health-related quality of life in patients with chronic kidney disease: A systematic review and meta-analysis. Sports Medicine, 44(8), 1125-1138. https://doi.org/10.1007/s40279-014-0176-8
Cho, J. H., Lee, J. Y., Lee, S., Park, H., Choi, S. W., & Kim, J. C. (2018). Effect of intradialytic exercise on daily physical activity and sleep quality in maintenance hemodialysis patients. International Urology and Nephrology, 50(4), 745-754. https://doi.org/10.1007/s11255-018-1796-y
Clarkson, M. J., Fraser, S. F., Bennett, P. N., McMahon, L. P., Brumby, C., & Warmington, S. A. (2017). Efficacy of blood flow restriction exercise during dialysis for end stage kidney disease patients: Protocol of a randomised controlled trial. BMC Nephrology, 18(1). https://doi.org/10.1186/s12882-017-0713-4
Colberg, S. R., Sigal, R. J., Fernhall, B., Regensteiner, J. G., Blissmer, B. J., Rubin, R. R., …Braun, B. (2010). Exercise and Type 2 Diabetes: The American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care, 33(12), e147-e167. https://doi.org/10.2337/dc10-1548
Da Silva, V. G., Amaral, C., Monteiro, M. B., do Nascimento, D. M., & Boschetti, J. R. (2011). Effects of inspiratory muscle training in hemodialysis patients. Jornal Brasileiro de Nefrologia, 33(1), 62-68. https://doi.org/10.1590/S0101-28002011000100009
Davison, S. N., Levin, A., Moss, A. H., Jha, V., Brown, E. A., Brennan, F., …Obrador, G. T. (2015). Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: Developing a roadmap to improving quality care. En Kidney International, 88(3), 447-459. https://doi.org/10.1038/ki.2015.110
Garber, C. E., Blissmer, B., Deschenes, M. R., Franklin, B. a., Lamonte, M. J., Lee, I. M., …Swain, D. P. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine and Science in Sports and Exercise, 43(7), 1334-1359. https://doi.org/10.1249/MSS.0b013e318213fefb
Gomes Neto, M., de Lacerda, F. F. R., Lopes, A. A., Martinez, B. P., & Saquetto, M. B. (2018). Intradialytic exercise training modalities on physical functioning and health-related quality of life in patients undergoing maintenance hemodialysis: systematic review and meta-analysis. Clinical Rehabilitation, 32(9), 1189-1202. https://doi.org/10.1177/0269215518760380
Gould, D. W., Graham-Brown, M. P., Watson, E. L., Viana, J. L., & Smith, A. C. (2014). Physiological benefits of exercise in pre-dialysis chronic kidney disease. Nephrology, 19(9), 519-527. https://doi.org/10.1111/nep.12285
Greenwood, S. A., Koufaki, P., Rush, R., Macdougall, I. C., & Mercer, T. H. (2014). Exercise Counselling Practices for Patients with Chronic Kidney Disease in the UK: A Renal Multidisciplinary Team Perspective. Nephron Clinical Practice, 128(1-2), 67-72. https://doi.org/10.1159/000363453
Groussard, C., Rouchon-Isnard, M., Coutard, C., Romain, F., Malardé, L., Lemoine-Morel, S., …Boisseau, N. (2015). Beneficial effects of an intradialytic cycling training program in patients with end-stage kidney disease. Applied Physiology, Nutrition and Metabolism, 40(6), 550-556. https://doi.org/10.1139/apnm-2014-0357
Workeneh, T., & Mitch, W. (2018). Review of muscle wasting associated with chronic kidney disease. Contributions to Nephrology, 196, 243-249.
Hamm, L. F., Sanderson, B. K., Ades, P. A., Berra, K., Kaminsky, L. A., Roitman, J. L., & Williams, M. A. (2011). Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals. Journal of Cardiopulmonary Rehabilitation and Prevention, 31(1), 2-10. https://doi.org/10.1097/HCR.0b013e318203999d
Hara, H., Nakamura, Y., Hatano, M., Iwashita, T., Shimizu, T., Ogawa, …Hasegawa, H. (2018). Protein Energy Wasting and Sarcopenia in Dialysis Patients. Contributions to Nephrology, 196, 243-249. https://doi.org/10.1159/000485729
Heiwe, S., & Jacobson, S. H. (2014). Exercise training in adults with CKD: A systematic review and meta-analysis. American Journal of Kidney Diseases, 64(3), 383-393. https://doi.org/10.1053/j.ajkd.2014.03.020
Howden, E. J., Weston, K., Leano, R., Sharman, J. E., Marwick, T. H., Isbel, N. M., & Coombes, J. S. (2015). Cardiorespiratory fitness and cardiovascular burden in chronic kidney disease. Journal of Science and Medicine in Sport, 18(4), 492-497. https://doi.org/10.1016/j.jsams.2014.07.005
Ikizler, T. A. (2019). Intradialytic nutrition and exercise: convenience versus efficacy. Kidney International, 96(3), 549-552. https://doi.org/10.1016/j.kint.2019.04.037
Intiso, D. (2014). The Rehabilitation Role in Chronic Kidney and End Stage Renal Disease. Kidney and Blood Pressure Research, 39(2-3), 180-188. https://doi.org/10.1159/000355795
Ishikawa, Y., Gohda, T., Tanimoto, M., Omote, K., Furukawa, M., Yamaguchi, S., …Tomino, Y. (2012). Effect of Exercise on Kidney Function, Oxidative Stress, and Inflammation in Type 2 Diabetic KK- A y Mice. Experimental Diabetes Research, 2012, 1-10. https://doi.org/10.1155/2012/702948
Isoyama, N., Qureshi, A. R., Avesani, C. M., Lindholm, B., Bárány, P., Heimbürger, O., …Carrero, J. J. (2014). Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. Clinical Journal of the American Society of Nephrology, 9(10), 1720-1728. https://doi.org/10.2215/CJN.10261013
Johansen, K. L., & Painter, P. (2012). Exercise in Individuals With CKD. American Journal of Kidney Diseases, 59(1), 126-134. https://doi.org/10.1053/j.ajkd.2011.10.008
Jorquera, A. C., & Cancino, L. J. (2012). Ejercicio, obesidad y síndrome metabólico. Revista Médica Clínica Las Condes, 23(3), 227-235. https://doi.org/10.1016/S0716-8640(12)70305-X
Kim, J. C., Kalantar-Zadeh, K., & Kopple, J. D. (2013). Frailty and protein-energy wasting in elderly patients with end stage kidney disease. Journal of the American Society of Nephrology, 24(3), 337-351. https://doi.org/10.1681/ASN.2012010047
Kim, J. S., Yi, J. H., Shin, J., Kim, Y. S., & Han, S. W. (2019). Effect of acute intradialytic aerobic and resistance exercise on one-day blood pressure in patients ndergoing hemodialysis: A pilot study. Journal of Sports Medicine and Physical Fitness, 59(8), 1413-1419. https://doi.org/10.23736/S0022-4707.18.07921-5
Koufaki, P., & Mercer, T. (2009). Assessment and Monitoring of Physical Function for People With CKD. Advances in Chronic Kidney Disease, 16(6), 410-419. https://doi.org/10.1053/j.ackd.2009.08.010
Kurella Tamura, M., Li, S., Chen, S. C., Cavanaugh, K. L., Whaley-Connell, A. T., McCullough, P. A., & Mehrotra, R. L. (2014). Educational programs improve the preparation for dialysis and survival of patients with chronic kidney disease. Kidney International, 85(3), 686-692. https://doi.org/10.1038/ki.2013.369
Leehey, D. J., Moinuddin, I., Bast, J. P., Qureshi, S., Jelinek, C. S., Cooper, C., …Collins, E. G. (2009). Aerobic exercise in obese diabetic patients with chronic kidney disease: a randomized and controlled pilot study. Cardiovascular diabetology, 8, 62. https://doi.org/10.1186/1475-2840-8-62
Luyckx, V. A., Tonelli, M., & Stanifer, J. W. (2018). The global burden of kidney disease and the sustainable development goals. Bulletin of the World Health Organization, 96(6), 414-422C. https://doi.org/10.2471/BLT.17.206441
Manfredini, F., Mallamaci, F., D'Arrigo, G., Baggetta, R., Bolignano, D., Torino, C., … Zoccali, C. (2017). Exercise in patients on dialysis: A multicenter, randomized clinical trial. Journal of the American Society of Nephrology, 28(4), 1259-1268. https://doi.org/10.1681/ASN.2016030378
Matsuzawa, R., Hoshi, K., Yoneki, K., Harada, M., Watanabe, T., Shimoda, T., …Matsunaga, A. (2017). Exercise Training in Elderly People Undergoing Hemodialysis: A Systematic Review and Meta-analysis. Kidney International Reports, 2(6), 1096-1110. https://doi.org/10.1016/j.ekir.2017.06.008
McAdams-Demarco, M. A., Law, A., Salter, M. L., Boyarsky, B., Gimenez, L., Jaar, B. G., … Segev, D. L. (2013). Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis. Journal of the American Geriatrics Society, 61(6), 896-901. https://doi.org/10.1111/jgs.12266
Miller, B. W., Cress, C. L., Johnson, M. E., Nichols, D. H., & Schnitzler, M. A. (2002). Exercise during hemodialysis decreases the use of antihypertensive medications. American Journal of Kidney Diseases, 39(4), 828-833. https://doi.org/10.1053/ajkd.2002.32004
Ministerio de Salud. (2017). Recomendaciones de Actividad Física para Personas con Comorbilidad. Retrieved from http://familiarycomunitaria.cl/FyC/wp-content/uploads/2018/04/2017.11.13_Recomendaciones-Actividad-Fisica-FINAL-DM2.pdf
Morishita, S., Tsubaki, A., Nashimoto, S., Fu, J. B., & Onishi, H. (2018). Face scale rating of perceived exertion during cardiopulmonary exercise test. BMJ Open Sport and Exercise Medicine, 4(1), 474. https://doi.org/10.1136/bmjsem-2018-000474
Moscoso, P., Arismendi, C., Lobo, R. B., Cárdenas, R. S., & Silva, L. O. (2020). Efectividad de un entrenamiento cardiorrespiratorio, muscular y ventilatorio en el rendimiento aeróbico de pacientes hemodializados. Revista Colombiana de Nefrología, 7(1), 25-35. https://doi.org/10.22265/acnef.7.1.369
Müller-Ortiz, H., Pedreros-Rosales, C., Vera-Calzaretta, A., González-Burboa, A., Zúñiga-San Martín, C., & Oliveros-Romero, M. S. (2019). Exercise training in advanced chronic kidney disease. Revista Medica de Chile, 147(11), 1443-1448. https://doi.org/10.4067/S0034-98872019001101443
Narva, A. S., Norton, J. M., & Boulware, L. E. (2016). Educating patients about CKD: The path to self-management and patient-centered care. Clinical Journal of the American Society of Nephrology, 11(4), 694-703. https://doi.org/10.2215/CJN.07680715
Olvera-Soto, M. G., Valdez-Ortiz, R., Alvarenga, J. C. L., & Espinosa-Cuevas, M. de los Á. (2016). Effect of resistance exercises on the indicators of muscle reserves and handgrip strength in adult patients on hemodialysis. Journal of Renal Nutrition, 26(1), 53-60. https://doi.org/10.1053/j.jrn.2015.06.006
Paglialonga, F., Lopopolo, A., Scarfia, R. V., Consolo, S., Galli, M. A., Salera, S., …Edefonti, A. (2014). Intradialytic cycling in children and young adults on chronic hemodialysis. Pediatric Nephrology, 29(3), 431-438. https://doi.org/10.1007/s00467-013-2675-5
Parsons, T. L., Toffelmire, E. B., & King-VanVlack, C. E. (2006). Exercise Training During Hemodialysis Improves Dialysis Efficacy and Physical Performance. Archives of Physical Medicine and Rehabilitation, 87(5), 680-687. https://doi.org/10.1016/j.apmr.2005.12.044
Peña-Amaro, P., García-López, J., Zagalaz-Sánchez, M. L., Jimeno-Ucles, R., & Expósito-Rodríguez, A. (2009). El ejercicio físico en pacientes en insuficiencia renal crónica terminal y programa de hemodiálisis. Dialisis y Trasplante, 30(4), 127-132. https://doi.org/10.1016/S1886-2845(09)72696-7
Pinho, C. A., Tromm, C. B., Tavares, A. M. V, Silva, L. A., Cesar, P., Silveira, L., …Pinho, R. A. (2012). Effects of different physical training protocols on ventricular oxidative stress parameters in infarction-induced rats. Life Sciences, 90(13-14), 553-559. https://doi.org/10.1016/j.lfs.2012.01.018
Raj, D. S. C., Sun, Y., & Tzamaloukas, A. H. (2008). Hypercatabolism in dialysis patients. Current Opinion in Nephrology and Hypertension, 17(6), 589-594. https://doi.org/10.1097/MNH.0b013e32830d5bfa
Rhee, S. Y., Song, J. K., Hong, S. C., Choi, J. W., Jeon, H. J., Shin, D. H.,…Oh, J. (2019). Intradialytic exercise improves physical function and reduces intradialytic hypotension and depression in hemodialysis patients. Korean Journal of Internal Medicine, 34(3), 588-598. https://doi.org/10.3904/kjim.2017.020
Rossi, A. P., Burris, D. D., Lucas, F. L., Crocker, G. A., & Wasserman, J. C. (2014). Effects of a renal rehabilitation exercise program in patients with CKD: A randomized, controlled trial. Clinical Journal of the American Society of Nephrology, 9(12), 2052-2058. https://doi.org/10.2215/CJN.11791113
Segall, L., Moscalu, M., Hogaş, S., Mititiuc, I., Nistor, I., Veisa, G., & Covic, A. (2014). Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients. International Urology and Nephrology, 46(3), 615-621. https://doi.org/10.1007/s11255-014-0650-0
Segura-Ortí, E. (2010). Ejercicio en pacientes en hemodiálisis: Revisión sistemática de la literatura. Nefrologia, 30(2), 236-246.
Sheng, K., Zhang, P., Chen, L., Cheng, J., Wu, C., & Chen, J. (2014). Intradialytic exercise in hemodialysis patients: A systematic review and meta-analysis. American Journal of Nephrology, 40(5), 478-490. https://doi.org/10.1159/000368722
Sigal, R. J., Kenny, G. P., Wasserman, D. H., Castaneda-Sceppa, C., & White, R. D. (2006). Physical Activity/Exercise and Type 2 Diabetes: A consensus statement from the American Diabetes Association. Diabetes Care, 29(6), 1433-1438. https://doi.org/10.2337/dc06-9910
Simo, V. E., Jiménez, A. J., Guzmán, F. M., Oliveira, J. C., Nicolas, M. F., Potau, M. P., …de Arellano, M. R. (2015). Benefits of a low intensity exercise programme during haemodialysis sessions in elderly patients. Nefrologia, 35(4), 385-394. https://doi.org/10.1016/j.nefroe.2015.03.005
Smith, A. C., Burton, J. O., Hons, B. A., & Hons, M. (2012). Exercise in Kidney Disease and Diabetes : Time for Action. Journal of Renal Care, 52-58. https://doi.org/10.1111/j.1755-6686.2012.00279.x
Stenvinkel, P., Carrero, J. J., von Walden, F., Ikizler, T. A., & Nader, G. A. (2016). Muscle wasting in end-stage renal disease promulgates premature death: established, emerging and potential novel treatment strategies. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 31(7), 1070-1077. https://doi.org/10.1093/ndt/gfv122
Tamura, M. K., Covinsky, K. E., Chertow, G. M., Yaffe, K., Landefeld, C. S., & McCulloch, C. E. (2009). Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 361(16), 1539-1547. https://doi.org/10.1056/NEJMoa0904655
Tuegel, C., & Bansal, N. (2017). Heart failure in patients with kidney disease. Heart, 103(23), 1843-1853. https://doi.org/10.1136/heartjnl-2016-310794
Umpierre, D., Kramer, C. K., Leita, C. B., Gross, J. L., Ribeiro, J. P., & Schaan, B. D. (2011). Physical Activity Advice Only or Structured exercise training and association With HbA 1c Levels in Type 2 Diabetes. JAMA: the journal of the American Medical Association, 305, 1790-1799. https://doi.org/10.1001/jama.2011.576
Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., …Schutte, A. E. (2020). 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension, 75(6), 1334-1357. https://doi.org/10.1161/HYPERTENSIONAHA.120.15026
Van Craenenbroeck, A. H., Van Craenenbroeck, E. M., Van Ackeren, K., Vrints, C. J., Conraads, V. M., Verpooten, G. A., …Couttenye, M. M. (2015). Effect of Moderate Aerobic Exercise Training on Endothelial Function and Arterial Stiffness in CKD Stages 3-4: A Randomized Controlled Trial. American Journal of Kidney Diseases, 66(2), 285-296. https://doi.org/10.1053/j.ajkd.2015.03.015
Walker, S. R., Brar, R., Eng, F., Komenda, P., Rigatto, C., Prasad, B., …Tangri, N. (2015). Frailty and physical function in chronic kidney disease: The CanFIT study. Canadian Journal of Kidney Health and Disease, 2(1). https://doi.org/10.1186/s40697-015-0067-4
Wang, H., Naghavi, M., Allen, C., Barber, R. M., Carter, A., Casey, D. C., … Zuhlke, L. J. (2016). Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1459-1544. https://doi.org/10.1016/S0140-6736(16)31012-1
Wang, X. H., & Mitch, W. E. (2014). Mechanisms of muscle wasting in chronic kidney disease. Nature Reviews Nephrology, 10(9), 504-516. https://doi.org/10.1038/nrneph.2014.112
World Health Organization. (2010). Recomendaciones Mundiales sobre Actividad Física para la Salud. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/44441/9789243599977_spa.pdf
Yamagata, K., Hoshino, J., Sugiyama, H., Hanafusa, N., Shibagaki, Y., Komatsu, Y., … Kohzuki, M. (2019). Clinical practice guideline for renal rehabilitation: Systematic reviews and recommendations of exercise therapies in patients with kidney diseases. Renal Replacement Therapy, 5(1), 28. https://doi.org/10.1186/s41100-019-0209-8
Yoo, J. Il, Choi, H., & Ha, Y. C. (2017). Mean hand grip strength and cut-off value for sarcopenia in Korean adults using KNHANES VI. Journal of Korean Medical Science, 32(5), 868-872. https://doi.org/10.3346/jkms.2017.32.5.868
Zelle, D. M., Klaassen, G., Van Adrichem, E., Bakker, S. J. L., Corpeleijn, E., & Navis, G. (2017). Physical inactivity: A risk factor and target for intervention in renal care. Nature Reviews Nephrology, 13(3), 152-168. https://doi.org/10.1038/nrneph.2016.187
Zúñiga SM, C., Dapueto P, J., Müller O, H., Kirsten L, L., Alid A, R., & Ortiz M, L. (2009). Evaluación de la calidad de vida en pacientes en hemodiálisis crónica mediante el cuestionario "Kidney Disease Quality of Life (KDQOL-36)". Revista Medica de Chile, 137(2), 200-207. https://doi.org/10.4067/S0034-98872009000200003
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