Combination effect of nutrition and exercise intervention in patients with maintenance dialysis: A systematic review and meta-analysis

OBJECTIVE: Although nutritional and exercise interventions in mixed populations of non-dialysis and dialysis chronic kidney disease patients can improve muscle health, no study has specifically targeted dialysis patients or assessed their dietary intake. This systematic review and me-ta-analysis examined whether combined interventions improve physical performance, nutritional status, dietary intake, and quality of life (QOL) in adults receiving dialysis. METHODS: Following the PRISMA 2020 statement (PROSPERO CRD42024543470, registered on May 16, 2024), PubMed, Ichushi Web, and Web of Science were searched to September 30, 2024 for randomized, cluster-randomized, or crossover trials comparing combined nutrition plus exercise with sole either alone or with no intervention in adults (≥18 years) on hemodialysis or peritoneal dialysis. Favorable outcomes included physical performance, skeletal muscle mass, body mass index, energy and protein intake, QOL, and mortality, whereas the unfavorable outcome was gastrointestinal symptoms. Random-effects meta-analyses calculated mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Eight trials with 231 hemodialysis patients were eligible; seven contributed to quantitative synthesis. Nutritional interventions involved mainly oral supplements, and exercise (resistance, aerobic, or neuromuscular electrical stimulation) was performed two to three times/week for 3-12 months. Combined therapy significantly improved the 6MWT distance (MD 45.17 m, 95% CI 12.60-77.75), gait speed (MD 0.09 m/s, 95% CI 0.02 to 0.17), and TUG time (MD -1.44 s, 95% CI -2.63 to -0.25). No significant differences were observed in the Sit-to-Stand test, lean body mass, BMI, intake, or QOL. CONCLUSIONS: Compared with nutritional intervention alone, combined nutrition and exercise intervention was associated with improved physical performance outcomes in hemodialysis patients but showed no clear benefit for dietary intake, body composition, or QOL. The certainty of evidence was very low for all outcomes.