Effect of resistance exercise plus cholecalciferol on nutritional status indicators in adults with Stage 4 chronic kidney disease
Author, year	Olvera‐Soto et al., 2019 68	Duration of intervention	12 weeks
Participants CKD stage Age (years)	CKD—non‐dialysis Stage 4 48 (36–52) I: 26 C: 13	Sarcopenia outcomes
		Muscle mass	Muscle strength	Physical performance
		Between groups: %∆ SMM by BIA (NS) Within group (intervention): ↑SMM by BIA (NS)	Between groups: %∆ Grip strength (right hand)* %∆ Grip strength (left hand)* Within group (intervention): ↑Grip strength (right hand)*** ↑Grip strength (left hand)**	NA
Intervention description
I: Intervention group: resistance training 60 min ×3/week + daily oral cholecalciferol supplementation. Resistance exercise programme; start: 15 min warm‐up period, next: light or medium resistance bands used to perform each of the 6 exercises with 8 repetitions of each: scapular retraction, scapular protraction, scapular depression with shoulder abduction, elbow flexion, shoulder abduction, sit‐ups. Record keeping: patients received training to fill a log to report days, duration, and intensity of exercise sessions. Cholecalciferol intake: dosing scheme according to serum levels: serum concentration >20 ng/dL; supplement with 600 IU cholecalciferol/day, serum concentration 10–19.9 ng/dL; supplement with 1600 IU cholecalciferol/day, serum concentration <10 ng/dL; supplement with 7200 IU cholecalciferol/day. Record keeping: patients received training to fill a log to report days, frequency, and dosage of cholecalciferol intake. Control group: standard medical care without participation in exercise programme.
Effect of oral nutritional supplementation with and without exercise on nutritional status and physical function of adult haemodialysis patients: a parallel controlled clinical trial (AVANTE‐HEMO Study)
Author, year	Martin‐Alemany et al., 2019 72	Duration of intervention	12 weeks
Participants CKD stage Age (years)	ESRD on haemodialysis (2×/week) 29 ± 9.3 (1) ONS: 13 (2) ONS + RE: 9 (3) ONS + AE: 12	Sarcopenia outcomes
		Muscle mass	Muscle strength	Physical performance
		NA	Within group (ONS): ↑Grip strength* ↑STS (NS) Within group (ONS + RE): ↑Grip strength* ↑STS* Within group (ONS + AE): ↑Grip strength* ↑STS* Effect size (Cohen's d): Grip strength ONS + RE (1.01) ONS + AE (0.60) ONS (0.11) STS ONS + RE (0.81) ONS + AE (1.20) ONS (0.52)	Within group (ONS): ↓TUG* ↑6MWT* Within group (ONS + RE): ↓TUG* ↑6MWT* Within group (ONS + AE): ↓TUG* ↑6MWT* Effect size (Cohen's d): TUG ONS + RE (1.04) ONS + AE (1.6) ONS (0.91) 6MWT ONS + RE (0.94) ONS + AE (1.11) ONS (0.35)
Intervention description
All patients were provided with a 35 kcal/kg diet plan adjusted for age, sex, and physical activity and consists of: 1.2 g protein/kg, 25–35% fat, and 50–60% carbohydrates as percentages of the total energy requirement. Oral nutritional supplementation group (ONS): during haemodialysis sessions ×2/week 1 can of specialized ONS for maintenance dialysis. Each can consist of 480 kcal, 20 g protein, 20 g lipids, and 56 g carbohydrates. Content includes water, maltodextrin, canola oil, lactalbumin, ascorbic acid, and citric acid as antioxidant. ONS plus aerobic exercise group (ONS + AE): during haemodialysis sessions ×2/week ONS: ½ can of the specialized formula described above during 1st hour of haemodialysis session; other ½ of the can administered after AE routine. AE: 20–30 min pedalling stationary in the first 2 h of haemodialysis with aim of moderate intensity (12–13 RPE). ONS plus resistance exercise group (ONS + RE): during haemodialysis sessions ×2/week ONS: ½ can of the specialized formula described above during 1st hour of haemodialysis session; other ½ of the can administered after RE routine. RE: 40 min of 4 types of exercise using resistance bands performed in the first 2 h of haemodialysis (4 sets/20 repetitions) with aim of moderate intensity (12–13 RPE). Both exercise groups: RE and AE was supervised by a trained dietitian with experience in exercise programmes for dialysis patients. Weight, resistance of the bands in RE, time of AE, and resistance of the bicycles were increased when the patient's RPE was less than the target.

The effect of resistance exercise to augment long‐term benefits of intradialytic oral nutritional supplementation in chronic haemodialysis patients
Author, year	Dong et al., 2011 69	Duration of intervention	6 months
Participants CKD stage Age (years)	ESRD on haemodialysis 43 ± 13 ONS: 12 ONS + RE:10	Sarcopenia outcomes
		Muscle mass	Muscle strength	Physical performance
		Between groups at 3, 6 months: ∆ SMM (kg) by DXA (NS) ∆ ASMM (kg) by DXA (NS)	NA	NA
Intervention description
ONS group: Received 2 cans ONS within 30 min prior to dialysis session 3×/week. Each supplement dose (2 cans) contained 480 mL, 960 Kcal (132.8 kcal from protein, 412.8 kcal from carbohydrates, and 412.8 kcal from fat). Weekly visits were completed by study personnel with each subject to evaluate tolerance and compliance to the supplement and to restock additional supplement. ONS + RE group: ONS Received same intervention as ONS only group. RE Supervised 3 sets of 12 repetitions of leg‐press using a specialized machine to target quadriceps, hamstring, and gluteus muscles within 30 min prior to dialysis session 3×/week. Participants sat on the leg press machine with feet placed on a platform, legs at a 90‐degree angle, and instructed to push the platform forward, leaving knees slightly bent. Individualized exercise intensity: first month set at 70% of each participant's 1 RM using weight equal to participant's body weight Additional weight (~25–50 lb) added at each repetition until temporary muscle failure. At the month 3 and month 6 assessments, 1‐RM was repeated in all participants to evaluate progress and determine a new 1‐RM.

The effects of high‐load strength training with protein‐containing or non‐protein‐containing nutritional supplementation in patients undergoing dialysis
Author, year	Molsted et al., 2013 70	Duration of intervention	16 weeks
Participants CKD stage Age (years)	ESRD on haemodialysis and peritoneal dialysis 55 ± 14 E + PRO: 16 E + Non‐PRO: 13	Sarcopenia outcomes
		Muscle mass	Muscle strength	Physical performance
		NA	All participants: ↑STS*** (between control period and training period) Diff between the two groups: STS (NS)	NA
Intervention description
Participants were recruited to a control period of 16 weeks with no intervention followed by an intervention period of 16 weeks with strength training. Progressive high‐load strength training in both groups 3×/week outside of dialysis supervised by physiotherapists and exercise instructors. Participants chose which 3 days they exercised with advice to spread out sessions during the week; if necessary, exercising 2 consecutive days was allowed, to comply with dialysis schedule. Warm‐up and exercise: 5 min of stationary ergometer followed by leg press, leg extension, and leg curl. Rest period between each set of exercises: 60–90 s. Number of exercise repetitions to be completed until muscle exhaustion with load progressively increased according to changes in 1 repetition maximum (tested and adjusted 6 times during study period). Supplementations in both groups: Both contained a low amount of potassium and phosphate as recommended to patients undergoing dialysis. The participants were instructed not to ingest meals at least 2 hours on either side of the training sessions. PRO group: Provided with protein supplementation of 125 mL containing 9.4 g protein (100% whey, 14.3% leucine), 25 g carbohydrate, and 12.5 g lipid (250 kcal). The non‐PRO group: Provided with energy supply of 54.5 mL containing 2.4 g carbohydrate and 27.3 g lipid (250 kcal).

The effects of resistance exercise and oral nutritional supplementation during haemodialysis on indicators of nutritional status and quality of life
Author, year	Martin‐Alemañy et al., 2016 71	Duration of intervention	3 months
Participants CKD stage Age (years)	ESRD on haemodialysis (2×/week) 34 (24.5–43) ONS plus RE: 17 Control ONS: 19	Sarcopenia outcomes
		Muscle mass	Muscle strength	Physical performance
		NA	Within group (ONS): ↑Grip strength* Within Group (ONS + RE): ↑Grip strength*	NA
Intervention description
ONS both groups Consisted of 434 kcal, 19.2 g protein and 22.8 g lipids, low in vitamins A and D and high in folates and vitamin B6, with high‐oleic safflower oil, corn syrup solids, and fructooligosaccharides (FOSs). ONS plus RE ONS Oral nutritional supplement given during dialysis, with ½ a can administered during the 1st hour of the haemodialysis session and ½ a can administered after the RE routine RE RE performed once/week with total of 24 sessions of RE at the end of study during the 2nd hour of haemodialysis session (four sets of 30 repetitions for 40 min). 1 week prior to start of clinical study, patients performed physical conditioning exercise without any extra weight 500 g ankle weights and medium‐resistance springs for hands and arms used in RE with adjustment according to location of the vascular access. Four types of RE used: lower leg extension; arm extension with medium resistance springs leg raises from semi‐recumbent position; knees‐bends to chest Each exercise lasted 10 min separated by 3 min of rest. The patients were advised to work with a level of perceived exertion of ‘somewhat strong’ (12–13 RPE) Control group (ONS) During haemodialysis sessions, patients received a can of a specialized ONS for maintenance dialysis patients

Data shown as mean ± SD or median (range). 1‐RM, one repetition maximum; 6MWT, 6 min walking test; AE, aerobic exercise; ASMM, appendicular skeletal muscle mass; C, control; CKD, chronic kidney disease; DXA, dual‐energy absorptiometry; E, exercise; I, intervention; NA, not available; ONS, oral nutritional supplementation; RE, resistance exercise; RPE, rated perceived exertion; SMM, skeletal muscle mass; STS, sit‐to‐stand test; TUG, timed‐up‐and‐go test.

∆, change; %∆, per cent change; ↑, increase; ↓, decrease; ↔, no change. NS, not significant.

^* P < 0.05.

^** P < 0.01.

^*** P < 0.001.