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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1253-1259
An experimental study to evaluate the effect of low-intensity intradialytic exercises on serum urea, creatinine, and fatigue of chronic kidney disease patients undergoing hemodialysis


1 College of Nursing, All India Institute of Medical Science, New Delhi, India
2 Department of Nephrology, All India Institute of Medical Science, New Delhi, India
3 Department of Cardio Thoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
4 Department of Biostatistics, All India Institute of Medical Science, New Delhi, India

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Date of Web Publication4-May-2022
 

   Abstract 


In chronic kidney disease (CKD) toxins accumulate in the muscles and cause fatigue, mental impairment, and muscle dysfunction (cramps). Exercise results in the opening of capillaries thereby increasing blood flow and allowing greater movement of urea and creatinine from the tissues to the vascular compartment and subsequent removal through dialysis. An experimental study of 64 CKD patients (32 each in experimental and control group), six low-intensity intra-dialytic exercises (IDE) were implemented for experimental group using video demonstration at 90 min after initiation of hemodialysis (HD) repeated thrice at an interval of 10 mins. Pre- and post-HD serum urea, creatinine, and fatigue levels were assessed at baseline, two, four and six weeks. Fatigue was measured using FACIT scale. Significant difference was found between the control and experimental group in serum urea, creatinine and fatigue levels (P = 0.007, P = 0.001, P = 0.001) at six weeks post HD. The experimental group showed a significant decrease in creatinine levels from baseline to six weeks (P = 0.04). Ninety-seven percent of patients were compliant to low-intensity IDE with patients feeling better and comfortable along with decrease in felt fatigue levels. No significant association was found between duration of illness, duration of maintenance HD and comorbidities and serum urea, serum creatinine, and fatigue levels (P = 0.5, P = 0.21, P = 0.78). The present study shows low-intensity IDE when performed regularly, was effective in decreasing serum urea, creatinine, and fatigue levels of CKD patients undergoing HD with vital signs remaining within the normal range. No overt complications were reported; hence, the exercises were safe.

How to cite this article:
Devagourou A, Sharma KK, Yadav RK, Gupta VP, Kalaivani M. An experimental study to evaluate the effect of low-intensity intradialytic exercises on serum urea, creatinine, and fatigue of chronic kidney disease patients undergoing hemodialysis. Saudi J Kidney Dis Transpl 2021;32:1253-9

How to cite this URL:
Devagourou A, Sharma KK, Yadav RK, Gupta VP, Kalaivani M. An experimental study to evaluate the effect of low-intensity intradialytic exercises on serum urea, creatinine, and fatigue of chronic kidney disease patients undergoing hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1253-9. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1253/344744



   Introduction Top


In chronic kidney disease (CKD), there is a progressive irreversible destruction of renal tissues. Kidney Disease Outcomes Quality Initiative 2012 classified 5 stages of CKD, stage 1 to 5 with stage 5 as the end-stage renal disease based on estimated glomerular filtration rate. The overall global prevalence of CKD (2016) was found to be 14.3% and 36.1% in general and high-risk population respectively.[1] Patients in CKD stage 5 require renal replacement therapies which include peritoneal dialysis, hemodialysis (HD), and renal transplant.[2] Maintenance HD (MHD) is the most widely used modality of managing CKD patients which is commonly prescribed for 3–6 h per session three times a week and is continued throughout the life or till a successful renal transplant.[3],[4] The effect of dialysis is seen by serum urea-creatinine levels, pre and post HD which is also used to calculate the treatment index (Kt/V).[5] Most common complications of HD include hypotension, fluid, and electrolyte imbalances. Besides these, patients undergoing HD also suffer from muscle cramps (33%–86%)[6] and fatigue which can lead to early disruption of the treatment. Toxic substances that are accumulated in the muscles causing fatigue, mental impairment, and muscle dysfunction are removed better when CKD patients perform regular exercises.[7],[8] In low-intensity exercises 40%–54% of maximum heart rate (MHR) is used while in moderate-intensity exercises it is 55%–69% and in high-intensity exercises, it is more than or equal to 70%.[9] Three major advantages of performing low-intensity intradialytic exercises (IDE) have been identified. First, physical exercises during HD sessions do not cost patients extra time hence ensuring greater compliance. Second, patients perform their exercises under the supervision of clinicians hence any complications can be detected and managed promptly. In addition, IDE increase blood flow to the muscles thereby causing greater movement of urea and creatinine from the tissues to the vascular compartment and subsequent removal through dialysis.[8] Thus, the present study aims to generate further evidence to improve the urea creatinine clearance and decrease fatigue by introduction of IDEs protocol.


   Methods Top


A quasi-experimental study was conducted at a tertiary care hospital, New Delhi, India, where CKD (stage 5) patients meeting the inclusion criteria were classified into experimental and control groups (32 each, 80% power, and alpha 5) using convenient sampling along with randomization of days. Study variables were serum urea, creatinine, and fatigue levels which were assessed at baseline, two, four, and six weeks. Blood sample testing was done at renal laboratory of the hospital and fatigue was assessed using FACIT fatigue scale (permission and licensure from the author was obtained r = 0.90, coefficient alpha range = 0.93–0.95). Patients included in the study were aged between 18 and 65, having HD access, on MHD >3 months, willing to participate, and who could perform the exercises independently. While patients who were hemodynamically unstable, having a history of angina in past three months, foot ulcer, sores, pitting edema, or any other contraindication to perform exercises were excluded. Ethical clearance was obtained from ethical committee of the All India Institute of Medical Science, New Delhi, informed written consent was obtained from the patients, and confidentiality and anonymity of the patients were maintained. Six low-intensity IDEs were chosen (2 upper and 4 lower limbs) which were repeated 10 times each over 1 min. The exercises were implemented using video-based demonstration on one to one basis to the experimental group patients. The intervention was done after 90 min of start of HD and the set of exercises were repeated thrice at an interval of 10 min. Vital signs were monitored before initiating and 30 min after the completion of exercises. Satisfaction level was assessed at the end of 6 weeks and exercise log sheet was maintained for the experimental group. Data Analysis using appropriate descriptive and inferential statistics was done using STATA version 12.0 (StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP.), statistics used were frequency, percentage, mean, median, range, and standard error. Inferential statistics used were Chi-square, Fisher’s exact test, paired t-test, Wilcoxon Rank Sum, Person’s Chi-square, and Spearman Rank test. Chi-square and Fisher’s exact test were used to compare the two groups based on demographic and clinical characteristics such as age, gender, annual income, duration of illness, duration of MHD, presence of comorbidities, and any other illness. The association of duration of illness, duration of MHD, presence of comorbidities, and compliance of exercises with serum urea, serum creatinine, and fatigue levels were done using Spearman Rank Test and Mann-Whitney test respectively.


   Results Top


The homogeneity of demographic and clinical characteristics of the patients in experimental and control are presented in [Table 1]. The mean age of patients was 44.1 ± 2.4 (years) in the control group and 39.2 ± 2.3 (years) in experimental group. Eighty-one percent of patients in both the groups were males. In educational status, 47% patients were graduate and above in control group while that in experimental group it was 56%. In control group 56% of patients were working in different trades while 44% were not working. In the experimental group, 50% of patients were working and 50% were not working. In terms of area of residence 59% of control group patients resided in urban region while in the experimental group, it was 75%. The median values for the duration of illness (years) and MHD (months) in the control group were 2 and 21 while in the experimental group it was 2.5 and 27. In both the groups, seventy-two percent of the patients had no illness while 6% had tuberculosis and hypothyroidism each. When considering the HD access 29 patients in each group had an arteriovenous fistula. Both control and experimental group patients had diabetes and hypertension as comorbidities. Hypertension was present in 13 patients of the control group and eight of experimental group. Similarly, diabetes was present in two patients of control group and four in experimental group [Table 2]. [Figure 1] and [Figure 2] show serum urea and creatinine levels of the study groups. At baseline there was no statistically significant difference in pre- and post-HD levels of serum urea and creatinine. There was statistically significant difference between the study groups in the post HD levels of serum urea and creatinine (P = 0.007, P = 0.001). Furthermore, the experimental group showed statistically significant decrease in the post HD levels of serum creatinine from 9.22 ± 2.59 (4.7–15.5) to 2.62 ± 0.93 (1.1–5.1) (P = 0.04). The mean fatigue scores of control and experimental group at baseline were similar (P = 0.09) [Table 3] [Figure 3]. However, there was statistically significant (P = 0.001) difference between the means of control (19.18 ± 5.01) and experimental (13.09 ± 4.86) group at 6th week. Within the groups, there was statistically significant difference from base to 6th week in both control and experimental groups (P = 0.02, 0.001) i.e., the fatigue was relatively decreased. [Table 4] shows that the overall compliance of the experimental group patients to the exercises was 97%. Compliance to upper limb exercises was 99.3% and to the lower limb exercises was 96%. Least com-pliance (86%) was seen for leg cross exercise. The noncompliant subjects initially needed some time to build stamina. 50% of the experimental group patients agreed that the exercises were useful to relieve fatigue while 31% strongly agreed for the same [Table 5]. Twenty-eight percent strongly agreed and 63% agreed that IDE were useful to relieve muscle cramps. Patients feeling comfortable during the exercise were 84%. Patients when asked whether they would like to continue with the exercises, 66% agreed and 19% strongly agreed to continue. Out of the total experimental group patients, 53% patients expressed that they would suggest other patients perform the exercises and 66% agreed that the exercises were explained to their satisfaction. [Table 6] depicts that there was no statistically significant correlation between duration of illness, duration of MHD, presence or absence of comorbidities, and exercise compliance with (study variable) serum urea creatinine and fatigue levels of the study patients.
Table 1: Demographic characteristics of study subjects (n=64).

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Table 2: Biophysiological Parameters of study subjects n=64.

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Figure 1: Comparison of mean serum urea (mg%) of study subjects.
t-test P <0.05.


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Figure 2: Comparison of mean serum creatinine (mg%) of study subjects.

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Table 3: Comparison of fatigue assessment scores of study subjects (n=64).

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Figure 3: Comparison of mean fatigue scores of study subjects.

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Table 4: Adherence of intra-dialytic exercises by experimental group (n=32).

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Table 5: Satisfaction score of intra-dialytic exercises among experimental group (n=32).

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Table 6: Correlation of outcome variables with clinical profile and exercise compliance (n=64).

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   Discussion Top


In the present study control and experimental groups were homogenous in terms of demographic and clinical characteristics with respect to mean age of patients (43.25 ± 1.2. P = 0.14), gender (male 81% and female 19%, P = 1.00), and comorbidities (DM in 7 and HTN in 21 patients, P = 0.23). Similar findings were reported by Rashedi and Ghaleb,[5] who incorporated six -week leg exercise, the mean age was 43 ± 1.3 (ranging from 20–60 years), 66.7% were males and rest females, 10 patients were diabetic while 20 were hypertensive. Also, Merlinine[6] in their study reported 74.2% of patients were male while 25.8% were female. Contrary to this, Hanan[8] reported nearly equal number of male (47%) and females (50%) in their study who used range of motion (ROM) exercises. Similarly, Lekha et al,[10] who used leg stretching exercises reported that there were 55% males and 45% females in their study. In the present study, with regard to the duration of illness the median was 2.3 (1–9) and 90% of patients had AV fistula while in Rashedi and Ghaleb,[5] the median duration was four (0–14) and 53% patients had AV fistula with the study conducted in middle east.

Blood samples for measuring serum urea and creatinine were drawn at the beginning and end of HD session of 4 h each. At 6th week serum urea levels decreased by 13.76 mg% in experimental group (P = 0.22) but increased by 1.9 mg% in the control group (P = 0.97) with both groups significantly different (P = 0.007). This was similar findings to Paluchamy and Vaidyanathan,[3] at 12 weeks posttest who incorporated 10–15 min of knee and ankle flexion and extension followed by cycling for 5 min depending upon patient’s tolerance during 2nd h of HD (n = 20). Ribeiro et al,[11] used 8-week resistance exercises protocol (n = 60) in the form of low-intensity IDE and found significant reduction in serum urea levels (P <0.0001). Hanan et al,[11] demonstrated that with the use of ROM exercises performed on all upper and lower joints in the first 2 h of dialysis for 15 min there was a significant difference in the serum urea levels of experimental and control groups at eight week (n = 30, P <0.001) and not at 4th week. Contrary to the present study findings, Böhm et al.,[8] used intra-dialytic cycle ergometer for 30 min with intensity 60%–70% MHR (n = 30) did not find a significant difference in serum urea levels (P = 0.64). They reasoned that blood samples were drawn immediately after completion of exercises and not at the completion of the entire dialysis treatment of 4 h duration.

A significant difference in serum creatinine was found at six weeks between the groups (P = 0.001) as well as within the experimental group (P = 0.04). Similar findings were demonstrated by Soliman,[12] at eight weeks (n = 30, P <0.001) who used aerobic exercises along with ROM exercises and stated that the effect could be due to aerobic exercise intervention. However, our findings were in contrast to the findings of Paluchamy and Vaidyanathan,[3] who demonstrated that the use of ROM exercises for 15 min did not result in any statistically significant difference in the mean serum creatinine levels within the experimental group patients (n = 20) but there was a significant difference between the experimental and control groups at P <0.05. Similarly, Böhm et al,[8] who used aerobic exercises in the beginning of the 2nd h of 3rd weekly day of HD did not find any statistically significant difference between the serum creatinine levels of study groups (P = 0.76) at eight weeks. This difference in the findings could be due to the fact that the exercises were not performed on regular basis in each dialysis session in Böhm et al,[8] as reported by the authors.

The present study found that there was statistically significant difference between the mean fatigue scores of control and experimental group (P = 0.001). The mean fatigue scores of control group decreased from 20.40 ± 5.7 to 19.18 ± 5.01 while that of the experimental group decreased from 18.09 ± 9.9 to 13.09 ± 4.86 which was also statistically significant (P = 0.02, P = 0.001). However, with the use of low intensity IDEs, the decrease was significantly more in the experimental group rather than the control group (P = 0.001). These findings were in congruence with earlier available evidence Ibrahim et al,[13] Lekha et al,[10] and Ribeiro et al,[11] Ibrahim et al,[13] where patients were divided into experimental and control groups (n = 100, 50 in each arm), external rotation, flexion, and internal rotation exercises were performed in arms, elbow, wrist, knee, ankle and abdomen for 12 weeks with a maximum duration of 40 min. The researcher had used multidimensional assessment of fatigue scale at 12 weeks and found a significant difference between the experimental group and control group (P = 0.001). The present study findings were also consistent with Lekha et al,[10] who used intradialytic stretching exercises to relieve muscle cramps in 60 CKD patients undergoing HD divided into experimental and control groups with more males (55%) than females. The exercises comprised of five-leg and ankle stretching for 15 min repeated twice in the 3rd and 4th h of HD. They found that 66% of the patients did not report any muscle cramps after 6th day of intervention, hence patients were more comfortable. In another study, Ribeiro et al,[11] demonstrated that with the use of resistance exercises in the form of low intensity with 40% MHR, 8th exercises, three sets of 12 repetitions for 30 patients over 12 weeks, there was a significant improvement in functional capacity and general health aspect of quality of life determined with the help of SF36 questionnaire.

Paluchamy and Vaidyanathan,[3] monitored vital signs of patients during IDE and found that there was statistically significant decrease in mean systolic pressure (P <0.05) with no statistically significant difference in diastolic pressures. In the present study, there was no statistically, significant difference in vital signs of the patients however this was probably due to the fact that whenever there was an untoward change in blood pressure it was managed pharmacologically immediately for which we do not have data. Therefore, it can be said that with the performance of low-intensity IDE there were no changes in the hemodynamic state of CKD patients and that the exercises were well tolerated.


   Conclusion Top


The present study shows low-intensity IDE when performed regularly was effective in decreasing serum urea, creatinine, and fatigue levels of CKD patients undergoing HD. The compliance of IDE was very high. It is simple, safe and can be easily administered.


   Limitations Top


The present study had the following limitation that randomization of the patients could not be done instead days were randomized and long-term effects of the exercise could not be assessed.

Conflict of interest: None declared.



 
   References Top

1.
Ene-Iordache B, Perico N, Bikbov B, et al. Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): A cross-sectional study. Lancet Glob Health 2016;4:e307-19.  Back to cited text no. 1
    
2.
National Kidney Foundation. Available from: https://www.kidney.org/, https://www.kidney. org/atoz/content/about-chronic-kidney-disease. [Last accessed on 06/01/19]  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
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. 4
    
5.
Rashedi SA, Ghaleb MA. Effectiveness of intradialytic leg exercise on dialysis efficacy among patients undergoing hemodialysis. IJARIIE 2017;3:2395-6.  Back to cited text no. 5
    
6.
Merline MS, Deepa R, Nirmala T. Effect of intradialytic exercise on fatigue among patients undergoing hemodialysis at selected hospital, Coimbatore. Int J Appl Res 2018;4:394-7.  Back to cited text no. 6
    
7.
8.
Böhm J, Monteiro MB, Andrade FP, Veronese FV, Thomé FS. Acute effects of intradialytic aerobic exercise on solute removal, blood gases and oxidative stress in patients with chronic kidney disease. J Bras Nefrol 2017;39: 172-80.  Back to cited text no. 8
    
9.
Available from: https://www.medicinenet.com/ aerobic_exercise/article.htm. [Last accessed on 06/01/19]  Back to cited text no. 9
    
10.
Lekha J, Abraham EJ, Malarvizhi G. Effectiveness of intradialytic stretching exercises on prevention and reduction of muscle cramps among patients undergoing haemodialysis at PSG hospitals Coimbatore. J Nurs Health Sci 2017;6:47-53.  Back to cited text no. 10
    
11.
Ribeiro R, Coutinho GL, Iuras A, et al. Effect of resistance exercise intradialytic in renal patients chronic in hemodialysis. J Bras Nefrol 2013;35:13-9.  Back to cited text no. 11
    
12.
Soliman HM. Effect of intradialytic exercise on fatigue, electrolytes level and blood pressure in hemodialysis patients: A randomized controlled trial. J Nurs Educ Pract 2015; 5:1925-4059.  Back to cited text no. 12
    
13.
Ibrahim MM, Mokhtar MA. Leg exercise: Effect on reducing fatigue and improving activities of daily living for hemodialysis patients. IOSR J Nurs Health Sci 2018;7:11-9.  Back to cited text no. 13
    

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Correspondence Address:
Anubha Devagourou
College of Nursing, All India Institute of Medical Science, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.344744

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