Exercise prescriptions for patients on hemodialysis in Brazil: a scoping review.

INTRODUCTION: Exercise is being incorporated into the treatment of patients on hemodialysis; however, little is known about the major characteristics of these interventions. OBJECTIVE: To describe the exercise protocols prescribed for hemodialysis patients in Brazil. METHODS: A scoping review was conducted following JBI and Prisma-ScR guidelines. Searches were carried out in Medline, Embase and three other databases until May 2024. Other sources (websites, books and guidelines) were also investigated. Evidence from patients on hemodialysis describing exercise protocols in all settings and designs in Brazil was included. RESULTS: Forty-five pieces of evidence were found, resulting in 54 exercise protocols from 16 Brazilian states. Strength exercises (33.3%), followed by aerobic exercises (22.2%), were the most prescribed, mainly to be performed during dialysis (85.2%). The most prevalent professionals supervising the programs were physiotherapists and exercise physiologists (37.0% and 18.5%, respectively). All protocols implemented the principles of type and frequency training, while progression was adopted in only 53.7%. The main prescription was three times per week (88.9%). Exercise intensity was predominantly determined by subjective methods (33.3%). CONCLUSION: Aerobic and strength exercises during dialysis were the most commonly prescribed modalities in Brazil, with the majority of programs being properly supervised by qualified professionals. However, existing protocols have not employed systematic progression throughout the intervention, which would be appropriate for providing better physiological responses and adaptations.

Exploring the impact of short daily haemodialysis on muscle strength and bone health in end-stage kidney disease patients.

BACKGROUND: Short-daily haemodialysis (SDH) has been strongly recommended over conventional haemodialysis (CHD) for end-stage kidney disease patients, though few studies have directly compared the effects of these two haemodialysis (HD) modalities on clinical variables related to patient's health. METHODS: We conducted a cross-sectional study in individuals undergoing HD, comparing epidemiological, clinical, metabolic, inflammatory, anthropometric, bone health/metabolism, and skeletal muscle function according to dialysis modality. One-hundred seventy-eight patients (20.8% females, 62 ± 2.5 years old), were analysed in this study, 86 (48%) of whom were undergoing CHD versus 92 (51%) who were undergoing SDH. RESULTS: SDH patients had significantly higher serum albumin levels (3.93 vs. 3.66 g/dL, P < 0.0001) and higher Kt/v (2.6 vs. 2.38, P < 0.0001). SDH group presented a significantly lower number of erythropoietin-stimulating agents compared with CHD group (percentage: 53.3 vs. 83.7%, P < 0.0001) and had lower levels of serum phosphate (4.9 vs. 5.3 mg/dL, P = 0.004) and parathyroid hormone (PTH) (398.4 vs. 480.4 pg/mL, P < 0.001) compared with CHD patients. In terms of bone health and metabolism, SDH patients had significantly higher total BMD, femur BMD, lumbar BMD, and femoral neck BMD compared with CHD patients (all P < 0.05). SDH patients also had lower anti-osteogenic and inflammatory biomarkers, including FGF23, sclerostin, TNF, IL-18, IL-17a, and C-reactive peptide (all P < 0.05). CHD modality was demonstrated to be a risk factor for low BMD (odds ratio: 4.02; 95% CI: 1.59-10.2, P = 0.003). In terms of skeletal muscle function, SDH patients had significantly higher 6-minute walking test (444.6 vs. 424.9 m, P = 0.04) and higher fat-free mass (52.3 vs. 51.68 kg, P = 0.02) compared with CHD patients. Higher fat-free mass and handgrip strength were associated with a 34% and 23% lower risk of low BMD, respectively. SDH patients had lower levels of the uremic toxin asymmetric dimethyl-l-arginine (ADMA) (1.8 vs. 2.07 µM, P = 0.002) and fasting blood glucose (132.6 vs. 141.7 mg/dL, P < 0.02) than CHD group. SDH patients also displayed higher levels of haemoglobin when compared with CHD group (11.9 vs. 10.2 g/dL, P < 0.0001). CONCLUSIONS: The present study improves our understanding of the relationship between dialysis modality and clinical variables that may influence HD patient's health. Grip strength and lean mass were positively correlated with bone mineral density in HD patients regardless of dialysis modality. SDH was associated with better bone mineral density, inflammatory profile, and skeletal muscle function when compared with CHD patients. These findings provide more evidence of the clinical benefits of SDH that should be explored in greater detail.

Effect of Intradialytic Oral Nutritional Supplementation with or without Exercise Improves Muscle Mass Quality and Physical Function in Hemodialysis Patients: A Pilot Study.

BACKGROUND: Oral nutritional supplementation (ONS) with or without exercise (EX) could improve muscle mass (MM) in chronic kidney disease. METHODS: Patients were randomized into two groups: (1) ONS and (2) ONS + EX. Thigh muscle area (cm2) and intramuscular lipid content via attenuation were evaluated at baseline and 6 months with computed tomography (CT) to measure MM quantity and quality. Physical function was measured by six-minute walk test (6 MWT), gait speed, handgrip strength (HGS), and Time Up and Go test (TUG) at baseline and 3 and 6 months. RESULTS: The ONS group (n= 14) showed statistically significant improvement in gait speed and HGS; ONS + EX group (n = 10) showed differences in gait speed, in 6 MWT, and HGS. In the ANOVA (3 times × 2 groups), no differences were observed between groups. Greater effect sizes in favor to ONS + EX group were observed in the 6 MWT (d = 1.02) and TUG test (d = 0.63). Muscle quality at six months revealed a significant trend in favor of the EX-group (p = 0.054). CONCLUSIONS: Both groups had improved physical function, and greater effect sizes were seen in the ONS + EX group for the 6 MWT and TUG test. Neither MM quantity or quality was improved in either group.

Effect of Oral Nutritional Supplementation With and Without Exercise on Nutritional Status and Physical Function of Adult Hemodialysis Patients: A Parallel Controlled Clinical Trial (AVANTE-HEMO Study).

OBJECTIVE: Protein energy wasting affects the nutritional status (NS) and physical function (PF) of dialysis patients. Among the different anabolic strategies to improve NS and PF, oral nutritional supplementation (ONS) and resistance exercise (RE) or aerobic exercise (AE) have been shown to be effective. Nevertheless, the combination of both anabolic strategies has not been completely evaluated. The aim of this study is to assess the effect of exercise combined with ONS versus ONS without exercise during hemodialysis sessions on PF and NS indicators. METHODS: Young hemodialysis patients (29 ± 9.3 years) with predominantly unknown causes of renal disease (80%) were divided into the following 3 groups during a period of 12 weeks: (1) ONS (n = 15), (2) ONS + RE (n = 15), and (3) ONS + AE (n = 15). Anthropometric, biochemical, PF, and quality of life measurements were recorded at baseline and after 3 months. Repeated measures analysis of variance and effect sizes (Cohen's d) were used to assess the effect of exercise and nutrition (ISRCTN registry 10251828). RESULTS: At the completion of the study, the ONS and ONS + RE groups exhibited statistically significant increases in body weight, body mass index, and in the percentage of fat mass (P < .05); the greatest effect sizes were observed in the ONS + RE group (d = 0.30 for body weight, d = 0.63 for body mass index, and d = 0.90 for the percentage of fat mass). Groups with RE and AE had statistically significant increases and large effect sizes in the six-minute walk test (RE: d = 0.94, P = .02; AE: d = 1.11, P = .03), sit-to-stand test (RE: d = 0.81, P = .041; AE: d = 1.20, P = .002), timed up and go test (RE: d = 1.04, P = .036; AE: d = 1.6, P = .000), and muscle strength (RE: d = 1.01, P = .000; AE: d = 0.60, P = .003). Regarding quality of life, the ONS + RE group had more areas of improvement at the end of the study, followed by the ONS + AE group. No statistically significant differences were found in the repeated measures ANOVA. CONCLUSIONS: The combination of exercise with ONS had larger effects on PF than on ONS alone. Further studies to examine the impact of exercise on the effect of oral nutritional supplementation in dialysis patients are indicated.

Sustained exercise programs for hemodialysis patients: The characteristics of successful approaches in Portugal, Canada, Mexico, and Germany.

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.