Principal findings
This network meta-analysis examined the effect of nine physical activities on the health outcomes of HD patients. These included the following exercises: RE, AE, EMS, ROM, RE + AE, STE, RMT, PMT, and WE. Compared to UC/SE alone, all activity interventions did not affect Kt/V or IL-6. Significant 6-mwt elevations are caused by AE, RE + AE, and RMT, with RE + AE having the most impact. AE is effective in raising QOL. Yet, STE significantly decreased QOL more than UC/SE alone. While ROM and RE + AE were linked to increased Hb, AE and RE + AE performed at higher VO2max. RE performed best in decreasing CRP. Only ROM simultaneously decreased systolic and diastolic pressure among nine different physical activities.
Comparisons with other studies
Previous reviews and meta-analyses have evaluated the effects of IDE on HD patients. However, these studies did not wholly screen all available evidence. A lot of outcomes were not investigated in previous analyses. This study contained 58 RCTs to evaluate 9 exercise types. To this day, this network meta-analysis is the most extensive study investigating the influence of physical activity on HD patients.
Compared to ESRD patients without HD, HD patients have limited activity capacity. Inadequate dialysis and immobility impair their physical strength somewhat [
15]. Lower exercise capacity is associated with higher mortality risk and worse prognosis [
15]. Some guidelines recommend moderate-intensity exercise to improve HD patients’ exercise capacity [
16]. This study considered 6-mwt and QOL as essential indicators for evaluating cardiopulmonary function and exercise ability [
17‐
19]. VO
2max refers to the oxygen content patients can absorb and assess maximum exercise intensity [
20]. In this study, AE, RE + AE, and RMT were demonstrated with the efficacy of elevating 6-mwt. Among these three activities, AE benefits the QOL. AE and RE + AE can increase VO
2max. The effectiveness of AE and RE + AE in 6-mwt and VO
2max is consistent with previous studies [
21]. Biochemical and molecular physiology analyses proved that aerobic training and combining resistance activity improve exercise capacity. Endurance training increases the number of muscle mitochondria, enhances oxidative phosphorylation, and stimulates mitochondrial biogenesis by activating the peroxisome proliferator-activated receptor g coactivator 1a signaling pathway in response to an increase in intracellular Ca
2+ and reactive oxygen species. Increased cyclic adenosine monophosphate (AMP) and p38 mitogen-activated protein kinase result from enhanced adrenergic stimulation and adenosine triphosphate (ATP) breakdown [
22]. Some clinical studies suggested HD patients with aerobic training during the first 2 h of the dialysis sessions. AE is primarily supervised stationary cycling with a moderate-to-high intensity based on VO
2max assessment.
Chronic inflammation is also a complication for ESRD patients. CRP and IL-6 are standard parameters used to estimate the inflammation condition [
23]. An abnormal state will induce vascular calcification, cardiovascular disease [
24,
25], and even accelerate aging [
26]. For CRP, We demonstrated that all nine types of physical exercises did not stimulate CRP. Consistent with this outcome, three studies found a decrease after RE. Moraes et al. discovered reductions in CRP after RE, while Dong et al. found the same results after high-intensity RE [
5,
27]. They presented similar results as the published meta-analysis. When RE was carried out with a high level of intensity, the effects on CRP were more apparent. A previous study also discovered a reduced CRP in medium-intensity AE intervention. However, we found no difference between AE and UC/SE. This inconsistency indicated that there is probably an association between CRP reduction and exercise intensity. A published study consistently reported this view, they supposed better results of CRP in patients who perform AE with medium-intensity training or RE with high-intensity procedures. Therefore, adjusting training intensity is vital in reducing CRP in HD patients [
12]. IL-6 has proven to be a better predictor of cardiovascular mortality and general mortality in these patients [
28,
29], which is associated with more inflammatory causes. Though only 4 included RCT contained available data of IL-6, and only 3 exercises were covered, the small-study effect analysis ensured the reliability of our data. In our study, AE, RE and STE would not increase or reduce IL-6. In addition, there was no statistically significant difference in the effect on IL-6 when comparing between these three exercises. This hinted that exercise did not increase the risk of death due to the inflammatory response. But there was no additional benefit in terms of reducing the inflammatory response and attenuating inflammation-induced cardiovascular deaths at the same time. It seems that we could conservatively affirm that exercise will not aggravate the effects of inflammatory state or even cardiovascular risk in dialysis patients based on the results of CRP and IL-6. Moreover, since it is difficult to measure IL-6 in clinical practice [
30], other reliable and diverse inflammatory markers are needed to connect their predictive role for patient prognosis.
Hypertension is a prevalent complication for HD patients. The incidence is almost 90% worldwide [
31]. Hypertension in HD patients is frequently hard to treat. 22% of those patients can still not benefit from antihypertensive drugs. Hypertension is a high-risk factor for cardiovascular disease and all-cause mortality in dialysis patients [
32]. As we know, blood pressure inevitably rises during physical activity. This study examined the safety of movements on systolic/diastolic pressure and found no significant blood pressure elevation compared to usual care/sham exercise in nine activities. A meta-analysis supported this little influence on hypertension. However, single studies have found varying and inconclusive effects of several exercise training types on HD patients' blood pressure levels [
33]. Some investigators found a sbp reduction different from 4 to 10 mmHg in AE and a dbp decrease from 3 to 6 mmHg in AE + RE. On the contrary, in this study, we discovered sbp and dbp reduction in AE + RE and AE, respectively. Only ROM reduces sbp/dbp at the same time. Most studies did not report the measurement methods of blood pressure. Differences in blood pressure measurement approaches may explain these divergences [
21]. Although the blood pressure effect is controversial, we can confirm that physical activity does not increase blood pressure and is safe for HD patients with hypertension.
HD is vital in prolonging ESRD patients’ survival. Kt/V is a sensitive indicator applied to measure dialysis adequacy. Most countries recommend a target dose of 1.2–1.4 [
34]. Although exercise was reported to improve dialysis efficacy by increasing blood flow, diffusing the toxins and urea into circulation, and enlarging surface area [
35], this study did not identify the overall effect of physical activity on Kt/V based on the mechanism. Consistent with us, other meta-analyses [
36,
37] did not show a statistically significant impact on the change in Kt/V (MWD 0.2, 95% CI –0.12 to 0.28). Nada et al. [
37] reported that AE had no positive effect on Kt/V. Duration and physical status are critical to Kt/V improvement with IDE. According to the mechanism above, sp Kt/V could be improved in a single intervention part. Most trials observed Kt/V at the beginning and end-up timepoint. Rare studies traced Kt/V throughout the experiments, which may account for the controversies between different studies. Besides, Kt/V is related to residual renal function. Although patients accept the HD method to clear urea and other elements, many still have residual renal function. The difference in residual renal function may also be a reason for inconsistent Kt/V.