Original Paper – Advances in CKD 2017
Blood Purif 2017;43:235–243 Published online: January 24, 2017
DOI: 10.1159/000452751
Physical Activity and Sleep Patterns in
Hemodialysis Patients in a
Suburban Environment
Schantel Williams a Maggie Han a Xiaoling Ye a Hanjie Zhang a
Anna Meyring-Wösten a Marcee Bonner b Candace Young b Stephan Thijssen a
Daniel Marsh b Peter Kotanko a, c
a
Renal Research Institute, New York, NY, and b Renal Associates, Baton Rouge, LA, and c Icahn School of Medicine,
New York, NY, USA
Key Words
Pervasive sensing · Activity pattern · Sleep pattern · Activity
tracker · Hemodialysis ·
Abstract
Background/Aims: Hemodialysis (HD) patients are less ac-
tive than their healthy counterparts. They are often plagued
with sleep disorders that affect the quality of their sleep. Our
aim was to objectively quantify activity and sleep quality
among HD patients in a suburban HD population. Methods:
Activity and sleep parameters were measured using a com-
mercially available activity tracker in 29 HD patients from
Baton Rouge, LA, USA. Patients in the feedback group re-
ceived their activity and sleep data at each dialysis treat-
ment. In addition, questionnaires were administered at the
beginning and end of the study period. Patients were strati-
fied based on activity levels and sleep quality. Results: Pa-
tients walked an average of 5,281 steps/day and slept 370.5
min/night. Informing patients about their daily number of
steps taken, did not increase activity. Only 3% of the popula-
tion followed were active, defined as walking more than
10,000 steps per day. Patients walked significantly less on
dialysis days compared to the other days of the week. Many
of the patients experienced poor sleep quality, with patients
© 2017 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/bpu
in the first shift experiencing the greatest disturbance to
their sleep/wake cycle. Conclusion: Patients in a suburban
environment walked much less than those in a previously
studied urban population. They rarely met the recommend-
ed goal of 10,000 steps/day, even on non-dialysis days. Inter-
ventions to increase physical activity may target any day of
the week, particularly HD days. Prospective, long-term stud-
ies are needed to evaluate the use of activity trackers in di-
alysis patients and their impact on physical activity.
© 2017 S. Karger AG, Basel
Introduction
It has been shown that hemodialysis (HD) patients are
less active than their healthy counterparts [1]. Living a
sedentary lifestyle is associated with poor health out-
comes. In an observational study conducted using the
National Health and Nutrition Examination Survey by
Beddhu et al. [2], it was found that taking part even in a
low-intensity activity, for example, walking, had a posi-
tive impact on survival. It is important to learn more
about the physical activity of patients on HD. The effect
of interventions on lifestyle to improve outcomes and
quality of life may be determined only when an objective
Peter Kotanko, MD
Renal Research Institute
315 East 62nd St.
New York, NY 10065 (USA)
E-Mail peter.kotanko @ rriny.com
measure of patients’ activity outside of the health care
provider’s purview is available [3]. Traditionally, physi-
cians are dependent on subjective patient reports during
their time away from the dialysis clinic. In recent years,
the availability and adoption of wearable activity trackers
have increased. Having patients use commercially avail-
able activity trackers provides an objective measurement
of how active they are in free-living conditions. These
activity trackers have been validated against the gold
standard of physical activity measurement, the Actigraph,
a triaxle accelerometer [4]. In addition, commercially
available activity trackers are easily available, easy to use,
and inexpensive [5].
In the study by Han et al. [6], which evaluated the in-
terdialytic activity of HD patients, it was found that di-
alysis patients walked on average 8,454 steps with no dif-
ference in physical activity levels on dialysis and non-di-
alysis days. The authors also found that patients on HD
had irregular sleep habits and this was more prominent
in patients on earlier dialysis shifts. The population stud-
ied by Han et al. [6] lived in an urban area: New York City.
These patients may be unique and different from those
living in suburban areas and it is important to determine
if the activity levels exhibited are characteristic of other
HD populations.
The objectives of this study were to (1) assess physical
activity levels and sleep of HD patients living in a subur-
ban environment and (2) determine if providing feed-
back on activity during dialysis treatments will have an
impact on physical activity levels.
Methods
Study Design
The activity and sleep data of 29 chronic HD patients were col-
lected using the Fitbit® FlexTM (Fitbit, San Francisco, CA, USA)
device over a course of 5 weeks. Participants were randomly as-
signed to 2 groups after enrollment. The ‘feedback’ group (n = 15)
received a report of activity and sleep data in the week leading to
the date of each HD treatment, while the control group (n = 14)
did not. The human activity profile (HAP) and a questionnaire on
patient experience using the device and attitude toward physical
activity were administered at the beginning and end of the study
period. The study was approved by Western IRB (protocol No.
20152105).
Setting
HD patients treated in 2 out-patient facilities located in Baton
Rouge, LA of the Fresenius Kidney Care, were recruited to par-
ticipate in this study. Patient recruitment occurred on a rolling
basis from February 2016 to August 2016. Baton Rouge is a city
located on the Mississippi River, with a population of approxi-
mately 440,000 residents.
236 Blood Purif 2017;43:235–243
DOI: 10.1159/000452751
Participants
Patients were eligible to participate if they were receiving HD
3 times a week, on HD for more than 3 months, and between 18
and 75 years. Patients were required to have the ability to walk
without assistance or assistive devices to ensure that the device is
able to track activity. Patients were excluded if they had unstable
health (e.g. acute infections, congestive heart failure (CHF) NYHA
class 4 and/or unstable angina), were hospitalized within 3 months
before enrollment for non-access-related reasons, or were cogni-
tively impaired. The clasp of the device contains trace amounts of
nickel, so patients with a known nickel allergy were ineligible to
participate. Additionally, patients who had previously worn activ-
ity tracking devices were excluded, so the total effect of providing
feedback could be observed.
Thirty one participants were enrolled in the study. Two of them
died during the study period; their data were not included in the
analysis.
Physical Activity and Sleep
All participants were equipped with the Fitbit® FlexTM tracking
bracelet and were instructed to wear the bracelet at all times, even
during activities like bathing, as it is waterproof. The Fitbit® FlexTM
tracks activity parameters (steps taken, distance traveled) and sleep
duration and quality (minutes asleep, total time in bed). A Fitbit®
user account was created and the device was configured for each
subject’s age, height, weight and gender. Patients did not have ac-
cess to their accounts. The device was worn on the non-vascular
access arm, with the device settings configured to reflect if this was
the dominant or nondominant hand. Data were downloaded from
the device to the user account during each HD treatment. Partici-
pants were asked to keep a daily sleep log, in which they recorded
the times they went to bed and the times they woke up. Sleep start
and end times were entered into the user account by the research
coordinators in order to calculate sleep duration and quality. The
devices were charged during each HD treatment. Activity and
sleep data were exported via Fitbit® Premium for analysis.
Based on their average daily step counts, participants were sep-
arated into 3 categories. Participants were considered sedentary,
fairly active, or active if they walked less than 5,000 steps, between
5,000 and 10,000 steps, or more than 10,000 steps, respectively [7].
The National Institute of Health (NIH) recommends at least
7 h (420 min) of sleep per night [8]. Sleep efficiency (in %) was
calculated as 100 times the ratio of sleep duration to total time in
bed. A sleep efficiency of 85% or above is considered sleep of good
quality [9]. Based on sleep duration and sleep efficiency, patients
were categorized into 3 groups: poor, intermediate, and good sleep
quality. Patients who slept <420 min with a sleep efficiency of
<85% were considered to have poor sleep quality. Patients who
slept ≥420 min with a sleep efficiency of <85% or slept <420 min
with a sleep efficiency of ≥85% were considered to have intermedi-
ate sleep quality. Patients who slept ≥420 min with a sleep effi-
ciency of ≥85% were considered to have good sleep quality.
Questionnaires
The Physical Activity Questionnaire was developed to capture
subject attitudes toward their physical activity, and was adminis-
tered at the end of the study period. Statements such as ‘I was able
to incorporate this device into my daily activities’ and ‘I desire to
continue wearing this device to track my own activity’ were que-
ried of the patients.
Williams  et al.
 Laboratory Test
Laboratory measurements were done at Spectra Laboratories
(New Jersey, USA). For study purposes, clinical and laboratory
data were manually obtained from the participants’ electronic
health record. In addition to collecting test results from routine
monthly blood tests, pre-albumin and C-reactive protein (CRP)
were also tested. Blood samples were collected before the start of a
mid-week dialysis session.
Statistical Analysis
Baseline (first week in the study) demographics, anthropomet-
rics, comorbidities, treatment-related parameters, activity param-
eters and sleep parameters were described by mean and SD for
continuous variables and frequency distribution for categorical
variables. T tests was used to test the statistical significance of the
difference between the feedback and control groups for continu-
ous variables; Fisher’s exact test was used for categorical variables.
Paired t tests were also performed to test the differences among the
daily average steps on HD days, non-HD days, and Sundays. Sun-
days were excluded from non-HD days.
In order to assess the effect of HD scheduling on sleep quality,
we also performed paired t tests to compare the sleep duration and
sleep efficiency between the night after HD treatment and the
night before HD treatment, night after HD treatment and night
between 2 non-HD days, and night before HD treatment and night
between 2 non-HD days per shift.
Statistical analysis was performed with SAS version 9.4 and
Rx64 3.2.0.
Results
Demographics, anthropometrics, treatment-related pa-
rameters and laboratory parameters are presented in ta-
ble 1. On average, participants were 52 years, with a body
mass index (BMI) of 33.7 kg/m2, and 167 cm tall. The study
cohort comprised of 41.4% male and 72.4% black; 58.6% of
the participants were diabetic and 17.2% had CHF. Aver-
age HD treatment time was 238 min with an average eKt/V
of 1.5, and dialysis vintage was 4.0 years. Average levels of
pre-albumin, serum albumin, CRP and hemoglobin were
30.0 mg/dl, 3.9 g/dl, 15.6 mg/l, and 11.0 g/dl, respectively.
Patients received treatments at the HD clinic during
3 different shifts, namely, shift 1 from 6 a.m. to 10 a.m.,
and shift 2 from 10 a.m. to 2 p.m., shift 3 from 2 p.m. to
6 p.m. Many of the patients enrolled were scheduled to
receive HD treatments on the first shift (n = 21). The re-
maining patients who scheduled to receive HD treat-
ments during shifts 2 and 3 were 5 and 3, respectively.
Sleep
On average, patients slept 370.5 min and had a sleep
efficiency score of 83.3%. The patients were categorized to
have had poor, intermediate and good sleep quality. Good
sleep quality meant they had a sleep efficiency of 85% or
Interdialytic Activity Monitoring –
Suburban Environment
greater and slept at least 420 min or more; poor sleep qual-
ity meant that they had a sleep efficiency of less than 85%
and did not sleep for at least 420 min. The intermediate
sleep group was able to fulfill either sleep duration or sleep
efficiency criteria [8, 9]. Forty-five percent (n = 11) had
poor sleep, 38% (n = 13) had intermediate sleep quality
and 17% (n = 5) had good sleep quality (fig. 1).
There was no significant difference in sleep efficiency
with regard to the different shifts, but there was a differ-
ence in sleep duration in relation to shift. As shown in
table  2, there was a significant difference between the
number of minutes slept the night before an HD treat-
ment and the night after HD treatment for those patients
dialyzed on the first shift (284 vs. 420 min, p < 0.0001), as
well as, the night between 2 non-HD days (284 vs. 414
min, p < 0.001). For patients on shifts 2 and 3, there was
no significant difference in sleep duration or sleep effi-
ciency between the night before HD treatment and the
night after HD treatment (fig. 2A, B).
Physical Activity
On average, patients walked 5,291 steps each day.
There was no difference in the number of steps walked by
the feedback vs. the control group. For the purpose of our
analysis, all data acquired during the study were pooled.
Based on Centers for Disease Control and Prevention
(CDC) physical activity recommendations, patients were
stratified by the activity level with 45% (n = 13) classified
as sedentary, 52% (n = 15) as fairly active and 3% (n = 1)
as active [7] (fig. 3).
There was a significant difference in the number of
steps taken on dialysis days and non-dialysis days (p <
0.05). On average, patients walked 1,822 steps less on di-
alysis days compared to non-dialysis days. There was no
significant difference between the number of steps taken
on dialysis days and Sundays. When categorized by activ-
ity level, it was shown that there was no difference in the
number of steps taken by an active patient on any day of
the week. The fairly active group is driving the difference
we see between non-dialysis days, dialysis days and Sun-
days. In this group, there is no difference in the number
of steps taken on dialysis days and Sundays, but there is a
significant difference between dialysis days and non-dial-
ysis days (p < 0.05). The sedentary group took significant-
ly less steps on HD days vs. non-dialysis days (fig. 4A–D).
Physical Activity Questionnaire
At the end of the 5-week study period, participants
were given a questionnaire to determine how well they
liked the device. They were asked as to how much they
Blood Purif 2017;43:235–243 237
DOI: 10.1159/000452751
Table 1. Characteristics of the entire study population, feedback group, and control group

Variable All, mean (SD) Feedback, mean (SD) Control, mean (SD) Δ (Feedback – Control),
95% CI

Patients, n 29 15 14
Demographics
Age, years 52 (14) 56 (13) 48 (15) 8 (–2 to 19)
Race, black, % 72.4 66.7 78.6 –11.9 (–45.7 to 22.4)
Male, % 41.4 60 21.4 38.6 (4.3 to 72.4)
Anthropometrics
BMI, kg/m2 33.7 (12.3) 32.7 (9.1) 34.7 (8.9) –2.0 (–8.8 to 4.9)
Height, cm 167 (10) 167 (9) 167 (11) 0 (–7 to 7)
Diabetic, % 58.6 60 57.1 2.9 (–31.9 to 37.6)
CHF, % 17.2 20 14.3 5.7 (–21.9 to 32.6)
Treatment-related parameters
HD vintage, years 4.9 (3.1) 4.4 (3.2) 3.4 (3.0) 1.3 (–1.3 to 3.4)
eKt/V 1.5 (0.2) 1.5 (0.2) 1.5 (0.3) 0 (–0.2 to 0.1)
Post-HD body weight, kg 93.5 (23.9) 90.6 (22.5) 96.7 (5.8) –6.1 (–24.5 to 12.3)
IDWG, kg 2.4 (2.1) 2.7 (1.4) 2.0 (2.8) 0.7 (–1.0 to 2.3)
HD treatment time, min 238 (26) 243 (24) 232 (29) 11 (–10 to 31)
Pre-SBP, mm Hg 148.9 (19.0) 139.2 (17.8) 159.1 (14.7) –19.9 (–32.4 to –7.4)*
Post-SBP, mm Hg 135.7 (20.5) 132.3 (19.7) 139.4 (21.4) –7.1 (–22.8 to 8.5)
Pre-DBP, mm Hg 78.7 (11.4) 74.8 (12.1) 83.0 (9.2) –8.2 (–8.2 to –16.5)
Post-DBP, mm Hg 71.6 (11.2) 69.8 (11.0) 73.6 (11.4) –3.8 (–3.7 to –12.2)
Laboratory parameters
CRP, mg/l 15.6 (12) 14.4 (7.4) 13.1 (6.0) 1.2 (–8.3 to 10.8)
Pre-albumin, mg/dl 30.0 (7.9) 31.6 (9.0) 28.5 (6.8) 3.1 (–3.8 to 10.0)
Serum albumin, g/dl 3.9 (0.3) 3.9 (0.3) 4.0 (0.4) –0.1 (–0.4 to 0.1)
Hemoglobin, g/dl 11.0 (1.3) 11.2 (1.4) 10.8 (1.3) 0.4 (–0.7 to 1.4)
Activity parameters
Steps 5,291 (2,338) 5,365 (2,765) 5,211 (2,010) 154 (–1,699 to 2,008)
Distance, km 2.3 (1.0) 2.3 (1.2) 2.2 (0.8) 0.1 (–0.6 to 0.9)
Sleep parameters
Sleep duration, min 370.5 (76.2) 389.9 (69.6) 349.8 (80.0) 40.1 (–16.9 to 97.2)
Sleep efficiency, % 83.3 (6.5) 86.1 (4.6) 80.3 (7.1) 5.7 (0.0 to 0.0)*

IDWG = Interdialytic weight gain; SBP = systolic blood pressure; DBP = diastolic blood pressure.
* p < 0.05.

agreed with the statements on the questionnaire. They
could rank their level of agreement in 5 categories: ‘not at
all’, ‘somewhat’, ‘moderately’, ‘definitely’, or ‘most defi-
nitely’. Over 90% stated they were able to incorporate the
device into their daily activities. More than half the pa-
tients felt that they did walk more than usual during the
study period and felt that they wanted to continue wear-
ing the activity tracker (table 3).
Discussion
The main findings of our study were that the dialysis
patients living in a suburban environment walked less
than the recommended 10,000 steps per day and often
walked significantly less on dialysis days compared to
non-dialysis days. This is consistent with the literature
indicating that dialysis patients are not as active as the
general population [1, 10]. In addition, 83% of the pa-
tients followed were found to have poor or intermediate
sleep quality, confirming findings from previous reports
[11].
A majority of the patients slept less than the NIH rec-
ommended 420 min and had a sleep efficiency of less than
85%. A systematic review by Fonesca et al. [12] found that
50–80% of HD patients suffered from sleep-disordered
breathing. There is also a high rate of periodic limb move-
ment disorder and restless leg syndrome. Any of these
sleep disorders can contribute to poor sleep quality in di-
alysis patients.

238 Blood Purif 2017;43:235–243 Williams  et al.

 

DOI: 10.1159/000452751
 3 Sex
76% 24% F M

Patients (n)
2
Sleep quality
1 Poor
Intermediate
0 Good

95
48%
38% 17%
90

85

Sleep efficiency (%)

80

75
45%
70 52%
Fig. 1. Scatter histogram of average sleep 65
efficiency and sleep duration of entire co-
hort (n = 29). Sleep efficiency (%) = (sleep 60
duration/total time in bed)*100. NIH rec-
180 240 300 360 420 480 0 1 2 3
ommendation of 420 min/day is indicated
[8]. Sleep efficiency <85% is considered Sleep duration (min) Patients (n)
poor sleep [9].

Table 2. Daily average sleep duration and sleep efficiency; 95% CI

Shift N Night after Night before Night between Δ Lower Upper p value
HD treatment HD treatment 2 non-HD limit limit
(HD) (non-HD) days (other) of Δ of Δ

Sleep duration, min

1 21 420 284 414 HD vs. non-HD 136 103.4 169.3 <0.0001
HD vs. other 6 –20.7 32.9 0.6389
Non-HD vs. other –130 –158.3 –102.1 <0.0001
2 5 417 356 418 HD vs. non-HD 61.0 –3.4 125.3 0.0581
HD vs. other –1.0 –69.3 67.4 0.971
Non-HD vs. other –61.9 –179.3 55.5 0.217
3 3 391 397 418 HD vs. non-HD –6.6 –131.3 118.2 0.8421
HD vs. other –27.4 –109.9 55.1 0.289
Non-HD vs. other –20.8 –218.2 176.5 0.6941
Sleep efficiency, %
1 21 83 83 84 HD vs. non-HD 0 –2.53 1.96 0.7919
HD vs. other –1 –3.51 0.45 0.1225
Non-HD vs. other –1 –3.44 0.96 0.2529
2 5 83 84 83 HD vs. non-HD –1 –2.76 1.46 0.44
HD vs. other 0 –2.79 3.76 0.7018
Non-HD vs. other 1 –2.43 4.70 0.4257
3 3 82 86 81 HD vs. non-HD –4 –12.71 5.44 0.2266
HD vs. other 1 –14.01 15.27 0.87
Non-HD vs. other 4 –3.79 12.33 0.1503

Interdialytic Activity Monitoring – Blood Purif 2017;43:235–243 239

Suburban Environment DOI: 10.1159/000452751
 A Shift 1 Shift 2
Average daily minutes

Average daily minutes

600 600
asleep

asleep
400 400

200 200

0 0
Night after Night before Night between 2 Night after Night before Night between 2
a HD HD non-HD days b HD HD non-HD days

Shift 3
Average daily minutes

600
asleep

400

200

0
Night after Night before Night between 2
c HD HD non-HD days

B Shift 1 Shift 2
1.00 1.00

0.75 0.75
Percent

Percent

0.50 0.50

0.25 0.25

0 0
Night after Night before Night between 2 Night after Night before Night between 2
a HD HD non-HD days b HD HD non-HD days

Shift 3
1.00

0.75
Percent

0.50

0.25

0
Night after Night before Night between 2
c HD HD non-HD days

Fig. 2. A Average daily minutes asleep of individuals separated by
shift. Treatment shifts are scheduled for the following times:
a shift 1 from 6 a.m. to 10 a.m.; b shift 2 from 10 a.m. to 2 p.m.;
c shift 3 from 2 p.m. to 6 p.m. * p < 0.05. Shift 1: on average, pa-
tients slept significantly less on nights before HD than on nights
after HD and nights between 2 non-HD days. Shifts 2 and 3: no
significant differences between nights were found not clinically.
B  Average daily sleep efficiencies separated by shift. Sleep effi-
ciency (%) = (minutes asleep/total time in bed)*100. Treatment
shifts are scheduled for the following times: a shift 1 from 6 a.m.
to 10 a.m.; b shift 2 from 10 a.m. to 2 p.m.; c shift 3 from 2 p.m. to
6 p.m. * p < 0.05.

Twenty-one of the 29 patients followed were dialyzed
on the first shift, between the hours of 6 a.m. and 10 a.m.
When the sleep patterns of these patients were evaluated,
there was a significant difference between the number of
minutes slept the night before dialysis compared to the
night after dialysis and the nights between 2 non-dialysis
days. This is consistent with previous findings from a
similar analysis by Han et al. [6]. The early start time of
HD treatment may contribute to the abnormal sleep pat-
terns observed, since patients need to wake up before

240 Blood Purif 2017;43:235–243 Williams  et al.

 

DOI: 10.1159/000452751

Activity level
Sedentary Fairly active Active
3
45% 52%
2 are less active than patients residing in an urban popu-
Count
1 design of neighborhoods, and access to amenities such
0
5,000 10,000
Average daily steps
Fig. 3. Histogram of average daily steps.
their scheduled treatment to get ready, for example,
showering, brushing teeth, eating breakfast, as well as,
travel to the dialysis clinic.
It has been found that the Fitbit® FlexTM overestimates
sleep duration and quality due to its limited ability to
sense when the wearer is awake [13]. However, the device
used does correlate with actual sleep [14]. Polysomnogra-
phy, the gold-standard for measuring sleep, is time con-
suming, impractical on a routine basis, and expensive.
The Fitbit® FlexTM can be used to measure sleep, as long
as the user is aware that the data collected point to an
overestimation of sleep duration and quality.
Consequently, our measurements of sleep duration and
quality, which are already low, may have been overesti-
mated [15].
The patients studied in the Baton Rouge cohort
walked significantly less than their New York City
counterparts (5,291 vs. 8,454 steps, p < 0.0001). The pa-
tients in Baton Rouge were younger, had a higher BMI
and had a higher prevalence of diabetes, while the pa-
tients in New York City had a higher prevalence of CHF
and longer HD vintage. When analyzing the activity
patterns between the 2 cohorts, it was also found that
the New York City cohort walked approximately the
same number of steps during the week and had a sig-
nificant drop in activity on Sundays, while in Baton
Rouge, there was no difference in the number of steps
Interdialytic Activity Monitoring –
Suburban Environment
walked between Sundays and other non-dialysis days.
Baton Rouge participants walked significantly less on
HD days than what was reported in New York City pa-
tients (4,166 vs. 9,408 steps, p < 0.05). This difference
3%
may be due to the different modes of transportation
taken to HD treatments, for example, driving vs. public
transportation. HD patients in a suburban environment
lation. A number of factors may contribute to the low-
er level of activity in suburban vs. urban areas, for ex-
ample, the availability and use of public transportation,
as shops and parks.
Many of these factors, which may contribute to urban
residents walking more than their suburban counter-
parts, may be measured and compiled into a walk score.
This score is calculated by walkscore.com, a website that
evaluates how walkable an area is based on parameters
such as presence of sidewalks, proximity of stores, and
availability of public transportation. Walk scores range
from 0 to 100 and has been shown to be a valid measure
of walkability [16]. New York City has more walkable
neighborhoods than Baton Rouge. Using patient zip
codes to calculate Walk Scores, a preliminary analysis of
the association of walkability and activity level was con-
ducted. Higher walk scores were associated with higher
physical activity levels. More research into the effect of
walkability on physical activity in dialysis patients needs
to be performed.
This study conducted in Baton Rouge was a follow-up
study based on the observations found in a New York
City population [6]. As such, there are similar limita-
tions, namely, the small sample size and the short dura-
tion of the study. In addition, in studies of this nature,
there may be an inherent selection bias. Patients who
were more interested in learning about their activity and
sleep habits may have chosen to participate in the study
over patients who were less interested. In future studies,
it would be better to enroll a larger number of patients
and follow them for a longer period of time. This will al-
low for a better evaluation of sleep and activity in dialysis
patients.
Conclusion
The population studied in Baton Rouge was very dif-
ferent than the population studied in New York City.
Patients had higher prevalence of diabetes and were
more overweight. They also walked less and had a dif-
Blood Purif 2017;43:235–243 241
DOI: 10.1159/000452751
 All patients (n = 29) Sedentary (n = 13)
*
10,000 * 6,000 *
9,000
8,000 5,000
7,000 4,000
6,000

Steps
Steps 5,000 3,000
4,000
3,000 2,000
2,000 1,000
1,000
0 0
A HD Non-HD Sunday B HD Non-HD Sunday

Fairly active (n = 15) Active (n = 1)

*
10,000 *
9,000 14,000
8,000 12,000
7,000
6,000 10,000
Steps

5,000 8,000

Steps
4,000 6,000
3,000 4,000
2,000
1,000 2,000
0 0
C HD Non-HD Sunday D HD Non-HD Sunday

Fig. 4. A–D Average and SD of steps on HD days, non-HD days, and Sundays by activity level. * p < 0.05.

Table 3. Key results from Physical Activity Questionnaire

Statement Level of agreement, % (n)

‘not at all’ ‘somewhat’ or ‘definitely or
‘moderately’ ‘most definitely’

(1) ‘I have walked more than usual’ 21 (6) 27 (8) 52 (15)

(2) ‘It has become more important to me to be more 3 (1) 31 (9) 66 (19)
physically active’
(3) ‘I was able to incorporate this device into my daily 0 (0) 7 (2) 93 (27)
activities’
(4) ‘I desire to continue wearing this device to track my 14 (4) 24 (7) 62 (18)
own activity’

ferent pattern of activity than the group in New York
City. The dialysis patients in Baton Rouge walked sig-
nificantly less on dialysis days than on non-dialysis days
but rarely walked the recommended number of steps
per day. This leaves a lot of potential for intervention.
The patients studied slept poorly, but this was more
pronounced the night before dialysis for patients on the
first shift. Further research is needed on how the use of
activity and sleep monitors in dialysis patients can im-
prove care and the development of targeted interven-
tions.
Disclosure Statement
Peter Kotanko holds stock in Fresenius Medical Care. The re-
maining authors declared no competing interest.

242 Blood Purif 2017;43:235–243 Williams  et al.

 

DOI: 10.1159/000452751
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