# Exercise as it relates to Disease/Exercise prescription for people on Hemodialysis

Exercise Prescription for People on Hemodialysis

## What is hemodialysis

Hemodialysis (also haemodialysis) is a renal replacement therapy for when the kidneys are in a state of renal failure. In hemodialysis, a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood. The blood is cleaned in the dialyzer by the removal of small waste products such as creatinine, urea, potassium, phosphate, and free water.Most commonly hemodialysis treatment is administered 3 times per week for about 4 hours a session however variables such as body mass, free fat mass, age, and medical condition will determine the prescribed amount and duration of dialysis.
Approximately 1.7 million Australians (1 in 10) aged 18 years and over have indicators of reduced kidney function and less than 10% are aware they have this condition. The three most common causes of kidney disease in Australia in 2012 were diabetes, glomuleronephritis (inflammation of the kidney) and hypertension (high blood pressure).

## Side effects & issues

The following are possible side effects during and post Hemodialysis treatment.
* Muscle cramps, nausea, dizziness, headaches, low blood pressure, fatigue, and bleeding at the access point
The following are common psychological issues that hemodialysis patients may exhibit.
* Emotional distress - self-perception as a burden to caregivers, Loss of purpose in life, threat of death, suicidal thoughts, rejection of need for haemodialysis.
* Treatment-related concerns - negative symptoms, intrusiveness, access-site related concerns, future treatment.
* Social support - informational support, instrumental support.

## Complications to exercise

* Patients often suffer co-morbidities such as diabetes, anemia, visual impairment, depression, hypotension, neuropathy, and bone disease.
* Declined physical functioning and inactivity for patients on hemodialysis is a major concern which can lead to death.
* Muscle atrophy is extremely common and the resulting weakness leaves patients at an increased risk of falls and fractures.
* Hemodialysis patients have a markedly lower VO$_2$peak compared to sedentary individuals of the same age and sex.
* Undergoing the treatment can lower the patients perceived quality of life however the treatment will increase their chance of survival.

## Exercise prescription

Hemodialysis patients can undertake an exercise programme and their healthcare team should encourage moderate physical activity under supervision. Potential benefits of exercise training include improvements in:
* Survival rate.
* Control of co-morbidities.
* Quality of life, related to improved physical functioning capacity or direct effects on mood.
* Exercise capacity.
* Strength.
A planned physical exercise programme needs to account for the limitations of the hemodialysis patient. Patients should be routinely evaluated to determine their level of exercise participation, cardiac risk factors and physical functioning.
A combined program of aerobic, strength, and balance modalities is most beneficial for hemodialysis patients. Exercise compliance is highest when performed during (intra-dialysis) or directly after dialysis, compliance is lowest when exercise is prescribed on non-dialysis days.
Exercise programmes should be initiated close to the commencement of hemodialysis therapy, at a very low intensity and progressed as slowly as tolerated in order to avoid further complications and discontinuation of exercise. Aerobic exercise such as walking or cycling for at least 20 minutes 3 times a week after dialysis can reduce muscle cramps associated with the treatment and improve VO$_2$peak and physical functioning. Strength and balance programs can be performed intra-dialysis 3 times per week. All major muscle groups can be trained and the lower extremities can be emphasised for patients who report difficulty walking, climbing stairs, or rising from a chair.

## Recommended resources

More information on Hemodialysis Fast facts on chronic kidney disease Physical signs of kidney disease Kidney Health Australia PH:1800 454 363 The National Kidney Foundation Support forum for Dialysis patients

## References

* 1 2 Mihăescu, A., Olariu, N., Rusu, A., Avram, C., Gaiţă, D., & Schiller, A. (2011). Body composition, fitness score and arterial stiffness assesment in a chronic hemodialysis population. Timisoara Physical Education & Rehabilitation Journal, 4(7), 43-48.
* ↑ National Kidney Foundation. (2014). Hemodialysis. Retrieved from National Kidney Foundation website: http://www.kidney.org/atoz/content/hemodialysis
* ↑ Kidney Health Australia. (2014). Fast facts on CKD in Australia. Retrieved from Kidney Health Australia website: http://www.kidney.org.au/KidneyDisease/FastFactsonCKD/tabid/589/Default.aspx
* 1 2 3 Bennett, P. N., Breugelmans, L., Chan, D., Calo, M., & Ockerby, C. (2012). A Combined Strength and Balance Exercise Program to Decrease Falls Risk in Dialysis Patients: A Feasibility Study. Journal Of Exercise Physiology Online, 15(4), 26-39.
* 1 2 Hadian Jazi, Z., & Aliasgharpour, M. (2012). The effect of walking on the frequency and intensity of pain caused by muscle cramps in haemodialysis patients: A pilot study. International Sportmed Journal, 13(4), 161-169.
* 1 2 Lai, A., Loh, A., Mooppil, N., Krishnan, D., & Griva, K. (2012). Starting on haemodialysis: A qualitative study to explore the experience and needs of incident patients.Psychology, Health & Medicine, 17(6), 674-684.
* ↑ Segura-Ortí, E., & Martínez-Olmos, F. (2011). Test-Retest Reliability and Minimal Detectable Change Scores for Sit-to- Stand-to-Sit Tests, the Six-Minute Walk Test, the One-Leg Heel-Rise Test, and Handgrip Strength in People Undergoing Hemodialysis. Physical Therapy, 91(8), 1244-1252.
* 1 2 Couto, C. (2007). Resistance exercise training improves strength and quality of life in patients undergoing haemodialysis. Australian Journal Of Physiotherapy, 53(4), 288.
* ↑ Sánchez, M., Amaro, P., Vidal, A., Padorno, C., & Patiño, M. (2010). The effects of physical exercise in chronic end-stage kidney failure patients on haemodialysis. Journal Of Human Sport & Exercise, 5(1), 101-113
* 1 2 3 Johansen, K. L. (2005). Exercise and Chronic Kidney Disease: Current Recommendations. Sports Medicine, 35(6), 485-499.
* 1 2 Wang, Y., & Jardine, M. J. (2011). Benefits of exercise training in patients receiving haemodialysis: a systematic review and meta-analysis. British Journal Of Sports Medicine, 45(14), 1165-1166.
* 1 2 Marchesan, M., Da Silva Nunes, V., & Rombaldi, A. (2014). Physical training improves physical fitness and the quality of life of patients on hemodialysis. Brazilian Journal Of Kineanthropometry & Human Performance,16(3), 334-344.
* 1 2 3 Ouzouni, S., Kouidi, E., Sioulis, A., Grekas, D., & Deligiannis, A. (2009). Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients. Clinical Rehabilitation, 23(1), 53-63.
* ↑ Orcy, R., Dias, P., Seus, T., Barcellos, F., & Bohlke, M. (2012). Combined Resistance and Aerobic Exercise is Better than Resistance Training Alone to Improve Functional Performance of Haemodialysis Patients - Results of a Randomized Controlled Trial. Physiotherapy Research International, 17(4), 235-243.
* ↑ MacDonald, J. H., Marcora, S. M., Jibani, M., Phanish, M. K., Holly, J., & Lemmey, A. B. (2005). Intradialytic exercise as anabolic therapy in haemodialysis patients– a pilot study. Clinical Physiology & Functional Imaging, 25(2), 113-118.