Comparative efficacy of exercise modalities for cardiopulmonary function in hemodialysis patients: A systematic review and network meta-analysis

Abstract

Background: To provide reliable evidence to exercise rehabilitation therapists and clinicians, we compared and analyzed the effects of different exercise modalities on cardiopulmonary function in hemodialysis patients using Bayesian network meta-analysis.

Methods: PubMed, OVID, Web of Science, Cochrane Library, Embase, Scopus, CINAHL, SPORT Discus, SinoMed, CNKI, Wanfang, and VIP were searched from inception to July 20, 2022. We included randomized controlled trials comparing 12 exercise modalities to improve cardiorespiratory fitness in hemodialysis patients. All statistical analysis was performed using STATA and R.

Result: A total of 82 randomized controlled trials involving 4146 maintenance hemodialysis patients were included in this study. The pair-wise meta-analysis showed that all exercise modalities had a positive effect on all indicators of cardiorespiratory capacity. The network meta-analysis demonstrated that Blood flow restriction training (BFRT), Cycle exercise (CE), Inspiratory muscle training (IMT), Combined aerobic and resistance training (CT), and Aerobic training (AT) were significantly better than usual care for 6-min walkability; Medium intensity continuous training (MICT), CT, CE, and AT were considerably better than usual care for VO₂Peak; body and mind training (MBT) and CT significantly improved SBP compared to usual care; and only MBT was significantly better than usual care for DBP. Both the two-dimensional plot and the radar plot demonstrated that CT had the best combined-effect on each index of cardiorespiratory fitness. Subgroup and sensitivity analyses demonstrated the robustness of the results. The evidence was mainly "low" to "very low" for this network meta-analysis.

Conclusion: There is no one exercise that can achieve the best effect on all of the outcomes. The benefits of MBT in decreasing arterial blood pressure are unsurpassed by other exercise methods. The intervention effect of the CT is better and more stable. Electrical muscle stimulation training (MEST) can be employed in individuals who do not wish to exercise actively but may cause an increase in blood pressure. On the basis of the characteristics of different exercise types, guidelines developers, clinicians, and patients may employ them appropriately.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Keywords: Bayesian network meta-analysis; cardiopulmonary function; chronic kidney failure; exercise; renal dialysis.

Figure 1

PRISMA flow diagram chart for systematic review and network meta-analysis.

Figure 2

Comparing the effects of different exercise modalities 6WMT (A), VO₂Peak (B), SBP (C), and DBP (D) in hemodialysis patients. AT, aerobic training; Usual, usual care; CT, combined training; RT, resistance training; CE, cycle dynamometers; MEST, electrical muscle stimulation; IMT, inspiratory muscle training; BFRT, blood flow restriction exercise; HICT, high-intensity circuit training; MICT, medium intensity continuous training; VRT, virtual reality training; MBT, body and mind training.

Figure 3

Heat map ranked according to the degree of relevant change in 6WMT, VO₂Peak, SBP, and DBP parameters. The numbers reflect the P-score, ranked continuously from 0 to 1. A higher SUCRA indicates a more significant increase in 6WMT, VO₂Peak. In the case of blood pressure parameters, a higher SUCRA suggests a more pronounced effect on lowering blood pressure. ^*The exercise mode corresponding to the outcome was not included in the literature. ^*Treatment without data on the outcome within the circle.

Figure 4

Results of network meta-analysis of four outcomes. Comparisons should be read from left to right. (A) Outcomes of 6 WMT and VO₂Peak. (B) Outcomes of SBP and DBP. Outcomes are located at the intersection between the column-defining treatment and the row-defining treatment. Data are in MD (95% CIs). For 6MWT and VO₂Peak, MDs above 0 favor the column-defining treatment. For SBP and DBP, MDs below 0 favor the column-defining treatment. The certainty of the evidence [according to confidence in network meta-analysis (CINeMA)] was incorporated in this figure as footnotes. ^*Moderate quality of evidence. ^†Low quality of evidence. ^‡Very low quality of evidence. The significant results in league tables have been bolded. AT, aerobic training; Usual, usual care; CT, combined training; RT, resistance training; CE, cycle dynamometers; MEST, electrical muscle stimulation; IMT, inspiratory muscle training; BFRT, blood flow restriction exercise; HICT, high-intensity circuit training; MICT, medium intensity continuous training; VRT, virtual reality training; MBT, body and mind training.