{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T19:07:39Z","timestamp":1782846459105,"version":"3.54.5"},"reference-count":42,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:00:00Z","timestamp":1782777600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Hemodialysis patients are characterized by insulin resistance. Cold dialysis (CD), with or without intradialytic exercise training (IET), can be beneficial for overall health in this population. The present study aimed to examine the long-term effect of the combined effect of cold dialysis and intradialytic exercise training on glucose disposal and various health and quality-of-life parameters in hemodialysis patients. Materials and Methods: Fourteen stable hemodialysis patients were randomly allocated in one of the two groups: the Cold Dialysis (35 \u00b0C) + Exercise Group (N = 7) (CD) and the Standard dialysis (37 \u00b0C) + Exercise Group (N = 7) (SD). Glucose disposal and insulin sensitivity, body composition, functional capacity, and quality of life were assessed before and after a 7-month intervention period. Results: Insulin sensitivity was improved by 16.7% in the CD group compared to the SD group. The area under the curve (AUC) for glucose and insulin disposal rate was also improved in the CD group compared to the SD group. Functional capacity and quality-of-life indices improved significantly in both groups (all p \u2264 0.05) independent of dialysate temperature. Conclusions: Seven months of cold dialysis combined with intradialytic exercise training was associated with improvements in insulin sensitivity and glucose metabolism in stable hemodialysis patients. Long-term exercise training has proven benefits for hemodialysis patients\u2019 health that can be further enhanced by cold dialysis. Trial Registration: The study is registered at ClinicalTrials.gov (NCT03905551).<\/jats:p>","DOI":"10.3390\/medicina62071268","type":"journal-article","created":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T16:56:55Z","timestamp":1782838615000},"page":"1268","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cold Dialysis Combined with Intradialytic Exercise Improves Insulin Sensitivity in Hemodialysis Patients: A Pilot Randomized Clinical Trial"],"prefix":"10.3390","volume":"62","author":[{"given":"Argyro A.","family":"Krase","sequence":"first","affiliation":[{"name":"Department of Physical Education and Sport Science, School of Physical Education, Sports and Dietetics, University of Thessaly, 42100 Trikala, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0029-1189","authenticated-orcid":false,"given":"Christoforos D.","family":"Giannaki","sequence":"additional","affiliation":[{"name":"Department of Life Sciences, School of Life and Health Sciences, University of Nicosia, Nicosia 2417, Cyprus"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6270-8782","authenticated-orcid":false,"given":"Ilias","family":"Ntoumas","sequence":"additional","affiliation":[{"name":"Department of Physical Education and Sport Science, School of Physical Education, Sports and Dietetics, University of Thessaly, 42100 Trikala, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5515-8089","authenticated-orcid":false,"given":"Ioannis","family":"Stefanidis","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina","family":"Karatzaferi","sequence":"additional","affiliation":[{"name":"Department of Physical Education and Sport Science, School of Physical Education, Sports and Dietetics, University of Thessaly, 42100 Trikala, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2462-995X","authenticated-orcid":false,"given":"Giorgos K.","family":"Sakkas","sequence":"additional","affiliation":[{"name":"Department of Physical Education and Sport Science, School of Physical Education, Sports and Dietetics, University of Thessaly, 42100 Trikala, Greece"},{"name":"Department of Life Sciences, School of Life and Health Sciences, University of Nicosia, Nicosia 2417, Cyprus"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1111\/nep.13147","article-title":"Insulin resistance in chronic kidney disease","volume":"22","author":"Xu","year":"2017","journal-title":"Nephrology"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Koppe, L., Pelletier, C.C., Alix, P.M., Kalbacher, E., Fouque, D., Soulage, C.O., and Guebre-Egziabher, F. (2014). Insulin resistance in chronic kidney disease: New lessons from experimental models. Nephrology Dialysis Transplantation, Oxford University Press.","DOI":"10.1093\/ndt\/gft435"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Nakashima, A., Kato, K., Ohkido, I., and Yokoo, T. (2021). Role and treatment of insulin resistance in patients with chronic kidney disease: A review. Nutrients, 13.","DOI":"10.3390\/nu13124349"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S117","DOI":"10.1016\/j.kint.2023.10.018","article-title":"KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease","volume":"105","author":"Stevens","year":"2024","journal-title":"Kidney Int."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1902","DOI":"10.1080\/02640414.2015.1017733","article-title":"The BASES expert statement on exercise therapy for people with chronic kidney disease","volume":"33","author":"Koufaki","year":"2015","journal-title":"J. Sports Sci."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1007\/s11255-020-02711-8","article-title":"Long-term intradialytic hybrid exercise training on fatigue symptoms in patients receiving hemodialysis therapy","volume":"53","author":"Grigoriou","year":"2021","journal-title":"Int. Urol. Nephrol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1007\/s11255-021-02931-6","article-title":"Seven months of aerobic intradialytic exercise training can prevent muscle loss in haemodialysis patients: An ultrasonography study","volume":"54","author":"Krase","year":"2022","journal-title":"Int. Urol. Nephrol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1189","DOI":"10.1177\/0269215518760380","article-title":"Intradialytic exercise training modalities on physical functioning and health-related quality of life in patients undergoing maintenance hemodialysis: Systematic review and meta-analysis","volume":"32","author":"Lopes","year":"2018","journal-title":"Clin. Rehabil."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"985","DOI":"10.1111\/sms.12714","article-title":"\u201cExercise as medicine\u201d in chronic kidney disease","volume":"26","author":"Wilkinson","year":"2016","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1176","DOI":"10.2215\/CJN.03160322","article-title":"Long-term effect of physical exercise on the risk for hospitalization and death in dialysis patients: A post-trial long-term observational study","volume":"17","author":"Mallamaci","year":"2022","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"818921","DOI":"10.3389\/fpubh.2022.818921","article-title":"The role of physical activity and mortality in hemodialysis patients: A review","volume":"10","author":"Zhang","year":"2022","journal-title":"Front. Public Health"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"119","DOI":"10.5527\/wjn.v6.i3.119","article-title":"Cold dialysis and its impact on renal patients\u2019 health: An evidence-based mini review","volume":"6","author":"Sakkas","year":"2017","journal-title":"World J. Nephrol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1111\/sdi.70010","article-title":"Effects of Low Dialysate Temperature on Intradialytic Hypotension and Dialysis Adequacy in Chronic Hemodialysis: A Systematic Review and Meta-Analysis","volume":"38","author":"Tan","year":"2025","journal-title":"Semin. Dial."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1408","DOI":"10.2215\/CJN.00200115","article-title":"Randomized controlled trial of individualized dialysate cooling for cardiac protection in hemodialysis patients","volume":"10","author":"Odudu","year":"2015","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"13","DOI":"10.3909\/ricm0585","article-title":"Dialysis-induced myocardial stunning: The other side of the cardiorenal syndrome","volume":"12","author":"Breidthardt","year":"2011","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1883","DOI":"10.1093\/ndt\/gfl126","article-title":"A systematic review of the clinical effects of reducing dialysate fluid temperature","volume":"21","author":"Selby","year":"2006","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1097\/MAT.0000000000002117","article-title":"The Acute, Combined, and Separate Effects of Cold Hemodialysis and Intradialytic Exercise in Insulin Sensitivity and Glucose Disposal","volume":"70","author":"Krase","year":"2024","journal-title":"ASAIO J."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1038\/nm.3891","article-title":"Short-term cold acclimation improves insulin sensitivity in patients with type 2 diabetes mellitus","volume":"21","author":"Hanssen","year":"2015","journal-title":"Nat. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2879","DOI":"10.1111\/j.1365-2702.2012.04091.x","article-title":"Assessment of body fluid status in hemodialysis patients using the body composition monitor measurement technique","volume":"21","author":"Mamat","year":"2012","journal-title":"J. Clin. Nurs."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1053\/j.ackd.2009.08.010","article-title":"Assessment and monitoring of physical function for people with CKD","volume":"16","author":"Koufaki","year":"2009","journal-title":"Adv. Chronic Kidney Dis."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2797","DOI":"10.1681\/ASN.V12122797","article-title":"Association among SF36 quality of life measures and nutrition, hospitalization, and mortality in hemodialysis","volume":"12","author":"Kopple","year":"2001","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1046\/j.1365-2702.2003.00860.x","article-title":"Chronic renal failure: Assessing the Fatigue Severity Scale for use among caregivers","volume":"13","author":"Schneider","year":"2004","journal-title":"J. Clin. Nurs."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Association AD (2010). Diagnosis and classification of diabetes mellitus. Diabetes Care, 33, S62\u2013S69.","DOI":"10.2337\/dc10-S062"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"539","DOI":"10.2337\/diacare.24.3.539","article-title":"A Model-Based Method for Assessing Insulin Sensitivity From the Oral Glucose Tolerance Test","volume":"24","author":"Mari","year":"2001","journal-title":"Diabetes Care"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2402","DOI":"10.1210\/jcem.85.7.6661","article-title":"Quantitative insulin sensitivity check index: A simple, accurate method for assessing insulin sensitivity in humans","volume":"85","author":"Katz","year":"2000","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"R1721","DOI":"10.1152\/ajpregu.00935.2007","article-title":"Liver fat, visceral adiposity, and sleep disturbances contribute to the development of insulin resistance and glucose intolerance in nondiabetic dialysis patients","volume":"295","author":"Sakkas","year":"2008","journal-title":"Am. J. Physiol.-Regul. Integr. Comp. Physiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"175","DOI":"10.3758\/BF03193146","article-title":"G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences","volume":"39","author":"Faul","year":"2007","journal-title":"Behav. Res. Methods"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Mak, R.H.K. (2000). Impact of end-stage renal disease and dialysis on glycemic control. Seminars in Dialysis, Wiley Online Library.","DOI":"10.1046\/j.1525-139x.2000.00007.x"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Krase, A.A., Flouris, A.D., Karatzaferi, C., Giannaki, C.D., Stefanidis, I., and Sakkas, G.K. (2020). Separate and combined effects of cold dialysis and intradialytic exercise on the thermoregulatory responses of hemodialysis patients: A randomized-cross-over study. BMC Nephrol., 21.","DOI":"10.1186\/s12882-020-02167-z"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"827","DOI":"10.2147\/IJGM.S26889","article-title":"Pharmacokinetics and pharmacodynamics of insulin analogs in special populations with type 2 diabetes mellitus","volume":"4","author":"Morello","year":"2011","journal-title":"Int. J. Gen. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1834","DOI":"10.1210\/jcem.82.6.3979","article-title":"Alterations in the glucose-stimulated insulin secretory dose-response curve and in insulin clearance in nondiabetic insulin-resistant individuals","volume":"82","author":"Jones","year":"1997","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"4226","DOI":"10.1210\/jc.2017-01250","article-title":"Cold-induced brown adipose tissue activity alters plasma fatty acids and improves glucose metabolism in men","volume":"102","author":"Iwen","year":"2017","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1016\/j.redox.2017.04.011","article-title":"Metabolic regulation and the anti-obesity perspectives of human brown fat","volume":"12","author":"Scheele","year":"2017","journal-title":"Redox Biol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1139\/y89-062","article-title":"Energy balance and diabetes. The effects of cold exposure, exercise training, and diet composition on glucose tolerance and glucose metabolism in rat peripheral tissues","volume":"67","author":"Bukowiecki","year":"1989","journal-title":"Can. J. Physiol. Pharmacol."},{"key":"ref_35","first-page":"622","article-title":"An analysis of thermal regulation in hemodialysis with one and three compartment models","volume":"35","author":"Gotch","year":"1989","journal-title":"ASAIO J."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"442","DOI":"10.2215\/CJN.04580415","article-title":"Effect of lowering the dialysate temperature in chronic hemodialysis: A systematic review and meta-analysis","volume":"11","author":"Mustafa","year":"2016","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"166","DOI":"10.5527\/wjn.v5.i2.166","article-title":"Cooling dialysate during in-center hemodialysis: Beneficial and deleterious effects","volume":"5","author":"Sozio","year":"2016","journal-title":"World J. Nephrol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1093\/ndt\/gfg512","article-title":"Effect of cool temperature dialysate on the quality and patients\u2019 perception of haemodialysis","volume":"19","author":"Ayoub","year":"2004","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2550","DOI":"10.1093\/ndt\/gfad102","article-title":"Home-based exercise in patients on maintenance dialysis: A systematic review and meta-analysis of randomized clinical trials","volume":"38","author":"Battaglia","year":"2023","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Jiang, H.Q., Wang, Y., Peng, J., Wu, S., and Wu, C. (2025). The efficacy of different types of intradialytic exercise for patients undergoing hemodialysis: A systematic review and network meta-analysis of randomized controlled trials. BMC Nephrol., 26.","DOI":"10.1186\/s12882-025-04381-z"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"F856","DOI":"10.1152\/ajprenal.00317.2018","article-title":"Exercise interventions for improving objective physical function in patients with end-stage kidney disease on dialysis: A systematic review and meta-analysis","volume":"316","author":"Clarkson","year":"2019","journal-title":"Am. J. Physiol. Ren. Physiol."},{"key":"ref_42","first-page":"CD012598","article-title":"Dialysate temperature reduction for intradialytic hypotension for people with chronic kidney disease requiring haemodialysis","volume":"2019","author":"Tsujimoto","year":"2019","journal-title":"Cochrane Database Syst. Rev."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/7\/1268\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T18:17:45Z","timestamp":1782843465000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/7\/1268"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,30]]},"references-count":42,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["medicina62071268"],"URL":"https:\/\/doi.org\/10.3390\/medicina62071268","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,30]]}}}