Original Report: Laboratory Investigation American
Journal of
Nephrology
Am J Nephrol 2013;38:475–482 DOI: 10.1159/000356340
Received: August 9, 2013 Accepted: October 10, 2013 Published online: November 29, 2013
Interaction between Intradialytic Exercise and Hemodialysis Adequacy Danielle L. Kirkman a, b Lisa D. Roberts a Marten Kelm c Jürgen Wagner c Mahdi M. Jibani b Jamie H. Macdonald a a College of Health and Behavioural Sciences, Bangor University, and b Betsi Cadwaladr University Health Board, Bangor, UK; c B. Braun Avitum AG, Melsungen, Germany
Abstract Background/Aims: According to mathematical modeling, intradialytic exercise of sufficient intensity and duration implemented in the second half of dialysis should be as efficacious as increasing dialysis time for dialysis adequacy. This assumption has not been tested in vivo. Methods: In this controlled trial, 11 hemodialysis (HD) patients (mean (SD) age 56 (13) years) were recruited. Each patient completed three trial arms in a randomized order: routine care (CONT), increased HD time of 30 min (TIME), and intradialytic exercise (EXER), 60 min of cycling at 90% of the lactate threshold in the last 90 min of HD. The primary outcome was eKt/Vurea. Secondary outcomes included reduction and rebound ratios of urea, creatinine, phosphate and β2-microglobulin. Outcomes were calculated from blood sampling collected pre-, post- and 30 min post-HD and confirmed with dialysate sampling. Results: Exercise was not as efficacious as increased HD time for eKt/Vurea (EXER vs. CONT, mean change (95% CI): 0.03 (–0.05 to 0.12); TIME vs. CONT: 0.15 (0.05–0.26)). Exercise was less efficacious at improving reduction ratios of urea and creatinine. However, exercise was more efficacious than in-
© 2013 S. Karger AG, Basel 0250–8095/13/0386–0475$38.00/0 E-Mail [email protected] www.karger.com/ajn
creased dialysis time for phosphate reduction ratio (EXER vs. CONT: 8.6% (0.5–16.7); TIME vs. CONT: 5.0% (–1.0 to 11.1)). Conclusion: This study utilized a rigorously controlled in vivo design to test mathematical models and assumptions regarding dialysis adequacy. Intradialytic exercise towards the end of HD cannot replace the prescription of increased HD time for dialysis adequacy, but may be an adjunctive therapy for serum phosphate control. © 2013 S. Karger AG, Basel
Introduction
Currently, 65% of stage 5 chronic kidney disease (CKD) patients receive hemodialysis (HD) in the USA [1]. HD adequacy is a predictor of hospitalization [2, 3] and mortality [4]. Previous methods of enhancing dialysis adequacy rely on increasing the dose or frequency of dialysis but these have been confronted with barriers of patient compliance and cost implications [5]. Therapeutic strategies to enhance dialysis adequacy, including the removal of solutes other than urea, are highly warranted [6–8]. The present work was carried out at the College of Health and Behavioural Sciences, Bangor University, and Betsi Cadwaladr University Health Board, Bangor, UK.
Danielle Kirkman Department of Kinesiology and Applied Physiology College of Health Sciences 219 McDowell Hall, Newark, DE 19716 (USA) E-Mail dkikman @ udel.edu
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/15/2015 8:14:25 PM
Key Words β2-Microglobulin · Exercise · Hemodialysis adequacy · Inorganic phosphates · Urea
Methods Design In this controlled study (clinicaltrials.gov: NCT01481688), each participant carried out three trial arms: CONTROL, EXERCISE and TIME. Trial arm order was randomized using a computer-generated (www.randomizer.org) list of random numbers.
476
Am J Nephrol 2013;38:475–482 DOI: 10.1159/000356340
Participants Eligible participants, recruited between 01.07.2011 and 31.08.2011 from Gwynedd Hospital, UK, presented with stage 5 CKD dialyzing three times/week. Participants were excluded if they presented with: age
Journal of
Nephrology
Am J Nephrol 2013;38:475–482 DOI: 10.1159/000356340
Received: August 9, 2013 Accepted: October 10, 2013 Published online: November 29, 2013
Interaction between Intradialytic Exercise and Hemodialysis Adequacy Danielle L. Kirkman a, b Lisa D. Roberts a Marten Kelm c Jürgen Wagner c Mahdi M. Jibani b Jamie H. Macdonald a a College of Health and Behavioural Sciences, Bangor University, and b Betsi Cadwaladr University Health Board, Bangor, UK; c B. Braun Avitum AG, Melsungen, Germany
Abstract Background/Aims: According to mathematical modeling, intradialytic exercise of sufficient intensity and duration implemented in the second half of dialysis should be as efficacious as increasing dialysis time for dialysis adequacy. This assumption has not been tested in vivo. Methods: In this controlled trial, 11 hemodialysis (HD) patients (mean (SD) age 56 (13) years) were recruited. Each patient completed three trial arms in a randomized order: routine care (CONT), increased HD time of 30 min (TIME), and intradialytic exercise (EXER), 60 min of cycling at 90% of the lactate threshold in the last 90 min of HD. The primary outcome was eKt/Vurea. Secondary outcomes included reduction and rebound ratios of urea, creatinine, phosphate and β2-microglobulin. Outcomes were calculated from blood sampling collected pre-, post- and 30 min post-HD and confirmed with dialysate sampling. Results: Exercise was not as efficacious as increased HD time for eKt/Vurea (EXER vs. CONT, mean change (95% CI): 0.03 (–0.05 to 0.12); TIME vs. CONT: 0.15 (0.05–0.26)). Exercise was less efficacious at improving reduction ratios of urea and creatinine. However, exercise was more efficacious than in-
© 2013 S. Karger AG, Basel 0250–8095/13/0386–0475$38.00/0 E-Mail [email protected] www.karger.com/ajn
creased dialysis time for phosphate reduction ratio (EXER vs. CONT: 8.6% (0.5–16.7); TIME vs. CONT: 5.0% (–1.0 to 11.1)). Conclusion: This study utilized a rigorously controlled in vivo design to test mathematical models and assumptions regarding dialysis adequacy. Intradialytic exercise towards the end of HD cannot replace the prescription of increased HD time for dialysis adequacy, but may be an adjunctive therapy for serum phosphate control. © 2013 S. Karger AG, Basel
Introduction
Currently, 65% of stage 5 chronic kidney disease (CKD) patients receive hemodialysis (HD) in the USA [1]. HD adequacy is a predictor of hospitalization [2, 3] and mortality [4]. Previous methods of enhancing dialysis adequacy rely on increasing the dose or frequency of dialysis but these have been confronted with barriers of patient compliance and cost implications [5]. Therapeutic strategies to enhance dialysis adequacy, including the removal of solutes other than urea, are highly warranted [6–8]. The present work was carried out at the College of Health and Behavioural Sciences, Bangor University, and Betsi Cadwaladr University Health Board, Bangor, UK.
Danielle Kirkman Department of Kinesiology and Applied Physiology College of Health Sciences 219 McDowell Hall, Newark, DE 19716 (USA) E-Mail dkikman @ udel.edu
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/15/2015 8:14:25 PM
Key Words β2-Microglobulin · Exercise · Hemodialysis adequacy · Inorganic phosphates · Urea
Methods Design In this controlled study (clinicaltrials.gov: NCT01481688), each participant carried out three trial arms: CONTROL, EXERCISE and TIME. Trial arm order was randomized using a computer-generated (www.randomizer.org) list of random numbers.
476
Am J Nephrol 2013;38:475–482 DOI: 10.1159/000356340
Participants Eligible participants, recruited between 01.07.2011 and 31.08.2011 from Gwynedd Hospital, UK, presented with stage 5 CKD dialyzing three times/week. Participants were excluded if they presented with: age
