Efficacy of Neuromuscular Electrical Stimulation in Patients on Hemodialysis: An Updated Systematic Review and Meta-analysis

Rationale & Objective Kidney disease is associated with reduced physical function, muscle mass, and quality of life (QoL). Neuromuscular electrical stimulation (NMES) is a promising intervention to address these outcomes. This study aimed to update previous meta-analyses by including the latest randomized controlled trials (RCTs). Study Design Systematic review and meta-analysis of RCTs. Setting & Study Populations RCTs evaluating effects of NMES in adult patients with kidney disease. Selection Criteria for Studies Outcomes included muscle strength, muscle mass, functional capacity, physical performance, activities of daily living, physical activity, health-related QoL, and adverse events. Data Extraction A systematic search was conducted in PubMed, Cochrane Library, and ICHUSHI (April 27, 2024). Analytical Approach Random-effects meta-analyses were performed using Review Manager 5.4. Risk of bias and certainty of evidence were assessed using RoB 2.0 and GRADE. Results Twelve RCTs involving 289 participants were included. All participants underwent hemodialysis; no studies included patients on peritoneal dialysis, with predialysis chronic kidney disease, or post-kidney transplant recipients. NMES significantly improved lower-limb muscle strength (standardized mean difference, 0.84; 95% CI, 0.56-1.11; P < 0.001), 6-minute walk distance (mean difference, 48.15; 95% CI, 15.86-80.44; P = 0.003), and sit-to-stand performance (standardized mean difference, 0.80; 95% CI, 0.17-1.43; P = 0.01), without significantly increasing adverse events. No significant effects were found on appendicular skeletal muscle mass, timed up and go test, Short Physical Performance Battery, activities of daily living, physical activity, or HRQoL. The certainty of evidence ranged from very low to moderate across outcomes. Limitations Most studies had small sample sizes and high risk of bias. Conclusions NMES is a safe and effective intradialytic intervention for improving lower-limb muscle strength and functional capacity in patients undergoing hemodialysis. High-quality RCTs involving broader kidney disease populations are warranted to further establish its clinical utility. Plain-Language Summary People with kidney disease sometimes become weak and are less able to walk; many cannot exercise enough. We asked whether neuromuscular electrical stimulation (NMES)—electrical pulses delivered through pads or belts to the skin to make leg muscles contract—could help when used during dialysis. We searched PubMed, Cochrane Library, and ICHUSHI and pooled the results of 12 randomized trials (289 participants). NMES increased lower-limb strength and improved walking distance and sit-to-stand performance. It did not clearly improve muscle mass, physical performance scores, daily activities, physical activity, or quality of life. Adverse events were rare and similar to those experienced during usual care. Most trials were small and at risk of bias; therefore, stronger studies are needed. NMES might be a practical and safe add-on in patients who opt for exercise.