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Intradialytic training in patients with end-stage renal disease: a systematic review and meta-analysis of randomized clinical trials assessing the effects of five different training interventions

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Abstract

Objective

Patients with end-stage renal disease (ESRD) undergoing hemodialysis may have reduced dialysis adequacy (Kt/V), low cardiorespiratory fitness, and worse prognosis. Different types of intradialytic training (IDT) may serve as an adjunct therapy for the management of the ESRD. This systematic review and meta-analysis aimed to assess the impact of different types of IDT on clinical outcomes and functional parameters in ESRD.

Methods

PubMed, Embase, CINAHL, Cochrane CENTRAL, Scopus, SPORTDiscus, and Google Scholar were searched for randomized clinical trials in adult patients with ESRD which compared IDT with usual care (UC), without language restrictions and published up to July 2019; a handsearch of references was also performed. Certainty of evidence was assessed using GRADE, and risk of bias in primary studies with the RoB 1.0 tool.

Results

Fifty studies were included (n = 1757). Compared to UC, aerobic IDT improved Kt/V (WMD = 0.08), VO2peak (WMD = 2.07 mL/kg/min), 6-minute walk test (6MWT) distance (64.98 m), reduced systolic blood pressure (− 10.07 mmHg) and C-reactive protein (− 3.28 mg/L). Resistance training increased 6MWT distance (68.50 m). Combined training increased VO2peak (5.41 mL/kg/min) and reduced diastolic blood pressure (− 5.76 mmHg). Functional electrostimulation (FES) and inspiratory muscle training (IMT) improved 6MWT distance (54.14 m and 117.62 m, respectively). There was no impact on total cholesterol, interleukin-6, or hemoglobin levels. There was no difference in incidence of adverse events between the IDT and control groups. The certainty of evidence was variable according to the GRADE scale, with most outcomes rated very low certainty. The risk of bias assessment of primary studies showed unclear risk in most.

Conclusions

Aerobic, resistance, and combined training during hemodialysis, as well as FES and IMT, demonstrated to be effective for the treatment of the patient with ESRD. Our data should be interpreted in light of the unclear risk of bias of most evaluated articles and the low to very low certainty of evidence for evaluated outcomes.

Prospero registration ID

CRD42017081338.

Data Sharing Repository

https://osf.io/fpj54/.

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Author information

Author notes

  1. Filipe Ferrari and Lucas Helal contributed equally as first authors.

Authors and Affiliations

  1. Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350-Santa Cecília, Porto Alegre, RS, 90035-003, Brazil

    Filipe Ferrari, Lucas Helal, Douglas Soares & Ricardo Stein

  2. Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Filipe Ferrari & Ricardo Stein

  3. Exercise Pathophysiology Laboratory (LaFiEx), Hospital de Clínicas de Porto Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Lucas Helal

  4. School of Physical Therapy, Universidade do Vale do Rio dos Sinos, São Leopoldo, Brazil

    Thiago Dipp

  5. Experimental and Molecular Cardiovascular Laboratory and Heart Failure Unit, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

    Douglas Soares

  6. Exact Sciences and Engineering, Universidade de Caxias do Sul, Caxias do Sul, Brazil

    Ângela Soldatelli

  7. Center for Workplace Health, American Heart Association, Houston, TX, USA

    Andrew Lee Mills

  8. Faculdade Social da Bahia, Bahia, Brazil

    Cláudio Paz & Mário César Carvalho Tenório

  9. Department of Biotechnology, Universidade Estadual de Feira de Santana, Feira de Santana, Brazil

    Marcelo Trotte Motta

  10. Department of Nephrology, Universidade Católica de Pelotas, Pelotas, Brazil

    Franklin Correa Barcellos

  11. Vitta Centro de Bem-Estar Físico, Porto Alegre, Brazil

    Ricardo Stein

  12. Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

    Ricardo Stein

Authors
  1. Filipe Ferrari
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  2. Lucas Helal
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  3. Thiago Dipp
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  4. Douglas Soares
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  5. Ângela Soldatelli
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  6. Andrew Lee Mills
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  7. Cláudio Paz
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  8. Mário César Carvalho Tenório
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  9. Marcelo Trotte Motta
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  10. Franklin Correa Barcellos
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  11. Ricardo Stein
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Contributions

Study conception and design, data acquisition: LH, FF, TD, FCB; interpretation of data and statistical analysis: FF, LH, DS, TD, AA, CP, MCCT, MTM, FCB, RS; manuscript writing: LH, FF, ALM, MCCT, FCB, RS; critical revision of the manuscript for intellectual content: FF, LH, FCB, RS.

Corresponding author

Correspondence to Ricardo Stein.

Ethics declarations

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Filipe Ferrari receives financial support from the Conselho Nacional de Pesquisa (CNPq); Lucas Helal receives financial support from the Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior (CAPES). Ricardo Stein is an Established Investigator of the Conselho Nacional de Pesquisa (CNPq), Brasília, Brazil.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Data sharing policy statement

We followed the International Committee of Medical Journal Editors Data Sharing Statement for the data sharing policy of this study. All the data and materials related to this study are available at https://osf.io/fpj54/ (Creative Commons CC-By Attribution 4.0), without restrictions to authors request, timing and purpose of use.

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Ferrari, F., Helal, L., Dipp, T. et al. Intradialytic training in patients with end-stage renal disease: a systematic review and meta-analysis of randomized clinical trials assessing the effects of five different training interventions. J Nephrol 33, 251–266 (2020). https://doi.org/10.1007/s40620-019-00687-y

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  • DOI: https://doi.org/10.1007/s40620-019-00687-y

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