CKD stage 5D, has a high incidence, 100-200 people per million, and high prevalence,
750-1500 per million. More than 40-50% are above 65 years old, with a lower rate in women
but with higher frailty than men. This cohort presents high comorbidity, malnutrition,
sedentary behavior, low health-related quality of life, frailty and high dependency
levels. Mortality risk is close to 15% per year. Cardiovascular disease is the main cause
of death in end-stage CKD. It is also a high risk factor for peripheral artery disease
and lower limbs amputation.
Supporting this cohort results in high direct and indirect costs. Additionally, these
patients present high anxiety and depression rates. Comorbidity between depression and
somatic illness leads to a significant increase of the illness load since there is higher
symptomatology, higher morbidity, higher health costs, and worse functioning and quality
of life. Current evidence suggests a bidirectional relationship between depression and
medical illness. Mechanisms suggested explaining this complex relationship would include
both biological and behavioral aspects. Depression is also associated with the worst
adherence to treatment of comorbid patients.
There is wide evidence regarding the weak points of end-stage CKD patients in
hemodialysis, and they include three intervention aspects: exercise, nutrition and
psychological support. Evidence shows that exercise for patients in hemodialysis results
in increased survival rate, functional capacity, strength, and health-related quality of
life. Additionally, different studies have shown the benefits of psychological
interventions and the positive effect of educational programs on nutritional care for
patients in hemodialysis. Several combined interventions have been implemented leading to
heterogeneous results.
Despite the well-known benefits of exercise, this kind of programs are not being
implemented in the routine clinical care of hemodialysis patients. Patients' lack of
interest regarding participation in exercise programs, time constraints, and lack of
knowledge by health professionals at the hemodialysis units, are some of the factors
underpinning the low implementation rate of intradialysis exercise programs.
Virtual reality (VR) refers to computer-generated interactive simulation that offers
users the opportunity to participate in environments that look like objects and events of
the real world.
VR exercise has been successfully implemented in neuro-rehabilitation, resulting in
better balance, gait, and mobility in cerebrovascular accidents, multiple sclerosis,
Guillain-Barre syndrome, and Parkinson's disease. Few studies have explored the impact of
VR exercise in renal rehabilitation. Three of the partners (Universidad Cardenal
Herrera-CEU, Universitat Politècnica de Valéncia, and Hospital de Manises) have
implemented two randomized trials of non-immersive VR exercise intradialysis. Currently,
those partners are developing a third trial with this technology and they have verified
that this type of exercise has good tolerance and high adherence rates. Additionally, it
has a positive impact on strength, functional capacity, physical activity level, and
health-related quality of life.
Until now, the most traditional way to assess and implement psychological and
psycho-educative treatments has been 'face to face'. Nevertheless, more than 50% of
people suffering from depression are not being treated appropriately. This is why
alternative treatment models to assess and treat are being implemented, and technology
(as the internet) is an option to increase the number of patients that can be treated.
Additionally, few studies have explored technology as a means to educate renal patients
regarding nutrition or psychological health.
Thus, the hypothesis of the present study is that a health virtual platform designed for
holistic treatment of patients undertaking hemodialysis will result in health benefits
for this cohort, regarding physical activity, nutritional and psychological health. The
platform will be designed according to the aims highlighted by experts, barriers, and
needs of end-stage CKD patients and their caregivers. As mentioned above, end-stage
chronic kidney disease patients have high comorbidity, malnutrition, sedentarism, low
health-related quality of life, low physical function, frailty, and high dependency
levels. So they rely on non-formal caregivers for their activities of daily living. This
cohort presents high anxiety and depression levels and the combination of somatic disease
plus depression results in higher symptoms, higher comorbidity, higher health resources,
and worst quality of life. Besides, there is a bidirectional relationship between
depression and disease, and depression is associated with lower adherence to medical
treatment.
