Update Article | Artigo de Atualização
Effects of aerobic exercise during haemodialysis in
patients with chronic renal disease: literature review
Efeitos do exercício aeróbio durante a hemodiálise em pacientes
com doença renal crônica: uma revisão da literatura
Authors Abstract
Joseane Böhm 1 Introduction: Patients with chronic
Mariane Borba kidney disease (CKD) have reduced
Monteiro1 physical and functional capacity when
Fernando Saldanha compared with the general popula-
Thomé2 tion. Hemodialysis (HD) restricts
patients`activities, favoring a sedentary
1
Centro Universitário lifestyle and leading to functional limita-
Metodista – IPA. tions. HD patients are less active, pres-
2
Departamento de Medi-
cina Interna da Univer- ent low exercise tolerance and have high
sidade Federal do Rio physical deconditioning. Physical exer-
Grande do Sul – UFRGS; cise programs have been proposed as a
Hospital de Clínicas de
Porto Alegre – HCPA.
strategy not only to treat clinical symp-
toms, but also to reduce physical limita-
tions and improve the quality of life of
these patients. Objective: The purpose
of this study was to review the litera-
ture on the effects of physical exercise
(aerobic exercise on a cycle ergometer
for the lower limbs) on CKD undergoing
HD. Methods: The Medline, PubMed,
Scielo, Embase and DirectScience data-
bases were searched. Results: Fourteen
randomized controlled clinical trials
were analyzed as regards the timing of
the intervention during the HD session,
exercise intensity and frequency, the du-
ration of the intervention and the main
Submitted on: 11/29/2010
results. Conclusion: The studies demon-
Approved on: 10/06/2011
strated that aerobic exercises performed
during HD improve the aerobic capacity
Correspondence to: and physical conditioning, reduce fa-
Joseane Böhm tigue and anxiety, improve muscle cap-
Avenida do Forte, 113/386
Bairro Vila Ipiranga illarization and resting blood pressure,
Porto Alegre – RS – Brazil increase exercise duration and improve
Zip code 91360-000
E-mail: jbohm@pop.com.br
urea clearance.
Keywords: Exercise. Resistance training.
This study was undertaken Renal dialysis. Oxygen uptake. Fatigue.
at IPA.
The authors report no
conflict of interest.
Resumo
Introdução: Pacientes com doença renal
crônica (DRC) têm capacidade física e
funcional reduzida quando comparados
à população geral. O tratamento hemodi-
alítico torna as atividades desses pacientes
restritas, favorecendo o estilo de vida sed-
entário e a limitação funcional. Pacientes
em hemodiálise (HD) são menos ativos,
apresentam baixa tolerância ao exercício
e alto descondicionamento físico. Em vir-
tude dessas alterações, têm sido propostos
programas de exercício físico que visam
não somente ao tratamento dos sinais
clínicos da doença, mas de suas reper-
cussões na função e na qualidade de vida.
Objetivo: Realizar uma revisão da litera-
tura sobre os efeitos do exercício físico
em pacientes portadores de DRC submeti-
dos a programas de exercício aeróbio em
cicloergômetro para membros inferiores
durante a HD. Métodos: Foram realiza-
das consultas às bases de dados Medline,
PubMed, Scielo, Embase e ScienceDirect.
Resultados: Analisaram-se 14 estudos ex-
perimentais randomizados controlados,
considerando o período de realização
da intervenção na HD, a intensidade e
a frequência do exercício, a duração da
intervenção e os principais resultados.
Conclusão: Os estudos demonstraram que
exercícios aeróbios realizados durante a
HD promovem a melhora da capacidade
aeróbia e o condicionamento físico, além
de redução da fadiga e ansiedade, mel-
hora da capilarização muscular e pressão
arterial de repouso, aumento no tempo
de duração dos exercícios e melhora na
depuração da ureia.
Palavras-chave: Exercício. Treinamento
de resistência. Diálise renal. Consumo de
oxigênio. Fadiga.
189
 Aerobic exercise during hemodialysis.
Introduction
Chronic kidney disease (CKD) is the slow, progres-
sive and irreversible loss of renal function, with con-
sequent metabolic and hydroelectrolytic imbalance.
Because of its high rates of morbidity and mortality,
it is considered an important public health problem,
with a negative impact on the health-related quality
of life.1
Data from the Brazilian Nephrology Society
(January 20092) have shown that approximately
77,589 patients were on dialysis, with 89.6% on he-
modialysis (HD). 57.3% of the patients on dialysis
were aged 18 – 60 years, and the prevalence rate of
patients on HD was 405/million inhabitants. The
mortality rate was 17.1%, with approximately 1.4
billion reais being spent every year on the dialysis and
renal transplantation programs in Brazil.3
CKD patients have lower physical and functional
capacity than the general population,4 with HD fur-
ther limiting these patients and favoring sedentariness
and functional limitation.5 HD patients are less active,
have lower exercise tolerance and have high physical
deconditioning, probably related to muscle atrophy,
anemia, uremic myopathy and neuropathy, dysauto-
nomia, reduced suppleness, reduced muscle strength,
malnutrition and co-morbidities.6
Programs of physical exercises aiming not only
at reducing the clinical signs, but also at improving
cardio-respiratory and muscle functions, have been
proposed as a strategy to improve the quality of life
of CKD patients.7,8
The purpose of this study was to review the lit-
erature on the effects of cycloergometer-based aerobic
exercises for lower limbs on CKD patients on HD.
Methods
We searched the Medline, PubMed, Scielo, Embase
and ScienceDirect databases, in July 2010, according
to the following criteria: publication date between
January 2002 and July 2010; articles in Portuguese
and English; articles with the following descriptors in
the title and/or abstract – exercício aeróbico / aerobic
exercise, hemodiálise / hemodialysis and doença renal
crônica / chronic kidney disease.
For article selection, we initially read the abstracts,
seeking information meeting the following inclu-
sion criteria: studies of adult participants older that
eighteen years, CKD patients on HD for over three
months, and randomized controlled trials, which as-
sessed the effects of cycloergometer-based aerobic ex-
ercise for lower limbs on HD patients.
190 J Bras Nefrol 2012;34(2):189-194
Although studies involving other participants be-
sides those on HD, such as patients on peritoneal di-
alysis, sedentary individuals, healthy individuals and
individuals practicing domiciliary exercises, were in-
cluded, only the results concerning the participants on
HD were considered. The articles remaining after the
final selection were read in full.
Results
Fourteen randomized, controlled, experimental stud-
ies were analyzed, with consideration of the period
of exercise performance during HD, exercise intensity
and frequency, study duration and main results.
The exercise was performed, on average, during
the second hour of HD. Four studies9-12 did not in-
form the period of exercise performance. One study
performed the intervention during the first hour13
and another one used the first ninety minutes of
HD.14 Exercise intensity ranged between 40% and
60% of the peak oxygen uptake (VO2peak)14-16 and
between 50 – 85% of the training maximum heart
rate (maxHR).9,10,12,13,17,18 Two studies4,11 used the
percentage of the anaerobic threshold and other sev-
en10,12,15,16,19-21 used Borg`s Perceived Exertion Scale
(PES) for exercise prescription. In most studies, par-
ticipants did the exercises three times a week. Two
studies12,15 used two exercise sessions/week. The to-
tal duration of the physical exercise protocols ranged
from 6 to 40 weeks. Table 1 shows the main charac-
teristics and results of the studies analyzed.
Discussion
Several studies have demonstrated cardio-respiratory
impairment in CKD patients. These patients have
a peak VO2 between 15 – 21 mL/kg/min,1 which is
20 – 50% lower than the values found in sedentary,
healthy individuals,22 who have values ranging from
35 to 40 mL/kg/min.1 The practice of aerobic exer-
cises by HD patients has been shown to improve their
cardio-respiratory capacity.
Storer et al.,14 assessing the effects of aerobic
training with an intensity of 50% of peak VO2, dem-
onstrated improved physical performance of the in-
tervention group, even after low intensity aerobic
exercise on lower limb cyclo-ergometer. In spite of
the improvement observed in those who practiced the
exercise, peak VO2 remained 30% of that seen in a
group of healthy individuals. The authors suggested
that low intensity aerobic exercise is not sufficient
to restore the functional capacity to the level of that
 Table 1 Synthesis of the randomized controlled clinical trials referring to the performance of cyclo-ergometer-based aerobic exercises of the lower
limbs during hemodialysis

Groups Mean age ± SD Exercise Exercise Exercise

Authors n HD period Variables Alterations
n years intensity frequency duration

PeakVO2 No difference

8-15 points Resting BP, No difference

Moug et al.12 IG: 10 42.4 ± 12.6 at BEPS or
16 NR 2x/week 6 weeks Work capacity, increase
Scotland CG: 6 41 ± 8.3 60-85% of
maxHR anxiety, reduction

depression no difference

13 points PeakVO2 No difference

16
Parsons et al. IG: 6 First at BEPS or
13 49-60 3x/week 8 weeks Resting BP reduction
Canada CG: 7 2 hours 40-50% of
peakVO2 urea clearance increase

fatigue reduction
Chang et al.13 IG: 36 50.8 ± 10.72 50-65% of
71 First hour 3x/week 8 weeks
Taiwan CG: 35 52 ± 8.7 maxHR. level of physical
increase
activity

PeakVO2 + 22%
14
Storer et al. IG: 12 44 ± 9 First 90 50% of
24 3x/week 10 weeks Walk speed + 19%
United States CG: 12 39 ± 9 min peakVO2
Go up and downstairs + 15%

First 12-16 points at

Vilsteren et al.15 IG: 53 52 ± 15
96 BEPS or 60% 2-3x/week 12 weeks PeakVO2 No difference
Holland CG: 43 58 ± 16 2 hours of peak VO2

90% of the Aerobic capacity, Increase

Koufaki et al.11 IG: 18 57.3 ± 3
33 NR anaerobic 3x/week 12 weeks
United Kingdom CG: 15 50.5 ± 5
threshold Sit-stand test Increase

DePaul et al.9 IG: 20 55 ± 16 80% of

38 NR 3x/week 12 weeks Aerobic capacity Increase
Canada CG: 18 54 ± 14 maxHR

n: number; HD: hemodialysis; IG: intervention group; CG: control group; NR:not reported; SD: standard deviation; BEPS: Borg`s exertion perception scale; maxHR: maximum heart rate; peak
Aerobic exercise during hemodialysis.

J Bras Nefrol 2012;34(2):189-194

VO2: peak oxygen uptake; BP: blood pressure; 6’WT: 6-minute walk test.

191
192
Table 1 Continuation
Groups Mean age ± SD Exercise Exercise Exercise
Authors n HD period Variables Alterations
n years intensity frequency duration
12-14 pointss
Painter et al.10 IG: 22 at BEPS
48 43.3-50.1 NR 3x/week 20 weeks PeakVO2 + 13%
United States CG: 26 or 70% of

J Bras Nefrol 2012;34(2):189-194

maxHR
PeakVO2 + 20%
Aerobic exercise during hemodialysis.

4 90% of the
Sakkas et al. IG: 9 56 ± 15 First 2
15 anaerobic 3x/week 24 weeks Muscle capillarization, + 24%
United Kingdom CG: 6 60 ± 12 hours
threshold
Exercise duration + 33%
PeakVO2 + 24%

Konstantinidou IG: 10 48.3 ± 12.1 First 2 70% of Exercise duration, + 22%

22 3x/week 24 weeks
et al.17 Greece CG: 12 50.2 ± 7.9 hours maxHR pulmonary ventilation, + 12%
anaerobic threshold + 18%

Koh et al.19 IG: 14 52.3 ± 10.9 First 2 12-13 points at

30 3x/week 24 weeks 6’WT + 14%
Australia CG: 16 51.3 ± 14.4 hours BEPS

PeakVO2 + 22.4%

Petraki et al.21 IG: 22 First 2 13 points at Exercise duration, + 40.9%

43 NR 3x/week 28 weeks
Greece CG: 21 hours BEPS baroreflex sensitivity + 23%
resting BP - 6%
PeakVO2 increase
Kouidi et al.18 IG: 30 54.6 ± 8.9 First 2 60-70% of
59 3x/week 40 weeks Exercise duration, increase
Greece CG: 29 53.2 ± 6.1 hours maxHR.
functional capacity increase
PeakVO2 + 21.1%
Ouzouni et al.20 IG: 19 First 2 13-14 points at
33 48.8 ± 13.9 3x/week 40 weeks Exercise duration, + 23.6%
Greece CG: 14 hours BEPS
Resting BP - 6%
n: number; HD: hemodialysis; IG: intervention group; CG: control group; NR:not reported; SD: standard deviation; BEPS: Borg`s exertion perception scale; maxHR: maximum heart rate; peak
VO2: peak oxygen uptake; BP: blood pressure; 6’WT: 6-minute walk test.

of healthy individuals, due to uremic myopathy and
other associated pathologies.
13 – 40% increases in peakVO2 have been report-
ed after 8 – 40-week-training programs.4,10,14,17,18,20,21
Painter et al.10 observed a 13% increase of peak VO2
after twenty weeks of training. Those authors did not
observe any relationship between the increase in the
oxygen uptake and the hematocrit level.
DePaul et al.9 observed increased aerobic capaci-
ty in the intervention group after 12 weeks of train-
ing, although such improvement was not sustained
5 months after interruption of the program, indi-
cating the need of training continuity. Koh et al.19
found no statistically significant difference in the
results of the 6-minute-walk test after 24 weeks of
aerobic training.
Assessing the effects of aerobic training, using
90% of the anaerobic threshold for exercise prescrip-
tion, Sakkas et al.4 observed increases of 24% in mus-
cle capillarization, 33% in exercise duration and 20%
in peak VO2. The authors reported that renal failure
does not damage the enzymatic respiratory chain, the
musculoskeletal system of uremic patients respond-
ing to exercise in the same fashion as that of the gen-
eral population. Using the same training intensity,
Koufaki et al.11 found improved aerobic capacity in
the patients receiving the intervention, with reduced
time of execution of the sitting-standing test, whereas
the controls had reduced aerobic capacity during the
12 weeks of the study.
Konstantinidou et al.17 compared the effects of
three models of training: on non-HD days, during
HD and domiciliary. Aerobic capacity increased in
the three training models, and the results were more
evident with training on non-HD days. Yet, when
questioned, the patients preferred to perform the ex-
ercises during the HD sessions.
After a 4-week rehabilitation program, Kouidi
et al.18 reported that an improvement of the aerobic
capacity was associated with changes in the left ven-
tricular functional capacity, improving some sudden
death risk indicators in HD patients. Aerobic exer-
cise should be performed during the first two hours of
HD, as cardiovascular instability, which may develop
after this period, precludes exercise performance. 1
Ouzouni et al.,20 also in a 40-week period study,
observed a 21.1% increase of peak VO2, a 23.6% in-
crease of exercise duration, and a 6% reduction of the
resting blood pressure (BP). Petraki et al.21 observed
a 22.4% increase in peak VO2, a 40.9% increase in
exercise duration, and a 23% improvement of the ar-
terial baroreflex sensitivity, with a 6% reduction of
Aerobic exercise during hemodialysis.
the resting BP, indicating improvement of the cardiac
autonomic control index.
There were no changes in the maximum work
capacity of the patients assessed by Parsons et al.,16
although these authors demonstrated that aerobic ex-
ercise during HD reduced resting BP and improved
the efficacy of urea clearance. Moug et al.12 did not
find significant changes in the aerobic capacity and
resting BP, in spite of improved work capacity and
reduced anxiety.
Van Vilsteren et al.15 did not report significant
changes of peak VO2 with low and moderate-inten-
sity aerobic exercise, due to muscle fatigue after the
performance of strength exercises before dialysis, al-
though the authors observed that the presence of a su-
pervisor during the physical exercises offered motiva-
tional support and stimulated the patients to remain
active and better comply with the training program.
Conversely, Chang et al.13 observed that active pa-
tients had less fatigue and better physical activity level
between the fourth and eighth weeks of training. The
patients from the intervention group had persistent
reduction of fatigue levels and better conditioning
was evident in those performing physical exercises.
The authors concluded that because the performance
of exercises during HD is safe, does not add costs, and
does not demand extra patient`s time, the interven-
tion can be considered a routine component of HD.
Conclusion
After the literature review, we concluded that the per-
formance of aerobic exercises during HD improves
the functional capacity, providing cardio-respirato-
ry and muscle benefits to the patients. The stud-
ies demonstrated that exercises promote improved
aerobic capacity and physical conditioning, reduce
fatigue and anxiety, improve muscle capillarization
and resting BP, increase exercise duration and im-
prove urea clearance.
Because recommendations on the frequency, in-
tensity and duration of these programs diverge, there
must be adequacy to the reality of each service and
each patient. Once CKD may significantly influence
the quality of life, it becomes important to undertake
studies on alternative treatments to promote improve-
ment of the clinical status, reducing the rates of co-
morbidity and mortality.
The presence of a supervisor during the practice of
exercises offers motivational support and stimulates the
patients to remain active, increasing compliance with
the training program. The practice of aerobic exercises
J Bras Nefrol 2012;34(2):189-194 193
 Aerobic exercise during hemodialysis.
must be continuous, as it is safe, does not incur in extra
costs and does not demand extra time. It can thus be
considered a routine component of HD therapy.
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