LONDON, United Kingdom — A personalized exercise program integrated into routine dialysis can improve strength, endurance, and quality of life, new research indicates.

Fitness "improved significantly over a 1-year period, after which patients stabilized," said Kirsten Anding-Rost, MD, from the KfH Dialysis Center in Bischofswerda, Germany.

The program "was a really big success," she explained. "Normally in dialysis patients, health status steadily declines, so if you do something that maintains health status, it's actually very good."

Dr Anding-Rost presented results from the study here at the European Renal Association–European Dialysis and Transplant Association 52nd Congress.

The 46 study participants were typical dialysis patients. Mean age was 63 years, there were a lot of comorbidities, and three patients had undergone leg amputation.

The exercise program consisted of 30 minutes of combined resistance training that worked eight major muscle groups and 30 minutes of endurance training in the supine position on a bicycle ergometer.

Patients trained two times a week for 5 years, and were assessed with maximum strength testing and mean cycling power per training session.

"To adapt the training intensity to the personal fitness of each patient, we had to first measure the personal fitness of each patient," Dr Anding-Rost explained. And throughout the study period, exercise intensity was continuously adjusted to match improvements in fitness.

Of the initial 46 participants, 36 completed 1 year of the study and 20 completed 5 years.

 
In our dialysis unit, exercise is part of the dialysis treatment and is prescribed by the nephrologist.
 

Improvements in strength depended on how adherent patients were to their training sessions. For those with high adherence, improvements were significant in all eight muscle groups targeted by the resistance exercises.

In the moderate-adherence group, "we still saw an improvement in some muscle groups, but it was not as good as in the high-adherence group," Dr Anding-Rost reported.

There was a "nice improvement" in the average cycling power gained during the first 3 months of the exercise program, she said. After that, patient endurance remained more or less stable.

During the first 3 months, there was a 55% improvement in maximum exercise capacity in the high-adherence group and a 45% improvement in the moderate-adherence group.

There were also significant improvements on all three tests of physical function and in quality of life, ranging from 11% to 31%.

Physically weak patients actually had greater improvements in physical function than stronger patients.

"We saw a trend toward more training over the years, so by the end, most people were training three times a week," Dr Anding-Rost reported. "And if you exclude transplantation and death, the adherence rate after 5 years was still almost 80%.

Patient motivation is crucial for the successful implementation of an exercise program during dialysis.

"In our dialysis unit, exercise is part of the dialysis treatment and is prescribed by the nephrologist," she told Medscape Medical News. "And we consistently have 70% to 80% of our patients exercising."

It helps that patients who are exercising are together in one room during the dialysis session, she added. And patients are motivated to continue to exercise not only by their trainer, but by all staff, including physicians.

In almost all countries, "the biggest problem is a lack of funding for exercise therapy during dialysis," Dr Anding-Rost said. "If you want to offer a professional exercise program that meets all the criteria expected from such a program, it will cost money. The bikes are expensive and you need a trainer, who costs money as well."

"We have to convince health insurance companies to support this therapy," she explained. In Saxony, "one health insurance company has agreed to pay for it," which is very exciting.

Exercise and Well-Being

Good epidemiologic studies and small randomized controlled studies have shown that exercise improves health, mobility, and well-being in patients with chronic kidney disease and in patients on dialysis, said Mick Kumwenda, MD, from Glan Clwyd Hospital in Rhyl, North Wales, United Kingdom.

For example, in a study of 23 hemodialysis patients, Dr Kumwenda and colleagues showed that intradialytic exercise elicited normal anabolic and strength response, although not function, and that response in dialysis patients was similar to that seen in healthy control subjects (J Cachexia Sarcopenia Muscle. 2014;5:199-207).

And in a systematic review and meta-analysis involving nearly 900 patients, exercise training was shown to improve physical fitness, dialysis efficiency, and depression (Open J Nephrol. 2013;3:25-36).

"However, there is still a need for a well-designed randomized controlled trial of exercise training in patients on hemodialysis or peritoneal dialysis, as well as renal transplant recipients, to examine hard clinical end points, along with the cost-effectiveness of the program, and to determine the rate of patient compliance with different programs," Dr Kumwenda told Medscape Medical News.

"In the meantime, the management of patients with chronic kidney disease and those on renal replacement therapies should include patient's rehabilitation education to avoid low activity and to initiate and maintain safe physical activity programs in collaboration with physio and occupational therapists," he added.

Dr Anding-Rost and Dr Kumwenda have disclosed no relevant financial relationships.

European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) 52nd Congress: Abstract FO029. Presented May 29, 2015.

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