intradialysis exercises improve QOL, general and sychological health

1. Spotlight on hemodialysis practice
(floating of ideas)
part 2
By
Alyaa Risq Esmail Mostafa ElAskary
Salwa Elwasif, MD

2. • a bimonthly publication
• Edited by Prof. Richard A Sherman from
Rutgers University, New Jersey.
• It focuses exclusively on cutting-edge clinical
aspects of dialysis therapy.
• It publishes review articles by the most
respected names in the field of dialysis

3. •Impact factor:1.818

6. 28 beds
26 regular
11 HCV -ve
13 HCV-
PCR -ve
2 HCV +ve
2
emergency

7. HD service
Equipments
machine lines
Vascular
access
personnel's
medical paramedical

8. Exercises in hemodialysis
• Effect of gender on survival
• Assessment of physical function
Brief notes

10. Life expectancy?
In general population In CKD
> <

11. Introduction
• The question arises as to why in the general population being
female carries a survival advantage, whereas this gender
advantage is lost in the ESKD hemodialysis population, and
indeed survival may even be worse for women treated with
hemodialysis.

12. 1) Lead‐time bias
Mortality in dialysis patients is calculated from
the time that patients start dialysis, although this starting
time may vary between registries, with some registries
calculating from the first dialysis treatment and others
after 90 days or 3 months of dialysis

13. • Creatinine is a breakdown product of muscle
metabolism and so depends upon muscle mass and
physical activity.
• Women are likely to have lower muscle mass, lower
dietary protein intake and be less physically active
compared to aged-matched men.

14. • post-menopausal women experience a greater
decrease in lean mass, muscle fiber size, and muscle
strength with age.
• A higher proportion of women start dialysis with
moderate to severe muscle atrophy, a finding
associated with greater mortality.

15. • using serum creatinine and eGFR to decide upon
when patients should start dialysis may potentially
result in a lead time bias, with male patients starting
dialysis earlier than females.

16. 2 )Loss of residual renal function
• Observational studies have highlighted that survival
for both peritoneal and hemodialysis patients is
greater for those with preserved renal function.
• more female patients would start dialysis anuric from
cortical necrosis following catastrophic post-partum
hemorrhage,

17. 2 )Loss of residual renal function
• Other causes of anuria include hemolytic uremic
syndrome which has a higher incidence in women.
• studies have observed that women are more likely to
suffer with intra-dialytic hypotension compared to
men and thus, perhaps, a faster decline in residual
renal function.

18. Do women receive the same amount of dialyzer clearance?
• observed a significant reduction in mortality for
women receiving greater urea clearance compared to
the standard target clearance. Female dialysis patients
with a urea reduction ratio (URR) of more than 75%
had a 15% lower mortality risk compared to those
with a URR of 70%-75%.
• As their estimated Kt/V urea (eKt/V urea) increased
above 1.05, mortality in women fell significantly.

19. Do women receive the same amount of dialyzer clearance?
• These positive correlations between increased urea
clearance and patient survival in women were not
observed in male dialysis patients suggesting that
once male patients achieved the standard Kt/V urea
target more urea clearance had no additional benefit.
This would suggest that the standard Kt/V urea target
has been set too low for women

20. • Patients' urea clearances are adjusted for their total body
water (V).
• For any given age, height, and weight, the calculated V
is lower in women than in men.
• Thus, the man in would dialyze for longer time than the
woman to achieve the same Kt/V.

21. What about obesity…?

22. • The issue of body fat's influence on dialysis dose applies
to both genders. Increasing body weight increases BMI;
in dialysis patients it is most often that the ratio of fat to
fat free weight increases, which leads to an over
estimation of total body water (V) since adipose tissue
contains less water than muscle.
• Thus, obese patients need longer dialysis sessions than
that based on their true V to achieve the same target
single pool Kt/V urea as smaller patients

23. Estimation of internal organs size between both
genders from patients of Royal Free Hospital
% DifferenceFemaleMaleParameters
15.46575Weight kg
28.332.641.9V Watson, L
8.71.721.87BSA, m2
11.711961336Brain, g
7.921042270Liver, g
8.49.510.3Kidney length, cm

24. • Body surface area (BSA) correlates better with
HMRC than weight, body water or body mass index
(BMI)
• Women usually have a smaller body size compared to
men but a relatively higher proportion of HMRC.
Therefore, scaling dialysis dose to V may lead to less
dialysis in women.

25. • At rest the highest metabolic activity is found in the
internal organ compartment (225.9 kJ/kg) which is
much greater than that of resting skeletal muscle (54.5
kJ/kg). This internal organ compartment has been
termed the “high metabolic rate compartment”
(HMRC).

26. • The relative proportion of the HMRC for a small
individual is increased compared to that of a larger
person . Indicating that women produce relatively
more uremic toxins for their body size and so need a
relatively greater urea clearance.

27. 4 ) Do women have shorter dialysis sessions
• Another consequence of the generally smaller size of
women is that the associated smaller V means that a
lower Kt will be required to achieve a target Kt/V. This
usually means that a woman will receive a shorter
treatment than a man. To compare the effect of using
Kt/V urea.

28. 4 ) Do women have shorter dialysis sessions
• Shorter dialysis session times increase risks for failure
to achieve sodium and volume homeostasis and
excessive ultrafiltration rates, the latter leading to
intra-dialytic hypotension and premature loss of
residual renal function which both have their own ill
effects on outcomes.

29. Discussion
dialysis paradox???

31. • Reduction in kidney function is associated with
pathophysiologic processes that contribute to the loss of
independence.
• Reduced kidney function and CKD lead to the retention
of uremic solutes inciting pathophysiologic processes
contributing to organ impairment (eg, skeletal muscle
dysfunction or sarcopenia), initially manifesting as
weakness or fatigue , functional limitations and disability.
Introduction

32. Functional limitations are measured by:
•basic physical performance tests (eg, gait speed,
timed up and go)
•self‐reported mobility limitation (ie, difficulty
walking ¼ mile or climbing 10 steps).

34. Frailty is a related phenotype defined as a clinical
syndrome characterized by possessing at least three of
the following five features:
•weak grip strength (muscle impairment),
•slow gait speed (physical performance),
•low physical activity,
•low energy
•weight loss.

35. A SSESSMENT OF PHYSICAL FUNC TION
• The Short Form 36 Health Survey (SF‐36) is one of
the most widely used across multiple populations
• The SF‐36 includes 36 items evaluating functional
status and perceptions of health status in eight scales
scored from 0 to 100 with higher scores associated
with greater perceived HRQOL.

36. SF‐36 scales include
1. Physical functioning (Limitations in moderate activities , moving a
table)
2. Role physical (limitations of work).
3. Bodily pain (pain interfering with work),
4. General health perception (rating of health relative to others),
5. Vitality (energy and tiredness),
6. Social functioning (limitations to time and type of social
activities).
7. Role emotional (reduced work time and quality).
8. Mental health (anxiety , depressed mood).

37. Comparison of the physical vs mental component
scores
• Kidney disease patients had worse scores compared
to the general population on the PCS subscale scores
and to a lesser degree on measures of the mental
component score (MCS).

38. PCS score
• the PCS was shown to be associated with age, gender,
race, education, smoking status, and comorbidity.
• lower PCS score (based on the SF‐12) was observed in
participants who were older (65 and older vs <65
years), female, black or Hispanic race, had lower
income, had lower education, increased comorbidities,
greater BMI >= 30 , had albuminuria, and lower
estimated glomerular filtration rate (eGFR).

39. PCS score
• lower PCS score also observed in current or past
smoking, diabetes, history of myocardial infarction,
peripheral vascular disease, congestive heart failure,

40. • Results from the HEMO study, a randomized clinical
trial examining the effects of hemodialysis dose on
outcomes, suggested that over a 3‐year follow‐up
high‐dose hemodialysis (eKt/V 1.45 vs 1.04) was
associated with less bodily pain (4.49 points, P <
0.001) and higher PCS (1.23 point, P = 0.007)
compared to lower dose dialysis

41. • The frequent hemodialysis network (FHN)
randomized controlled trial demonstrated that
increased frequency hemodialysis (six times weekly)
significantly improved PCS
• Furthermore, a decline in PCS over time increased
risk of mortality with each 5‐ point decrease in PCS
associated with a 9% increase in mortality

42. • Among patients with CKD not treated with dialysis,
only low PCS scores have been associated with
increased rates of progression of CKD,
cardiovascular events, and death.
• Patients treated with dialysis underscore the need for
early mobilization of rehabilitation or physical
therapy.

43. • The 6‐minute walk distance (6MWD) which
measures the impact of kidney disease on skeletal
muscle wasting is strongly associated with mortality
in CKD.
• This test measures the maximal distance covered
during 6 minutes. Persons with CKD on average
demonstrate 30%‐40% lower performance on the
6MWD than predicted for age and gender.

44. • Walking less than 350 m on the 6MWD was
associated with an 82% greater risk of mortality
compared to 350 m or greater.
• Among patients with ESKD treated with dialysis,
every 20 m greater performance on the 6MWD is
associated with a 11% reduction in risk of mortality

46. Exercise interventions to improve physical function
• The exercise introduction to enhance performance in
dialysis patient trial (excite) is the largest exercise
study demonstrating the effectiveness of a 6‐month
personalized, home‐based walking exercise program to
improve walking capacity and muscle strength
• Excluded those with limited mobility or high degree of
fitness (6mwd > 550 m), exertional angina, or stage 4
NYHA heart failure

47. Exercise interventions to improve physical function
• Exercise training involved gradual increased intensity
of walking.
• Results:
Hospitalization was only reduced among those in the
exercise group that had completed the trial compared
to controls that completed the trial.
Among those who completed the trial, there were
significant improvements in muscle strength.

48. CONCLUSION
• Assessment of physical capacities and identification
of functional limitations is essential to those patients
with kidney disease at high risk of hospitalization,
and mortality.
• Poor physical functioning characterized by a
KDQOL‐36 physical functioning subscale score
(PF‐10) < 75 is associated with increased risk of
hospitalization or death in CKD.

50. Despite decades of research, there are few published
guidelines related to the safety and efficacy of exercise
training in hemodialysis patients.
This leads to disparate recommendations regarding the
type, intensity, and timing for exercise, especially for
patients with multiple comorbidities.

51. Many common recommendations are not supported by
research data, so their justification is uncertain. These
recommendations include exercising in the first hour of
dialysis; not exercising if hypertensive, cramping, or
volume overloaded; avoiding heavy weights on vascular
access limb

52. clinicians managing an exercise program;
intradialytic exercise or interdialytic exercise is better;
and strength training during dialysis is impractical.

53. Intradialytic exercise should only be performed in the
first hour of dialysis
• MYTH #1:
patients should be provided the opportunity to choose the
optimal timing for their exercise, based on a combination
of factors, including:
• personal preference
• history of intradialytic symptoms
• ultrafiltration goal
• staff availability
• workflow.

54. Exercise should be avoided in hypertensive patients
• MYTH #2
• There is a real need for clinical decision making, by
appropriately trained staff, and observation of the
dialysis patient during, and after exercise training.
• BP should be assessed and utilized alongside clinical
decision making, and patient symptoms, to ensure that
pragmatic exercise training can be realized.

55. Intradialytic exercise should be avoided in
volume overloaded patients
MYTH #3.
• clinical recommendations in many United Kingdom (UK)
renal units that operate pragmatic intradialytic exercise
programs are to avoid intradialytic cycling or resistance
training when a patient IDWG exceeds 4 kg.
• This recommendation reflects concerns that excessive IDWG
may impact resting BP and heart rate (HR) indices, which
may be further increased with exercise training.

56. Intradialytic exercise should be avoided in
volume overloaded patients
MYTH #3.
• There is no published evidence to support an absolute
contraindication to intradialytic exercise with an IDWG of <4
kg.
• This cut‐off point should be interpreted alongside patient
symptoms and other physiological parameters.

57. Dialysis patients with an arteriovenous fistul a (avf) or
graft should avoid lifting heavy weights
• MYTH #4.
• patients are often given conservative advice to limit RT using
their AVF arm, there are no data in the literature to support this.
It appears that light exercises can commence almost
immediately following the AVF surgery to help with
maturation. Moreover, once the access matures, few limitations
should be placed on RT activities as long as progression is slow
and closely monitored. The conservative clinical practice to
restrict RT with the AVF arm is likely a significant and
unnecessary barrier to exercise in HD patients

58. Exercise programs in dialysis clinic scan be
effectively managed by the existing clinic staff
• MYTH #5.
• Implementing exercise programs in HD clinics are challenging,
even when dedicated exercise professionals are available to help
manage the program. It is even more difficult when the programs
are man‐aged by existing clinic staff. Staff‐managed programs
typically rely on dedicated nurses and technicians that have more
pressing work‐related duties They also typically lack the necessary
training to be able to assess patient readiness for exercise or
provide them with significant guidance on how to develop an
exercise plan.

59. As a result, staff led programs typically consist of
simple activities such as intradialytic cycling with
little attention paid to work rate or progression, and
tend to include only the most motivated patients
who need the least time and effort to encourage
them to exercise

60. MYTH #6.
An important debate in the literature is whether in‐center
(intradialytic) or out‐of‐clinic (interdialytic) exercise is more
efficacious. In theory, interdialytic exercise would appear to have
many advantages over intradialytic activity, primarily due to fewer
restrictions on the type, volume, and intensity of exercises that can
be performed when patients are not confined to a dialysis chair or
bed. The main arguments in favor of intradialytic exercise is that it
is very time efficient for patients, and also compliance can be
monitored more closely. However, few studies have directly
compared the efficacy of intradialytic and interdialytic exercise,
and the data from these studies suggest that compliance and
benefits with both types of activities were largely similar.
Interdialytic (out of center) exercise is more
efficacious than intradialytic exercise

61. Exercise during dialysis causes muscle cramping
• MYTH #7.
• Muscle cramps are one of the most frequent symptoms
associated with dialysis therapy. The etiology of
dialysis‐associated cramps is not clear, although changes in
plasma osmolality and extracellular fluid volume have been
suggested. Exercise training has the potential to reduce
muscle cramps. post‐exercise muscle cramping and fatigue
may occur, but this is usually short‐lived and discontinues
with frequent exercise training’ By contrast, commentaries
have suggested that exercise training may actually reduce
dialysis‐associated muscle cramps though there is little
published evidence from clinical trials to support or refute
these claims.

62. spotlights
• Patients who continued use of a loop diuretic after
starting chronic HD (N = 5219) had significantly
lower adjusted rates of hospitalization (HR 0.93) and
intradialytic hypotension (HR 0.95) and an
insignificantly lower death rate (HR 0.92), CI
0.84‐1.01), than patients who stopped diuretics upon
initiating HD (N = 6078).

63. • Transcranial Doppler ultrasound found that cerebral artery flow
velocity fell during HD and that this decline correlated with an
intradialytic deterioration in cognitive function. Follow up
evaluations in 73 patients found that drops in flow velocity
correlated with loss of global and executive function as well as
progressive changes in white matter on brain MRI. Patient
transplanted and followed up during the study (N = 12) had
significant improvements in memory and MRI findings

64. • A randomized trial of IV iron sucrose in high doses (400
mg/month unless ferritin >700 μg/L or transferrin
saturation ≥40%) and low doses (for ferritin <20 μg/L or
saturation <20%) in 2141 HD patients found a reduced
monthly requirement for ESA in the high dose group
(27,757 IU v 38,805 IU). Cardiovascular events,
infection, hospitalizations and death did not differ over
the median 2.1 year follow‐up

65. Use of vitamin D receptor agonists
• risk for infections in dialysis patients was 48% lower in
those using vitamin D receptor agonists than in those who
did not; all were observational studies. Nutritional
vitamin D supplements did not decrease infection risk
even though the risk of infection was lower (HR 0.61, all
randomized trials) in those with normal or high 25‐OH D
levels than in those with low levels.

67. • The progression of coronary artery calcification in 34 HD
patients was compared with that in 23 PD patients; all
were transplant candi‐ dates and only 12% were diabetic.
Calcification progressed in most patients regardless of
dialysis modality. However, progression was usually
absent in patients without baseline calcification (no
progres‐ sion in 6 of 8 HD and 4 of 6 PD patients)

69. THANK YOU