The goal of the COMprehensive EXercise (COMEX) pilot study is to test feasibility, tolerability and adherence of this novel video-based intra-dialytic chair exercise program for hemodialysis patients over 3 months.

The investigators incorporated patient-provider preferences of the key stakeholders, and used a multi-disciplinary team with experts in physical therapy, psychology and nephrology to develop a comprehensive exercise program for HD patients. Aim of this pilot study is to assess the feasibility, tolerability and adherence to COMEX over 3 months and inform design of future randomized controlled trial. A secondary goal is to explore molecular mechanisms in muscle and blood of exercise adaptation in HD patients

Inclusion Criteria:

For patients:

• Age ≥18 years to 85 years
• Undergoing maintenance hemodialysis for >3 months at one of the participating dialysis sites
• Patients must be willing and able to sign the consent form.

For providers:

• Eligible if they are a registered nurse, dialysis technician, dialysis social worker, dietitian, dialysis unit administrator or nephrologist involved in providing care for one of the patient participants in the study

Exclusion Criteria:

For all patients:

• Uncontrolled BP (>180/100 mm Hg)
• Inadequately dialyzed (Kt/V<1.2)
• History of Intradialytic hypotension (SBP<90mm Hg) or hypertension (SBP>180mmHg) during/post dialysis within last 1 month
• Contraindication to exercise eg unstable angina, uncompensated congestive heart failure
• Refractory/untreated psychiatric disorders
• History of poor adherence to HD treatment.
• Scheduled for living donor kidney transplant, intention to change to peritoneal dialysis, home HD, or plans to relocate to another center within the next 6 months.
• Currently in acute or chronic care hospital
• Life expectancy < 6 months or intention to withdraw dialysis therapy within 6 months.
• Current pregnancy, or actively planning to become pregnant in the next 6 months
• Currently a prisoner
• Current use of investigational drugs or participation in another non-observational clinical trial that contradicts or interferes with the therapies or measured outcomes in this trial
• Unable or unwilling to follow the study protocol for any reason (including mental incompetence)
• Unable or unwilling to provide informed consent or sign IRB-approved consent form
• Has a tunneled dialysis catheter
• If diabetic, blood sugar control is not stable

For patients undergoing biopsy and blood draw:

• Allergy to lidocaine
• Anemia, <10.0 Hgb
• Chronic use of oral corticosteroids or other medication that affect muscle function
• Any bleeding disorder that would contraindicate biopsy or blood draw such as a history of clinically significant bleeding diathesis (e.g. hemophilia A or B, Von Willebrand's Disease or congenital Factor VII deficiency)