LAUSR

It is widely acknowledged that patients with end-stage kidney disease receiving maintenance hemodialysis (HD) may benefit from increasing their physical activity levels. Decades of exercise-related clinical trials have demonstrated improvements in various metrics related to dialysis patient's health and quality of life. Yet, the implementation of exercise programs in dialysis clinics today is scarce, and physical inactivity and dysfunction remain a hallmark of the disease. To address this issue, many groups worldwide are beginning to rethink how physical activity and exercise are prescribed in HD patients, as well as how to evaluate the efficacy of these programs. The vast majority of exercise interventions in HD patients have included intradialytic cycling as the predominant or only exercise prescription. Moreover, efficacy has most often been evaluated using standard measures of strength, physical function, and/or traditional cardiovascular disease risk factors (e.g., blood pressure, lipids, etc.). More recently, there has been a greater emphasis on novel intervention approaches that are focused on providing patients with a greater variety of options for exercise and enhanced motivational tools. The benefits of exercise on patient reported outcome measures (PROMs) and other clinically important outcomes are also becoming more prevalent. The purpose of this review was to: (1) critically review the data from several recently published large randomized clinical trials of exercise in HD patients, (2) discuss some of the novel approaches that groups across the world are taking to improve implementation and efficacy of exercise-related interventions in HD, and (3) discuss policy prescriptions that may be needed to continue improving exercise prescriptions for this critically ill patient population. While it may be too early to declare that exercise in dialysis is ready for prime time, exciting advances have been made in recent years, yet more work is needed to realize its full potential.