The optimal exercise modality and intensity for hemodialysis patients incorporating Bayesian network meta-analysis and systematic review

Abstract

Background: Physical inactivity is highly prevalent in patients with hemodialysis, and a large body of evidence reported the positive effect of different exercise modalities on their health outcomes. However, the effective dosage of exercise for hemodialysis patients still requires verification. Objective: We aimed to determine the most effective exercise intensity and modality for improvements in physical function, blood pressure control, dialysis adequacy, and health-related quality of life for hemodialysis patients. Design: Systematic review with network meta-analysis of randomized trials. Data sources: Five electronic databases (PubMed, EMBASE, Web of Science, Cochrane CENTRAL, and Scopus) were searched for randomized controlled trials. Data extraction and quality appraisal were conducted by two authors independently. Data were analyzed by the R (version.3.6.2) and the Stata (version.15.0). Result: We included 1893 patients involving four exercise modalities and six exercise intensities. Combined training (aerobic exercise plus resistance exercise) has been the top-ranking exercise modality for improving the 6-min walk test (6MWT) (surface under the cumulative ranking curve analysis (SUCRA) score, 90.63), systolic blood pressure control (SUCRA score, 77.35), and diastolic pressure control (SUCRA score, 90.56). Moreover, the top-ranking exercise intensity was moderate-vigorous for 6MWT (SUCRA score, 82.36), systolic blood pressure (SUCRA score, 77.43), and diastolic blood pressure (SUCRA score, 83.75). Regarding dialysis adequacy and health-related quality of life, we found no exercise modality or intensity superior to the placebo. Conclusion: This network meta-analysis indicated that combined training and moderate-vigorous intensity might be the most effective interventions to improve 6MWT and blood pressure control. This finding helps further guide clinical exercise prescriptions for hemodialysis patients. Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021268535].

Keywords: blood pressure control; dialysis efficiency; exercise dosage; hemodialysis; network meta-analysis.

FIGURE 1

Flow of studies through the review.

FIGURE 2

Network plots of clinical trials for hemodialysis patients comparing different exercise modalities or intensities to (A): 6MWT-exercise modalities. (B): 6MWT-exercise intensities. (C) Kt/V- exercise modalities. (D): Kt/V-exercise intensities. (E) blood pressure-exercise modalities. (F): blood pressure-exercise intensities. (G): Mental health-exercise modalities. (H) Physical health-exercise modalities.

FIGURE 3

Forest plots for each outcome category represent the comparisons of the active intervention with no intervention (control group). (A): 6MWT-exercise modalities and (B): 6MWT-exercise intensities. (C) Kt/V-exercise modalities. (D): Kt/V-exercise intensities. (E) Systolic blood pressure-exercise modalities. (F): Systolic blood pressure-exercise intensities. (G): Diastolic blood pressure-exercise modalities. (H): Diastolic blood pressure-exercise intensities. (I) Mental health-exercise modalities. (J) Physical health-exercise modalities.

FIGURE 4

Schematic details of the treatments according to the surface under the cumulative ranking curve analysis (SUCRA).