Combined nutrition and exercise interventions potentially improve protein-energy wasting/malnutrition-related outcomes in patients with chronic kidney disease (CKD). The aim was to systematically review the effect of combined interventions on nutritional status, muscle strength, physical performance and QoL. MEDLINE, Cochrane, Embase, Web of Science and Google Scholar were searched for studies up to the date of July 2023. Methodological quality was appraised with the Cochrane risk-of-bias tool. Ten randomized controlled trials (nine publications) were included (334 patients). No differences were observed in body mass index, lean body mass or leg strength. An improvement was found in the six-minute walk test (6-MWT) (n = 3, MD 27.2, 95%CI [7 to 48], p = 0.008), but not in the timed up-and-go test. No effect was found on QoL. A positive impact on 6-MWT was observed, but no improvements were detected in nutritional status, muscle strength or QoL. Concerns about reliability and generalizability arise due to limited statistical power and study heterogeneity of the studies included.

Poor physical performance and protein-energy wasting (PEW) are health issues of major concern in haemodialysis patients. The conventional haemodialysis (CHD) regime, three times per week 3–5 h, is subject of discussion because of high morbidity and mortality rates. When patients switch from CHD to longer dialysis sessions, i.e. nocturnal haemodialysis (NHD), improvement in protein intake and increase in body weight is seen. However, it is unclear whether physical performance and more important aspects of PEW, such as body composition, improve as well. Therefore, the aim of this study is to investigate whether physical performance improves and PEW decreases, when patients switch from CHD to NHD. A second aim is to assess the influence of NHD on the biomarkers fibroblast growth factor-23 and sclerostin which are thought to be associated with malnutrition and mortality in patients on haemodialysis. This study is a prospective multicentre cohort study with an inclusion aim of 50 patients: 25 patients in a control group (three times per week, 3–5 h CHD) and 25 patients in a nocturnal group (three times per week, 7–9 h NHD). Primary outcome is change in physical performance, measured by the Short Physical Performance Battery. Additional measurements are a 6-min walk test, handgrip strength, a physical activity questionnaire and physical activity monitoring. The secondary outcome of the study is PEW, which will be evaluated by body weight, dual-energy X-ray absorptiometry, bio-electrical impedance spectroscopy, mid-upper arm muscle circumference, subjective global assessment, visual analogue scale for appetite and dietary records. Laboratory measurements including fibroblast growth factor-23 and sclerostin, and quality of life assessed with the Kidney Disease Quality of Life-Short Form are also studied. In every patient, four repeated measurements will be performed during one year of follow-up. This study will investigate whether physical performance improves and PEW decreases when patients switch from CHD to NHD, compared to a control group who continue treatment with CHD. Strengths of this study are the comparison with a conventional haemodialysis cohort, and the broad variety of objective measurements combined with patient-reported outcomes of physical performance and PEW. NTR4715 , Netherlands Trial Register. Registered 30 July 2014.

Patients treated with conventional hemodialysis have poor physical performance, explained by insufficient metabolic clearance and shortage of time by time-consuming dialysis. Nocturnal hemodialysis improves metabolic control and results in increased spare time. Our aim is to investigate whether physical performance in nocturnal hemodialysis is superior to conventional hemodialysis. A systematic search was conducted in MEDLINE, Embase, CINAHL, PhycInfo and Web of Science until January 2018. Primary outcomes were physical performance, activity, strength and muscle mass in home or in-center nocturnal hemodialysis. Methodological quality was assessed with the Newcastle-Ottawa scale. Ten studies met the inclusion criteria, including 2 RCTs, evaluating 526 nocturnal hemodialysis patients with a mean follow-up of 15, 3 months. The methodological quality of 4 studies was limited. Physical capacity tests were done in 3 studies with different methodology: short-physical performance battery, exercise spirometry and 6-min walk test. The latter 2 showed significant improvements in physical performance. Four studies assessed lean mass using dual-energy X-ray absorptiometry (2×) and bioelectrical impedance analysis (2×), of which 1 demonstrated increased lean body and skeletal muscle mass. In 5 studies a Quality of Life questionnaire was used, of which 2 showed improved physical component score. The evidence on the effect of nocturnal hemodialysis on physical performance is either of insufficient methodological quality or only measures isolated aspects of physical performance. As literature emphasizes the importance of physical activity on clinical outcomes, it is necessary to conduct larger studies of high methodological quality using capacity tests for answering the question whether nocturnal hemodialysis can improve physical performance of patients with end-stage renal disease. NTR4715, Netherlands Trial Register. Registered 30 July 2014.

End-stage kidney disease patients treated with conventional hemodialysis (CHD) are known to have impaired physical performance and protein-energy wasting (PEW). Nocturnal hemodialysis (NHD) was shown to improve clinical outcomes, but the evidence is limited on physical performance and PEW. We investigate whether NHD improves physical performance and PEW. This prospective, multicenter, non-randomized cohort study compared patients who changed from CHD (2–4 times/week 3–5 h) to NHD (2–3 times/week 7–8 h), with patients who continued CHD. The primary outcome was physical performance at 3, 6 and 12 months, assessed with the short physical performance battery (SPPB). Secondary outcomes were a 6-minute walk test (6MWT), physical activity monitor, handgrip muscle strength, KDQOL-SF physical component score (PCS) and LAPAQ physical activity questionnaire. PEW was assessed with a dietary record, dual-energy X-ray absorptiometry, bioelectrical impedance spectroscopy and subjective global assessment (SGA). Linear mixed models were used to analyze the differences between groups. This study included 33 patients on CHD and 32 who converted to NHD (mean age 55 ± 15.3). No significant difference was found in the SPPB after 1-year of NHD compared to CHD (+0.24, [95% confidence interval −0.51 to 0.99], p = 0.53). Scores of 6MWT, PCS and SGA improved (+54.3 [95%CI 7.78 to 100.8], p = 0.02; +5.61 [−0.51 to 10.7], p = 0.03; +0.71 [0.36 to 1.05], p < 0.001; resp.) in NHD patients, no changes were found in other parameters. We conclude that NHD patients did not experience an improved SPPB score compared to CHD patients; they did obtain an improved walking distance and self-reported PCS as well as SGA after 1-year of NHD, which might be related to the younger age of these patients.

Sufficient protein intake is of great importance in hemodialysis (HD) patients, especially for maintaining muscle mass. Daily protein needs are generally estimated using bodyweight (BW), in which individual differences in body composition are not accounted for. As body protein mass is best represented by fat free mass (FFM), there is a rationale to apply FFM instead of BW. The agreement between both estimations is unclear. Therefore, the aim of this study is to compare protein needs based on either FFM or BW in HD patients. Protein needs were estimated in 115 HD patients by three different equations; FFM, BW and BW adjusted for low or high BMI. FFM was measured by multi-frequency bioelectrical impedance spectroscopy and considered the reference method. Estimations of FFM x 1.5 g/kg and FFM x 1.9 g/kg were compared with (adjusted)BW x 1.2 and x 1.5, respectively. Differences were assessed with repeated measures ANOVA and Bland-Altman plots. Mean protein needs estimated by (adjusted)BW were higher compared to those based on FFM, across all BMI categories (P < 0.01) and most explicitly in obese patients. In females with BMI >30, protein needs were 69 ± 17.4 g/day higher based on BW and 45 ± 9.3 g/day higher based on BMI adjusted BW, compared to FFM. In males with BMI >30, protein needs were 51 ± 20.4 g/day and 23 ± 20.9 g/day higher compared to FFM, respectively. Our data show large differences and possible overestimations of protein needs when comparing BW to FFM. We emphasize the importance of more research and discussion on this topic.

Introduction: The cardiovascular biomarkers troponin T, N‐terminal pro‐B‐type natriuretic peptide, and fibroblast growth factor 23 are elevated in hemodialysis patients and associated with an increased cardiovascular mortality risk. Nocturnal hemodialysis improves the fluid status in hemodialysis patients. Therefore, we investigated whether nocturnal hemodialysis (7–8 h sessions) was associated with lower levels of troponin T, N‐terminal pro‐B‐type natriuretic peptide, and fibroblast growth factor 23 in comparison to conventional hemodialysis. Second, we investigated whether these biomarkers were independently associated with physical performance in hemodialysis patients. Methods: A prospective cohort of 33 hemodialysis patients was compared to 32 patients who voluntarily switched from conventional hemodialysis to nocturnal hemodialysis. First, we studied the difference between the two cohorts in change over 12 months of troponin T, N‐terminal pro‐B‐type natriuretic peptide, and fibroblast growth factor 23 with linear mixed models. Second, the associations between these biomarkers and physical‐activity monitor, six minute walk test, and physical component summary score were assessed at baseline, 6 and 12 months. Findings: N‐terminal pro‐B‐type natriuretic peptide increased 122% during conventional hemodialysis, whereas it decreased 31% during nocturnal hemodialysis ( p = 0.001). In conventional hemodialysis, fibroblast growth factor 23 rose numerically by 19% (23%–66%) in 12 months, while a decline of 44% (21%–58%) was found in nocturnal hemodialysis patients ( p = 0.17). Troponin T did not differ between groups. Regarding physical performance, a higher N‐terminal pro‐B‐type natriuretic peptide (per 1000 ng/L) and fibroblast growth factor 23 (per 1000 RU/mL) were associated with lower physical component summary scores of −0.02 ( p = 0.02) and −0.04 ( p = 0.05), respectively. Troponin T was not associated with physical performance. Discussion: Our findings showed that nocturnal hemodialysis was associated with a decrease in N‐terminal pro‐B‐type natriuretic peptide. This suggested that nocturnal hemodialysis diminished volume overload and thereby myocardial stretch. Additionally, lower levels of N‐terminal pro‐B‐type natriuretic peptide and fibroblast growth factor 23 were found to be associated with better self‐reported physical performance scores.