Physical function, exercise, and clinical outcomes in peritoneal dialysis: a narrative review

Abstract

Background

Peritoneal dialysis (PD) is a home-based kidney replacement therapy, yet many patients experience low physical activity, reduced muscle strength, and impaired cardiorespiratory fitness. Contemporary evidence increasingly links these functional deficits to clinically meaningful outcomes.

Objective

This study aims to review studies published from 2020 to present to summarize (i) the burden and assessment of impaired physical function in PD, (ii) associations with clinical outcomes, and (iii) effects of exercise interventions.

Methods

Based on PubMed dataset, a contemporary narrative review of peer-reviewed literature (2020-present) evaluating sarcopenia/frailty, objective and patient-reported physical function measures (e.g., handgrip strength, Short Physical Performance Battery, timed up-and-go, 6-minute walk distance, incremental shuttle walk test), and structured exercise interventions in adults treated with PD.

Results

Impaired physical function is common in PD and variably defined across studies, contributing to heterogeneous prevalence estimates of sarcopenia and frailty. Lower physical activity and poorer performance on objective tests are consistently associated with higher risks of mortality, hospitalization, and PD technique failure, with aerobic capacity measures showing particularly strong prognostic value in several cohorts. Exercise interventions (aerobic, resistance, or combined; often home-based) are generally feasible and safe, and improve functional performance and health-related quality of life, with additional benefits for fatigue, mood, and pain; effects on hard endpoints remain uncertain.

Conclusions

Since 2020, evidence supports physical function as a key risk marker in PD and exercise as an effective strategy to improve function and patient-reported outcomes. Larger, longer trials and implementation-focused research are needed to determine effects on survival and technique outcomes and to embed routine functional assessment and exercise prescription into PD care.

What is already known

• •Patients receiving peritoneal dialysis frequently experience reduced physical activity, sarcopenia, and impaired physical performance.
• •Poor physical function in dialysis populations is associated with worse clinical outcomes, including mortality and hospitalization.
• •Exercise interventions in chronic kidney disease can improve physical capacity and some patient-reported outcomes.

What this paper adds

• •This review synthesizes contemporary evidence (2020-present) demonstrating that impaired physical function is a key risk marker for mortality, hospitalization, and technique failure in peritoneal dialysis.
• •Cardiorespiratory fitness measures, particularly the 6-minute walk distance and incremental shuttle walk test, show strong prognostic value in PD populations.
• •Exercise interventions are feasible and beneficial in PD, improving functional performance and quality of life, while highlighting gaps in long-term outcome evidence and implementation in routine care.

Alt-text: Unlabelled box dummy alt text

1. Introduction

Peritoneal dialysis (PD) represents a vital home-based kidney replacement therapy for patients with end-stage kidney disease, offering greater autonomy and flexibility compared to in-center hemodialysis. However, despite these potential lifestyle advantages, patients undergoing PD are not immune to the profound physical dysfunction and systemic complications inherent to advanced chronic kidney disease. A sedentary lifestyle is prevalent in this population, contributing to a cycle of deconditioning, muscle wasting, and diminished functional capacity (Garibotto et al., 2021). This physical decline is not merely a matter of reduced quality of life; it is intricately linked to critical clinical endpoints, including technique survival, hospitalization rates, and mortality (Nakayama et al., 2021; Yabe et al., 2023).

Over the past five years, a growing body of research has specifically focused on elucidating the complex interplay between physical function, structured exercise, and disease trajectory in the PD population. Key areas of investigation include the high prevalence and defining components of sarcopenia and frailty, the prognostic value of objective physical performance measures, and the feasibility and efficacy of targeted exercise interventions (Battaglia et al., 2024; Kanbay et al., 2024). However, important gaps remain in the integration of this knowledge into routine PD care. Therefore, this narrative review aims to provide a contemporary synthesis of evidence (2020-present), focusing on (i) the burden and assessment of impaired physical function in PD, (ii) its association with clinical outcomes, and (iii) the effects of exercise interventions, with particular emphasis on their clinical applicability.

2. Methods

This study is a narrative review aimed at synthesizing recent evidence on physical function and exercise in adults undergoing peritoneal dialysis. A structured literature search was conducted using PubMed and Embase to identify relevant studies published from January 2020 to April 2026.

Search terms included combinations of keywords and Medical Subject Headings (MeSH), such as "peritoneal dialysis," "physical function," "exercise," "physical activity," "sarcopenia," "frailty," "mobility," and "cardiorespiratory fitness." The detailed search strategy is provided in Table S1. Reference lists of selected articles were also screened to identify additional relevant studies.

This review synthesizes evidence from a range of study designs, including observational cohort studies, cross-sectional analyses, randomized controlled trials, and systematic reviews published from 2020 onwards. The included studies are heterogeneous in terms of design, population characteristics, and outcome measures, reflecting the evolving nature of research in this field.

As a narrative review, this study did not follow a formal systematic review protocol, and no protocol was registered (e.g., PROSPERO). Study selection and synthesis were based on relevance and clinical significance rather than predefined systematic criteria.

3. Overview of findings

The following sections present a narrative synthesis of the evidence identified through the literature search. The findings are organized into key thematic domains based on the included studies, including (i) the prevalence and components of impaired physical function, (ii) associations between physical function and clinical outcomes, (iii) the effects of exercise interventions, and (iv) clinical perspectives and implementation considerations.

3.1. The prevalence and components of impaired physical function in peritoneal dialysis patients

Impaired physical function in PD patients is a multifactorial syndrome, most comprehensively captured by the concepts of sarcopenia and frailty. Sarcopenia, characterized by the loss of muscle mass and strength, is exceedingly common. A 2022 meta-analysis reported a pooled prevalence of sarcopenia of 25.6% in dialysis patients, with studies specific to PD cohorts showing considerable variation from 8.3% to 44.5% depending on the diagnostic criteria applied (Meenetkum et al., 2025; Wathanavasin et al., 2022). This wide range underscores a lack of consensus on the optimal definition for the dialysis population. Recent definitions, such as those from the Sarcopenia Definitions and Outcomes Consortium, which emphasize low muscle function without mandatory mass measurement, may identify a larger proportion of at-risk patients, though potentially leading to overdiagnosis.

The individual components of sarcopenia carry significant weight. Low muscle strength, often assessed by handgrip strength (HGS), appears to be a more potent indicator of disability and risk than low muscle mass alone. Studies consistently show that low HGS is highly prevalent and more strongly associated with functional limitations and dependency in activities of daily living than low muscle mass (Kang et al., 2022; Sabatino et al., 2025). Muscle quality, beyond mere quantity, is also compromised. Research indicates associations between the accumulation of advanced glycation end products, common in PD due to glucose exposure, and reduced muscle stiffness/density as measured by elastography, linking metabolic alterations to muscle degeneration (Fonseca et al., 2021).

Frailty, a broader syndrome of decreased physiological reserve, is closely related. In PD patients, fatigue and low muscle strength are primary phenotypic components (Cao et al., 2025). The etiology of this physical dysfunction is complex, involving anabolic resistance, where the muscle protein synthesis response to stimuli like dietary protein and exercise is blunted (Garibotto et al., 2021). Myostatin, a negative regulator of muscle growth, is often elevated in chronic kidney disease and may contribute to this catabolic state; in PD patients, lower serum myostatin levels have been paradoxically linked to poorer physical function and higher hospitalization risk, suggesting a complex, possibly compensatory, relationship (Bataille et al., 2021).

Objective assessment reveals widespread deficits. Cardiorespiratory fitness, measured by tests like the incremental shuttle walk test (ISWT) or 6-minute walk distance (6MWD), is significantly reduced. One study found PD patients had lower peak oxygen consumption than kidney transplant recipients (Theodorakopoulou et al., 2021). Lower extremity strength and balance are also impaired, with tests like the five-times sit-to-stand and timed-up-and-go showing prolonged completion times (Silva et al., 2021; Tao et al., 2021). These objective measures correlate strongly with patients' self-reported physical function and health-related quality of life (HRQoL), validating their clinical relevance (Tarca et al., 2024). Table 1 summarizes the physical function assessment tools for peritoneal dialysis patients.

Table 1.

Common tools used to assess physical function in patients undergoing peritoneal dialysis.

Domain	Assessment tool	Measurement	Common cut-off	Clinical relevance
Muscle strength	Handgrip strength (HGS)	Upper limb strength using dynamometer	<27 kg men / <16 kg women	HGS is a simple and reliable indicator of muscle strength and sarcopenia in dialysis populations. Studies show that low HGS is strongly associated with functional limitations, dependence in daily activities, and increased mortality risk in PD patients, often providing stronger prognostic information than muscle mass alone (Kang et al., 2022; Meenetkum et al., 2025; Sabatino et al., 2025).
Lower limb strength	Five-times sit-to-stand (FTSTS)	Time to stand 5 times	>12 s suggests impairment	The FTSTS evaluates lower extremity muscle strength and functional mobility. Prolonged completion times indicate impaired lower limb performance, which is common in PD patients due to muscle wasting and physical inactivity. Poor performance on this test has been linked to frailty and reduced physical independence(Silva et al., 2021; Tao et al., 2021).
Physical performance	Short Physical Performance Battery (SPPB)	Balance, gait speed, chair stand	≤8 indicates frailty risk	The SPPB provides a multidimensional assessment of lower extremity function and frailty status. Lower scores have been associated with increased hospitalization risk and poorer functional status in PD cohorts. Because it integrates multiple domains of physical performance, it is widely used in geriatric and nephrology research (Bataille et al., 2021; Silva et al., 2023).
Mobility	Timed Up and Go Test (TUGT)	Time to rise, walk, turn	>12–15 s abnormal	The TUGT test evaluates mobility, balance, and fall risk. PD patients often demonstrate prolonged TUGT times due to reduced muscle strength and impaired coordination. Abnormal TUGT performance reflects functional limitations and has been associated with frailty and decreased health-related quality of life (Silva et al., 2021; Tao et al., 2021).
Aerobic capacity	6-minute walk test (6MWD)	Distance walked in 6 min	<338 m linked with mortality	The 6MWD measures submaximal cardiorespiratory fitness and functional exercise capacity. In PD populations, shorter walking distances have been independently associated with increased mortality risk, particularly among elderly patients. The test also correlates with nutritional status and overall physical function (Yabe et al., 2023).
Aerobic capacity	Incremental shuttle walk test (ISWT)	Progressive walking capacity	Lower distance predicts technique failure	The ISWT evaluates aerobic capacity and integrated cardiopulmonary performance. Evidence suggests that shorter ISWT distances predict poorer PD technique survival, higher hospitalization rates, and lower peritonitis-free survival. This highlights the importance of cardiorespiratory fitness for maintaining independent PD therapy (Nakayama et al., 2021).

3.2. The association between physical function and clinical outcomes in peritoneal dialysis

Robust evidence from recent years establishes that impaired physical function is a powerful independent predictor of adverse clinical outcomes in PD, often surpassing traditional biochemical markers. Perhaps the most compelling association is with mortality. Lower levels of physical activity, assessed by questionnaires, are strongly linked to increased risk of death (Tabibi et al., 2020; Wang et al., 2025). Objectively, a shorter 6MWD, particularly below a threshold of approximately 338 m, is a significant predictor of all-cause mortality, especially in elderly PD patients (Yabe et al., 2023). The combination of exercise intolerance (low 6MWD) and malnutrition identifies a subgroup with a particularly dismal survival prognosis.

Technique survival, a patient-centered outcome crucial for maintaining home-based therapy, is also closely tied to physical capacity. The ISWT, a measure of aerobic capacity, has emerged as a significant predictor. Patients with a shorter ISWT distance have markedly lower technique survival rates, as well as lower peritonitis-free and PD-related hospitalization-free survival rates (Nakayama et al., 2021). This relationship appears stronger than that observed for muscle strength measures like HGS or quadriceps strength, highlighting the importance of integrated cardiopulmonary and musculoskeletal fitness for maintaining independent PD therapy. While low HGS is also associated with poorer patient and technique survival, its predictive value may be more pronounced than that of low muscle mass alone (Kang et al., 2022).

The risk extends to hospitalization events. Lower serum myostatin levels, along with poor performance on the Short Physical Performance Battery, gait speed, and HGS, have all been independently associated with a higher likelihood of hospitalization in prospective cohorts (Silva et al., 2023). This suggests that functional impairment, reflecting both muscle pathology and systemic illness, increases vulnerability to acute decompensations.

The connection between sarcopenia and cardiovascular events is more complex. A meta-analysis indicated that sarcopenia is associated with a significantly higher risk of cardiovascular events in dialysis patients (Wathanavasin et al., 2022). However, a specific study in a mixed dialysis cohort found no significant difference in cardiovascular events or mortality between patients with and without sarcopenia diagnosed by the EWGSOP2 criteria, and no association with pre-atherosclerotic markers like carotid intima-media thickness (Baltacı et al., 2023). This discrepancy may relate to diagnostic criteria and cohort characteristics, but it underscores that low physical function is a marker of high overall risk, even if the direct link to cardiovascular events requires further granularity.

3.3. The impact of exercise interventions on physical function and patient-reported outcomes in peritoneal dialysis

Given the strong prognostic implications of low physical function, exercise interventions are a logical and promising therapeutic strategy. Recent systematic reviews and meta-analyses confirm that structured exercise is feasible, safe, and beneficial for PD patients. A 2022 Cochrane review of exercise in dialysis patients, which included PD studies, found that exercise training probably improves depressive symptoms and functional capacity, with low-certainty evidence suggesting improvements in fatigue, the physical component of HRQoL, and pain (Bernier-Jean et al., 2022). A dedicated 2025 meta-analysis of randomized controlled trials in PD patients concluded that exercise significantly improves specific domains of kidney disease-related quality of life, including burden of kidney disease, physical pain, and social support (Man et al., 2025).

The benefits manifest across various functional domains. Exercise interventions, including home-based aerobic and resistance programs, have been shown to improve objective measures such as the 6MWD, sit-to-stand test performance, timed-up-and-go time, and gait speed (Bennett et al., 2020; Watanabe et al., 2021; Zhang et al., 2021). Combined aerobic and resistance training appears particularly effective. Notably, these improvements occur without increasing the risk of abdominal wall complications, such as hernias, as demonstrated by a large observational study which found no association between typical aerobic exercise and such events (Li et al., 2025).

Patient-reported outcomes see meaningful gains. Beyond the quantified improvements in HRQoL scales, exercise alleviates key symptoms that define the illness experience. It can reduce fatigue, a core component of frailty, and ameliorate depressive symptoms, with effects potentially more pronounced when the intervention is sustained beyond four months (Bernier-Jean et al., 2022). Pain, a common and debilitating symptom reported by up to 35.9% of PD patients, may also be improved through exercise, enhancing overall comfort and activity tolerance (Davison et al., 2021).

Novel delivery methods are being explored. Virtual reality training has emerged as a promising tool, particularly for enhancing engagement. While evidence in PD per se is limited compared to hemodialysis, meta-analyses in dialysis populations indicate virtual reality can improve physical endurance (e.g., 6MWD), reduce anxiety and depression, and enhance social functioning and self-efficacy (Kang et al., 2025). This points to its potential as an adjunct for home-based rehabilitation.

However, the impact of exercise on hard clinical endpoints and some physiological parameters remains less clear. No study has yet demonstrated that exercise reduces mortality or major cardiovascular events in PD patients, though this is likely due to a lack of large, long-term trials rather than evidence of ineffectiveness (Kanbay et al., 2024). Furthermore, while exercise improves muscle function, its effect on bone mineral density in PD is ambiguous; one pilot study found no improvement in bone mineral density after a home-based exercise program, and another observational study suggested high levels of physical activity might even be associated with lower bone mineral density, possibly due to complex bone-kidney interactions (Raimundo et al., 2020).

3.4. Clinical perspectives, barriers, and practical recommendations for implementing exercise

There is a strong and growing consensus among nephrology professionals on the importance of physical activity for PD patients (Table 2). International surveys reveal that the vast majority (over 90%) of PD clinicians believe structured exercise is beneficial, and patients themselves acknowledge its value (Y Battaglia et al., 2024; Bennett et al., 2023). Clinical practice points have been developed by organizations like the International Society for Peritoneal Dialysis and the Global Renal Exercise Network to guide safe and effective activity, addressing common concerns such as exercising with a full or empty abdomen, swimming, and lifting restrictions (Bennett et al., 2022). These guidelines generally support the safety of core strengthening and most aerobic activities, advocating for a shift away from unnecessarily restrictive advice (Bennett et al., 2022, 2023; MacRae et al., 2025).

Table 2.

Barriers to exercise implementation in patients undergoing peritoneal dialysis and potential strategies.

Barrier category	Specific barrier	Description	Potential strategies
Health system barriers Health system barriers	Limited physiotherapy resources	Many nephrology units lack dedicated physiotherapists or rehabilitation specialists, limiting the ability to assess physical function and supervise exercise programs. Surveys indicate that fewer than 10% of kidney units have structured exercise services for dialysis patients (Clyne et al., 2025).	Integrate physiotherapists into multidisciplinary nephrology teams; establish kidney rehabilitation programs within dialysis services.
	Lack of reimbursement	Exercise and rehabilitation services for CKD and dialysis patients are often not reimbursed in many healthcare systems, reducing institutional motivation to implement structured programs (Clyne et al., 2025).	Advocate for policy changes recognizing exercise as a therapeutic intervention; incorporate exercise programs into chronic disease management pathways.
Clinical practice barriers Clinical practice barriers	Limited physician counseling	Many patients report receiving little or no direct advice regarding physical activity from their nephrologists or dialysis teams, despite clinicians acknowledging the importance of exercise.	Provide clinician education on exercise prescription; include physical activity counseling as part of routine dialysis consultations.
	Lack of routine functional assessment	Physical performance tests such as HGS Or sppb are rarely implemented in routine nephrology practice, making it difficult to identify patients at risk of functional decline (Battaglia et al., 2024; Tarca et al., 2024).	Introduce standardized screening protocols for physical function during regular PD clinic visits.
Patient-level barriers Patient-level barriers Patient-level barriers	Safety concerns	Patients often fear that exercise may cause catheter displacement, hernias, or other abdominal complications, leading to avoidance of physical activity. These concerns persist despite evidence supporting exercise safety in PD (Li et al., 2025; MacRae et al., 2025).	Provide education on safe exercise practices and recommended activities; distribute guideline-based patient education materials.
	Lack of structured programs	Many patients do not have access to convenient or tailored exercise programs suited to the PD population, particularly for home-based therapy (Suri et al., 2023).	Develop simple home-based exercise programs using walking, resistance bands, or telehealth-guided sessions.
	Fatigue and symptom burden	Fatigue, depression, and pain are common in PD patients and may reduce motivation or capacity to engage in regular exercise.	Implement gradual, individualized exercise programs and combine them with psychosocial support or symptom management strategies.
Behavioral barriers	Low motivation and adherence	Sustaining long-term exercise adherence can be difficult without structured support or feedback mechanisms.	Use wearable devices, telemonitoring, or virtual reality-based programs to enhance engagement and adherence.

Despite this professional consensus, a significant implementation gap persists. A major European survey (EUSUREX) highlighted systemic barriers: a lack of dedicated physiotherapy resources and reimbursement structures in most healthcare systems. In many countries, fewer than 10% of kidney units have an integrated physiotherapist or structured exercise program for all chronic kidney disease modalities, with Sweden being a notable exception (Clyne et al., 2025). Consequently, while clinicians believe in exercise, formal assessment of physical performance is not routine, and most patients do not receive a specific exercise prescription.

Patient-level barriers are also prominent. Surveys identify key obstacles: lack of direct advice from physicians, absence of safe and convenient programs, and cost (Suri et al., 2023). Furthermore, patients express specific preferences; they are more interested in exercise programs that improve immediate symptoms like strength and fatigue rather than long-term cardiovascular prevention, indicating a need for patient-centered program design. Common areas of confusion among patients include permissible lifting weights, the safety of swimming, and whether to drain dialysate before activity, pointing to a need for clearer, evidence-based patient education.

Practical recommendations for closing this gap are emerging. Firstly, routine assessment of physical function using simple tools like HGS, Short Physical Performance Battery, timed-up-and-go, or the 6MWD should be integrated into clinical practice to identify at-risk patients (García-Menéndez et al., 2025; Tarca et al., 2024). Secondly, prescribing exercise should be considered a standard part of PD care. Feasibility studies demonstrate that even simple, home-based programs using walking poles or resistance bands are viable and effective (Bennett et al., 2020). To facilitate the translation of current evidence into clinical practice, a practical framework for exercise prescription in patients undergoing peritoneal dialysis is summarized in Table 3. This framework outlines key components including exercise modality, intensity, frequency, and practical considerations relevant to PD therapy. A multidisciplinary approach involving nephrologists, nurses, dietitians, and exercise professionals is crucial for success (Battaglia et al., 2024). Finally, leveraging technology, such as remote monitoring, activity trackers, and VR platforms, can support adherence and tailor interventions in a home-based therapy setting (Kang et al., 2025).

Table 3.

Suggested exercise prescription framework for patients undergoing peritoneal dialysis.

Component	Recommendation	Rationale
Aerobic exercise	Walking, cycling, or similar activities 3–5 days per week, 20–40 min per session	Improves cardiorespiratory fitness and walking capacity, which are strongly associated with survival and functional independence in PD patients.
Resistance training	2–3 sessions per week targeting major muscle groups using resistance bands or light weights	Enhances muscle strength and counteracts sarcopenia commonly observed in dialysis populations.
Flexibility and balance	Stretching and balance exercises 2–3 times per week	May reduce fall risk and improve functional mobility in older PD patients.
Exercise intensity	Moderate intensity (approximately 11–13 on Borg scale)	Safe and achievable for most dialysis patients while still producing physiological benefits.
Dialysate considerations	Exercise may be performed with full or drained abdomen depending on comfort and activity type	Current guidelines indicate that most physical activities can be safely performed with appropriate precautions.
Program setting	Home-based or hybrid programs with periodic clinical supervision	Home-based exercise improves feasibility and adherence for patients undergoing PD therapy.

4. Limitations

This review has several limitations. First, the literature search was limited to PubMed/Embase database, which may have resulted in the omission of relevant studies indexed elsewhere. Second, as a narrative review, this study did not follow a formal systematic review methodology, and no protocol was registered. Third, no standardized quality assessment of included studies was performed, which may limit the ability to evaluate the strength of the evidence. Finally, study selection and synthesis were based on clinical relevance, which may introduce selection bias.

5. Future directions

Although the evidence from 2020 onward firmly establishes that impaired physical function, encompassing low muscle strength, reduced cardiorespiratory fitness, and sarcopenia, is a highly prevalent, multidimensional problem in PD patients that independently predicts mortality, technique failure, and hospitalization, there is a pressing need for large-scale, long-term, randomized controlled trials with adequate power to determine whether exercise interventions can directly improve major clinical outcomes such as patient survival, cardiovascular event rates, and long-term technique survival in PD. The optimal "dose" of exercise (type, intensity, frequency) and the most effective strategies to overcome anabolic resistance in this population require further elucidation. Furthermore, research must work towards standardizing the assessment and diagnostic criteria for sarcopenia and frailty specifically in the PD population to improve risk stratification and intervention targeting (Jegatheesan et al., 2021).

Future directions should also focus on implementation science. Research must address how to sustainably integrate physical function assessment and structured exercise prescription into diverse healthcare systems, overcoming the identified barriers of resource limitations and lack of reimbursement. Personalized, technology-supported exercise regimens that align with patient preferences and lifestyles hold great promise. Ultimately, embracing a paradigm where functional rehabilitation is a core component of comprehensive PD care, alongside metabolic and volume control, is essential for improving the holistic well-being and long-term outcomes of patients living with this home-based therapy.

6. Conclusion

In summary, impaired physical function is highly prevalent in patients undergoing peritoneal dialysis and represents a strong and clinically meaningful predictor of adverse outcomes, including mortality, hospitalization, and technique failure. Measures of cardiorespiratory fitness appear particularly valuable for risk stratification. Integrating routine functional assessment and individualized exercise prescription into PD care represents an important step toward patient-centered management.

Declarations

Ethical approval

Not applicable.

Human and animal rights

This article is based on previously published studies and does not contain any new studies with human participants or animals performed by any of the authors.

Informed consent

Not applicable.

Funding

This work was supported by the Shanghai Nursing Association 2026 Outstanding Young Talent Incubation Program, and 2025 Shanghai “Rising Stars in Medicine” Young Medical Talent Development Grant Program.

CRediT authorship contribution statement

Wanhaier Abudoureheman: Writing – review & editing, Writing – original draft, Conceptualization. Fan Zhang: Writing – review & editing, Writing – original draft, Supervision, Project administration, Funding acquisition, Data curation, Conceptualization.

Declaration of competing interest

The author(s) declared no potential conflicts of interest.

Data availability

Not applicable.