Exercise is Medicine

Intradialytic Exercise is Medicine for

Hemodialysis Patients
Kristen Parker

35). This is exacerbated by symptoms such

ABSTRACT as anemia, fatigue, nausea, hypertension,
When a persons kidneys fail, hemodialysis (HD) is the most common treatment mo- headaches, edema, shortness of breath,
dality. With a growing number of patients requiring this life-sustaining treatment, and metabolic acidosis, and bone deminerali-
with evidence illustrating the significant physical dysfunction of this population, en- zation (32). It is also common for preva-
couraging exercise is essential. The use of intradialytic exercise, as a novel and effi- lent HD patients to have some level of
cient use of time during HD, is well established in Australia and some European osteoporosis or renal osteodystrophy. As
nations; however, it is slower to start in North America. While a large number of small the failed kidneys no longer manage the
studies have demonstrated numerous benefits and safe delivery of intradialytic exer- balance of calcium, phosphate, and active
cise training for patients with end-stage kidney disease, intradialytic exercise is rarely vitamin D, there is a high risk of secondary
delivered as standard of care. It is of utmost importance for health care staff to over- hyperparathyroidism. The risks of sponta-
come barriers and bring theory into practice. Included in this report are current rec- neous fractures, postural issues, osteoar-
ommendations from governing bodies, expert opinion, as well as established thritis, and bone pain increase with each
policies and procedures from a successful intradialytic exercise program in Canada. passing year on HD (6).
Prolonged exposure to HD treatments
has a catabolic effect on muscles, and this
INTRODUCTION can greatly impact quality of life, independence, fall risk, and
Approximately 421,349 Americans (45) and 18,823 Canadians mortality (20). Also compounding this expedited muscle loss
(8) receive hemodialysis (HD), which requires these patients to are nutritional factors, hormonal changes, low-grade inflam-
be connected to a machine to filter wastes, salt, and fluid out of mation, metabolic acidosis, neuropathy, inactivity, and com-
their blood through an artificial kidney called a dialyzer. Pa- plications from multiple comorbidities (52). Furthermore,
tients receive dialysis through an access; it can be a central ve- each HD treatment contributes to a loss of amino acids and
nous catheter (CVC), arteriovenous fistula (AVF), or a synthetic increased cytokines (42).
arteriovenous graft (AVG). While there can be options for self- There is a higher risk of hospitalization associated with in-
managed home HD, most patients choose an in-center treat- creasing HD vintage, and this causes great concern (12). A typ-
ment, at a frequency of three times a week with an average du- ical HD patient spends an average of 11.1 d per year in
ration of 4 h. Patients must adhere to strict fluid and dietary hospital (45). When discharged, it is reported that HD patients
guidelines to protect their cardiovascular systems, bones, and have a 37% chance of being readmitted to the hospital within
muscle mass. Furthermore, HD patients have documented chal- 1 month (45). Lengthy hospitalizations induce muscle wasting,
lenges with physical function, and over the last decade, there has which when added to the estimated 4 to 6 wk per year of im-
been a shift toward the need for more exercise interventions for mobilization for HD treatments, contributes to an even greater
this population, especially during dialysis treatments. decline of physical function in these patients.
Increasing activity levels is a promising solution to combat
THE TYPICAL HD PATIENT muscle wastage and associated decreased physical function in
Much has been published on the multiple comorbidities HD patients. Exercise training can be delivered as either an
and poor physical function experienced by HD patients (22, extradialytic (outside dialysis treatments) or an intradialytic
(during dialysis) option. Reports have shown that although
Southern Alberta Renal Program, Alberta Health Services, Calgary, AB, CANADA extradialytic exercise may produce larger benefits in terms of
Address for correspondence: Kristen Parker MKin, CEP, CSCS, MES, Southern exercise capacity and functional ability, compliance is lower
Alberta Renal Program, Alberta Health Services, 3103 31 Sunpark Plaza SE, when compared with intradialytic interventions (25,34). There-
Calgary, AB T2X 3W5, Canada (E-mail: kristen.parker@ahs.ca). fore, intradialytic exercise, typically done during the first 2 h of
This article originally appeared in Curr. Sports Med. Rep. 2016; 15(4):269275. HD treatment, is a sensible nonpharmacological medicine for
2379-2868/0110/9096
HD patients. The most popular example of intradialytic exer-
Translational Journal of the ACSM cise training involves placing a cycle ergometer in front of the
Copyright 2016 by the American College of Sports Medicine treatment chair, or at the foot of a bed (17). Alternatively, other

90 Volume 1 Number 10 August 15 2016 Intradialytic Exercise is Medicine for Hemodialysis Patients

Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
novel treatments include resistance training (4), Zumba (3),
guided meditation with stretching (31), or yoga (5).
BENEFITS OF INTRADIALYTIC EXERCISE
More than 30 years of intradialytic exercise research has
been completed, including six systematic reviews, which have
attempted to synthesize the evidence from randomized con-
trolled trials (10,18,26,46,47,49).
In addition to these six reviews, other reports have shown
favorable changes in V O2peak (53), HR variability (27), arterial
stiffness (55), and blood pressure (BP) (30). A review on car-
diovascular changes reported increases of 12% to 24% in
V O2peak with exercise prescriptions of low to moderate inten-
sity (40). Research by Sietsema et al. (48) revealed a distinct
survival advantage for those with V O2peak values of greater
than 17.5 mLkg1min1. It also is suggested that longer exer-
cise interventions (>6 months) are required for the most favor-
able increases in V O2peak (47).
Enhancements to muscle size (21), strength (9), and power
(53) also are assets in the maintenance of activities of daily liv-
ing in HD patients. While the majority of resistance training
studies in the literature utilized strength training equipment
(Therabands, dumbbells, ankle weights, body weight, etc.),
the study by Storer et al. (53) reported increased muscle strength,
power, and fatigability as a result of 9 wk of cycling at 50% of
peak work rate for 20 to 40 min three times a week. This im-
provement in muscle power while using a cardiovascular mode
of exercise may be due to the significant muscle weakness al-
ready experienced by the subjects.
Interestingly, studies have demonstrated improvements in
dialysis adequacy when exercise is performed concurrently
with dialysis treatments (24,41). The findings in these studies
suggest that intradialytic cycling can increase perfusion to the
working leg muscles. This moves the trapped urea (and other
toxins) from the muscle compartments to the blood stream
for removal during HD. It has been suggested that 1 h of aero-
bic exercise could be comparable with an additional 20 min of
dialysis time; however, further study on this is warranted (24).
Furthermore, research findings show improvements in fa-
tigue levels (31), depression (27), quality of life (36), sleep (56),
restless legs (16), inflammation (1), and hospitalization rates
(39). While there is a lot of variability to methodologies and typ-
ically poor power with small subject groups, the overall consensus
in the literature seems to point toward the idea that something
is better than nothing. A future shift toward larger, multicenter
trials with precise exercise intensities and durations will en-
hance the robustness of the evidence on intradialytic exercise.
BARRIERS TO IMPLEMENTATION
Despite the potential benefits and several guidelines calling
for increased activity for dialysis patients, there are still few on-
going intradialytic exercise programs operating as a standard of
care. This captive audience provides a unique opportunity to
combine exercise therapy with a medical treatment in a safe,
time-efficient, and highly monitored environment. The Dialysis
Outcomes and Practice Patterns Study (DOPPS) survey exam-
ined dialysis outcomes in 12 countries and reported Germany,
Sweden, Australia/New Zealand, and Canada to have the
highest number of intradialytic exercise programs (54). While
Canada is reported to be among the top 5 countries for deliv-
ering intradialytic exercise as surveyed during the DOPPS trial,
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this must be interpreted with caution. Ma et al. (28) found
only four ongoing intradialytic exercise programs existed in
the 58 facilities that responded to a survey in the province of
Ontario. The DOPPS study determined that intradialytic exer-
cise occurred in <20% of the U.S. and UK locations surveyed.
There is a great need to identify and address the barriers to im-
plementation to increase the provision of intradialytic exercise.
Funding concerns, staff workload, and lack of equipment
have been cited as major barriers to implementing intradialytic
exercise programs (28,57). Other concerns include nephrolo-
gists perceptions about safety (13) and inadequate knowledge
on the subject of exercise (49). Interestingly, Delgado and Johansen
(13) surveyed 198 nephrologists and found 100% believed
physical activity was important for their patients; however,
35% did not think their patients would be open to a discussion
on exercise. Ironically, in a study by the same authors 2 years
later, only 4% of HD patients stated they were not interested
in the topic. A strong belief in exercise importance was expressed
by these patients, with 93% reporting that they would probably
do more if their doctor or a health care professional guided
them in taking this medicine (14). It is suggested that under-
standing may be improved by changes to the curriculum during
medical school and through establishing closer communications
with physiotherapists or kinesiologists in the HD setting (49).
Regardless, the literature suggests that the greatest challenges
lie within staff perceptions and not necessarily with the patients
opinions of exercise. Once programming is implemented, many
patients may consider intradialytic exercise to be a welcome dis-
traction that enhances their overall feelings of self-efficacy and
their ability to be active players in their own health care.
CURRENT RECOMMENDATIONS FOR THE DELIVERY OF
INTRADIALYTIC EXERCISE
The National Kidney Foundation encourages >30 min of
moderate-intensity exercise for HD patients most days of the
week if possible (33). Currently, there are extradialytic exercise
recommendations for chronic kidney disease (CKD) and
ESKD patients (2,38,51). Although no consensus on guidelines
have been established for intradialytic exercise, some authors
who have put forth recommendations to encourage a stronger
exercise presence within HD units (17,51).
In the following section, an example of a successful, ongoing
program in the Canadian province of Alberta will be used to de-
scribe a pragmatic mode of delivery of intradialytic cycling. It
also is acknowledged that future study on the tests and prescrip-
tion used in this setting is needed for further validation.
SPECIFIC DETAILS ON THE INTRADIALYTIC EXERCISE PROGRAM
AT THE SOUTHERN ALBERTA RENAL PROGRAM
The Southern Alberta Renal Program (SARP) provides
intradialytic cycling at five HD units (and one pediatric unit)
in the city of Calgary and in six rural communities. Also of-
fered is an extradialytic exercise program, called KEEP (Kid-
ney Exercise and Education Program), for patients with any
stage of kidney disease (including patients who had a kidney
transplant) to attend free of charge each week with a spouse
or caregiver.
Policies and procedures for the program have been created
and refined, based on current research and best practices from
around the world. Internet technology staff has developed spe-
cific areas for charting exercise prescriptions in the patient
Translational Journal of the ACSM 91
database. The renal unit staff records exercise times, vitals, and
notes in the dialysis recording sheet during each treatment.
Two full-time kinesiologists work to help create a culture of
exercise at the Calgary dialysis units, while exercise cham-
pion nurses oversee the intradialytic exercise at the rural sites.
The kinesiologists do weekly rounds to follow up with each
patient once a week. The kinesiologists are responsible for
new patient assessments, obtaining clearance from doctors, fall
prevention assessments, staff inservices, patient referrals, and
postrehabilitation exercise prescriptions. Most importantly,
the kinesiologist encourages and motivates the patients to cycle
during each HD treatment if safe to do so.
On days when the kinesiologist is not on site, the nurses and
nurse aids assist the patients with cycling. This invaluable assis-
tance from the nursing staff is encouraged through managerial
support and a redefinition of staff roles. Staff job descriptions
have been changed to include exercise-related duties. The staff
also must be trained on safe progression of exercise and ways
to prevent (or manage) adverse effects if they occur (i.e., hypo-
tension postexercise). Support from nephrologists and nursing
colleagues has been reinforced through ongoing education sem-
inars, research studies, patient testimonials, exercise contests,
and fundraising challenges in collaboration with the local
branch of the Kidney Foundation.
RECOMMENDATIONS FROM SARPs INTRADIALYTIC
EXERCISE PROGRAM
As there is still a need for further research before a con-
sensus regarding the guidelines for intradialytic exercise can
be reached, the following SARP recommendations may aid in
the delivery of intradialytic exercise on HD units:
1. All patients new to the HD unit should be assessed
by the kinesiologist, physiotherapist, or exercise
champion for exercise safety. A thorough medical
history must be done, which covers the following:
comorbidities and etiology of ESKD, all relevant
blood work, medications, cardiac history, bone
health, symptoms (angina, shortness of breath, or
pain), past surgeries, injuries, hospitalizations, falls
history, past/current exercise habits, current living
situation, ambulation aids, and ability to do activ-
ities of daily living.
2. Patients should be excluded from exercise (or may
require further assessment from a doctor) if they
have any of the following:
a. Unstable cardiac status (angina, decompensated
congestive heart failure, severe arteriovenous ste-
nosis, uncontrolled arrhythmias, etc.)
b. Physical limitations that would affect usage of
the bike
c. Poor blood sugar control
d. Active infection or illness
e. Poorly functioning CVC or AVF/AVG
3. Baseline, 1-month, and 6-month outcome measures
are recommended for patient motivation and pro-
gram efficacy. The following list of assessments
can be performed efficiently and briefly in the
92 Volume 1 Number 10 August 15 2016
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
waiting area before patients are brought to their
dialysis chair. Lengthy protocols such as the 6-min
walk test and the incremental shuttle walk test, al-
though necessary in research studies, prove to be
difficult to achieve in the health care setting. Most
patients arrive shortly before their scheduled dialy-
sis appointment, and the nursing staff work on
strict timelines in which to set up patients.
4. SARP has chosen a simple battery of the following
tests based on valid research and the ease of use:
a. A 30-s sit-to-stand test or STS-30 provides rele-
vant data and ensures all mobile patients, regard-
less of physical function, can complete this test
with a score (44). Many older HD patients find
it difficult to perform just one or two sit-to-stands,
making fixed-rep tests, such as the STS-5 or STS-
10, unfeasible.
b. Grip strength has been chosen in the SARP pro-
gram as it has a high correlation with mortality
risk in HD patients and is easy to administer with
a dynamometer (29).
c. A self-administered Duke Activity Status Index
questionnaire can be done to efficiently predict
V O2peak (19) and has proven validity within
CKD patients (43).
d. If time permits, a simple 8-ft up-and-go or bal-
ance test is recommended to assess balance and
falls risk (Table 1).
5. Daily assessment for exercise safety can be done by
a physiotherapist or kinesiologist. It also can be
completed as part of the initial predialysis assess-
ment by a nurse. The following preexercise criteria
should be met before exercise is granted:
a. Targeted ultrafiltration rate (UFR) <13 mLh1kg1
(see footnote*)
b. BP <180/100 or >100/50 mm Hg
c. Resting HR <100 bpm
d. No hospitalization or illness within the last week
e. Properly functioning CVC or adequate needling
of AVF or AVG
f. No abnormal symptoms (cold, flu, headaches,
dizziness, nausea, etc.)
g. No hemoglobin <90 gL1 or 9 gdL1. (The Na-
tional Kidney Foundation Kidney Disease Out-
comes Quality Initiative guidelines for optimal
hemoglobin are 11 to 12 gdL1; however, some
units around the world have different recom-
mended ranges. Patients with more complex
*Targeted ultrafiltration rate (UFR): As most patients on dialysis have a dry
weight or targetweight, anyweight gain between dialysis treatments is consid-
ered to be fluid the kidneys no longer excrete. This fluid gain is a significant factor
in determining safety of exercise and blood pressure stability each treatment. In
the past, patients were assessed based on an absolute cut-off (such as 94 kg of
fluid), however, taking the duration of dialysis and the patient s dry weight into
consideration results in a more individualized value for assessing safety of exer-
cise. This targeted UFR is a determining factor in all exercise approval each
day in the SARP program (15).
Intradialytic Exercise is Medicine for Hemodialysis Patients
TABLE 1.
Current Intradialytic Exercise Recommendations.
Mode Exercise Plan Outline
Aerobic exercise During the first 2 h of dialysis (three times
a week)
55% to 70% of maximum HR or a
moderate RPE.
Patients are encouraged to progress
toward a goal of 30 to 40 min (with a
maximum of 180 min).
The most popular mode is with a cycle
ergometer placed in front of the chair
or at the foot of the bed
Monitor HR, BP, RPE, and symptoms
Resistance Two sessions per week.
training
One to two sets of 12 to 15 repetitions
(or 60% to 70% repetition maximum)
Use Therabands, dumbbells, body
weight, weight cuffs, etc.
Resistance training is possible during
dialysis and can include the nonfistula
arm (or both if the patient has a
well-functioning CVC).
Flexibility 5 to 7 dwk1
Hold stretch to light tension for 20
to 30 s
10-min total body routine
Balance Encourage both static and dynamic
balance exercises most days of the
week in those at risk for falls.
Based on the recommendations by the American College of Sports Med-
icine (2), Smart et al. (50), and Greenwood et al. (17).
cardiac histories may need to be put on hold un-
til their hemoglobin improves.)
h. Blood sugars are controlled (between 7 and
14 mmol or 126 and 252 mgdL1)
i. Oxygen saturation levels at rest should be above
90% and remain above 88% during exercise
without symptoms
6. If patients meet safety criteria, the staff can bring a
pedal bike in front of their chair to use within the
first 2 h of the dialysis treatment. All new partici-
pants start with a perceived exertion of easy on
the Borg Scale of Perceived Exertion (7). During
the initial 5- to 10-min bike trial, patients are given
an orientation on safety, gradual progression, and
proper warm-up/cool down procedures. At SARP,
patients are not encouraged to take rest breaks
during the course of their exercise session, as this
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may contribute to an increased risk of intradialytic
hypotension. They simply train with shorter dura-
tions and progress gradually as they are able to.
7. Participants self-progress their exercise duration
by 2 to 5 min per session with the goal of achieving
at least 30 min of exercise during each dialysis ses-
sion. Many patients can continue to increase their
duration beyond 30 min. After the easy 5-min
warm-up, a moderate to somewhat hard pace
is encouraged. A 2- to 5-min cool down at an
easy pace is essential for adequate redistribution
of blood volume and the prevention of a hypotensive
event. Vitals are measured preexercise, midexercise,
and again 2 min postexercise.
8. Preexercise, midexercise, and postexercise oxygen
saturation values are taken in all patients, and
blood glucose levels are monitored preexercise and
postexercise in diabetics. Adverse events are rare
and are categorized as minor in nature (cramps,
mild hypotension, muscle soreness, etc.). No serious
cardiac events or hospitalizations have resulted
from any of the 50,000+ exercise sessions in SARP
since 2009.
9. The SARP program has 36 pedal bikes (Monark
Rehab Trainer 881E; Monark Exercise AB, Vansbro,
Sweden) averaging about five to six bikes per unit.
Smaller units operate with two to three bikes. Each
bike has a small piece of yoga mat placed underneath
it to prevent slippage of the bike. Also, plastic plat-
form pedals with a heel cup have been custom de-
signed and are affixed to the existing pedals with a
Velcro strap across the top of the patients foot. This
allows for easier set-up for the staff when placing pa-
tients feet on the pedals and is helpful for those who
have neuropathy, hemiparesis, or significant weak-
ness. The Monark 881E trainer has proven easy to
maneuver for the staff and can be stored easily, fur-
ther enhancing the compliance of the unit staff.
Other units employing similar programs have used
a variety of bikes to meet the needs of their patients
and staff. This is an important factor in a successful
program.
10. While there is published literature on incorporat-
ing resistance and flexibility training into the dial-
ysis unit (4,51), this may not be easy to accomplish
if patients have CVC or AVF/AVG issues. Patients
in SARP are provided with Therabands and do sim-
ple strength, flexibility, and balance exercises for
large muscle groups (4,37). They receive customized
prescriptions for specific conditions, musculoskele-
tal imbalances, or rehabilitation of past injuries.
11. Special considerations:
a. While many intradialytic exercise studies require
stress testing prior to commencing, this is highly
challenging and costly to do with a pragmatic
program. The patients may perceive this as a
Translational Journal of the ACSM 93
 barrier, and furthermore, due to poor physical fit-
ness, many would be unable to achieve a true
maximal effort. In rare circumstances, those with
cardiac symptoms or complicated cardiac histo-
ries are sent for stress testing to ensure safety dur-
ing exercise. As a testament to reduced aerobic
capabilities in HD patients, Storer et al. (53) noted
that none of their subjects were able to tolerate the
50% of peak work rate on a cycle ergometer;
therefore, this had to be adjusted to a lower load
(30%) to enable the patients to participate.
b. The Borg scale is highly recommended for moni-
toring exercise intensity because HD patients
commonly take beta-blockers and also may have
fluctuations with their day-to-day fluid gains, en-
ergy levels, and symptoms.
c. If a patient misses their previous HD treatment,
no exercise is permitted. Missing treatments can
cause symptoms of fluid overload such as short-
ness of breath, edema, and hyperkalemia.
d. Patients with a history of hyperkalemia or hypo-
kalemia may require at least 30 min of HD to
lower the risk associated with these acute condi-
tions prior to commencing exercise.
e. Establishing the needling of a new AVF or AVG
should temporarily place the patient on hold
from intradialytic exercise until three consecutive
successful HD sessions have been achieved with
double needles (although this can be left to the dis-
cretion of the nursing staff in each case).
f. Due to fluid restrictions, HD patients who get
thirsty can be encouraged to suck on ice cubes to
help quench thirst as a solution for minimizing
water consumption.
g. As intradialytic hypotension is a potential risk
during HD, susceptible patients may need longer
cool-downs. Furthermore, all patients should have
their feet elevated on the footrest of the chair im-
mediately after the cessation of exercise.
h. The effects of intradialytic exercise on cramping
have not been studied; however, anecdotally, pa-
tients may experience relief from cramping as a
result of the increased blood flow to the leg mus-
cles and periphery. Biking should be encouraged
in those who tend to cramp during their treat-
ments, assuming they meet the criteria for safe
exercise, as it may prevent or reduce the severity
of cramping.
BALANCE TRAINING AND FALL PREVENTION
Within the SARP program, there is a strong emphasis
on fall prevention and the maintenance of activities of daily
living. Falls are especially of concern, since the risk of frac-
tures is greater due to renal osteodystrophy (11). The crea-
tion of a fall prevention program in 2012 has further
enhanced the quality of life for patients. A multidisciplinary
approach involves the following:
94 Volume 1 Number 10 August 15 2016
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1. Screening: Three questions are asked by the nurse
every 6 wk, which determine high-risk patients.
2. Detailed assessment: The kinesiologist or fall pre-
vention nurse conducts a detailed assessment on
high-risk patients. Based on scoring in a variety of
areas, an algorithm provides suggestions for risk
mitigation.
3. Risk mitigation: Patients receive education, symp-
tom management, exercises, as well as referrals for
podiatry, optometry, social work, nephrology, occu-
pational therapy, registered dieticians, physiotherapy/
kinesiology, or pharmacy. This provides support for
the patient in an effort to maintain independence
and prevent future falls.
4. Fall reporting tool: The staff records details on re-
ported falls through a list of drop-down items on
the patient database. This provides nephrologists,
nurses, and health care workers with easy-to-access
data on causes of falls and program efficacy.
INTRADIALYTIC EXERCISE AS A POTENTIALLY COST-EFFECTIVE
STANDARD OF CARE
After years of research on the benefits and safety of
intradialytic exercise, a movement needs to occur toward ap-
plication. Success with such a program requires a deliberate
choice by policy makers and management to bring about a
whole-team approach to exercise. While many excellent pro-
grams are nurse-led, an exercise professional may be instrumen-
tal in creating a culture of exercise within the dialysis unit,
and this person should not be considered a luxury but rather
a necessity and essential player in enhancing health care. Fur-
thermore, encouraging better self-management for high-risk pa-
tients may result in a reduced burden to overwhelmed health
care systems (39). In the United States, HD patients make up a
very small percentage of the patient population (1%), but they
contribute a staggering cost (7%) to Medicare (45). In 2013,
ESKD cost the U.S. government $30.9 billion (45). The cost bur-
den also is acknowledged in Canada and other nations (23).
More research is needed to establish both clinical and cost-
effectiveness of intradialytic exercise programs. Perhaps the
cost of hiring a physiotherapist or kinesiologist could be offset
when considering the potential for avoided health care costs
and improvements in patient quality of life.
CONCLUSION
Research on intradialytic exercise has proven to be ad-
vantageous for HD patients. These individuals must be treated
less like patients and be encouraged to take a more active
role in their health as they navigate the challenges associated
with ESKD. Medical and health professionals must overcome
barriers in an effort to support further enhancements in their
patients health and fitness. Well-planned, supervised intradialytic
exercise programming can be both safe and efficient, with
great potential for improved quality of life.
The author would like to thank Monica Kilburn-Smith and Dr.
Sharlene Greenwood for their support and editing talents. The staff
at SARP also must be commended for their innovation and commit-
ment in creating and maintaining an ongoing standard of care. A
Intradialytic Exercise is Medicine for Hemodialysis Patients
special thank you goes to Dr. Patricia Painter for her years of dedi-
cation to enhance the body of work on exercise for people with
chronic kidney disease.
The author declares no conflict of interest and does not have
any financial disclosures.
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Intradialytic Exercise is Medicine for Hemodialysis Patients