Key result
Maintenance hemodialysis patients experienced significantly higher fatigue, sleepiness, and exhaustion composite scores on dialysis days (coefficient 0.21) and later in the day (coefficient 0.33).
Cohort (n=55)
No
Mean Difference: 0.21 (95% CI 0.02–0.39)
p-value: p=0.03
Maintenance hemodialysis patients experience significant daily and diurnal variation in fatigue, sleepiness, and exhaustion, with worse symptoms on dialysis days and later in the day.
Symptom timing in hemodialysis may inform daily assessments; hypothesis-generating for trials targeting dialysis-day or diurnal peaks.
BACKGROUND: Many patients on maintenance dialysis experience significant sleepiness and fatigue. However, the influence of the hemodialysis (HD) day and circadian rhythms on patients' symptoms have not been well characterized. We sought to use ecological momentary assessment to evaluate day-to-day and diurnal variability of fatigue, sleepiness, exhaustion and related symptoms in thrice-weekly maintenance HD patients. METHODS: Subjects used a modified cellular phone to access an interactive voice response system that administered the Daytime Insomnia Symptom Scale (DISS). The DISS assessed subjective vitality, mood, and alertness through 19 questions using 7- point Likert scales. Subjects completed the DISS 4 times daily for 7 consecutive days. Factor analysis was conducted and a mean composite score of fatigue-sleepiness-exhaustion was created. Linear mixed regression models (LMM) were used to examine the association of time of day, dialysis day and fatigue, sleepiness, and exhaustion composite scores. RESULTS: The 55 participants completed 1,252 of 1,540 (81%) possible assessments over the 7 day period. Multiple symptoms related to mood (e.g., feeling sad, feeling tense), cognition (e.g., difficulty concentrating), and fatigue (e.g., exhaustion, feeling sleepy) demonstrated significant daily and diurnal variation, with higher overall symptom scores noted on hemodialysis days and later in the day. In factor analysis, 4 factors explained the majority of the observed variance for DISS symptoms. Fatigue, sleepiness, and exhaustion loaded onto the same factor and were highly intercorrelated. In LMM, mean composite fatigue-sleepiness-exhaustion scores were associated with dialysis day (coefficient and 95% confidence interval [CI] 0.21 [0.02 - 0.39]) and time of day (coefficient and 95% CI 0.33 [0.25 - 0.41]. Observed associations were minimally affected by adjustment for demographics and common confounders. CONCLUSIONS: Maintenance HD patients experience fatigue-sleepiness-exhaustion symptoms that demonstrate significant daily and diurnal variation. The variability in symptoms may contribute to poor symptom awareness by providers and greater misclassification bias of fatigue related symptoms in clinical studies.
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Abdel-Kader et al. (2014) conducted a cohort in End-stage kidney disease (ESKD) on maintenance hemodialysis (n=55). Hemodialysis day vs. Non-hemodialysis day was evaluated on Mean composite fatigue-sleepiness-exhaustion (FSE) score (coefficient 0.21, 95% CI 0.02-0.39, p=0.03). Maintenance hemodialysis patients experienced significantly higher fatigue, sleepiness, and exhaustion composite scores on dialysis days (coefficient 0.21) and later in the day (coefficient 0.33).
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