4TH POSTING : ACTIVITY of ESRD/ HEMODIALYSIS PATIENTS

Dyad 1 : Nancelle Dumlao / Rodel Perez

Endurance exercise training during haemodialysis improves strength, power, fatigability and physical performance in maintenance haemodialysis patients

By: Thomas W. Storer, Richard Casaburi, Steven Sawelson and Joel D. Kopple
Published online on April 19, 2005
Nephrology Dialysis Transplantation 2005 20(7):1429-1437

There are many maintenance hemodialysis (MHD) patients who often complain of being unable to perform any activity which requires extra effort except for the simple self-care routines. This fact is supported by many studies and one of which was done by Johansen (1999) where his subjects report low exercise tolerance. Body weakness is brought about by many factors such as muscle atrophy, myopathy, malnutrition and carnitine deficiency (Koppel, et al, 2004) . Many authors stressed that the weakness from muscle atrophy is a significant grounds of reduced physical function. Hence, the thrust in the management of MHD patients should include increasing the muscle mass and strength. This study attempted to examine whether endurance training can enhance muscle strength and physical performance of these patients by improving their cardiopulmonary condition. The hypotheses tested were (A) in the erythropoietin era (hgb should equal 11-12g/dl), the MHD patients have reduced endurance performance as well as marked reduction in muscle function and the ability to perform routine physical activities; (B) endurance exercise training helps improve cardiopulmonary fitness as well as muscle strength, power, fatigability and physical performance; and (C) endurance training resulted to rapid increases in activity tolerance during the exercise training. The quantitative study comprised of three groups. The subjects (exercising MHD patients) comprised of 7 males and 5 females MHD non-diabetic patients who do not regularly exercise prior to the study. There was a first comparison group (non-exercising patients) comprised of 12 MHD patients with no exercise training but were assessed for most outcome measures before or after an 18-week study period. Then, for the purpose of establishing reference values, a second comparison group (healthy individuals) comprised of 12 healthy, sedentary volunteers were assessed only at baseline. Both comparison groups have similar ages, gender, race and ethnicity; they take erythropoietin to keep hemoglobin level at 11-12 g/dl; and they take all their medications all throughout the study period. However, there are some limitations of the study which includes the relatively young age of the subjects as compared to majority MHD patients; small sample sizes and differences in the comparison groups may limit generalizability of the results.
The study has positive results in terms of improving the exercise capacity of the MHD patients due to a number of endurance exercise-training studies. They focused on the cardiopulmonary responses to endurance training. There were three significant outcomes of the study, namely : (1)MHD patients has made considerable improvements in cardiopulmonary function, muscle function and physical performance when they complete a short-term, low work rate, progressive, semi-recumbent leg-cycle endurance training during hemodialysis; (2) in just 9 weeks of cycle exercise training, the MHD patients has significantly improved their ability to perform high work rate exercise; and (3) tolerance of exercise training increases rapidly and that the rate of change in exercise tolerance can be maintained within an average of 8.6 weeks of training.

In summary, it has been proven that lower intensity endurance training can improve muscle function and physical functioning of MHD patients, thus they may be used as a preliminary conditioning to help assist the patient to be able perform resistance exercise training. In some instances where resistance exercise training is not possible, then the patients may utilize endurance training to achieve good initial improvements. In the study, just nine weeks of leg-cycling during the hemodialysis sessions enhanced not only cardiopulmonary functions but more importantly, it increased muscle strength, power , fatigability and physical function.

Considering the numbers of hours being spent in hemodialysis, it is sad that when the patients go home, they do not have sufficient physical strength to help them enjoy their time at home with the loved ones. The studies on what particular activities and exercise program that these patients could actually be allowed or even encouraged to do has greatly contributed in improving the quality of these patients lives. Doing not only low intensity exercises but endurance training during the long hours of hemodialysis gives the patient not just improved physical strength but also renewed socio-psychological and perhaps spiritual well being.

References:

1. Johansen KL. Physical functioning and exercise capacity in patients on dialysis. Adv Ren Replace Ther 1999; 6: 141–148[ISI][Medline]
2. Kopple JD, Casaburi R, Storer TW. Impaired exercise capacity and exercise training in maintenance hemodialysis patients. J Renal Nutr 2004; 15: 44–48
3. Johansen K, Shubert T, Doyle J, Soher B, Sakkas G, Kent-Braun J. Muscle atrophy in patients receiving hemodialysis: effects on muscle. Kidney Int 2003; 63: 291–297[CrossRef][ISI][Medline]
4. Kouidi E, Albani M, Natsis K et al. The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrol Dial Transplant 1998; 13: 685–699[Abstract/Free Full Text]


http://ndt.oxfordjournals.org/cgi/content/full/20/7/1429?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Effects+of+intradialytic+exercise+training+on+health-related+quality+of+life+indices+in+haemodialysis+patients.&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

DYAD 4
BALAJADIA, BOND
ZANO, ALEXIS

Intradialytic versus home based exercise training in hemodialysis patients: a randomised controlled trial

Exercise training in hemodialysis patients improves fitness, physical function, quality of life and markers of cardiovascular disease such as arterial stiffness. The majority of trials investigating this area have used supervised exercise training during dialysis (intradialytic), which may not be feasible for some renal units. The aim of this trial is to compare the effects of supervised intradialytic with unsupervised home-based exercise training on physical function and arterial stiffness.This is a randomised, controlled clinical trial.

A total of 72 hemodialysis patients will be randomised to receive either six months of intradialytic exercise training, home-based exercise training or usual care. Intradialytic patients will undergo three training sessions per week on a cycle ergometer and home-based patients will be provided with a walking program to achieve the same weekly physical activity. Primary outcome measures are six-minute walk distance (6 MWD) and aortic pulse wave velocity (PWV). Secondary outcome measures include augmentation index, peripheral and central blood pressures, physical activity and self-reported health. Measures will be made at baseline, three and six months.

The objective of this trial is to compare a supervised intradialytic training program with a home-based exercise program and usual care. The results of this study will help determine the efficacy of home-based exercise training in hemodialysis patients which may be a more cost effective way of conducting an exercise program as many dialysis units are too crowded and busy to allow for intradialytic exercise programs. This may help in the development of exercise guidelines for dialysis patients. The study will also assess whether the various exercise interventions impact on arterial stiffness a surrogate marker of cardiovascular morbidity in these patients.

Reference: Koh, K et. al. Intradialytic versus home based exercise training in hemodialysis patients: a randomised controlled trial. PMC. January 2009

Dyad 6 guomanman and chenya

The effective exercise training on muscle atrophy in hemodialysis patient

Patients with end-stage renal disease on haemodialysis (HD) have limited wotk capacity. many structural and functional alterationsl in skeletal muscles contribute to this disability.

To evaluate the effects of exercise training on uraemic myopathy, seven HD patients(mean age 44.1±17.2 years)were studied. open muscle biopsies were taken from their vastus lateralis muscle before and after a 6 months exercise rehabilitation programme and examined by routine light-and transmission electron-microscopy. histochemical stainings of frozen sections were performed and morphometric analysis was also applied to estimate the proportion of each fibre type and the muscle fibre area. spiroergometric and neurophysiological testing and peak extension forces of the lower limbs were measured before and after exercise training.

results
all patients showed impaired exercise capacity, which was associated with marked muscular atrophy (mean area 2548±463) and reduction in muscle strength and nerve conduction velocity. all types of fibres were atrophied, but type 2 were more affected. the ultrastructural study showed severe degenerative changes in skeletal muscle fibres, mitochondria, and capillaries. exercise training had an impressive effect on muscular atrophy; in particular the proportion of type 2 fibres increased by 51% and mean muscle fibre area by 29%. favourable changes were also seen on the structure and number of capillaries and mitochondria. these results were confirmed by a 48% increase in VO2 peak and a 29% in exercise time, as well as an improvement in the peak muscle strength of the lower limbs and in nerve conduction velocity.

Skeletal muscle atrophy in HD patients contribute to their poor exercise tolerance. the application of an exercise training rehabilitation programme
improved muscle atrophy markedly, and therefore had benficial effects in overall work performance.

reference

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A modified yoga-based exercise program in hemodialysis patients

Uludag University Medical Faculty, Internal Medicine Nephrology Department, Görükle, Bursa, Turkey 22 August 2006.

To evaluate the effects of a yoga-based exercise program on pain, fatigue, sleep disturbance, and biochemical markers in hemodialysis patients.
Method：
In 2004 a randomized controlled trial was carried out in the outpatient hemodialysis unit of the Nephrology Department, Uludag University Faculty of Medicine. Clinically stable hemodialysis patients (n = 37) were included and followed in two groups: the modified yoga-based exercise group (n = 19) and the control group (n = 18). Yoga-based exercises were done in groups for 30 min/day twice a week for 3 months. All of the patients in the yoga and control groups were given an active range of motion exercises to do for 10 min at home. The main outcome measures were pain intensity (measured by the visual analogue scale, VAS), fatigue (VAS), sleep disturbance (VAS), and grip strength (mmHg); biochemical variables – urea, creatinine, calcium, alkaline phosphatase, phosphorus, cholesterol, HDL-cholesterol, triglyceride, erythrocyte, hematocrit – were evaluated.
Results
After a 12-week intervention, significant improvements were seen in the variables: pain −37%, fatigue −55%, sleep disturbance −25%, grip strength +15%, urea −29%, creatinine −14%, alkaline phosphatase −15%, cholesterol −15%, erythrocyte +11%, and hematocrit count +13%; no side-effects were seen. Improvement of the variables in the yoga-based exercise program was found to be superior to that in the control group for all the variables except calcium, phosphorus, HDL-cholesterol and triglyceride levels.
Conclusion
A simplified yoga-based rehabilitation program is a complementary, safe and effective clinical treatment modality in patients with end-stage renal disease.
Reference：http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WCS-4KPN9T3-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=947054787&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=79c5bfa3450a726f00b62a540ddf7a2c
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W9N-48FC35C-C&_user=10&_origUdi=B6WCS-4KPN9T3-1&_fmt=high&_coverDate=05%2F31%2F2003&_rdoc=1&_orig=article&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2bf39046c201fd7963266917837edf83

RESPONSE: Hemodialysis- ACTIVITY
By: Dyad 2: Gil Legarda and Joanalyn Balino


Effects of Resistance Exercise Training and Nandrolone Decanoate on Body Composition and Muscle Function among Patients Who Receive Hemodialysis: A Randomized, Controlled Trial
By: Kirsten L. Johansen, Patricia L. Painter, Giorgos K. Sakkas, Patricia Gordon, Julie Doyle, and Tiffany Shubert

A cohort study by Johansen et al. The purpose of this study was to determine whether anabolic steroid administration and resistance exercise training induce anabolic effects among patients who receive maintenance hemodialysis. There were a total of 287 patients screened, 80 HD patients were enrolled in the study and 79 were randomly assigned to treatment groups in a one is to one is to one is to one is to one manner (1:1:1:1) using variable clock sizes and investigators were blinded until completing the study. Men and women were the subjects who were undergoing hemodialysis 3 times/ week at the outpatient dialysis unit that were affiliated with University of California, San Fransico. Participants should have an adequate delivery with kt/V and good compliance with therapy of hemodilaysis or they should not missed 2 dialysis treatment for a month before entering or enrolling in the study. If they had been to dialysis for 3 months, In catabolic state such as HIV with opportunistic infection in the past 3 months, infection required intravenous antibiotics within 2 months and any kind of malignancy were excluded. Also patients unable to give informed consent, active users of intravenous drugs, had a thigh dialysis graft or contraindicated for exercise training such as MI within six months, active angina, uncompensated CHF or orthopaedic limitations. The study held in affiliated dialysis units of University of California. The researchers used a Human Activity profile to measure the physical functioning of the patients. This instrument or HAP consist of 94 activities and patients were ask to report if they do the activities or no longer.The groups baseline characteristics were compared using ANOVA or Kruskal-Wallis tests. The researchers reviewed and used the patients body composition, muscle size, muscle strength, physical activity, and physical performance to measure the outcomes as well as the questionnaires.

There were 68 patients completed the study. The were reasons for non-compliance. Six participants discontinued the study drug but if they were available on follow up they were still included in the analysis. The 91 Percent of the patients assigned to received nandrolone deaconote received 100 percent of it. There were two patients discontinued the drugs because of drug rejection. The medication has no significance with the BMI but it can affect body composition.

In the physical assessment of the patients we will be able to see that their body composition is small or they have a lean body type. Concerning with the quality of life of the haemodialysis patients should have regular exercise for maintaining their body shape and to lessen their anxiety. The study suggesting and showing that nandrolone ecanoate and resistance exercise is a safe options for treatment of the muscle wasting and weakness that commonly seen in our hemodialysis patients. These two interventions are significantly can increase muscle size and strength. But further investigations and study are needed if this interventions are significantly help the hemodialysis patients in terms of survival or can decrease some hemodialysis complications.


Reference:
Johansen K. L. et al. (2006). Effects of Resistance Exercise Training and Nandrolone Decanoate on Body Composition and Muscle Function among Patients Who Receive Hemodialysis: A Randomized, Controlled Trial. Journal of the American Society od Nephrology Vol. 17 pages 2307–2314 Retrieved July 3, 2009 from .http://jasn.asnjournals.org/cgi/reprint/17/8/2307?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT

Dyad 6 guomanman and chenya


Controlling Bone Disease Improves Survival Of Hemodialysis Patients
maintaining certain blood levels of markers of bone metabolism and disease can prolong the lives of patients on hemodialysis, according to a new study. The findings indicate that keeping parathyroid hormone, calcium, and phosphorous levels in control is critically important for dialysis patients with chronic kidney disease (CKD).
Because mineral and bone disorder affects most patients with CKD, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) has set specific treatment targets for the indicators of this disorder--serum levels of parathyroid hormone, calcium, and phosphorous. While research has shown that elevations in these markers are associated with increased morbidity and mortality in dialysis patients, no study has investigated the long-term control of these parameters.

Dr. Mark Danese of Outcomes Insights, Inc. (Newbury Park, CA), and his colleagues, Dr. Vasily Belozeroff and Dr. Karen Smirnakis of Amgen, Inc. (Thousand Oaks, CA) and Dr. Kenneth Rothman of Research Triangle Institute (Research Triangle Park, NC), set out to determine whether more consistent control of parathyroid, calcium, and phosphorous levels within the KDOQI target ranges is associated with improved survival. The study was conducted among 24,803 adults initiating dialysis between 2000 and 2002. The researchers assessed whether survival was improved when patients were within the three target levels simultaneously. They also examined whether survival was improved when patients were within each of the three target levels for prolonged periods of time.

The researchers reported that it was important to meet as many of the targets as possible at any given time. Meeting the target for none of the three markers was associated with a 51% higher risk of death compared with patients who achieved targets simultaneously for all three markers. Patients meeting only one target had a 35% to 39% increased risk of death, and patients meeting any two targets had a 15% to 21% higher risk of death.

Dr. Danese and his team also found that the longer an individual met one or more targets, the better. For each marker, patients who achieved target values for less than three months had the highest risk of death compared with those who did so for one year. Compared with patients whose individual target levels were maintained for one year, patients with a parathyroid in target for less than three months had a 34% higher risk of death, patients with calcium in target for less than three months had a 16% higher risk of death, and patients with phosphorous in target for less than three months had a 62% higher risk of death.

The study also revealed that prior to the introduction of the KDOQI guidelines, relatively few patients either simultaneously met the targets for parathyroid hormone, calcium, and phosphorous or met any target for a full year. The authors discovered that levels of these parameters outside the KDOQI target ranges may account for as much as 20% of deaths in dialysis patients.

"These results suggest that there is a need for more consistent achievement of the KDOQI mineral metabolism targets, and that meeting this need may result in improved survival for incident hemodialysis patients," the authors write. They note that this can be a challenge, however, because the use of current treatment options often requires a tradeoff between controlling parathyroid hormone and controlling calcium and phosphorous.