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.