In-Center Hemodialysis Symptom Burden: Differences Between Men and Women

Patients with kidney failure (KF) requiring hemodialysis often struggle with troublesome symptoms that significantly impact quality of life. Despite women having longer life expectancy compared with men in the general population, among patients with KF, female patients often have poorer survival.1Mata N.L.D.L. Rosales B. MacLeod G. et al.Sex differences in mortality among binational cohort of people with chronic kidney disease: population based data linkage study.BMJ. 2021; 375e068247PubMed Google Scholar This disparity suggests underlying differences in disease mechanisms, which could influence the symptomatic experiences of these patients. We sought to examine gender differences in symptoms among patients with KF receiving in-center hemodialysis. We analyzed data from the Timing of Antihypertensive Medications on Key Outcomes in Hemodialysis (TAKE-HOLD) study, a cluster randomized trial that examined timing of blood pressure medications on the occurrence of intradialytic hypotension.2Chang T.I. Tatoian E.T. Montez-Rath M.E. Chertow G.M. Timing of antihypertensive medications on key outcomes in hemodialysis: a cluster randomized trial.Kidney360. 2021; 2: 1752-1760Crossref PubMed Scopus (5) Google Scholar The study was approved by a Stanford Institutional Review Board (IRB) panel (protocol 43790), was adherent to the Declaration of Helsinki, and was registered on clinicaltrials.gov (NCT03327909). All patients were receiving in-center hemodialysis. We categorized each patient's gender as woman or man based on self-identification. During the baseline period, participants completed the Dialysis Symptoms Index (DSI), a validated 30-question survey that assesses symptoms experienced in the prior week.3Weisbord S.D. Fried L.F. Arnold R.M. et al.Development of a symptom assessment instrument for chronic hemodialysis patients: the dialysis symptom index.J Pain Symptom Manage. 2004; 27: 226-240Abstract Full Text Full Text PDF PubMed Scopus (226) Google Scholar In the Dialysis Symptoms Index, patients rated whether they experienced the symptom, and if so, how much that symptom bothered them on a scale of 1 ("not at all") to 5 ("very much"). Total Dialysis Symptoms Index scores range from 0 to 150 with lower scores indicating fewer symptoms experienced or lower severity of symptoms. We compared proportions of women and men with symptoms using absolute risk differences (ARDs). In participants with each symptom, we compared differences in mean severity scores. We had information on 127 participants, of whom 36% (N = 46) were women and 64% (N = 81) were men. Baseline characteristics were similar between women and men (Table 1). Overall symptom burden as determined by total Dialysis Symptoms Index score was numerically higher in women (median 28, interquartile range [IQR] 12.5-57.3) than men (median 24, IQR 13.0-41.0), although the difference was not statistically significant (P = 0.24). The proportion of women experiencing symptoms was often higher than men and severity of symptoms was often higher for women than men (Fig 1, Table S1). In particular, women were significantly more likely to report headaches (ARD 28.0%; 95% confidence interval [CI], 11.3%-44.9%), shortness of breath (ARD 18.1%; 95% CI, 1.4%-34.7%), and dry skin (ARD 18.3%; 95% CI, 0.8%-35.8%). Conversely, men were more likely to report decreased sexual arousal (ARD 19.1%; 95% CI, 5%-33.2%). However, among women reporting decreased sexual arousal, their mean severity scores were slightly higher than in men (absolute difference in means 0.5; 95% CI, 0.9 to 2.0).Table 1Baseline characteristics by genderaAll values are N (%) except where indicated.WomenN = 46MenN = 81DemographicsAge, y, mean ± SD62.7 ± 14.360.6 ± 13.7Race Asian10 (21.7)24 (29.6) African American2 (4.3)4 (4.9) White26 (56.5)40 (49.4) Other or prefer not to say8 (17.4)13 (16.0)Hispanic ethnicity21 (45.7)45 (55.6)Vintage, y, median [Q1,Q3]2.4 [1.4, 4.3]2.9 [1.3, 5.3]Private insurance6 (13.0)9 (11.1)Currently employed7 (15.2)14 (17.3)Cause of kidney failure Diabetes mellitus28 (60.9)47 (58.0) Hypertension9 (19.6)16 (19.8) Glomerulonephritis2 (4.3)3 (3.7) Other/Not Specified7 (15.2)15 (18.5)Comorbid conditions Heart failure9 (19.6)20 (24.7) Cardiovascular disease13 (28.2)20 (24.7) Diabetes mellitus36 (78.3)57 (70.4) Unable to ambulate and/or needs assistance with activities of daily living11 (23.9)24 (29.6)Laboratory results Hemoglobin level, g/dL, mean ± SD10.3 ± 1.010.7 ± 1.3 Albumin level, g/L, mean ± SD3.8 ± 0.34.0 ± 0.3 Kt/V, mean ± SD1.67 ± 0.221.49 ± 0.19a All values are N (%) except where indicated. Open table in a new tab Our results show gender differences in symptoms experienced by patients with KF receiving in-center hemodialysis. Women generally reported a larger number of symptoms that were of greater severity than men. In particular, they reported more headaches, shortness of breath, and dry skin, whereas men were more likely to report decreased sexual arousal. However, even when a lower proportion of women reported the presence of a given symptom, they often found it to be of greater severity than men. Our findings confirm prior studies showing that women tend to have a higher prevalence and intensity of symptoms compared with men and perceive a higher negative impact of hemodialysis on their quality of life.4Carrero J.J. Hecking M. Chesnaye N.C. Jager K.J. Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease.Nat Rev Nephrol. 2018; 14: 151-164Crossref PubMed Scopus (477) Google Scholar Numerous factors may influence the symptoms experienced by women and men undergoing hemodialysis, including diagnosed depression and physiological distinctions in cardiac and vascular function, blood volume, and the effects of factors like fluid removal and solute clearance during dialysis.5Lopes G.B. Matos C.M. Leite E.B. et al.Depression as a potential explanation for gender differences in health-related quality of life among patients on maintenance hemodialysis.Nephron Clin Pract. 2010; 115: c35-c40Crossref PubMed Scopus (46) Google Scholar Additionally, underlying hormonal differences and the impact of KF on the endocrine system could play a role.6Lima-Posada I. Bobadilla N.A. Understanding the opposite effects of sex hormones in mediating renal injury.Nephrology. 2021; 26: 217-226Crossref PubMed Scopus (15) Google Scholar Medications used to treat comorbid conditions, such as hypertension and diabetes, may result in different side effect profiles in men than women, and the prescription and effectiveness of medications to treat dialysis-related symptoms may also vary by gender.7Tamargo J. Rosano G. Walther T. et al.Gender differences in the effects of cardiovascular drugs.Eur Heart J Cardiovasc Pharmacother. 2017; 3: 163-182Crossref PubMed Scopus (218) Google Scholar Finally, other gender-specific factors, including access to care, differences in coping mechanisms, and the perception and reporting of symptoms, could further contribute to the observed variations.8García G.G. Iyengar A. Kaze F. Kierans C. Padilla-Altamira C. Luyckx V.A. Sex and gender differences in chronic kidney disease and access to care around the globe.Semin Nephrol. 2022; 42: 101-113Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Despite the insights gained from this study, we acknowledge certain limitations. We recognize that our research did not consider gender nonbinary or gender fluid individuals. Our research may also be affected by under or overreporting of symptoms, which may occur differently in women and men, and we did not have information on medications used to treat symptoms. The cross-sectional nature of this data prevents making inferences about causation. Additionally, the sample size precluded examination of the impact of race, ethnicity or English proficiency on the results, and the generalizability of our findings may be influenced by specific demographic and clinical characteristics of the participants. In conclusion, our research sheds light on gender differences in symptom experiences among patients receiving hemodialysis. Both men and women frequently report symptoms, and women generally had a higher burden of symptoms that were of greater severity compared with men. These findings underscore the importance of addressing symptom burdens in all patients receiving hemodialysis and consider gender-specific aspects in the management of certain hemodialysis-related symptoms. Research idea and study design: TIC, SL; data acquisition: TIC; data analysis/interpretation: GP, SL, TIC; statistical analysis: SL; supervision or mentorship: TIC. Each author contributed important intellectual content during article drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. This study was funded by a Norman S. Coplon Extramural Grant from Satellite Healthcare. The funder played no part in the design or conduct of the study; analysis or interpretation of the data; preparation, review, or approval of the article; or decision to submit the article for publication. Dr Chang has served as a consultant for Bayer, Janssen Pharmaceuticals, Novo Nordisk, Fresenius Medical Care, Tricida, Gilead, Prokidney, AstraZeneca, and the George Clinical Institute; and has received salary support from CSL Behring through funds paid directly to Stanford University. The remaining authors declare that they have no relevant financial interests. Received February 13, 2024. Evaluated by 1 external peer reviewer, with direct editorial input from the Statistical Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form May 23, 2024. Download .pdf (.07 MB) Help with pdf files Supplementary File (PDF)