***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    Input: 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 INTRODUCTION Cardiovascular disease is the major cause of death in hemodialysis patients . Regular aerobic or intradialytic exercise may play a role in reducing cardiovascular mortality in these patients . The aim of this study was to evaluate the relationship between intradialytic exercise and echocardiographic findings . METHODS AND MATERIAL S Forty patients were enrolled in the study from Shahrekord Hemodialysis Center . They were r and omly assigned into the exercise and control groups . In the exercise group , the patients had a 30-minute exercise program per dialysis session , 3 times a week , for 3 months .  Electrocardiography and echocardiography  were done at the beginning of the study and 3 months later . RESULTS The mean age and body mass index of the patients were 43.2 + /- 10.5 years and 21.7 + /- 5.4 kg/m2 , respectively .  Left ventricular ejection fraction increased and systolic pulmonary artery pressure and right ventricular size decreased significantly after the study in the exercise group patients . CONCLUSIONS Our results showed the improvement of cardiac systolic and diastolic function in patients who had physical exercise during dialysis sessions . Regular intradialysis exercise can be suggested for hemodialysis patients without cardiac disease Background The anabolic response to progressive resistance exercise training ( PRET ) in haemodialysis patients is unclear . This pilot efficacy study aim ed to determine whether high-intensity intradialytic PRET could reverse atrophy and consequently improve strength and physical function in haemodialysis patients . A second aim was to compare any anabolic response to that of healthy participants completing the same program . Methods In a single blind controlled study , 23 haemodialysis patients and 9 healthy individuals were r and omly allocated to PRET or an attention control ( SHAM ) group . PRET completed high-intensity exercise leg extensions using novel equipment . SHAM completed low-intensity lower body stretching activities using ultra light resistance b and s. Exercises were completed thrice weekly for 12 weeks , during dialysis in the haemodialysis patients . Outcomes included knee extensor muscle volume by magnetic resonance imaging , knee extensor strength by isometric dynamometer and lower body tests of physical function . Data were analysed by a per protocol method using between-group comparisons . Results PRET elicited a statistically and clinical ly significant anabolic response in haemodialysis patients  ( PRET — SHAM , mean difference [ 95 % CI ] : 193[63 to 324 ] cm3 ) that was very similar to the response in healthy participants  ( PRET — SHAM , 169[−41 to 379 ] cm3 ) . PRET increased strength in both haemodialysis patients and healthy participants . In contrast , PRET only enhanced lower body functional capacity in the healthy participants . Conclusions Intradialytic PRET elicited a normal anabolic and strength response in haemodialysis patients . The lack of a change in functional capacity was surprising and warrants further investigation 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 OBJECTIVES Regular exercise is known to reduce arterial stiffness ( AS ) in hemodialysis patients . However , the impact of a more realistic intradialytic form of exercise , such as pedaling , is unclear . We aim ed to examine ( i ) the effect of intradialytic pedaling exercise on AS over 4 months and ( ii ) the longer term effect of pedaling on AS 4 months after exercise cessation . METHODS Patients on stable in-center hemodialysis ( 3 x/week ) were r and omly assigned 1:1 to either intradialytic pedaling exercise ( EX ) or to a control group receiving usual hemodialysis ( nonEX ) for 4 months . At baseline and 4 months , peripheral and central blood pressure ( BP ) indices , heart rate ( HR ) , augmentation index HR corrected ( AIx75 ) , and carotid-femoral pulse wave velocity ( cfPWV ) were assessed ( applanation tonometry ) . Measurements were repeated in the EX group 4 months postexercise cessation . RESULTS As per protocol analysis was completed in 10 EX group participants ( 58 ± 17 years , body mass index 26 ± 4 kg/m2 ) and 10 nonEX group participants ( 53 ± 15 years , body mass index 27 ± 6 kg/m2 ) . Peripheral and central BP was unchanged in both groups . AIx75 was unchanged in the EX group , however , a significant median increase of 3.5 % [ interquartile range , IQR 1.0 , 8.5 ] was noted in the nonEX group ( P = 0.009 ) . We noted a significantly greater absolute decrease in cfPWV in the EX group compared to controls : -1.00 [ IQR -1.95 , 0.05 ] vs. 0.20 [ IQR -0.10 , 0.90 ] ( P = 0.033 ) . Interestingly , the decrease in cfPWV observed in the EX group was partially reversed 4 months after exercise cessation . CONCLUSION Intradialytic pedaling exercise has a beneficial impact on AS . This relationship warrants further investigation . CLINICAL TRIALS REGISTRATION Trial Number # NCT03027778 ( clinical trials.gov ) BACKGROUND Protein-energy wasting ( PEW ) is common in patients undergoing hemodialysis ( HD ) . Studies have assessed the positive effect of oral nutritional supplementation ( ONS ) or resistance exercise ( RE ) on nutritional status ( NS ) markers in patients undergoing HD . METHODS The aim of this study was to assess the effect of ONS and RE on NS and the quality of life ( QOL ) of 36 patients undergoing HD . In a r and omized clinical trial , patients were divided into the following two groups : a control group ( ONS ) that received a can of ONS during their HD sessions and an intervention group ( ONS + RE ) that received a can of ONS and underwent a 40-min session of RE during their HD sessions . Both interventions lasted 12 weeks . The patients ' anthropometric , biochemical , dietetic and bioelectrical impedance measurements as well as their QOL , evaluated using the Kidney Disease Quality of Life Short Form , were recorded . RESULTS At baseline , 55.5 % of patients presented with PEW according to International Society of Renal Nutrition and Metabolism criteria ( 20 patients ) . We found statistically significant changes from baseline in both groups , such as increases in body weight , body mass index , midarm circumference , midarm muscle circumference , triceps skinfold thickness , fat mass percentage , h and grip strength , phase angle and serum albumin . A decrease in the prevalence of PEW was observed in both groups at the end of the intervention . A delta comparison between groups showed no statistically significant differences in the anthropometric and biochemical parameters . No significant improvement was observed in QOL and body composition measured by bioimpedance vector analysis . Dietary energy and protein intake increased significantly during the study period for all patients . CONCLUSION Oral nutritional supplementation during HD improves NS . The addition of RE during HD does not seem to augment the acute anabolic effects of intradialytic ONS on NS Background Exercise during hemodialysis treatments improves physical function , markers of cardiovascular disease and quality of life . However , exercise programs are not a part of st and ard therapy in the vast majority of hemodialysis clinics internationally . Hemodialysis unit-based accredited exercise physiologists may contribute to an increased intradialytic exercise uptake and improved physical function . Methods and design This is a stepped wedge cluster r and omised controlled trial design . A total of 180 participants will be recruited from 15 community satellite hemodialysis clinics in a large metropolitan Australian city . Each clinic will represent a cluster unit . The stepped wedge design will consist of three groups each containing five r and omly allocated cluster units , allocated to either 12 , 24 or 36 weeks of the intervention . The intervention will consist of an accredited exercise physiologist-coordinated program consisting of six lower body resistance exercises using resistance elastic b and s and tubing . The resistance exercises will include leg abduction , plantar flexion , dorsi flexion , straight-leg/bent-knee raise , knee extension and knee flexion . The resistance training will incorporate the principle of progressive overload and completed in a seated position during the first hour of hemodialysis treatment . The primary outcome measure is objective physical function measured by the 30-second sit to st and test . Secondary outcome measures include the 8-foot timed-up- and -go test , the four square step test , quality of life , cost-utility analysis , uptake and involvement in community activity , self-reported falls , fall ’s confidence , medication use , blood pressure and morbidity ( hospital admissions ) . Discussion The results of this study are expected to determine the efficacy of an accredited exercise physiologist supervised resistance training on the physical function of people receiving hemodial 
    Output:
    
Aerobic exercise alone was not significantly associated with aerobic capacity and quality of life improvement .
Conclusion : The results provide support to interventions that combine intradialytic aerobic and resistance exercises to improve physical functioning and quality of life in end-stage renal disease patients undergoing hemodialysis