Pain, sleep disturbance and survival in hemodialysis patients

Abstract

Background: Patients' perception of pain during hemodialysis (HD) and at times between HD treatment and its association with survival have not been well studied in end-stage renal disease (ESRD). We evaluated the experience of pain during HD and at times when the patient was not receiving HD, and assessed possible associations of the perception of pain and sleep disturbance with patient survival.

Methods: A total of 128 ESRD patients treated with HD completed questionnaires on psychosocial status, quality of life and sleep disorders. A modified McGill Pain questionnaire was used to assess the nature, location, frequency, intensity and duration of pain both during and at times between HD sessions. The Pittsburgh Sleep Quality Index was used to screen for sleep disturbances over a 30-day period.

Results: Controlling for age, diabetes mellitus, serum albumin concentration and human immunodeficiency virus infection, there was a significant association between mortality and both frequency and intensity of pain while patients were not on HD. There was no association between survival and duration of pain while off HD or any of the pain parameters while patients were on HD. There was no association between survival and the presence of a sleep disorder.

Conclusions: Pain perception while off HD may be of more importance to patients than pain during HD. The mechanisms underlying the association are unknown but may involve linkage of pain with severity of medical illness or the generation of a maladaptive cytokine response. Multicenter prospective studies of pain interventions using well-validated pain perception tools are needed to establish causal relationships. Interventions directed toward treating pain on non-HD days may improve ESRD patient survival.

Fig. 1.

Pain intensity on HD.

Fig. 2.

Pain frequency on non-dialysis days.

Fig. 3.

Survival and pain frequency on non-dialysis days. Kaplan–Meier analysis of HD patients with high versus low frequency of pain on non-dialysis days. Lower line represents high frequency (above the mean) and upper line represents low frequency (below the mean). See text for details.

Fig. 4.

Survival and pain intensity on non-dialysis days. Kaplan–Meier analysis of HD patients with high versus low intensity of pain on non-dialysis days. Lower line represents high intensity (above the mean) and upper line represents low intensity (below the mean). See text for details.

Fig. 5.

Survival and sleep. Kaplan–Meier analysis of HD patients with presence and absence of sleep disorders. Heavy line represents presence of sleep disorders and light line represents absence of sleep disorders. See text for details.