الفهرس 
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Abstract
End-stage renal disease is characterized by irreversible kidney function, its prevalence is increasing annually. It is associated with numerous of complicated metabolic and hormonal alterations that cause subsequent complications and further alter the functionality of all organ systems.
Generally, patients with ESRD have low levels of physical activity, and muscle performance, also, have lower quality of life (QOL) than healthy individuals. To replace renal dysfunction, patients have only two options: life-long dialysis or renal transplantation. Of these options, hemodialysis is the treatment of choice.
Although hemodialysis lengthens the lifespan of patients with renal insufficiency, it can cause notable changes such as decreased efficiency and ability to perform activities, social isolation, immobility, and lowered self-confidence. In addition to suffer from many physiological changes, these patients face various mental and psychological stresses as disturbance in their mental status and sleep quality, anxiety, sadness, and loneliness, all of which have an impact on their health and make their health-promoting behavior less effective. For this, practicing intradialytic exercise during HD can improve physical capacity, reduce blood pressure, and contribute to improve QOL.
Intradialytic exercise improves the efficiency of dialysis by removing substances such as urea and creatinine, waste products from the liver and muscles, and aiding the removal of such toxins from the blood. It also will help carrying out patient daily activities including housework, walking, and staying as independent as possible. Furthermore, it reduces cramping that occurs during dialysis sessions. Additionally, these exercises do not cost patients extra time as the patients will not have to attend additional exercises session. Therefore, this study was carried out to determine the effect of intradialytic exercise on physiological parameters, biochemical markers, and quality of life among patients on hemodialysis.
Aim of this study:
The study aims to determine the effect of intradialytic exercise on physiological parameters, biochemical markers, and quality of life among patients on hemodialysis.
Research design:
A quasi –experimental research design was utilized to meet the aim of the present study.
Setting:
This study was conducted at the hemodialysis units of the National Medical Institute in Damanhour, Elbeheira governorate, Egypt. Subjects:
The subjects comprised fifty patients on maintenance hemodialysis three sessions per week. Those patients were randomly assigned and divided attentively into two equal groups, 25 in each group. The study group received and practiced intradialytic exercise program and the control group received routine hospital care.
Tools:
Data of the present study were collected using the following tools:
Tool I: ” Socio-demographic and Clinical Data Structured Interview Schedule”
It was developed by the researcher based on reviewing the relevant recent literature (Hinkle & Cheever, 2018; National Kidney Foundation, 2019). It was divided into four parts:
Part I: Socio-demographic characteristics:
It was used to identify patient socio-demographic characteristics; it included the patients’ age, gender, marital status, residence, education, and occupation. These data were obtained from the medical file and confirmed by interviewing the patients.
Part II: Clinical Data:
It was used to assess health status which included items about clinical data such as history of renal failure, cause of the disease, duration of disease, dialysis access site, medication, date of the first dialysis session, duration of hemodialysis, hemodialysis (hours) per weeks, duration of each dialysis session. These data were collected by interviews the patients.
Part III: Biochemical markers:
Which included items related to blood urea, serum creatinine, potassium, phosphorus, calcium and hemoglobin. Those data were collected four times during the study (before starting the exercise and after performing the exercise at the end of each month for three months).
Part IV: Physiological parameters:
Which included pulse, respiration, blood pressure, pulse pressure and body weight.
Tool II: The Kidney Diseases Quality of Life Short Form (KDQoL-SFTM 1.3): This tool was developed by Hays et al 2019) adapted and translated into Arabic language by the researcher to assess QOL multi- items that measures the health status of hemodialysis patients. - This tool includes 12 domains which contains: symptom/problems, effect of kidney disease on daily life, burden of kidney disease, work status, cognitive function, quality of social interaction, sexual function, sleep, social support, dialysis staff encouragement, patient satisfaction and finally the overall quality of life domain.
Method The study was accomplished as follows: ▪ An official ethical committee approval and agreement from Faculty of Nursing, Alexandria University to carry out the study was obtained. ▪ An official permission to carry out the study was obtained from the head of urology department and head of hemodialysis unit and the hospital director at the selected settings, after explanation of the aim of the study. ▪ Content validity of the study tools was tested by three experts in the field of Medical-Surgical Nursing, Faculty of Nursing - University of Alexandria, and two experts in Nephrology field, to assure the content validity, completeness, clarity of items and appropriate translation. Modifications included correction and clarifying of the items were done accordingly.
▪ Reliability testing for (tool II) was estimated using the Cronbach’s Alpha test and was equal (0.885). It was done to measure the internal consistency of the tools (to evaluate how well the tool consistently measures what it was designed to measure). ▪ Data was collected in a period of 5 months from beginning of June 2021 to end of October 2021. ▪ Data were collected by the researcher through a personal interview with patients at the beginning of the hemodialysis session to collect demographic, social and clinical data using the first tool (part I and II) ▪ Pretest collection of the biochemical values, Physiological parameters and quality of life were conducted using tool I (part III and IV) and tool II. ▪ The purpose of the study was explained to each patient individually. ▪ The control group received routine hospital care and the study group received and practiced intradialytic exercise program. - Intradialytic exercise was performed during the second hours of dialysis according to patients’ tolerance and stopped next two hours of hemodialysis, intradialytic exercises performed to all upper and lower limbs joints; body part that connected to dialysis machine was excluded and maintaining patient on supine position to avoid intradialytic hypotension. The patient was instructed to stop exercise if any pain occurs. - Patients were received and practiced intradialytic exercise program, by the researcher; each session ranged from 15- 20 minutes. The total number of sessions in which patients practiced intradialytic exercise was about 36 sessions for three months (3sessions per week). ▪ An Arabic handout booklet with colored pictures was designed by the researcher based on review of the recent related literature was given to every patient in the study group from the beginning of the first session for more illustration how to do exercise. ▪ After three months of implantation of exercise program, every patient recruited in both groups was interviewed individually using (tool I and tool II) that used in pretest (pre intradialytic exercise program) to determine the effect of intradialytic exercise on physiological parameters, biochemical markers, and quality of life among patients on hemodialysis. ▪ Comparison between the study and control groups was carried out using appropriate statistical analysis to determine the effect of intradialytic exercise on physiological parameters, biochemical markers and quality of life among patient on hemodialysis.
The main findings of this study showed that:
- Less than half of the patient in the study group aged from 20 years to less than 40 years and less than half of patient in the control group were aged from 50 years to 60 years. More than half of patients in the study group were female and more than half of patients in the control group were male. Majority of the studied patients were married, illiterate, living in rural areas and didn’t work.
- The current study revealed that hypertension, renal stones and over the counter medication were the most common causes of renal failure, the majority of the studied patient did not practice any exercises at home.
- The current study revealed that there was a significant improvement in the level of blood urea, creatinine, serum phosphate, serum potassium but it was noticed that slightly improvement in serum calcium and haemoglobin level in the study group after application of intradialytic exercise program.
- There were statistical significant differences between the study and control groups in serum urea, creatinine, potassium and phosphorus after application of the intradialytic program (p= .001*, .003*, .023*, .001*) respectively.
- On the other hand, there were no significant differences between patients in the study and control groups in relation to physiological parameters (pulse, heart rate, respiration, pulse pressure, blood pressure and body weight before and after application of intradialytic exercise program (p ˃ 0.05). But it was noticed that there was slight improvement in pulse pressure and blood pressure in the study group after application of intradialytic exercise program.
- There was a significant statistical relationship between the study and control groups in most domains of QOL after application of intradialytic exercise as in relation to domain of symptom/problems, effect of kidney disease, burden of kidney disease, cognitive function, social interaction, sexual function, sleep, social support, patient satisfaction and overall quality of life (p= .001, .001, .012, .001, .001, .049, .001, .001, .042 and .001) respectively.
- Moreover, the majority of patients in the study group had fair quality of life (QOL) post intradialytic exercises and less than two thirds of patients in the control group had poor QOL.
Conclusion
Based on the results of the current study, it was concluded that Hemodialysis patients who practice intradialytic exercise exhibit significant improvement in biochemical markers and quality of life than those who do not practice it. But there were no significant differences in physiological parameters.
Recommendations
Based on the finding of this study the following recommendations are suggested:
Recommendations for the patients:
- The developed booklet about intradialytic exercises should be available and distributed to all hemodialysis patients.
- Intradialytic exercises for hemodialysis patients should be included in the curriculum of undergraduate courses in nursing schools, technical institute of nursing and faculty of nursing.
- Application of educational program should be carried out for hemodialysis patients at hemodialysis unit to be aware about the importance of intradialytic exercises which help them to improve their quality of life.
Recommendations for further research:
- Replication of the study using a larger sample from different geographical areas is important to help generalize results.
- Intradialytic exercises program should be applied to peritoneal dialysis patients to evaluate its effect on their quality of life.