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Background

Skeletal muscle atrophy and accumulation of intramuscular lipids is common in End Stage Renal Disease (ESRD)

(Acidosis, protein-energy malnutrition, comorbid illnesses, corticosteroids, biologic aging, oxidative stress, dialysis treatment, and low levels of physical activity)

Loss of muscle quantity (atrophy) and quality (intramuscular lipids) is associated with metabolic and functional deficits and reduced quality of life

Muscle atrophy is one of the strongest predictors of mortality in ESRD

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Rationale

High-intensity progressive resistance training (PRT) enhances skeletal muscle in patients with catabolic diseases. Therefore, prescribing PRT to ESRD patients seems rational

Biggest barrier to regular exercise for ESRD patients is sedentariness caused by dialysis treatment (12-18 hours/week)

Despite evidence of benefits, few clinical units around the globe utilize an active approach towards patient downtime

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Purpose and Hypothesis

The purpose of this study was to determine whether a PRT program administered during routine hemodialysis treatment could safely induce favorable shifts in skeletal muscle quantity and quality in patients with ESRD

Researchers hypothesized that the PRT intervention would increase skeletal muscle cross-sectional area (CSA) and reduce intramuscular lipid infiltration while inducing additional health-related adaptations

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Methodology- Participants

n= 49 (25= Control, 24= PRT) (5 participants dropped out)

Patients were randomly assigned via computer generator into:

PRT + usual care (Intervention)

usual care (control)

Randomization assignments were generated by an investigator not involved in testing or training and delivered to patients in sealed envelopes

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Methodology – Dependent Variables

All outcome measures were collected at baseline and 12 week after randomization

Thigh muscle CSA (muscle quantity) and attenuation (muscle quality) (CT Scan)

CT scans also provided areas of subcutaneous and total fat of the mid-thigh

Peak force (kg) of the knee extensors, hip abductors, and triceps (dynamometer). Summed to create total strength measure

6-min walk was used as an index of exercise capacity

Nutritional and anthropometric measures were collected after dialysis

C-reactive protein (catabolism and inflammation), albumin, creatinine, and complete blood count (blood sample)

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Methodology – Independent Variables

Patients in PRT exercised under an exercise physiologist during routine hemodialysis treatment three times per week for 12 weeks

All PRT exercises were performed in a seated or supine position in a standard hemodialysis chair. Muscles containing necessary medical equipment (ex: AVF) exercised before treatment

PRT: Two sets of eight repetitions of 10 exercises. Major muscle groups of the upper and lower extremities. RPE 15 to 17 of 20

(shoulder press, side shoulder raise, triceps extension, biceps curl, external shoulder rotation, knee extension, supine hip flexion, supine hip abduction, supine straight-legged raise, seated hamstring curls, [abs] bilateral leg raises in a supine position or seated position)

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Statistical Analysis

Group effect was analyzed by analysis of covariance (ANCOVA)

Normally distributed data was described using mean + SD

Non-normally distributed data described as median and ranges

(Mann-Whitney U test; 95% confidence intervals)

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Results

Thigh muscle CSA (quantity) did not change significantly between groups by week 12

Muscle quality (attenuation) improved to a statistically significant degree in the PRT group vs the control group

Statistically significant and clinically meaningful increases in total strength, body weight, BMI, and mid-arm and mid-thigh circumference in the PRT group compared to control group

Statistically significant reduction in inflammatory marker (CRP) in the PRT group while increasing

in controls

Statistically significant improvements of Physical Function and Vitality (quality of Life) vs the control group

(worsened)

No significant changes between groups over time in total or subcutaneous fat of the mid-thigh, or waist circumference as an estimate of central adiposity.

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Results

Table 2:

Summary of Primary & Secondary Outcome Measures

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Conclusion

The 12-wk PRT intervention performed during routine hemodialysis treatment sessions resulted in statistically and clinically significant health-related adaptations.

Improved muscle quality, strength, body composition, proinflammatory state, and quality of life

Intradialytic PRT can be a practical method for patients with ESRD to improve health status

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References

Cheema, B., Abas, H., Smith, B., O’Sullivan, A., Chan, M., Patwardhan, A., Kelly, J., Gillin, A., Pang, G., Lloyd, B., & Fiatarone Singh, M. (2007). Randomized controlled trial of intradialytic resistance training to target muscle wasting in ESRD: The progressive exercise for anabolism in kidney disease (peak) study. American Journal of Kidney Diseases, 50(4), 574–584. https://doi.org/10.1053/j.ajkd.2007.07.005