|Year : 2020 | Volume
| Issue : 3 | Page : 365-372
Effect of intradialytic exercise on quality of life of patients with end-stage renal disease on hemodialysis
Noha H Ali1, Hanan M Eltokhy1, Maha A Hassan1, Nesreen G El-Nahas2
1 Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Egypt
2 Faculty of Physical Therapy, Cairo University, Cairo, Egypt
|Date of Submission||19-Mar-2020|
|Date of Decision||08-Apr-2020|
|Date of Acceptance||14-Apr-2020|
|Date of Web Publication||2-Oct-2020|
BSc Noha H Ali
Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Helwan University Hospital, Cairo, 11742
Source of Support: None, Conflict of Interest: None
Background Up to 90% of patients diagnosed with end-stage renal disease (ESRD) regularly receive hemodialysis (HD) as renal replacement therapy. Patients with ESRD have a diminished physical function, so physical therapy during HD sessions can be a significant part of physical rehabilitation for these patients. The improvement in quality of life (QoL) is regarded as a main target in the management of patients with ESRD.
Aim The aim of the study was to evaluate the effect of a physical therapy program on the QoL in patients with ESRD on HD.
Patients and methods This sectional study was conducted on 60 ESRD patients on regular HD who are allocated from the HD unit, Internal Medicine Department of El-Zahraa University Hospital from March 2018 to August 2018. The patients were subjected to anthropometric measurements including weight, height, and BMI; all laboratory variables were recorded. The QoL was assessed using the short-form 36 questionnaire and the score was calculated at the beginning of the study and after 6 months.
Results There was a statistically significant decrease in blood urea (49.54±15.62 to 33.92±13.89) and plasma creatinine (6.19±1.43 to 4.20±1.95) after 6 months of starting intradialytic exercise in comparison to the baseline. There is statistically significant improvement in the results of some items of the short-form 36 health questionnaire after 6 months from the start of the study.
Conclusion Exercise program during the intradialytic period can provide a significant improvement of QoL and physical ability of patients with chronic kidney disease.
Keywords: end-stage renal disease, intradialytic exercise, quality of life
|How to cite this article:|
Ali NH, Eltokhy HM, Hassan MA, El-Nahas NG. Effect of intradialytic exercise on quality of life of patients with end-stage renal disease on hemodialysis. Sci J Al-Azhar Med Fac Girls 2020;4:365-72
|How to cite this URL:|
Ali NH, Eltokhy HM, Hassan MA, El-Nahas NG. Effect of intradialytic exercise on quality of life of patients with end-stage renal disease on hemodialysis. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 26];4:365-72. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/365/296942
| Introduction|| |
End-stage renal disease (ESRD) is increasing worldwide. The number of patients receiving renal replacement therapy is estimated as more than 1.4 million, with the annual incident rate growing to 8% .
Although advances in hemodialysis (HD) have improved patient survival, such treatment alone does not guarantee quality of life (QoL) preservation, and many studies have shown significant reductions in the QoL of patients with chronic renal failure under HD. These findings are related to changes found in muscle structure and function, resulting from uremia, which may manifest as atrophy, proximal muscle weakness − predominantly in the lower limbs, difficulty in walking, and cramps .
ESRD patients have poor health-related quality of life (HRQoL) compared to the general population .
Physical activity is identified as an important factor in improving QoL among patients on HD, as it can improve the physical performance in activities of daily living, so physical therapy during HD sessions can be a significant part of physical rehabilitation for these patients .
| Aim|| |
The aim of this study was to evaluate the effects of a physical therapy program on the QoL in patients with ESRD during HD.
| Patients and methods|| |
A cross-sectional observational study was conducted on 60 ESRD patients. All patients were recruited from the HD Unit of El-Zahraa University Hospital from March 2018 to August 2018 after obtaining Local Medical Ethics Committee approval and consent from all participants in the study.
ESRD patients on regular HD three times per week with 4-h sessions; those of age more than 18 years were included in the study.
Patients with acute kidney disease, patients with ESRD not on HD, physical impairments that would invalidate the study (amputation, deep vein thrombosis, and active bleeding in the gastrointestinal system) and patients with severe heart failure, or myocardial ischemia were excluded in the study.
All patients were subjected to full and detailed history taking such as personal, demographic (age, sex, weight, and height), cause of chronic kidney disease and duration of HD, and history of chronic disease.
Calculation of the BMI using the equation
- Clinical examination: including blood pressure, general examination, local examination including chest, cardiac, and abdominal and neurological.
- Blood pressure was measured at the beginning and the end of the exercise session.
- Laboratory investigation which included: complete blood count, fasting and postprandial blood sugar, serum cholesterol and triglycerides, liver enzymes, total protein, serum albumin, and kidney function tests (blood urea and serum creatinine).
Intradialytic physical exercise
A 6-month adapted rehabilitation program was conducted by means of progressive submaximal individualized cycling exercise, consisting of three sessions per week. The exercise was prescribed during the first 2 h of dialysis session using a pedal leg cycle that allows cycling in a supine position at different resistance levels. This pedal leg cycle also allows for passive motorized pedaling (the patient can pedal without effort).
The aim of this 6-month individualized program was to reach 30 min duration of continuous cycling at moderate exercise intensity.
To estimate the targeted moderate exercise intensity, an exercise protocol with an increasing intensity on the pedal leg cycle was performed at the inclusion, before the rehabilitation program. During this first evaluation, after a warm-up of 5 min without resistance, the patient pedaled with a self-selected chosen cadence against an increasing resistance imposed by the pedal leg cycle, until the patient reached a level perceived as moderate. A similar monthly assessment was realized to update the intensity of cycling exercise. During these sessions, the patient was regularly asked about the level of shortness of breath, and any feelings of fatigue and pain in order to reduce the exercise intensity, if necessary.
During a dialysis session, the cycling exercise was performed in the first half of the session. After a 5 min warm-up without resistance, the patient gradually reached the moderate intensity and then the patient was instructed to maintain this cycling exercise intensity for at least 10 min during the first month, 15 min during the second month, 20 min for the next 2 months in order to achieve the targeted exercise duration of 30 min in the 2 last months.
Finally, a period of relaxation phase (pedaling without resistance) followed by a period of passive pedaling recovery ended the exercise session.
Assessment of quality of life
Assessment is through the generic 36-item short-form health questionnaire (SF-36 questionnaire) before the start of the study and after 6 months .
At the end of the dialysis session, the patient was asked to estimate pain level and mood as perceived during the session.
Data were collected, coded, revised, and entered to the Statistical Package for the Social Sciences (IBM SPSS) version 20 (Kirkpatrick, Lee A., 1958-. A Simple Guide to IBM SPSS Statistics for Versions 20.0. Australia; Belmont, CA: Wadsworth, 2013). The data were presented as number and percentages for the qualitative data, mean, SD, and ranges for the quantitative data with parametric distribution and median with interquartile range for the quantitative data with nonparametric distribution. A P value greater than 0.05 is considered nonsignificant; less than 0.05* is considered significant, and a P value less than 0.001** is considered highly significant.
| Results|| |
This study was conducted on 60 ESRD patients on regular HD. They were 29 (48.3%) women and 31 (51.7%) men, their ages ranged from 26 to 58 years with mean±SD (43.33±8.67); their weight ranged from 55 to 96 kg with mean±SD (74.35±10.39); their height ranged from 1.59 to 1.78 m with 1.69±0.06; and the mean±SD of BMI was 26.20±3.94. Duration of HD ranged from 11.2 to 19.4 years with mean±SD of 14.95±1.96. There were 21 (35%) patients who had diabetes mellitus, 27 (45%) patients who had hypertension, and six (10%) patients had chronic glomerulonephritis ([Table 1]).
|Table 1 Demographic data and causes of end-stage renal disease of the 60 studied patients|
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There was ighly significant decrease in levels of blood urea, serum creatinine, serum triglycerides, and a significant decrease in levels of aspartate aminotransferase, cholesterol, postprandial blood sugar, and fasting blood sugar (FBS) after a follow-up of 6 months in comparison to their levels at the start of the study (P≤0.001) ([Table 2]).
|Table 2 Comparison between laboratory results of the 60 studied patients at the start and after 6 months of follow-up|
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There was highly significant decrease in measurements of systolic and diastolic blood pressure of patients after 6 months follow-up in comparison to their measurements at the start of the study (P≤0.001/0.002, respectively) ([Table 3]).
|Table 3 Comparison between systolic and diastolic blood pressure measurements of the 60 studied patients at the start and after 6 months of follow-up|
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There was positive significant correlation between BMI, dialysis duration, urea, creatinine, albumin, cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure, FBS and 2 h postprandial with the total score of the SF-36 health survey questionnaire, while there was a negative significant correlation between hemoglobin, total leukocyte count, and total protein with the total score of SF-36 questionnaire as shown in [Table 4] and [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6].
|Table 4 Correlation between total questionnaire with some parameters of patients after 6 months of follow-up|
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|Figure 3 Correlation of serum cholesterol and short-form 36 questionnaire|
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|Figure 4 Correlation of systolic blood pressure and short-form 36 questionnaire.|
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|Figure 5 Correlation of diastolic blood pressure and short-form 36 questionnaire.|
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|Figure 6 Correlation of serum triglycerides and short-form 36 questionnaire.|
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| Discussion|| |
ESRD patients on HD remain substantially less active than the general healthy population . Physical inactivity is therefore regarded as a major factor leading to impaired physical condition, reduced exercise capacity, and ultimately muscle wasting 
Intradialytic exercise (IDE) is defined as exercise training performed during the HD session to increase the patient’s strength and endurance. IDE has demonstrated a positive effect on the overall health and hospitalization rate of HD patients .
In the present study out of 60 patients, 29 (48.3%) were women and 31 (51.7%) were men. Similar results were found by Abdel Raoof et al.  who studied 30 patients (19 men and 11 women). Also the study of Bayoumi and Al Wakeel  consisted that more than 50% of their sample were men.
In this study, there were 21 (35%) patients who were diabetic, 27 (45%) patients who were hypertensive, and six (10%) patients who had chronic glomerulonephritis. This agreed with Abd ElHafeez et al. , who concluded that the common etiologies of chronic kidney disease in Africa were hypertension, chronic glomerulonephritis, and diabetes.
Our study showed a statistically significant decrease in serum blood urea and plasma creatinine after 6 months of starting IDE in comparison to the baseline before start of the study.
These results were in agreement with the study by Abdel Raoof et al.  in which patients received a program of moderate-intensity aerobic exercise using the Bicycle ergometer Zhejiang pedal exerciser, with an exercise period of 30 min for 8 weeks in which the mean of creatinine before was 9.95±1.02 and after exercise was 8.82±1.05 with highly significant decrease which supports our result. Similarly Rahmy et al.  found a statistically highly significant decrease in creatinine, blood urea in the group of patients who received moderate aerobic exercises on treadmill three times a week for 3 months plus their medical treatment, when compared with the control group who received only medical treatment with no training. On the other hand, our results disagreed with Orcy et al.  who found that aerobic exercise during HD showed no significant difference in the level of creatinine.
In this study, we found statistically significant decrease in cholesterol and triglycerides levels after 6months of exercise in comparison to the baseline laboratory data. In agreement with our results Gordon et al.  concluded that there was a significant reduction in serum total cholesterol, triglycerides, low-density lipoprotein cholesterol, and total cholesterol/high-density lipoprotein cholesterol ratio, and a significant increase in high-density lipoprotein cholesterol after 4 months for patients in the Hatha yoga exercise group.
On the other hand, Frih et al.  and Afshar et al.  showed no beneficial effects on lipid profiles.
Our study revealed statistically significant decrease in postprandial blood sugar, FBS, systolic blood pressure, and diastolic blood pressure after 6 months from the start of the study in comparison to baseline data. Young et al. , on the other hand, suggested that the IDE failed to improve blood pressure and this may be due to the different types of exercises.There were statistically significant improvements in the results of some items (general health, pain feeling, and physical function, walking several blocks) after 6 months from starting the study in comparison to baseline. These results were in agreement with the study by Young and colleagues, Chung and colleagues, and Sheng and colleagues who illustrated that IDE can lead to statistically significant increases in function and exercise capacity and a reduction in depression and extends these findings to a real-world setting ,,. Also, the study by Gomes Neto et al.  found a positive effect of IDE on physical function and QoL.
Rhee et al.  showed no significant increase in each domain of the questionnaire, except for body pain. The measured values of body pain were 68.6 for month 6 and 78.3 for month 0 (P<0.05). They concluded that this result indicates that the value of bodily pain decreased as the time passed.
| Conclusion|| |
This study showed that IDE improves the QoL of patients, so such simple training programs should be encouraged as the standard clinical practice in HD units.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]