Intradialytic Renal Rehabilitation and Mortality: Results from the Registry of Active Renal Rehabilitation in Dialysis Patients (REVEAL-D).

KEY POINTS: Intradialytic renal rehabilitation was associated with higher 3-year survival in patients on maintenance hemodialysis. This association was directionally consistent after multivariable adjustment and propensity score matching. The association seemed stronger in men with severe frailty; no rehabilitation-related adverse events were reported.

BACKGROUND

Frailty and sarcopenia are increasingly common among patients undergoing maintenance hemodialysis. Globally, some countries, including Japan, have recently introduced insurance reimbursement for intradialytic renal rehabilitation, a supervised intradialytic exercise instruction plus nutritional and lifestyle guidance. However, the survival benefit has not been fully evaluated.

METHODS

We evaluated 708 adult outpatients on dialysis (age, 69.8±11.2 years; men, 59%; and Clinical Frailty Scale ≥6, 13%) at ten institutions across Japan in January 2021 who were retrospectively assessed over a 3-year period, including 228 patients who received intradialytic renal rehabilitation, defined as supervised intradialytic exercise instruction plus nutritional and lifestyle guidance (≥1 session/wk for≥1 month), and 480 who did not receive this intervention. Cox regression models and propensity score matching were used to compare 3-year mortality after adjustment for the Clinical Frailty Scale, comorbidities, laboratory data, and other baseline characteristics.

RESULTS

During the follow-up, deaths were observed in 14.9% of the rehabilitation group and 23.1% of the nonrehabilitation group ( P = 0.01). Three-year survival was higher with rehabilitation (84.6% versus 75.6%, P = 0.007), particularly among men and those with severe frailty. In Cox models, renal rehabilitation was consistently associated with lower mortality (crude hazard ratio [HR], 0.59 [95% confidence interval (CI), 0.40 to 0.87]; adjusted HR 0.66 [0.44 to 1.00]). After propensity score matching, the association remained directionally similar (HR, 0.65 [0.40 to 1.05]). Sex-stratified analyses suggested a stronger association among men (adjusted HR, 0.49 [0.27 to 0.89]) than among women (adjusted HR, 0.98 [0.54 to 1.77]), although the formal test for interaction was not statistically significant ( P for interaction = 0.13). Patients meeting exercise-habit criteria (≥2 sessions/wk, ≥30 minutes for ≥1 year) also showed better survival relative to the nonexercise-habit group (adjusted HR 0.60 [0.37 to 0.96], P = 0.03). No adverse events related to rehabilitation were reported.

CONCLUSIONS

Intradialytic renal rehabilitation may be associated with better survival in patients on maintenance hemodialysis, particularly in men and in those with severe frailty.