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Nutritional therapy combined with exercise training was shown to have a sustained effect on protein synthesis even after dialysis sessions when the intervention was given before the sessions [26]. Also, intradialytic nutritional support was found to improve physical function and QOL in patients with PEW only when the therapy was combined with aerobic exercise training during dialysis sessions [27]. Thus, a combination of nutritional support and exercise training is more efficient than either of them alone.

Many dialysis patients have reduced ADL, and almost half of this population is reported to be sedentary, especially on dialysis days. Intradialytic exercise training has gained attention as a means to improve physical function [28]. Several systematic reviews unequivocally demonstrated that intradialytic exercise training can improve VO₂ peak, Kt/V, and QOL measured with the Short Form Health Survey-36 [29, 30]. The Japanese Society of Renal Rehabilitation guidelines strongly recommend exercise training in dialysis patients.

A study that investigated the efficacy and adherence to exercise training according to the timing of its application found that supervised exercise training on non-dialysis days was more efficient than training done on dialysis days or without supervision, even though adherence was lower if it was performed on non-dialysis days [31]. Matsuzawa et al. [30] demonstrated that the number of steps on non-dialysis days measured with a pedometer can be a powerful predictor of subsequent survival in dialysis patients. The predictive power was maximized if the cut-off value was set at 3,752 steps per day. Patients with fewer than 4,000 steps per day experienced a higher mortality rate for 84 months thereafter (HR 2.37; 95% CI 1.22–4.60) [32].

Exercise training may also have a favorable effect on nutritional status. A study investigating the effect of exercise training on ghrelin or obestatin, cytokines that affect nutritional status or appetite, found that patients in the exercise group exhibited an increase in acyl-ghrelin, an active form of ghrelin [33]. Thus, exercise training might improve appetite and thus nutritional status in patients.