Symptom Burden After Dialysis Initiation and Associations With Hospitalizations

Rationale & Objective Symptom burden is distressing for patients living with kidney failure, but there is limited information about the combination of symptoms and individual symptoms that most strongly predict healthcare utilization in this group. We classified and summarized patients' symptom burden levels and changes over time and estimated associations with hospitalizations among patients receiving incident hemodialysis. Study Design Longitudinal, observational. Setting & Participants Individuals initiating dialysis in the United States. Exposure(s) Kidney Disease Quality of Life-36 (KDQOL-36) measure. Outcome(s) First hospitalization after dialysis initiation. Analytical Approach Latent transition analysis (LTA) was used to identify symptom burden classes using the KDQOL-36. Cox regression models were used to assess whether individual KDQOL-36 symptoms and symptom burden groups were associated with hospitalization risk after dialysis initiation, independent of demographics and comorbidities. Results 1,818 participants were Black (29%), aged >65 years (59%), female (42%), had diabetes (49%), and hypertension (74%). LTA identified three symptom burden groups: low (low severity of all symptoms and kidney disease impacts), moderate (high physical health impact and overall burden of kidney disease), and high (high levels of all symptoms and kidney disease impact). After adjusting for patient characteristics, all KDQOL-36 scales except the Effects of Kidney Disease scale were associated with a higher hazard of hospitalization. Using the symptom burden groups, high symptom burden was associated with a 20% increase in the hazard of hospitalization. A 1-category worsening in pain interference and in fatigue was associated with 12% and 8% increased hazard of hospitalization, respectively. Limitations Findings may not generalize outside of the United States. Conclusions Pain interference and fatigue, as well as an overall symptom burden, are useful prognostic indicators in patients receiving in-center hemodialysis. Symptom burden should remain a treatment target in hemodialysis.