Physical fitness in patients treated with maintenance dialysis: a cross-sectional study

Physical fitness in patients treated with maintenance dialysis: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Physical fitness in patients treated with maintenance dialysis: a cross-sectional study Ana Carolina Pereira Baptista, Wagner Luiz Prado, Diego Giulliano Destro Christofaro, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4014563/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Low physical fitness has been associated with deterioration in overall health outcomes, resulting in increased hospitalization, morbidity, and mortality in patients treated with maintenance dialysis. This study aimed to compare self-reported physical fitness between patients treated with maintenance dialysis and those without chronic kidney disease (CKD). Methods: In this cross-sectional study, patients treated with maintenance dialysis (n=674) and individuals without CKD (control, n=518) self-reported physical fitness by responding to the International Fitness Scale (IFIS). Binary Logistic Regressions were adjusted for sex, age, schooling, diabetes, smoking, physical activity, sedentary behavior, and body max index. Results: Patients undergoing chronic hemodialysis are more likely to self-report lower general PF (OR=2.03; 95% CI: 1.35 to 3.05; p = 0.001), cardiorespiratory fitness (OR=3.18; 95% CI: 2.27 to 4.46; p<0.001), strength (OR=2.51; 95 % CI: 1.71 to 3.68; p<0.001) and agility (OR=1.83; 95% CI: 1.26 to 2.64; p=0.001) than the control group. Patients undergoing chronic hemodialysis who self-reported higher levels of physical activity were 5.64 times more likely to self-report high overall physical fitness (OR=5.64, 95% CI: 1.93 to 16.45, p<0.002). Conclusion: Patients treated with maintenance dialysis were twice as likely to self-report lower general physical fitness compared to individuals without kidney disease. Considering the consequences related to these factors, strategies to improve it, like initiatives related to the practice of physical exercises with this population, including strategically during hemodialysis, may be interesting. Kidney Dialysis Physical activity Chronic Kidney Failure Cardiorespiratory Fitness Muscle strength. Figures Figure 1 BACKGROUND Chronic kidney disease (CKD) is characterized by abnormalities in kidney structure or function for at least 3 months 1 . Patients with CKD present reduced ability to maintain metabolic and hydroelectrolytic balance 2 . Thus, these individuals are exposed to several factors which may contribute to the progressive worsening of general health 3 . CKD is an independent risk factor for functional impairment and frailty 4 . In patients treated with maintenance dialysis, lower physical fitness has been associated with a series of complications that may culminate in increased hospitalizations 5 morbidity and mortality in this population 6 . Physical fitness is defined as the ability to perform physical efforts, such as daily, occupational and leisure activities without excessive fatigue, and is considered as one of the strongest protective factors for the development of chronic diseases 7 . Yurdalan etl. al (2007) verified a significant reduction in all physical fitness components evaluated in patients treated with maintenance dialysis (n = 90) 8 . Bučar and Pajek (2018) reported greater functional deficits in balance, flexibility, and lower limb function. (n = 140). Both studies carried out an objective assessment of participants' physical fitness through the application of physical tests to measure their outcomes. Nevertheless, due to the challenges inherent in objectively assessing physical fitness through physical tests, it is not always viable to incorporate this variable in studies involving a large cohort of individuals 9 . Yet, relying solely on the isolated objective assessment of participants' physical fitness may present a snapshot of a situation that could be atypical. Factors such as the timing of the physical tests and potential fluctuations in the well-being of patients can influence these outcomes. Additionally, self-reporting of physical fitness provides a subjective perspective on individuals' abilities and their perceived sufficiency, highlighting the relativity of these assessments. Therefore, this study seeks to compare self-reported levels of physical fitness between patients undergoing maintenance dialysis and individuals without chronic kidney disease (CKD). METHODS Sample and ethics This cross-sectional study (survey) was conducted from October 2021 to July 2022. The recruitment of patients undergoing maintenance dialysis was actively carried out across a network of hemodialysis clinics located in Brazil. A total of 35 treatment units agreed to participate in the study. The online survey was shared with the multidisciplinary team at each clinic, who forwarded it to their patients to respond after formal consent. Patients with diagnoses of CKD on G5, undergoing chronic hemodialysis treatment at least twice a week for at least 3 months, from both sexes and older than 18 years were invited to answer the online survey. Healthy individuals over 18 years of age from both sexes, were invited to answer the online survey through social media, namely Facebook, Instagram, and WhatsApp. Individuals with diagnosis of CKD, but not undergoing hemodialysis, were not included in the sample. Visually impaired, illiterate, or individuals who felt unable to independently respond to the online survey were assisted by third parties. For chronic hemodialysis patients with visually illiterate or impaired conditions, the multidisciplinary team provided assistance in completing the questionnaire. This study was approved by the Ethics Committee of the Federal University of São Paulo (UNIFESP) (CAAE: 48533321.1.0000.5505, opinion: 5,384,426). All procedures were carried out by national law and the Helsinki Declaration. All participants provided informed consent prior to the study. Procedures Volunteers answered an electronic questionnaire (Google Forms) composed of 45 questions (52 for patients treated with maintenance dialysis). Both questionnaires have 6 sections: section 1: Free and Informed Consent Form; section 2: demographic, behavioral, clinical, and social characterization; section 3: physical fitness; section 4: level of physical activity; section 5: eating habits; and section 6: questioning how the questionnaire was completed (with or without help). For patients treated with maintenance dialysis, a link was provided so they could complete the survey either at home or at the dialysis unit, using their personal electronic devices. Individuals who were visually impaired, illiterate, unable to answer independently, lacked access to an electronic device or internet received assistance from either the researchers or a member of the multidisciplinary team to complete the forms. After filling in the questionnaire, the entire form was redirected to a spreadsheet generated by Google, in Microsoft Excel format, for further analysis. Only the main researcher had access to the identified responses, which is stored in a personal computer protect by passwords. The other researchers had only access to non-identified data. For the present study, the answers and questions present in sessions 1, 2, 3, and 4 were analyzed. The details of these domains are also described below. Instrument Self-reported physical fitness was assessed throughout IFIS, which is a self-report scale, validated for the Brazilian population, composed of five questions of the "Likert" scale, ranging from 1 (very bad) to 5 (very good). IFIS questions the individual about the perception he/she has about his/her general physical fitness, cardiorespiratory fitness, muscle strength, speed-agility, and flexibility, and the person should classify these components as "very bad", "bad", "or medium", "good" and "very good". The higher the score, the higher the self-reported physical fitness 9 , 10 . The IFIS is a validated instrument that has been translated into nine different languages, including Portuguese. Furthermore, the IFIS questionnaire is a good alternative to assess physical fitness in young adults and older adults 24 , 25 . This population is capable of comprehending the terminology and stating their perceptions accurately and clearly regarding overall physical fitness, cardiorespiratory fitness, muscular strength, speed-agility, and flexibility. The subjective perception of general physical fitness and fitness objectively measured by a battery of physical tests indicated a high degree of agreement 24 . Survey respondent characteristics Demographic data were obtained: name (open question asking them to type name and surnames), age (open question), sex (possible answers: male or female), current mass (open answer requesting the answer in kilograms), current height (open answer asking for the answer in meters), city and state in which you currently live (open question), level of education (possible answers: complete or incomplete elementary, complete or incomplete middle, complete or incomplete higher education), whether you smoke (possible answers: yes or no), if a doctor had already said you have diabetes (possible answers: yes or no), if currently work (possible answers: yes or no) and income [possible answers: less than 1 minimum wage, 1 minimum wage, from 1 to 2 minimum wages (1,088 real to 2,176 real), from 2 to 3 (2,176 real to 3,264 real), from 3 to 4 of (3,264 real to 4,352 real) or from 4 to 5 or more (4,352 real to 5,440 or more)]. For the group of patients treated with maintenance dialysis, we also questioned the weekly frequency with which they underwent hemodialysis (possible responses: 2,3,4,5,6 or 7 times a week) and how long they had been undergoing treatment (possible answers: less than 3 months, less than 1 year, between 1 and 2 years, between 2 and 3 years, between 3 and 4 years or between 4 and 5 years or more). In the control group questionnaire, there was also the following question: "Have any doctors ever told you that you have chronic kidney disease?" (Possible answers: yes or no). To assess the level of physical activity, the participants were asked the following questions: "Do you currently practice physical activities?" (Possible answers: yes or no); "Currently what kind of physical exercise do you perform?" [Possible answers: I don't perform physical exercise; walking; bodybuilding; functional exercises (jumping, squatting, spinning, running, pushing, pulling)]; "Currently how many times a week do you perform physical activity?" (Possible answers: none to seven times); "How long is each physical activity session?" (Possible answers: I do not practice physical activity; less than 30 min; between 30 and 60 min or more than 60 min) and "What is the intensity of this physical activity?" [Possible answers: I don't practice physical activity; light (considering the following examples given: bathing, shaving, driving, washing dishes, making the bed); moderate (considering the following examples given: gardening, playing volleyball, water aerobics, pedaling, fast walking); intense/vigorous (considering the following examples given: climbing stairs, swimming, jumping rope, playing football, running). Based on the answers, the time spent during each physical activity session during the study was multiplied by the number of days of the week in which the participant exercised. The sedentary behavior was also evaluated through the following question: "On average how many HOURS do you spend sitting or lying down in a day? Don't consider the hours you spend sleeping" (open question). Statistical analysis The data were stored and analyzed using SPSS 25.0. Data normality was verified by the Shapiro-Wilks test. The results are presented as median and interquartile range for continuous variables and frequency (absolute and relative – %) for categorical ones. Comparison between groups was performed using the Mann-Whitney and Chi-square tests. Binary Logistic Regression was used to verify the association between undergoing chronic hemodialysis and reporting low physical fitness adjusted for sex, age, education level, diabetes, smoking status, sedentary behavior (SB), and body mass index (BMI)]. In the binary logistic regression analysis, low physical fitness was defined as a score below 3 on the International Fitness Scales (IFIS). With the exception of age and sedentary behavior (treated as continuous variables), the variables: sex, education level, diabetes, smoking status were treated in a categorized manner. All variables were entered together into the model. For the analysis of physical activity, the participants who added 150 minutes or more of moderate to high-intensity physical activity were classified as physically active, whereas those who did not reach this threshold were classified as inactive 36 , 37 . Binary Logistic Regression was also used to verify the association between physical activity and self-report fitness level in dialysis patients (considering the same adjustment variables), but contemplating only participants undergoing hemodialysis with physical activity as a comparator factor (inactive adopted as reference) 36 , 37 . Significance was set at p < 0.05 and 95% confidence interval (95%CI). RESULTS A total of 674 patients treated with maintenance dialysis and 518 without CKD participated in this study. The number of patients according to the dialisys vintage was: less than 1 year: 116 (17.2%), between 1 and 2 years: 117 (17.4%), between 2 and 3 years: 91 (13.5%), between 3 and 4 years: 103 (15.3%), between 4 and 5 years or more: 247 (36.6%). The number of patients according to the weekly frequency with which they underwent chronic hemodialysis was: 3 times a week: 604 (89.6%), 5 times a week: 15 (2.2%), 6 times a week: 11 (1.6%), 4 times a week: 32 (4.7%), twice a week: 12 (1.8%). Among patients treated with maintenance dialysis, 373(55.3%) answered the questionnaire with help, while 301(44.7%) answered alone. Regarding the way in which the participants in the control group filled out the questionnaire, 70 (13.5%) answered it with help, while 448 (86.5%) answered it alone. Patients treated with maintenance dialysis were older, with lower BMI, engaged in fewer moderate to vigorous physical activities, had fewer sedentary behavior, and higher frequency of diabetes when compared to participants who did not undergo hemodialysis ( Table 1 ). Table 1 Sample characterization. Hemodialysis (n = 674) No hemodialysis (n = 518) Variables Median (IR) Median (IR) P Age (Years) 57.00 (21.00) 41.00 (32.00) < 0.001 Mass (kg) 70.50 (21.00) 72.00 (20.00) 0.333 Height (cm) 167.00 (13.00) 165.00 (14.00) 0.010 BMI (kg/m 2 ) 25.28 (6.59) 25.81 (6.14) 0.015 MVPA (min/week) 0.00 (0.00) 60.00 (150.00) < 0.001 SB (hours/day) Sex (% Female/%Male) 8.00 (6.00) 41/59 9.00 (8.00) 68/32 < 0.001 Education %(95CI) %(95CI) Incomplete fundamental 30.3 (26.8–33.7) 7.9 (5.5–10.2) Complete fundamental 11.3 (8.8–13.6) 5.2 (3.3–7.1) Incomplete high school 7.1 (5.1-9.0) 3.1 (1.6–4.5) Complete high school 28.5 (25.0-31.9) 17.0 (13.7–20.2) < 0.001 Incomplete graduate 7.4 (5.4–9.4) 18.0 (14.6–21.2) Graduated 15.4 (12.7–18.1) 48.8 (44.5–53.1) Cardiovascular risk factors %(95CI) %(95CI) Diabetes 35.6 (31.9–39.2) 9.3 (6.7–11.7) < 0.001 Smoking 9.6 (7.4–11.9) 9.5 (6.9–12.0) 1.000 MVPA = minutes of moderate to vigorous physical activities/week; SB = hours of sedentary behavior/ day. Multivariate Binary Logistic Regression analysis revealed that patients treated with maintenance dialysis were twice as likely to report lower general physical fitness. Similar findings were observed for cardiorespiratory fitness, muscular strength, and speed/agility. No associations were observed for flexibility (Table 2 ) . Table 2 Association between self-report fitness level in patients treated with maintenance dialysis and participants without chronic kidney disease (n = 1192). Fitness Component Reference Group Outcome Definition OR 95% CI P-value General Physical Fitness High Self-reported fitness level Ref Ref Ref Low 1.86 1.22–2.83 0.004 Cardiorespiratory Fitness High Self-reported fitness level Ref Ref Ref Low 3.04 2.14–4.34 < 0.001 Strength High Self-reported fitness level Ref Ref Ref Low 2.34 1.58–3.46 < 0.001 Flexibility High Self-reported fitness level Ref Ref Ref Low 1.14 0.78–1.65 0.491 Agility High Self-reported fitness level Ref Ref Ref Low 1.75 1.20–2.57 0.004 Adjusted by sex, age, education level, diabetes, smoking status, physical activity, sedentary behavior, and BMI. Note: OR = Odds Ratio; CI = Confidence Interval; P-value indicates statistical significance. In Fig. 1 , we present the self-reported fitness levels of patients treated with maintenance dialysis and participants without chronic kidney disease. Table 3 presents the associations between self-reported physical activity level and self-reported physical fitness level in patients undergoing dialysis. Higher self-reported physical activity level was independently associated with better self-reported physical fitness. Table 3 Association between physical activity and self-report fitness level in dialysis patients (n = 674). Fitness Component Reference Group Outcome Definition OR 95% CI P-value General Physical Fitness Inactive Self-reported fitness level Ref Ref Ref Active 5.64 1.93–16.45 0.002 Cardiorespiratory Fitness Inactive Self-reported fitness level Ref Ref Ref Active 6.23 2.84–13.63 < 0.001 Strength Inactive Self-reported fitness level Ref Ref Ref Active 6.29 2.19-18.00 0.001 Flexibility Inactive Self-reported fitness level Ref Ref Ref Active 2.65 1.43–4.90 0.002 Agility Inactive Self-reported fitness level Ref Ref Ref Active 4.89 1.99–12.03 0.001 Adjusted by sex, age, education level, diabetes, smoking status, sedentary behavior, and BMI. Note: OR = Odds Ratio; CI = Confidence Interval; P-value indicates statistical significance. DISCUSSION To the best of our knowledge, this is one of the very few studies to compare self-reported levels of physical fitness between patients undergoing maintenance dialysis and individuals without CKD. The main result is that patients treated with maintenance dialysis self-reported lower physical fitness in all assessed components, but flexibility, compared with individuals without CKD. The decline in physical fitness components in CKD patients reported in the presented study and in others, is related with adverse outcomes, including lower quality of life 13 , higher oxidative stress, a higher degree of inflammation 14 , an increase in hospitalizations 5 and a higher mortality rate 14 , 15 . Factors such as uremic neuropathy, anemia, heart disease, hypertension, fatigue, depression, and lower limb pain contribute to the observed reduction in physical fitness 15 , 16 . Previously, Yurdalan et al. (2007) identified a significant reduction in all physical fitness components among patients undergoing maintenance dialysis using the Eurofit Test Battery 35 . Similarly, Bučar and Pajek (2018) revealed functional deficits, in balance and flexibility 8 . Medeiros et al. (2002) highlighted gender-specific differences in cardiorespiratory fitness, strength, and flexibility. Kaysen et al. (2011) and Painter et al. confirmed impaired physical performance and exercise capacity in patients on maintenance dialysis 15 , 33 . Even in agreement with these studies, the results here presented emphasized the importance of self-reported data, offering a more general assessment and eliminating biases associated with fluctuating well-being. Furthermore, individuals' self-perception of their physical fitness reflects their beliefs about their capabilities and introduces a relative aspect to the assessment. This nuanced analysis prompts reflection on vulnerability and may encourage greater engagement in physical exercise. The analysis of Table 3 revealed positive correlations between the self-reported level of physical activity and self-reported physical fitness among patients treated with maintenance dialysis. It was found that patients undergoing maintenance dialysis who reported higher levels of physical activity were 5.64 times more likely to indicate high overall physical fitness (OR = 5.64, 95% CI: 1.93 to 16.45, p < 0.002). In line with our findings, Huang et al. (2020) showed in a pragmatic randomized controlled trial that engaging in moderate-intensity combined intradialytic exercise for 24 weeks can improve physical fitness 38 . To validate the representativeness of our samples, we compared our results with the Brazilian Dialysis Survey 2020 and general population data from the Brazilian Institute of Geography and Statistics (IBGE 2023). According to the Brazilian Dialysis Survey 2020, the sex of patients treated with maintenance dialysis was: 58% men and 42% women, conclusion of our study: 59% men and 41% women; According to the Brazilian Dialysis Survey 2020, the weekly frequency with which patients treated with maintenance dialysis underwent treatment: 90.8% of patients responded that they performed less than ≤ 4 sessions/week, finding of our study: 96.6% ≤ 4 sessions/week. According to the Brazilian Dialysis Survey 2020, the most prevalent age group was between 45 and 64 years old, representing 42.5%; finding of our study: the median age of the patients was 57 years old (IR:21). According to the Brazilian Dialysis Survey 2020, the region in Brazil with the highest number of patients treated with maintenance dialysis was Southeast; finding of our study: most of the individuals who responded to our questionnaire were from this region too 28 , 26 . Despite certain limitations, our findings closely align with national demographic and treatment patterns. The study acknowledges limitations, including expected differences in sample characteristics between the groups. Reported mass, sued to BMI calculations may not precisely represent the actual dry mass of patients, considering the complexities of CKD pathophysiology. The self-reported nature of data introduces potential biases in interpretation. Given the high prevalence of low physical fitness in individuals with CKD and its associated consequences, our study underscores the necessity of implementing strategies to address these components. Initiatives related to the practice of physical exercises with this population, including strategically during hemodialysis, may be interesting 17 – 22 . CONCLUSION Considering the high prevalence of low physical fitness in patients treated with maintenance dialysis, and the consequences related to these factors, strategies are necessary to work these components in these individuals. Initiatives related to the practice of physical exercises with this population, including strategically during hemodialysis, may be interesting Declarations ETHICS APPROVAL AND CONSENT TO PARTICIPATE This study was approved by the Ethics Committee of the Federal University of São Paulo (UNIFESP) (CAAE: 48533321.1.0000.5505, opinion: 5,384,426). All procedures were carried out by national law and the Helsinki Declaration. All participants provided informed consent prior to the study. AVAILABILITY OF DATA AND MATERIALS The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. COMPETING INTERESTS The authors declare that they have no competing interests. FUNDING Not applicable. DECLARATION OF CONFLICTING INTERESTS The Authors declares that there is no conflict of interest. AUTHORS' CONTRIBUTIONS All authors were involved in all stages of the study. ACKNOWLEDGEMENTS Not applicable. References WorkGroup KDIGO. Clinical practice guideline for the evaluation and management of chronic kidney disease. 2013.Kidney Int Suppl 3.4. Junior, João Egidio Romão. Doença renal crônica: definição, epidemiologia e classificação. J. Bras. Nefrol. 2004. 26.3 suppl. 1: 1-3. Ikizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 2013; 84: 1096–1107. Painter P, Roshanravan B. The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Current opinion in nephrology and hypertension. 2013;22(6):615-23. DeOreo PB. 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American Journal of Kidney Diseases. 57.1. 2011; 101-112. Painter, P., et al. Exercise capacity in hemodialysis, CAPD, and renal transplant patients. Nephron. 42.1. 1986; 47-51. Yurdalan, S. Ufuk, Selma Kondu, and Mehtap Malkoç. "Assessment of health-related fitness in the patients with end-stage renal disease on hemodialysis: using Eurofit Test Battery." Renal failure 29.8. 2007. 955-960. Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al.World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine. 2020;54(24):1451-62. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, Salem GJ, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510-30. Huang, Mei, et al. "The effect of intradialytic combined exercise on hemodialysis efficiency in end-stage renal disease patients: a randomized-controlled trial." International Urology and Nephrology 52. 2020. 969-976. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4014563","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":277873231,"identity":"41f7560f-1ecd-478c-a5dc-1fa643e0f199","order_by":0,"name":"Ana Carolina Pereira Baptista","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Carolina Pereira","lastName":"Baptista","suffix":""},{"id":277873232,"identity":"3a76ef28-aedf-463f-be0c-6409d448d4c4","order_by":1,"name":"Wagner Luiz Prado","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYBACgwMQuh7EZvgAYkoAMQ8RWhIbgGzGGSRrYeYhSsvx49cefNzDkLi9/fDGxzY1dYnzZzcwPnjbhluL2ZmccsMZzxjqZc6kFRvnHDucuOHOAWbDufi0HMhJk+Y5wJAgwZBjJp3bcCBxg0QCmzQvPi3n36RJ/wFp4X9jJm3ZAHTYjAT23/i02N9IPybNANIiAbSFsYE5seFGAhszPi2WN96wSfYckABqeVZs2HPssPGGOwebJeecw63F4Hz6M4kfB2yADkve+OBHTZ3s/NnNBz+8KcOtBRgFBgyQuIADxgZ86oGA/QEBBaNgFIyCUTDiAQC/3FgudBIhjwAAAABJRU5ErkJggg==","orcid":"","institution":"California State University","correspondingAuthor":true,"prefix":"","firstName":"Wagner","middleName":"Luiz","lastName":"Prado","suffix":""},{"id":277873233,"identity":"e22bb8c4-a18d-4215-8b41-592001a83b33","order_by":2,"name":"Diego Giulliano Destro Christofaro","email":"","orcid":"","institution":"São Paulo State University","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"Giulliano Destro","lastName":"Christofaro","suffix":""},{"id":277873234,"identity":"11423e89-7c3e-4e43-8e7e-ad58af84767b","order_by":3,"name":"Michael Torres","email":"","orcid":"","institution":"California State University","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Torres","suffix":""},{"id":277873235,"identity":"e603b2ef-17fd-4104-acc2-1a22be29db13","order_by":4,"name":"João Paulo Botero","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"João","middleName":"Paulo","lastName":"Botero","suffix":""}],"badges":[],"createdAt":"2024-03-04 23:29:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4014563/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4014563/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52449235,"identity":"10970ebd-2f58-4a86-a1d1-461058c478db","added_by":"auto","created_at":"2024-03-11 18:52:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41386,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSelf-reported Fitness Level in patients treated with maintenance dialysis and participants without chronic kidney disease.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4014563/v1/317c4fde84e33afa3cc207c0.png"},{"id":57820352,"identity":"4c8a3ffb-f695-4c45-ac5a-09c6f7956252","added_by":"auto","created_at":"2024-06-06 05:38:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":636694,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4014563/v1/188658db-d8eb-4e83-b4e9-5f8b56a7fba0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Physical fitness in patients treated with maintenance dialysis: a cross-sectional study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eChronic kidney disease (CKD) is characterized by abnormalities in kidney structure or function for at least 3 months\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Patients with CKD present reduced ability to maintain metabolic and hydroelectrolytic balance\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Thus, these individuals are exposed to several factors which may contribute to the progressive worsening of general health\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCKD is an independent risk factor for functional impairment and frailty\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In patients treated with maintenance dialysis, lower physical fitness has been associated with a series of complications that may culminate in increased hospitalizations\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e morbidity and mortality in this population\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePhysical fitness is defined as the ability to perform physical efforts, such as daily, occupational and leisure activities without excessive fatigue, and is considered as one of the strongest protective factors for the development of chronic diseases\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eYurdalan etl. al (2007) verified a significant reduction in all physical fitness components evaluated in patients treated with maintenance dialysis (n\u0026thinsp;=\u0026thinsp;90)\u003csup\u003e8\u003c/sup\u003e. Bučar and Pajek (2018) reported greater functional deficits in balance, flexibility, and lower limb function. (n\u0026thinsp;=\u0026thinsp;140). Both studies carried out an objective assessment of participants' physical fitness through the application of physical tests to measure their outcomes. Nevertheless, due to the challenges inherent in objectively assessing physical fitness through physical tests, it is not always viable to incorporate this variable in studies involving a large cohort of individuals \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eYet, relying solely on the isolated objective assessment of participants' physical fitness may present a snapshot of a situation that could be atypical. Factors such as the timing of the physical tests and potential fluctuations in the well-being of patients can influence these outcomes. Additionally, self-reporting of physical fitness provides a subjective perspective on individuals' abilities and their perceived sufficiency, highlighting the relativity of these assessments. Therefore, this study seeks to compare self-reported levels of physical fitness between patients undergoing maintenance dialysis and individuals without chronic kidney disease (CKD).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample and ethics\u003c/h2\u003e \u003cp\u003eThis cross-sectional study (survey) was conducted from October 2021 to July 2022. The recruitment of patients undergoing maintenance dialysis was actively carried out across a network of hemodialysis clinics located in Brazil. A total of 35 treatment units agreed to participate in the study. The online survey was shared with the multidisciplinary team at each clinic, who forwarded it to their patients to respond after formal consent.\u003c/p\u003e \u003cp\u003ePatients with diagnoses of CKD on G5, undergoing chronic hemodialysis treatment at least twice a week for at least 3 months, from both sexes and older than 18 years were invited to answer the online survey. Healthy individuals over 18 years of age from both sexes, were invited to answer the online survey through social media, namely Facebook, Instagram, and WhatsApp. Individuals with diagnosis of CKD, but not undergoing hemodialysis, were not included in the sample.\u003c/p\u003e \u003cp\u003eVisually impaired, illiterate, or individuals who felt unable to independently respond to the online survey were assisted by third parties. For chronic hemodialysis patients with visually illiterate or impaired conditions, the multidisciplinary team provided assistance in completing the questionnaire.\u003c/p\u003e \u003cp\u003e This study was approved by the Ethics Committee of the Federal University of S\u0026atilde;o Paulo (UNIFESP) (CAAE: 48533321.1.0000.5505, opinion: 5,384,426). All procedures were carried out by national law and the Helsinki Declaration. All participants provided informed consent prior to the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eVolunteers answered an electronic questionnaire (Google Forms) composed of 45 questions (52 for patients treated with maintenance dialysis). Both questionnaires have 6 sections: section 1: Free and Informed Consent Form; section 2: demographic, behavioral, clinical, and social characterization; section 3: physical fitness; section 4: level of physical activity; section 5: eating habits; and section 6: questioning how the questionnaire was completed (with or without help). For patients treated with maintenance dialysis, a link was provided so they could complete the survey either at home or at the dialysis unit, using their personal electronic devices. Individuals who were visually impaired, illiterate, unable to answer independently, lacked access to an electronic device or internet received assistance from either the researchers or a member of the multidisciplinary team to complete the forms. After filling in the questionnaire, the entire form was redirected to a spreadsheet generated by Google, in Microsoft Excel format, for further analysis.\u003c/p\u003e \u003cp\u003eOnly the main researcher had access to the identified responses, which is stored in a personal computer protect by passwords. The other researchers had only access to non-identified data.\u003c/p\u003e \u003cp\u003eFor the present study, the answers and questions present in sessions 1, 2, 3, and 4 were analyzed. The details of these domains are also described below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInstrument\u003c/h2\u003e \u003cp\u003eSelf-reported physical fitness was assessed throughout IFIS, which is a self-report scale, validated for the Brazilian population, composed of five questions of the \"Likert\" scale, ranging from 1 (very bad) to 5 (very good). IFIS questions the individual about the perception he/she has about his/her general physical fitness, cardiorespiratory fitness, muscle strength, speed-agility, and flexibility, and the person should classify these components as \"very bad\", \"bad\", \"or medium\", \"good\" and \"very good\". The higher the score, the higher the self-reported physical fitness \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe IFIS is a validated instrument that has been translated into nine different languages, including Portuguese. Furthermore, the IFIS questionnaire is a good alternative to assess physical fitness in young adults and older adults\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. This population is capable of comprehending the terminology and stating their perceptions accurately and clearly regarding overall physical fitness, cardiorespiratory fitness, muscular strength, speed-agility, and flexibility. The subjective perception of general physical fitness and fitness objectively measured by a battery of physical tests indicated a high degree of agreement \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eSurvey respondent characteristics\u003c/h2\u003e \u003cp\u003eDemographic data were obtained: name (open question asking them to type name and surnames), age (open question), sex (possible answers: male or female), current mass (open answer requesting the answer in kilograms), current height (open answer asking for the answer in meters), city and state in which you currently live (open question), level of education (possible answers: complete or incomplete elementary, complete or incomplete middle, complete or incomplete higher education), whether you smoke (possible answers: yes or no), if a doctor had already said you have diabetes (possible answers: yes or no), if currently work (possible answers: yes or no) and income [possible answers: less than 1 minimum wage, 1 minimum wage, from 1 to 2 minimum wages (1,088 real to 2,176 real), from 2 to 3 (2,176 real to 3,264 real), from 3 to 4 of (3,264 real to 4,352 real) or from 4 to 5 or more (4,352 real to 5,440 or more)].\u003c/p\u003e \u003cp\u003eFor the group of patients treated with maintenance dialysis, we also questioned the weekly frequency with which they underwent hemodialysis (possible responses: 2,3,4,5,6 or 7 times a week) and how long they had been undergoing treatment (possible answers: less than 3 months, less than 1 year, between 1 and 2 years, between 2 and 3 years, between 3 and 4 years or between 4 and 5 years or more). In the control group questionnaire, there was also the following question: \"Have any doctors ever told you that you have chronic kidney disease?\" (Possible answers: yes or no).\u003c/p\u003e \u003cp\u003eTo assess the level of physical activity, the participants were asked the following questions: \"Do you currently practice physical activities?\" (Possible answers: yes or no); \"Currently what kind of physical exercise do you perform?\" [Possible answers: I don't perform physical exercise; walking; bodybuilding; functional exercises (jumping, squatting, spinning, running, pushing, pulling)]; \"Currently how many times a week do you perform physical activity?\" (Possible answers: none to seven times); \"How long is each physical activity session?\" (Possible answers: I do not practice physical activity; less than 30 min; between 30 and 60 min or more than 60 min) and \"What is the intensity of this physical activity?\" [Possible answers: I don't practice physical activity; light (considering the following examples given: bathing, shaving, driving, washing dishes, making the bed); moderate (considering the following examples given: gardening, playing volleyball, water aerobics, pedaling, fast walking); intense/vigorous (considering the following examples given: climbing stairs, swimming, jumping rope, playing football, running).\u003c/p\u003e \u003cp\u003eBased on the answers, the time spent during each physical activity session during the study was multiplied by the number of days of the week in which the participant exercised.\u003c/p\u003e \u003cp\u003eThe sedentary behavior was also evaluated through the following question: \"On average how many HOURS do you spend sitting or lying down in a day? Don't consider the hours you spend sleeping\" (open question).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were stored and analyzed using SPSS 25.0. Data normality was verified by the Shapiro-Wilks test. The results are presented as median and interquartile range for continuous variables and frequency (absolute and relative \u0026ndash; %) for categorical ones. Comparison between groups was performed using the Mann-Whitney and Chi-square tests. Binary Logistic Regression was used to verify the association between undergoing chronic hemodialysis and reporting low physical fitness adjusted for sex, age, education level, diabetes, smoking status, sedentary behavior (SB), and body mass index (BMI)]. In the binary logistic regression analysis, low physical fitness was defined as a score below 3 on the International Fitness Scales (IFIS). With the exception of age and sedentary behavior (treated as continuous variables), the variables: sex, education level, diabetes, smoking status were treated in a categorized manner. All variables were entered together into the model. For the analysis of physical activity, the participants who added 150 minutes or more of moderate to high-intensity physical activity were classified as physically active, whereas those who did not reach this threshold were classified as inactive\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Binary Logistic Regression was also used to verify the association between physical activity and self-report fitness level in dialysis patients (considering the same adjustment variables), but contemplating only participants undergoing hemodialysis with physical activity as a comparator factor (inactive adopted as reference)\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and 95% confidence interval (95%CI).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 674 patients treated with maintenance dialysis and 518 without CKD participated in this study.\u003c/p\u003e\n\u003cp\u003eThe number of patients according to the dialisys vintage was: less than 1 year: 116 (17.2%), between 1 and 2 years: 117 (17.4%), between 2 and 3 years: 91 (13.5%), between 3 and 4 years: 103 (15.3%), between 4 and 5 years or more: 247 (36.6%). The number of patients according to the weekly frequency with which they underwent chronic hemodialysis was: 3 times a week: 604 (89.6%), 5 times a week: 15 (2.2%), 6 times a week: 11 (1.6%), 4 times a week: 32 (4.7%), twice a week: 12 (1.8%). Among patients treated with maintenance dialysis, 373(55.3%) answered the questionnaire with help, while 301(44.7%) answered alone.\u003c/p\u003e\n\u003cp\u003eRegarding the way in which the participants in the control group filled out the questionnaire, 70 (13.5%) answered it with help, while 448 (86.5%) answered it alone.\u003c/p\u003e\n\u003cp\u003ePatients treated with maintenance dialysis were older, with lower BMI, engaged in fewer moderate to vigorous physical activities, had fewer sedentary behavior, and higher frequency of diabetes when compared to participants who did not undergo hemodialysis \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e).\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample characterization.\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHemodialysis (n\u0026thinsp;=\u0026thinsp;674)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo hemodialysis (n\u0026thinsp;=\u0026thinsp;518)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (IR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (IR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.00 (21.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.00 (32.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMass (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70.50 (21.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72.00 (20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e167.00 (13.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e165.00 (14.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.28 (6.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.81 (6.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMVPA (min/week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.00 (150.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSB (hours/day)\u003c/p\u003e\n \u003cp\u003eSex (% Female/%Male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.00 (6.00)\u003c/p\u003e\n \u003cp\u003e41/59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.00 (8.00)\u003c/p\u003e\n \u003cp\u003e68/32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e%(95CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e%(95CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete fundamental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.3 (26.8\u0026ndash;33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9 (5.5\u0026ndash;10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete fundamental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.3 (8.8\u0026ndash;13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.2 (3.3\u0026ndash;7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.1 (5.1-9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.1 (1.6\u0026ndash;4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.5 (25.0-31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.0 (13.7\u0026ndash;20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.4 (5.4\u0026ndash;9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.0 (14.6\u0026ndash;21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGraduated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.4 (12.7\u0026ndash;18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.8 (44.5\u0026ndash;53.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular risk factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e%(95CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e%(95CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.6 (31.9\u0026ndash;39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.3 (6.7\u0026ndash;11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.6 (7.4\u0026ndash;11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.5 (6.9\u0026ndash;12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eMVPA\u0026thinsp;=\u0026thinsp;minutes of moderate to vigorous physical activities/week; SB\u0026thinsp;=\u0026thinsp;hours of sedentary behavior/ day.\u003c/p\u003e\n\u003cp\u003eMultivariate Binary Logistic Regression analysis revealed that patients treated with maintenance dialysis were twice as likely to report lower general physical fitness. Similar findings were observed for cardiorespiratory fitness, muscular strength, and speed/agility. No associations were observed for flexibility (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between self-report fitness level in patients treated with maintenance dialysis and participants without chronic kidney disease (n\u0026thinsp;=\u0026thinsp;1192).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFitness Component\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReference Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome Definition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral Physical Fitness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.22\u0026ndash;2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiorespiratory Fitness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.14\u0026ndash;4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrength\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.58\u0026ndash;3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlexibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78\u0026ndash;1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.491\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.20\u0026ndash;2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAdjusted by sex, age, education level, diabetes, smoking status, physical activity, sedentary behavior, and BMI. \u003cem\u003eNote: OR\u0026thinsp;=\u0026thinsp;Odds Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval; P-value indicates statistical significance.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, we present the self-reported fitness levels of patients treated with maintenance dialysis and participants without chronic kidney disease.\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents the associations between self-reported physical activity level and self-reported physical fitness level in patients undergoing dialysis. Higher self-reported physical activity level was independently associated with better self-reported physical fitness.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between physical activity and self-report fitness level in dialysis patients (n\u0026thinsp;=\u0026thinsp;674).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFitness Component\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReference Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome Definition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral Physical Fitness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.93\u0026ndash;16.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiorespiratory Fitness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.84\u0026ndash;13.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrength\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.19-18.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlexibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.43\u0026ndash;4.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-reported fitness level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.99\u0026ndash;12.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAdjusted by sex, age, education level, diabetes, smoking status, sedentary behavior, and BMI. \u003cem\u003eNote: OR\u0026thinsp;=\u0026thinsp;Odds Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval; P-value indicates statistical significance.\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo the best of our knowledge, this is one of the very few studies to compare self-reported levels of physical fitness between patients undergoing maintenance dialysis and individuals without CKD. The main result is that patients treated with maintenance dialysis self-reported lower physical fitness in all assessed components, but flexibility, compared with individuals without CKD. The decline in physical fitness components in CKD patients reported in the presented study and in others, is related with adverse outcomes, including lower quality of life\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, higher oxidative stress, a higher degree of inflammation\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, an increase in hospitalizations\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and a higher mortality rate\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Factors such as uremic neuropathy, anemia, heart disease, hypertension, fatigue, depression, and lower limb pain contribute to the observed reduction in physical fitness\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePreviously, Yurdalan et al. (2007) identified a significant reduction in all physical fitness components among patients undergoing maintenance dialysis using the Eurofit Test Battery\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Similarly, Bučar and Pajek (2018) revealed functional deficits, in balance and flexibility\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Medeiros et al. (2002) highlighted gender-specific differences in cardiorespiratory fitness, strength, and flexibility. Kaysen et al. (2011) and Painter et al. confirmed impaired physical performance and exercise capacity in patients on maintenance dialysis\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Even in agreement with these studies, the results here presented emphasized the importance of self-reported data, offering a more general assessment and eliminating biases associated with fluctuating well-being. Furthermore, individuals' self-perception of their physical fitness reflects their beliefs about their capabilities and introduces a relative aspect to the assessment. This nuanced analysis prompts reflection on vulnerability and may encourage greater engagement in physical exercise.\u003c/p\u003e \u003cp\u003eThe analysis of Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e revealed positive correlations between the self-reported level of physical activity and self-reported physical fitness among patients treated with maintenance dialysis. It was found that patients undergoing maintenance dialysis who reported higher levels of physical activity were 5.64 times more likely to indicate high overall physical fitness (OR\u0026thinsp;=\u0026thinsp;5.64, 95% CI: 1.93 to 16.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.002). In line with our findings, Huang et al. (2020) showed in a pragmatic randomized controlled trial that engaging in moderate-intensity combined intradialytic exercise for 24 weeks can improve physical fitness\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo validate the representativeness of our samples, we compared our results with the Brazilian Dialysis Survey 2020 and general population data from the Brazilian Institute of Geography and Statistics (IBGE 2023). According to the Brazilian Dialysis Survey 2020, the sex of patients treated with maintenance dialysis was: 58% men and 42% women, conclusion of our study: 59% men and 41% women; According to the Brazilian Dialysis Survey 2020, the weekly frequency with which patients treated with maintenance dialysis underwent treatment: 90.8% of patients responded that they performed less than \u0026le;\u0026thinsp;4 sessions/week, finding of our study: 96.6% \u0026le; 4 sessions/week. According to the Brazilian Dialysis Survey 2020, the most prevalent age group was between 45 and 64 years old, representing 42.5%; finding of our study: the median age of the patients was 57 years old (IR:21). According to the Brazilian Dialysis Survey 2020, the region in Brazil with the highest number of patients treated with maintenance dialysis was Southeast; finding of our study: most of the individuals who responded to our questionnaire were from this region too\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Despite certain limitations, our findings closely align with national demographic and treatment patterns.\u003c/p\u003e \u003cp\u003eThe study acknowledges limitations, including expected differences in sample characteristics between the groups. Reported mass, sued to BMI calculations may not precisely represent the actual dry mass of patients, considering the complexities of CKD pathophysiology. The self-reported nature of data introduces potential biases in interpretation.\u003c/p\u003e \u003cp\u003eGiven the high prevalence of low physical fitness in individuals with CKD and its associated consequences, our study underscores the necessity of implementing strategies to address these components. Initiatives related to the practice of physical exercises with this population, including strategically during hemodialysis, may be interesting\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eConsidering the high prevalence of low physical fitness in patients treated with maintenance dialysis, and the consequences related to these factors, strategies are necessary to work these components in these individuals. Initiatives related to the practice of physical exercises with this population, including strategically during hemodialysis, may be interesting\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Federal University of São Paulo (UNIFESP) (CAAE: 48533321.1.0000.5505, opinion: 5,384,426). All procedures were carried out by national law and the Helsinki Declaration. All participants provided informed consent prior to the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDECLARATION OF CONFLICTING INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors declares that there is no conflict of interest.\u003c/p\u003e\n\u003ch4\u003eAUTHORS' CONTRIBUTIONS\u003c/h4\u003e\n\u003cp\u003eAll authors were involved in all stages of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorkGroup KDIGO. Clinical practice guideline for the evaluation and management of chronic kidney disease. 2013.Kidney Int Suppl 3.4.\u003c/li\u003e\n \u003cli\u003eJunior, Jo\u0026atilde;o Egidio Rom\u0026atilde;o. Doen\u0026ccedil;a renal cr\u0026ocirc;nica: defini\u0026ccedil;\u0026atilde;o, epidemiologia e classifica\u0026ccedil;\u0026atilde;o. J. Bras. Nefrol. 2004. 26.3 suppl. 1: 1-3.\u003c/li\u003e\n \u003cli\u003eIkizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 2013; 84: 1096\u0026ndash;1107.\u003c/li\u003e\n \u003cli\u003ePainter P, Roshanravan B. The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Current opinion in nephrology and hypertension. 2013;22(6):615-23.\u003c/li\u003e\n \u003cli\u003eDeOreo PB. 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Effects of exercise intervention on physical fitness and health-relalted quality of life in hemodialysis patients. Journal of Korean Academy of Nursing 39.4 (2009): 584-593.\u003c/li\u003e\n \u003cli\u003eSheng K, Zhang P, Chen L, Cheng J, Wu C, Chen J. Intradialytic exercise in hemodialysis patients: a systematic review and meta-analysis. American journal of nephrology. 2014;40(5):478-90.\u003c/li\u003e\n \u003cli\u003eBaker LA, March DS, Wilkinson TJ, Billany RE, Bishop NC, Castle EM, et al. Clinical practice guideline exercise and lifestyle in chronic kidney disease. BMC nephrology. 2022;23(1):75.\u003c/li\u003e\n \u003cli\u003ePu J, Jiang Z, Wu W, Li L, Zhang L, Li Y, et al. Efficacy and safety of intradialytic exercise in hemodialysis patients: a systematic review and meta-analysis. BMJ open. 2019;9(1):20633.\u003c/li\u003e\n \u003cli\u003eMatsuzawa, Ryota, et al. \u0026quot;Decline in the functional status and mortality in patients on hemodialysis: results from the Japan Dialysis Outcome and Practice Patterns Study.\u0026quot; Journal of Renal Nutrition 29.6. 2019; 504-510.\u003c/li\u003e\n \u003cli\u003eMerellano-Navarro, Eugenio, et al. Validity of the International Fitness Scale \u0026ldquo;IFIS\u0026rdquo; in older adults. Experimental gerontology. 95. 2017; 77-81.\u003c/li\u003e\n \u003cli\u003eOrtega, F. B., et al. Self‐reported and measured cardiorespiratory fitness similarly predict cardiovascular disease risk in young adults. Scandinavian journal of medicine \u0026amp; science in sports 23.6. 2013; 749-757.\u003c/li\u003e\n \u003cli\u003eNerbass, Fabiana B., et al. Brazilian dialysis survey 2020. Brazilian Journal of Nephrology. 44.2022; 349-357.\u003c/li\u003e\n \u003cli\u003eMarinho, Ana Wanda Guerra Barreto, et al. 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Acesso em: 24 nov. 2023.\u003c/li\u003e\n \u003cli\u003e\u0026Aacute;lvarez-Gallardo, Inmaculada C., et al. \u0026quot;International fitness scale (IFIS): Construct validity and reliability in women with fibromyalgia: The al-\u0026Aacute;ndalus Project.\u0026quot; Archives of physical medicine and rehabilitation. 97.3. 2016; 395-404.\u003c/li\u003e\n \u003cli\u003eS\u0026aacute;nchez‐Jim\u0026eacute;nez, A., et al. \u0026quot;Physical impairments and quality of life of colorectal cancer survivors: a case\u0026ndash;control study.\u0026quot; European journal of cancer care. 24.5. 2015; 642-649.\u003c/li\u003e\n \u003cli\u003e\u0026Aacute;lvarez-Salvago, Francisco, et al. Health status among long-term breast cancer survivors suffering from higher levels of fatigue: a cross-sectional study. Supportive Care in Cancer. 26. 2018; 3649-3658.\u003c/li\u003e\n \u003cli\u003eMar\u0026iacute;n‐Jim\u0026eacute;nez, Nuria, et al. Association of self‐reported physical fitness with pain during pregnancy: The GESTAFIT Project. Scandinavian journal of medicine \u0026amp; science in sports. 29.7. 2019; 1022-1030.\u003c/li\u003e\n \u003cli\u003eKaysen, George A., et al. Baseline physical performance, health, and functioning of participants in the Frequent Hemodialysis Network (FHN) trial. American Journal of Kidney Diseases. 57.1. 2011; 101-112.\u003c/li\u003e\n \u003cli\u003ePainter, P., et al. Exercise capacity in hemodialysis, CAPD, and renal transplant patients. Nephron. 42.1. 1986; 47-51.\u003c/li\u003e\n \u003cli\u003eYurdalan, S. Ufuk, Selma Kondu, and Mehtap Malko\u0026ccedil;. \u0026quot;Assessment of health-related fitness in the patients with end-stage renal disease on hemodialysis: using Eurofit Test Battery.\u0026quot; Renal failure 29.8. 2007. 955-960.\u003c/li\u003e\n \u003cli\u003eBull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al.World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine. 2020;54(24):1451-62.\u003c/li\u003e\n \u003cli\u003eChodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, Salem GJ, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510-30.\u003c/li\u003e\n \u003cli\u003eHuang, Mei, et al. \u0026quot;The effect of intradialytic combined exercise on hemodialysis efficiency in end-stage renal disease patients: a randomized-controlled trial.\u0026quot; International Urology and Nephrology 52. 2020. 969-976.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Kidney Dialysis, Physical activity, Chronic Kidney Failure, Cardiorespiratory Fitness, Muscle strength.","lastPublishedDoi":"10.21203/rs.3.rs-4014563/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4014563/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Low physical fitness has been associated with deterioration in overall health outcomes, resulting in increased hospitalization, morbidity, and mortality in patients treated with maintenance dialysis. This study aimed to compare self-reported physical fitness between patients treated with maintenance dialysis and those without chronic kidney disease (CKD).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this cross-sectional study, patients treated with maintenance dialysis (n=674) and individuals without CKD (control, n=518) self-reported physical fitness by responding to the International Fitness Scale (IFIS). Binary Logistic Regressions were adjusted for sex, age, schooling, diabetes, smoking, physical activity, sedentary behavior, and body max index.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e \u0026nbsp;Patients undergoing chronic hemodialysis are more likely to self-report lower general PF (OR=2.03; 95% CI: 1.35 to 3.05; p = 0.001), cardiorespiratory fitness (OR=3.18; 95% CI: 2.27 to 4.46; p\u0026lt;0.001), strength (OR=2.51; 95 % CI: 1.71 to 3.68; p\u0026lt;0.001) and agility (OR=1.83; 95% CI: 1.26 to 2.64; p=0.001) than the control group. Patients undergoing chronic hemodialysis who self-reported higher levels of physical activity were 5.64 times more likely to self-report high overall physical fitness (OR=5.64, 95% CI: 1.93 to 16.45, p\u0026lt;0.002).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Patients treated with maintenance dialysis were twice as likely to self-report lower general physical fitness compared to individuals without kidney disease. Considering the consequences related to these factors, strategies to improve it, like initiatives related to the practice of physical exercises with this population, including strategically during hemodialysis, may be interesting.\u003c/p\u003e","manuscriptTitle":"Physical fitness in patients treated with maintenance dialysis: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-11 18:52:42","doi":"10.21203/rs.3.rs-4014563/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"513da08a-0ca0-49cc-bfb2-f1a0fd8af3b1","owner":[],"postedDate":"March 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-06T05:30:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-11 18:52:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4014563","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4014563","identity":"rs-4014563","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}