Effects of exercise training on depression, anxiety, and physical health-related quality of life in end-stage renal disease patients receiving maintenance hemodialysis: a systematic review and meta-analysis of randomized controlled trials

Background: Maintenance hemodialysis patients commonly have adverse emotional states of depression and anxiety, leading to a serious decline in their quality of life. Exercise therapy acts as a supplementary measure that has the potential to relieve negative emotions. However, gaps remain in the current literature. Objective: To explore the effect of exercise intervention on depression, anxiety, and physical health-related quality of life in maintenance hemodialysis patients, and analyze the influence of population characteristics and intervention plans on the curative effect of exercise therapy. Methods: A literature search was conducted across 12 databases from inception to November 14, 2025. Two researchers independently screened literature and extracted data based on PICOS framework. R software and Stata software were utilized for data analysis to evaluate intervention effects by calculating standardized mean differences (SMD) and 95% confidence intervals (CI). Sensitivity analysis was done by the leave-one-out method. Egger's test and trim-and-fill method were used to explore potential publication bias. The revised Cochrane risk-of-bias tool was used to assess the methodological quality of included studies, and the GRADE method assessed the overall quality of evidence. Results: A total of 27 studies involving 1,597 participants were included. Meta-analysis results demonstrated that exercise improved depression and physical health-related quality of life in maintenance hemodialysis patients, while its effect on anxiety remains uncertain. Subgroup analyses indicated that exercise therapy yielded better outcomes in patients under 60 years of age. Intervention durations exceeding 24 weeks, the adoption of combined aerobic and strength training protocols, and a total weekly exercise volume of more than 120 min were associated with significant improvements in depression. Implementing exercise therapy with specialized equipment could better enhance physical health-related quality of life. Conclusion: The findings of this study demonstrate that exercise significantly ameliorates depression and modestly improves physical health-related quality of life in maintenance hemodialysis patients. However, due to the small number of included studies, high statistical heterogeneity, and limited assessment of publication bias, the ameliorating effect on anxiety cannot be definitively confirmed, necessitating future large-scale and rigorously designed randomized controlled trials for further verification. Furthermore, this study revealed that the intervention effects are moderated by variables including age, equipment utilization, exercise type, intervention duration, and total weekly exercise volume. Future research should prioritize the development of tailored exercise prescriptions for hemodialysis patients while concurrently enhancing the methodological rigor of study designs. Healthcare professionals should pay attention to improving the mental health of this group by implementing exercise therapy. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251196880, Identifier: CRD420251196880.