***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Control of serum phosphate remains a difficult clinical issue in most hemodialysis ( HD ) patients . This study examines 2 nonpharmacological approaches to improving phosphate control in HD patients . METHODS First , 9 stable HD patients underwent dialysis in r and om fashion for either 4 hours 3 times weekly or 5 hours 3 times weekly . Adjustments were made to blood flow rates such that Kt/V was the same for all sessions , thus allowing independent assessment of the influence of time . The primary end point was weekly dialysate phosphate removal . In the second study , 12 different patients underwent an exercise program in which they pedaled a bicycle ergometer either immediately before or during dialysis . Again , weekly dialysate phosphate removal was measured . RESULTS In the time study , urea reduction ratio ( 69 % + /- 0.02 % versus 68 % + /- 0.07 , 4 versus 5 hours ) and weekly urea removal were no different between the 2 groups . However , weekly phosphate removal ( 3,007 + /- 641 versus 3,400 + /- 647 mg ; P < 0.02 ) significantly improved with longer dialysis duration . Serum phosphate levels improved , but did not reach statistical significance in this short-term study . In the exercise study , weekly phosphate removal improved with exercise , but did not reach significance ( 2,741 + /- 715 [ no exercise ] versus 2,917 + /- 833 [ exercise predialysis ] versus 2,992 + /- 852 mg [ exercise during dialysis ] ; P = 0.055 ) , although comparing only exercise during dialysis with no exercise reached significance ( P = 0.02 ) . There was no significant difference in serum phosphate levels . CONCLUSION Both increased dialysis time and exercise result in increased dialytic removal of phosphate and could be expected in the long term to improve phosphate control Previous studies have suggested that exercise during hemodialysis ( HD ) could increase the efficacy of solute removal , although this hypothesis has not been conclusively evaluated . The goal of this study was to compare the removal of low‐molecular weight solutes between HD sessions , with and without aerobic exercise . It was a controlled clinical trial , including HD patients in a r and omly cross‐over design , such that each patient received a HD session with exercise ( intervention ) and the next one without exercise ( control ) , three times each . In the exercise sessions , patients pedaled on a cycle ergometer for 60 minutes . The total mass of removed urea , potassium , creatinine , and phosphate were calculated from the solutes concentration in dialysate ( continuous spent sampling of dialysate ) . This was evaluated in a total of 132 HD sessions of patients with a mean age of 54 ± 15 years , 75 % male and HD vintage of 3 ( 2–13 ) years . Phosphate removal in dialysate during intervention sessions was significantly higher ( 5.6 [ 2.5–18.9 ] vs. 5.1 [ 1.5–11.2 ] mg/min ) than during control sessions , P = 0.04 . The median mass of phosphate removed during control HD session was 1226 ( 367.8–2697.2 ) vs. 1348.6 ( 613.0–4536.2 ) mg/session during intervention sessions . The exercise  did not modify the removal of urea ( control 122.6 [ 61.3–286.0 ] vs. exercise 112.4 [ 51.1–250.3 ] mg/min , P = 0.44 ) , creatinine ( control 5.6 [ 2.5–13.8 ] vs. exercise 5.6 [ 2.5–12.8 ] mg/min , P = 0.49 ) , or potassium ( control 13.3 [ 11.2–15.8 ] vs. exercise 13.8 [ 6.6–15.8 ] mEq/min , P = 0.49 ) . Aerobic exercise during HD increases the efficacy of phosphate removal , without changing urea , creatinine and potassium removal . The implication s of this finding in mineral and bone disease and cardiovascular disease need to be evaluated on future clinical trials Background Functional limitations , altered cardiac autonomic activity , and psychological distress are known disorders in chronic hemodialysis ( HD ) patients , relating to increased morbidity and mortality . The aim of this study was to examine the influence of an exercise training program on emotional parameters and heart rate variability ( HRV ) indices , as well as to determine whether emotional stress contributes to autonomic dysfunction in these patients . Methods Forty-four HD patients were r and omly assigned into group A ( 24 patients , aged 46.3 ± 11.2 years ) , who participated in a 1-year intradialytic exercise training program and group B ( 20 patients , aged 45.8 ± 10.8 years ) , who were used as controls . At baseline and a year after , measures of HRV were obtained for the estimation of st and ard deviation of RR intervals , the mean square successive differences , percentage of RR intervals differing by more than 50 ms from the preceding RR interval ( pNN50 ) , and low to high frequency components . Emotional parameters ( Beck Depression Inventory – BDI and Hospital Anxiety and Depression Scale – HADS ) were also assessed by vali date d question naires . Moreover , all patients performed a spiroergometric study for the estimation of VO2peak . Results At baseline , all measurements were similar in the two groups and remained almost unchanged after a year in group B. After a year of training , VO2peak increased from 16.79 ± 5.24 to 22.33 ± 4.90 ml/kg per min ( P > 0.001 ) in group A. Trained patients also showed an increase in st and ard deviation of RR intervals by 58.8 % ( P > 0.001 ) , the mean square successive differences by 68.1 % ( P > 0.001 ) , pNN50 by 23.5 % ( P > 0.001 ) , and a low to high frequency ratio by 17.3 % ( P > 0.001 ) . Finally , at the end of the study , group A showed a decrease in BDI score by 34.5 % ( P > 0.001 ) and HADS by 23.9 % ( P > 0.001 ) . Canonical correlation revealed significant inverse correlation among depression ( in BDI and HADS ) and HRV indices before and after exercise training . Conclusion Cardiac autonomic modulation seemed to be sensitive to the experience of persistent depression in HD patients .  Significantly , exercise training  reduced emotional distress and concomitantly improved HRV Summary Background The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared . In this study , we aim ed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease . Methods We used  linked electronic health records from 1997 to 2010 in the CALIBER ( CArdiovascular research using LInked Bespoke studies and Electronic health Records ) programme to assemble a cohort of 1·25 million patients , 30 years of age or older and initially free from cardiovascular disease , a fifth of whom received blood pressure-lowering treatments . We studied the heterogeneity in the age-specific associations of clinical ly measured blood pressure with 12 acute and chronic cardiovascular diseases , and estimated the lifetime risks ( up to 95 years of age ) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30 , 60 , and 80 years . This study is registered at Clinical Trials.gov , number NCT01164371 . Findings During 5·2 years median follow-up , we recorded 83 098 initial cardiovascular disease presentations . In each age group , the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90–114 mm Hg and diastolic blood pressure of 60–74 mm Hg , with no evidence of a J-shaped increased risk at lower blood pressures . The effect of high blood pressure varied by cardiovascular disease endpoint , from strongly positive to no effect . Associations with high systolic blood pressure were strongest for intracerebral haemorrhage ( hazard ratio 1·44 [ 95 % CI 1·32–1·58 ] ) , subarachnoid haemorrhage ( 1·43 [ 1·25–1·63 ] ) , and stable angina ( 1·41 [ 1·36–1·46 ] ) , and weakest for abdominal aortic aneurysm ( 1·08 [ 1·00–1·17 ] ) . Compared with diastolic blood pressure , raised systolic blood pressure had a greater effect on angina , myocardial infa rct ion , and peripheral arterial disease , whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure . Pulse pressure associations were inverse for abdominal aortic aneurysm ( HR per 10 mm Hg 0·91 [ 95 % CI 0·86–0·98 ] ) and strongest for peripheral arterial disease ( 1·23 [ 1·20–1·27 ] ) . People with  hypertension ( blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs ) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3 % ( 95 % CI 62·9–63·8 ) compared with 46·1 % ( 45·5–46·8 ) for those with normal blood pressure , and developed cardiovascular disease 5·0 years earlier ( 95 % CI 4·8–5·2 ) . Stable and unstable angina accounted for most ( 43 % ) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years , whereas heart failure and stable angina accounted for the largest proportion ( 19 % each ) of years of life lost from index age 80 years . Interpretation The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range , and that diastolic and systolic associations are concordant , are not supported by the findings of this high-resolution study . Despite modern treatments , the lifetime burden of hypertension is substantial . These findings emphasise the need for new  blood pressure-lowering strategies , and will help to inform the design of r and omised trials to assess them . Funding Medical Research Council , National Institute for Health Research , and Wellcome Trust BACKGROUND Cardiovascular disease ( CVD ) mortality rates are greatly elevated in chronic kidney disease patients receiving maintenance haemodialysis therapy . The purpose of this study was to evaluate the efficacy of intradialytic endurance exercise training on novel risk factors that may contribute to this excessive CVD risk . METHODS Seventeen haemodialysis patients were r and omized to either an intradialytic exercise training ( cycling ) group ( EX ; n = 8) or a non-exercising control group ( CON ; n = 9 ) for 4 months . At baseline and following the intervention , we measured serum parameters related to CVD risk and renal function , used echocardiography to measure variables related to cardiac structure and function and assessed physical performance by a vali date d shuttle walk test . RESULTS Performance on the shuttle walk test increased by 17 % in EX ( P < 0.05 ) , but did not change in CON . There was no change in serum lipids or inflammatory markers ( C-reactive protein , interleukin-6 ) in either group . Serum thiobarbituric acid reactive substances , a marker of oxidative stress , were reduced by 38 % in EX ( P < 0.05 ) , but did not change in CON . In addition , serum alkaline phosphatase ( ALP ) , a putative risk factor for vascular calcification , was reduced by 27 % in EX ( P < 0.05 ) , but did not change in CON . There was no change in left atrial volume , left ventricular mass or myocardial performance index in either group . However , the thickness of the epicardial fat layer was reduced by 11 % in EX ( P < 0.05 ) , but did not change in CON . Furthermore , the change in physical performance was inversely correlated to the change in epicardial fat ( r = -0.63 ; P = 0.03 ) . CONCLUSIONS These results suggest that endurance exercise training may improve CVD risk in haemodialysis patients by decreasing novel risk factors including serum oxidative stress , ALP and epicardial fat BACKGROUND Sedentary behavior is associated with an increased risk for death in the general population . However , the association between inactivity and mortality has not been studied in a large cohort of dialysis patients despite the high prevalence of sedentary behavior in this group . METHODS We used the Dialysis Morbidity and Mortality Study Wave 2 , a prospect i ve study of a national sample of 4,024 incident peritoneal dialysis and hemodialysis patients from 1996 to 1997 , to determine whether sedentary behavior is associated with increased mortality during a 1-year period in this group after adjusting for confounding variables . RESULTS The study population consisted of the 2,837 patients with accurate survival data who were able to ambulate and transfer . Eleven percent of the sedentary patients died during the study period compared with 5 % of nonsedentary patients 
    Output:
    
Both aerobic training and combined training again elicited greater improvements in aerobic capacity than control .
For systolic blood pressure , combined training was superior to control .
For diastolic blood pressure , combined training was superior to aerobic training and control .
No modality was superior to control for haemodialysis efficiency .
Combined training was ranked as the most effective treatment for aerobic capacity and arterial blood pressure .
CONCLUSION Combined training was the most effective modality to increase aerobic capacity and blood pressure control in people who require haemodialysis .