Progressive resistance training during maintenance hemodialysis in patients with end stage renal disease

Background: The global incidence of end-stage renal disease (ESRD) continues to rise annually. Accompanying this rise is an increase in the number of patients on hemodialysis. These trends are being driven by an unprecedented burden of hypokinetic, non-communicable diseases, and particularly the type 2 diabetes-obesity pandemic. The progression of kidney disease is associated with an exponential increase in atherosclerotic cardiovascular disease (CVD) and associated mortality. CVD is the leading cause of hospitalization and death in this cohort. As the ESRD patient population continues to grow, greater efforts must be directed toward improving patient outcomes in this cohort, including morbidity, mortality and health-related quality of life (HRQoL). Aims: This thesis addresses several gaps related to the investigation and application of progressive resistance training (PRT) in the hemodialysis setting. The specific aims were: (i) to systematically review the extant literature on PRT in patients with ESRD, and to outline recommendations for robust clinical trials; (ii) to assess the feasibility and efficacy of including a novel customized resistance training device within a comprehensive intradialytic PRT intervention in a conventional hemodialysis unit; (iii) to investigate the effect of a 12-week intradialytic PRT intervention on measures of CVD risk, specifically, arterial stiffness (i.e. pulse wave velocity; PWV) and associated outcomes (i.e. hemodynamic, anthropometric, and hematologic). Research Program: The research program was undertaken from March 2011 to March 2015 and culminated in a clinical trial enrolling 22 participants conducted across four dialysis centers in Adelaide, South Australia. Conclusions: Chapter 7 presents general conclusions to the thesis, as follows: (i) According to the systematic review of the extance literature (Chapter 4) clinical trials are required to investigate a range of novel research questions related to the benefits and application of PRT in this cohort and its patient subgroups (e.g. diabetes, depression, dyslipidemia, etc.). Future studies must be of high methodological quality to inform clinical practice guidelines. (ii) According to the study presented in Chapter 5, PRT using the novel training device was feasible and improved measures of physical and psychological health and HRQoL. This device can be utilized in most dialysis centers. Future studies are required to evaluate dose-response effects of PRT prescriptions in subpopulations, and the application of PRT in standard dialysis practice. (iii) According to the study presented in Chapter 6, 12 weeks of low-to-moderate intensity intradialytic PRT did not change PWV, hemodynamic, anthropometric or hematologic measures in patients with ESRD. More research is needed to determine whether different intensities or durations of PRT can affect vascular health or other outcomes related to survival in this patient group

A combined strength and balance exercise program to decrease falls risk in dialysis patients : a feasibility study

People suffering end-stage kidney disease receiving hemodialysis have a greater risk of falling and suffering debilitating injuries. The purpose of this study was to examine the feasibility and impact of a combined strength and balance exercise intervention on falls risk in hemodialysis patients. Twenty-four adults (mean age = 67.8 yrs) from two Australian outpatient hemodialysis clinics completed the intervention. Falls risk was measured using the Physiological Profile Assessment (PPA). There was a significant reduction in the median overall falls risk z-score from 1.67 to .52 (z = -3.11, P<.008; r = .45). Median reaction time improved from .30 to .26 sec (z = -2.86, P<.008; r = .41). A strength and balance intervention to reduce the falls risk for dialysis patients is feasible and may reduce falls risk for at risk patients

Resistance training in chronic renal failure

Chronic kidney disease (CKD), also known as chronic renal failure, is an irreversible disease characterized by the progressive loss of kidney function over time, usually a period of months to years.1,2 Prevalence data for CKD are difficult to ascertain given that the early stages of the disease process are typically asymptomatic,3 and given inconsistencies in diagnostic and classification systems. 4 However, recent data from the National Health and Nutrition Examination Survey (NHANES) suggest that 13.1% of adults (aged >20 years) living in the United States had Stage 1–4 CKD in 2004.5 More recent estimates by the United States Renal Data System suggest that 15.1% of the adult population in the United States has CKD.6 The prevalence of CKD has increased gradually over the past several decades within the United States5 and globally,7 and these trends are expected to continue. 7,8 Global estimates suggest that the prevalence of CKD is threatening to reach epidemic proportions in both developed and developing countries and that much of the burden can be attributed to the obesity/type 2 diabetes pandemic.7 Certain ethnic populations are severely affected by late-stage CKD. These cohorts include African-Americans9; Hispanic-Americans10; and the aboriginal people of Canada,11 the United States,12 New Zealand,13 and Australia,14 among others. The prevention and treatment of CKD globally will become a major challenge in the coming decades.

Progressive resistance training in end-stage renal disease : systematic review

BACKGROUND: This systematic review provides an overview of the extant literature on progressive resistance training (PRT) in patients with end-stage renal disease (ESRD) and outlines recommendations for future trials. METHODS: A systematic review of all published literature evaluating the chronic (>6 weeks) application of PRT in patients with ESRD using electronic databases. RESULTS: The search yielded 16 clinical trials, including 11 randomized controlled trials (RCT), 4 uncontrolled trials and one trial involving a within-subjects control period plus RCT. RCT quality, assessed via the CONSORT statement, ranged from low (4/10) to high (10/10) with a mean score of 7.3/10; 7/11 RCT had a quality score ≥7.5. All trials evaluated chronic adaptation to PRT across a range of important outcomes. PRT can induce muscle hypertrophy and improve aspects of physical functioning and health-related quality of life in ESRD. There is preliminary evidence that PRT may reduce protein-energy malnutrition and cardiovascular disease risk factors, including C-reactive protein, total cholesterol, triglyceride, and measures of insulin resistance in patients with or at-risk of comorbid type 2 diabetes. The evidence base for PRT adapting some of the endpoints investigated to date remains inconsistent (e.g. physical performance tests, obesity outcomes), and many other pertinent clinical outcomes remain to be investigated. CONCLUSION: RCT are required to investigate a range of novel research questions related to the benefits and application of PRT in this cohort and its patient subgroups (e.g. diabetes, depression, dyslipidemia, etc.). Future studies must be of high methodological quality to inform clinical practice guidelines

Effect of progressive resistance training on measures of skeletal muscle hypertrophy, muscular strength and health-related quality of life in patients with chronic kidney disease : a systematic review and meta-analysis

Background and Objective Skeletal muscle wasting resulting in reduced muscular strength and health-related quality of life (HR-QOL) is common in chronic kidney disease (CKD) and may be reversed with progressive resistance training (PRT). Therefore, we systematically assessed the effect of PRT on measures of skeletal muscle hypertrophy, muscular strength and HR-QOL in this cohort to inform clinical practice and guidelines. Design We performed a systematic review and meta-analysis. Inclusion Criteria We included randomised controlled trials (RCTs) that investigated the independent effect of PRT (>6 weeks) on measures of skeletal muscle hypertrophy [muscle mass or cross-sectional area (CSA)], muscular strength and/or HR-QOL in adults with CKD. Data Extraction and Analysis The standardised mean difference (SMD) from each study was pooled to produce an overall estimate of effect and associated 95 % confidence interval (95 % CI) between treatment and control groups on primary outcomes. Results Seven RCTs in 271 patients with Stage 3-5 CKD yielded seven studies on muscular strength (N = 249), six studies on total body muscle mass (N = 200) and six studies on HR-QOL (N = 223). PRT significantly improved standardised muscular strength [SMD 1.15 (95 % CI 0.80-1.49)] and HR-QOL [SMD 0.83 (95 % CI 0.51-1.16)], but not total body muscle mass [SMD 0.29 (95 % CI -0.27 to 0.86)] in our primary analysis. However, secondary analysis of six studies showed that PRT induced significant muscle hypertrophy of the lower extremities (leg mass, or mid-thigh or quadriceps CSA) [SMD 0.43 (95 % CI 0.11-0.76)], a pertinent analysis given that most studies implemented lower-body PRT only. Conclusions Robust evidence from RCTs indicates that PRT can induce skeletal muscle hypertrophy and increase muscular strength and HR-QOL outcomes in men and women with CKD. Therefore, clinical practice guidelines should be updated to inform clinicians on the benefits of PRT in this cohort

Development, feasibility, and efficacy of a customized exercise device to deliver intradialytic resistance training in patients with end stage renal disease : non-randomized controlled crossover trial

Introduction. This study assessed the feasibility and efficacy of a novel resistance training device used within an intradialytic progressive resistance training (PRT) intervention. Methods. Nonrandomized, within-subjects crossover design with outcomes assessed at baseline (week 0), postcontrol (week 13) and post-PRT intervention (week 26). Twenty-two hemodialysis patients (59% men, 71611 years) performed PRT three sessions per week for 12 weeks. The resistance training device was developed to enable the performance of 2 upper body and 3 lower body exercises, unilaterally and bilaterally, both before and during dialysis, with loads of 2.5 to 59 kg. Feasibility outcomes included adverse events, adherence and training load progression. Changes in upper and lower body muscular strength, six-minute walk, aspects of health-related quality of life (HRQoL) and depression were evaluated. Findings. The PRT intervention was delivered without serious adverse events, resulted in 71.2% ± 23.3% adherence and significant adaptation of all training loads from pre to mid to post training (83.8%–185.6%, all P<0.05). Lower body strength (P<0.001) and HRQoL subscales (Role-Physical, Social Functioning, Role-Emotional) significantly increased (all P<0.01) and a trend toward reduced depression was noted (P50.06). No significant changes were noted in other outcomes. Discussion. PRT using the novel resistance training device was feasible and improved measures of physical and psychological health. This device can be utilized in most dialysis centers. Future studies are required to evaluate dose-response effects of PRT prescriptions in subpopulations, and the translation of PRT to standard dialysis practice

Effect of intradialytic resistance training on pulse wave velocity and associated cardiovascular disease biomarkers in end stage renal disease

Aims: Cardiovascular disease (CVD) is the leading cause of mortality in patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis treatment. This study investigated the effect of a 12-week intradialytic progressive resistance training (PRT) intervention on pulse wave velocity (PWV) and associated hemodynamic, anthropometric, and hematologic outcomes in patients with ESRD. Methods: Twenty-two patients with ESRD (59% men, 71.3 ± 11.0 years) were recruited. Supervised PRT (3 sets of 11 exercises) was prescribed three times per week during routine dialysis. The primary outcome was brachial-ankle PWV via applanation tonometry. Secondary outcomes included augmentation index, brachial and aortic blood pressures, endothelial progenitor cells, C-reactive protein, blood lipids and anthropometrics. Results: The intradialytic PRT regimen resulted in no significant change in PWV between control and intervention periods [mean difference = 0 (95% CI = -0.1 to 0.1); P=0.58]. Similarly, no significant change was noted in any secondary outcome measures between the control and intervention periods. Post-hoc analyses limited to high adherers (≥75% attendance; n=11) did not differ from the primary analysis, indicating no dose-response effect of our intervention. Conclusion: Our 12-week PRT intervention did not change PWV or any secondary outcomes. Future studies should determine if higher dosages of intradialytic PRT (i.e. longer duration and/or higher intensity) can be applied as a method improve arterial stiffness to potentially reduce cardiovascular disease and associated mortality this cohort

Effect of Progressive Resistance Training on Measures of Skeletal Muscle Hypertrophy, Muscular Strength and Health-Related Quality of Life in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis

First online: 03 April 2014Background and Objective: Skeletal muscle wasting resulting in reduced muscular strength and health-related quality of life (HR-QOL) is common in chronic kidney disease (CKD) and may be reversed with progressive resistance training (PRT). Therefore, we systematically assessed the effect of PRT on measures of skeletal muscle hypertrophy, muscular strength and HR-QOL in this cohort to inform clinical practice and guidelines. Design: We performed a systematic review and meta-analysis. Inclusion Criteria: We included randomised controlled trials (RCTs) that investigated the independent effect of PRT (>6 weeks) on measures of skeletal muscle hypertrophy [muscle mass or cross-sectional area (CSA)], muscular strength and/or HR-QOL in adults with CKD. Data Extraction and Analysis: The standardised mean difference (SMD) from each study was pooled to produce an overall estimate of effect and associated 95 % confidence interval (95 % CI) between treatment and control groups on primary outcomes. Results: Seven RCTs in 271 patients with Stage 3–5 CKD yielded seven studies on muscular strength (N = 249), six studies on total body muscle mass (N = 200) and six studies on HR-QOL (N = 223). PRT significantly improved standardised muscular strength [SMD 1.15 (95 % CI 0.80–1.49)] and HR-QOL [SMD 0.83 (95 % CI 0.51–1.16)], but not total body muscle mass [SMD 0.29 (95 % CI −0.27 to 0.86)] in our primary analysis. However, secondary analysis of six studies showed that PRT induced significant muscle hypertrophy of the lower extremities (leg mass, or mid-thigh or quadriceps CSA) [SMD 0.43 (95 % CI 0.11–0.76)], a pertinent analysis given that most studies implemented lower-body PRT only. Conclusions: Robust evidence from RCTs indicates that PRT can induce skeletal muscle hypertrophy and increase muscular strength and HR-QOL outcomes in men and women with CKD. Therefore, clinical practice guidelines should be updated to inform clinicians on the benefits of PRT in this cohort.Birinder S. Cheema, Danwin Chan, Paul Fahey, Evan Atlanti