Back in 1999, UCSF researchers strapped some high tech motion detectors onto about 30 patients on dialysis and compared one week’s worth of activity to that of matched controls. Mind you, these control patients were selected to be sedentary—i.e., they told the researchers that they exercised less than once a week on average. The patients on dialysis were 35% less active than even these sedentary controls. Similarly low levels of physical activity have been confirmed again recently; nearly 95% of patients on dialysis in this study met criteria for “low fitness.”
Okay so what? We all know that our patients tend to be over 60 years of age, and some have peripheral vascular disease or other comorbidities that limit their mobility. We already talk to them about taking their phos binders and eating less salt, do they really need advice about how much they should move about?
Here are some arguments that suggest this this just might help:
• We know that patients on dialysis tend to have a higher burden of cardiovascular disease and diabetes, compared to the general population. And exercise not only prevents a heart attack in an other wise healthy individuals, it also prevents secondary events in individuals who already have some of the comorbidities. For example patients with diabetes who walk two hours per week can drop their all cause cardiovascular mortality to one-third of that seen in sedentary diabetics.
• Just like in the diabetics, being sedentary increases the risk of mortality in our patients as well. In one of the largest observational studies to date, patients who never exercised had a 60% higher chance of dying during their first year of dialysis compared to others who reported that they at least attempted to exercise. This increase in mortality risk is the same as if the patient had an albumin of 2.5 mg/dL compared to 3.5 mg/dL for example.
• Exercise preserves function later in life. Studies have shown a reduction in falls, cognitive impairment and physical function (i.e. ability to complete activities of daily living) in elderly people who exercise.
So both from a longevity and quality of life point of view, our patients would be helped by exercise. There is a lot of back-and-forth about why patients on dialysis tendency towards being sedentary—is it the burden of comorbidity, is it a uremic toxin that saps their muscle strength, or is the procedure itself (when we talk about hemodialysis in particular)? We don’t know yet.
Other people are looking into whether to push aerobic or resistance exercise. But very few studies have tried innovative ways of incorporating exercise into the dialysis session. And in this world of expensive treatments, converting a few dialysis chairs into stationary bikes in the dialysis center may be our most cost effective intervention! Failing that, we should at least mention the bike during our rounds.
Suchi Anand, MD
3 comments:
As a former dialysis patient, it would have been interesting to try to incorporate exercise during dialysis sessions, but on a practical side, motion during dialysis can be quite limited, as some dialysis machines are quite sensitive to movement and alarms can go off many times during a session. This can make the dialysis technicians quite cranky and believe me, patients do not want cranky technicians.
I have for years been in the habit of exercising daily, and I cannot see for the life of me how sitting immobile in a chair for 4 hours every other day could possibly help my cardiovascular fitness. If, as anonymous says, clinics could have available one of these exercise bikes and really encourage patients to use them (and then not get cranky when an alarm goes off), it is a small step forward. Maybe it should be standard protocol to talk to patients about their exercise regime just as you'd talk to them about their diet. If you explain to patients how a little exercise incorporated into their day is just as important as taking their binders, and WHY, you might see some real statistical improvement in their overall health.
But this just makes to much sense to ever happen.
Oh, there's more. Yes, it would be sensible to establish why dialysis patients are resistant to exercise, but it's not a one-size-fits-all issue. Some have co-morbidities that make regular exercise difficult, but I'm sure some bright spark can come up with an exercise regime for just about anyone. Be creative. And if someone is too uremically toxic to exercise a bit, then their care team needs to rethink their dialysis prescription. And if a dialysis patient is getting the standard inclinic, thrice weekly dose of dialysis, well, we all have heard the horror stories about THAT! Who wants to exercise when the very treatment that's supposed to keep them alive at the same time disables them? Maybe these patients should be having MORE dialysis.
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