Physical Activity and Dialysis Effectiveness

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Muscle wasting and fatigue are common side-effects in patients who have been receiving dialysis treatment over a long period. Over time, these effects could have a negative impact on their physical functioning and thereby affecting their activities of daily living (ADL): instrumental and basic [1]. In general, the quality of life (QoL) of dialysis patients is known to decline over time [2].

The common factors leading to a decline in physical functionality of dialysis patients are inactivity, functional and structural muscle abnormalities, inflammation and anaemia [3]. Physical inactivity is a known risk factor of mortality in chronic kidney disease population [4]. Although peritoneal fluid infusion into the peritoneum does not affect one’s physical capacity, studies indicate low physical functioning and physical activity within peritoneal dialysis population and which is strongly associated with mortality among patients who are new to dialysis [3, 5-7]. A study performed in Yokosuka, Japan, highlights two factors which contributed to the risk of short-term mortality after dialysis initiation: impaired mobility at the start of dialysis and the decline in mobility after starting dialysis [8].

Knowing the increased mortality risks associated with physical inactivity, patients on dialysis are encouraged to stay active by doing the things they like with a certain degree of life/behaviour adjustment, like eating right and performing regular exercise. Participating in regular physical activity can improve one’s musculoskeletal health, control body weight and reduce symptoms of depression [9]. Kidney Disease Outcomes Quality Initiative (KDOQI) recommends that dialysis patients should be encouraged to increase their level of physical activity, emphasizing on increasing strength and endurance to the point where they are able to adopt the recommended levels of physical activity. Dialysis patients are recommended to set a goal of moderate intensity cardiovascular exercise for 30 minutes every day. However, they should be referred to either physical therapy or cardiac rehabilitation on a periodic basis in order to ensure that their unique challenges to exercise are identified and to enable them to follow the exercise regime successfully [10].

There are several options where physical activity can be incorporated into the lives of dialysis patients: during, before or after the dialysis exchange sessions. In several studies, physical activities like cycling, 6-min walk or a low impact exercise were performed and supervised by centre staff during dialysis sessions and their effects on dialysis effectiveness were monitored and measured [11-14]. In a study by Parson, it was reported that mild exercise during the first two hours of haemodialysis therapy enhanced dialysate urea removal but not serum urea clearance [15]. Another two separate studies, by Kong and Sun respectively, reported decrease in post-hemodialysis rebound rates of urea and creatinine in response to a single exercise session during hemodialysis therapy [16-17]. Zaluska reported a dialysis efficacy improvement of 16% during the first hour of dialysis over a six months period but not without the influence of protein catabolic rate which increases urea clearance [18]. Another study, examining the effects of a 12-week exercise program in 13 continuous ambulatory peritoneal dialysis (CAPD) patients, reported no significant changes in serum urea, creatinine, albumin and haematocrit levels [19]. Nonetheless, several studies have shown that introduction of an exercise program to dialysis patients, either delivered in-centre or home-based, improves physical capacity and certain aspects of QoL [11-14,18]. These results from various studies are encouraging and highlight the need of long-term studies to evaluate effects of sustainable exercise programs on clinical endpoints, including death and cardiovascular disease, in dialysis population [20-21].

References:

  1. Bowling, C.B., Sawyer, P., Campbell. R.C., et al. Impact of Chronic Kidney Disease on Activities of Daily Living in Community-Dwelling Older Adults. J Gerontol A Biol Sci Med Sci. 2011 June; 66A (6): 689-694.
  2. Bakewell, A.B., Higgins, R.M. and Edmunds, M.E. Quality of life in peritoneal dialysis patients: Decline over time and association with clinical outcomes. Kidney International Vol. 61 (2002), pp. 239-248.
  3. Kosmadakis, G. C., Bevington, A., Smith, A.C., et al. Physical Exercise in Patients with Severe Kidney Disease. Nephron Clin Pract 2010; 115: c7-c16.
  4. Beddhu, A., Baird, B.C., Zitterkoph, J., et al. Physical Activity and Mortality in Chronic Kidney Disease (NHANES III). Clin J Am Soc Nephrol. 2009 Dec; 4 (12): 1901-1906.
  5. Painter, P.L., Agarwal, A. and Drummond, M. Physical Function and Physical Activity in Peritoneal Dialysis Patients. Perit Dial Int. 2017 Nov-Dec; 37 (6): 598-604.
  6. Johansen, Kirsten & Kaysen, George & Dalrymple, Lorien & A Grimes, Barbara & V Glidden, David & Anand, Shuchi & M Chertow, Glenn. (2012). Association of Physical Activity with Survival among Ambulatory Patients on Dialysis: The Comprehensive Dialysis Study. CJASN 8 (2).
  7. Wakamiya A., Hiraki K., Oishi D. et al. Physical Activity in Peritoneal Dialysis Patients. Journal of the Japanese Physical Therapy Association (2014) Vol 17 Issue 1: pp 473-479.
  8. Arai, Y., Kanda, E., Kikuchi, H. et al. Decreased mobility after starting dialysis is an independent risk factor for short-term mortality after initiation of dialysis. Nephrology (Carlton). 2014 Apr; 19 (4): 227-33.
  9. World Health Organization. The World Health Report (2002). Reducing risks, promoting healthy lifestyle. World Health Organization, Geneva pp. 61, 218-219, 226-227. Retrieved in 2018 from http://www.who.int/whr/2002/en/index.html.
  10. K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. American Journal of Kidney Diseases, Vol 45, No 4, Suppl 3 (April), 2005: pp S60-S67.
  11. Anding K., Bär T., Trojniak-Hennig J. et al. A structured exercise programme during haemodialysis for patients with chronic kidney disease: clinical benefit and long-term adherence. BMJ Open 2015; 5: e008709.
  12. Thangara T., Imtiaz R., Hiremath S. and Zimmerman D. Physical Activity in Patients Treated with Peritoneal Dialysis: A Systematic Review and Meta-analysis. Canadian Journal of Kidney Health and Disease 2018 Volume 5: 1-13.
  13. Manfredini F., Mallamaci F., D’Arrigo G. et al. Exercise in Patients on Dialysis: A multicentre, Randomized Clinical Trial. J Am Soc Nephrol 2017 Apr; 28 (4): 1259-1268.
  14. Hernandez H.J., Obamwonyi G. and Harris-Love M.O. Physical Therapy Considerations for Chronic Kidney Disease and Secondary Sarcopenia. J. Funct. Morphol. Kinesiol. 2018, 3,5; doi:10.3390/jfmk3010005.
  15. T.L. Parsons, E.B. Toffelmire, C.E. King-VanVlack. The effect of an exercise program during hemodialysis on dialysis efficacy, blood pressure and quality of life in end-stage renal disease (ESRD) patients, Clin Nephrol. Vol. 61, No. 4, 261-74, 2004.
  16. C.H. Kong, J. E. Tattersall, R. N. Greenwood and K Farrington. The effect of exercise during haemodialysis on solute removal, Nephrol Dial Transplant, 14: 2927-31, 1991.
  17. Y. Sun, B. Chen, Q. Jia, J. Wang. The effect of exercise during hemodialysis on adequacy of dialysis, [Chinese], Zhonghua Nei Ke Za Z, Vol. 41, 79-81, 2002.
  18. Zaluska, W.T. Zaluska, A. Bednarek-Skublewska, A. Ksiazek A. Nutrition and hydration status improve with exercise training using stationary cycling during hemodialysis (HD) in patients with endstage renal disease (ESRD), Ann Univ Mariae Curie Sklodowska, Vol. 57, 342-346, 2002.
  19. Lo C. Y., Li L., Lo W.K. et al. Benefits of exercise training in patients on continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1998 Dec; 32 (6): 1011-8.
  20. Johansen K. and Painter P. Exercise for Patients With CKD: What More is Needed? Advances in Chronic Kidney Disease, Vol 16 No 6 (November), 2009: pp 407-409.
  21. Tentori F., Elder S. J., Thumma j., et al. Physical Exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes. Nephrol Dial Transplant (2010) 25: 3050-3062.

Author:

Siti Noor Huda

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