the effect of an intradialytic exercise programme on blood

The effect of an intradialytic exercise programme on blood pressure and antihypertensive medication use

Pedro Martins, RN, Fresenius Medical Care, NephroCare Lisboa, Portugal

47th EDTNA/ERCA International Conference | Genoa | Italy | 15-18 September 2018

Presentation outline

Introduction1

Objectives2

Methods3

Results4

Conclusions5

EDTNA/ERCA 15-18.09.2018 The effect of an intradialytic exercise program on blood pres. and antihypertensive med…., Pedro Martins © FMC-P

Figure 1 – Causes of endothelial dysfunction in CKD

Clin J Am Soc Nephrol 9: 1305–1318, July, 2014

Introduction

The problem: Blah…Blah…Blah… (1)


Introduction

The problem: facts! (1)

Figure 3 – Nonlinear relationship between outside BP and mortality “reverse epidemiology”

• n = 326

• W-shaped curve

• Out-of-dialysis unit BP shows

superior prognostic value for

mortality

• Best ambulatory sys BP: 110-120

mmHg

• Best home sys BP: 120-130 mmHg

Hypertension. 2010;55:762-768.Hypertension kills!


• Systematic review

• 12 sdtuies analyse nonadherence to AHM

• Nonadherence to AHM ranged between

12.5% - 95.7% (mean: 38.2%)

• Factors associated with nonadherence: younger

age, non-caucasian ethnicity, smoker, living

single, lack of healthcare support, dialysis

vintage, diabetes, hypertension, recurrent

hospitalization, depressive symptoms,

medication regimen complexity…

PLoS ONE. Public Library of Science (2015)

Patients hate to take pills!

Introduction

The problem: facts! (2)


Figure 4 - Training-induced increase in NO bioavailability in CKD: plausible mechanisms

Clin J Am Soc Nephrol 9: 1305–1318, July, 2014

• Vasodilatory, antiatherosclerotic effect

• Inhibits leukocyte adhesion and platelet aggregation

may

be

exercis

ecan

help

!?!.

..

Introduction

The solution? Blah…Blah…Blah…(1)


Introduction

The solution? Facts! (1)

American Journal of Kidney Diseases, Vol 39, No 4 (April)2002: pp 828-833

Exercise group

Control group

Figure 5 - Exercise during hemodialysis decreases the use of antihypertensive medications

Exercise seems to improove blood pressure control in HD patients


• To analyze the influence of an intradialytic exercise

programme:

- On Blood pressure;

- On the use of Antihypertensive medication.

Objectives


Methods

June

2014

Other 18 clinics

Progressively since

september, 2016


Methods

Inclusion Criteria Exclusion Criteria

Physical capacity for Intradialytic exercise

Programme (IEP)

Minimum HD vintage: 2 months

High risk of vascular access´s hematoma

Unstable angina

Uncontrolled arrhythmia

Myocardial infarction <3M

Myocarditis

Systemic infection (fever)

High risk of ruptured aneurysm

Hb < 8.5 g/dL

Table 1 – Screening Criteria


Methods

Criteria for not exercising Criteria to interrupt

Blood glucose < 80 mg/dL (diabetics) Blood glucose < 80 mg/dL (diabetics)

Interdialytic weight gain ≥ 5 Kg Vertigo

Fever Dyspnea

SBP > 190 mmHg or DBP > 100 mmHg

HR > 150 bpm

Chest pain

Nausea

TRAINING PROTOCOL


Methods

30 min after the

beginning of

treatment

1 h 30 min before

the end of treatment

TRAINING PROTOCOL

BP and HR assessed after 15 min from the

beginning of training and every 30 min

Aerobic and resistance exercise training


Methods

AEROBIC EXERCISE TRAINING

Warm Up: 5 min

Conditioning: up to 60 min (50-70 rpm)

Cool Down: 5 min


Borg Scale

Rating Perception of exertion

Methods

RESISTANCE EXERCISE TRAINING

1-4 sets; 12 repetitions


Methods

Retrospectively, clinical records about:

- Blood pressure (30 days average systolic and diastolic pre dialysis BP before

and after 6-month IEP)

- AHM use (before and after 6month IEP)

- Overhydration (bioimpedace spectroscopy before and after 6 month IEP)


Results


Results

54%


Antihypertensive medication n (%)

Amlodipine 55 (13.1%)

Captopril 2 (0.5%)

Clonidine 12 (2.9%)

Enalapril 12 (2.9%)

Irbesartan 5 (1.2%)

Lisinopril 27 (6.4%)

Losartan 29 (6.9%)

Minoxidil 4 (1%)

Nifedipine 38 (9.1%)

Perindopril 8 (1.9%)

Ramipril 18 (4.3%)

Rilmenidine 8 (1.9%)

Results

AHM use: 33.4%


Results

Reduction in the number of patients taking AHM after IEP

13.8% of patients stop taking AHM

n = 419 n = 419


Results

Reduction in the average number of different AHM after IEP

n = 140 n = 419


Results

AHM adjustment during the study period

Medication adjustment during study

(patients not taking AHM previously)

Medication adjustment during study

(patients taking AHM previously)

73%

n = 140n = 279


10.4

17.4

77.975.2

11.8

7.4

0

10

20

30

40

50

60

70

80

90

100

Adherence to training sessions >= 70% Adherence to training sessions < 70%

Increased No change Reduced

Medication adjustment during study according to adherence to training sessions (%)

n = 292 n = 121


Results

n = 408 n = 408


Results

Blood pressure variation during the study period

Results

Overhydration variation during the study period

n = 356


• Intradialytic exercise is a safe intervention (no major adverse events)

• In addition to other benefits, intradialytic exercise can reduce

antihypertensive medication use reducing medication regimen

complexity

• Intradialytic exercise can be used as an adjunctive therapy for blood

pressure control


Conclusions

Strengths

• Sample size

• Exercise adherence (76%)

Limitations/suggestions

• No control group

• No ambulatory and/or home BP

• AHM use based on medical records

(prescriptions)

• No cardiovascular mortality assessment


Conclusions

Acknowledgments

João Mendes IT Operational Support

Fresenius Medical Care, NephroCare Portugal

Lisboa, Portugal

Nuno Penha NephroCare Operations Manager


Lisboa, Portugal

Alexandra Seabra Training and Development Manager


Lisboa, Portugal

João Fazendeiro Country Nursing Director


Porto, Portugal

Maria Teresa Parisotto Chief Nurse Advisor

Fresenius Medical Care, Care Value Management EMEA

Bad Homburg, Germany


the effect of an intradialytic exercise programme on blood

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