DOI: 10.1111/sdi.

12815

EXERCISE AND PHYSICAL ACTIVITY

I N D I A LY S I S P AT I E N T S
Guest Editors: Paul Bennett, Kenneth R. Wilund and Stephanie Thompson

Addressing myths about exercise in hemodialysis patients

Kenneth R. Wilund1 | Jin Hee Jeong2 | Sharlene A. Greenwood3,4

1
Department of Kinesiology and Community
Health, University of Illinois at Urbana‐ Abstract
Champaign, Urbana, Illinois Despite decades of research, there are few published guidelines related to the safety
2
Department of Population Health Sciences,
and efficacy of exercise training in hemodialysis patients. This has led to disparate
Medical College of Georgia, Augusta
University, Augusta, Georgia recommendations regarding the type, intensity, and timing for exercise, especially for
3
Department of Therapies and Renal patients with multiple comorbidities. Many common recommendations are not sup‐
Medicine, King's College Hospital NHS
Trust, London, UK
ported by research data, so their justification is uncertain. These recommendations
4
Department of Renal Medicine, Faculty of include exercising in the first hour of dialysis; not exercising if hypertensive, cramp‐
Life Sciences and Medicine, King’s College ing, or volume overloaded; avoiding heavy weights on vascular access limb; clinicians
London, London, UK
managing an exercise program; intradialytic exercise or interdialytic exercise is bet‐
Correspondence ter; and strength training during dialysis is impractical. The purpose of this review is
Kenneth R. Wilund, Department of
Kinesiology and Community Health, to describe the evidence that supports or refutes these beliefs. In summary, these
University of Illinois at Urbana‐Champaign, beliefs or myths have generally led to an overly conservative approach to exercise
906 S. Goodwin Avenue, Urbana, IL 61801.
Email: kwilund@illinois.edu that serves as a barrier to increasing physical activity levels in an overly sedentary
population that could benefit from moving more.

1 | I NTRO D U C TI O N
Exercise and physical activity recommendations for patients with end
stage kidney disease (ESKD) are often vague and not supported by
data. This makes it challenging for clinicians and exercise profession‐
als alike to prescribe physical activity programs for patients. To help
address some of these issues, this review will highlight common per‐
ceptions and concerns about exercise in ESKD patients, particularly for
those receiving maintenance hemodialysis (HD) therapy, and provide
evidence regarding their validity. We will include a discussion on topics
related to the appropriate type and timing of exercise and contraindica‐
tions to different types of exercise for HD patients. Furthermore, we
expose surprising gaps in the literature addressing exercise and dialysis.
2 | M Y TH # 1: I NTR A D I A LY TI C E X E RC I S E
S H O U LD O N LY B E PE R FO R M E D I N TH E
FI R S T H O U R O F D I A LYS I S
Many have recommended that intradialytic exercise to be performed in
the first hour or two of dialysis, primarily due to the hypothetical con‐
cerns that exercise may exacerbate the hemodynamic instability and/or
cramping that is most prevalent in the later stages of a dialysis session.1,2
However, there are not much data to support this recommendation, and
there are several disadvantages to following this advice. First, most clin‐
ics have limited exercise equipment, so limiting the time it can be used to
present logistical challenges with sharing equipment between patients.
It is also inconvenient to patients who may prefer to exercise at the end
of their shift, for example, because they prefer to sleep in the beginning.
Lastly, there is anecdotal and emerging evidence indicating some pa‐
tients may get relief from cramping, restless legs,3 and other intradialytic
symptoms by cycling at the end of their shift, as opposed to exercise
exacerbating these problems. Indeed, the optimal timing for intradialytic
exercise may vary due to many clinic and patient related factors.
The most prominent concern with the timing of intradialytic ex‐
ercise is related to its impact on intradialytic hemodynamic stress. It
is well known that exercise typically causes an increase in blood pres‐
sure as well as post‐exercise hypotension.4 The post‐exercise hypo‐
tension is most concerning, as this could presumably increase the
risk of adverse ischemic events, particularly during the latter phase
of HD when the total blood volume is reduced by ultrafiltration.5
Remarkably few studies have evaluated hemodynamic safety con‐
cerns with intradialytic exercise. Dungey et al recently showed that
intradialytic cycling might indeed cause post‐exercise hypotension,

Seminars in Dialysis. 2019;1–6. wileyonlinelibrary.com/journal/sdi

© 2019 Wiley Periodicals, Inc. | 1
2 |
though this was not associated with intradialytic symptoms or ex‐
acerbated markers of disease.6 Moreover, a recent trial by Rhee et
al showed that intradialytic cycling and resistance training reduced
symptoms associated with intradialytic hypotension.7
Surprisingly, only two studies to date have directly compared the
impact of the timing of the exercise on intradialytic symptoms. 2,8
In a
pilot study conducted in the 1980s, Moore et al, showed that 5 min‐
utes of moderate intensity cycling (60% of VO2 peak) was well tolerated
during the first and second hour of treatment. However, five out of eight
patients were unable to cycle during the third‐hour due to hypotensive
symptoms, including decreases in blood pressure, stroke volume, and
cardiac output.2 For several decades, this study has been cited as the
primary evidence for restricting exercise during the last hour of HD.
However, it should be noted that the five patients who could not com‐
plete the third‐hour exercise bout had a very high ultrafiltration (UF)
volume (4.6 ± 1.3 L). This suggests that volume overloaded patients re‐
quiring very high UF rates may suffer fewer intradialytic symptoms if
exercising near the beginning of their treatment. However, we do not
believe this should be used as evidence for restricting exercise in the
final hour of HD for patients with adequate volume control and more
typical UF rates. Indeed, a recent study by Jeong et al found no differ‐
ence in intradialytic hemodynamic parameters when patients cycled for
30 minutes at a moderate intensity during either the first or third hour
of treatment, compared to an HD treatment with no exercise.8
Taken together, these data add to the evidence in the literature
that intradialytic exercise is safe,9-11 even when performed in the
last hour of treatment. While more data are clearly needed to con‐
firm these findings, a blanket contraindication against exercise in the
last hour of HD does not seem warranted. Instead, patients should be
provided the opportunity to choose the optimal timing for their exer‐
cise, based on a combination of factors, including: patient's personal
preference; history of intradialytic symptoms; ultrafiltration goal; and
staff availability and workflow. It is our experience that most patients
prefer to exercise early in their treatment, but this is not universal, es‐
pecially for patients who dialyze during morning clinic shifts. Involving
patients in the discussion of when to exercise could lead to improved
health through better adherence to a chosen exercise program.
3 | M Y TH # 2 . E X E RC I S E S H O U LD B E
AVO I D E D I N H Y PE RTE N S I V E D I A LYS I S
PATI E NT S
Hypertension guidelines for contraindicating exercise may not be
relevant, or at least considered to be too conservative for dialysis
patients. According to general guidelines, a patient is considered
to have hypertension if their blood pressure (BP) is 140/90 over
a period of time.12 However, the Dialysis Outcomes and Practice
Patterns study (DOPPS) data indicate systolic blood pressure (SBP)
of 140‐160 is associated with lower mortality than “normal” BP.13
The complexity of the pathophysiological mechanisms that occurs
as a result of end‐stage kidney disease, and dialysis therapy, mean that
less conservative guidelines for exercising dialysis patients should be
WILUND et al.
Practical tips for nephrologists
• Published evidence supports the safety of exercise for
most patients, despite hemodialysis patients having
multiple comorbidities.
• The most effective form of exercise for hemodialysis pa‐
tients is likely to be any type that they are willing to do.
• Advise dialysis patients to move more, whenever they
have the opportunity and energy to do so.
Areas for future research
• Compare the effectiveness of traditional exercise pre‐
scriptions (eg, intradialytic cycling) to a liberalized ap‐
proach that allows patients the autonomy to choose the
types of physical activity in which they prefer to
participate.
• Examine the effects of intradialytic and interdialytic ex‐
ercise on patient reported outcomes such as cramping,
fatigue, and sleep patterns.
• Evaluate the efficacy of strategies to decrease hyperca‐
tabolism in hemodialysis patients.
considered to enable much needed exercise training to be realized in
routine care of dialysis patients. If we follow standard protocols for BP,
it would be difficult to exercise any dialysis patients. Pragmatic guide‐
lines for intradialytic exercise training in the UK contraindicate exer‐
cise training if there is uncontrolled hypertension (>180/100).14
The PrEscription of Intra‐Dialytic Exercise to Improve quAlity of
Life in Patients with Chronic Kidney Disease (PEDAL) randomized con‐
trolled trial (ISRCTN83508514) is underway in the UK. The protocol
for this study was designed by experts in the field of exercise and CKD,
and reflects the more pragmatic approach to exercising hypertensive
patients, stipulating an on‐the‐day embargo to exercise training with
erratic/fluctuating BP > 180/100. A further consideration for conser‐
vative guidelines is that there are not always standard CV responses to
intra‐dialytic exercise training (eg, HR and BP do not always increase at
onset, or reduce at cessation). This may be due to BP medications and/
or autonomic dysfunction, as well as ultrafiltration. There is a real need
for clinical decision making, by appropriately trained staff, and observa‐
tion of the dialysis patient during, and after exercise training. BP should
be assessed and utilized alongside clinical decision making, and patient
symptoms, to ensure that pragmatic exercise training can be realized.
4 | M Y TH # 3 . I NTR A D I A LY TI C E X E RC I S E
S H O U LD B E AVO I D E D I N VO LU M E
OV E R LOA D E D PATI E NT S
Predialysis volume overload is the sum of interdialytic weight gain
(IDWG) and residual postdialysis volume overload.15 While few
WILUND et al.
guidelines exist, clinical recommendations in many United Kingdom
(UK) renal units that operate pragmatic intradialytic exercise pro‐
grams are to avoid intra‐dialytic cycling or resistance training when
14
a patient's IDWG exceeds 4 kg. This recommendation reflects con‐
cerns that excessive IDWG may impact resting BP and heart rate
(HR) indices, which may be further increased with exercise training.
There is no published evidence to support an absolute con‐
traindication to intradialytic exercise with an IDWG of >4 kg. This
arbitrary cut‐off point should, therefore, be interpreted alongside
patient symptoms and other physiological parameters. For example:
an excessive IDWG that severely impacts resting BP and HR indi‐
ces (eg, BP > 160/100 and HR > 100 bpm) with symptoms of volume
overload, would contra‐indicate intradialytic exercise training for
that session. However, an IDWG >4 kg in the absence of these symp‐
toms and signs should not preclude intradialytic exercise training. It
is of utmost importance to have appropriately trained rehabilitation
staff who are able to clinically reason as to whether it is appropriate
to proceed with exercise training, and who are able to monitor car‐
diovascular parameters and patient symptoms through‐out the ex‐
ercise session. Other parameters used to assess fluid overload may
prove useful in the clinical decision making for the appropriateness
of exercise during dialysis. This includes excessive ultrafiltration
rates (eg, >13 mL kg−1 min−1),16 pre‐dialysis overhydration (>15% by
bioimpedance spectroscopy), and large intradialytic reductions in
relative blood volume (from Critline). However, research is needed
to evaluate the utility of these approaches for helping guide exercise
prescription.
5 | M Y TH # 4 . D I A LYS I S PATI E NT S W ITH
A N A RTE R I OV E N O U S FI S T U L A ( AV F ) O R
G R A F T ( AVG) S H O U LD AVO I D LI F TI N G
H E AV Y W E I G HT S W ITH TH E I R ACC E S S A R M
There is a widely held notion that heavy resistance training (RT) can
cause harm to a patient's vascular access, yet there are limited data
to support or refute this notion. This has led to patients receiving
very conservative recommendations, such as “avoid lifting heavy
weights”, or “do not lift more than 5‐10 pounds with your access
arm.” While it is clear that precautions should be taken over con‐
servative recommendations, serve as a barrier to RT in a population
that needs more encouragement to exercise, as opposed to reasons
to remain sedentary.
One reason for this conservative advice for RT with the access
arm may be related to the initial healing process immediately follow‐
ing arterio‐venous fistula (AVF) surgery. In one of the few published
guidelines related to this topic, a position statement out of Australia
suggests that “Hemodialysis patients should avoid upper limb ac‐
tivity with temporary or healing arterio‐venous fistulas.”1 However,
there is no timeframe put on this recommendation, and it is likely
that clinical practice varies significantly. Light forearm exercises (eg,
ball squeezing) begun as early as 24 hours after the AVF surgery has
been shown to improve fistula maturation.17,18 However, in clinical
| 3
practice it is common to commence forearm exercises 2 weeks after
the AVF surgery. Handgrip exercises also have been shown to im‐
prove forearm endothelial function in the nonaccess arm,19 though
no data appears to exist demonstrating analogous benefits in the
AVF arm.
While some restrictions on RT following recovery from AVF sur‐
gery is logical to promote healing, there are no data to suggest that
significant limitations should be placed on RT once the AVF has ma‐
tured. For example, the Southern Alberta Renal Program has unpub‐
lished clinical practice guidelines stating that once a patient's AVF
is established, minimal restrictions should be put on RT intensity or
volume, as long as progression is gradual. Indeed, the only activity
that is contraindicated is one in which the AVF would be pressed
against a pad of a machines (eg, a pectoral fly).
In one of the more intense upper body RT protocols published
to date, Cheema et al conducted a 12 weeks progressive RT pro‐
tocol in HD patients that included two sets of eight repetitions of
10 RT exercises at an RPE of 15‐17 (moderately hard), including five
upper body exercises with dumbells. The nonaccess arm exercises
were performed during dialysis, while the access arm exercises were
performed in the clinic lobby just prior to dialysis. Importantly, there
were no adverse events related to the AVF reported from the RT in
this trial. 20 Lastly, anecdotal evidence suggests that a small subset
of HD patients perform regular, intense RT without damaging their
AVF (see, eg, https://www.facebook.com/RenalWarrior/). While
recognizing the obvious limitations of anecdotes, they suggest the
possibility that the conservative approach to RT in HD patients is
misguided.
Though patients are often given conservative advice to limit RT
using their AVF arm, there are no data in the literature to support
this. It appears that light exercises can commence almost immedi‐
ately following the AVF surgery to help with maturation. Moreover,
once the access matures, few limitations should be placed on RT
activities as long as progression is slow and closely monitored. The
conservative clinical practice to restrict RT with the AVF arm is likely
a significant and unnecessary barrier to exercise in HD patients,
though clinical trials are needed to help develop more specific guide‐
lines supported by data instead of anecdote.
6 | M Y TH #5 . E X E RC I S E PRO G R A M S I N
D I A LYS I S C LI N I C S C A N B E E FFEC TI V E LY
M A N AG E D BY TH E E X I S TI N G C LI N I C S TA FF
Implementing exercise programs in HD clinics are challenging, even
when dedicated exercise professionals are available to help manage
the program. It is even more difficult when the programs are man‐
aged by existing clinic staff. Staff‐managed programs typically rely
on dedicated nurses and technicians that have more pressing work‐
related duties. 21-23 They also typically lack the necessary training to
be able to assess patient's readiness for exercise or provide them
with significant guidance on how to develop a robust exercise plan.
As a result, staff led programs typically consist of simple activities
4 |
such as intradialytic cycling with little attention paid to work rate or
progression, and tend to include only the most motivated patients
who need the least time and effort to encourage them to exercise.
These factors clearly limit the efficacy of staff‐led interventions.
Despite this, there are unique examples of intradialytic exercise
programs run exclusively by the clinic staff, such as in Mexico City.
In brief, patients at this clinic cycle continuously during their 4 hour
dialysis treatments with no resistance. The key to the success of this
program is that the Nephrologists at the clinic have mandated the pro‐
gram for all eligible patients. This suggests that top‐down support for
exercise programs in the clinics may be very important for their suc‐
cess. Indeed, physician approval for physical activity has been cited as
an important facilitator for patients engaging in exercise.22,24
In general, clinic staff often perceive there to be a lack of support
from the clinic management 21,23 and recognize the need for dedi‐
cated exercise professionals to run the program. 21,22 Some recent
data suggest that even programs run by a dedicated exercise profes‐
25
sional may have limited reach and effectiveness.
In the last several decades there have been many well‐inten‐
tioned exercise programs initiated by clinical staff that have even‐
tually failed. While there are indeed some success stories, many of
these programs are very limited in size and scope due to lack of time
and expertise to manage the program effectively. An alternative ap‐
proach that may be more effective than a traditional intradialytic
exercise program is to use this period to promote physical activity
outside of the clinic. Perhaps exercise professionals could serve as
consultants and help train the clinic staff to better manage the pro‐
gram. The cost of these consulting services may replace the costs
of buying and maintaining bikes and other exercise equipment in
the clinic. Unfortunately, until the benefits of exercise gain greater
acceptance in the Nephrology community, it is unlikely that neces‐
sary financial resources will be provided by clinics to sustain these
programs.
7 | M Y TH #6 . I NTE R D I A LY TI C (O U T O F
C E NTE R ) E X E RC I S E I S M O R E E FFI C AC I O U S
TH A N I NTR A D I A LY TI C E X E RC I S E
An important debate in the literature is whether in‐center (intradia‐
lytic) or out‐of‐clinic (interdialytic) exercise is more efficacious. In
theory, interdialytic exercise would appear to have many advantages
over intradialytic activity, primarily due to fewer restrictions on the
type, volume, and intensity of exercises that can be performed when
patients are not confined to a dialysis chair or bed. The main argu‐
ments in favor of intradialytic exercise is that it is very time efficient
for patients, and also compliance can be monitored more closely.
However, few studies have directly compared the efficacy of intra‐
dialytic and interdialytic exercise, and the data from these studies
suggest that compliance and benefits with both types of activities
were largely similar. 26,27
For example, in a long‐term study by Kouidi et al, 48 HD patients
were randomly assigned to exercise for 3 days/wk using supervised:
WILUND et al.
(a) interdialytic exercise; or (b) intradialytic exercise. After both 1
and 4 years, both groups demonstrated improvements in physical
fitness and self‐reported quality of life. However, while the benefits
appeared moderately better in the interdialytic group, the dropout
rate was higher. By contrast, in a 6‐month intervention by Koh et al,
neither interdialytic nor intradialytic exercise significantly improved
physical function or arterial stiffness compared to a nonexercising
control group. Surprisingly, the intradialytic exercise group had a
reduction in self‐reported physical function. These equivocal data
make it difficult to assess the relative efficacy of intradialytic vs in‐
terdialytic exercise.
Another important consideration regarding the best timing for
exercise is that dialysis represents a hypercatabolic period. 28 Since
exercise increases metabolic rate, intradialytic exercise in partic‐
ular could potentially exacerbate the catabolic effects of dialysis.
Indeed, several of the largest intradialytic training interventions
have yielded modest or inconsistent improvements in muscle mass
or body composition. 20,29-32 On the other hand, recent systematic
reviews and meta‐analyses indicate modest, yet statistically signif‐
icant improvements in muscle hypertrophy, strength, and function
from intradialytic exercise in HD patients, regardless of the type
or timing of the exercise. 33,34 Furthermore, there is no evidence
that intradialytic exercise of any type has deleterious effects on
body composition or function. Taken together, this suggests that
the lack of robust anabolic benefits in some studies may be due to
the low volume and intensity of exercise that is typically prescribed
in these studies, and not because exercise during the hypercata‐
bolic period of dialysis is deleterious. Interventions that include a
greater volume and intensity of resistance training are needed to
investigate this hypothesis.
The recently published EXCITE trial demonstrated that a
6 months interdialytic walking program significantly improved per‐
formance on a 6 minute walk test and some QOL related metrics.35
These data were important because it suggests that inexpensive,
low‐to‐moderate intensity interdialytic exercise programs that do
not burden the HD clinic staff are feasible and effective. While this
finding is encouraging, the magnitude of this improvement in physi‐
cal function was modest (~12%), and similar to what has been seen in
many other studies that employed both intradialytic and interdialytic
exercise.
There are pros and cons to both interdialytic and intradialytic
exercise. Historically, one‐size‐fits‐all approaches using mandated
exercise prescriptions (eg, progressive intradialytic cycling or fixed
resistance training protocols) have been the standard in the HD lit‐
erature. However, the lack of robust benefits in most trials suggests
that strong consideration should be given to change this paradigm.
We believe instead that interventions should be designed to allow
patients more autonomy to select types of activities in which they
choose to engage. This could certainly include both intradialytic and
interdialytic activities based on patients’ needs and preference and
individual safety risk profiles. A liberalized activity prescription also
may result in greater participation and more sustained and robust
changes in patient's lifestyles.36
WILUND et al.
8 | M Y TH #7. E X E RC I S E D U R I N G D I A LYS I S
C AU S E S M U S C LE C R A M PI N G
Muscle cramps are one of the most frequently cited symptoms as‐
sociated with dialysis therapy. The etiology of dialysis‐associated
cramps is not clear, although changes in plasma osmolality and ex‐
tracellular fluid volume have been suggested.37 Exercise training has
the potential to reduce muscle cramps. Anecdotal evidence suggests
that post‐exercise muscle cramping and fatigue may occur, but this
is usually short‐lived and discontinues with frequent exercise train‐
ing’ By contrast, commentaries have suggested that exercise training
may actually reduce dialysis‐associated muscle cramps,38,39 though
there is little published evidence from clinical trials to support or
refute these claims.
Several modified exercise strategies should be considered in pa‐
tients prone to muscle cramps occur during dialysis. For example,
shorter, more frequent exercise sessions, or interspersing moderate
exercise training with low intensity training, may have benefits. In
addition, it is prudent to work closely with the clinic staff to consider
whether other factors, such as fluid overload and peripheral vascular
disease, may be influencing cramps.40 This is clearly an area where
further research is needed.
9 | M Y TH # 8 . S TR E N G TH TR A I N I N G
D U R I N G D I A LYS I S I S I M PR AC TI C A L
A small number of randomized controlled trials using resistance‐only
training prescription have been reasonably successful at increas‐
ing muscle strength and mid‐thigh muscle cross‐sectional area.41
However, some studies have failed to show significant changes in
any strength and functional capacity outcomes.42 The restrictive en‐
vironment in the hemodialysis unit, including the physical constraints
of the dialysis bed or chair position and fistula access, may preclude
use of a sufficient strength training dose. High levels of weight or re‐
sistance load may increase intra‐abdominal pressure and cause body
movement that triggers the dialysis machine alarms. Also, the pos‐
ture required to perform some types of resistance training exercises
is not able to be achieved while on a dialysis couch or chair.
However, it is important to recognise that significant improvement
in health‐related quality of life indices, which seem to be driven by the
self‐reported physical function components of the SF‐36 question‐
naires used in the published resistance training studies, is an import‐
ant observation. The dissociation between objective and subjective
measures of functional limitations does not minimize the importance
of someone's perceived ability to perform a task. This is because the
individual is more likely to actually perform a task if they believe it is
achievable, and is also more likely to engage in active living.43
In summary, although a sufficient dose of strength training may
be difficult to achieve during intra‐dialytic strength training, the
behavior change element of performing the exercises may still be
of benefit. It should also recognized that frail patients only require
small changes in strength to realize large changes in function.
| 5
10 | S U M M A RY
It is clear that questions remain regarding the optimal frequency,
intensity, type, and timing, and intensity of exercise in HD pa‐
tients. While larger and longer clinical trials may help address
some of these issues, it is not prudent to provide overly conserva‐
tive exercise recommendations while we wait for clear answers
to every question. Instead, we must continue to rely on common
sense and professional judgement to encourage our patients to
increase their physical activity levels to any extent possible. While
there are many considerations to exercise in this population, mov‐
ing less is almost never beneficial for the patient. By contrast, find‐
ing ways to get patients to move more is generally beneficial. The
conservative approach to exercise prescription in this population
has likely done more harm than good because it has built barriers
and fear into patients and clinicians that limit the potential that our
patients have for improving their health and QOL.
REFERENCES
1. Smart NA, Williams AD, Levinger I, et al. Exercise & Sports Science
Australia (ESSA) position statement on exercise and chronic kidney
disease. J Sci Med Sport. 2013;16(5):406‐411.
2. Moore GE, Painter PL, Brinker KR, Stray‐Gundersen J, Mitchell JH.
Cardiovascular response to submaximal stationary cycling during
hemodialysis. Am J Kidney Dis. 1998;31(4):631‐637.
3. Gopaluni S, Sherif M, Ahmadouk NA. Interventions for chronic kid‐
ney disease‐associated restless legs syndrome. Cochrane Database
Syst Rev. 2016;11:CD010690.
4. Halliwill JR. Mechanisms and clinical implications of post‐exercise
hypotension in humans. Exerc Sport Sci Rev. 2001;29(2):65‐70.
5. Rodriguez HJ, Domenici R, Diroll A, Goykhman I. Assessment of dry
weight by monitoring changes in blood volume during hemodialysis
using Crit‐Line. Kidney Int. 2005;68(2):854‐861.
6. Dungey M, Bishop NC, Young HM, Burton JO, Smith AC. The im‐
pact of exercising during haemodialysis on blood pressure, markers
of cardiac injury and systemic inflammation—preliminary results of
a pilot study. Kidney Blood Press Res. 2015;40(6):593‐604.
7. Rhee SY, Song JK, Hong SC, et al. Intradialytic exercise improves
physical function and reduces intradialytic hypotension and depres‐
sion in hemodialysis patients. Korean J Intern Med. 2017. https://doi.
org/10.3904/kjim.2017.020. [Epub ahead of print].
8. Jeong JH, Biruete A, Fernhall B, Wilund KR. Effects of acute intra‐
dialytic exercise on cardiovascular responses in hemodialysis pa‐
tients. Hemodial Int. 2018;22(4):524‐533.
9. Sheng K, Zhang P, Chen L, Cheng J, Wu C, Chen J. Intradialytic ex‐
ercise in hemodialysis patients: a systematic review and meta‐anal‐
ysis. Am J Nephrol. 2014;40(5):478‐490.
10. Cheema BS, Smith BC, Singh MA. A rationale for intradialytic exer‐
cise training as standard clinical practice in ESRD. Am J Kidney Dis.
2005;45(5):912‐916.
11. Bennett PN, Breugelmans L, Barnard R, et al. Sustaining a hemodi‐
alysis exercise program: a review. Semin Dial. 2010;23(1):62‐73.
12. Williams B, Poulter NR, Brown MJ, et al. British Hypertension
Society guidelines for hypertension management 2004 (BHS‐IV):
summary. BMJ. 2004;328(7440):634‐640.
13. Robinson BM, Tong L, Zhang J, et al. Blood pressure levels and mor‐
tality risk among hemodialysis patients in the Dialysis Outcomes
and Practice Patterns Study. Kidney Int. 2012;82(5):570‐580.
14. Greenwood SA, Naish P, Clark R, et al. Intra‐dialytic exercise train‐
ing: a pragmatic approach. J Ren Care. 2014;40(3):219‐226.
6 |
15. Hecking M, Karaboyas A, Antlanger M, et al. Significance of interdi‐
alytic weight gain versus chronic volume overload: consensus opin‐
ion. Am J Nephrol. 2013;38(1):78‐90.
16. Flythe JE, Assimon MM, Wang L. Ultrafiltration rate scaling in he‐
modialysis patients. Semin Dial. 2017;30(3):282‐283.
17. Kong S, Lee KS, Kim J, Jang SH. The effect of two different hand ex‐
ercises on grip strength, forearm circumference, and vascular mat‐
uration in patients who underwent arteriovenous fistula surgery.
Ann Rehabil Med. 2014;38(5):648‐657.
18. Oder TF, Teodorescu V, Uribarri J. Effect of exercise on the diam‐
eter of arteriovenous fistulae in hemodialysis patients. ASAIO J.
2003;49(5):554‐555.
19. Rus R, Ponikvar R, Kenda RB, Buturovic‐Ponikvar J. Effects of hand‐
grip training and intermittent compression of upper arm veins on
forearm vessels in patients with end‐stage renal failure. Ther Apher
Dial. 2005;9(3):241‐244.
20. Cheema B, Abas H, Smith B, et al. Progressive exercise for anab‐
olism in kidney disease (PEAK): a randomized, controlled trial
of resistance training during hemodialysis. J Am Soc Nephrol.
2007;18(5):1594‐1601.
21. Painter P, Clark L, Olausson J. Physical function and physical activ‐
ity assessment and promotion in the hemodialysis clinic: a qualita‐
tive study. Am J Kidney Dis. 2014;64(3):425‐433.
22. Young HM, Hudson N, Clarke AL, et al. Patient and staff percep‐
tions of intradialytic exercise before and after implementation: a
qualitative study. PLoS ONE. 2015;10(6):e0128995.
23. Thompson S, Tonelli M, Klarenbach S, Molzahn A. A qualitative
study to explore patient and staff perceptions of intradialytic exer‐
cise. Clin J Am Soc Nephrol. 2016;11(6):1024‐1033.
24. Jhamb M, McNulty ML, Ingalsbe G, et al. Knowledge, barriers and
facilitators of exercise in dialysis patients: a qualitative study of pa‐
tients, staff and nephrologists. BMC Nephrol. 2016;17(1):192.
25. Young H, Jeurkar S, Churchward DR, et al. Implementing a theory‐
based intradialytic exercise programme in practice: a quality im‐
provement project. Clin Kidney J. 2018;11(6):832‐840.
26. Kouidi E, Grekas D, Deligiannis A, Tourkantonis A. Outcomes of
long‐term exercise training in dialysis patients: comparison of two
training programs. Clin Nephrol. 2004;61(Suppl 1):S31‐S38.
27. Koh KP, Fassett RG, Sharman JE, Coombes JS, Williams AD. Effect
of intradialytic versus home‐based aerobic exercise training on
physical function and vascular parameters in hemodialysis patients:
a randomized pilot study. Am J Kidney Dis. 2010;55(1):88‐99.
28. Carrero JJ, Stenvinkel P, Cuppari L, et al. Etiology of the protein‐
energy wasting syndrome in chronic kidney disease: a consensus
statement from the International Society of Renal Nutrition and
Metabolism (ISRNM). J Ren Nutr. 2013;23(2):77‐90.
29. Dong J, Sundell MB, Pupim LB, Wu P, Shintani A, Ikizler TA. The
effect of resistance exercise to augment long‐term benefits of in‐
tradialytic oral nutritional supplementation in chronic hemodialysis
patients. J Ren Nutr. 2011;21(2):149‐159.
WILUND et al.
30. Kopple JD, Cohen AH, Wang H, et al. Effect of exercise on mRNA
levels for growth factors in skeletal muscle of hemodialysis pa‐
tients. J Ren Nutr. 2006;16(4):312‐324.
31. Johansen KL, Painter PL, Sakkas GK, Gordon P, Doyle J, Shubert T.
Effects of resistance exercise training and nandrolone decanoate
on body composition and muscle function among patients who re‐
ceive hemodialysis: a randomized, controlled trial. J Am Soc Nephrol.
2006;17(8):2307‐2314.
32. Chen JL, Godfrey S, Ng TT, et al. Effect of intra‐dialytic, low‐in‐
tensity strength training on functional capacity in adult haemo‐
dialysis patients: a randomized pilot trial. Nephrol Dial Transplant.
2010;25(6):1936‐1943.
33. Chan D, Cheema BS. Progressive resistance training in end‐stage
renal disease: systematic review. Am J Nephrol. 2016;44(1):32‐45.
34. Clarkson MJ, Bennett PN, Fraser SF, Warmington SA. Exercise in‐
terventions for improving objective physical function in end‐stage
kidney disease patients on dialysis: a systematic review and meta‐
analysis. Am J Physiol Renal Physiol. 2019. [Epub ahead of print].
35. Manfredini F, Mallamaci F, D'Arrigo G, et al. Exercise in patients on
dialysis: a multicenter, randomized clinical trial. J Am Soc Nephrol.
2017;28(4):1259‐1268.
36. Burnet K, Kelsch E, Zieff G, Moore JB, Stoner L. How fitting is
F.I.T.T.?: a perspective on a transition from the sole use of fre‐
quency, intensity, time, and type in exercise prescription. Physiol
Behav. 2019;199:33‐34.
37. Canzanello V. Haemodialysis‐associated muscle cramps. Semin Dial.
1991;5:299‐304.
38. Kobrin SM, Berns JS. Quinine—a tonic too bitter for hemodialysis‐
associated muscle cramps? Semin Dial. 2007;20(5):396‐401.
39. Karmiel J. The easy bike program: an exercise‐during‐dialysis pro‐
gram. Top Clin Nutr. 1996;12:74‐78.
40. Young H, Dungey M, Burton J, Smith A. Haemodialysis‐associ‐
ated cramping: role and implications of exercise. Br J Renal Med.
2012;17(2):12‐14.
41. Heiwe S, Jacobson SH. Exercise training for adults with chronic kid‐
ney disease. Cochrane Database Syst Rev. 2011;10:CD003236.
42. Segura‐Orti E. Exercise in haemodialysis patients: a literature sys‐
tematic review. Nefrologia. 2010;30(2):236‐246.
43. Koufaki P, Greenwood SA, Macdougall IC, Mercer TH. Exercise
therapy in individuals with chronic kidney disease: a systematic re‐
view and synthesis of the research evidence. Annu Rev Nurs Res.
2013;31:235‐275.
How to cite this article: Wilund KR, Jeong JH, Greenwood
SA. Addressing myths about exercise in hemodialysis
patients. Semin Dial. 2019;00:1–6. https://doi.org/10.1111/
sdi.12815