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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 902-910
Effectiveness of intradialytic exercise on dialysis adequacy, physiological parameters, biochemical markers and quality of life – A pilot study


1 Saveetha College of Nursing, Saveetha University, Chennai, Tamil Nadu, India
2 Faculty of Nursing, Sri Ramachandra University, Chennai, Tamil Nadu, India

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Date of Submission23-Oct-2017
Date of Acceptance14-Dec-2017
Date of Web Publication28-Aug-2018
 

   Abstract 

End-stage renal disease is emerging as a major public health problem in the developing countries. It must be treated with renal replacement therapy and hemodialysis (HD) is the most widely used therapy and the only maintenance treatment if kidney transplant is not feasible. This study aimed to determine the effectiveness of intradialytic exercise on dialysis efficacy, physiological parameters, biochemical markers, and quality of life among patients on HD. Experimental research design was adopted to conduct the study with 20 patients in our HD unit who met the inclusion criteria and patients were randomly allocated into experimental group and control group. The experimental group received intradialytic exercise during the first 2 h of HD besides receiving routine care compared to the control group. Data were tabulated and analyzed using the SPSS package. The finding of the present pilot study reveals that the prescribed intradialytic exercise intervention resulted in significant improvement in Kt/V, serum creatinine, blood urea, serum potassium, phosphorous, and quality of life. Based on the findings of the present study, it can be concluded that intradialytic exercise program is a safe complementary intervention and does not need an extra time of the patient and showed improvement in patients' outcome.

How to cite this article:
Paluchamy T, Vaidyanathan R. Effectiveness of intradialytic exercise on dialysis adequacy, physiological parameters, biochemical markers and quality of life – A pilot study. Saudi J Kidney Dis Transpl 2018;29:902-10

How to cite this URL:
Paluchamy T, Vaidyanathan R. Effectiveness of intradialytic exercise on dialysis adequacy, physiological parameters, biochemical markers and quality of life – A pilot study. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Oct 14];29:902-10. Available from: http://www.sjkdt.org/text.asp?2018/29/4/902/239661

   Introduction Top


End-stage renal disease (ESRD) is emerging as a major health problem in the developing countries.[1] Chronic kidney disease involves progressive, irreversible destruction of the nephrons in both kidneys leads to accumulation of toxins and fluids creating fluid and electrolyte imbalances and must be treated with renal replacement therapy for the survival (National Kidney Foundation). The common and the most widely used renal replacement therapy in hemodialysis (HD).

Despite advances in ESRD with HD, physical functioning and health-related quality of life is still lower among these patients due to pain, fatigue and sleep pattern disturbances compared to a healthy population. Some complementary interventions such as relaxation therapy, yoga, meditation, exercise program may influence to improve the quality of life.

We aimed to investigate the effectiveness of exercise program to improve the well-being of the patient with end-stage renal disease on HD. Previous literature has documented a variety of potential benefits that ESRD patients may achieve from exercise training.[1] Improvements in reaction time and lower extremity muscle strength,[2] left ventricular systolic function,[3] and psychosocial functioning[4] have all been demonstrated in randomized clinical trials. Studies have also provided evidence supporting the association of exercise training with improvement in urea clearance,[5] decrease in pulse pressure,[6] increase in aerobic capacity,[1] reduced need for antihypertensive medications,[7] increase in hemoglobin concentration, hematocrit levels as well lipid metabolism,[8] relieves fatigue[9] exercise improves the removal of toxin through dialysis.[10]

Considering the potential positive effects of intradialytic exercise, we conducted the study on intradiaytic exercise using cycle ergometer which helps to improve the urea clearance by opening vascular beds in the working muscle and exposing more tissue which allows the fluid in the tissue to move to the intravascular compartment.[11] In addition, shift of the ions such as potassium and phosphate from the intracellular compartment into muscle interstitial fluid occurs during exercise.[12] Intradialytic exercise is therapeutic for these patients because it tends to blunt or even reverse some of the insidious changes that occur in endstage renal failure.


   Materials and Methods Top


The experimental research design was adopted to conduct the study with 20 patients in the Dialysis Unit of Saveetha Medical College and Hospital from March to May 2017 after obtaining approval from ethical clearance with reference number 014/05/2016/IEC/SU, and formal permission was obtained from the hospital authority. Those who met the inclusion criteria were selected and randomly allocated into experimental group (n = 10) and control group (n = 10). Patients on HD with symptomatic cardiovascular disease such as unstable angina, recent myocardial infarction, congestive cardiac failure Grade II, body temperature more than 101°F, persistent hyperkalemia before dialysis, active liver disease, musculoskeletal limitations, severe peripheral poly-neuropathy, dementia or other mental disorders, on other exercise program, hemodynamically unstable during the dialysis treatment and lower limb amputation were excluded from the study. The patients were given explained about the purposes of the study and written informed consent was taken from each participant. Demographic variables were collected by interview method. The pre-test was conducted on physiological parameters such as weight and blood pressure checked by a standardized and calibrated digital scale and sphygmomanometer. Blood samples were drawn for biochemical markers such as blood urea, serum creatinine, serum potassium, serum calcium, serum phosphate, and hemoglobin. Kt/V value was calculated, and KDQOL-SF™ version 1.3 scale was completed to assess the quality of life for each participant. The intradialytic exercise was prescribed for 10 to 15 minutes a day during the first 2 h of HD session for three times a week for 12 weeks according to the tolerance of the patients by using bicycle ergometer to the experimental group.

Participants were asked to do the exercise once all the tubings of the vascular access were connected to the hemodialysis machine and all the alarms associated with connection of tubings got turned off and the patient became stabilized. The exercise was performed with the participants in dorsal position on the bed. The duration of exercise program for each session was 10-15 minutes. Each session began with 3-5 minutes of warm up exercise which included extension, flexion, internal and external rotation of knee and plantar flexion, dorsiflexion, inversion, eversion and rotation of ankle. It was done for each leg.

Cycling was done for 5 min using the bicycle ergometer and rest for 3–5 min and if needed again the cycling was continued for another 5 – 10 min depending on the tolerance of the patient with or without rest for 3–5 min. Exercise session ended with cool down exercise for 3–5 min after cycling.

Control group received routine care. Tolerance of the patients, especially target heart rate for doing exercise period was calculated by Karvonen formula, monitored the vital signs like blood pressure, heart rate during exercise and informed the client to report any side effects such as dyspnea, dizziness, and palpitation. Pre-demonstration on exercise was demonstrated before initiating the exercise. Posttest was conducted at the end of 12 weeks immediately after the dialysis session. Confidentiality was maintained throughout the procedure. The effectiveness of intradialytic exercise on Dialysis adequacy, physiological parameters, biochemical parameters and quality of life of the clients was determined in experimental group and comparison between the experimental group and control group was done using Statistical Package for Social Science version 20.0 (IBM Corp., Armonk, NY). P <0.05 were considered statistically significant.


   Results Top


Twenty patients completed the study, 10 in experimental group and 10 in control group. The majority of the patients was male and was in the age group of 51–70 years in both the groups. There were no significant differences in sociodemographic variables and clinical variables between experimental group and control group which shows the homogeneity of the samples as shown in [Table 1] and [Table 2].
Table 1: Distribution of patients on hemodialysis according to demographic variables.

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Table 2: Distribution of patients on hemodialysis according to clinical variables.

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There was a significant (P <0.01) increase in the level of Kt/V and this showed that the intervention of intradialytic exercise was effective on dialysis efficacy among patients on HD. When comparing the Kt/V value between the experimental group an control group, the mean value of 1.15 in the experimental group was significantly higher compared to 0.99 in control group (P <0.01) and this demonstrated that the intervention was effective as presented in [Table 3] and [Table 4].
Table 3: Effectiveness of intradialytic exercise on Kt/V in the experimental group.

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Table 4: Comparison of Kt/V values between the experimental group and control group after the intervention.

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The systolic mean value in the pretest was 145.9 as compared to 137.0 in the posttest showing that the systolic blood pressure was reduced. The difference in the mean values was statistically significant (P <0.05). However, the differences in the diastolic mean values (81.4 vs. 83.0) were not statistically significant as shown in [Table 5]. The difference in the mean values of both systolic and diastolic pressure and weight was not statistically significant as shown in [Table 6]. However, there is statistically significant difference in weight in experimental group after the intervention as demonstrated in [Table 5].
Table 5: Effectiveness of intradialytic exercise on physiological parameters in the experimental group.

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Table 6: Comparisons of physiological parameters between the experimental group and control group after the intervention.

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[Table 7] demonstrates the comparison of biochemical parameters in the pretest and posttest among patients in the experimental group. The serum creatinine mean value in the pretest was 10.62 as compared to 10.23 in the posttest and the difference was not statistically significant. However, the differences in the mean values for blood urea, serum calcium, and serum phosphate were statistically significant (P <0.05). Serum potassium and hemoglobin showed no difference. This showed that there was a significant improvement in the level of blood urea, serum calcium, and serum phosphate. There was a significant difference in the reduction of serum creatinine, blood urea, serum potassium, and serum phosphate level at the level of P <0.05, but there is no difference in the serum calcium and hemoglobin level between the experimental group and control group.
Table 7: Effectiveness of intradialytic exercise on Biochemical Markers in the experimental group.

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When considering the effectiveness of intra-dialytic exercise on quality of life in the experimental group, there was a significant improvement in the level of quality of life at the level of P <0.05 in all four domains such as physical health, mental health, kidney disease problems, and patient satisfaction as shown in [Table 8]. This showed that the patients in experimental group had felt good quality life and there was a significant difference in the quality of life among patients between the experimental group and control group at the level of P <0.05.
Table 8: Comparison of quality of life among the patients with hemodialysis in the experimental group before and after the intervention.

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   Discussion Top


Patients on HD are less active when compared to healthy sedentary work individuals and have low intrinsic motivation for physical activity. Physical activity results in improvement in physical function and well-being. Although there are many studies that have proven the potential benefits of intradialytic exercise, exercise during dialysis is not implemented in many dialysis units.

The results of this study revealed that there were no significant changes were found in sociodemographic variables and clinical variables between the experimental group and the control group. Majority of the patients were male and falls in the age group of 51–70 years. Sociodemographic data reveals that the majority of the patients were male and falls in the age group of 51–70 years. These findings are consistent with the study obtained by Bayoumi et al, who presented that their demographic data for patients undergoing HD about two-third 60 and below years of age patients and more than 50% of their sample were males.[13] On the other hand, Johansen, suggested that the recommendations for older adults (65 years and above) and adults aged 50–64 years with clinically significant chronic conditions and/or functional limitations.[14]

With regard to Kt/V, there was a significant increase in the level of Kt/V, and this showed that the intervention of intradialytic exercise was effective on dialysis efficacy. The results of this study findings are parallel with the study conducted by Mohseni et al, who reported that overall 11% increase in URR and 38% improvement in Kt/V after eight weeks of intradialytic exercise program.[15] Accordingly, the study demonstrated by Giannaki et al, who revealed that Kt/V significantly improved by 20% and concluded that the prolonged low-intensity intradialytic exercise improved hemo-dialysis efficiency, with no adverse effects.[16] Recently a study conducted by Neil Smart et al. also supported the present study.[17]

In the present study, we found that there is a significant reduction in systolic blood pressure after the prescription of intradialytic exercise in the experimental group. This finding is consistent with the findings of Miller et al, which showed that stationary cycling is safe during HD and can lead to significant reductions in blood pressure.[7] Similarly, Henrique et al, stated that intradialytic exercise shows a significant reduction in systolic blood pressure, diastolic blood pressure, and average arterial pressure.[18]

In relation to biochemical markers in the present study serum creatinine, blood urea, serum potassium, calcium, phosphate, and hemoglobin level were compared between experimental group and control group and found that among patients in the experimental group, there was a significant improvement in the level of blood urea, serum calcium, and serum phosphate, but serum potassium and hemoglobin showed no difference. However, there was a significant difference in the reduction of serum creatinine, blood urea, serum potassium and serum phosphate. However, there were no difference in the serum calcium and hemoglobin level between the experimental group and control group. Makhlough et al, also reported that significant improvements in serum phosphate levels (decreased by 1.84 mg/dL) and serum potassium levels and serum calcium, but hemoglobin levels did not change significantly in the exercise group in his study.[19] Similarly in a study done by Orcy, et al, aerobic exercise during HD increases the efficacy of phosphate removal, without changing urea, creatinine and potassium removal.[20] Interestingly, Adorati, has demonstrated that exercise during dialysis reduces urea rebound, increases creatinine removal and, importantly, increases phosphate removal, and also contributes to the general well-being of the dialysis patient. These studies were come in accordance with the findings of the present study.[21] Findings of Musaivan indicated that there is an improvement in the level of hemoglobin in the experimental group at the end of 8th week when compared with the start of the study but present study is in contrast with these findings.[22]

Vaithilingam et al, suggested intra-dialytic exercise result in increased dialytic removal of a phosphate and could be expected in the long term to improve phosphate control.[23]

Quality of life depends on dialysis efficacy and literature review shows that there are many factors that influence dialysis efficacy like the type of dialyzer machine, dialyzer membrane, the frequency of dialysis, duration of dialysis, physiological variations among patients, etc. The present study examined the effectiveness of intradialytic exercise on the all four domains of quality and revealed that experimental group had a sense of the overall good quality of life and there was a significant difference in the quality of life among patients between the experimental group and control group. Those findings are consistent with the findings of Wu et al, who showed exercise during maintenance HD significantly improved the exercise capacity and HRQoL for uremic patients within a short time period.[24] Similarly, El Shemy et al found that there were significant differences and improvement in studied patients of all domains of QOL scores, (P <0.05) and also strong statistically significant positive correlations in all domains of SF36.[25] This was also supported by the findings of who concluded that physical exercise during dialysis improves the physical (physical function, daily activities, pain and discomfort, sleep), and psychological problems in HD patients, and finally enhance their quality of life.[26] The result of the study is limited in biochemical markers related to intradialytic exercise such as lipid profile, fasting blood sugar, and cytokines. However, we feel that a similar study should be replicated using larger sample size to further investigate the effects of intradialytic exercise.


   Conclusion Top


The finding of the present pilot study reveals that the prescribed intradialytic exercise intervention resulted in significant improvement in Kt/V, serum creatinine, blood urea, serum potassium, phosphorous, and quality of life with no adverse effects. It also found that this exercise program is safe complementary intervention and do not cost the patient extra time.


   Acknowledgment Top


The authors would like to thank all the participants who accepted to be involved in the research study.

Conflict of interest: None declared.

 
   References Top

1.
Johansen KL. Exercise in the end-stage renal disease population. J Am Soc Nephrol 2007; 18:1845-54.  Back to cited text no. 1
    
2.
van Vilsteren MC, de Greef MH, Huisman RM. The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemo-dialysis patients in the Netherlands: Results of a randomized clinical trial. Nephrol Dial Transplant 2005;20:141-6.  Back to cited text no. 2
    
3.
Deligiannis A, Kouidi E, Tourkantonis A. Effects of physical training on heart rate variability in patients on hemodialysis. Am J Cardiol 1999;84:197-202.  Back to cited text no. 3
    
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Kouidi E, Iacovides A, Iordanidis P, et al. Exercise renal rehabilitation program: Psychosocial effects. Nephron 1997;77:152-8.  Back to cited text no. 4
    
5.
Bennett PN, Breugelmans L, Agius M, Simpson-Gore K, Barnard B. A haemodialysis exercise programme using novel exercise equipment: A pilot study. J Ren Care 2007; 33:153-8.  Back to cited text no. 5
    
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Parsons TL, Toffelmire EB, King-VanVlack CE. The Effect of an exercise programme during hemodialysis on dialysis efficacy, blood pressure and quality of life in end-stage renal disease (ESRD) patients. Clin Nephrol 2004; 61:261-74.  Back to cited text no. 6
    
7.
Miller BW, Cress CL, Johnson ME, Nichols DH, Schnitzler MA. Exercise during hemo-dialysis decreases the use of antihypertensive medications. Am J Kidney Dis 2002;39:828-33.  Back to cited text no. 7
    
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Goldberg AP, Hagberg J, Delmez JA, et al. The metabolic and psychological effects of exercise training in hemodialysis patients. Am J Clin Nutr 1980;33:1620-8.  Back to cited text no. 8
    
9.
Mohamed H, Soliman M. Effect of intra-dialytic exercise on fatigue, electrolytes level and blood pressure in hemodialysis patients: A randomized controlled trial. J Nurs Educ Pract 2015;5:17-28.  Back to cited text no. 9
    
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Yurtkuran M, Alp A, Yurtkuran M, Dilek K. A modified yoga-based exercise program in hemo-dialysis patients: A randomized controlled study. Complement Ther Med 2007;15:164-71.  Back to cited text no. 10
    
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Borzou SR, Gholyaf M, Zandiha M, Amini R, Goodarzi MT, Torkaman B. The effect of increasing blood flow rate on dialysis adequacy in hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:639-42.  Back to cited text no. 11
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12.
Lott ME, Hogeman CS, Vickery L, Kunselman AR, Sinoway LI, MacLean DA. Effects of dynamic exercise on mean blood velocity and muscle interstitial metabolite responses in humans. Am J Physiol Heart Circ Physiol 2001;281:H1734-41.  Back to cited text no. 12
    
13.
Bayoumi M, Al Wakeel J. Impacts of exercise programs on hemodialysis patient's quality of life and physical fitness. Qual Prim Care 2015;23:192-200.  Back to cited text no. 13
    
14.
Johansen KL. Exercise and dialysis. Hemodial Int 2008;12:290-300.  Back to cited text no. 14
    
15.
Mohseni R, Emami Zeydi A, Ilali E, Adib-Hajbaghery M, Makhlough A. The effect of intradialytic aerobic exercise on dialysis efficacy in hemodialysis patients: A randomized controlled trial. Oman Med J 2013;28:345-9.  Back to cited text no. 15
    
16.
Giannaki CD, Stefanidis I, Karatzaferi C, et al. The effect of prolonged intradialytic exercise in hemodialysis efficiency indices. ASAIO J 2011;57:213-8.  Back to cited text no. 16
    
17.
Smart N, McFarlane J, Cornelissen V. The effect of exercise therapy on physical function, biochemistry and dialysis adequacy in hemodialysis patients: A systematic review and meta-analysis. Open J Nephrol 2013;3:25-36.  Back to cited text no. 17
    
18.
Henrique DM, Reboredo Mde M, Chaoubah A, Paula RB. Aerobic exercise improves physical capacity in patients under chronic hemo-dialysis. Arq Bras Cardiol 2010;94:823-8.  Back to cited text no. 18
    
19.
Makhlough A, Ilali E, Mohseni R, Shahmohammadi S. Effect of intradialytic aerobic exercise on serum electrolytes levels in hemodialysis patients. Iran J Kidney Dis 2012; 6:119-23.  Back to cited text no. 19
    
20.
Orcy R, Antunes MF, Schiller T, Seus T, Böhlke M. Aerobic exercise increases phosphate removal during hemodialysis: A controlled trial. Hemodial Int 2014;18:450-8.  Back to cited text no. 20
    
21.
Adorati M. The effect of intradialytic exercise on solute removal. Nephrol Dial Transplant 2000;15:1264.  Back to cited text no. 21
    
22.
Musavian AS, Soleimani A, Alavi NM, Baseri A, Savarz F. Comparing the effects of active and passive intradialyic pedaling exercise on dialysis efficacy, electrolyte, hemoglobin, hematocrit, blood pressure and health-rated quality of life. Int J Nurs Midwifery 2015;4: e25922.  Back to cited text no. 22
    
23.
Vaithilingam I, Polkinghorne KR, Atkins RC, Kerr PG. Time and exercise improve phosphate removal in hemodialysis patients. Am J Kidney Dis 2004;43:85-9.  Back to cited text no. 23
    
24.
Wu Y, He Q, Yin X, He Q, Cao S, Ying G. Effect of individualized exercise during maintenance haemodialysis on exercise capacity and health-related quality of life in patients with uraemia. J Int Med Res 2014;42:718-27.  Back to cited text no. 24
    
25.
EL Shemy MB, Elghite Elhossiny Elkazeh EA, ELkually R. Efficacy of exercise program in intra hemodialysis on patients' quality of life. IOSR J Nurs Health Sci 2016;5:17-30.  Back to cited text no. 25
    
26.
Heidarzadeh M, Zamanzadeh V, Maghvan AP, Oshvandi K. The effect of physical exercise on physical and psychological problems. Iran J Nurs Midwifery Res 2010;15:20-6.  Back to cited text no. 26
    

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Correspondence Address:
Mrs. Thenmozhi Paluchamy
Saveetha College of Nursing, Saveetha University, Chennai, Tamil Nadu
India
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DOI: 10.4103/1319-2442.239661

PMID: 30152428

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