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Saudi J Kidney Dis Transpl 2018;29(4):902-910

© 2018 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Brief Communication

Effectiveness of Intradialytic Exercise on Dialysis Adequacy, Physiological

Parameters, Biochemical Markers and Quality of Life – A Pilot Study
Thenmozhi Paluchamy1, Rajeswari Vaidyanathan2
1
Saveetha College of Nursing, Saveetha University, 2Faculty of Nursing, Sri Ramachandra
University, Chennai, Tamil Nadu, India

ABSTRACT. End-stage renal disease is emerging as a major public health problem in the
developing countries. It must be treated with renal replacement therapy and hemodialysis (HD) is
the most widely used therapy and the only maintenance treatment if kidney transplant is not
feasible. This study aimed to determine the effectiveness of intradialytic exercise on dialysis
efficacy, physiological parameters, biochemical markers, and quality of life among patients on
HD. Experimental research design was adopted to conduct the study with 20 patients in our HD
unit who met the inclusion criteria and patients were randomly allocated into experimental group
and control group. The experimental group received intradialytic exercise during the first 2 h of
HD besides receiving routine care compared to the control group. Data were tabulated and
analyzed using the SPSS package. The finding of the present pilot study reveals that the
prescribed intradialytic exercise intervention resulted in significant improvement in Kt/V, serum
creatinine, blood urea, serum potassium, phosphorous, and quality of life. Based on the findings
of the present study, it can be concluded that intradialytic exercise program is a safe
complementary intervention and does not need an extra time of the patient and showed
improvement in patients’ outcome.

Introduction of toxins and fluids creating fluid and electro-

End-stage renal disease (ESRD) is emerging
as a major health problem in the developing
countries.1 Chronic kidney disease involves
progressive, irreversible destruction of the
nephrons in both kidneys leads to accumulation
Correspondence to:
Mrs. Thenmozhi Paluchamy,
Saveetha College of Nursing, Saveetha
University, Chennai, Tamil Nadu, India.
E-mail: thenmozhi.sethu@gmail.com
lyte imbalances and must be treated with renal
replacement therapy for the survival (National
Kidney Foundation). The common and the
most widely used renal replacement therapy in
hemodialysis (HD).
Despite advances in ESRD with HD, physical
functioning and health-related quality of life is
still lower among these patients due to pain,
fatigue and sleep pattern disturbances com-
pared to a healthy population. Some comple-
mentary interventions such as relaxation the-
rapy, yoga, meditation, exercise program may
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Intradialytic exercise on dialysis efficacy
influence to improve the quality of life.
We aimed to investigate the effectiveness of
exercise program to improve the well-being of
the patient with end-stage renal disease on HD.
Previous literature has documented a variety
of potential benefits that ESRD patients may
achieve from exercise training.1 Improvements
in reaction time and lower extremity muscle
strength,2 left ventricular systolic function,3
and psychosocial functioning4 have all been
demonstrated in randomized clinical trials.
Studies have also provided evidence suppor-
ting the association of exercise training with
improvement in urea clearance,5 decrease in
pulse pressure,6 increase in aerobic capacity,1
reduced need for antihypertensive medica-
tions,7 increase in hemoglobin concentration,
hematocrit levels as well lipid metabolism,8
relieves fatigue9 exercise improves the removal
of toxin through dialysis.10
Considering the potential positive effects of
intradialytic exercise, we conducted the study
on intradiaytic exercise using cycle ergometer
which helps to improve the urea clearance by
opening vascular beds in the working muscle
and exposing more tissue which allows the
fluid in the tissue to move to the intravascular
compartment.11 In addition, shift of the ions
such as potassium and phosphate from the
intracellular compartment into muscle intersti-
tial fluid occurs during exercise.12 Intradialytic
exercise is therapeutic for these patients
because it tends to blunt or even reverse some
of the insidious changes that occur in end-
stage renal failure.
Materials and Methods
The experimental research design was adop-
ted to conduct the study with 20 patients in the
Dialysis Unit of Saveetha Medical College and
Hospital from March to May 2017 after
obtaining approval from ethical clearance with
reference number 014/05/2016/IEC/SU, and
formal permission was obtained from the hos-
pital authority. Those who met the inclusion
criteria were selected and randomly allocated
into experimental group (n = 10) and control
group (n = 10). Patients on HD with sympto-
903
matic cardiovascular disease such as unstable
angina, recent myocardial infarction, conges-
tive cardiac failure Grade II, body tempera-
ture more than 101°F, persistent hyperkalemia
before dialysis, active liver disease, musculo-
skeletal limitations, severe peripheral poly-
neuropathy, dementia or other mental disorders,
on other exercise program, hemodynamically
unstable during the dialysis treatment and
lower limb amputation were excluded from the
study. The patients were given explained about
the purposes of the study and written informed
consent was taken from each participant.
Demographic variables were collected by
interview method. The pre-test was conducted
on physiological parameters such as weight
and blood pressure checked by a standardized
and calibrated digital scale and sphygmo-
manometer. Blood samples were drawn for
biochemical markers such as blood urea, serum
creatinine, serum potassium, serum calcium,
serum phosphate, and hemoglobin. Kt/V value
was calculated, and KDQOL-SF™ version 1.3
scale was completed to assess the quality of
life for each participant. The intradialytic
exercise was prescribed for 10 to 15 minutes a
day during the first 2 h of HD session for three
times a week for 12 weeks according to the
tolerance of the patients by using bicycle
ergometer to the experimental group.
Participants were asked to do the exercise
once all the tubings of the vascular access were
connected to the hemodialysis machine and all
the alarms associated with connection of
tubings got turned off and the patient became
stabilized. The exercise was performed with
the participants in dorsal position on the bed.
The duration of exercise program for each
session was 10-15 minutes. Each session
began with 3-5 minutes of warm up exercise
which included extension, flexion, internal and
external rotation of knee and plantar flexion,
dorsiflexion, inversion, eversion and rotation
of ankle. It was done for each leg.
Cycling was done for 5 min using the bicycle
ergometer and rest for 3–5 min and if needed
again the cycling was continued for another 5
– 10 min depending on the tolerance of the pa-
tient with or without rest for 3–5 min. Exercise
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904 Paluchamy T, Vaidyanathan R

session ended with cool down exercise for 3–5
min after cycling.
Control group received routine care. Tolerance
of the patients, especially target heart rate for
doing exercise period was calculated by
Karvonen formula, monitored the vital signs
like blood pressure, heart rate during exercise
and informed the client to report any side
effects such as dyspnea, dizziness, and palpi-
tation. Pre-demonstration on exercise was
demonstrated before initiating the exercise.
Posttest was conducted at the end of 12 weeks
immediately after the dialysis session. Confiden-
tiality was maintained throughout the procedure.
The effectiveness of intradialytic exercise on
Dialysis adequacy, physiological parameters,
biochemical parameters and quality of life of
the clients was determined in experimental
group and comparison between the experi-
mental group and control group was done
using Statistical Package for Social Science
version 20.0 (IBM Corp., Armonk, NY). P
<0.05 were considered statistically significant.
Results
Twenty patients completed the study, 10 in
experimental group and 10 in control group.

Table 1. Distribution of patients on hemodialysis according to demographic variables.

Experimental group Control group
Demographic variables χ2
n % N %
Age in years
18–30 2 20 - -
31–50 3 30 3 30 2.33 (P = 0.31)
51–70 5 50 7 70 (NS)
>71 - - - -
Gender
Male 9 90 9 90
0.0 (P = 1.00)
Female 1 10 1 10
Residence
Rural 9 90 5 50
Semi Urban 1 10 2 20 4.48 (P = 0.11)
Urban - - 3 30
Marital status
Married 7 70 8 80
Unmarried 2 20 1 10
0.40 (P = 0.82)
Widow - - - -
Divorcee 1 10 1 10
Educational status
Illiterate 4 40 5 50
Primary school 4 40 5 50
2.22 (P = 0.33)
Higher secondary 2 20 - -
Graduate and above - - - -
Occupational Status
House wife 2 20 6 60
Daily wages 4 40 3 30
3.94 (P = 0.14)
Government job - - - -
Private job 4 40 1 10
Income in Rupees
<Rs. 5000 9 90 10 100
5001–10,000 1 10 - -
1.05 (P = 1.00)
10,001–15,000 - - - -
>15,000 - - - -
NS: Not significant, %: Percentage, P: Calculated probability.
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Intradialytic exercise on dialysis efficacy 905

The majority of the patients was male and was the differences in the diastolic mean values
in the age group of 51–70 years in both the (81.4 vs. 83.0) were not statistically significant
groups. There were no significant differences as shown in Table 5. The difference in the
in sociodemographic variables and clinical mean values of both systolic and diastolic
variables between experimental group and pressure and weight was not statistically signi-
control group which shows the homogeneity of ficant as shown in Table 6. However, there is
the samples as shown in Tables 1 and 2. statistically significant difference in weight in
There was a significant (P <0.01) increase in experimental group after the intervention as
the level of Kt/V and this showed that the demonstrated in Table 5.
intervention of intradialytic exercise was Table 7 demonstrates the comparison of bio-
effective on dialysis efficacy among patients chemical parameters in the pretest and posttest
on HD. When comparing the Kt/V value bet- among patients in the experimental group. The
ween the experimental group an control group, serum creatinine mean value in the pretest was
the mean value of 1.15 in the experimental 10.62 as compared to 10.23 in the posttest and
group was significantly higher compared to the difference was not statistically significant.
0.99 in control group (P <0.01) and this However, the differences in the mean values
demonstrated that the intervention was effec- for blood urea, serum calcium, and serum
tive as presented in Tables 3 and 4. phosphate were statistically significant (P
The systolic mean value in the pretest was <0.05). Serum potassium and hemoglobin
145.9 as compared to 137.0 in the posttest showed no difference. This showed that there
showing that the systolic blood pressure was was a significant improvement in the level of
reduced. The difference in the mean values was blood urea, serum calcium, and serum phos-
statistically significant (P <0.05). However, phate. There was a significant difference in the
Table 2. Distribution of patients on hemodialysis according to clinical variables.
Experimental group Control group
Demographic variables χ2
n % N %
Family history of ESRD
Yes 1 10 7 70
7.5 (P = 0.01)
No 9 90 3 30
Duration of ESRD
<1 year 4 40 4 40
1–3 years 5 50 6 60
1.09 (P = 0.58)
3–5 years 1 10 - -
>5 years - - - -
Cause for kidney disease
Diabetes mellitus 1 10 3 30
Hypertension 3 30 3 30
Polycystic kidney disease - - 1 10 5.0 (P = 0.29)
Unknown etiology - - 1 10
Any other cause 6 60 2 20
Duration of HD
<6 months 3 30 2 20
6 months–1 year 1 10 2 20
1–2 years 4 40 1 10 6.0 (P = 0.20)
2–3 years 1 10 5 50
>3 years 1 10 - -
HD treatment per week
Thrice in a week 6 60 6 60
0.0 (P = 1.0)
Twice in a week 4 40 4 40
%: Percentage, P: Calculated probability, ESRD: End-stage renal disease, HD: Hemodialysis.
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906 Paluchamy T, Vaidyanathan R

Table 3. Effectiveness of intradialytic exercise on Kt/V in the experimental group.

Mean SE (mean Paired
Variables Test Mean SE P
difference difference) “t”
Pre test 1.07 0.04
Kt/V 0.08 0.20 4.0 0.003
Post test 1.15 0.03
SE: Standard error, Pre: Pre test, Post: Post test, P-value: Calculated probability.

Table 4. Comparison of Kt/V values between the experimental group and control group after the
intervention.
Mean SE (mean Unaired
Variables Group Mean SE P
difference difference) “t”
EG 1.15 0.03
Kt/V 0.08 0.16 3.14 0.006
CG 0.99 0.04
SE: Standard error, Pre: Pre test, Post: Post test, P-value: Calculated probability.

Table 5. Effectiveness of intradialytic exercise on physiological parameters in the experimental group.

Mean SE (Mean Paired
Blood pressure Test Mean SE P
difference difference) “t”
Systolic blood Pre 145.9 5.0
8.9 2.81 3.17 0.011
pressure Post 137.0 5.17
Diastolic blood Pre 81.4 4.87 0.716
1.6 4.26 0.38
pressure Post 83.0 4.49 (NS)
Pre 59.02 2.3
Weight 0.77 0.28 2.79 0.02
Post 58.25 2.47

Table 6. Comparisons of physiological parameters between the experimental group and control group
after the intervention.
Mean SE (Mean Unpaired
Blood pressure Test Mean SE P
difference difference) “t”
Systolic blood EG 137.0 5.17 0.132
11.0 6.97 1.58
pressure CG 148.0 4.67 (NS)
Diastolic blood EG 83.0 4.49
0 6.34 0 1.0 (NS)
pressure CG 83.0 4.49
EG 58.25 2.47 0.56
Weight 3.55 6.0 0.59
CG 61.8 5.47 (NS)
SE: Standard error, EG: Experimental group, CG: Control Group, P-value: Calculated probability, NS:
Not significant.

reduction of serum creatinine, blood urea,
serum potassium, and serum phosphate level at
the level of P <0.05, but there is no difference
in the serum calcium and hemoglobin level
between the experimental group and control
group.
When considering the effectiveness of intra-
dialytic exercise on quality of life in the expe-
rimental group, there was a significant improve-
ment in the level of quality of life at the level
of P <0.05 in all four domains such as physical
health, mental health, kidney disease problems,
and patient satisfaction as shown in Table 8.
This showed that the patients in experimental
group had felt good quality life and there was
a significant difference in the quality of life
among patients between the experimental group
and control group at the level of P <0.05.
Discussion
Patients on HD are less active when com-
pared to healthy sedentary work individuals
and have low intrinsic motivation for physical
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Intradialytic exercise on dialysis efficacy 907

Table 7. Effectiveness of intradialytic exercise on Biochemical Markers in the experimental group

Biochemical Mean SE (mean Paired “t”
Test Mean SE P
variables difference difference)
Pre 10.62 0.68
Serum creatinine 0.39 0.55 0.71 0.49
Post 10.23 0.72
Pre 94.02 6.34
Blood urea 12.64 5.22 2.42 0.04
Post 81.38 4.17
Pre 7.82 0.41
Serum calcium 0.56 0.22 2.60 0.03
Post 8.38 0.35
Pre 5.03 0.23
Serum phosphate 0.43 0.18 2.34 0.04
Post 4.60 0.14
Pre 5.58 0.20
Serum potassium 0.4 0.20 2.03 0.08
Post 5.18 0.15
Pre 8.23 0.44
Hemoglobin 0.12 0.21 0.58 0.58
Post 8.35 0.51
SE: Standard error, Pre: Pre test, Post: Post test, P-value: Calculated probability.

activity. Physical activity results in improve- male and falls in the age group of 51–70 years.
ment in physical function and well-being. Sociodemographic data reveals that the majo-
Although there are many studies that have rity of the patients were male and falls in the
proven the potential benefits of intradialytic age group of 51–70 years. These findings are
exercise, exercise during dialysis is not imple- consistent with the study obtained by Bayoumi
mented in many dialysis units. et al, who presented that their demographic
The results of this study revealed that there data for patients undergoing HD about two-
were no significant changes were found in third 60 and below years of age patients and
sociodemographic variables and clinical varia- more than 50% of their sample were males.13
bles between the experimental group and the On the other hand, Johansen, suggested that
control group. Majority of the patients were the recommendations for older adults (65
Table 8. Comparison of quality of life among the patients with hemodialysis in the experimental group
before and after the intervention.
Mean SE (mean Unpaired
Variables P
difference difference) “t”
Symptoms and problems 111.50 47.91 2.33 0.03
Effects of kidney disease on daily life 80.00 19.47 4.10 0.001
Burden of kidney disease 90.00 18.25 4.93 0.000
Work status 40.00 18.25 2.19 0.42
Cognitive function 72.00 16.78 4.28 0.000
Quality of social interaction 54.00 11.94 4.52 0.000
Sleep 17.00 13.84 1.22 0.235
Social support 40.00 15.63 2.59 0.19
Dialysis staff encouragement 32.50 10.96 2.96 0.008
Patient satisfaction 29.99 3.51 8.53 0.000
Physical Functioning 32.50 44.88 0.72 0.478
Role Limitation caused by physical health 50.00 32.14 1.55 0.137
Role limitation caused by emotional health 80.00 35.90 2.22 0.39
Social functioning 12.00 9.72 1.23 0.233
Emotional well-being 80.00 23.73 3.37 0.003
Pain 14.50 10.29 1.40 0.178
Energy/fatigue 4.00 17.10 0.23 0.818
SE: Standard error, P-value: Calculated probability.
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908
years and above) and adults aged 50–64 years
with clinically significant chronic conditions
and/or functional limitations.14
With regard to Kt/V, there was a significant
increase in the level of Kt/V, and this showed
that the intervention of intradialytic exercise
was effective on dialysis efficacy. The results
of this study findings are parallel with the
study conducted by Mohseni et al, who repor-
ted that overall 11% increase in URR and 38%
improvement in Kt/V after eight weeks of
intradialytic exercise program.15 Accordingly,
the study demonstrated by Giannaki et al, who
revealed that Kt/V significantly improved by
20% and concluded that the prolonged low-
intensity intradialytic exercise improved hemo-
dialysis efficiency, with no adverse effects.16
Recently a study conducted by Neil Smart et
al. also supported the present study.17
In the present study, we found that there is a
significant reduction in systolic blood pressure
after the prescription of intradialytic exercise
in the experimental group. This finding is
consistent with the findings of Miller et al,
which showed that stationary cycling is safe
during HD and can lead to significant reduc-
tions in blood pressure.7 Similarly, Henrique et
al, stated that intradialytic exercise shows a
significant reduction in systolic blood pres-
sure, diastolic blood pressure, and average
arterial pressure.18
In relation to biochemical markers in the pre-
sent study serum creatinine, blood urea, serum
potassium, calcium, phosphate, and hemoglo-
bin level were compared between experi-
mental group and control group and found that
among patients in the experimental group,
there was a significant improvement in the
level of blood urea, serum calcium, and serum
phosphate, but serum potassium and hemo-
globin showed no difference. However, there
was a significant difference in the reduction of
serum creatinine, blood urea, serum potassium
and serum phosphate. However, there were no
difference in the serum calcium and hemo-
globin level between the experimental group
and control group. Makhlough et al, also re-
ported that significant improvements in serum
phosphate levels (decreased by 1.84 mg/dL)
Paluchamy T, Vaidyanathan R
and serum potassium levels and serum cal-
cium, but hemoglobin levels did not change
significantly in the exercise group in his
study.19 Similarly in a study done by Orcy, et
al, aerobic exercise during HD increases the
efficacy of phosphate removal, without changing
urea, creatinine and potassium removal.20
Interestingly, Adorati, has demonstrated that
exercise during dialysis reduces urea rebound,
increases creatinine removal and, importantly,
increases phosphate removal, and also contri-
butes to the general well-being of the dialysis
patient. These studies were come in accor-
dance with the findings of the present study.21
Findings of Musaivan indicated that there is an
improvement in the level of hemoglobin in the
experimental group at the end of 8th week
when compared with the start of the study but
present study is in contrast with these findings.22
Vaithilingam et al, suggested intra-dialytic
exercise result in increased dialytic removal of
a phosphate and could be expected in the long
term to improve phosphate control.23
Quality of life depends on dialysis efficacy
and literature review shows that there are
many factors that influence dialysis efficacy
like the type of dialyzer machine, dialyzer
membrane, the frequency of dialysis, duration
of dialysis, physiological variations among
patients, etc. The present study examined the
effectiveness of intradialytic exercise on the all
four domains of quality and revealed that
experimental group had a sense of the overall
good quality of life and there was a significant
difference in the quality of life among patients
between the experimental group and control
group. Those findings are consistent with the
findings of Wu et al, who showed exercise
during maintenance HD significantly improved
the exercise capacity and HRQoL for uremic
patients within a short time period.24 Similarly,
El Shemy et al found that there were signi-
ficant differences and improvement in studied
patients of all domains of QOL scores, (P
<0.05) and also strong statistically significant
positive correlations in all domains of SF36.25
This was also supported by the findings of
who concluded that physical exercise during
dialysis improves the physical (physical func-
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Intradialytic exercise on dialysis efficacy
tion, daily activities, pain and discomfort,
sleep), and psychological problems in HD
patients, and finally enhance their quality of
life.26 The result of the study is limited in
biochemical markers related to intradialytic
exercise such as lipid profile, fasting blood
sugar, and cytokines. However, we feel that a
similar study should be replicated using larger
sample size to further investigate the effects of
intradialytic exercise.
Conclusion
The finding of the present pilot study reveals
that the prescribed intradialytic exercise inter-
vention resulted in significant improvement in
Kt/V, serum creatinine, blood urea, serum
potassium, phosphorous, and quality of life
with no adverse effects. It also found that this
exercise program is safe complementary inter-
vention and do not cost the patient extra time.
Acknowledgment
The authors would like to thank all the
participants who accepted to be involved in the
research study.
Conflict of interest: None declared.
Date of manuscript receipt: 23 October 2017.
Date of final acceptance: 14 December 2017.
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