Fatigue in Patients Receiving Maintenance Dialysis: A Review of Definitions, Measures, and Contributing Factors

doi:10.1053/j.ajkd.2008.05.005

American Journal of Kidney Diseases

Volume 52, Issue 2, August 2008, Pages 353-365

https://doi.org/10.1053/j.ajkd.2008.05.005 Get rights and content

Fatigue is a debilitating symptom or side effect experienced by many patients on long-term dialysis therapy. Fatigue has a considerable effect on patient health-related quality of life and is viewed as being more important than survival by some patients. Renal providers face many challenges when attempting to reduce fatigue in dialysis patients. The lack of a reliable, valid, and sensitive fatigue scale complicates the accurate identification of this symptom. Symptoms of daytime sleepiness and depression overlap with fatigue, making it difficult to target specific therapies. Moreover, many chronic health conditions common in the long-term dialysis population may lead to the development of fatigue and contribute to the day-to-day and diurnal variation in fatigue in patients. Key to improving the assessment and treatment of fatigue is improving our understanding of potential mediators, as well as potential therapies. Cytokines have emerged as an important mediator of fatigue and have been studied extensively in patients with cancer-related fatigue. In addition, although erythropoietin-stimulating agents have been shown to mitigate fatigue, the recent controversy regarding erythropoietin-stimulating agent dosing in patients with chronic kidney disease suggests that erythropoietin-stimulating agent therapy may not serve as the sole therapy to improve fatigue in this population. In conclusion, fatigue is an important and often underrecognized symptom in the dialysis population. Possible interventions for minimizing fatigue in patients on long-term dialysis therapy should aim at improving health care provider awareness, developing improved methods of measurement, understanding the pathogenesis better, and managing known contributing factors.

Section snippets

Definition of Fatigue

Fatigue is a subjective sense of weakness, lack of energy, and tiredness.¹¹ Lee et al¹² proposed that it can be conceptualized as located on a continuum of exhaustion and tiredness on one end, with energy and vitality at the opposite end of the continuum. This position has been supported by the National Institutes of Health Patient-Reported Outcomes Measurement Information System initiative, in which the items from the 36-Item Short-Form Health Survey (SF-36) vitality scale measure fatigue and

Measurement of Fatigue

There are a number of choices when selecting a brief assessment tool for fatigue in patients with ESRD. The most widely used instrument in the dialysis population is the vitality scale of the SF-36.19, 20 The SF-36 vitality subscale, which consists of 4 items, is considered to be at one end of a spectrum of fatigue. The vitality construct captures a mild reduction in energy level, but fails to capture the negative aspects of fatigue, such as weakness, lack of motivation, and difficulty with

Contributors to Fatigue in ESRD

In the dialysis population, physiological, behavioral, treatment-related, and individual characteristics may correlate with fatigue (Fig 1). Physiological causes include anemia, malnutrition, uremia, dialysis inadequacy, hyperparathyroidism, coexisting chronic illnesses, sleep disorders, depression, and side effects of medications. Dietary and fluid restriction may also have a role.³³ Physical inactivity has been associated with greater levels of fatigue.³⁴ Sociodemographic factors, including

Interventions to Reduce Fatigue

Because of the complexity of fatigue, a multidisciplinary approach to treatment should be adopted by nephrologists (Table 2). To address the level of fatigue, this symptom first needs to be recognized and accurately measured by health care providers. All renal providers should receive training on identifying and addressing the issue of fatigue. Developing improved methods of defining and measuring fatigue, including real-time or ecological momentary assessment, will help identify patterns in

Conclusion

Fatigue is a common and complex phenomenon that significantly decreases HRQOL in dialysis patients. Although highly prevalent, fatigue is often an unrecognized and undertreated symptom in the dialysis population. The lack of adequate methods for measurement, lack of provider awareness, and the complex pathogenesis of fatigue have confounded the development of effective interventions to treat fatigue. Thus, there is a strong need to develop improved assessment methods and investigate the role of

Acknowledgements

Support: Dr Unruh was supported by Grants DK66006 and DK77785 from the National Institute of Diabetes and Digestive and Kidney Diseases, by the Paul Teschan Research Fund, and by the Fresenius Medical Care Young Investigator Grant of the National Kidney Foundation.

Financial Disclosure: None.

References (130)

F.E. Murtagh et al.
The prevalence of symptoms in end-stage renal disease: A systematic review
Adv Chronic Kidney Dis
(2007)
M. Unruh et al.
Effects of hemodialysis dose and membrane flux on health-related quality of life in the HEMO Study
Kidney Int
(2004)
P. Stone et al.
Fatigue in patients with cancer
Eur J Cancer
(1998)
K.A. Lee et al.
Validity and reliability of a scale to assess fatigue
Psychiatry Res
(1991)
E. Ream et al.
Fatigue: A concept analysis
Int J Nurs Stud
(1996)
S.N. Davison et al.
Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: A simple assessment of symptom burden
Kidney Int
(2006)
P.C. Dagnelie et al.
Psychometric properties of the revised Piper Fatigue Scale in Dutch cancer patients were satisfactory
J Clin Epidemiol
(2006)
E.M. Smets et al.
The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue
J Psychosom Res
(1995)
S. Tyring et al.
Etanercept and clinical outcomes, fatigue, and depression in psoriasis: Double-blind placebo-controlled randomised phase III trial
Lancet
(2006)
S.B. Yellen et al.
Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system
J Pain Symptom Manage
(1997)

E.D. Hacker et al.

Ecological momentary assessment of fatigue in patients receiving intensive cancer therapy

J Pain Symptom Manage

(2007)

M. Unruh et al.

Racial differences in health-related quality of life among hemodialysis patients

Kidney Int

(2004)

R. Dantzer et al.

Twenty years of research on cytokine-induced sickness behavior

Brain Behav Immun

(2007)

M. Rao et al.

Cytokine gene polymorphism and progression of renal and cardiovascular diseases

Kidney Int

(2007)

A. Herbelin et al.

Influence of uremia and hemodialysis on circulating interleukin-1 and tumor necrosis factor alpha

Kidney Int

(1990)

B. Memoli et al.

Changes of serum albumin and C-reactive protein are related to changes of interleukin-6 release by peripheral blood mononuclear cells in hemodialysis patients treated with different membranes

Am J Kidney Dis

(2002)

B. Memoli et al.

Hemodialysis related induction of interleukin-6 production by peripheral blood mononuclear cells

Kidney Int

(1992)

T.B. Harris et al.

Associations of elevated interleukin-6 and C-reactive protein levels with mortality in the elderly

Am J Med

(1999)

I. Janszky et al.

Self-rated health and vital exhaustion, but not depression, is related to inflammation in women with coronary heart disease

Brain Behav Immun

(2005)

C. Schubert et al.

The association between fatigue and inflammatory marker levels in cancer patients: A quantitative review

Brain Behav Immun

(2007)

V.S. Balakrishnan et al.

Cytokine gene polymorphisms in hemodialysis patients: Association with comorbidity, functionality, and serum albumin

Kidney Int

(2004)

P.L. Kimmel et al.

Immunologic function and survival in hemodialysis patients

Kidney Int

(1998)

R.M. Bologa et al.

Interleukin-6 predicts hypoalbuminemia, hypocholesterolemia, and mortality in hemodialysis patients

Am J Kidney Dis

(1998)

F. Brambilla et al.

Plasma interleukin-1 beta concentrations in panic disorder

Psychiatry Res

(1994)

M.A. Bremmer et al.

Inflammatory markers in late-life depression: Results from a population-based study

J Affect Disord

(2008)

C. Kasapis et al.

The effects of physical activity on serum C-reactive protein and inflammatory markers: A systematic review

J Am Coll Cardiol

(2005)

P. Trzonkowski et al.

Immune consequences of the spontaneous pro-inflammatory status in depressed elderly patients

Brain Behav Immun

(2004)

S.D. Ross et al.

The effect of anemia treatment on selected health-related quality-of-life domains: A systematic review

Clin Ther

(2003)

M. Jones et al.

Impact of epoetin alfa on clinical end points in patients with chronic renal failure: A meta-analysis

Kidney Int

(2004)

L.B. Pupim et al.

Nutrition and metabolism in kidney disease

Semin Nephrol

(2006)

E.P. Brass et al.

Intravenous l-carnitine increases plasma carnitine, reduces fatigue, and may preserve exercise capacity in hemodialysis patients

Am J Kidney Dis

(2001)

R.S. Suri et al.

Frequent Hemodialysis Network (FHN) randomized trials: Study design

Kidney Int

(2007)

A. Sklar et al.

Identification of factors responsible for postdialysis fatigue

Am J Kidney Dis

(1999)

A.H. Sklar et al.

Postdialysis fatigue

Am J Kidney Dis

(1996)

R.M. Lindsay et al.

Hemeral (daily) hemodialysis

Adv Ren Replace Ther

(2001)

N.G. Kutner et al.

Continued survival of older hemodialysis patients: Investigation of psychosocial predictors

Am J Kidney Dis

(1994)

M.L. Unruh et al.

Restless legs symptoms among incident dialysis patients: Association with lower quality of life and shorter survival

Am J Kidney Dis

(2004)

P.J. Mills et al.

Sleep apnea: A model for studying cytokines, sleep, and sleep disruption

Brain Behav Immun

(2004)

D.D. Cardenas et al.

The problem of fatigue in dialysis patients

Nephron

(1982)

W.K. Chang et al.

Chronic fatigue in long-term peritoneal dialysis patients

Am J Nephrol

(2001)

A. Laupacis et al.

A disease-specific questionnaire for assessing quality of life in patients on hemodialysis

Nephron

(1992)

P.S. Parfrey et al.

Clinical features and severity of nonspecific symptoms in dialysis patients

Nephron

(1988)

S.D. Weisbord et al.

Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis patients

J Am Soc Nephrol

(2005)

N. Ramkumar et al.

Patient preferences for in-center intense hemodialysis

Hemodial Int

(2005)

S.D. Weisbord et al.

Renal provider recognition of symptoms in patients on maintenance hemodialysis

Clin J Am Soc Nephrol

(2007)

R.M. Lindsay et al.

Minutes to recovery after a hemodialysis session: A simple health-related quality of life question that is reliable, valid, and sensitive to change

Clin J Am Soc Nephrol

(2006)

J.S. Lai et al.

Fatigue Archival Analysis Report

E.R. Lenz et al.

The middle-range theory of unpleasant symptoms: An update

ANS Adv Nurs Sci

(1997)

A. Chaudhuri et al.

Fatigue and basal ganglia

J Neurol Sci

(2000)

B.O. Lee et al.

The fatigue experience of haemodialysis patients in Taiwan

J Clin Nurs

(2007)

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: Originally published online as doi:10.1053/j.ajkd.2008.05.005 on June 23, 2008.

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Narrative ReviewFatigue in Patients Receiving Maintenance Dialysis: A Review of Definitions, Measures, and Contributing Factors

Section snippets

Definition of Fatigue

Measurement of Fatigue

Contributors to Fatigue in ESRD

Interventions to Reduce Fatigue

Conclusion

Acknowledgements

Adv Chronic Kidney Dis

Kidney Int

Eur J Cancer

Psychiatry Res

Int J Nurs Stud

Kidney Int

J Clin Epidemiol

J Psychosom Res

Lancet

J Pain Symptom Manage

J Pain Symptom Manage

Kidney Int

Brain Behav Immun

Kidney Int

Kidney Int

Am J Kidney Dis

Kidney Int

Am J Med

Brain Behav Immun

Brain Behav Immun

Kidney Int

Kidney Int

Am J Kidney Dis

Psychiatry Res

J Affect Disord

J Am Coll Cardiol

Brain Behav Immun

Clin Ther

Kidney Int

Semin Nephrol

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Adv Ren Replace Ther

Am J Kidney Dis

Am J Kidney Dis

Brain Behav Immun

The problem of fatigue in dialysis patients

Nephron

Chronic fatigue in long-term peritoneal dialysis patients

Am J Nephrol

A disease-specific questionnaire for assessing quality of life in patients on hemodialysis

Nephron

Clinical features and severity of nonspecific symptoms in dialysis patients

Nephron

Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis patients

J Am Soc Nephrol

Patient preferences for in-center intense hemodialysis

Hemodial Int

Renal provider recognition of symptoms in patients on maintenance hemodialysis

Clin J Am Soc Nephrol

Minutes to recovery after a hemodialysis session: A simple health-related quality of life question that is reliable, valid, and sensitive to change

Clin J Am Soc Nephrol

Fatigue Archival Analysis Report

The middle-range theory of unpleasant symptoms: An update

ANS Adv Nurs Sci

Fatigue and basal ganglia

J Neurol Sci

The fatigue experience of haemodialysis patients in Taiwan

J Clin Nurs

Narrative Review
Fatigue in Patients Receiving Maintenance Dialysis: A Review of Definitions, Measures, and Contributing Factors