Int Urol Nephrol (2016) 48:1705–1711
DOI 10.1007/s11255-016-1388-7
NEPHROLOGY - ORIGINAL PAPER
The effect of hemodialysis on balance measurements and risk
of fall
Ertugrul Erken1   · Ruya Ozelsancak2 · Safak Sahin3 · Emine Ece Yılmaz4 ·
Dilek Torun2 · Berrin Leblebici4 · Yunus Emre Kuyucu5 · Siren Sezer6 
Received: 27 May 2016 / Accepted: 27 July 2016 / Published online: 6 August 2016
© Springer Science+Business Media Dordrecht 2016
Abstract  Results Fall Index scores of healthy controls were lower
Background  Patients with end-stage renal disease (ESRD)
have increased risk of falls and fall-related complications.
Other than aging and factors related to chronic kidney dis-
ease, treatment of hemodialysis may also contribute to this
increased risk. The aim of this study was to demonstrate
the impairment of balance after a session of hemodialysis
with a quantitative assessment and reveal an increased fall
risk that would possibly be related to treatment of hemodi-
alysis for patients on maintenance hemodialysis.
Methods  Fifty-six patients with ESRD on chronic hemodi-
alysis program and 53 healthy individuals were involved in
this study. Fall Index percentages were calculated, and fall
risk categories were determined for all patients and healthy
controls using Tetrax posturography device (Sunlight Med-
ical Ltd Israel). The patient group was evaluated twice for
balance, before and after a routine session of hemodialysis.
* Ertugrul Erken
ertugrulerken@hotmail.com
Ruya Ozelsancak
rusancak@hotmail.com
Safak Sahin
drsafaksahin@gmail.com
Emine Ece Yılmaz
eceyilmaz@gmail.com
Dilek Torun
dilektorun@hotmail.com
Berrin Leblebici
berrinleblebici@yahoo.com
Yunus Emre Kuyucu
kuyucuemre@hotmail.com
Siren Sezer
sirensezer@hotmail.com
than that of ESRD patients (p  = 0.001). In the patient
group, we found the mean Fall Index to be significantly
higher at the post-dialysis assessment compared to the pre-
dialysis assessment (p  = 0.003). The number of patients
with high risk of falling also increased at the post-dialysis
assessment yet the difference did not reach significance.
Fall Index was correlated with the increase in age only at
the pre-dialysis balance measurement (p = 0.038). Patients
with better dialysis adequacy had significantly lower Fall
Index scores than the others at the pre-dialysis balance
measurement (p  = 0.004). The difference was not signifi-
cant at the post-dialysis measurement.
Conclusions In the current study, we evaluated the bal-
ance of ESRD patients before and after a routine session of
hemodialysis treatment. This is the first study to investigate
the effect of hemodialysis on balance, using an electronic
1
Department of Nephrology, Faculty of Medicine,
Gaziosmanpasa University, Tokat, Turkey
2
Department of Nephrology, Adana Research and Training
Hospital, Faculty of Medicine, Baskent University, Adana,
Turkey
3
Department of Internal Medicine, Faculty of Medicine,
Gaziosmanpasa University, Tokat, Turkey
4
Department of Physical Therapy and Rehabilitation, Adana
Research and Training Hospital, Faculty of Medicine,
Baskent University, Adana, Turkey
5
Department of Biostatistics, Faculty of Medicine,
Gaziosmanpasa University, Tokat, Turkey
6
Department of Nephrology, Faculty of Medicine, Baskent
University, Ankara, Turkey
13

1706
posturographic balance system. We found the Fall Index
score to be significantly higher after hemodialysis, indicat-
ing a negative effect of hemodialysis on postural stability.
As expected, our data showed an increased Fall Index score
correlated with the increase in age both in ESRD patients
and in healthy controls. However, the correlation with age
was not observed for the patient group at the post-dialy-
sis balance measurement. We might conceive that young
patients with ESRD are also prone to fall risk after a session
of hemodialysis. Methods that provide quantitative assess-
ment for fall risk could be rather beneficial for high-risk
populations such as patients on maintenance hemodialysis.
Keywords  Balance · Hemodialysis · Fall risk · End-stage
renal disease · Postural stability
Introduction
The incidence of end-stage renal disease (ESRD) is increas-
ing worldwide, and chronic hemodialysis is the most com-
monly used treatment modality. Since chronic kidney dis-
ease (CKD) and aging are entities that usually interact with
each other, clinicians are accustomed to treat senile ESRD
patients on maintenance hemodialysis. Therefore, neph-
rologists are mostly focused on cardiovascular and cerebro-
vascular risks, but they are also required to draw some of
their attention to geriatric medicine and other complica-
tions these patients can experience. Like many other sys-
tems, the locomotor and neurologic systems may be nega-
tively effected in patients with ESRD [1, 2]. These patients
usually have reduced levels of physical activity, myopa-
thies, neuropathies and even drug-induced complications
that distort their locomotion and balance [2, 3].
Disregulation of postural stability and balance results in
increased risk of falls. Hip fractures related with fall inju-
ries are an important cause of morbidity and mortality for
the elderly [1]. Patients with ESRD are even more prone
to fall injuries than the general population due to addi-
tional factors superimposed by CKD, comorbidities and
dialytic therapies [3–5]. Mineral bone disorder, electrolite
imbalance, anemia-related symptoms, metabolic acidosis,
polypharmacy, malnutrition, muscle athropies and fatigue,
intradialytic hypotension and dialysis-related arrhythmias,
peripherical and autonomic neuropathies are among these
factors contributing to increase the likelihood of falls in
patients with ESRD [4, 6]. As mentioned, some of these
factors are related to the treatment of hemodialysis which
is thought to impair postural stability and balance. The aim
of the current study is to investigate the effect of hemodi-
alysis treatment on balance and look for a possible relation
between hemodialysis and the increased incidence of fall
injuries in patients with ESRD.
13
Int Urol Nephrol (2016) 48:1705–1711
Materials and methods
Study group selection
ESRD patients were diagnosed by Department of Nephrol-
ogy at Baskent University Faculty of Medicine Research
and Training Hospital in Adana. Fifty-six patients on
chronic hemodialysis program (thrice weekly) were
included to the study (male/female: 32/24, mean age:
51.8  ± 15.2 years, mean duration on maintenance hemo-
dialysis 65.1 ± 52.8 months). Patients using canes or
walkers and patients with neurological or musculoskeletal
disorders causing gait difficulties were excluded from the
study. Fifty-three age- and gender-matched healthy volun-
teers (male/female: 30/23, mean age: 52 ± 14.3 years) con-
stituted the healthy control group. Informed consents were
obtained from all participants, and the study was permitted
by the ethics review board. Demographic features of patient
and control groups are shown in Table 1.
Balance measurements
Fall Index percentages were calculated, and fall risk cat-
egories were determined for all patients and healthy con-
trols using Tetrax posturography device (Sunlight Medical
Ltd Israel). This interactive balance assessment device can
monitor postural oscillations and evaluate the balance of a
test subject. The patient group was evaluated twice for bal-
ance, before and after a routine session of hemodialysis.
The system uses the Tetrax four-point balance platforms
which can record the vertical pressure fluctuations from the
heels and the tiptoes of the subject. He/she tries to stand
on the platform for a period of time (approximately 5 min),
and his/her postural stability is measured electronically.
The results define the subject’s general stability, weight
distribution, Fourier transformations (postural sway) and
synchronizations between foot parts. These parameters are
analyzed to determine the Fall Index of the subject. This
index was shown to be related to the risk of falls [7, 8].
The Fall Index score (from 0 to 100 %) can also be divided
into three categories of fall risk. Fall Index scores from 0
Table 1  Demographic features of the patient and healthy control
groups
Patient group Control group p value
(n = 56) (n = 53)
Age 51.8 ± 15.2 52.04 ± 14.3 0.934
Gender (M/F) 32/24 30/23 0.999
Height (cm) 163.7 ± 10.7 167.4 ± 7.9 0.043
Weight (kg) 67.09 ± 17.73 77.58 ± 15.65 0.001
BMI (kg/m2) 24.8 ± 5.5 27.6 ± 5.1 0.008
Int Urol Nephrol (2016) 48:1705–1711 1707
to 36 are evaluated to be ‘low risk,’ those from 37 to 58 are
evaluated to be ‘medium risk’ and those from 59 to 100 are
evaluated to be ‘high-risk’ individuals for falls [7, 8].
Clinical data collection
The subjects were monitored for complaints of dizziness
and episodes of orthostatic hypotension during the balance
measurements. Comorbid conditions of ESRD patients like
diabetes mellitus (DM), systemic hypertension (HT) and
anemia were recorded. Dialysis adequacy of ESRD patients
was calculated as single-pool Kt/V (Daugirdas equation),
and Kt/V value ≥1.4 was considered as the recommended
adequacy of dialysis [9]. Laboratory findings of the patient
group are shown in Table 2. Blood pressure (BP) readings
were noted before and after the dialysis session. Body mass
index (BMI) of the patient group was calculated using their
dry weight.
Statistical analysis
Data were analyzed using SPSS software (Statistical
Package for the Social Sciences, version 19.0, SPSS inc.,
an IBM Co., Somers, NY). Values were expressed as
mean ± SD. Differences between group results were evalu-
ated using the unpaired t test and Chi-square test for mean
data. Paired t test and McNemar test were used to analyze
results for non-categorical variables. Linear regression
analysis was performed with enter method. p values <0.05
were accepted as statistically significant.
Results
Expression of Fall Index
The mean Fall Index score of the healthy control group was
33.06 ± 24.73 and it was significantly lower than both of the
pre-dialysis and post-dialysis Fall Index scores of the patient
group (p values 0.001 and <0.001, respectively; Fig. 1).
Fall Index score of the healthy controls was increased
with age (p value 0.001), and regression analysis revealed
that 19.4 % of the Fall Index could be explained by increase
Table 2  Laboratory findings of the patient group (n = 56)
Mean ± SD
Hemoglobin (g/dl) 11.32 ± 1.54
Calcium (mg/dl) 8.86 ± 0.73
Phosphorus (mg/dl) 5.2 ± 1.47
Kt/V 1.54 ± 0.33
in age. Fall Index was also correlated with the increase in
age for the patient group at the pre-dialysis balance meas-
urement (p value 0.038), yet the correlation was not sig-
nificant at the post-dialysis measurement (p value 0.124).
The rates of the Fall Index scores in the linear regression
analysis that could be explained by increase in age for the
pre-dialysis and post-dialysis balance measurements were
7.7 and 4.3 %, respectively.
Comparison of pre‑dialysis and post‑dialysis balance
measurements
Mean post-dialysis Fall Index was significantly higher than
the pre-dialysis Fall Index, indicating a decreased measure-
ment of balance after hemodialysis treatment (post-dialysis
59.07  ± 30.92 > 50.91 ± 31.38, p  = 0.003; Fig. 1). BP
values (sytolic = SBP, diastolic = DBP and mean = MBP)
were significantly lower after dialysis. Complaints of diz-
ziness during evaluation for balance also increased at
the post-dialysis measurement for the total 56 patients
(Table 3).
The number of patients with low risk of falling at the
pre-dialysis assessment was 22 (39.2 %) which decreased
to a number of 16 (28.5 %) at the post-dialysis assessment.
At the same time, the number of patients with high risk of
falling in the pre-dialysis assessment was 23 (41 %) which
increased to a number of 28 (50 %) at the post-dialysis
assessment yet the differences did not show statistical sig-
nificance (Table 4).
Fig. 1  Fall Index (y-axis) in healthy controls and ESRD patients
using Tetrax posturography device
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1708 Int Urol Nephrol (2016) 48:1705–1711

Table 3  Comparison of Fall Index scores and BP values before and Discussion

after hemodialysis treatment in the patient group
Pre-dialysis Post-dialysis t p value
Fall Index 50.91 ± 31.38 59.07 ± 30.92 3.129
SBP 111.1 ± 18.3 104.2 ± 15.8 5.540
DBP 69.4 ± 9.23 65.7 ± 8.7 4.528
MBP 83.1 ± 11.9 78.1 ± 10.4 5.616
Dizziness (%) 0.21 ± 0.41 0.38 ± 0.49 3.245
Thirty-one (55.3 %) of the total 56 ESRD patients had
the diagnosis of HT, and 12 (21.4 %) had DM. The mean
pre-dialysis and post-dialysis Fall Index scores of either
hypertensive or diabetic subgroups were not different
from the non-hypertensives and non-diabetics. Number
of patients with complaints of dizziness during balance
measurements was increased for the diabetic subgroup at
the post-dialysis measurement, but the difference was not
significant (p value 0.1). Orthostatic hypotension was only
denoted in four patients (three of them after the dialysis
and one before the dialysis session); none of these patients
were diabetic.
Plasma calcium, phosphorus and hemoglobin lev-
els and Kt/V values of the ESRD patients were analyzed
along with their Fall Index balance measurements. Serum
calcium (corrected to albumin) and phosphorus levels of
the patients were not correlated with either pre-dialysis or
post-dialysis balance scores (p values 0.55, 0.25 for cal-
cium and 0.38, 0.37 for phosphorus, respectively). When
we grouped the total 56 patients for their hemoglobin lev-
els, the patients with hemoglobin levels less than 11 g/
dl (n  = 22) had lower mean Fall Index score than those
with hemoglobin levels ≥11 g/dl/l (n  = 34) both in pre-
dialysis and post-dialysis measurements, but the results did
not reveal significance (p values 0.165 and 0.095, respec-
tively). Patients with better dialysis adequacy (Kt/V ≥ 1.4,
n = 19) had significantly lower mean Fall Index score than
the others (Kt/V < 1.4, n = 37) at the pre-dialysis balance
measurement (42.45 < 67.36, p value 0.004). The differ-
ence was not significant at the post-dialysis measurement
(54.4 < 68.15, p value 0.116).
Postural stability and balance are two similar terms; the
former can be explained as the ability to maintain the body
0.003
position, while the latter determines the risk of falling.
<0.001
Impaired postural stability and balance could lead to fall
<0.001
injuries and result in serious health problems and mortality
<0.001
especially for the elderly population [2, 10].
0.002
Patients with ESRD on hemodialysis have an increased
risk of falls. The rate of falls was found to be 1.18–1.60
falls/year which is quite higher than the fall rates of the
seniors living in the community [11, 12]. Previous studies
also indicate that these patients have increased risk of hip
fracture associated with increased risk of mortality [4, 12,
13]. Most patients with ESRD may have neuropathies in
connection to DM or accelerated atherosclerosis. Bone and
muscle pains related to CKD and physical inactivity lead to
muscle athropies. Besides, hemodialysis treatment distorts
the locomotor system functions due to electrolite imbal-
ance and hemodynamic changes, making it even harder for
them to maintain their balance [3, 14, 15].
In the current study, we evaluated the balance of 56
ESRD patients before and after a routine session of hemo-
dialysis treatment. This is the first study to investigate the
effect of hemodialysis on balance, using an electronic
balance system. The posturographic device we preferred
for this study offers a method with proved reliability [8,
16, 17]. We found the Fall Index score to be significantly
higher after hemodialysis compared to the pre-dialysis
measurement, indicating a negative effect of hemodialy-
sis on postural stability (p  = 0.003). Patients with ESRD
usually have impaired balance, and hemodialysis treatment
seems to be the reason for an even more increased risk of
falls.
We know that gait and balance difficulties increase with
age [15, 18]. As expected, our data showed an increased
Fall Index score correlated with the increase in age both in
ESRD patients and in healthy controls. However, the cor-
relation with age was not observed for the patient group at
the post-dialysis balance measurement. We might conceive
that young patients with ESRD are also prone to fall risk
after a session of hemodialysis.

Table 4  The number of patients separated by their fall risk categories before and after hemodialysis treatment (p, McNemar test)
Post-dialysis fall risk χ2 p value
Low risk (0–36 %) Middle risk (37–58 %) High risk (59–100 %)

Pre-dialysis fall risk

Low risk (0–36 %) 13 8 1 4.873 0.181
Middle risk (37–58 %) 3 1 7
High risk (59–100 %) 0 3 20

13
Int Urol Nephrol (2016) 48:1705–1711 1709
The Tetrax device that we used for balance measure-
ments gives a Fall Index score that can be classified as
low-, medium- and high-risk subjects for fall [7, 8]. With
these risk categories, we found out that the number of
ESRD patients at high-risk category increased and also the
number of patients at low-risk category decreased after a
session of hemodialysis. But, the differences did not show
statistical significance. When we look at the mean data
for Fall Index score, the mean pre-dialysis Fall Index was
50.91 (indicating a medium fall risk), and the mean post-
dialysis Fall Index was 59.07 (indicating a high fall risk).
Therefore, a similar risk assessment study with a larger
population of hemodialysis patients may reveal a signifi-
cant increase in the number of patients with high risk of fall
injuries at the post-dialysis assessment.
In a previous study by Sims et al. [6], results of a timed
walking test after a session of hemodialysis did not show
a significant effect on balance in 22 patients aged 60 years
or older. Contrary to this, our data revealed an increased
Fall Index score after hemodialysis. Not only did we use
an electronic balance assessment device but also we had a
larger and younger patient group. Thus, we could have been
more accurate to demonstrate a possible negative effect on
balance given rise by hemodialysis treatment.
Another study by Lockhart et al. [14] analyzed kin-
ematic gait and mobility characteristics of five ESRD
patients with a motion capture system. These five patients
showed less strength measures and longer movement times
after hemodialysis treatment. Their dynamic stability meas-
ures were not different after hemodialysis sessions. The
researchers laid emphasis on hemodialysis-related fatigue
to be a major factor for the results.
Indeed, muscle fatigue is frequent complaint among
patients on maintenance hemodialysis. Though it may be
masked by coexisting symptoms of anemia and cardiovas-
cular disease, the main reasons for muscle fatigue are mus-
cle athropies, uremic myopathy and endothelial dysfunc-
tion. Muscle fatigue may be more prominent after a session
of hemodialysis due to rapid changes in volume and elec-
trolite concentrations in extracellular fluids causing a tem-
porary blunting of neuromuscular stimulations [14, 19].
Some researchers mention that high serum calcium
levels along with uremia may contribute to myopathy
[19–21]. There are also studies asserting that supplemen-
tation of vitamin D improves postural stability and helps
to prevent fall-related complications among the elderly or
patients with CKD [22–24]. When we compared serum
calcium and phosphorus levels of our patients to their Fall
Index measurements, we did not find any associations. On
the other hand, most patients with ESRD receive calcitriol
unless they have hypercalcemia, hyperphosphatemia or
adynamic bone disease, and testing for vitamin D levels
(which is 25-OH cholecalciferol) has no extra benefit [24].
Another comorbid condition that is very common among
patients with CKD is anemia, and it may negatively affect
postural stability particularly in the elderly [15, 25]. Most
of the ESRD patients receive erythropoiesis-stimulating
agents for management of anemia and usually maintained
with hemoglobin levels between 11 and 12 g/dl [26, 27].
Interestingly enough, even if it the result was insignificant,
patients with hemoglobin levels <11 g/dl had lower Fall
Index scores in this study. Rather small sample size and
other comorbidities which may interfer the balance meas-
urements could have been the limitations to reveal some
possible effects of electrolite disturbances and anemia on
balance.
Chronic uremia may lead to peripheral neuropathy, myo-
pathy and muscle athrophies and result in increased likeli-
hood of fall injuries in patients with ESRD [15, 28]. There-
fore, better dialysis adequacy meaning better removal of
uremic toxins might improve the postural stability and bal-
ance for ESRD patients. Our results revealed significantly
less Fall Index scores (better balance) for patients with bet-
ter dialysis adequacy. Interestingly, the significance of the
difference was not observed at the post-dialysis measure-
ment for the same patients. We could say that the negative
effects of hemodialysis treatment on balance might possi-
bly be blunting the positive effects on gait and balance like
clearance of uremic toxins and correction of metabolic aci-
dosis, for a period of time just after hemodialysis. Inform-
ing our patients about the increased fall risk at this time
period on the way to their homes could help reduce the
incidence of fall injuries. We should also encourage chronic
HD patients to do exercise to improve their muscle strength
and postural stability [18, 19, 29].
Intradialytic hypotension and/or orthostatic hypotension
after hemodialysis are factors that can also pave the way
for fall injuries and fall-related complications. Autonomic
dysfunction, high-volume ultrafiltration during dialysis and
use of antihypertensives are factors that produce tendency
for dialysis hypotension. Hypotensive symptoms and pos-
tural hypotension after hemodialysis for elderly hemodialy-
sis patients are frequently notified in reports [5, 15, 30]. In
our study, complaints of dizziness increased significantly at
the post-dialysis balance measurement along with the Fall
Index scores as we expected. An important point was that
our dialysis population was younger than those of the pre-
vious studies [3, 5, 6, 30]. More than that, a recent study
by Farragher et al. [31] reported almost equal fall rates
in chronic hemodialysis patients and peritoneal dialysis
patients notifying that post-hemodialysis hypotension is not
the only contributor for falls in the dialysis population. Our
opinion is, the increased risk of falls related to treatment of
hemodialysis may not be peculiar to elderly or hypotensive
patients, but rather it may be the sum of the possible con-
tributing risk factors.
13

1710
Conclusions
Hemodialysis patients have an increased risk of falls due to
many factors, and some of these risk factors are related to
treatment of hemodialysis [4, 11, 13]. Yet it is not certain if
hemodialysis treatment causes balance problems for younger
patients with lesser comorbid conditions. Our results show
that ESRD patients have a significantly increased Fall Index
score after a session of hemodialysis and adjusting for age
revealed that post-dialysis balance measurements are less
likely to be explained by increase in age. In addition, ESRD
patients with better dialysis adequacy had better Fall Index
measurements at the pre-dialysis assessment.
A limitation for this study could be the sample size. A
larger group of hemodialysis patients could have revealed
a significantly increased number of patients with high-risk
category at the post-dialysis assessment along with the
increased Fall Index score.
We suggest all chronic hemodialysis patients to be ques-
tioned for previous history of falls and tested for gait and
balance with any reliable method available. Patients with
high-risk categories can be reevaluated for correctable fac-
tors like polypharmacy, inadequate dialysis, electrolite dis-
turbances, hypotensive symptoms and post-dialysis fatigue.
There are many methods developed for determining gait
and balance problems for elderly population [17]. Methods
that provide quantitative assessment for fall risk could be
rather beneficial for high-risk populations such as patients
on maintenance hemodialysis.
Compliance with ethical standards 
Conflict of interest  The authors declare that they have no competing
interests.
Informed consent  Human patients and healthy controls were tested,
and the study was carried out with the informed consent from all par-
ticipants.
Animal and human rights The study did not involve any animal
experiments or animal samples.
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