Establishing the needs of a holistic lifestyle intervention for patients on haemodialysis

Supervisors

• Professor James Burton (jb343@le.ac.uk)
• Dr Roseanne Billany  
• Dr Matthew Graham-Brown

Project is available to UK applicants only.

Background

Patients with end stage kidney disease receiving haemodialysis treatment have the highest rates of mortality, cardiovascular disease (CVD), and symptom burden across all of the stages of chronic kidney disease (CKD). Their quality of life is often extremely low. Physical activity and exercise can help to alleviate some of these factors and there have been well-conducted clinical trials that have evaluated their effects. One of these was the CYCLE-HD study which showed significant improvements in measures of cardiovascular structure and function after a programme of intra-dialytic cycling (cycling during dialysis). Despite this beneficial evidence, studies have not translated into clinical practice; exercise is not a component of current routine care. In part, this may be due to studies showing a lack of evidence for intra-dialytic cycling to improve quality of life and physical function (the CYCLE-HD and PEDAL studies). Moreover, the uptake of the cycling by patients in both studies was limited with many patients unable or unwilling to participate. Physical activity levels in these patients remain incredibly low.

There have been many studies identifying barriers to exercise in patients receiving haemodialysis. The biggest barrier is the high burden of comorbidities that affect patients’ health and quality of life. Cardiovascular disease and events, muscle wasting, and bone disorders are extremely common. Whilst these can be causes of less physical activity, they can also be a consequence leading to a cycle of inactivity. A second common barrier is lack of resources and knowledge available in haemodialysis units to implement exercise programmes.

It is clear that exercise and physical activity have beneficial effects. However, a more holistic approach is required to develop a programme of education, exercise, activity and lifestyle for patients receiving dialysis to give them autonomy and choice in how they engage in these behaviours that is not limited to intra-dialytic cycling. Other solutions exist and could be used to help develop this menu of options for patients. For example, Kidney BEAM, an online digital health physical activity intervention for people living with CKD or the My Kidneys & Me platform developed by our group in Leicester. What is realistically deliverable within the NHS must also be explored and considered.

This doctoral studentship will have the overall aim of developing a proposed holistic education, exercise, activity and lifestyle programme for patients receiving haemodialysis using a range of methodologies and follow the National Institute of Health Research (NIHR) complex intervention framework to guide and support development and testing. The project plan and methodology will be refined and finalised when the successful candidate has begun their studentship, however the following outline is currently proposed:

1. Establish the activity, exercise and lifestyle needs of patients on haemodialysis
   • A systematic review of the literature, characterising lifestyle interventions that are proven to be beneficial for patients on haemodialysis and what impact different interventions have on relevant patient outcomes (quality of life, physical function, cardiovascular disease, mortality, hospitalisations)
   • Conduct qualitative focus groups and interviews with patients, carers, clinicians, stakeholders and commissioners to establish the different views on what a program should look like and crucially how to best embed the program into the routine care of patients on dialysis, identifying particularly what staff training and support will be required.
2. Co-design a holistic intervention with stakeholder partners utilising available, pre-existing resources to be implementation ready
   • With the information from objective 1 convene an expert group of patients, clinicians and stakeholders from across the multi-professional team to review the gathered information.
   • Use insights gathered to form a programme that is ready to be tested across Leicestershire dialysis units. This will include information on how to set-up and deliver the programme.

The successful candidate will become embedded within the Leicester Kidney Lifestyle Team (LKLT) which sits within the Department of Cardiovascular Sciences. The LKLT is a vibrant multidisciplinary research group, which aims to help patients living with kidney disease achieve the best possible health and wellbeing through appropriate lifestyle management. Training and support in a wide variety of areas is available where necessary to support this studentship.

References

• Cozzolino M, Mangano M, Stucchi A, Ciceri P, Conte F, Galassi A. Cardiovascular disease in dialysis patients. Nephrol Dial Transplant. 2018;33(suppl_3):iii28-iii34. doi:10.1093/ndt/gfy174
• Graham-Brown MPM, March DS, Young R, et al. A randomized controlled trial to investigate the effects of intra-dialytic cycling on left ventricular mass. Kidney Int. 2021;99(6):1478-1486. doi:10.1016/j.kint.2021.02.027
• Greenwood SA, Young HML, Briggs J, et al. Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): a multicentre, randomised controlled trial in the UK. Lancet Digit Health. 2024;6(1):e23-e32. doi:10.1016/S2589-7500(23)00204-2
• Lightfoot CJ, Wilkinson TJ, Vadaszy N, Graham-Brown MPM, Davies MJ, Yates T, Smith AC. Improving self-management behaviour through a digital lifestyle intervention: An internal pilot study. J Ren Care. 2024 Jan 31. doi: 10.1111/jorc.12488. Epub ahead of print. PMID: 38296833.
• Greenwood SA, Koufaki P, Macdonald JH, et al. Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: the PEDAL RCT. Health Technol Assess. 2021;25(40):1-52. doi:10.3310/hta25400
• Wilund KR, Viana JL, Perez LM. A Critical Review of Exercise Training in Hemodialysis Patients: Personalized Activity Prescriptions Are Needed. Exerc Sport Sci Rev. 2020;48(1):28-39. doi:10.1249/JES.0000000000000209