The role of psychological factors in fatigue among end-stage kidney disease patients: a critical review

Abstract

Fatigue is a common and debilitating symptom, affecting 42-89% of end-stage kidney disease patients, persisting even in pre-dialysis care and stable kidney transplantation, with huge repercussions on functioning, quality of life and patient outcomes. This paper presents a critical review of current evidence for the role of psychological factors in renal fatigue. To date, research has concentrated primarily on the contribution of depression, anxiety and subjective sleep quality to the experience of fatigue. These factors display consistent and strong associations with fatigue, above and beyond the role of demographic and clinical factors. Considerably less research is available on other psychological factors, such as social support, stress, self-efficacy, illness and fatigue-specific beliefs and behaviours, and among transplant recipients and patients in pre-dialysis care. Promising evidence is available on the contribution of illness beliefs and behaviours to the experience of fatigue and there is some indication that these factors may vary according to treatment modality, reflecting the differential burdens and coping necessities associated with each treatment modality. However, the use of generic fatigue scales casts doubt on what specifically is being measured among dialysis patients, illness-related fatigue or post-dialysis-specific fatigue. Therefore, it is important to corroborate the available evidence and further explore, qualitatively and quantitatively, the differences in fatigues and fatigue-specific beliefs and behaviours according to renal replacement therapy, to ensure that any model and subsequent intervention is relevant and grounded in the experiences of patients.

Keywords: anxiety; depression; fatigue; kidney disease; sleep quality.

Fig. 1

Preliminary biopsychosocial model of fatigue in end-stage kidney disease. This figure illustrates how fatigue can be triggered by illness, biochemical imbalances, or stress and worrying, and it can then be perpetuated and maintained by a vicious cycle of negative beliefs, depression and/or anxiety and maladaptive behavioural patterns. ¹Grey boxes with arrows exemplify potential areas for intervention. Clinical management revolves around illness control and maintaining biochemical values within optimal ranges, as well as management of comorbidities. Cognitive techniques can be used to identify and change negative beliefs (e.g. catastrophizing) and to reduce depression and anxiety. Behavioural strategies, as part of psychotherapy, or physiotherapy can support patients in developing a stable activity pattern, and healthy sleep and dietary habits. ²All-or-nothing  =  behaviour characterized by bursts of activity followed by rest. ³Physiological arousal =  in response to stress, chronic activation of the central and autonomic nervous systems as well as the endocrine system. ⁴Deconditioning  =  changes in body systems due to physical inactivity and disuses, such as loss in muscle strength and tone.