Exercise and Nutrition in Hemodialysis: What Works?

For people on maintenance hemodialysis, supervised exercise has the clearest evidence for preserving physical function. Adding nutritional support may improve walking capacity and mobility tests, but it has not proved reliably better than exercise alone across body composition, diet, quality of life, or other outcomes that matter to patients.

That distinction matters. Dialysis can make muscle loss, low exercise tolerance, and impaired mobility common problems. The practical goal is often to keep someone walking, rising from a chair, and living independently—not to chase an abstract fitness score. Exercise belongs at the center of that plan. Nutrition may be a sensible addition, particularly when clinicians identify inadequate intake or malnutrition risk, but the evidence does not yet justify calling the combination the universal best prescription.

The best direct evidence: modest mobility gains, very low certainty

A 2026 systematic review and meta-analysis by Uno et al. pooled eight randomized, cluster-randomized, or crossover trials involving 231 people receiving maintenance hemodialysis; seven trials entered the quantitative analyses. Every participant was on hemodialysis, so these findings do not directly answer the question for peritoneal dialysis or advanced chronic kidney disease before dialysis.

Compared with nutrition alone, exercise alone, or no added intervention, combined nutrition-plus-exercise programs improved several mobility outcomes. The pooled difference was 45.17 meters for the six-minute walk test, 0.09 meters per second for gait speed, and 1.44 seconds faster on Timed Up and Go. The reported confidence intervals excluded no effect for each of those outcomes, making the pooled results statistically significant.

Those are useful directions of change, especially for a population in which mobility loss can narrow daily life quickly. But the review rated certainty as very low for every outcome. That means the true effects could differ substantially from the pooled estimates. Small trials can overestimate benefits, and a short-term improvement in a clinic test does not automatically establish fewer hospitalizations, longer survival, or durable independence.

Combined nutrition and exercise may improve walking-related function in maintenance hemodialysis, but the evidence is too uncertain to prove that nutrition adds a dependable benefit beyond exercise itself.

The same review found no clear difference in sit-to-stand performance, lean body mass, body mass index, dietary intake, or quality of life. This pattern matters because it limits the anabolic story often attached to protein-plus-training programs. Better performance on some mobility tests does not prove that the intervention rebuilt muscle or broadly improved nutrition status.

Why exercise remains the foundation

The case for exercise does not depend on nutritional supplementation. A 2022 Cochrane review concluded that exercise training in adults undergoing maintenance dialysis improves physical fitness, walking capacity, and health-related quality of life, although the studies varied in quality and were often small. A 2023 network meta-analysis similarly found that different exercise modalities in maintenance hemodialysis can improve physical function, dialysis adequacy, and health-related quality of life.

That broader literature changes how to read the combination trials. If exercise alone already improves function, a favorable result for nutrition plus exercise does not identify nutrition as the active ingredient. The key unanswered question is narrower: when the exercise program is comparable, does a defined nutrition prescription add a meaningful and durable benefit? The current evidence says maybe for mobility, not yet as a general rule.

A 2023 meta-analysis of combined aerobic and resistance exercise included 23 studies and 1,214 maintenance hemodialysis participants. Seventeen interventions took place during dialysis. The analysis reported improvements in peak oxygen uptake, six-minute walk performance, 30- and 60-second sit-to-stand tests, dialysis adequacy, and several health-related quality-of-life domains. This supports a mixed aerobic-and-resistance structure when a patient can tolerate both types of training.

There is no single exercise modality that wins every endpoint. Resistance work may target strength and transfers; aerobic work may support walking capacity and cardiorespiratory fitness. The comparative literature suggests that the preferred program should reflect the outcome a patient needs most, the dialysis unit's staffing, symptoms, and safety constraints.

What these programs actually looked like

Most studied programs were supervised and based in dialysis units, often during dialysis sessions. In the combination review, interventions commonly paired oral nutritional supplements with resistance exercise, aerobic exercise, or neuromuscular electrical stimulation two to three times weekly for three to 12 months.

One concrete model comes from Shin et al.'s 2025 study, which paired intradialytic neuromuscular electrical stimulation with oral protein supplementation in people receiving chronic hemodialysis. It shows that a combined approach can fit within dialysis care. It does not settle whether the approach beats a well-designed exercise-only program, and some combined-intervention studies emphasize surrogate measures such as phase angle rather than patient-important functional outcomes.

Resistance training during dialysis also looks workable in routine care. In a 2023 quasi-experimental study by Baião et al., 18 people on short daily hemodialysis completed supervised intradialytic resistance sessions twice weekly. The study reported improvements in body composition and physical function over eight months. Because it was quasi-experimental rather than a randomized head-to-head test, it supports feasibility and a promising direction of effect, not proof of superiority.

Why function deserves attention in dialysis care

Muscle-related impairment is not a cosmetic concern in this population. In a 2022 prospective study of 60 hemodialysis outpatients aged 75 to 95, 20% had confirmed or severe sarcopenia under the EWGSOP2 diagnostic algorithm, while 97% met at least one criterion for probable sarcopenia. A separate 2025 case-control study found that older adults on hemodialysis performed worse than robust controls without chronic kidney disease on gait speed, sit-to-stand, Timed Up and Go, cognitive Timed Up and Go, and balance testing.

These observational studies show associations and describe a clinical burden; they do not prove that a particular program will reverse sarcopenia. They do explain why trials focus on gait speed, walking distance, and Timed Up and Go. Those measures track the activities that determine whether a person can move through a grocery store, climb steps, or get safely out of a chair.

Limits that should shape the prescription

• Population: Direct combination evidence is limited to maintenance hemodialysis. Applying it to peritoneal dialysis or non-dialysis advanced CKD is an extrapolation.
• Duration: Most interventions lasted three to 12 months. That window can detect functional change but cannot establish lasting effects on hospitalization, survival, or sustained body-composition change.
• Safety reporting: Adverse-event reporting was sparse. The combination review prespecified gastrointestinal symptoms but did not provide a clear pooled harm signal in its abstract.
• Implementation: The evidence mostly concerns supervised, intradialytic care. It offers much less guidance on home programs, adherence outside the unit, or low-supervision programs.

The practical verdict

For maintenance hemodialysis, start with supervised exercise. A combined aerobic-and-resistance program is a reasonable default for patients who can participate in both, while intradialytic resistance-focused training is a practical option where dialysis-unit support exists.

Consider nutrition as an adjunct rather than a proven upgrade. Oral supplementation paired with supervised exercise or neuromuscular stimulation may modestly improve mobility outcomes, but the direct evidence comes from only 231 participants across eight eligible trials and carries very-low-certainty ratings. Patients should make nutrition decisions with their nephrology and renal dietetics teams, because protein, energy, fluid, potassium, phosphorus, and comorbidities all affect what is appropriate. The evidence supports a functional program with supervision; it does not support a one-size-fits-all supplement-and-exercise formula.