Rehabilitation Services for Elderly

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Rehabilitation Services for Elderly DialysisPatients

Rehabilitation Services for Elderly DialysisPatientsSarbjit Vanita JassalDivision of Nephrology, University Health Network, Toronto, CanadaBased on recent data, Canadians starting dialysisbetween the ages of 75 and 79 yr will have an averagelife expectancy of 3.2 yr.1In the United States, pa-tients 65 to 79 yr of age starting dialysis have a re-ported life expectancy of 25 mo.2During this time,patients may experience transient or permanentloss of personal independence, which, in turn, has anegative impact on their quality of life and financialsituation and a significant impact on health careutilization.3In general, older patients have complexmedical histories and a higher incidence of chronicailments such as arthritic pain, vision loss, or fa-tigue. Often patients adapt by walking more slowlyor taking more rests and developing fixed routineswith little variability or limiting activities. Overtime, these symptoms and adaptations have a cu-mulative effect on functional status, possibly lead-ing to dependency. In the renal literature, prevalentpatients on hemodialysis seem to have high levels offunctional loss.4Preliminary studies show that thisis exacerbated by acute hospitalization.5The impactof a lower functional status may be reduced by of-fering rehabilitation to dialysis patients. In the non-dialysis literature such programs are common andseem to limit the impact of functional disability onpatients, their families, and the healthcare system.6,7In this chapter, I will review the benefits and con-cepts of geriatric rehabilitation, the role of thenephrologists, and highlight some common com-plications.WHAT IS GERIATRIC REHABILITATION?Rehabilitation can be defined as a process by whichform and function is restored after injury or illness,such that life can be lived to the fullest capacitycompatible with the degree of abilities and disabil-ities.8This definition recognizes two important char-acteristics of rehabilitation in the older population—first that restoration of function is most likely to occurin those with a recent loss of function and, second, thatrehabilitation involves a process by which patientsboth learn new ways to restore function but also meth-ods which help them adapt to the new disability.Geriatric rehabilitation depends highly on amodel of interdisciplinary care. In this model, dif-ferent team members have both overlapping andcomplementary skills. Unlike acute care unitswhere the physician often heads the team, rehabili-tation teams do not depend on leadership from oneparticular discipline. Rather, treatment decisionsare led by the team member most involved with thepatient. Team members include physicians, nurses,social workers, occupational therapists, physiother-apists, speech therapists, psychologists, and phar-macists. Nurses play a key role because they spendthe most time with the patient. Through theirdaily interactions with patients, nurses empowerpatients to assume self-care and responsibilityand evaluate their psychosocial needs. Oftennurses help reduce muscle deconditioning by en-couraging patients to perform self-care activitiesoutside of their formal therapy sessions. Aftermultiple team members assess the impact of dis-ease on functionality from a variety of perspec-tives, they identify, through discussion, which ofthe disciplines is best suited to developing solu-tions before working in a collaborative manner.As an example, one patient with difficulty walk-ing indoors may work with a physiotherapist toincrease muscle strength, whereas another maybenefit from occupational therapy sessions tolearn to overcome visual limitations.Correspondence:S. V. Jassal, Associate Professor, University ofToronto, Staff Physician, University Health Network, Director, Ge-riatric Dialysis Rehabilitation Program, Toronto Rehab Institute,8NU-857, 200 Elizabeth Street, Toronto M5G 2C4, Canada.Phone: 416-340-3196; Fax: 416-340-4999;E-mail: vanita.jassal@uhn.on.caCopyright2009 by the American Society of NephrologyAmerican Society of NephrologyGeriatric Nephrology Curriculum1PUBLISHED BENEFITS OF REHABILITATION INDIALYSIS CARENumerous programs have reported using rehabilitation intheir dialysis units. Most develop exercise programs designedto build muscle strength through exercise regimens during di-alysis or within the home.9–14Such programs have been largelysuccessful but are often confounded by high drop-out ratesand the high costs of providing staff to supervise the exercises.Cardiac rehabilitation is recommended for dialysis patientswho have recently survived myocardial infarction, had bypasssurgery, or those with chronic stable angina. Dialysis patientshave been shown to benefit from actively participating in car-diac rehab, with outcome studies showing a 35% reduced riskfor cardiac mortality.15However, cardiac rehab seems to beunderused in dialysis patients, with only 10% of dialysis pa-tients, compared with 23% of the general population, under-going cardiac rehabilitation after coronary artery bypass graft(CABG) surgery.15Reasons behind this apparent paradox havenot been clearly identified.In the older individual, building muscle can be challenging,because patients do not have the strength or capacity to per-form strenuous or repetitive exercises. Sensory changes, suchas in hearing or vision, or decreases in cognitive function alsolimit the ability to learn new exercises. Geriatric renal rehabil-itation has not been widely formalized and, in many cases, isavailable only on a case-by-case basis. Published results of out-comes with dialysis rehabilitation are available but often lim-ited by small study size and the inclusion of young patients(70 yr of age) with few comorbid conditions (Table 1).16–22Success rates, as measured by the proportion of patients re-turning home, vary from 20 to 100%. In the largest and mostrecent report, approximately 70% of patients23,24met theirpersonalized goals and returned home (Figure 1). At the timeof admission, patients had a significant burden of comorbidityand high levels of functional dependence. In our unit, dialysisis offered on site on a daily dialysis schedule. Staffing levelshave been increased in both the dialysis suite and on the wardto accommodate the higher burden of comorbidity and higherdependency levels.24ISSUES UNIQUE TO REHABILITATION OF ELDERLYDIALYSIS PATIENTSComorbidity BurdenElderly dialysis patients have a high incidence of comorbiditywith recent studies in prevalent hemodialysis patients showingthe mean number of medical conditions to be around high number of comorbid illnesses place a heavymedical burden on the rehabilitation unit staff and the phar-macy. Elderly dialysis patients have a high rate of transfer outto acute care for new or recurrent acute illnesses. Of those whoed CareLong-term careOther020406080100120HomeAssistNumber of patientsFigure 1.Graph showing discharge disposition of patients ad-mitted to the Toronto Dialysis Geriatric Rehabilitation Program.Patients who did not return to rehabilitation after an acute inter-current illness or who transferred to palliative care are shown ashaving been discharged to Other.Table 1.Summary of studies evaluating inpatient rehabilitation in dialysis patientsPublicationNPercentPatients WithDiabetesComorbidityDetailsMeanAge (yr)AverageLOS (d)PercentDischargedHomeCommentsLi (2008)2416451CCI7.82.5 74.548.568Majority had a high burden of comorbid diseases.24% patients required transfer to an acute careinstitution, of whom 40% did not return to rehabForrest (2005)1940 Not reported Not reported 62.312.180.0 Prior medically complicated conditions in 8 patients(20%)Forrest (2004)1834 Not reported Not reported 68.716.072.2 Mostly admitted post-procedure. Prior acutehospitalization in 27%Frank (2002)205 Not reported Not reported 76.4—20.0 Used Berg Balance Scores and mobility forfunctional assessmentGarrison (1997)21310010050.0 18.0–34.0 100.0 Small sample size, postamputation onlyCzyrny (1994)1719 Not Reported Not Reported PostamputationCowen (1995)1628 Not reported Not reported 61.517.589.0 Reported converted functional impairment measurescoresGreenspun (1986)224100Not reported 55.244.2n/aPostamputationLOS, length of stay; CCI, Charlson Comorbidity Index.2American Society of NephrologyAmerican Society of Nephrologyare transferred, almost 40% are too unwell to return to reha-bilitation.24Dialysis SchedulingShort daily dialysis is recommended where possible. It is welltolerated and may lead to improved nutrition and better par-ticipation in therapy sessions. Patients report less fatigue andfewer symptoms associated with rapid fluid shifts. Scheduleddialysis and rehabilitation therapy sessions lead to improvedoutcomes and shorter length of hospital stay.19Enforced Immobility During DialysisPatients may benefit from occupational therapy and physio-therapy assessment during the dialysis session. Customizedseating aids may improve seating balance while simple physio-therapy exercises may reduce the impact of remaining rela-tively immobile for longer sessions.THE SICK ROLE: THE IMPORTANCE OFENCOURAGEMENTMany healthcare workers perceive dialysis patients as beingheavily dependent and unable to participate in exercise. In con-trast, patients are interested in maintaining their functional inde-pendence and taking part in exercise. In a study to identify thebarriers to exercise, one important factor identified was that nei-ther nurses nor doctors encourage elderly patients to be active.26Studies to see whether changing staff attitudes can alter patientperceptions or activity levels are underway.ROLE OF THE NEPHROLOGIST IN DIALYSIS-RELATED GERIATRIC REHABILITATIONThe nephrologist role is to work with the team and to take alead position on identification and referral of patients who maybenefit from rehabilitation; customization of the individualmedical goals and targets (goals should be adapted to allow thepatient to best achieve personal independence and functionand yet maintain long-term health); and reduction of polyp-harmacy and rationalization of medication.One of the more difficult roles a nephrologist must play isthe identification of patients who would benefit from rehabil-itation. Few nephrologists are formally trained in rehabilita-tion medicine, and there is little literature to advise on screen-ing or referral protocols. Nevertheless, it is the nephrologistwho follows the chronic predialysis and dialysis patient mostclosely and who is involved in their long-term care planning.The nephrologist is therefore best placed to identify functionaldecline and question if rehabilitation would improve function-ality. A practical first step is to perform a full geriatric assess-ment after major events such as dialysis initiation and at setintervals thereafter. Unfortunately, this field is relatively newand it remains unclear whether all patients should be screened,and if so, how often and with what tools. Clearly clinical eventssuch as hospitalization, falls, or a change in social status (e.g.,moving home or the death of a spouse or carer) should prompta functional reassessment by either the primary physician ormembers of the allied health team.Nephrologists should also work closely with the rehabilita-tion team to evaluate and, if necessary, reset health targets forolder dialysis patients. Although nephrologists routinely adjustultrafiltration/target weight and blood sugar targets, some pa-tients may require temporary relaxation in these goals partic-ularly during periods of functional loss. Relaxation of dietaryrestrictions may allow improved nutrition and allow patientsto meet their calorie requirements during a period of repairand recovery. Minor adjustments in volume status can have asignificant effect on fatigue. In our experience, debilitated in-dividuals often report or manifest symptoms during theirphysiotherapy or occupational therapy sessions. Adjustmentof target weight based on these observations or symptoms canimpact function, with small changes (e.g.,an increase or de-crease of 200 ml of ultrafiltration) being effective in some cases.(We have maximized this through the use of short daily dialysisregimens.) Some flexibility around blood sugar control mayalso be helpful for individuals who are prone to labile diabetes.Although tight blood sugar control is always a long-term ob-jective, we have found it necessary to relax blood sugar goalsduring the initial rehabilitation period. By having a tolerancefor a higher mean blood sugar, the patient may feel more ableto focus on other aspects of care. Success in these other aspectsof personal functioning, empowers them to then address self-care issues around blood sugar management. Sadly, the need tofulfill benchmark targets may limit the longer-term use of in-dividualized care plans in patients with borderline functionalindependence.Nephrologists play a key role in helping to rationalize med-ications. Many dialysis patients experience polypharmacy. In-patient rehabilitation care is an ideal setting for discontinua-tion of medications such as gastric acid suppressants, sedatives,and laxatives, the aim being to reduce unnecessary drugs andminimize drug interactions.Pain management and detection and treatment of depres-sion are two important aspects of rehabilitation care. Manypatients undergoing rehabilitation report chronic pain. Ar-thritic knees or hands can limit the use of aids and thereforeimpact both functionality and recovery. The presence ofchronic uncontrolled pain may lead to depression and ofcoursevice versa, meaning that pain management strategiesshould include antidepressants if appropriate.IDENTIFYING AND MANAGING COMMONPROBLEMS IN DIALYSIS REHABILITATIONPainPain management is a major issue in ESRD. The topic is largeand complex because of the altered metabolism of many drugs,American Society of NephrologyAmerican Society of Nephrology3and the reader is encouraged to read further on the topic.27–29Key summary principles are discussed below.Appropriate drugs include acetaminophencodeine andopiates. Nonsteroidal anti-inflammatory drugs (NSAIDs) canbe used in anuric patients with arthritic symptoms. Ideallythese should only be used in short courses at low dose becauseof the lower drug clearance and high risk of gastrointestinalside effects.Preferred opiates include hydromorphone, fentanyl, andmethadone. Morphine,meperidine, and detroporoxypheneshould be avoided because of accumulation of the drug. Cau-tion must be exercised with transdermal administration of fen-tanyl because it seems to have a variable absorption dependingon the location of the patch. In addition, absorption may varydepending on the temperature of the skin in that area. (Per-sonal note: We avoid the use of fentanyl in our unit.)If prescribing opiates, aim to use regular doses of long-act-ing agents at set times,e.g.,twice a day; doses should be sup-plemented with additional breakthrough medications, partic-ularly initially because the use of breakthrough medicationshelps determine how much uptitration is needed. Medicationdoses can be reassessed every 3 to 5 d. The regular dose of along-acting agent should be increased to be equal to the totalaverage dose of opiate used since the last titration. Therefore, ifthe patient is taking 3 mg hydromorphone long acting twicedaily and is, on average, taking an additional 1-mg break-through dose five times a day, one would increase the totallong-acting hydromorphone doses to 6 mg twice a day (for atotal of 12 mg opiate/24 h) in the hope that pain will be suffi-ciently well controlled to not require breakthrough drugs.Down titration is best done by a gradual reduction in the opiatedoses administered twice daily.The use of adjuvant therapies such as heat packs, transder-mal electrical nerve stimulation therapy, acupuncture, and an-tidepressants nortriptyline (in preference to amitriptyline) andgabapentin is encouraged.Sleep DisordersSleep disorders and chronic fatigue are common symptoms indialysis patients. Sleep hygiene programs include regular sleepscheduling, keeping the patient out of bed and the bedroomuntil bedtime, a snack before bedtime, and instruction onmental imagery or deep breathing relaxation techniques.Sleeping during dialysis, although common, should be dis-couraged. A patient with a poor sleep pattern may be sufferingfrom concomitant depression, and assessment is advised. Ifassociated with depression, the use of antidepressants with amildly sedative effect may be beneficial. Mirtazapine is oftenused because it causes relatively short-term drowsiness (6 to8 h) and also acts as an appetite stimulant.DepressionDepression is common in both dialysis patients and those un-dergoing rehabilitation. Frail elderly dialysis patients are there-fore at particularly high risk, especially around the time of di-alysis initiation. Unfortunately, symptoms, such as fatigue orpoor sleep and loss of appetite, can be attributed both to dial-ysis dependency and to depression, and therefore, depressionis best detected by having a high index of suspicion. Patientsrespond well to antidepressants. In our unit, the preference isfor the newer agents such as citalopram and sertraline in par-ticular because they have a lower incidence of drug–drug in-teractions. As mentioned previously, mirtazapine is particu-larly useful in patients with poor appetite and/or sleepproblems. Venlafaxine is our preferred choice for patients withsignificant anxiety symptoms.Confusional StatesCognitive impairment is common in dialysis patients30andmay significantly impact the success rates with rehabilitation.Associated delirium or agitation is not uncommon and mayimprove after medication rationalization or treatment of anyintercurrent illness. Careful assessment of sensory functions,such as hearing or vision, may be beneficial. Patients with re-duced vision or hearing may not be aware of “normal” externalstimuli and what may be a simple startle reaction may be mis-interpreted as agitation. Agitated patients may respond well toroutine. If possible, dialysis scheduling should facilitate dialysisin the same station at the same time each day for vulnerablepatients.CONCLUSIONSWidespread development of programs offering rehabilitationto dialysis patients is likely increasingly worthwhile as the av-erage age of the dialysis patients increases. Programs seem ef-fective in minimizing the disability associated with aging andchronic disease. Nephrologists play an important role in iden-tification of patients; setting appropriate medical goals; andmanaging common problems such as pain control. Specifictraining in care of the elderly patient may be of benefit to neph-rologists.TAKE HOME POINTS•There is a high burden of dependency and disability in the older dialysispopulation•Recent onset dependence and disability may be reversed throughtargeted rehabilitation programs•Rehabilitation outcomes are improved if nephrologists work in conjunc-tion with rehabilitation specialist teams; important areas for collabora-tion include identification of appropriate candidates, medical goal ad-justment, and pain and medication management•Scheduled dialysis sessions are associated with better rehabilitationoutcomes; short daily dialysis sessions are best tolerated (opinion)DISCLOSURESNone.4American Society of NephrologyAmerican Society of NephrologyREFERENCES*Key References1. Jassal SV, Trpeski L, Zhu N, Fenton SSA, Hemmelgarn BR: Changes insurvival over the years 1990–1999 for elderly patients initiating dialy-sis.CMAJ177: 1033–1038, 20072. Kurella M, Covinsky KE, Collins AJ, Chertow GM: Octogenarians andnonagenarians starting dialysis in the United States.Ann Intern Med146: 177–183, 20073. USRDS Data report. 20074. Cook WL, Jassal SV: Functional dependencies among the elderly onhemodialysis.Kidney Int73: 1289–1295, 2008*5. Lo D, Chiu E, Jassal SV: A prospective pilot study to measure changesin functional status associated with hospitalization in elderly dialysis-dependent patients.Am J Kidney Dis52: 956–961, 20086. Forster A, Young J, Lambley R, Langhorne P: Medical day hospitalcare for the elderly versus alternative forms of care.Cochrane Data-base Syst RevCD: 001730, 20087. Clark GS, Siebens HC: Rehabilitation of the geriatric patient. In:Re-habilitation Medicine, edited by DeLisa JA, Philadelphia, Lippincott,1993, pp 642–6658. Eisenberg MG:Dictionary of Rehabilitation. New York, Springer, 19959. Johansen KL, Painter PL, Sakkas GK, Gordon P, Doyle J, Shubert T:Effects of resistance exercise training and nandrolone decanoate onbody composition and muscle function among patients who receivehemodialysis: a randomized, controlled trial.J Am Soc Nephrol17:2307–2314, 200610. Painter P, Johansen KL: Improving physical functioning: time to be apart of routine care.Am J Kidney Dis48: 167–170, 200611. Painter P, Carlson L, Carey S, Paul SM, Myll J: Low-functioning hemo-dialysis patients improve with exercise training.Am J Kidney Dis36:600–608, 200012. Johansen KL, Shubert T, Doyle J, Soher B, Sakkas GK, Kent-Braun JA:Muscle atrophy in patients receiving hemodialysis: effects on musclestrength, muscle quality, and physical function.Kidney Int63: 291–297, 200313. Painter P: The importance of exercise training in rehabilitation ofpatients with end-stage renal disease.Am J Kidney Dis24: S9, 199414. Painter P: Why exercise can make a difference.Nephrol News Issues20: 52, 200615. Kutner NG, Zhang R, Huang Y, Herzog CA: Cardiac rehabilitation andsurvival of dialysis patients after coronary bypass.J Am Soc Nephrol17: 1175–1180, 200616. Cowen TD, Huang CT, Lebow J, DeVivo MJ, Hawkins LN: Functionaloutcomes after inpatient rehabilitation of patients with end-stagerenal disease.Arch Phys Med Rehabil76: 355–359, 199517. Czyrny JJ, Merrill A: Rehabilitation of amputees with end-stage renaldisease. Functional outcome and cost.Am J Phys Med Rehabil73:353–357, 199418. Forrest GP: Inpatient rehabilitation of patients requiring hemodialysis.Arch Phys Med Rehabil85: 51–53, 200419. Forrest G, Nagao M, Iqbal A, Kakar R: Inpatient rehabilitation ofpatients requiring hemodialysis: improving efficiency of care.ArchPhys Med Rehabil86: 1949–1952, 2005*20. Frank C, Morton AR: Rehabilitation of geriatric patients on hemodial-ysis; a case series.Geriatr Today5: 136–139, 200221. Garrison SJ, Merritt BS: Functional outcome of quadruple amputees withend-stage renal disease.Am J Phys Med Rehabil76: 226–230, 199722. Greenspun B, Harmon RL: Rehabilitation of patients with end-stagerenal failure after lower extremity amputation.Arch Phys Med Rehabil67: 336–338, 198623. Jassal SV, Chiu E, Li M: Geriatric hemodialysis rehabilitation care.AdvChronic Kidney Dis15: 115–122, 200824. Li M, Porter E, Lam R, Jassal SV: Quality improvement through theintroduction of interdisciplinary geriatric hemodialysis rehabilitationcare.Am J Kidney Dis50: 90–97, 2007*25. Cook WL, Jassal SV: Prevalence of falls among seniors maintained onhemodialysis.Int Urol Nephrol37: 649–652, 200526. Kontos PC, Miller KL, Brooks D, Jassal SV, Spanjevic L, Devins GM, DeSouza MJ, Heck C, Laprade J, Naglie G: Factors influencing exerciseparticipation by older adults requiring chronic hemodialysis: a quali-tative study.Int Urol Nephrol39: 1303–1311, 200727. Arnold RM, Verrico P, Davison SN: Opioid use in renal failure #161.JPalliat Med10: 1403–1404, 200728. Davison SN: Pain in hemodialysis patients: prevalence, cause, severity,and management.Am J Kidney Dis42: 1239–1247, 2003*29. Davison SN: Chronic pain in end-stage renal disease.Adv ChronicKidney Dis12: 326–334, 200530. Murray AM, Tupper DE, Knopman DS, Gilbertson DT, Pederson SL, Li S,Smith GE, Hochhalter AK, Collins AJ, Kane RL: Cognitive impairment inhemodialysis patients is common.Neurology67: 216–223, 2006American Society of NephrologyAmerican Society of Nephrology5REVIEW QUESTIONS: REHABILITATION SERVICESFOR ELDERLY DIALYSIS PATIENTS1. A 72-yr-old lady presents with acute chest pain to the emer-gency room. She has been living independently in her ownhome for some years without difficulty. She is noted to havechronic kidney disease on initial bloodwork. Over the follow-ing few days, her cardiac condition deteriorates. Because ofmarked fluid overload and her background CKD, she needs tostart dialysis emergently. One month after initiating dialysis,she is noted by the dialysis staff to be unsteady on her feet whencoming to dialysis. Since discharge, she is known to have hadmultiple falls at home and is currently complaining of pain inher left shoulder after a fall. She has no fracture but has signif-icant bruising and pain and has limited movements of the arm.Her BP is 160/85 mmHg predialysis and 140/78 mmHg post-dialysis. Her medications include a renal vitamin, aspirin 81mg OD, ramipril 10 mg OD, metoprolol 50 mg po twice daily,atorvastatin 20 mg qHS, lorazepam 10 mg qHS, quinine sulfate300 mg OD on dialysis days for cramps, allopurinol 100 mgOD, hydroxyzine 25 mg three times daily for itch, omeprazole20 mg OD, zopiclone 7.5 mg qHS, and acetaminophen 1000mg QID prn for pain. Which of the following statements istrue:a. Her falls are likely only happening on postdialysis days andtherefore related to hypotension; the most appropriate ac-tion is adjustment of target weightb. The most appropriate first step is to manage her pain byintroduction of an opiate on a regular schedulec. The most appropriate first step is to prescribe a walker tohelp with her unsteadinessd. Her falls are likely multifactorial and, taken together withher unsteadiness and polypharmacy, she may benefit fromreferral to a rehabilitation specialist for evaluation, andtreatment.2. An 85-yr-old hemodialysis patient is referred for rehabilita-tion after the family notice a decline in his functional statusover the past few months. The rehabilitation team review theliterature for clinical evidence about the effectiveness of inpa-tient geriatric rehabilitation in elderly, dialysis patients. Whichof the following statements is true:a. Strong, grade A (randomized controlled trial) evidencethat rehabilitation is effective in elderly dialysis patientsb. Some Grade B evidence (from observational studies) thatrehabilitation is effective in elderly dialysis patientsc. No evidence in either direction (either supporting effec-tiveness or no effectiveness) in elderly dialysis patientsd. Strong evidence (randomized controlled trial) that reha-bilitation is not effective in elderly dialysis patients3. A 68-yr-old man is admitted to an acute medical ward withsymptoms consistent with pneumonia. He is seen by thephysio as part of the discharge planning process and is noted tobe having difficulty walking and transferring because of mus-cle weakness. His bone mineralization profile shows he hasmild secondary hyperparathyroidism with elevated PTH lev-els. He starts undergoing physiotherapy and rehabilitationwith the physio on an adhoc basis. He is a dialysis patient andreceives dialysis in the outpatient dialysis suite on Monday,Wednesday, and Friday mornings where possible. He is apleasant man who is cooperative and readily amenable tochanging his dialysis time to later in the afternoon to suit thestaff. There is concern that he does not appear to be makingany progress in his walking. Which of the following statementsis true:a. Rehabilitation provided on an acute medical ward is inef-fectiveb. Changing patients to a fixed dialysis schedule may reducethe length of stayc. Dialysis patients are likely to require twice as long for re-habilitation as nondialysis patientsd. The muscle weakness is unlikely to resolve with exercisesas it is related to a myopathy associated with secondaryhyperparathyroidism6American Society of NephrologyAmerican Society of Nephrology

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