Research Article
Blood Purif 2021;50:180–187
DOI: 10.1159/000509273
Low-Intensity Intradialytic Exercise
Attenuates the Relative Blood Volume Drop
Due to Intravascular Volume Loss during
Hemodiafiltration
José Rodríguez-Chagolla a, b Raúl Cartas-Rosado c Claudia Lerma c
Oscar Infante-Vázquez c Raúl Martínez-Memije c Brayans Becerra-Luna c
Hector Pérez-Grovas a  
aDepartment of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico; bDepartment of
Nephrology, Centro Médico ISSEMYM Arturo Montiel Rojas, Toluca City, Mexico; cDepartment of Electromechanical
Instrumentation, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
Keywords
Hemodynamic response · Intradialytic exercise ·
Hemodiafiltration · Ultrafiltration · Relative blood volume
Abstract
Introduction: Patients in hemodiafiltration (HDF) eliminate
volume overload by ultrafiltration. Vascular volume loss is
among the main mechanisms contributing to adverse events
such as intradialytic hypotension. Here, we hypothesize that
the intradialytic exercise (IDEX) is an intervention that could
improve the acute response of physiological mechanisms in-
volved during vascular volume loss. To test this hypothesis,
we evaluated the hemodynamic response to mild aerobic
exercise during HDF. Methods: Nineteen end-stage renal
disease (ESRD) patients (11 women: 40 ± 10.8 years old, and
8 men: 42 ± 21 years old) receiving HDF thrice a week, with
6 months of previous physical conditioning, participated in
this study. Three HDF sessions were scheduled for each pa-
tient: 1 resting in supine position, 1 resting in sitting position,
and 1 doing aerobic exercise. The first 2 sessions were taken
as control. The ultrafiltration rate was set to 800 mL/h in each
session. The hemodynamic response was monitored through
karger@karger.com © 2021 S. Karger AG, Basel
www.karger.com/bpu
Received: September 14, 2019
Accepted: June 6, 2020
Published online: January 15, 2021
the relative blood volume (RBV), and cardiovascular vari-
ables measured noninvasively by photoplethysmography.
Adequacy variables such as Kt/V and percentage reduction
of urate, urea, creatinine (Cr), and phosphate were also mon-
itored. Findings: The decrease rate of the RBV was smaller in
the session with IDEX compared to the sessions with no ex-
ercise. No differences were found neither in the cardiovascu-
lar variables nor in the adequacy variables among the 3 ses-
sions. There were no hypotension events during the session
with exercise, and 8 events during the sessions without ex-
ercise (p = 0.002). Discussion: Mild exercise during HDF de-
creased the RBV drop and was associated with less hypoten-
sion events. The lack of differences in the hemodynamic vari-
ables suggests an adequate acute response of cardiovascular
compensation variables to intradialytic hypovolemia.
© 2021 S. Karger AG, Basel
Introduction
Hemodialysis (HD) therapy corrects volume overload
by extracting fluid by ultrafiltration [1]. The vascular vol-
ume loss activates compensatory mechanisms to avoid
130.209.6.61 - 8/13/2021 11:16:34 PM
Raúl Cartas-Rosado Department of Electromechanical Instrumentation
Instituto Nacional de Cardiología Ignacio Chavez
Juan Badiano 1, Col. Belisario Domínguez Sección XVI
Mexico City 14080 (Mexico)
Glasgow Univ.Lib.
Downloaded by:
rcartas @ gmail.com
adverse effects, mainly intradialytic hypotension, which
is estimated to occur in 1 of every 5 therapies [2].
The hemodynamic response to volume loss during
HD has been poorly described; however, experimental
studies in animals showed that the hemodynamic re-
sponse is similar in uremic and nonuremic dogs [3]. The
main compensatory mechanisms acting in response to
vascular volume loss during HD are the intravascular re-
filling, an increase in cardiac output (CO) through higher
cardiac contractility and faster heart rate (HR), and the
modulatory activity of the autonomic nervous system re-
flected as an increase of peripheral vascular resistance [2,
4, 5]. There are various pharmacological and nonphar-
macological interventions aimed at reducing intradialytic
adverse events such as the use of midodrine, arginine va-
sopressin, compression stockings, low dialysate tempera-
tures, hemodiafiltration (HDF), nocturnal HD, and dif-
ferent ultrafiltration and sodium profiles [6].
The intradialytic exercise (IDEX) has proven to be a
safe maneuver that also helps to reduce adverse effects
and does not exacerbate hemodynamic instability [7]. It
has been documented additional positive effects of doing
IDEX such as an improvement in the aerobic capacity,
risk indicators of sudden death [8], dialysis efficacy [9],
functional capacity [10], quality of life, lipid profile, and
benefits over the inflammatory state by decreasing the
high sensitivity C-reactive protein [11, 12].
Although the hemodynamic response to volume loss
during HD with IDEX has been poorly studied, it has
been suggested that the IDEX conditions chronic adapta-
tions that help to improve the acute physiological re-
sponse to volume loss (in particular the cardiovascular
hemodynamic response) and could reduce intradialytic
adverse events [6], which in turn conditions episodes of
transitional myocardial ischemia [13]. This work aims to
compare the hemodynamic response to intravascular vol-
ume loss during HDF in 3 different interventions: resting
in supine position, resting in sitting position, and doing
aerobic exercise.
Material and Methods
This was an analytical, longitudinal, experimental, and pro-
spective study that included 19 patients (11 women and 8 men)
with ESRD from the Instituto Nacional de Cardiología Ignacio
Chávez (INCICh) in Mexico City. All patients have been undergo-
ing kidney replacement therapy with regular HDF thrice a week
for at least 6 months. Inclusion criteria were being 18 years or old-
er, being in dry weight, not being physically limited for exercising
during HDF, not having decompensated lungs or any heart dis-
ease, being in clinical follow-up at the nephrology unit of the
Table 1. Baseline characteristics of the studied population (N = 19)
Characteristic Value
Age, years 41±14
HDF vintage, months 42±13
Etiology of ESRD IgA nephropathy (2)
Nephritis Lupica (3)
Nephroangioesclerosis (2)
Membranoproliferative
glomerulonephritis (3)
Adult polycystic kidney
disease (1)
Nondetermined (7)
Diabetic nephropathy (1)
Albumin, g/dL 4.1±0.23
Hemoglobin, g/dL 10.5±2.0
Previous cardiovascular events 3
Cycling distance per session, km 19.0±2.4
INCICh, and not having vascular access dysfunction. According
to the policy of the nephrology unit, all patients had controlled
blood pressure through the strict prescription of dry weight with-
out the use of antihypertensive drugs.
Patients were informed about the procedure and were asked to
sign an informed consent before the study and advised to avoid the
consumption of substances with cardiovascular effects during 7
days before the study, as well as to prevent >2 kg of weight gain
between HDF sessions. The general characteristics of the studied
population are listed in Table 1.
Study Protocol
All patients underwent 3 HDF sessions of 3 h each, with at least
48-h of difference between them. One session was performed, while
the patients were exercising, and the other 2, taken as control, were
performed with the patients in supine and sitting positions without
exercise. The exercise consisted of pedaling a spinning bike without
resistance, combined with resting periods of no pedaling lasting <5
min. The patients were encouraged by the clinical staff to pedal dur-
ing the entire therapy. Ultrafiltration rate was standardized to 800
mL/h, and it was modified only if the patient had adverse events
including cramps and intradialytic hypotension. Although patients
were instructed to try not to exceed 2 kg of interdialytic weight gain
(IDWG), some patients were unable to adhere to the recommenda-
tions. Additional measures were taken in case the patient gained a
different IDWG than the target weight. If an excessive weight gain
happened, then the HDF session was extended to reach the prees-
tablished dry weight, but variables were measured only during the
first 3 h. If the IDWG was below 2 kg, then an additional bolus was
injected at the beginning of the HDF session to reach the 2,400 mL
established for the study. All sessions were performed using the
130.209.6.61 - 8/13/2021 11:16:34 PM

Exercise during Hemodiafiltration Blood Purif 2021;50:180–187 181

DOI: 10.1159/000509273
Glasgow Univ.Lib.
Downloaded by:
 Table 2. Clinical characteristics according to the session performed (N = 19)

Variable Supine Sitting IDEX p value

Hypotension events 7 (36.8) 1 (26.3) 0 (0.0) <0.01

Interdialytic volume gain, kg 2.1±0.9 2.3±1.1 2.1±0.7 0.82
Liters of substitution, L 19.6±1.8 19.7±1.8 19.3±1.5 0.80
Urate reduction, % 81.4±6.2 78.3±8.0 80.4±5.8 0.36
Urea reduction, % 76.1±6.7 78.8±6.5 78.2±6.0 0.58
Cr reduction, % 71.0±6.8 71.1±5.7 72.3±5.7 0.80
Phosphate reduction, % 48.6±15.6 49.0±15.0 58.4±10.3 0.06
Kt/V at the end of 3 h 1.39±0.5 1.38±0.4 1.28±0.5 0.71

Data are shown as mean±standard deviation or absolute value (percentage). IDEX, intradialytic exercise.

same Fresenius 4008 machine (Fresenius Medical Care, Bad Hom-
burg, Germany) with a polysulfone filter of 1.8 m2 surface area,
blood flow rate between 330 and 430 mL/min, flow rate of 500 mL/
min, and dialysate solution at 35°C containing Na+ = 138 mmol/L,
HCO3− = 32 mmol/L, Ca2+ = 2.5 mmol/L, K+ = 2 mmol/L, Mg2+ =
1 mmol/L, acetate = 3 mmol/L, and glucose = 200 mg/dL.
Evaluation of Hemodynamic Response
Brachial blood pressure, oxygen saturation, and other variables
were measured by oscillometry using a mCare 300 vital signs mon-
itor (Spacelabs Healthcare, Snoqualmie, WA, USA). Measurements
were taken every 10-min since the beginning of the therapy (0-min)
up to the end (180-min). Additional parameters were recorded
throughout the sessions using the Portapres equipment (Finapres
Medical Systems, Amsterdam, The Netherlands). Portapres mea-
sures blood pressure, HR, CO, systolic volume, and peripheral vas-
cular resistance beat-by-beat by photoplethysmography, using 2
finger cuffs. The cuffs were placed on the index and middle fingers
of either right or left hand, contrary to the arm where the patient
had the arteriovenous fistula or brachial pressure cuff. The vast
amount of beat-by-beat measurements acquired with the Portapres
were reduced to 19 measurements to match the number of mea-
surements taken every 10-min with the vital signs monitor. The
reduction was accomplished by averaging the measurements in a
4-min window centered every 10-min starting from 0-min. The
relative blood volume (RBV) was determined every 10-min using
the blood volume monitor integrated into the HD machine.
Adequacy Variables
Dialysis adequacy was determined by Kt/V [14]. Concentra-
tions of urate, urea, Cr, and phosphate were determined from the
accumulated effluent. Samples of the effluent were taken at the
beginning and at the end of each session to calculate the percent-
age of reduction of these variables.
Intradialytic Adverse Events
Intradialytic hypotension is defined as a decrease in systolic
blood pressure ≥20 mm Hg or a decrease in mean arterial pressure
of 10 mm Hg. In any case, the blood pressure drop is associated
with symptoms that might include: abdominal discomfort, yawn-
ing, nausea, vomiting, muscle cramps, restlessness, dizziness or
fainting, and anxiety.
Statistical Analysis
Continuous variables are reported as mean ± standard devia-
tion, and categorical variables as absolute values and percentages.
The normal distribution of continuous variables was assessed us-
ing the Kolmogorov-Smirnov test. The hemodynamic and ade-
quacy variables were compared between sessions using one-way
ANOVA.
The RBV obtained from each session was adjusted using a lin-
ear regression model to evaluate its correlation with intradialytic
time. Also, the RBV from sessions without IDEX (WIDEX) were
combined into a single data set to obtain a single linear regression
model to be compared against the IDEX session. The total duration
of therapy was divided into 3 intervals of 1 h each to determine the
percentage of change in blood volume for every elapsed hour of
therapy. The hourly percentage of change between sessions was
compared using factorial ANOVA. Intradialytic hypotension
events between sessions were compared by Cochran’s Q test. All
tests were performed using STATISTICA 8.0 (StatSoft, Inc.).
Results
The clinical characteristics of each session are summa-
rized in Table 2. Clinical conditions that could interfere
with the outcome of the study, such as IDWG, liters of
substitution that were used during the HDF session, as
well as adequacy variables had no significant differences
between the sessions (p > 0.5).
The Kolmogorov-Smirnov test did not yield signifi-
cant p values for any continuous variable, thus confirm-
ing the assumption of normal distribution of the mea-
surements for each patient. The mean values, 95% confi-
dence intervals, and p values resulting from the ANOVA
for the hemodynamic variables are shown in the plots of
Figure 1. There were no significant differences (p > 0.05)
between the sessions.
Figure 2 shows the changes in RBV and the best linear
fit for each session. The models obtained were y =
130.209.6.61 - 8/13/2021 11:16:34 PM

182 Blood Purif 2021;50:180–187 Rodríguez-Chagolla et al.

DOI: 10.1159/000509273
Glasgow Univ.Lib.
Downloaded by:
 Color version available online
165 86
p = 0.66 p = 0.93
160 84

Diastolic blood pressure, mm Hg

Systolic blood pressure, mm Hg
155
82
150
145 80

140 78
135 76
130
74
125
72
120
115 70
110 68
Supine Sitting IDEX Supine Sitting IDEX

115 84
p = 0.79 p = 0.14
82
110
Mean arterial pressure, mm Hg

80
105 78

Heart rate, bpm

100 76
74
95
72
90 70
68
85
66
80 64
Supine Sitting IDEX Supine Sitting IDEX

2.2 7.0
p = 0.24 p = 0.23
2.0 6.5

1.8
Cardiac output, L/min

6.0
TPR, mm Hg × min/L

1.6 5.5

1.4 5.0

1.2 4.5

1.0 4.0

0.8 3.5
Supine Sitting IDEX Supine Sitting IDEX

Fig. 1. ANOVA results for the hemodynamic variables between sessions. The circles indicate the mean value and
the whiskers correspond to 0.95 CIs. TPR, total peripheral resistance; IDEX, intradialytic exercise; CI, confidence
interval.

97.651−0.075x for the supine position, y = 99.743−0.070x
for the sitting position, and y = 99.495−0.055x for the
IDEX session. When the supine and sitting sessions were
combined to form the WIDEX session, the obtained lin-
ear model was y = 98.697−0.073x. Table 3 summarizes the
parameters of all the regression models. All models were
statistically significant (p < 0.05) for the correlation with
intradialysis time (i.e., there was a significant reduction
in RBV over time in all 3 cases). However, the IDEX ses-
sion had a smaller slope than supine and sitting sessions
130.209.6.61 - 8/13/2021 11:16:34 PM

Exercise during Hemodiafiltration Blood Purif 2021;50:180–187 183

DOI: 10.1159/000509273
Glasgow Univ.Lib.
Downloaded by:
 Color version available online
Supine Sitting
115 115

110 110

105 105
Relative blood volume, %

Relative blood volume, %

100 100

95 95

90 90

85 85

80 80

75 y = 97.651 – 0.075x 75 y = 99.743 – 0.070x

70 70
0 20 40 60 80 100 120 140 160 180 0 20 40 60 80 100 120 140 160 180
a Time, min b Time, min

IDEX Linear regression models for the three sessions

115 102
Supine
110 100 Sitting
IDEX
105 98
Relative blood volume, %

Relative blood volume, %

96
100
94
95
92
90
90
85
88
y = 99.495 – 0.055x
80 86
75 84
70 82
0 20 40 60 80 100 120 140 160 180 0 20 40 60 80 100 120 140 160 180
c Time, min d Time, min

WIDEX and IDEX Linear regression models for WIDEX and IDEX
115 102
WIDEX WIDEX: y = 98.697 – 0.073x
110 IDEX 100 IDEX: y = 99.495 – 0.055x

105 98
Relative blood volume, %

Relative blood volume, %

96
100
94
95
92
90
90
85
88
80 86
75 84
70 82
0 20 40 60 80 100 120 140 160 180 0 20 40 60 80 100 120 140 160 180
e Time, min f Time, min

Fig. 2. Changes in the RBV for all patients in the supine position (a), sitting position (b), and session with IDEX
(c). Linear regression models obtained from the 3 evaluated sessions (d). IDEX session compared against the
WIDEX sessions (e). Linear regression models for the WIDEX and IDEX sessions (f). Solid lines represent the
best linear fit and dashed lines the 95% CIs. IDEX, intradialytic exercise; WIDEX, without IDEX; RBV, relative
blood volume; CI, confidence interval.
130.209.6.61 - 8/13/2021 11:16:34 PM

184 Blood Purif 2021;50:180–187 Rodríguez-Chagolla et al.

DOI: 10.1159/000509273
Glasgow Univ.Lib.
Downloaded by:
 Discussion

Color version available online

10
Supine Sitting IDEX
9 The main result of this work shows that ESRD patients
*
8
doing mild exercise while undergoing maintenance HDF
RVB percentage change, %

showed differences in the rate of attenuation of their RBV,

7
in contrast to the attenuation shown when they did not
6 exercise. Our results showed that this attenuation is influ-
5 enced by a joint interaction of intradialytic physical activ-
ity and the cumulative HDF time, which may significantly
4
reduce the risk of hypotension. These patients had prior
3 physical conditioning, and their HDF sessions had very
2 similar parameters for comparison purposes. The other
1
hemodynamic variables tracked during the study did not
First Second Third show differences among sessions. Similarly, in the research
Time elapsed, h work published by Ookawara et al. [15] a mild exercise
program was also executed by ESRD patients with the out-
come of an analogous phenomena in the vascular refilling.
Fig. 3. Two-way ANOVA results for the interaction of factors ses-
sion and time. The effects of factor session yielded F = 5.60, p < To explain this phenomenon, the authors argue an in-
0.05, and the effects of the factor time yielded F = 3.98, p = 0.02. crease in blood volume after the first 20–30 min of IDEX.
The joint interaction of the 2 factors yielded F = 3.26, p = 0.013. The absence of statistical significance in the noninva-
Only the first hour of the session in supine position (*) was sig- sive hemodynamic variables of our study indicates that
nificant (p < 0.01) compared to the rest of the groups. the hemodynamic response is able to adapt to both body
position and exercise during therapy. The similarity be-
tween the groups could be explained by the characteris-
Table 3. Parameters of the linear regression models obtained
tics of the sessions (i.e., mild IDEX or same ultrafiltration
Session m b R R2 p value rate), which are relevant differences when our study is
compared to others, where the IDEX made by the patients
Supine −0.075 97.651 −0.687 0.472 ≪0.05 is either of sub-maximum or maximum level. Banerjee et
Sitting −0.070 99.743 −0.749 0.561 ≪0.05 al. [16] studied the effects of sub-maximal IDEX in a
IDEX −0.055 99.495 −0.683 0.467 ≪0.05 group of patients. They found an increase in CO and
WIDEX −0.073 98.697 −0.695 0.484 ≪0.05
stroke volume, and a decrease in peripheral vascular re-
IDEX, intradialytic exercise; WIDEX, without IDEX. sistance. Their results might indicate that the type of ex-
ercise conditions the cardiovascular response.
Another mechanism that could explain how the IDEX
increases the RBV is the redistribution of the blood vol-
either separated or combined as WIDEX, indicating that ume by splenic contraction and release of RBCs. These
the IDEX session had slowest decrease of RBV as a func- phenomena happen in normal conditions and can trans-
tion of intradialytic time. late into plasma volume expansion of up to 10% for the
The two-factor ANOVA of the hourly percentage next 24 h after intense exercise [17].
change of RBV for the 3 evaluated sessions yielded p = ESRD patients participating in our study had physical
0.02 for the factor time and p < 0.05 for the factor session. conditioning for at least 6 months before the study. This
The joint interaction of these 2 factors was also significant reduces the risks of adverse events because at the start of
(Fig. 3, p = 0.01). Given this level of significance, a post the HDF therapy patients may have little tolerance to
hoc analysis was run to find which groups are different. physical activity [8]. We consider that this condition con-
The percentage change of RBV in the first hour of the su- tributes to the absence of significant changes in the non-
pine position session was significantly larger than in the invasive hemodynamic variables.
other 2 h and the other 2 sessions (sitting and IDEX). We also found that body position does not affect the
Table 2 shows that no hypotension events occurred dur- hemodynamic response. McGuire et al. [6] found that
ing the session with exercise, and 8 events in the sessions HD performed in sitting position favors a decrease in
without exercise (p < 0.01). blood volume as a result of fluid moving from the capil-
130.209.6.61 - 8/13/2021 11:16:34 PM

Exercise during Hemodiafiltration Blood Purif 2021;50:180–187 185

DOI: 10.1159/000509273
Glasgow Univ.Lib.
Downloaded by:
lary circulation to the interstitial compartment due to an
increase in capillary hydrostatic pressure. Furthermore,
throughout several years of performing HDF sessions
with mild exercise, we have seen that hypotension events
are minimal.
Safety of Intradialytic Exercise
The exercise in healthy subjects produces a hypovole-
mia-like phenomenon at the start of the physical activity
[15, 18] that has generated distrust to perform IDEX, as-
suming that a greater number of adverse events such as
hypotension could be favored by the initial state. Patients
at the HD unit start exercising during the first 5 min of the
session. At that moment, the vascular volume depletion
favored by exercise does not represent a risk for the pa-
tient. During the 57 HDF sessions conducted for this
study, 8 female patients experienced hypotension events
during the last hour of therapy: 7 in supine and 1 in sitting
position. This represents a total of 14% of sessions with
adverse events. The absence of hypotension events in the
IDEX session becomes relevant when we highlight the
crossover design of the study (where the patients were
their own control), the uniformity in the prescription of
the HDF sessions (where the ultrafiltration rate was the
same for all patients), and the strategies adopted since the
beginning of the sessions to reduce the hypotension events.
It is known that during the last third hour of HD ther-
apy, the brachial and aortic arterial blood pressures de-
crease by effect of ultrafiltration [6]. In our study, we ob-
served different percentage changes in the RBV when pa-
tients exercised during HDF therapy, mainly in the first
third hour of the session, which is a phenomenon that
could lead to hypotension events in groups without prior
physical conditioning. This finding has been reported in
the previous studies, where it was demonstrated a de-
crease in the number of hypotension events [19].
Our results reinforce the safeness of doing continuous
mild exercise throughout the HDF therapy if it is preced-
ed by previous physical conditioning. The absence of sev-
eral cardiovascular or musculoskeletal adverse events at-
tributed to exercise was also addressed by Sheng et al. [20]
in his review of IDEX during HD.
Adequacy Variables
The adequacy variables we analyzed behave similarly
between the sessions. Although the extracted phosphate
for the session with IDEX seems higher than the other 2
sessions, there were no significant differences among ses-
sions (p = 0.06). A higher level of phosphate in plasma
after acute exercise is a phenomenon described in healthy
186 Blood Purif 2021;50:180–187
DOI: 10.1159/000509273
subjects [21]. The exercise could favor the redistribution
of phosphate by mechanisms similar to those described
for the blood volume. Besides, previous studies have doc-
umented that pre-dialysis or intradialysis physical activ-
ity, as well as repetitive movements such as that made by
our patients, increase phosphate removal by 6–9% [22,
23]. Another phenomenon that contributes to this higher
reduction is the hydrophilic characteristic of phosphate,
which gives it a distribution volume similar to H2O, and
in turn, it could favor its movement from extravascular to
intravascular compartments [24].
Study Limitations
Patients included in our research work received previ-
ous physical conditioning for at least 6 months before the
study, and there were few patients with comorbidities
such as diabetes mellitus and geriatric conditions or with
ischemic heart disease. Additionally, our study includes
only patients with hypertension controlled by dialysis
(without hypertensive drugs) who were close to dry
weight with the intention to limit the number of variables
to control in the study protocol. These characteristics
may not be the same as those of other populations on HD
and should be taken into account when the exercise ma-
neuver is to be implemented, mainly when there are pa-
tients with known hypotension risk factors such as inter-
dialysis gains >3 kg, ultrafiltration rates exceeding 1,000
cm3/h, being female, being older than 65 years, having a
medical history of ischemic heart disease, arrhythmias,
autonomic neuropathy, severe anemia, or intake of anti-
hypertensive medication [25]. Further studies are re-
quired to compare the cardiovascular effects and efficacy
of our protocol against short-duration high-intensity ex-
ercise protocol or other exercise protocols.
Conclusions
Our results suggest that the hemodynamic response to
vascular volume loss in ESRD patients with previous
physical conditioning undergoing maintenance HDF
therapy is different when performing IDEX. This differ-
ence is reflected in the RBV, which attenuates its decrease.
No differences were found neither in the hemodynamic
variables acquired noninvasively nor in the adequacy
variables when the IDEX therapy was compared against
the WIDEX therapy. These results improve the knowl-
edge of the physiological response to mild IDEX during
HDF therapy, and it could contribute to better HDF pre-
scription guidelines.
130.209.6.61 - 8/13/2021 11:16:34 PM
Rodríguez-Chagolla et al.
Glasgow Univ.Lib.
Downloaded by:
 Acknowledgements Funding Sources

This research work was jointly developed by the HD Unit of the
Nephrology Service and the Department of Electromechanical In-
strumentation at the Instituto Nacional de Cardiología Ignacio
Chávez in Mexico City with the valuable collaboration of doctors
and fellows of Nephrology.
Statement of Ethics
This study was approved by the Ethics Committee of the Insti-
tuto Nacional de Cardiología, with adherence to the Declaration
of Helsinki. All patients agreed to participate and signed an in-
formed consent.
Conflict of Interest Statement
The authors declare no conflicts of interest.
This research was conducted with the sponsorship of CONA-
CYT (National Council of Science and Technology, Mexico)
through grant PN1083.
Author Contributions
J. Rodríguez-Chagolla: writing (original draft), investigation,
methodology, and resources. R. Cartas-Rosado: statistical analysis,
data curation, writing (review and editing), visualization, and
funding acquisition. O. Infante-Vázquez: conceptualization,
methodology, supervision, and writing (review and editing). C.
Lerma: statistical analysis, data curation, writing (review and edit-
ing), and visualization. R. Martínez Memije: methodology, data
curation, and writing (review and editing). B. Becerra Luna: meth-
odology, data curation, and writing (review and editing). H. Pérez-
Grovas: conceptualization, methodology, supervision, and re-
sources.

References
 1 Fauchald P. Transcapillary colloid osmotic
gradient and body fluid volumes in renal fail-
ure. Kidney Int. 1986;29(4):895–900.
 2 Javed F, Savkin AV, Chan GS, Mackie JD,
Lovell NH. Recent advances in the monitor-
ing and control of haemodynamic variables
during haemodialysis: a review. Physiol Meas.
2012;33(1):R1–31.
  3 Daugirdas JT, Ing TS, Chen WT, Vestal RE,
Izzo JL Jr, Hano JE, et al. Hemodynamic re-
sponse to volume depletion in acutely uremic
dogs. Am J Physiol. 1984; 247(2 Pt 2): H229–
36.
  4 Daugirdas JT. Dialysis hypotension: a hemo-
dynamic analysis. Kidney Int. 1991; 39(2):
233–46.
  5 Daugirdas JT. Pathophysiology of dialysis hy-
potension: an update. Am J Kidney Dis. 2001;
38(4 Suppl 4):S11–7.
  6 McGuire S, Horton EJ, Renshaw D, Jimenez
A, Krishnan N, McGregor G. Hemodynamic
instability during dialysis: the potential role of
intradialytic exercise. Biomed Res Int. 2018;
2018:8276912.
  7 Jeong JH, Biruete A, Fernhall B, Wilund KR.
Effects of acute intradialytic exercise on car-
diovascular responses in hemodialysis pa-
tients. Hemodial Int. 2018;22(4):524–33.
  8 Kouidi EJ, Grekas DM, Deligiannis AP. Ef-
fects of exercise training on noninvasive car-
diac measures in patients undergoing long-
term hemodialysis: a randomized controlled
trial. Am J Kidney Dis. 2009;54(3):511–21.
 9 Mohseni R, Emami Zeydi A, Ilali E, Adib-
Hajbaghery M, Makhlough A. The effect of
intradialytic aerobic exercise on dialysis effi-
cacy in hemodialysis patients: a randomized
controlled trial. Oman Med J. 2013; 28(5):
345–9.
10 Pellizzaro CO, Thomé FS, Veronese FV. Ef-
fect of peripheral and respiratory muscle
training on the functional capacity of hemo-
dialysis patients. Ren Fail. 2013;35(2):189–97.
11 Song WJ, Sohng KY. Effects of progressive re-
sistance training on body composition, phys-
ical fitness and quality of life of patients on
hemodialysis. J Korean Acad Nurs. 2012;
42(7):947–56.
12 Afshar R, Shegarfy L, Shavandi N, Sanavi S.
Effects of aerobic exercise and resistance
training on lipid profiles and inflammation
status in patients on maintenance hemodialy-
sis. Indian J Nephrol. 2010;20(4):185–9.
13 Burton JO, Jefferies HJ, Selby NM, McIntyre
CW. Hemodialysis-induced repetitive myo-
cardial injury results in global and segmental
reduction in systolic cardiac function. Clin J
Am Soc Nephrol. 2009;4(12):1925–31.
14 Daugirdas JT. Simplified equations for moni-
toring Kt/V, PCRn, eKt/V, and ePCRn. Adv
Ren Replace Ther. 1995;2(4):295–304.
15 Ookawara S, Miyazawa H, Ito K, Ueda Y,
Kaku Y, Hirai K, et al. Blood volume changes
induced by low-intensity intradialytic exer-
cise in long-term hemodialysis patients.
ASAIO J. 2016;62(2):190–6.
16 Banerjee A, Kong CH, Farrington K. The hae-
modynamic response to submaximal exercise
during isovolaemic haemodialysis. Nephrol
Dial Transplant. 2004;19(6):1528–32.
17 Stewart IB, Warburton DE, Hodges AN, Lys-
ter DM, McKenzie DC. Cardiovascular and
splenic responses to exercise in humans. J
Appl Physiol. 2003;94(4):1619–26.
18 Halliwill JR. Mechanisms and clinical impli-
cations of post-exercise hypotension in hu-
mans. Exerc Sport Sci Rev. 2001;29(2):65–70.
19 Rhee SY, Song JK, Hong SC, Choi JW, Jeon
HJ, Shin DH, et al. Intradialytic exercise im-
proves physical function and reduces intra-
dialytic hypotension and depression in hemo-
dialysis patients. Korean J Intern Med. 2019;
34(3):588–98.
20 Sheng K, Zhang P, Chen L, Cheng J, Wu C,
Chen J. Intradialytic exercise in hemodialysis
patients: a systematic review and meta-analy-
sis. Am J Nephrol. 2014;40(5):478–90.
21 Karakukcu C, Polat Y, Torun YA, Pac AK.
The effects of acute and regular exercise on
calcium, phosphorus and trace elements in
young amateur boxers. Clin Lab. 2013; 59(5–
6):557–62.
22 Vaithilingam I, Polkinghorne KR, Atkins RC,
Kerr PG. Time and exercise improve phos-
phate removal in hemodialysis patients. Am J
Kidney Dis. 2004;43(1):85–9.
23 Farese S, Budmiger R, Aregger F, Bergmann
I, Frey FJ, Uehlinger DE. Effect of transcuta-
neous electrical muscle stimulation and pas-
sive cycling movements on blood pressure
and removal of urea and phosphate during
hemodialysis. Am J Kidney Dis. 2008; 52(4):
745–52.
24 Bammens B, Evenepoel P, Verbeke K, Van-
renterghem Y. Removal of middle molecules
and protein-bound solutes by peritoneal di-
alysis and relation with uremic symptoms.
Kidney Int. 2003;64(6):2238–43.
25 Gul A, Miskulin D, Harford A, Zager P. Intra-
dialytic hypotension. Curr Opin Nephrol Hy-
pertens. 2016;25(6):545–50.
130.209.6.61 - 8/13/2021 11:16:34 PM

Exercise during Hemodiafiltration Blood Purif 2021;50:180–187 187

DOI: 10.1159/000509273
Glasgow Univ.Lib.
Downloaded by: