Exercise program demonstrates feasibility, safety for patients on peritoneal dialysis
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An exercise program in which patients on peritoneal dialysis were first trained by an exercise physiologist at their monthly in-center appointment and then carried out at home appeared to be feasible and safe. The results of this study were recently published in Kidney Medicine.
“Patients with end-stage kidney disease receiving peritoneal dialysis (PD) are generally physically inactive and frail,” Paul N. Bennett, PhD, of Satellite Healthcare, and colleagues, wrote. “Low activity and frailty in these patients are associated with decreased physical function and poor quality of life.”
According to the researchers, risk for falls in this patient population is high, with one fall potentially increasing mortality risk by 60%.
They argued that although home dialysis is meant to allow patients to maintain some independence, having low physical capacity makes this more difficult.
Suggesting that “guidelines recommend nephrologists to encourage physical activity levels in PD patients ... nephrologists and nephrology nurses frequently lack the knowledge, resources, and skills to prescribe detailed or appropriate exercise regimens.”
“Because of this,” the researchers contended, “PD patients are often discouraged from participating in exercise programs because of uncertainty about the best exercise regimen and potential barriers. The result of this is a lack of sustained U.S. exercise programs for PD patients.”
To test the feasibility and safety of such a program, the researchers recruited patients undergoing PD from a single center, randomly assigning them to either the intervention group or control (standard of care). The intervention consisted of exercise training with an exercise physiologist, as well as subsequent appointments with the exercise physiologist during a 3-month period. All participants in the intervention also received four telephone calls from the exercise physiologist during this time to “record adherence and respond to any participant exercise queries.”
Researchers described the exercise routines as being based on the American College of Sports Medicine guidelines and consisting of a 5-minute warm-up exercise and a 5-minute set of cool-down exercises. Initially, cardiovascular exercises (including walking or stationary cycling) were performed for 30 minutes at moderate intensity 3 days per week. “Progression was dependent on patient adherence for the previous month and exercise tolerance,” the researchers wrote, and could be increased by 1 day per week.
In addition, the program included a resistance training component for upper- and lower-body work (repetitions and implementation of a resistance band 2 days per week).
Regarding feasibility, the program demonstrated high rates of eligibility (76% of total patients at the center) and recruitment (63% of eligible patients). In addition, 72% of total patients completed the study and 77% of patients in the intervention were deemed adherent (defined as completing 50% of the prescribed exercise programs).
According to the researchers, no serious adverse events caused by the exercise program were reported (one report of minor abdominal discomfort and one of slight dizziness), which demonstrated its safety.
Appetite also appeared to improve for patients in the intervention group.
Researchers addressed that a strong feature of the program, the inclusion of an exercise physiologist, has cost implications as costs were approximated at $10 per patient per month.
Despite the costs, they argued that this type of exercise program is needed and should be further explored.
“The dialysis community’s past inaction in this area is likely contributing to the accelerated physical deterioration of PD patients,” they wrote. “Current PD care models provide training to perform complex procedures. The expectation is that the patients independently cope with the physical demands of providing PD for themselves, with limited attention by providers and physicians to assist in maintaining their own physical function.”
Researchers argued that this type of care model is not sufficient, concluding: “A more comprehensive care approach to limit physical and psychological decline to reduce adverse events is required. Thus, services by exercise professionals encouraging a more active lifestyle, limiting the physical deterioration of PD patients, may present an opportunity to maintain more independence and an improved quality of life.”
In a related editorial, Stephen Seliger, MD, MS, of the University of Maryland, noted that although there have been multiple interventional studies on the impact of exercise training in patients with ESRD during the past 4 decades, many have been limited by small numbers of participants and short durations of follow-up. In addition, these studies were further limited by a lack of blind outcome assessments and mostly focused on patients on hemodialysis, not PD.
“With the recent Advancing American Kidney Health initiative intended to markedly increase utilization of home dialysis modalities in the U.S.,” Seliger argued, “there is a need for greater evidence on the feasibility and effectiveness of exercise in PD patients.”
According to Seliger, this study by Bennet and colleagues “likely reflect[s] the very broad eligibility criteria of this trial,” as 76% of the patients in the facility were eligible. Therefore, he contended, the study demonstrated feasibility. He also suggested that “participant characteristics were broadly representative of PD patients nationally, with 58% having diabetes, mean age of 57 years, and 65% non-White.”
Furthermore, he wrote, “the lower risk of hemodynamic stability and absence of vascular cannulation [in home PD patients] potentially permits greater safety compared to intra-dialytic exercise in hemodialysis patients.” – by Melissa J. Webb
Disclosures: The authors report being employed by Satellite Healthcare when conducting this research.
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