Table 2.
Characteristics of included studies
| Eligibility Criteria | Months on Hemodialysis (Mean [SD]/Median [IQR]) | Participant Age (yr) (Mean [SD]) | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Author, Year | Country | Study Design | Type of Exercise Type of Control |
N (Control/Exercise) (Attrition%) | Inclusion Criteria | Exclusion Criteria | % Female | Control | Exercise | Control | Exercise | Comorbidities (%) | Outcomes Assessed |
| Indonesia | Single-group pre/post | Not stated Usual care |
30 (15/15) (0%) | Hemodialysis 2 times/wk Able to exercise during hemodialysis SBP >180 mm Hg DBP >120 mm Hg |
Asthma, IHD No completion of any exercise sessions |
43 | Not stated | Not stated | 51.03 | 51.03 | — | BP | |
| Anderson et al.,59 2004 | United States | Single-group pre/post | Aerobic NA |
19 (32% at 3 mo) (53% at 6 mo) | Hemodialysis 3 times/wk | AKI; type 1 DM; active cerebral ischemia Severe arrhythmia, IHD, CHF, or valve disease Unable to cycle |
21 | — | 49.1 (13.6) | — | BP, HTN medications | ||
| Chan et al.,54 2017 | Australia | Single-group pre/post | Resistance Usual care |
22 (22/18) (18%) | 40 yr and older; medically stable Hemodialysis >3 mo Ambulate independently <120 min moderate PA/wk |
Amputation Unable to exercise during hemodialysis No previous resistance training |
41 | 42.5 (7–163) | 71.3 (11.0) | DM: 36 HT: 23 MI: 10 CVA: 10 PVD: 5 |
Arterial resistance, BP | ||
| Cheng et al.,61 2019 | China | RCT | Resistance Usual care |
132 (65/67) (49%) | 18–80 yr old Hemodialysis 3 times/wk for ≥3 mo Kt/V >1.2 |
Severe CVD, MSK, or other medical problems Dyspnea or chest pain during exercise Instability during hemodialysis BP ≥180/100, or <90/60 mm Hg |
40 | 47 (26–78) | 43 (23–91) | 55.8 (12) | 54.6 (12.6) | — | BP |
| Cooke et al.,48 2018 | Canada | RCT | Aerobic Usual care |
32 (16/16) (38%) | Hemodialysis 3 times/wk for ≥12 wk Stable cardiac workup |
Serum PTH >250 pmol/L Severe arrhythmia, CVD, or PVD K >6.5 mmol/L in last 2 wk; active cancer Posthemodialysis SBP ≥160 mm Hg or DBP ≥100 mm Hg Planned major surgery during study |
30 | — | — | 52.5 (15.4) | 58.2 (17.2) | DM: 35 HT: 100 Smoking: 45 CAD: 10 MI: 5 CHF: 20 CVA: 10 PVD: 5 COPD: 15 |
Arterial resistance, BP |
| Fernandes et al.,62 2019 | Brazil | RCT | Aerobic Usual care |
44 (22/22) (11%) | 18 yr and older Hemodialysis >6 mo Clinically stable No lung, MSK, neurological issues |
Planned surgical intervention during study IHD event <3 mo Severe IHD, valve disease, or arrhythmia Require home oxygen Require mobility assist device |
50 | 85.9 (45.4) | 79.8 (56.4) | 42.6 (11.2) | 44.3 (11.3) | — | BP |
| Graham-Brown et al.,66 2021 | United Kingdom | Cluster RCT | Aerobic Usual care |
130 (65/65) (22%) | 18 yr and older Hemodialysis >3 mo |
Unable/unfit to participate in exercise Unable to undergo MRI scanning |
27 | 15.6 (4.8–38.4) | 14.4 (6–44.4) | 58.9 (14.9) | 55.5 (15.5) | AFib: 3.1 IHD: 13.8 |
LVM, arterial resistance |
| Greenwood et al.,67 2021 | United Kingdom | RCT | Combined Usual care |
335 (160/175) (16.42%) | Older than 18 yr Hemodialysis >3 mo |
Planned hemodialysis for >6 mo Hemodialysis <3 mo; clinically unstable Bilateral lower-limb amputations Dementia or severe cognitive impairment Unstable psychiatric disorders; pregnant |
40 | Not stated | Not stated | 59.8 (14.1) | 60.5 (15.0) | DM: 40 HT: 78 CVD: 20 |
Arterial resistance, cardiovascular mortality |
| Guio et al.,55 2017 | Brazil | Single-group pre/post | Aerobic Usual care |
24 (24/24) (42%) | 18 yr and older Hemodialysis 3 times/wk for ≥6 mo Arteriovenous fistula |
CVD; MSK, neurological reasons unable to exercise Active inflammatory/infectious disease <6 mo Hospitalization |
57 | 23 (10) | 50.2 (15.2) | — | BP, LVF | ||
| Huang et al.,63 2020 | China | RCT | Combined Sham exercise |
47 (23/24) (32%) | 18 yr and older Hemodialysis 3 times/wk for ≥3 mo |
Severe MSK pain; need assist sit, stand, or walk Dyspnea at rest or with ADLs; mental disease |
28 | 43 (89) | 26 (30) | 37.6 (10.3) | 43.8 (10.3) | — | BP |
| Isnard-Rouchon et al.,72 2017 | France | Prospective interventional cohort; nonrandomized | Aerobic Usual care |
80 (40/40) (18%) | Hemodialysis | None stated | 38 | — | — | 67.65 (13.4) | 66.8 (10.6) | DM: 36 HT: 84 IHD: 13 |
BP medications, CV hospitalizations |
| Koh et al.,47 2010 | Australia | RCT | Aerobic Usual care |
49 (22/27) (44%) | Older than 18 yr, stable dialysis Urea reduction ratio >70% for >3 mo |
Unstable angina, lower-limb amputation Current moderate exercise ≥120 min/wk |
42 | — | — | 51.3 (14.4) | 52.3 (10.9) | DM: 5 HT: 29 MI: 2 Mitral regurgitation: 1 Other arterial disease: 2 Angina: 3 |
Arterial resistance, BP |
| Kouidi et al.,60 2009 | Greece | RCT | Combined Usual care |
63 (31/32) (6%) | Hemodialysis ≥6 mo Able to reach target workload |
Bundle branch block; unstable HTN; DM; severe CHF; recent MI; unstable angina | 42 | 74.4 (46.8) | 75.6 (44.4) | 53.2 (6.1) | 54.6 (8.9) | HT: 71 CAD: 12 CHF: 29 |
LVF, HRV |
| Kouidi et al.,49 2010 | Greece | RCT | Combined Usual care |
44 (20/24) (12%) | Hemodialysis | Severe psychiatric, neurological, cardiac, lung, MSK issues DM; significant electrolyte instability Undisciplined patients |
41 | 75.6 (58.8) | 73.2 (55.2) | 45.8 (10.9) | 46.3 (11.2) | — | HRV |
| Liao et al.,50 2016 | Taiwan | RCT | Aerobic Usual care |
40 (20/20) (—) | Hemodialysis 3 times/wk for ≥6 mo | Severe HTN, lung issues, DM; high PTH levels Moderate CHF, arrhythmia; recent MI; unstable angina; active liver dysfunction; MSK problems Inflammation/infection; cancer; autoimmune disease Emotional instability Hospitalization in last mo; BMI >25 kg/m2 Lower-extremity arterial–venous access |
58 | 83 (71) | 71 (46) | 62 (9) | 62 (8) | DM: 43 Cardiomyopathy: 28 CVD: 20 PAD: 13 TIA: 8 |
BP, EPC count |
| Martínez-Olmos et al.70 2021 | Spain | Randomized cross-over | Aerobic Usual care |
56 (56/56) (37.5%) | Hemodialysis >3 mo | MI in last 6 wk, BKA Cerebrovascular disease Chest pain, dyspnea with exertion Inability to perform functional tests |
39 | 58.8 (—) | 52.8 (—) | 66.5 (14.8) | 68 (13.5) | DM: 41 | HTN medications |
| Mihaescu et al.,73 2013 | Romania | Prospective interventional cohort; nonrandomized | Resistance Usual care |
35 (16/19) (9%) | Hemodialysis 3 times/wk ≥3 mo | None stated | 69 | 55.2 (52.8) | 54 (56.4) | 55.1 (10.5) | 55.6 (8.9) | — | Arterial resistance, BP, HTN medications |
| Miller et al.,74 2002 | United States | Prospective interventional cohort; nonrandomized | Aerobic Usual care |
75 (35/40) (24%) | Hemodialysis >1 mo | Angina, CVD requiring oxygen; MI, CABG Stroke or TIA <3 mo Unable to pedal a bike |
57 | 28.7 (25.5) | 20.7 (27.5) | 56.1 (15.2) | 52.8 (16.0) | DM: 23 CAD/CHF: 25 |
BP, HTN medications |
| Momeni et al.,32 2014 | Iran | RCT | Aerobic Usual care |
40 (20/20) (—) | Older than 18 years Hemodialysis >3 mo |
Older than 60 years; IHD; LVEF <40% Using antiarrhythmic agents; unable to exercise Dyspnea/chest pain during exercise BP ≥160/100 mm Hg |
25 | — | — | 43.1 (10.5) | — | LVF | |
| Moore et al.,56 1993 | United States | Nonrandomized single-group cross-over | Aerobic Unloaded cycling (<50 rpm) |
23 (23/23) (61%) | Achieve 6/10 on Borg RPE. | Angina; IHD, MSK disease-limiting exercise Ability to complete study |
43 | — | — | — | — | — | Stroke volume, CO |
| Musavian et al.,57 2015 | Iran | Single-group pre/post | Aerobic Passive cycling (electric bike) |
18 (18/18) (11%) | 15–80 years Hemodialysis 3 times/wk for ≥3 mo |
CVD, IHD <6 mo; Stroke/TIAs Pulmonary, MSK, and immune disorders Severe HTN or SBP <90 mm Hg); severe DM; nonadherence |
19 | 27.24 (25.08) | 51.98 (1.57) | DM: 0 | BP | ||
| Oliveira E Silva et al.,64 2019 | Brazil | RCT | Aerobic Usual care |
30 (15/15) (17%) | Older than 18 years Hemodialysis ≥3 mo Stable medication Able to exercise |
Already physically active; IHD; stroke; cancer; liver failure; active infection BP >160/100 mm Hg during treadmill test |
50 | 21 (27.1) | 26 (14.58) | 58 (15) | 50 (17.2) | DM: 30 HT: 83 |
Arterial resistance, LVM, LVF |
| Painter et al.,75 1986 | United States | Prospective interventional cohort; nonrandomized | Aerobic Usual care |
27 (7/20) (30%) | Hemodialysis | None stated | — | 62.4 (46.8) | 45.6 (36.0) | 42 (16) | 42 (10) | DM: 11 | BP, HTN medications |
| Palar and Lobo,77 2022 | India | Prospective interventional cohort; nonrandomized | Resistance Usual care |
40 (20/20) (12.5%) | 20–80 years Hemodialysis >3 mo |
Uncontrolled HTN Unstable angina, recent MI Lower limb amputation |
29 | 3–6 mo: n=0 6–12 mo: n=0 1–3 years: n=5 >3 years: n=11 |
3–6 mo: n=6 6–12 mo: n=1 1–3 years: n=7 >3 years: n=5 |
20–35: n=7 36–50: n=6 51–65: n=3 66–90: n=0 |
20–35: n=2. 36–50: n=6. 51–65: n=9. 66–90: n=2 | DM: 13 | BP |
| Paluchamy et al.,65 2018 | India | RCT | Aerobic Usual care |
20 (10/10) (0%) | None stated | Unstable angina, recent MI, grade II CHF Fever (≥101°F); persistent prehemodialysis hyperkalemia Active liver disease; MSK limitations Severe peripheral neuropathy Dementia/other mental disorders; unstable during hemodialysis Lower limb amputee; already in exercise program |
10 | <6 mo: 20% 6 mo to 1 yr: 20% 1–3 yr: 60% >3 yr: 0 |
<6 mo: 30% 6 mo to 1 yr: 10% 1–3 yr: 50% >3 yr: 10% |
18–30: 0% 31–50: 30% 51–70: 70% |
18–30: 20% 31–50: 30% 51–70: 50% |
— | Baroreflex sensitivity |
| Parsons et al.,51 2004 | Canada | RCT | Aerobic Usual care |
18 (7/6) (28%) | Hemodialysis | CVD, MSK, neurological issue, and unable to exercise | 46 | 49 (26) | 35 (25) | 49 (25) | 60 (17) | DM: 15 | BP |
| Petraki et al.,52 2008 | Greece | RCT | Combined Usual care |
50 (24/26) (14%) | Hemodialysis ≥6 mo | Unstable HTN, grade II CHF Lown's grade III arrhythmia; recent MI; unstable angina DM; active liver disease; established cause of syncope |
25 | 72.8 (5.3) | 76.32 (7.0) | 50.52 (14.4) | 50.05 (13.2) | — | BP, baroreflex sensitivity |
| Pereira et al.,68 2022 | Brazil | RCT | Aerobic Usual care |
98 (49/49) (18.4%) | 50–70 years Hemodialysis ≥6 mo |
Previously hospitalized for CKD MSK diseases that prevent exercise Drugs that influenced HR Cognitive impairment; BMI >30 Pacemakers or cardiac surgery <6 mo |
38 | 5.77 (1.56) | 5.8 (3.42) | 71.55 (6.76) | 69.1 (6.17) | DM: 35 HT: 90 |
HRV |
| Reboredo et al.,53 2010 (a) | Brazil | Nonrandomized single-group cross-over | Aerobic Usual care |
18 (18/18) (22%) | None stated | Unstable angina; uncontrolled arrhythmia or DM Uncompensated CHF SBP ≥200 mm Hg and/or DBP ≥120 mm Hg; systemic infection; severe renal osteodystrophy Neurological, pulmonary, or MSK disturbances |
31 | 93.7 (43.9) | 47.6 (12.8) | HT: 86 LVH: 57 CHF: 28 |
BP | ||
| Reboredo et al.,58 2010 (b) | Brazil | RCT | Aerobic Usual care |
28 (14/14) (21%) | Older than 18 years No regular exercise for ≥6 mo |
DM; unstable angina; uncontrolled HTN On antiarrhythmic drugs; severe pneumopathies Acute systemic infection; severe renal osteodystrophy Disabling neurological and MSK disorders |
36 | 60.1 (54.4) | 41.9 (42.4) | 43.5 (12.8) | 49.6 (10.6) | — | LVF, HRV |
| Thenmozhi et al.,76 2018 | India | Prospective interventional cohort; nonrandomized | Aerobic Usual care |
130 (65/65) (—) | 25–65 years Hemodialysis ≥3 mo Clinically stable |
Unstable angina, recent MI, CHF grade II Fever (≥101°F); persistent prehemodialysis hyperkalemia Active liver disease; MSK limitations Severe peripheral neuropathy; lower limb amputee Dementia or other mental disorders Participation in other exercise program; unstable hemodialysis |
15 | 6 mo to 1 yr: 49% 1–3 yr: 46% >3 yr: 5% |
6 mo to 1 yr: 53% 1–3 yr: 42% >3 yr: 5% |
18–30: 11% 31–50: 34% 51–65: 55% |
18–30: 9% 31–50: 31% 51–65: 60% |
— | BP |
| Toussaint et al.,69 2008 | Australia | Randomized cross-over | Aerobic Usual care |
20 (10/10) (5%) | Hemodialysis >3 mo Able to exercise for 3 mo |
Symptomatic CVD Respiratory or MSK issue-limiting exercise |
53 | 72 (56) | 35 (51) | 70 (28–77) | 67 (60–83) | DM: 32 CAD: 47 |
Arterial resistance, BP, brain natriuretic peptide |
ADL, activities of daily living; AFib, atrial fibrillation; BMI, body mass index; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CHF, congestive heart failure; CMRI, cardiac magnetic resonance imaging; CO, cardiac output; Combined, aerobic and resistance exercise; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular attack; CVD, cardiovascular disease; DBP, diastolic BP; DM, diabetes mellitus; EPC, endothelial progenitor cell; HF, heart failure; HR, heart rate; HRV, heart rate variability; HTN, hypertension; IHD, ischemic heart disease; LVEF, left ventricular ejection fraction; LVF, left ventricular function; LVH, left ventricular hypertrophy; LVM, left ventricular mass; MRI, magnetic resonance imaging; MSK, musculoskeletal; N/A, not applicable; MI, myocardial infarction; PVD, peripheral vascular disease; RCT, randomized controlled trial; SBP, systolic BP; TIA, transient ischemic attack.