Renal Failure

ISSN: 0886-022X (Print) 1525-6049 (Online) Journal homepage: http://www.tandfonline.com/loi/irnf20

Effect of Exercise Performed during Hemodialysis:

Strength versus Aerobic

Maurícia Cristina de Lima, Camila de Lima Cicotoste, Kelly da Silva Cardoso,

Luiz Alberto Forgiarini Junior, Mariane Borba Monteiro & Alexandre Simões
Dias

To cite this article: Maurícia Cristina de Lima, Camila de Lima Cicotoste, Kelly da Silva Cardoso,
Luiz Alberto Forgiarini Junior, Mariane Borba Monteiro & Alexandre Simões Dias (2013) Effect of
Exercise Performed during Hemodialysis: Strength versus Aerobic, Renal Failure, 35:5, 697-704,
DOI: 10.3109/0886022X.2013.780977

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Published online: 08 Apr 2013.

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Renal Failure, 2013; 35(5): 697–704
Copyright © Informa Healthcare USA, Inc.
ISSN 0886-022X print/1525-6049 online
DOI: 10.3109/0886022X.2013.780977

CLINICAL STUDY

Effect of Exercise Performed during Hemodialysis: Strength versus

Aerobic

Maurícia Cristina de Lima1, Camila de Lima Cicotoste1, Kelly da Silva Cardoso1, Luiz Alberto
Forgiarini Junior2, Mariane Borba Monteiro2 and Alexandre Simões Dias3
1
Department of Physical Therapy Course, União das Américas Faculty, Foz do Iguaçu (PR), Brazil; 2Methodist University—
IPA, Porto Alegre (RS), Brazil; 3Post-graduated of Movement Sciences and Pulmonology Sciences, Universidade Federal do Rio
Grande do Sul, UFRGS, Porto Alegre (RS), Brazil

Abstract
Rational: Patients under regular dialysis can also present alterations in the cardiovascular, musculoskeletal, and meta-
bolic systems. Objectives: The aim of this study is to compare the effects of strength and aerobic exercises performed
during hemodialysis (HD) in individuals with chronic renal disease. Materials and Methods: Randomized clinical trial. It was
developed as a program of exercises three times a week, in the first 2 h of HD for 8 weeks. The patients were divided into
three groups: control (Group 1, n: 11), strength (Group 2, n: 11), and aerobic (Group 3, n: 10). G1 has not developed any
type of physical training; G2 utilized a training load of 40% of one repetition maximum (1RM) with anklets, and developed
three series of 15 repetitions. G3 pedaled seated in the dialysis seat, during 20 min, in an ergometric bicycle, with intensity
regulated by the perceived effort scale. Before and after 8 weeks, the following variables were evaluated: respiratory
muscular strength, pulmonary function, functional capacity, blood biochemistry, and quality of life. Main Findings: In the
pre- and post-training comparison, there was statistically significant improvement (p < 0.05) in the maximal inspiratory
pressure (MIP), number of steps achieved (NSA), and quality of life (QoL) in the trained groups, as compared to the non-
exercised group (G1). Conclusions: The strength and aerobic exercises developed during HD can improve the respiratory
muscular strength, functional performance, and quality of life, when compared to individuals presenting the disease who
have not developed any type of physical training.

Keywords: chronic renal disease, physical exercise, quality of life

INTRODUCTION activity level, and cardiovascular disease contribute to

The advanced chronic renal failure (CRF) characterizes
itself by irreversible renal injury, interfering directly in
glomerular filtration. In this stage, substitutive renal
therapy (SRT) with dialytic treatment and/or the devel-
opment of renal transplantation are employed.1,2
The main risk factors for development of CRF are
systemic arterial hypertension (SAH), diabetes mellitus,
and glomerulonephritis. Besides these factors, inflam-
matory processes, oxidative stress, endothelial dysfunc-
tion, uremia, and familial antecedents can also
contribute to the development of renal disease.3
With the progress in course in dialytic treatment, the
life expectation of these patients is increasing signifi-
cantly; however, factors like disease stage, physical
the decrease in the quality of life of individuals with
chronic renal disease.4,5 Besides, patients under regular
dialysis can also present alterations in the cardiovascular,
musculoskeletal, and metabolic systems, and such altera-
tions can compromise 40–50% of their exercise capacity
and peripheral muscular strength.6–8
It is suggested that the intolerance to exercise com-
monly presented by CRF patients results from the
decrease in physical aptitude, which is caused by their
low capacity of oxygen transportation and decreased
extraction of oxygen from peripheral skeletal muscula-
ture.5 The circulating toxins, excess of body liquid, elec-
trolytic disturbances, nutritional alterations, as well as
the inactiveness itself and the presence of inflammatory
processes all contribute together, in direct or indirect

Address correspondence to Maurícia Cristina de Lima, Undergraduate Course of Physical Therapy, União das Américas Faculty, União das
Américas Faculty,UNIAMÉRICA, Av. Tarquínio Joslin dos Santos, 1000 Bairro Universitário, CEP 85851-000-Foz do Iguaçu, Paraná,
Brazil. E-mail: mauricia@uniamerica.br
Received 4 December 2012; Revised 22 February 2013; Accepted 26 February 2013

697
698 M.C. de Lima et al.

Eligibility evaluation (n = 96)

Excluded (n = 15)
Renal transplantation (n = 1)
Neurologic deficit (n = 1)
Visual deficit (n = 1)
In transit patient (n = 1)
Did not agree with TCLE* (n = 5)
Dialysis schedule (n = 6)
Randomized (n = 33)

Allocated for Allocated for

intervention (n = 11) intervention (n = 11) Allocated (n = 11)
Strength group (n = 11) Aerobic group (n = 11) Control group (n = 11)

Dropout (n = 0) Dropout (n = 1)
Dropout (n = 0)
Interruption of Interruption of intervention
Interruption of
intervention (n = 0) (hospital admission) (n = 0)
intervention (n = 0)

Analyzed (n = 11) Analyzed (n = 10)

Analyzed (n = 11)
Excluded of analysis Excluded of analysis
Excluded of analysis (n = 0)
(n = 0) (Admission) (n = 1)

Figure 1. Flowchart, process of randomization (Consort 2010).

Note: TCLE ¼ Informed Consent Form.

manner, for the appearance of these situations, thus METHODS

decreasing the patients’ survival.9,10
Studies demonstrate that exercises developed with
patients subjected to hemodialysis (HD), in the first 2 h
of this procedure, can present a gain in “aerobic capacity,”
“muscular strength,” an “increase in dialysis efficiency,” as
well as an improvement in their “toxin clearance” and
“quality of life.” However, there is no consensus in the
literature about which exercise program would be more
indicated to be developed during HD.11–13
The routine prescription of physical exercises during
HD is still uncommon; so, it is necessary to amplify the
understanding about their effects in this group of indivi-
duals. After the clarification of such variables, the physical
activity could be developed in a safer manner, and their
results could be beneficial for this population.5,11,14–17
The purpose of this study was to compare two types of
physical exercises developed during HD (strength vs. aero-
bic) and their influence on the muscular strength, func-
tional capacity, pulmonary function, and quality of life.
Patients
Thirty-two patients participated in this study, according
to the randomization procedure illustrated in Figure 1
flowchart.
This was a randomized clinical trial type study, devel-
oped with 32 outpatients of the dialysis unit of
Nefroclínica, in Foz do Iguaçu (state of Paraná, Brazil).
The entire project was approved by the Institutional
Review Board/Independent Ethics Committee of IPA, in
Porto Alegre (state of Rio Grande do Sul), under the
protocol 279/2009; and the signature of both, the
Investigators Agreement by the responsible investigators
and the Informed Consent Form by the volunteer parti-
cipants, was required.
The inclusion criteria for this study were as follows:
patients being regularly subjected to HD, three times a
week; the gender being irrespective; being aged between
18 and 75 years; and not practicing any physical activity.

Renal Failure
 Effect of Exercise Performed during Hemodialysis: Strength versus Aerobic
The exclusion criteria were uncontrolled arterial
hypertension, ischemic cardiopathy, amputation, deep
vein thrombosis, excessive pallor, severe dyspnea,
femoral fistula, arrhythmias, precordial pain, orthopedic
or neurological compromising, and cognitive alterations
affecting their participation in the proposed protocol.
The clinical and anthropometric characteristics of par-
ticipants were verified in a previous evaluation and by the
analysis of medical history, in which were collected also
the clinical diagnoses indicating renal disease, age, gen-
der, body mass index (BMI), time of disease and of
dialysis, as well as smoking habits. The variables of
respiratory muscular strength, pulmonary function, tol-
erance to submaximal exercise, laboratory examinations,
and quality of life were measured before and after 8 weeks
of exercise programs.
Procedures
As respiratory muscular strength markers, the maximal
inspiratory pressure (MIP) and maximal expiratory pres-
sure (MEP) were evaluated through an analogical man-
ovacuometer (Globalmed  300 cmH2O, Brazil). With
the patient seated and utilizing a nasal clip, every respira-
tory pressure was measured three times with resting
interval of 1 min between them, the higher grade value
achieved being considered. The difference between the
three maneuvers should be lower than 10%. MEP was
measured from the total pulmonary capacity (TPC), and
both the buccal aerial flow and use of buccinator muscles
were avoided. MIP was evaluated from the residual
volume (RV), and, then, a maximal inspiration up to
TPC was developed. The calculation of the pressures
was developed according to the values professed by
Neder (2002),18 in agreement with the Guidelines of
Brazilian Society of Pneumology and Phthisiology.19
For the analysis of pulmonary function, the forced
expiratory volume in 1 s (FEV1), forced vital capacity
(FVC), and Tiffeneau index (FEV1/FVC) were evalu-
ated with a portable spirometer (Micro Plus, UK). With
the patient comfortably seated, using a nasal clip, and
maintaining erect his trunk, it was requested his/her fas-
ter, stronger, and more complete possible expiration,
until the total expulsion of pulmonary air, in the RV
level. Then, a maximal inspiration up to TPC was devel-
oped, with the mouthpiece placed between the teeth and
connected to spirometer. Three maneuvers were devel-
oped in every measurement and the higher value was
considered, which should be lower than 10%.19
Tolerance to submaximal exercise was measured with
step test (ST) for 4 min of time, quantifying the number
of steps achieved (NSA) in four times (ascend, ascend,
descend, descend). Before the test development, the
participant developed a pre-test, which consisted in indi-
vidual familiarization, being the rhythm of ascents and
descents equal to those afterward developed.19 The
bench was built in resistant wood and covered with non-
skid material, in the following dimensions: 15 cm of
© 2013 Informa Healthcare USA, Inc.
699
height, for 40 cm of deep and 60 cm of width.20,21 For
the test development, the patient utilized a frequency
meter (fitness polar, Finland) positioned above the
xiphoid process and below the nipples, controlling the
cardiac frequency in a digital watch coupled to the arm
opposite to arteriovenous fistula.
The results of urea, hemoglobin, potassium, calcium,
and phosphorus concentration, as well as the hematocrit,
were verified in the levels of blood exams developed
monthly, in the HD unit.
With respect to the quality of life measurement, the
patients answered the Kidney Disease and Quality-of-
Life—Short-Form version 1.3 (KDQoL-SF 1.3), which
includes some questions of the generic questionnaire SF-
36 (Medical Outcomes Short Form Study 36) and a
specific part about renal disease, composed of items
divided into 11 dimensions. The scores in every dimen-
sion vary between 0 and 100, with the higher scores
reflecting a better quality of life.22,23
Exercise Programs
The participating patients were divided into three
groups: group 1—control (G1); group 2—strength
(G2), and group 3—aerobic (G3). The group’s selection
was randomized into three blocks, in aleatory form
through 45 envelops, without external marks, which
were jumbled and numbered from 1 to 15, containing
inside a sheet with the pertaining group name.22 The
choice of patients’ shift obeyed the logistical issues of
research execution.
The exercise programs of G2 and G3 were developed
during 8 weeks, with the patient seated in the dialysis seat
during the first 2 h of HD, at the frequency of three times
a week. G1 were evaluated before and after 8 weeks and
did not receive any type of intervention or training, but
only the evaluations.
G2 were subjected to a peripheral musculature train-
ing composed by three series of 15 repetitions in every
lower limb. The program was composed of two active
exercises of knee flexion-extension, and hip and knee
flexion with dorsiflexion of foot, both resisted by anklet,
utilizing 40% of load of a one repetition maximum
(1RM).23 The 1RM test was developed in the seated
position with feet resting on the floor, at an angle of
90˚, straight and recumbent column, arms resting in the
dialysis seat support, where the patient executed a knee
flexion-extension in complete amplitude, starting the
repetition without load for adaptation; further, this
movement was started with 0.5 kg, with gradual weight
increase in steps of 0.5 kg, with resting interval of 1 min
between the series, until the patient achieved the weight
in which he/she did not succeed in developing the max-
imal amplitude, or felt important pain and/or tiredness.
The 1RM load was evaluated every 15 days and adjusted
to exercises in an individualized way, according to sub-
jective effort perception on the modified scale of
Borg.7,24
700 M.C. de Lima et al.

G3 pedaled on an ergometric bicycle (Biocycle 2700
movement, Brazil) for 20 min, with progressive indivi-
dualized load intensity, according to subjective effort
perception measured on the modified Borg scale, which
should remain between the values of 2 and 3 (mild to
moderate).17,25,26
G2 and G3 exercises were monitored “before,” “after
ten minutes,” and at “exercise protocol termination,”
and the following parameters were also verified: “systo-
lic” and “diastolic” blood pressures by means of an aner-
oid sphygmomanometer (Glicomed, Brazil) and
stethoscope (Littmann); heart rate, which should be in
the level of 70% of the maximal heart rate (MHR); and,
finally, the peripheral oxygen saturation (SpO2) through
a finger pulse oximeter (Nonin® Onyx®, Model 9500
finger pulse oximeter, USA).27 The patients were
instructed to interrupt the exercises in the presence of
both “hypertension” or “hypotension” above the initial
status (<200/110 mmHg or >90/70 mmHg), as well as an
“SpO2 falling” below 89%, and also in presence of the
following signals and symptoms: “headache,” “nape
pain,” “chest pain,” “nausea,” “vertigo,” “intense mus-
cular fatigue,” “cramps,” or any other debilitating mus-
cular symptom.28 At exercise termination, peripheral
muscles’ (“ischiotibial” and “triceps surae”) passive
elongations were developed, maintained for 20 s with
two series for every limb, and finalized with passive slip-
ping in the triceps sural muscle.7,17
Statistical Analysis
Data were analyzed with the SPSS 15.0 (Statistical
Package for Social Sciences) software, version 13.0, and
the quantitative variables were expressed in average and
standard deviation. One-way analysis of variance
(ANOVA) was applied for comparison between groups
with Tukey’s post-hoc test, when the variables presented
parametric distribution. To evaluate the intragroup com-
parison between quantitative variables, Student’s t-test
was developed for the matched samples, according to the
normality of every variable. The adopted significance
level was of 5% (p < 0.05).
RESULTS
The sample characteristics are demonstrated in Table 1,
with homogeneity being observed between all studied
groups, except for the parameter BMI, in the aerobic
group.
We observed a statistically significant decrease in the
MIP (p < 0.05) and MEP (p < 0.05) values compared to
what was anticipated, indicating respiratory muscular
weakness. The FEV1 and FVC were lower than predicted
in the three evaluated groups (Table 2), but within the
normality range. We did not observe significant altera-
tions when we evaluated the blood pressure of patients at
the beginning and end of the study (p > 0.05).
When all groups were compared after training, we
verified (Table 2) a statistically significant increase in
the MIP, MEP, and NSA values, but only in the groups
that developed training (G2 and G3) as compared to G1.
In the pre- and post-exercises comparison (Table 2),
there was a statistically significant increase of MIP and
NSA in the trained patients (G2 and G3 groups), as
compared to nontrained ones (G1 group). No statistical

Table 1. Sample characteristics.

Characteristics Control group (G1) Strength group (G2) Aerobic group (G3)
(n ¼ 11) (n ¼ 11) (n ¼ 10)
Gender, n
Male 6 7 5
Female 5 4 5
Age (years) 43.5  11.1 49.6  9.1 43.1  13.3
Weight (kg) 68.4  12.2 73.6  14.6 58.9  9
Height (m) 1.70  0.1 1.70  0.1 1.64  0.1
BMI (kg/m2) 27.4  3.7 26.0  5.1 22.99  5.6
Comorbidities
Hypertension 8 8 6
CCF 3 1
Diabetes 1 2 2
Smoking habits
Never smoked 10 7 8
Former smoker 0 1 1
Smoker 1 3 1
Hemodialysis time (years) 6.5  4,2 5.4  4 6.4  4.4
MIP (cmH2O) 59.1  18 60.1  23 59.5  29.3
MEP (cmH2O) 59  15 62  21 70  27
FEV1 (L) 2.4  0.6 2.4  0.6 2.1  0.4
FVC (L) 2.7  0.7 2.5  0.5 2.5  0.8
FEV1/FVC (L) 0.92  0.11 0.9  0.1 0.91  0.07

Note: BMI, body mass index; CCF, congestive cardiac failure; MIP, maximal inspiratory pressure; MEP, maximal expiratory pressure;
FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; FEV1/FVC, Tiffeneau index

Renal Failure
 Effect of Exercise Performed during Hemodialysis: Strength versus Aerobic 701

0.0018
Notes: Data presented as average  standard deviation. ANOVA utilized, followed by post-hoc Student Newmann-Keuls. MIP, maximal inspiratory pressure; MEP, maximal expiratory
p-Value
difference was observed in the spirometry values in all the

0.0112
0.052

0.155
0.753
studied groups.

0.7
In the blood examinations of samples collected before
and after the physical training program, a statistically
significant decrease of urea was observed in the group

Aerobic group (G3)

92.3  22.1

0.9  0.07
142  32
2.7  0.9
that developed aerobic training (Table 3).

97  31

3.1  1
Post-
In the quality of life questionnaire specific for renal
disease (KDQoL-SF 1.3), we observed in the trained
groups (G2 and G3) a statistically significant improve-
ment in the comparison before and after 8 weeks of

pressure; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; FEV1/FVC, Tiffeneau index; NSA, number of steps achieved; ND, not defined.
training, as compared to the control group (G1). In this
59.5  29.3

0.91  0.07
2.1  0.4
2.5  0.8
70  27

86  36
comparison, the strength group (G2) improved the qual-
Pre-

ity of life in the following domains: social support (p <

0.001), patient satisfaction (p < 0.01), and general health
(p < 0.007); the aerobic group (G3) improved in the
domains referring to physical functioning (p < 0.05),
pain (p <0.05), symptoms (p < 0.04), sleeping (p <
0.0001
p-Value
0.0022
0.0002

0.006), sexual function (p < 0.01), and energy/fatigue

0.068
0.999
0.21

(p < 0.02).
Strength group (G2)

0.9  0.11
93.5  21
101  18

131  31
2.7  0.5
3  0.7

DISCUSSION
Table 2. Intragroup analysis: respiratory muscles strength, pulmonary function, and tolerance to submaximal exercise.

Post-

The impact of CRF and its treatment could lead to multi-

ple and complex organic dysfunctions, causing the dis-
semination of several symptoms, such as
2.4  0.6
2.5  0.5
0.9  0.1

cardiorespiratory and musculoskeletal ones, and these

60.1  23
62  21

69  25

symptoms could stir up cardiovascular morbidities.9 In

Pre-

this study, we observed that 81.2% of the 32 patients

presented arterial hypertension, this result being similar
to comorbidities reported by other investigators.29,30
The cardiovascular dysfunctions of patients under HD
p-Value

0.1899
0.363

0.713

0.207

could decrease the tolerance to exercises in 50% of the

0.82

0.51

anticipated value, supposedly due to musculoskeletal

catabolism and intramuscular fat accumulation; these
events interfere with both types of stimulation: the sym-
0.85  0.14
2.3  0.6
2.5  0.7
Control group (G1)

52.7  14
60.5  17

92.5  21

pathetic one, thus inhibiting the chronotropic effect, and

the respiratory one, thus decreasing the respiratory mus-
Post-

cular strength and the “pulmonary function.”30–32

In this study, the patients presented both MIP and
MEP 56% and 59% lower, respectively, than previously
anticipated in the earlier evaluation of the three study
groups. Similar results were presented in another study,
0.92  0.11
2.4  0.6
2.7  0.7
59.1  18
59  15

101  23

with reduction of 52.9% in the MIP, and of 42.8% in the

Pre-

MEP.33 However, the cause of this weakness and the

grade of functional jeopardy are not clear in the litera-
ture,34 but a relationship with uremic myopathy, carni-
tine deficiency, vitamin D, and excess of parathormone is
suggested.9,16,35,36
3.2  0.6
3.9  0.8
0.8  0.0
104  16
108  25
Predicted

The hypotrophy of type II fibers, myofibrillar ATPase,

ND

jeopardy of energetic metabolism due to lower capacity

p < 0.05; p < 0.001.

to stimulate the pyruvate dehydrogenase activity,

decrease in the utilization of fat as metabolic source,
MEP (cmH2O)

chronic inflammation with cytokine alterations, and

FEV1/FVC (L)
MIP (cmH2O)

NSA (6 min)

intramuscular fat produced by dialysis are also men-

tioned as factors initiating muscular weakness.7,16,29,36,37
Variables

FVC (L)

A study emphasizes that children and teenagers with

FEV1

CRF already present respiratory muscular weakness with



© 2013 Informa Healthcare USA, Inc.

702 M.C. de Lima et al.
Table 3. Blood biochemistry.
Electrolytes G1 (Strength)
Pre Post
Urea (mg/dL) 184  44 178  38
Potassium (mEq/L) 6.1  0.7 5.6  0.7
Phosphorus (mg/dL) 6.2  1.3 6.6  1.6
Calcium (mg/dL) 9.3  0.9 10.1  2.6
Hematocrit (%) 35.6  2.8 35.9  2.5
Hemoglobin (g/dL) 11.3  1 11.4  0.9
Notes: We utilized ANOVA with post-hoc Student–Newman–Keul.

In the comparison of aerobic versus strength groups, p < 0.05. When comparing the aerobic group pre- versus post-exercise condition,
p ¼ 0.032.
conservative treatment only, based on the hypothesis that
air flow limitation results from muscular strength
decrease, which could retard the contractile function of
muscular fibers.38
It is yet emphasized that the higher the dialytic period
of time, the lower are the spirometric values observed in
CRF.39 The average HD time in our study, in the three
groups, corresponded to 6.5  4.6 years, and 40% of the
32 patients presented spirometric values lower than the
anticipated ones, but within the normality range. There
were no statistically significant differences in the spiro-
metry values at pre- and post-training analyses. Similar
results, in a study with 33 patients, were also observed; a
mild restrictive standard occurred in 21% of the patients,
followed by obstructive jeopardy in 6% of the patients
after HD, and mixed ventilatory disturbance in the
remaining patients.32
These alterations in the pulmonary function could be
attributed as much to muscular weakness as to aerial
obstruction and arrest, both caused by overload of liquid
in the interstitial space and airways, with repeated epi-
sodes of pulmonary irritation and bronchoconstriction
due to dialysis membrane bio-incompatibility, which
could damnify the capillary-alveolar wall, affect the diffu-
sion, induce interstitial fibrosis, and decrease the func-
tional capacity.8,28,31
To evaluate the functionality of patients under HD,
and thanks to space scarcity in the site, we have applied in
this study the ST following the rhythm determined by the
patient himself/herself (self-paced step test), verifying the
total number of steps ascended in 6 min, as a marker of
“work.” Despite the extensive experience with ST in
patients with chronic obstructive pulmonary disease
(COPD) and heart failure (HF), in bearers of chronic
renal disease (CRD) it is still little utilized, despite to be
indicated.19,21
The functional performance and respiratory muscular
strength, evaluated respectively by NSA (step test) and
manovacuometry (MIP), exhibited a statistically signifi-
cant increase in the trained groups (G2 and G3) in the
pre- and post-interventional analyses. Even though we
have not developed, in this study, a specific training of
respiratory musculature in G2 and G3, an improvement
G2 (Aerobic) G3 (Control)
Pre Post Pre Post

169  42 135  27 167  30 163  29
5.5  0.6 5.3  0.7 6.2  0.7 5.8  0.6
5.6  1.8 5.4  1.7 5.4  1.3 5.6  0.9
9  1.5 8.6  1.3 9.4  0.5 9.3  0.9
34.9  3 32.1  3.2 35.4  1.5 34.5  3
11.3  0.9 10.3  0.9 11.1  0.7 11.1  1.2
of inspiratory muscular strength in both groups
occurred, possibly due to the work imposed on muscu-
lature during the exercise protocols for peripheral mus-
cles. It is emphasized that in CRF, a direct correlation
between the functional capacity and the respiratory mus-
cles’ strength effectively occurs,31 which could thus jus-
tify our results.
There is evidence that the practice of physical exercises
developed during the first 2 h of HD could improve the
functionality and muscular strength of patients with
CRD, minimize the sympathetic nervous system reflex
hypotension, and increase the tolerance to exercise.1,4
These results were also observed in the trained groups
of this study (G2 and G3), which exercised during the
first 2 h of dialysis.
The majority of studies indicate that exercise protocols
with resistance for peripheral muscles could, effectively,
increase the volume of muscular fibers resistant to fati-
gue, the captation and transportation of oxygen by mus-
cles, their capacity to oxidize and metabolize glucose, as
well as the respiratory and peripheral muscles’
strength.17,31,33,37,39 Such events could thus justify the
results of this study for the strength group (G2), which
showed increase in the inspiratory and expiratory
strength, as well as the functional capacity at ST in the
pre- and post-training comparison.
An exercise protocol similar to that of this study was
developed, with strength training, in 49 patients during
HD, for 12 weeks; that protocol focused on upper and
lower limbs and verified significant increase in muscular
strength, measured with a dynamometer, in the quadri-
ceps musculature.7
On the other hand, many recommendations of exer-
cise during HD are referred to 30 min of aerobic activity,
with intensity between 70% and 85% of maximal heart
rate; however, it is known that the majority of dialyzed
patients present decrease in sympathetic stimula-
tion.40,41 Because of that, in our study, the 20 min of
aerobic activity were monitored according to individual
effort perception (modified Borg scale). Other studies
using similar protocols have also verified that such
patients can exhibit good response to training, being
monitored by the individualized sensation of
Renal Failure
 Effect of Exercise Performed during Hemodialysis: Strength versus Aerobic
effort.33,42–44 These studies reinforce our findings, and
emphasize the importance of inclusion and continuity of
exercise programs for HD patients, aiming at a decrease
in sedentary behavior.45
Other studies emphasize that a good physical exercise
program, developed during HD, could decrease uremia
and improve this population quality of life.46,47 We have
also observed a significant decrease of urea (p ¼ 0.032) in
G2, at pre- and post-exercise comparisons. Similar
results were verified with aerobic training on ergometric
bicycle, for 15 min, during the first 3 h of HD, three times
a week for 8 weeks.12 One of the hypotheses attributes
these results to the above 15 min’ duration of exercise,
which could increase the systemic and muscular blood
flow, favoring the balance between prostaglandins and
thromboxane hormones, which stimulates the peripheral
vasodilation and promotes toxin clearance.48–50
Supposedly, such metabolic alterations influence the
adenosine triphosphate (ATP), phosphocreatine (PCr),
and glycogen concentrations, being the substrate genera-
tors of energy for muscular contraction, and able to affect
the oxidative capacity.17,29
All of these alterations affect the HD patients’ percep-
tion with respect to their quality of life (QoL), which
could also improve with the practice of physical exer-
cises,9 decreasing the tiredness and fatigue signals and
symptoms, and the cramps manifested by dialysis.1,4 So,
we observe in this study a significant improvement in
QoL, mainly in the aerobic group, on intragroup analy-
sis. Possibly, these results are attributable to the improve-
ment in lactate production, caused by aerobic exercise
that inhibits the glycolytic enzymes, increases the mus-
cular sensitivity to insulin, and decreases the carbohy-
drate metabolism, which is responsible for the pain
complaints, weakness, and peripheral muscles’ fati-
gue,4,20 and could also justify the significant decrease of
pain referred by G2 (p < 0.05) in the intergroup analysis.
Study Limitations
This study has some limitations such as (1) sample size
that can limit the results; (2) the average age of the
patients, which may be lower than other populations in
HD, limiting the extrapolation of results; and (3) the lack
of a group practicing both strength and aerobic exercises
to compare the existing variables in the groups. Besides,
other studies are necessary to determine whether these
interventions improve the survival of these patients, and
the time period for which the exercise results remain
active. For that, it is necessary to create intervention
strategies to promote the inclusion of exercise and reha-
bilitation programs in the treatment protocols, in their
dialytic routines, in order to subside the building of
health policies addressed to chronic renal patients
under HD, in Brazil.
In conclusion, the strength and aerobic exercises
developed during HD can improve the respiratory mus-
cular strength, functional performance (step test), and
© 2013 Informa Healthcare USA, Inc.
703
quality of life, when compared to individuals presenting
the disease who have not developed any type of physical
training. Aerobic exercises, besides these benefits, can
also increase the urea clearance.
ACKNOWLEDGMENTS
The authors are grateful to the medical team, patients,
and staff of Nefroclínica of Foz do Iguaçu, state of
Paraná, especially to nephrologist physicians Marcelo
Augusto Gonçalves, Jaime Valdemar Borger, Marta Vaz
Dias de Souza Boger, Célia Regina Garcia Barufatti, and
Marcelo Eduardo Alfieri, for their confidence, for the
opportunity, and because they enabled the development
of this investigation.
Declaration of interest: The authors report no con-
flicts of interest. The authors alone are responsible for the
content and writing of the paper.
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Renal Failure