**7. Recommendations for safety and efficacy of exercise training in HD patients**

Exercising should be done within the first hour of dialysis; do not exercise if you are hypertensive, cramping, or have a volume overload. Avoiding excessive weights on the vascular access limb; physicians in charge of a workout program Intradialytic or interdialytic exercise is preferable. Strength training is also impractical during dialysis [42].

Aerobic activities dominate intraadialytic exercise regimes. AE is performed with a cycle ergometer or bicycle training. There are several workout plans that use varied exercise frequency, intensities, and durations. It has been demonstrated that AE lasting from 8 weeks to 6 months improved peak VO2 by around 17% in individuals with ESRD [43].

During dialysis, both endurance and RE training regimes have been routinely used. Most published research papers use intraadialytic cycling as the principal modality of endurance training. Patients bike on a cycle ergometer while receiving HD. Many research have employed intraadialytic resistance training as the predominant modality of exercise [44].

Whole body resistance training, in which muscles are progressively stressed by increasing weights or resistance over time, is the most effective way for enhancing muscular development, strength, and function. Unfortunately, patients confined to a dialysis chair or bed find it challenging to exercise, hence the majority of intradialytic resistance training regimens have relied on low- to moderate-intensity exercises employing ankle weights or elastic bands [45].

Because it affects intradialytic hemodynamic stress, exercise during dialysis session is best done within first 2 hours of dialysis. Exercise commonly raises blood pressure and results in post-exercise hypotension, as is widely recognized. The post-exercise hypotension is particularly alarming since it may raise the likelihood of harmful ischemia episodes, especially in the latter stages of HD when ultrafiltration is reducing the total blood volume [42].

Due to less limitations on the type, amount, and intensity of exercises that patients may conduct when they are not confined to a dialysis chair or bed, interdialytic exercise would appear to offer numerous advantages to intradialytic activities. IDE is supported primarily by the fact that it is highly time-effective for patients and that compliance can be thoroughly tracked [42].

Studies have shown that exercising while receiving dialysis treatments increases the effectiveness of the procedure. These studies' findings imply that intradialytic cycling can improve blood flow to the active leg muscles. This transfers the urea and other toxins that have been held in the muscle compartments to the blood stream for HD elimination. It has been proposed that an additional 20 minutes of dialysis might be equivalent to an hour of AE. Improvements in tiredness levels, sadness, quality of life, sleep, restless legs, inflammation, and hospitalization rates are also seen in the studies [12].

The following The Southern Alberta Renal Program (SARP) recommendations may aid in the delivery of IDE in HD units:

1.The physiotherapist should evaluate each patient's suitability for activity. ESRD comorbidities and etiology, all pertinent blood work, medications, cardiac history, bone health, symptoms (angina, shortness of breath, or pain), previous surgeries, injuries, hospitalizations, falls history, past/current exercise habits,

current living situation, ambulation aids, and ability to perform daily activities must all be covered in a thorough medical history.

	- Unstable cardiac state (arrhythmias, severe arterio-venous stenosis, decompensated congestive heart failure, and angina pectoris)
	- Physical conditions that would make using the bike difficult
	- Ineffective blood glucose regulation
	- A current disease or infection
	- An ineffective CVC or AVF/AVG
	- Aiming for an ultrafiltration rate (UFR) of less than 13 ml/h/kg
	- BP 180/100 or >100/50 mm Hg
	- Resting heart rate (BPM): 100
	- No illness or hospitalization in the previous week
	- AVF or AVG needing enough needling or a well working CVC
	- Absence of any unusual symptoms (headaches, nausea, dizziness, or the flu).
	- A minimum hemoglobin level of 9 g/dl is required; patients with more problematic cardiac histories may be put on hold until their hemoglobin levels rise.
	- Controlled blood sugar levels (between 126 and 252 mg/dl)
	- Without experiencing any symptoms, oxygen saturation levels should be over 90% at rest and above 88% during activity.
