Artificial Organs
34(7):586–593, Wiley Periodicals, Inc.
© 2010, Copyright the Authors
Journal compilation © 2010, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.
Exercise Training During Hemodialysis Reduces
Blood Pressure and Increases Physical Functioning
and Quality of Life
Maycon de Moura Reboredo, Diane Michela Nery Henrique, Ruiter de Souza Faria,
Alfredo Chaoubah, Marcus Gomes Bastos, and Rogério Baumgratz de Paula
Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia, NIEPEN, IMEPEN Foundation (Instituto Mineiro de
Estudos e Pesquisas em Nefrologia), Federal University of Juiz de Fora, Juiz de Fora, Brazil
Abstract: Hypertension and cardiovascular diseases are
highly prevalent in hemodialysis patients and are associ-
ated with the reduction of physical functioning and quality
of life. We evaluated the effects of supervised aerobic
exercise training on physical functioning, blood pressure,
quality of life, and laboratory data in hemodialysis patients.
Fourteen patients were evaluated at the beginning and
after 12 weeks of stretching exercises (control phase) and
at the end of 12 weeks of aerobic exercise training per-
formed during hemodialysis sessions (intervention phase).
Patients underwent a 6-min walking test (6MWT), 24-h
ambulatory blood pressure monitoring, a Medical Out-
comes Study 36—Item Short-Form Health Survey (SF-36)
quality of life questionnaire, and blood sample collections.
In patients with end-stage renal disease (ESRD)
on hemodialysis (HD), cardiovascular diseases rep-
resent the principal cause of morbidity and mortality
(1). Among these, hypertension is highly prevalent in
patients with ESRD, sometimes causing the disease,
sometimes complicating it (2,3). At the beginning of
HD treatment, approximately 80–90% of the patients
are hypertensive, and, after this initial period, nearly
60% continue to present elevated blood pressure
levels (3).
Cardiovascular diseases, as well as endocrine–
metabolic, osteomyoarticular complications and
doi:10.1111/j.1525-1594.2009.00929.x
Received January 2009; revised July 2009.
Address correspondence and reprint requests to Ms. Maycon de
Moura Reboredo, 1300 SL José Lourenço Khelmer Street, São
Pedro, Juiz de Fora 36036-330, Minas Gerais, Brazil. E-mail:
mayconreboredo@yahoo.com.br
586
aor_929 586..593
After the intervention phase, the 6MWT distance increased
from 508.7 ⫾ 91.9 m to 554.9 ⫾ 105.8 m (P = 0.001), sys-
tolic and diastolic blood pressure decreased respectively
from 150.6 ⫾ 18.4 mm Hg to 143.5 ⫾ 14.7 mm Hg and from
94.6 ⫾ 10.5 mm Hg to 91.4 ⫾ 9.7 mm Hg (P < 0.05), while
hemoglobin levels increased from 10.8 ⫾ 1.2 g/dL to
11.6 ⫾ 0.8 g/dL (P < 0.05). Moreover, there was a signifi-
cant increase in the physical functioning, social functioning,
and mental health dimensions of the SF-36. Aerobic
exercise training during hemodialysis increased physical
functioning, reduced blood pressure levels, and improved
the control of anemia and quality of life in patients
with end-stage renal disease. Key Words: Exercise—
Hemodialysis—Blood pressure—Quality of life.
other alterations present in ESRD, result in a reduc-
tion in physical functioning and have a negative
impact on the quality of life of patients on dialysis
treatment (4–6). In conjunction, the physical and
psychological alterations of these patients induce a
sedentary lifestyle, and the attempt to change this
behavior in ESRD is relatively recent in Brazil,
where the dialysis centers rarely offer an exercise
program during HD to these patients.
In this study, we evaluated the effects of supervised
aerobic exercise training on physical functioning,
blood pressure, quality of life, and laboratory data in
patients with ESRD subjected to HD.
PATIENTS AND METHODS
Patients
The sample included patients with ESRD under-
going HD three times per week, totaling 12 h weekly,
using at least 6 months in the Nephrology Unit of the
 AEROBIC EXERCISE TRAINING DURING HEMODIALYSIS
University Hospital of the Federal University of Juiz
de Fora.
A total of 18 patients, 7 men and 11 women, were
included, with a mean age of 47.6 ⫾ 11.4 years, on
HD for 77.2 ⫾ 50.1 months, who were not on a
regular exercise program for at least 6 months. The
exclusion criteria were unstable angina, uncontrolled
arrhythmia, uncompensated heart failure, uncon-
trolled hypertension with systolic blood pressure
(SBP) of ⱖ200 mm Hg and/or diastolic blood pres-
sure (DBP) of ⱖ120 mm Hg, uncontrolled diabetes
mellitus, severe pneumopathies, acute systemic in-
fection, severe renal osteodystrophy, as well as
neurological and musculoskeletal disturbances and
osteoarticular incapacity.
The study protocol was approved by the Research
Ethics Committee of the Federal University of Juiz
de Fora, and all patients signed an informed consent.
Study protocol
The 24 weeks of the study protocol were divided in
two phases (Fig. 1):
1 Control phase (12 weeks). At the beginning (week
-12) and at the end (week 0) of this phase, patients
underwent a 6-min walking test (6MWT), a 24-h
ambulatory blood pressure monitoring (ABPM),
Medical Outcomes Study 36—Item Short-Form
Health Survey (SF-36) questionnaire interview,
and blood sample collections. In this phase, the
patients were submitted to a placebo or attention
intervention protocol that consisted of 10-min
stretching exercises of the lower limbs during each
HD session, according to a protocol used by
Depaul et al. (7). During this period, patients were
oriented not to perform any type of regular physi-
cal exercise.
2 Intervention phase (12 weeks). This phase was ini-
tiated immediately after the control phase and con-
sisted of aerobic exercise training during HD three
times weekly for 12 weeks. At the end of this phase
(week 12), the patients underwent a 6MWT,
Control phase
Week –12
6MWT
ABPM
SF-36 questionnaire
Laboratory testing
FIG. 1. Study protocol.
587
ABPM, SF-36 interview, and blood samples
collections.
Six-minute walk test
The analysis of physical functioning was performed
by 6MWT during the nondialysis day following the
recommendations of the American Thoracic Society
(8). Patients were instructed to walk as fast as pos-
sible during the 6 min on a flat 30-m track, and the
distance walked was recorded in meters. Patients
were allowed to stop and rest during the test but were
instructed to resume walking as soon as they felt able
to do so. The two tests were completed on the same
day, with an interval of 30 min between each, regis-
tering the greatest distance obtained. At the end of
the test, the level of perceived exertion was obtained
by Borg scale (9).
ABPM
For blood pressure evaluation, the patients under-
went 24-h ABPM during the nondialysis day. ABPM
was performed by using an oscillometric monitor
(SpaceLabs 90207, Spacelabs Medical, Inc., Washing-
ton, USA) programmed to take readings at 20-min
intervals during the wakeful period (between 7:00 am
and 11:00 pm) and every 30 min during the sleeping
period. The patients were instructed to maintain
normal activities during the monitoring, as well as to
continue with their regular medications. They were
also instructed to fill out a report with the times of
their main activities, medications, and symptoms, if
they occurred.
Quality of life questionnaire (SF-36)
The SF-36 was used for the evaluation of quality of
life (10). The SF-36 is composed of 36 items that
evaluate the following dimensions: physical function-
ing, role physical, pain, general health, vitality, social
functioning, role emotional, and mental health. For
each of the eight dimensions, a score is obtained
Intervention phase (exercise training)
Week 0 Week 12
6MWT 6MWT
ABPM ABPM
SF-36 questionnaire SF-36 questionnaire
Laboratory testing Laboratory testing
Artif Organs, Vol. 34, No. 7, 2010
588 M. DE MOURA REBOREDO ET AL.

with values from 0 (highly compromised) to 100 (no activity, significant alterations in heart rate, SBP or
compromise). DBP, and fatigue of the lower limbs.

Statistical analysis
Laboratory data
Values were expressed as mean and standard
Hemoglobin, adequacy of dialysis (Kt/V), creati-
deviations (SD). The general linear model repeated
nine, phosphorus, potassium, calcium, albumin, total
measures analysis of variance was used for compari-
cholesterol, high-density lipoprotein, low-density
son of study measures with means comparisons per-
lipoprotein (LDL), and triglycerides were drawn
formed by using the least significant difference post
before the first HD session of the week and measured
hoc test. A P value of <0.05 was considered statisti-
at the Central Laboratory of the University Hospital.
cally significant. All statistical analyses were per-
The Kt/V was calculated by using this equation:
formed by using SPSS 11.0 for Windows (SPSS, Inc.,
Kt V = 2.2 − 3.3 ( R − 0.03 − VUf P ) , (1) Chicago, IL, USA).

where R is the post–pre serum urea ratio, VUf is the RESULTS

volume of fluid removed during dialysis, and P is the
postdialysis weight (11). Patient characteristics
Of the 18 patients starting the protocol, 14 com-
pleted the intervention phase. Four patients were
Aerobic exercise training excluded for the following reasons: One patient
Aerobic exercise training was supervised and per- received a kidney transplantation, the second was
formed during the first 2 h of HD and composed excluded for coronary artery disease, the third for
of three phases: warm-up, conditioning, and cool- nonadherence, and the fourth for bone neoplasia.
down. A horizontal electromagnetic cycle ergometer The patients’ mean age was 47.6 ⫾ 12.8 years, and
(Movement BM 4000, Brudden Equipamentos Ltda., 71% were women. The mean time of HD treatment
Pompéia, São Paulo, Brazil) was used for the aerobic was 93.7 ⫾ 43.9 months and the most frequent causes
exercise training. The warm-up phase consisted of of ESRD were chronic glomerulonephritis (50%)
10 min of stretching of the lower limbs, as well as and hypertensive nephrosclerosis (28.7%). Hyper-
low-load aerobic exercise (4.9 N·m) and low rotation tension (85.7%) and left ventricular hypertrophy
(up to 35 rpm) for 5 min. The conditioning phase (57.1%) were the most prevalent comorbidities
included 30 min of aerobic exercise. The time and (Table 1). At the end of the intervention phase, we
rotation were individually adapted according to the observed a slight and significant reduction in dry
tolerance of each patient. The exercise training inten- weight and body mass index (Table 2).
sity was determined by the Borg scale, in which the
patients must remain between 11 (fairly light) and 13
Aerobic exercise training
(somewhat hard). The intensity was measured every
At the end of the 12-week intervention phase, 38
5 min of training. If values of less than 11 on the Borg
sessions of aerobic exercise had been performed.
scale were detected, the patient was stimulated to
increase the rotation, if values of greater than 13 were
registered, the patient was encouraged to decrease TABLE 1. Demographic and clinical characteristics of the
rotation. The exercise load was prescribed according patients studied
to the tolerance of each patient in order to keep the
Patients
Borg’s score between 11 and 13. During the cool- Characteristics n = 14 (%)
down, the aerobic exercise was performed for
Age (years) 47.6 ⫾ 12.8
1–3 min at a low load and rotation, followed by the Gender (male/female) 4/10
stretching of the lower limbs for approximately Time on dialysis (months) 93.7 ⫾ 43.9
10 min. Blood pressure was monitored at rest, every Etiology of ESRD
Chronic glomerulonephritis 7 (50.0)
5 min of conditioning, and after cool-down. Heart Hypertension 4 (28.7)
rate was monitored continuously by heart rate Diabetes mellitus 1 (7.1)
monitor (Polar F1, Polar Electro Oy, Kempele, Ureteric obstruction 1 (7.1)
Amyloidosis 1 (7.1)
Finland). The criteria for interruption of aerobic Comorbidities
exercise included intense physical exhaustion, chest Hypertension 12 (85.7)
pain, hypoglycemia, dizziness, lipothymia, presyn- Left ventricular hypertrophy 8 (57.1)
Heart failure 4 (28.4)
cope, dyspnea disproportional to the intensity of the

Artif Organs, Vol. 34, No. 7, 2010

 AEROBIC EXERCISE TRAINING DURING HEMODIALYSIS 589

TABLE 2. Anthropometric data and mean of monthly interdialytic weight gain at the beginning (week -12) and at the end
(week 0) of the control phase and after the intervention phase (week 12)
Control phase Control phase Intervention phase
(week -12) (week 0) (week 12)
Dry weight (kg) 57.2 ⫾ 13.2 56.8 ⫾ 12 56.4 ⫾ 12.7*
Body mass index (kg/m2) 22.5 ⫾ 4.8 22.4 ⫾ 4.8 22.2 ⫾ 4.6*
Mean of monthly interdialytic weight gain (kg) 2.4 ⫾ 0.9 2.3 ⫾ 0.9 2.5 ⫾ 0.9

Values are mean ⫾ SD.

* P < 0.05 compared with week -12 by GLM repeated measures analysis of variance and LSD post hoc test.
GLM, general linear model; LSD, least significant difference.

With all patients considered, the adherence to the
exercise training was 81.36%.
In the first week of the intervention phase, the
mean time of three sessions of aerobic exercise
(warm-up and conditioning) of the 14 patients was
21.3 ⫾ 9.2 min, which increased gradually through-
out the study, reaching 33 ⫾ 4.2 min at the end of
12 weeks (P < 0.05). Except for two episodes of
hypotension in one patient following exercise, we did
not observe any clinical complications during the
study.
Physical functioning
At the beginning of the control phase (week -12),
the 6MWT distance was 504.6 ⫾ 99.1 m, and the per-
ceived exertion according to the Borg scale was
13.4 ⫾ 2.1. At the end of the control phase (week 0),
the 6MWT distance increased slightly and nonsignifi-
cantly to 508.7 ⫾ 91.9 m, while perceived exertion
decreased to 12.1 ⫾ 1.5. However, upon the comple-
tion of the intervention phase (week 12), 6MWT dis-
tance increased significantly to 554.9 ⫾ 105.8 m. In
this phase, the perceived exertion was 11.9 ⫾ 1.1, sig-
nificantly lower than the values of the control phase
(P < 0.05).
Blood pressure
At the beginning of the control phase, 12 of the 14
patients were hypertensive, and 11 were on antihy-
pertensive medications including combinations of
three or more drugs. The most frequently prescribed
antihypertensive medications were b-blockers,
angiotensin-converting enzyme inhibitors, AT1-
receptor blockers, centrally acting adrenergic,
calcium channel blockers, and diuretics. After the
control phase, blood pressure was not changed. In
24-h monitoring, SBP decreased from 155.4 ⫾
22.1 mm Hg to 150.6 ⫾ 18.4 mm Hg, and DBP
decreased from 96.4 ⫾ 12.7 mm Hg to 94.6 ⫾
10.5 mm Hg. During sleep period, SBP increased
from 147.5 ⫾ 23.7 mm Hg to 150.4 ⫾ 23.9 mm Hg,
and DBP increased from 89.4 ⫾ 13.8 mm Hg to
93.2 ⫾ 15.4 mm Hg.
We observed a significant reduction in the 24-h
blood pressure levels at the completion of the exer-
cise training compared with the end of the control
phase. Thus, the 24-h SBP dropped from 150.6 ⫾
18.4 mm Hg to 143.5 ⫾ 14.7 mm Hg, and DBP
dropped from 94.6 ⫾ 10.5 mm Hg to 91.4 ⫾ 9.7 mm
Hg (P < 0.05, respectively). During the sleep period,
patients experienced a statistically significant reduc-
tion of SBP from 150.4 ⫾ 23.9 mm Hg to 140.2 ⫾
19.4 mm Hg, and of DBP from 93.2 ⫾ 15.4 mm Hg
to 87.9 ⫾ 14.3 mm Hg (Fig. 2).
Finally, at the end of the intervention phase, we
observed a significant reduction of 12 mm Hg and
5 mm Hg in SBP and DBP 24-h blood pressure,
respectively, when compared to the beginning of the
control phase.
Of particular interest is the fact that this drop in
blood pressure occurred despite maintaining the
initial dosages and types of antihypertensive medica-
tions for nine patients, the reduction of the medica-
tions for one patient, and the withdrawal of all the
medications for another patient.
Quality of life
As can be seen in Table 3, after the control phase,
seven of the eight dimensions of the SF-36 question-
naire showed nonsignificant increases. At the end of
the intervention phase, physical functioning, social
functioning, and mental health dimensions all had
increased significantly in comparison with the begin-
ning of the control phase.
Laboratory data
Table 4 shows the laboratory data before and after
the control phase and after the intervention phase.As
we can see, during the control phase, no major alter-
ations were observed, with the exception of Kt/V,
which was significantly elevated as compared with

Artif Organs, Vol. 34, No. 7, 2010

590 M. DE MOURA REBOREDO ET AL.

A B
200 200

180 180
* **

Blood pressure (mm Hg)

Blood pressure (mm Hg)
160
160 **
140
140
120
120 **
** 100
100
80
80
60

SBP DBP SBP DBP SBP DBP SBP DBP SBP DBP SBP DBP
Week – 12 Week 0 Week 12 Week – 12 Week 0 Week 12
Control phase Intervention phase Control phase Intervention phase

FIG. 2. SBP values and DBP values obtained by the 24-h ambulatory blood pressure monitoring (A) and during the sleep period (B) at
the beginning (week -12) and at the end (week 0) of the control phase and after the intervention phase (week 12). *P < 0.05 compared
with week -12 and **P < 0.05 compared with week 0 by general linear model repeated measures analysis of variance and least significant
difference post hoc test.

the beginning of this phase (P < 0.05). However, at increased physical functioning, contributed to blood
the end of the intervention phase, we observed an pressure control, and improved several quality of life
additional increase in Kt/V associated with signifi- domains.
cant increases in hemoglobin, LDL, and triglycerides, Patients on HD have a considerable loss of physi-
as well as a significant reduction in creatinine. Fur- cal functioning that reaches 64% of peak oxygen
thermore, it is interesting to note that the increase in uptake (VO2 peak) when compared with healthy, sed-
hemoglobin was accompanied by a nonsignificant entary individuals of the same age group (4).The gold
reduction in weekly total dose of erythropoietin and standard test for evaluation of physical functioning is
in the monthly dose of intravenous iron. the cardiopulmonary test, which provides identifica-
tion of VO2 peak. However, the low tolerability and
the need for special and high cost equipment, makes
DISCUSSION
this test less used in the clinical setting (8,12).
In the present study, the supervised aerobic exer- However, the 6MWT used in our study is one of the
cise training during HD sessions for 12 weeks most utilized tests in the literature (7,8,12–15). This

TABLE 3. Scores obtained on the SF-36 quality of life questionnaire at the

beginning (week -12) and at the end (week 0) of the control phase and after the
intervention phase (week 12)
Control phase Control phase Intervention phase
Dimensions of the SF-36 (week -12) (week 0) (week 12)
Physical functioning 67.1 ⫾ 17.4 71.8 ⫾ 16.7 78.6 ⫾ 15.2*
Role physical 66.1 ⫾ 37.5 71.4 ⫾ 35.2 75.0 ⫾ 33.9
Pain 56.6 ⫾ 24.6 58.9 ⫾ 24.9 69.2 ⫾ 20.8
General health 69.8 ⫾ 18.6 68.6 ⫾ 18.3 65.3 ⫾ 18.3
Vitality 70.0 ⫾ 20.7 70.4 ⫾ 26.2 72.9 ⫾ 22.9
Social functioning 76.8 ⫾ 19.5 83.0 ⫾ 26.7 88.4 ⫾ 15.9*
Role emotional 66.6 ⫾ 41.4 71.4 ⫾ 28.8 78.6 ⫾ 36.1
Mental health 68.9 ⫾ 17.3 78.0 ⫾ 12.0 81.4 ⫾ 11.5*

Values are mean ⫾ SD.

*P < 0.05 compared with week -12 by GLM repeated measures analysis of variance and
LSD post hoc test.
GLM, general linear model; LSD, least significant difference.

Artif Organs, Vol. 34, No. 7, 2010

 AEROBIC EXERCISE TRAINING DURING HEMODIALYSIS
TABLE 4. Laboratory data, weekly dosage of erythropoietin and monthly dose of intravenous iron at the beginning
(week -12) and at the end (week 0) of the control phase and after the intervention phase (week 12)
Control phase
Variable (week -12)
Hemoglobin (g/dL) 10.8 ⫾ 1.7
Kt/V 1.2 ⫾ 0.5
Creatinine (mg/dL) 10.7 ⫾ 2.5
Phosphorous (mg/dL) 5.7 ⫾ 1.4
Potassium (mEq/L) 5.0 ⫾ 0.7
Calcium (mg/dL) 9.1 ⫾ 1.3
Albumin (g/dL) 4.0 ⫾ 0.2
Total cholesterol (mg/dL) 152.5 ⫾ 38.5
HDL (mg/dL) 45.9 ⫾ 19.1
LDL (mg/dL) 86.2 ⫾ 30.0
Triglyceride (mg/dL) 102.6 ⫾ 43.5
EPO dose (U/week) 6571.4 ⫾ 3936.3
IV iron (mg/month) 600 ⫾ 415.1
Values are mean ⫾ SD.
* P < 0.05 compared with week -12 and ** P < 0.05 compared with week 0 by GLM repeated measures analysis of variance and LSD post
hoc test.
EPO, erythropoietin; HDl, high-density lipoprotein; IV, intravenous; LSD, least significant difference.
test has several benefits: it is easy to apply, less costly,
less time consuming, and is very representative of the
activities of daily life (8,12). Its efficiency has been
confirmed in patients with chronic pulmonary
obstructive disease and chronic heart failure (12).
Corroborating this, in a previous study with 16
patients on HD, we showed a positive and statistically
significant correlation between the 6MWT distance
(516 ⫾ 88.8 m) and VO2 peak (20.5 ⫾ 4.9 mL/kg/
min) obtained in a cardiopulmonary test (R = 0.78)
(16). Based on these results, 6MWT was used in the
present protocol to evaluate physical functioning in
patients on HD.
Among our patients, the mean 6MWT distance at
the beginning of the control phase was similar to that
found in patients with ESRD on HD studied by
Painter et al. (13), Headley et al. (14), and Parsons
et al. (15). At the end of the control phase in our
study, the 6MWT distance had increased only 0.8%.
However, after 12 weeks of the exercise training,
6MWT distance had increased significantly, by 9%
when compared with that at the beginning of the
control phase, indicating that the exercise increased
the physical functioning of the patients. Our results
thus support previous reports of exercise in HD
patients (15,17). For example, Parsons et al. (15)
showed in a study of 13 patients on HD that 20 weeks
of exercise training during dialysis was associated
with an increase of 14% in the distance in 6MWT. In
parallel with the increase in the distance covered
during the 6MWT, we observed an improvement on
the perceived exertion in the 6MWT. As we showed,
after the intervention phase, the perceived exertion
evaluated by the Borg scale decreased significantly
591
Control phase Intervention phase
(week 0) (week 12)
10.8 ⫾ 1.2 11.6 ⫾ 0.8**
1.5 ⫾ 0.2* 1.7 ⫾ 0.4*
11.0 ⫾ 1.7 10.3 ⫾ 1.9**
5.6 ⫾ 1.1 5.3 ⫾ 0.8
4.9 ⫾ 0.5 5.2 ⫾ 0.6
9.3 ⫾ 1.3 9.5 ⫾ 0.9
3.9 ⫾ 0.4 3.9 ⫾ 0.6
160.2 ⫾ 48.0 170.1 ⫾ 46.8
45.1 ⫾ 18.5 45.4 ⫾ 19.0
95.8 ⫾ 37.9 104.4 ⫾ 28.7*
96.6 ⫾ 35.2 127.0 ⫾ 54.6**
7000.0 ⫾ 2000.0 6214.3 ⫾ 2516.9
514.3 ⫾ 441.8 385.7 ⫾ 411.1
despite the increase in the 6MWT distance. Further-
more, the increase of 35.5% in the time of aerobic
exercise observed at the end of the study reinforces
the benefits of the exercise training in improving
physical functioning. Similar data have been seen by
others in patients with ESRD (18,19).
It is well known that hypertension is highly preva-
lent in patients on HD, being present in up to 80% of
this population (3). Accordingly, in our study, 11
(87.5%) patients were hypertensive, and most of
them were on three or more antihypertensive drugs.
After the intervention phase, we observed a signifi-
cant reduction in blood pressure levels despite the
maintenance of the same antihypertensive medica-
tions or even after reducing the quantity in one
patient and withdrawing all the medications in the
other patient. Although a reduction in dry weight is
associated with blood pressure reduction, the small
drop on body weight observed could not completely
explain this finding in our patients. However, the
well-documented role of exercising in the blood pres-
sure control is in accordance with our findings and
reinforces the benefit of exercise training on blood
pressure control in patients with ESRD. Few authors
have used ABPM to evaluate the blood pressure
control after exercising. In a recent article published
by Anderson et al. (20), patients on HD were submit-
ted to aerobic exercise training for 6 months. Similar
to our data, at the end of the protocol, the authors
observed a significant drop in blood pressure after
aerobic training. This data was confirmed in another
study by Miller et al. (19) that showed that exercise
during HD decreases the need for antihypertensive
medications.
Artif Organs, Vol. 34, No. 7, 2010
592 M. DE MOURA REBOREDO ET AL.
Patients on HD have low scores of quality of life
that are frequently related to hospitalization and
death (6). In the present study, the increase in physi-
cal functioning, reduction of blood pressure levels,
and increase in hemoglobin levels were accompanied
by a significant improvement in quality of life. Even
before the intervention phase, we observed a slight
increase in seven of the eight dimensions of the ques-
tionnaire that could be attributed to the effect of
attention intervention consisting of stretching exer-
cises in the control phase. However, after the inter-
vention phase, we observed an additional increase in
the same dimensions, with statistical significance for
physical functioning, social functioning, and mental
health. These findings have been seen by other
authors among patients with ESRD on HD submit-
ted to exercise training and have been attributed to
the reduction of anxiety and depression, improve-
ment in well-being, self-esteem, and familial and
social interaction (13,21,22). Therefore, we could
speculate that, in our patients, the improvement in
quality of life might share the same mechanisms.
Regarding the laboratory data, the better control
of anemia after the intervention phase associated
with a reduction in doses of erythropoietin and intra-
venous iron deserves special mention. This benefit
has been well described by Goldberg et al. (23) after
exercise training in patients on HD.
At the end of the study protocol, patients pre-
sented a significant increase in Kt/V. This increase in
the Kt/V was observed at the end of the control
phase as well as in the intervention phase. We
believe that the improvement of the Kt/V in the
control phase could be related to a better compli-
ance of the patients with dialysis time, which we fre-
quently stimulated. This is in agreement with the
findings of Fourtounas et al. (24), who showed that
the most common cause of lower-than-expected
Kt/V was noncompliance with dialysis time due to
patients’ request of premature termination of dialy-
sis sessions. After the intervention phase, the addi-
tional increase in Kt/V was attributed not only to
the compliance of the patients with dialysis time but
also to an additional removal of urea and toxins
from the vascular compartment probably due to an
increase in systemic and muscular blood flow asso-
ciated with exercise, a finding previously reported by
others (15,25).
It is known that aerobic exercise improves the lipid
profile in various populations including patients with
ESRD on HD (23,26). However, contrary to these
data, our results showed an increase in triglycerides
and in LDL cholesterol. We could speculate that this
change was associated with other variables such as
Artif Organs, Vol. 34, No. 7, 2010
increase in appetite and dietetic factors. Further-
more, we believe that the increase of triglycerides
(from 96.6 ⫾ 35.2 mg/dL to 127.0 ⫾ 54.6 mg/dL) is
instead related to the normal variability of this
parameter, possibly associated with improvement in
appetite. Some authors have shown intraindividual
variability in triglycerides dosages from 20 up to 30%
(27). Besides, our patients did not have any other
evidence of hypercatabolism such as anemia, low
serum albumin levels, anorexia, or increase in plasma
creatinine levels. Actually, after exercising training,
most of these parameters had improved.
An unexpected finding of this study was a mild,
although statistically significant, decrease of esti-
mated dry weight at the end of the intervention
phase, which could indicate reduction of lean body
mass. However, if one considers some benefits such as
better blood pressure control, improvement of physi-
cal functioning, and the increases in hemoglobin
levels and in Kt/V after exercising, this possibility
does not seem to be relevant. Furthermore, the
estimate of dry weight in patients on regular HD
is an imprecise trial-and-error method and does
not account for changes in nutritional status and lean
body mass (28).
One frequent concern in performing exercise
during HD session is the possibility of complications.
It is recognized that the HD process induces acute
complications such as hypotension, muscular cramps,
arrhythmia, nausea, vomiting, and headaches, among
others, which could be magnified by exercising (29).
In our population, however, only one patient pre-
sented two episodes of hypotension after exercising.
This patient was diabetic and possibly had autonomic
dysfunction, which could have contributed to
the event (29). No other acute complication was
observed during the study protocol.
There are a few limitations to this study. One of
them is the absence of the control group. However,
the comparisons were carried out in the same group
of patients, both before (control phase) and after
the exercise training phase, which attenuates this
shortcoming. The other limitations are the short
duration of the exercise training and the small sample
size, which does not allow us to generalize our find-
ings to the whole population of ESRD patients.
CONCLUSION
Aerobic exercise training performed during HD
sessions for 12 weeks increased physical functioning,
reduced blood pressure levels, and contributed to the
control of anemia and quality of life in patients with
ESRD.
 AEROBIC EXERCISE TRAINING DURING HEMODIALYSIS
Acknowledgments: We thank the nursing and
medical staff at the Nephrology Unit of the Univer-
sity Hospital of the Federal University of Juiz de
Fora for their support during this study. This work
has been supported by the IMEPEN Foundation
and CAPES (Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior).
REFERENCES
1. Sarnak MJ, Levey AS. Epidemiology of cardiac disease in
dialysis patients. Semin Dial 1999;12:69–76.
2. Rahman M, Dixit A, Donley V, et al. Factors associated with
inadequate blood pressure control in hypertensive hemodialy-
sis patients. Am J Kidney Dis 1999;33:498–506.
3. Mailloux LU, Haley WE. Hypertension in the ESRD patient:
pathophysiology, therapy, outcomes and future directions. Am
J Kidney Dis 1998;32:705–19.
4. Painter P, Messer-Rehak D, Hanson P, Zimmerman SW, Glass
NR. Exercise capacity in hemodialysis, CAPD and renal trans-
plant patients. Nephron 1986;42:47–51.
5. Sietsema KE, Hiatt WR, Esler A, Adler S, Amato A, Brass EP.
Clinical and demographic predictors of exercise capacity in
end-stage renal disease. Am J Kidney Dis 2002;39:76–85.
6. Lowrie EG, Curtin RB, Lepain N, Schatell D. Medical out-
comes study short form-36: a consistent and powerful predic-
tor of morbidity and mortality in dialysis patients. Am J
Kidney Dis 2003;41:1286–92.
7. Depaul V, Moreland J, Eager T, Clase CM. The effectiveness
of aerobic and muscle strength training in patients receiving
hemodialysis and EPO: a randomized controlled trial. Am J
Kidney Dis 2002;40:1219–29.
8. American Thoracic Society. ATS statement: guidelines for the
six-minute walk test. Am J Respir Crit Care Med 2002;166:
111–7.
9. Borg G. Psychophysical bases of perceived exertion. Med Sci
Sports Exerc 1982;14:377–81.
10. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health
Survey Manual and Interpretation Guide. Boston: New
England Medical Center, The Health Institute, 1993.
11. Daugirdas JT. Chronic hemodialysis prescription: a urea
kinetic approach. In: Daugirdas JT, Ing TD, eds. Handbook of
Dialysis, 2nd Edition. Boston, MA: Little Brown, 1994;92–
120.
12. Solway S, Brooks D, Lacasse Y, Thomas S. A qualitative sys-
tematic overview of the measurement properties of functional
walk tests used in the cardiorespiratory domain. Chest
2001;119:256–70.
13. Painter P, Carlson L, Carey S, Paul SM, Myll J. Physical func-
tioning and health-related quality-of-life changes with exercise
training in hemodialysis patients. Am J Kidney Dis 2000;35:
482–92.
593
14. Headley S, Germain M, Mailloux P, et al. Resistance training
improves strength and functional measures in patients with
end-stage renal disease. Am J Kidney Dis 2002;40:355–64.
15. Parsons TL, Toffelmire EB, King-Vanvlack CE. Exercise train-
ing during hemodialysis improves dialysis efficacy and physical
performance. Arch Phys Med Rehabil 2006;87:680–7.
16. Reboredo MM, Henrique DMN, Faria RS, Bergamini BC,
Bastos MG, Paula RB. Correlação entre a distância obtida no
teste de caminhada de seis minutos e o pico de consumo de
oxigênio em pacientes portadores de doença renal crônica em
hemodiálise. [Correlation between the distance covered in the
six-minute walk test with peak oxygen uptake in end-stage
renal disease patients on hemodialysis]. J Bras Nefrol
2007;29:83–7 (Portuguese).
17. Ridley J, Hoey K, Ballagh-Howes N. The exercise-during-
hemodialysis program: report on a pilot study. CANNT J
1999;9:20–6.
18. Storer TW, Casaburi R, Sawelson S, Kopple JD. Endurance
exercise training during haemodialysis improves strength,
power, fatigability and physical performance in maintenance
haemodialysis patients. Nephrol Dial Transplant 2005;20:1429–
37.
19. Miller BW, Cress CL, Jonhson ME, Nichols DH, Schnitzier
MA. Exercise during hemodialysis decreases the use of anti-
hypertensive medications. Am J Kidney Dis 2002;39:828–33.
20. Anderson JE, Boivin MR, Hatchett L. Effect of exercise train-
ing on interdialytic ambulatory and treatment-related blood
pressure in hemodialysis patients. Ren Fail 2004;26:539–44.
21. Painter P, Moore G, Carlson L, et al. Effects of exercise train-
ing plus normalization of hematocrit on exercise capacity and
health-related quality of life. Am J Kidney Dis 2002;39:257–65.
22. Vilsteren MCBA, Greef MHG, Huisman RM. The effects of
a low-to-moderate intensity pre-conditioning exercise pro-
gramme linked with exercise counseling for sedentary haemo-
dialysis patients in The Netherlands: results of a randomized
clinical trial. Nephrol Dial Transplant 2005;20:141–6.
23. Goldberg AP, Hagberg JM, Delmez JA, Haynes ME, Harter
HR. Metabolic effects of exercise training in hemodialysis
patients. Kidney Int 1980;18:754–61.
24. Fourtounas C, Kopelias I, Paraskevopoulos A, Dimitriadis G,
Agroyannis B. Causes of impaired delivery of hemodialysis
prescription. Artif Organs 2006;30:878–81.
25. Kong CH, Tattersall JE, Greenwood RN, Farrington K. The
effect of exercise during haemodialysis on solute removal.
Nephrol Dial Transplant 1999;14:2927–31.
26. Cheema BSB, Singh MAF. Exercise training in patients receiv-
ing maintenance hemodialysis: a systematic review of clinical
trials. Am J Nephrol 2005;25:352–64.
27. Wasenius A, Stugaard M, Otterstad JE, Froyshov D. Diurnal
and monthly intra-individual variability of the concentration
of lipids, lipoproteins and apoproteins. Scand J Clin Lab Invest
1990;50:635–42.
28. Jaeger JQ, Mehta RL. Assessment of dry weight in hemo-
dialysis: an overview. J Am Soc Nephrol 1999;10:392–403.
29. Himmelfarb J. Hemodialysis complications. Am J Kidney Dis
2005;45:1122–31.
Artif Organs, Vol. 34, No. 7, 2010