In this blog for people with chronicA health condition marked by long duration, by frequent recurrence over a long time, and often by slowly progressing seriousness. For example, rheumatoid arthritis. kidney disease having maintenance dialysis, Dr Rebecca Gould, Cochrane UK Fellow and Sports and Exercise Medicine Registrar, looks at recent evidence on exercise in adults having dialysis.
Physical activity is recommended for people with chronic kidney disease, including those who have dialysis. However, many people find it challenging to be active. In the UK, around 60% of the general adult populationThe group of people being studied. Populations may be defined by any characteristics e.g. where they live, age group, certain diseases. are ‘active’. That is, they meet the recommended guidelines of at least 150 minutes of moderate-intensity physical activity per week. This number tends to be lower in people with long-term conditions. Among people with chronic kidney disease, around 6% of those having haemodialysis (HD), and 8% of those having peritoneal dialysis (PD) are thought to be active.
When people having dialysis have been asked their views of exercise, many thought it would be good for them and were interested in exercising during HD. Their concerns included tiredness, muscle fatigue, riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of damaging their fistula or intravenous access and movement setting off the haemodialysis machine alarm.
Evidence on exercise in people having dialysis
A Cochrane Review has looked at the effect of exercise programmes in adults having maintenance dialysis compared to no or sham exercise (published January 2022). This review included eighty-nine randomisedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group (the intervention group) will be given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group). controlled trialsA trial in which a group (the ‘intervention group’) is given a intervention being tested (for example a drug, surgery, or exercise) is compared with a group which does not receive the intervention (the ‘control group’)., with over 4000 people.
Most people in the trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. were having HD (often during the HD treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. itself). The exercise programmes that were included varied, were done three times a week and lasted 20 to 40 minutes. The exercise programmes lasted for at least 8 weeks. Most involved aerobic exercise alone (such as peddling on an exercise bike). Other trials included strength exercises only (such as using dumbbells or resistance bands), or a combination of the two exercise types.
Evidence on the potential benefits of exercise
When looking at all the different types of exercise programmes together, the review authors found that exercise programmes:
- probably improve symptoms of depression, particularly if the exercise lasts for more than four months
- probably improve functional capacity. (The ability to perform activities and tasks through an improvement in walking, and the strength and endurance of the leg muscles)
- may also slightly improve some aspects of quality of life. (The ability to be active, go to work, or do day-to-day activities)
- may slightly reduce fatigue and pain. It is worth noting though that a small proportion of people had pain or soreness and more fatigue.
Is it safe to exercise?
The Cochrane ReviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. can’t tell us much about safetyRefers to serious adverse effects, such as those that threaten life, require or prolong hospitalization, result in permanent disability, or cause birth defects.. This is because unwanted effects or harms of exercise were not accurately recorded in many studies. However, in 7 of the 9 studies that reported on harms, there were none.
There are a number of known safety considerations for exercise programmes:
Safety considerations for people starting haemodialysis (HD)
- The Renal AssociationA relationship between two characteristics, such that as one changes, the other changes in a predictable way. For example, statistics demonstrate that there is an association between smoking and lung cancer. In a positive association, one quantity increases as the other one increases (as with smoking and lung cancer). In a negative association, an increase in one quantity corresponds to a decrease in the other. Association does not necessarily mean that one thing causes the other. advise that exercise programmes should not be started within the first three months of starting HD.
Safety considerations for people with a peritoneal (PD) catheter
- For people who have recently had a PD catheter inserted, the International Society for Peritoneal Dialysis recommends activities that increase the pressure within the tummy (for example lifting more than 5-10kg in weight, sit-ups or jumping) should be avoided for 4-6 weeks, but it is safe to start walking straight away.
- It is also recommended that PD fluid is drained before activities which involve an increase in tummy pressure, or lots of bending forward. Some people may prefer to drain the fluid before other activities for comfort.
- Keeping the PD catheter insertion site healthy is important; it is advised to cover the area with a water-proof dressing during water-based activity. Clean the site after it gets wet (water or sweat).
- Using a breathable dressing (like gauze), and/or taping the catheter down during more vigorous activity, can reduce the risk of friction damage to the surrounding skin and damage to the catheter insertion.
General safety considerations
More generally, there are some medical conditions where it may be temporarily unsafe to exercise. For example, severe infection, recent heart attack or unstable angina. Uncontrolled heart failure, uncontrolled arrhythmias, very high blood pressure or severe aortic stenosis are other reasons why people may not be able to exercise until they receive treatment for these conditions.
If you’re having dialysis and are thinking about being (more) active
Speaking to a member of your dialysis team, such as a nurse, physiotherapist, or doctor, can be a good way to find out more about exercise, during or in between treatment, and discuss any worries you may have.
Speaking to other people, who have had similar experiences, can also be very useful. In addition to their helplines, some UK-based charities also have peer support schemes including Kidney Care UK’s Young Adult Kidney Group (for people aged 18 to 30) and National Kidney Federation (for home dialysis). Your local dialysis department may also have a formal peer support network.
Physical activity resources for people with chronic kidney disease
- Kidney Care UK, Kidney Research UK and National Kidney Federation are UK-based charities that provide information on physical activity for people living with chronic kidney disease.
- MOVE Project – Produced by Bangor University and the Wales Kidney Research Unit, the MOVE project has produced resources, including a booklet and videos, to support people having HD to become more active.
- We are undefeatable – a campaign from 16 leading health and social care charities, backed by Sport England, designed to inspire, and motivate people living with long-term conditions to get active in a way that’s right for them.
With thanks to Holly Loughton for her input. Holly blogs about living with chronic kidney disease on her blog ‘Secondhand Life’.
Join in the conversation on Twitter with @CochraneUK and @DrRebeccaGould or leave a comment on the blog.
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Rebecca has nothing to disclose.