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Dialysis Patients and Exercise

Prognosis for patients with kidney failure requiring renal replacement therapy remains poor. Three-year survival for patients on dialysis is only 51% and five-year survival is 35%.  Cardiovascular diseases and infections. (USRDS)

The World Health Organization (WHO) recommends physical activity for general population because exercise is known to improve mood, depression and quality of life, glycemic control and serum lipids, increase nitrous oxide and positively affect outcomes of patients with cardiovascular disease. Numerous studies performed on increased physical activity and aerobic exercise in dialysis and CKD population also demonstrate a positive impact.

So with the noted benefits, why is exercise not a part of routine dialysis care? There are some possible answers:

  • Nephrologists and patients are not convinced that exercise has a value in the care and outcome of dialysis patients—they may even have a fear that exercise may cause harm
  • Lack of motivation among both physicians and patients
  • Creating an exercise program may be expensive and complex
  • There is not adequate motivation or incentive from regulatory bodies

And often, physicians do not change their behavior or update their recommendations even when the guidelines change. In a study by Delgado et al. cross sectional survey of nephrologist showed that physician counseling practices and opinion regarding exercise did not change after the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDQOI) publication.

Changing the paradigm from fee-for-service to pay-for-performance and value-based care has shifted priorities for nephrologists, and physical activity and functional assessment are not among the parameters. However, Improve quality of life is the ultimate goal of the current health care community.

There are several studies aimed on adequacy and blood pressure improvement with intradialytic exercise. Although some studies showed significant improvement, a recent meta-analysis published in American Journal of Kidney Disease did not find significant changes in Kt/V or blood pressure. However, in the same study physical fitness measured by VO2 Peak improved, Six Minute Walk Test (6MWT) was positive in all studies, and health-related quality of life assessed by SF-36 was performed in seven studies which showed improvement in PCS and MCS.

Dialysis patients’ age is rising and majority have several comorbidities which require physical activities to be individualized and nephrologist may not feel comfortable to evaluate and recommend tailored exercise. An ideal program for incorporating routine exercise in dialysis patients should include physiotherapist to prescribe physical activities tailored to individual abilities and restriction; appropriate equipment and motivated and educated staff. With increasing work load of dialysis staff adding intradialytic exercise program may not be practical and would need additional resources. However, simple exercises such as walking twice a day, every day has shown to be effective in increasing functional status of patients.

Inactivity is one of the major factors in current obesity epidemic which leads to other prevalent diseases such as diabetes and heart disease. Increased physical activity remains the mainstay of prevention and treatment in many metabolic and skeletal diseases. Nowadays, every cardiothoracic program has cardiac rehabilitation program that provides individualized and supervised exercise programs. Since there is not enough motivation or incentive to create comprehensive exercise program to incorporate in our current dialysis facilities, nephrologists need to start promoting increased physical activity for our patients by educating ourselves, colleagues and dialysis staff about the benefits of exercise, counseling and encouraging patients to use simple and practical methods such as daily walking as a part of our routine patient care.

Ehsan Shahmir, MD

Ehsan Shahmir, MD

Ehsan Shahmir, MD, serves as group medical director for DaVita Kidney Care and has been with DaVita since 1995. He is also a practicing nephrologist in Vacaville, California, is the chief of the department of nephrology at NorthBay Medical Center, and is a member of NorthBay’s bioethics committee and physician wellness committee. Previously he served as NorthBay’s vice chief of the department of medicine and a member of their peer review committee. Dr. Shahmir received his medical degree from Tehran University School of Medicine in Iran and finished his fellowship at Harbor-UCLA.