The Effect of Exercise Therapy on Physical Function, Biochemistry and Dialysis Adequacy in Haemodialysis Patients: A Systematic Review and Meta-Analysis


Background:Patients undergoing dialysis have high mortality rates and a unique risk factor profile. Some improvements elicited by exercise training have been shown in dialysis populations, here we aimed to further explore the bene-fits of exercise. As well as changes in physical fitness we quantified cardiac function, depression, serum biochemistry, dialysis adequacy and energy intake following exercise training in people with chronic kidney disease (CKD) undertaking dialysis. Methods:A systematic literature search was completed in December 2012 identifying randomized, controlled trials of exercise training studies in haemodialysis (HD) patients. A subsequent meta-analysis was conducted.Results: Twenty four studies were included, totalling 879 patients. Exercise training produced significant improvements in physical fitness: peak VO2 5.03 mlO2·kg-1·min-1 (95% CI 3.73, 6.33, p < 0.0001), Knee extensor strength 2.99 kg (95% CI 0.46, 5.52, p = 0.02) and 6 minute walk distance 60.7 metres (95% CI 18.9, 103, p = 0.004). Significant increases in energy intake MD 238 Kcal·day-1 (95% CI 94, 383, p = 0.001), serum Interleukin-6 MD-0.58 pg·ml-1 (95% CI-1.01, -0.15, p = 0.008) and Creactive protein MD 0.92 mg/L-1 (95% CI 0.29, 1.56, p = 0.004), but not Albumin or BMI, were reported. Improved Beck Depression scores were reported MD-6.9 (95% CI-9.7,-4.1, p < 0.00001). Dialysis adequacy was reduced MD-0.23 (95% CI -0.29, -0.17, p < 0.00001), while serum potassium was higher MD 0.14 mmol·L-1 (95% CI 0.01, 0.27, p = 0.04). Moreover exercise training appeared safe, with no direct exercise-associated deaths in over 30,000 patient-hours. Conclusions: Our pooled analyses confirmed improvements in physical fitness following exercise training and suggested additional improvements in dialysis efficiency (kt/v), serum potassium, inflammation and depression in HD patients.

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Smart, N. , McFarlane, J. and Cornelissen, V. (2013) The Effect of Exercise Therapy on Physical Function, Biochemistry and Dialysis Adequacy in Haemodialysis Patients: A Systematic Review and Meta-Analysis. Open Journal of Nephrology, 3, 25-36. doi: 10.4236/ojneph.2013.31005.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] B. S. Cheema and M. A. Singh, “Exercise Training in Patients Receiving Maintenance Hemodialysis: A Systematic Review of Clinical Trials,” American Journal of Nephrology, Vol. 25, No. 4, 2005, pp. 352-364. doi:10.1159/000087184
[2] E. J. Howden, R. G. Fassett, N. M. Isbel and J. S. Coombes, “Exercise Training in Chronic Kidney Disease Patients,” Sports Medicine, Vol. 42, No. 6, 2012, pp. 473-488. doi:10.2165/11630800-000000000-00000
[3] K. L. Johansen and P. Painter, “Exercise in Individuals with CKD,” American Journal of Kidney Diseases, Vol. 59, No. 1, 2012, pp. 126-134. doi:10.1053/j.ajkd.2011.10.008
[4] E. Kouidi, A. Iacovides, P. Iordanidis, S. Vassiliou, A. Deligiannis, C. Ierodiakonou and A. Tourkantonis, “Exercise Renal Rehabilitation Program: Psychosocial Effects,” Nephron Clinical Practice, Vol. 77, No. 2, 1997, pp. 152-158.
[5] E. Kouidi, V. Karagiannis, D. Grekas, A. Iakovides, G. Kaprinis, A. Tourkantonis and A. Deligiannis, “Depression, Heart Rate Variability, and Exercise Training in Dialysis Patients,” European Journal Cardiovascular Prevention Rehabilitation, Vol. 17, No. 2, 2010, pp. 160-167. doi:10.1097/HJR.0b013e32833188c4
[6] E. J. Kouidi, D. M. Grekas and A. P. Deligiannis, “Effects of Exercise Training on Noninvasive Cardiac Measures in Patients Undergoing Long-Term Hemodialysis: A Randomized Controlled Trial,” American Journal of Kidney Diseases, Vol. 54, No. 3, 2009, pp. 511-521. doi:10.1053/j.ajkd.2009.03.009
[7] A. Deligiannis, E. Kouidi and A. Tourkantonis, “Effects of Physical Training on Heart Rate Variability in Patients on Hemodialysis,” American Journal of Cardiology, Vol. 84, No. 2, 1999, pp. 197-202. doi:10.1016/S0002-9149(99)00234-9
[8] K. E. Sietsema, A. Amato, S. G. Adler and E. P. Brass, “Exercise Capacity as a Predictor of Survival among Ambulatory Patients with End-Stage Renal Disease,” Kidney International, Vol. 65, No. 2, 2004, pp. 719-724. doi:10.1111/j.1523-1755.2004.00411.x
[9] N. Smart and M. Steele, “Exercise Training in Haemodialysis Patients: A Systematic Review and Meta-Analysis,” Nephrology (Carlton), Vol. 16, No. 7, 2011, pp. 626- 632.
[10] E. Segura-Orti, “Exercise in Haemodyalisis Patients: A Literature Systematic Review,” Nefrologia, Vol. 30, No. 2, 2010, pp. 236-246.
[11] A. R. Jadad, R. A. Moore, D. Carroll, C. Jenkinson, D. J. Reynolds, D. J. Gavaghan and H. J. McQuay, “Assessing the Quality of Reports of Randomized Clinical Trials: Is Blinding Necessary?” Controlled Clinical Trials, Vol. 17, No. 1, 1996, pp. 1-12. doi:10.1016/0197-2456(95)00134-4
[12] P. Alderson and S. Green, “Cochrane Collaboration Open Learning Material for Reviewers,” Version 1.1, 2002.
[13] J. P. T. Higgins, S. G. Thompson, J. J. Deeks and D. G. Altman, “Measuring Inconsistency in Meta-Analysis,” British Medical Journal, Vol. 327, No. 7414, 2003, pp. 557-560. doi:10.1136/bmj.327.7414.557
[14] A. Deligiannis, E. Kouidi, E. Tassoulas, P. Gigis, A. Tourkantonis and A. Coats, “Cardiac Effects of Exercise Rehabilitation in Hemodialysis Patients,” International Journal of Cardiology, Vol. 70, No. 3, 1999, pp. 253-266. doi:10.1016/S0167-5273(99)00090-X
[15] P. Koufaki, T. H. Mercer and P. F. Naish, “Effects of Exercise Training on Aerobic and Functional Capacity of End-Stage Renal Disease Patients,” Clinical Physiology and Functional Imaging, Vol. 22, No. 2, 2002, pp. 115-124. doi:10.1046/j.1365-2281.2002.00405.x
[16] G. Moros, R. Ros Mar, A. A. Villarroya, A. C. L. de Robles, M. Comin and S. Nerin Ballarriga, “Physical Exercise in Hemodialysis Patients,” Archivos de Medicina del Deporte, Vol. 17, No. 77, 2000, pp. 235-244.
[17] P. Painter, G. Moore, L. Carlson, S. Paul, J. Myll, W. Phillips and W. Haskell, “Effects of Exercise Training plus Normalization of Hematocrit on Exercise Capacity and Health-Related Quality of Life,” American Journal of Kidney Diseases, Vol. 39, No. 2, 2002, pp. 257-265. doi:10.1053/ajkd.2002.30544
[18] M. C. Van Vilsteren, M. H. de Greef and R. M. Huisman, “The Effects of a Low-to-Moderate Intensity Pre-Conditioning Exercise Programme Linked with Exercise Counselling for Sedentary Haemodialysis Patients in The Netherlands: Results of a Randomized Clinical Trial,” Nephrology Dialysis Transplantation, Vol. 20, No. 1, 2005, pp. 141-146. doi:10.1093/ndt/gfh560
[19] A. P. Goldberg, E. M. Geltman, J. M. Hagberg, J. R. Gavin III, J. A. Delmez, R. M. Carney, A. Naumowicz, M. H. Oldfield and H. R. Harter, “Therapeutic Benefits of Exercise Training for Hemodialysis Patients,” Kidney International Supplements, Vol. 16, 1983, pp. S303-S309.
[20] E. Kouidi, D. Grekas, A. Deligiannis and A. Tourkantonis, “Outcomes of Long-Term Exercise Training in Dialysis Patients: Comparison of Two Training Programs,” Clinical Nephrology, Vol. 61, Suppl. 1, 2004, pp. S31-S38.
[21] K. P. Koh, R. G. Fassett, J. E. Sharman, J. S. Coombes and A. D. Williams, “Intradialytic versus Home-Based Exercise Training in Hemodialysis Patients: A Randomised Controlled Trial,” BMC Nephrology, Vol. 10, 2009, p. 2.
[22] V. DePaul, J. Moreland, T. Eager and C. M. Clase, “The Effectiveness of Aerobic and Muscle Strength Training in Patients Receiving Hemodialysis and EPO: A Randomized Controlled Trial,” American Journal Kidney Diseases, Vol. 40, No. 6, 2002, pp. 1219-1229. doi:10.1053/ajkd.2002.36887
[23] R. M. Oliveros, M. Avendano, D. Bunout, S. Hirsch, M. P. De La Maza, C. Pedreros and H. Muller, “A Pilot Study on Physical Training of Patients in Hemodialysis,” Revista Médica de Chile, Vol. 139, No. 8, 2011, pp. 1046-1053.
[24] J. L. Chen, S. Godfrey, T. T. Ng, R. Moorthi, O. Liangos, R. Ruthazer, B. L. Jaber, A. S. Levey and C. Castaneda-Sceppa, “Effect of Intra-Dialytic, Low-Intensity Strength Training on Functional Capacity in Adult Haemodialysis Patients: A Randomized Pilot Trial,” Nephrology Dialysis Transplantation, Vol. 25, No. 6, 2010, pp. 1936-1943. doi:10.1093/ndt/gfp739
[25] K. L. Johansen, P. L. Painter, G. K. Sakkas, P. Gordon, J. Doyle and T. Shubert, “Effects of Resistance Exercise Training and Nandrolone Decanoate on Body Composition and Muscle Function among Patients Who Receive Hemodialysis: A Randomized, Controlled Trial,” Journal of the American Society of Nephrology, Vol. 17, No. 8, 2006, pp. 2307-2314. doi:10.1681/ASN.2006010034
[26] K. R. Wilund, E. J. Tomayko, P. T. Wu, H. Ryong Chung, S. Vallurupalli, B. Lakshminarayanan and B. Fernhall, “Intradialytic Exercise Training Reduces Oxidative Stress and Epicardial Fat: A Pilot Study,” Nephrology Dialysis Transplantation, Vol. 25, No. 8, 2010, pp. 2695-2701. doi:10.1093/ndt/gfq106
[27] J. Dong, M. B. Sundell, L. B. Pupim, P. Wu, A. Shintani and T. A. Ikizler, “The Effect of Resistance Exercise to Augment Long-Term Benefits of Intradialytic Oral Nutritional Supplementation in Chronic Hemodialysis Patients,” Journal of Renal Nutrition, Vol. 21, No. 2, 2011, pp. 149-159. doi:10.1053/j.jrn.2010.03.004
[28] S. Frey, A. R. Mir and M. Lucas, “Visceral Protein Status and Caloric Intake in Exercising versus Nonexercising Individuals with End-Stage Renal Disease,” Journal of Renal Nutrition, Vol. 9, No. 2, 1999, pp. 71-77. doi:10.1016/S1051-2276(99)90003-1
[29] M. Reboredo Mde, V. Pinheiro Bdo, J. A. Neder, M. P. Avila, E. R. M. L. Araujo, A. F. de Mendonca, M. V. de Mello, A. C. Bainha, J. Dondici Filho and R. B. de Paula, “Effects of Aerobic Training during Hemodialysis on Heart Rate Variability and Left Ventricular Function in End-Stage Renal Disease Patients,” Jornal Brasileiro de Nefrologia, Vol. 32, No. 4, 2010, pp. 367-373.
[30] R. Afshar, L. Shegarfy, N. Shavandi and S. Sanavi, “Effects of Aerobic Exercise and Resistance Training on Lipid Profiles and Inflammation Status in Patients on Maintenance Hemodialysis,” Indian Journal of Nephrology, Vol. 20, No. 4, 2010, pp. 185-189. doi:10.4103/0971-4065.73442
[31] M. Daniilidis, E. Kouidi, E. Giagoudaki, A. Fleva, P. Nikolaides, A. Vasilaki, et al., “The Immune Response in Hemodialysis Patients Following Physical Training,” Sport Sciences for Health, Vol. 1, 2004, pp. 11-16. doi:10.1007/s11332-004-0003-y
[32] A. Makhlough, E. Ilali, R. Mohseni and S. Shahmohammadi, “Effect of Intradialytic Aerobic Exercise on Serum Electrolytes Levels in Hemodialysis Patients,” Iranian Journal of Kidney Diseases, Vol. 6, No. 2, 2012, pp. 119- 123. doi:10.1681/ASN.2007010009
[33] K. L. Johansen, “Exercise in the End-Stage Renal Disease Population,” Journal of the American Society of Nephrology, Vol. 18, No. 6, 2007, pp. 1845-1854.
[34] S. D. Anker, W. Steinborn and S. Strassburg, “Cardiac Cachexia,” Annals of Medicine, Vol. 36, No. 7, 2004, pp. 518-529. doi:10.1080/07853890410017467
[35] M. Petraki, E. Kouidi, D. Grekas and A. Deligiannis, “Effects of Exercise Training during Hemodialysis on Cardiac Baroreflex Sensitivity,” Clinical Nephrology, Vol. 70, No. 3, 2008, pp. 210-219.
[36] “KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease,” International Society of Nephrology, Vol. 3, No. 1, 2013, pp. 1-163.
[37] T. L. Parsons, E. B. Toffelmire and C. E. King-Van Vlack, “The Effect of an Exercise Program during Hemodialysis on Dialysis Efficacy, Blood Pressure and Quality of Life in End-Stage Renal Disease (ESRD) Patients,” Clinical Nephrology, Vol. 61, No. 4, 2004, pp. 261-274.
[38] T. Akiba, N. Matsui, S. Shinohara, H. Fujiwara, T. Nomura and F. Marumo, “Effects of Recombinant Human Erythropoietin and Exercise Training on Exercise Capacity in Hemodialysis Patients,” Artificial Organs, Vol. 19, No. 12, 1995, pp. 1262-1268. doi:10.1111/j.1525-1594.1995.tb02297.x
[39] V. S. Balakrishnan, M. Rao, V. Menon, P. L. Gordon, M. Pilichowska, F. Castaneda and C. Castaneda-Sceppa, “Resistance Training Increases Muscle Mitochondrial Biogenesis in Patients with Chronic Kidney Disease,” Clinical Journal American Society Nephrology, Vol. 5, No. 6, 2010, pp. 996-1002. doi:10.2215/CJN.09141209
[40] R. M. Carney, B. Templeton, B. A. Hong, H. R. Harter, J. M. Hagberg, K. B. Schechtman and A. P. Goldberg, “Exercise Training Reduces Depression and Increases the Performance of Pleasant Activities in Hemodialysis Patients,” Nephron Clinical Practice, Vol. 47, No. 3, 1987, pp. 194-198.
[41] C. Castaneda, P. L. Gordon, K. L. Uh-lin, A. S. Levey, J. J. Kehayias, J. T. Dwyer, R. A. Fielding, R. Roubenoff and M. F. Singh, “Resistance Training to Counteract the Catabolism of a Low-Protein Diet in Patients with Chronic Renal Insufficiency. A Randomized, Controlled Trial,” Annals of Internal Medicine, Vol. 135, No. 11, 2001, pp. 965-976.
[42] C. Castaneda, P. L. Gordon, R. C. Parker, K. L. Uhlin, R. Roubenoff and A. S. Levey, “Resistance Training to Reduce the Malnutrition-Inflammation Complex Syndrome of Chronic Kidney Disease,” American Journal of Kidney Diseases, Vol. 43, No. 4, 2004, pp. 607-616. doi:10.1053/j.ajkd.2003.12.025
[43] Y. Chang, S. Y. Cheng, M. Lin, F. Y. Gau and Y. F. Chao, “The Effectiveness of Intradialytic Leg Ergometry Exercise for Improving Sedentary Life Style and Fatigue among Patients with Chronic Kidney Disease: A Randomized Clinical Trial,” International Journal of Nursing Studies, Vol. 47, No. 11, 2010, pp. 1383-1388. doi:10.1016/j.ijnurstu.2010.05.002
[44] B. Cheema, H. Abas, B. Smith, A. O’Sullivan, M. Chan, A. Patwardhan, J. Kelly, A. Gillin, G. Pang, B. Lloyd and M. F. Singh, “Progressive Exercise for Anabolism in Kidney Disease (PEAK): A Randomized, Controlled Trial of Resistance Training during Hemodialysis,” Journal of the American Society Nephrology, Vol. 18, No. 5, 2007, pp. 1594-1601. doi:10.1681/ASN.2006121329
[45] B. Cheema, H. Abas, B. Smith, A. O’Sullivan, M. Chan, A. Patwardhan, J. Kelly, A. Gillin, G. Pang, B. Lloyd and M. Fiatarone Singh, “Randomized Controlled Trial of Intradialytic Resistance Training to Target Muscle Wasting in ESRD: The Progressive Exercise for Anabolism in Kidney Disease (PEAK) Study,” American Journal of Kidney Diseases, Vol. 50, No. 4, 2007, pp. 574-584. doi:10.1053/j.ajkd.2007.07.005
[46] B. S. Cheema, H. Abas, B. C. Smith, A. J. O’Sullivan, M. Chan, A. Patwardhan, J. Kelly, A. Gillin, G. Pang, B. Lloyd, K. Berger, B. T. Baune and M. A. Fiatarone Singh, “Effect of Resistance Training during Hemodialysis on Circulating Cytokines: A Randomized Controlled Trial,” European Journal of Applied Physiology, Vol. 111, No. 7, 2011, pp. 1437-1445. doi:10.1007/s00421-010-1763-5
[47] P. Y. Chen, Y. C. Huang, Y. H. Kao and J. Y. Chen, “Effects of an Exercise Program on Blood Biochemical Val- ues and Exercise Stage of Chronic Kidney Disease Patients,” Journal of Nursing Research, Vol. 18, No. 2, 2010, pp. 98-107. doi:10.1097/JNR.0b013e3181dda726
[48] S. S. Fitts, M. R. Guthrie and C. R. Blagg, “Exercise Coaching and Rehabilitation Counseling Improve Quality of Life for Predialysis and Dialysis Patients,” Nephron Clinical Practice, Vol. 82, No. 2, 1999, pp. 115-121.
[49] M. Flesher, P. Woo, A. Chiu, A. Charlebois, D. E. Warburton and B. Leslie, “Self-Management and Biomedical Outcomes of a Cooking, and Exercise Program for Patients with Chronic Kidney Disease,” Journal of Renal Nutrition, Vol. 21, No. 2, 2011, pp. 188-195. doi:10.1053/j.jrn.2010.03.009
[50] A. P. Goldberg, E. M. Geltman, J. R. Gavin III, R. M. Carney, J. M. Hagberg, J. A. Delmez, A. Naumovich, M. H. Oldfield and H. R. Harter, “Exercise Training Reduces Coronary Risk and Effectively Rehabilitates Hemodialysis Patients,” Nephron Clinical Practice, Vol. 42, No. 4, 1986, pp. 311-316.
[51] H. R. Harter and A. P. Goldberg, “Endurance Exercise Training. An Effective Therapeutic Modality for Hemodialysis Patients,” Medical Clinics of North America, Vol. 69, No. 1, 1985, pp. 159-175.
[52] S. A. Headley, M. J. Germain, C. M. Milch, M. P. Buchholz, M. A. Coughlin and L. S. Pescatello, “Immediate Blood Pressure-Lowering Effects of Aerobic Exercise among Patients with Chronic Kidney Disease,” Nephrology (Carlton), Vol. 13, No. 7, 2008, pp. 601-606. doi:10.1111/j.1440-1797.2008.01030.x
[53] E. Konstantinidou, G. Koukouvou, E. Kouidi, A. Deligiannis and A. Tourkantonis, “Exercise Training in Patients with End-Stage Renal Disease on Hemodialysis: Comparison of Three Rehabilitation Programs,” Journal of Rehabilitation Medicine, Vol. 34, No. 1, 2002, pp. 40- 45. doi:10.1080/165019702317242695
[54] D. J. Leehey, I. Moinuddin, J. P. Bast, S. Qureshi, C. S. Jelinek, C. Cooper, L. C. Edwards, B. M. Smith and E. G. Collins, “Aerobic Exercise in Obese Diabetic Patients with Chronic Kidney Disease: A Randomized and Controlled Pilot Study,” Cardiovascular Diabetology, Vol. 8, 2009, p. 62.
[55] Y. Matsumoto, A. Furuta, S. Furuta, M. Miyajima, T. Sugino, K. Nagata and S. Sawada, “The Impact of Pre-Dialytic Endurance Training on Nutritional Status and Quality of Life in Stable Hemodialysis Patients (Sawada Study),” Renal Failure, Vol. 29, No. 5, 2007, pp. 587-593. doi:10.1080/08860220701392157
[56] S. Molsted, I. Eidemak, H. T. Sorensen and J. H. Kristensen, “Five Months of Physical Exercise in Hemodialysis Patients: Effects on Aerobic Capacity, Physical Function and Self-Rated Health,” Nephron Clinical Practice, Vol. 96, No. 3, 2004, pp. c76-c81. doi:10.1159/000076744
[57] S. Mustata, S. Groeneveld, W. Davidson, G. Ford, K. Kiland and B. Manns, “Effects of Exercise Training on Physical Impairment, Arterial Stiffness and Health-Related Quality of Life in Patients with Chronic Kidney Disease: A Pilot Study,” International Urology and Nephrology, Vol. 43, No. 4, 2011, pp. 1133-1141. doi:10.1007/s11255-010-9823-7
[58] S. Ouzouni, E. Kouidi, A. Sioulis, D. Grekas and A. Deligiannis, “Effects of Intradialytic Exercise Training on Health-Related Quality of Life Indices in Haemodialysis Patients,” Clinical Rehabilitation, Vol. 23, No. 1, 2009, pp. 53-63. doi:10.1177/0269215508096760
[59] P. L. Painter, L. Hector, K. Ray, L. Lynes, S. Dibble, S. M. Paul, S. L. Tomlanovich and N. L. Ascher, “A Randomized Trial of Exercise Training after Renal Transplantation,” Transplantation, Vol. 74, No. 1, 2002, pp. 42-48. doi:10.1097/00007890-200207150-00008
[60] E. Segura-Orti, E. Kouidi and J. F. Lison, “Effect of Resistance Exercise during Hemodialysis on Physical Function and Quality of Life: Randomized Controlled Trial,” Clinical Nephrology, Vol. 71, No. 5, 2009, pp. 527-537

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