Fatigue in Patients Receiving Maintenance Hemodialysis: A Review

Abstract

Fatigue surrounding hemodialysis treatments is a common and often debilitating symptom that impacts patients' quality of life. Intradialytic fatigue develops or worsens immediately before hemodialysis and persists through the dialysis treatment. Little is known about associated risk factors or pathophysiology, although it may relate to a classic conditioning response. Postdialysis fatigue (PDF) develops or worsens after hemodialysis and may persist for hours. There is no consensus on how to measure PDF. Estimates for the prevalence of PDF range from 20%-86%, likely due to variation in methods of ascertainment and participant characteristics. Several hypotheses seek to explain the pathophysiology of PDF, including inflammation, hypothalamic-pituitary-adrenal axis dysregulation, and osmotic and fluid shifts, but none is currently supported by compelling or consistent data. PDF is associated with several clinical factors, including cardiovascular and hemodynamic effects of the dialysis procedure, laboratory abnormalities, depression, and physical inactivity. Clinical trials have reported hypothesis-generating data about the utility of cold dialysate, frequent dialysis, clearance of large middle molecules, treatment of depression, and exercise as potential treatments. Existing studies are often limited by sample size, lack of a control group, observational design, or short intervention duration. Robust studies are needed to establish the pathophysiology and management of this important symptom.

Keywords: Fatigue; hemodialysis; intradialytic fatigue; postdialysis fatigue.

Figure 1.

Course of fatigue on a HD treatment day (a) and its relation to depressive symptoms (b). Reproduced from Brys, et al. with permission of the copyright holder (Elsevier). Abbreviations: BDI-II, Beck Depression Inventory-II; HD, hemodialysis

Figure 2.. Prevalence of PDF and TIRD.

The prevalence of PDF has varied between studies from 20% to 86% depending on how PDF was defined and ascertained (A). The proportion of patients reporting TIRD of various lengths has also varied between studies, with as many as 22.8% reporting needing >12 hours to recover from an HD treatment (B). *In these studies, patients were asked to report on 5-point Likert scales the duration, frequency, and intensity of fatigue. The patient was considered to have PDF if the average of these was ≥4 points. Abbreviations: HD, hemodialysis; PDF, post-dialysis fatigue; TIRD, time to recovery from dialysis

Figure 3.. Factors associated with PDF.

Factors associated with increased PDF can be categorized as the cardiovascular and hemodynamic effects of HD, laboratory abnormalities, and clinical factors. Abbreviations: HD, hemodialysis; PDF, post-dialysis fatigue