Home dialysis and physical activity:state of knowledge and recommendations for the nephrologist

Abstract

Home-Dialysis promotes the autonomy of dialysis patients, and should be accompanied by a higher level of physical activity and physical capacity than conventional hemodialysis. There are no data on daily-home-hemodialysis patients, but peritoneal dialysis patients have similar levels of physical activity and physical capacity to conventional hemodialysis patients. There are no studies evaluating the effect of a re-training program in daily-home-hemodialysis patients. Several studies have demonstrated the feasibility and safety of re-training programs in peritoneal dialysis patients, with beneficial effects on quality of life and physical capacity. Regular physical activity of 30 minutes, 5 times a week, is recommended for dialysis patients. All periods of low- to moderate-intensity physical activity should be taken into account when calculating the 30 minutes, and it is therefore possible to include physical activity as part of daily life, physical exercise, and leisure sports activities. It is the role of nephrologists to promote the practice of regular physical activity to their patients, possibly with the support of physical activity professionals whose role will be to assess patients’ physical condition, motivation, and lifestyle, design individualized physical rehabilitation programs for each patient, supervise these programs and empower patients towards a more active lifestyle and regular physical activity. The lack of studies should not be a hindrance to nephrologists, who can draw on existing recommendations from cardiology and International Society for Peritoneal Dialysis (ISPD).

Introduction

In dialysis patients, the benefits of physical activity (PA) on health status are multiple and well-demonstrated, such as improved quality of life and cardiovascular comorbidities[1][2][3][4][5]. In 2020, the European Society of Cardiology updated its recommendations on the practice of sport in patients with cardiovascular disease to include patients with chronic kidney disease[6],[7]. New recommendations have recently been issued by the learned societies of nephrology concerning the practice of PA for haemodialysis and peritoneal dialysis patients[8][9][10][11][12]. In spite of this, the practice of physical activity is underdeveloped among dialysis patients[13]. Numerous obstacles to PA have been identified, such as the burden of illness, chronic fatigue, dialysis sessions, numerous associated comorbidities and fear of injury[14],[15]. Obstacles also exist among doctors who, although they are now aware of the beneficial effects of PA, do not promote physical activity among their patients due to lack of time, lack of knowledge, or fear of the risks associated with PA[16].

Home dialysis techniques, such as peritoneal dialysis (PD) and daily home hemodialysis (DHH), offer patients a better quality of life, with extrarenal purification methods that are more physiological, less time-consuming and better integrated into daily life, reducing fatigue and restoring patients’ autonomy and free time[17],[18]. Home dialysis would thus reduce sedentary lifestyles and increase the level of physical activity, ultimately improving the physical condition of dialysis patients. In a retrospective longitudinal observational study comparing 19129 in-center-HD patients with 886 Home dialysis patients (PD=825 and DHH n=61), Eneanya et al. used a propensity score that took into account gender, age, ethnicity, albumin, number of comorbidities and residual renal function to show a statistically significant difference in physical score at dialysis initiation, as assessed by the SF36, in favor of home dialysis patients (41.1 ± 10.5 VS 38 ± 10.3 p<0.01). The latter persisted over time for home dialysis patients, but decreased when patients were transferred into a center[19]. Nevertheless, there are few studies in the literature on this subject. With regard to hemodialysis, the majority of studies focus on conventional hemodialysis patients dialyzed three times a week[20][21][22][23][24]. And in peritoneal dialysis patients, the presence of dialysate in the peritoneal cavity was often considered a limitation to the practice of many physical activities[25].

The aim of this article is firstly to describe the main findings on PA and home dialysis, and secondly to provide a reminder of the definition of PA and how to implement it, so that nephrologists can promote PA in home dialysis patients.

Daily home hemodialysis and physical activity

Daily hemodialysis (DHH) has undergone a revival over the last ten years, with the arrival of new, simplified dialysis machines enabling patients to carry out independent 2h-2h30 dialysis sessions at home, typically 5 to 7 days a week[26]. Among dialysis patients, DHH patients are usually those with the best health status. In 2021, in the REIN registry, 49% of them had no comorbidities, compared with 22% of all dialysis patients[27]. This suggests that these patients are in better physical condition, with less sedentary lifestyles and higher levels of physical activity. To our knowledge, there are no data in the literature specifically analyzing the physical activity levels and physical capacities of these patients. A prospective study is currently underway to assess the physical activity level of patients in DHH vs. in-center hemodialysis using a pedometer[28]. On the other hand, several studies have assessed the quality of life of DHH patients. The Frequent Hemodialysis Network (FHN) Daily Trial showed that DHH patients had an average 3.3-point improvement in a composite physical activity score assessed by the RAND 36 questionnaire, compared with an average 0.2-point improvement for conventional HD patients[29]. This is the only randomized study to compare patients on conventional HD (3 sessions per week) with patients on DHH (6 sessions per week). The study was carried out in North America, with 120 patients in each group. The FREEDOM study assessed the quality of life of DHH patients using the SF36 score[30]. This was a prospective multicenter observational study carried out in the USA, involving 291 patients. At 4 and 12 months, the remaining 217 and 154 patients respectively showed a significant improvement of 3 and 4 points respectively in the SF36 physical score compared with the initial assessment. This improvement concerned all 6 domains assessed by the SF36 physical score.

Peritoneal dialysis and Physical activity (PA)

While peritoneal dialysis (PD) provides patients with greater autonomy than conventional HD, the studies found no difference in patients’ physical activity levels or physical capacity between these two renal replacement therapy groups. In a systematic review published in 2013, grouping together 46 studies published between 1985 and 2011, and comparing the three renal replacement modalities (transplantation, HD and PD) Purnel et al. showed that there was no difference between HD and PD patients regarding physical activity levels[31]. More recently, Painter et al. compared the physical capacity assessed by a battery of physical tests (gait speed, chair stand, standing balance, 6-minute-walk, incremental shuttle walk) and the SF36 questionnaire, and the level of physical activity assessed by a CHAMPS (Community Healthy Activities Model Program for Seniors) self-questionnaire in two groups of 45

.....