Stability and Impact of Symptom Clusters in Patients With End-Stage Renal Disease Undergoing Dialysis

Exploring symptom clusters in Chinese patients with peritoneal dialysis: a network analysis

BACKGROUND

In recent years, the research on symptom management in peritoneal dialysis (PD) patients has shifted from a single symptom to symptom clusters and network analysis. This study collected and evaluated unpleasant symptoms in PD patients and explored groups of symptoms that may affect PD patients with a view to higher symptom management.

METHODS

The symptoms of PD patients were measured using the modified Dialysis Symptom Index. The symptom network and node characteristics were assessed by network analysis, and symptom clusters were explored by factor analysis.

RESULTS

In this study of 602 PD patients (mean age 47.8 ± 16.8 years, 47.34% male), most had less than 2 years of dialysis experience. Five symptom clusters were obtained from factor analysis, which were body symptom cluster, gastrointestinal symptom cluster, mood symptom cluster, sexual disorder symptom cluster, and skin-sleep symptom cluster. Itching and decreased interest in sex may be sentinel symptoms, and being tired or lack of energy and feeling anxious are core symptoms in PD patients.

CONCLUSIONS

This study emphasizes the importance of recognizing symptom clusters in PD patients for better symptom management. Five clusters were identified, with key symptoms including itching, decreased interest in sex, fatigue, and anxiety. Early intervention focused on these symptom clusters in PD patients holds promise for alleviating the burden of symptoms.

Symptom profiles in patients receiving maintenance hemodialysis and their association with quality of life: a longitudinal study

PURPOSE

Many patients receiving maintenance hemodialysis experience one or multiple symptoms. Using a latent profile analysis to identify symptom profiles may provide insights for person-centered symptom management strategies.

METHODS

This is a longitudinal study based on data from patients receiving maintenance hemodialysis at three hospitals in Shanghai, China. Of the 448 patients who completed the surveys at baseline (T1), 309 completed the 12-month follow-up survey (T2). Symptoms and quality of life were measured by the Chinese version of Kidney Disease Quality of Life 36 Short Form. The optimal classification of symptoms was identified using latent profile analysis.

RESULTS

Five symptom profiles were identified: High (9.2%), Fatigue and Gastrointestinal (7.1%), Fatigue and Skin (10.7%), Skin (23.2%), and Low (49.8%). The high-symptom profile and the-fatigue-and-skin-symptom profile were associated with a lower level of physical functioning, a higher burden of kidney disease, and more negative effects of kidney disease than the low symptom profile at T1 and T2. Multivariate regression analysis showed that the high-symptom profile predicted a poorer physical functioning at T2, and the-fatigue-and-skin-symptom profile predicted a poorer physical functioning and higher burden of kidney disease at T2.

CONCLUSION

Patients receiving maintenance hemodialysis reported unique symptom experiences which could be classified into different profiles. Patients reporting an overall high level of symptoms or a high level of fatigue and skin symptoms were more likely to have a poorer quality of life.

Evaluating the Psychometric Properties of Patient-Reported Outcome Measures for Assessing Symptoms in Hemodialysis: A Systematic Review Using COSMIN Guidelines

CONTEXT

Patient-reported outcome measures (PROMs) may have an important role in screening and monitoring for unpleasant symptoms in kidney failure. However, there is still little evidence on the psychometric properties of the measures available to assess physical and psychological symptoms in people on hemodialysis. This gap makes it difficult to decide which measure is the most appropriate for use in clinical practice and research with this population.

OBJECTIVES

This systematic review aimed to critically appraise, compare, and summarize the quality of the measurement properties of PROMs used to assess symptoms in adults on hemodialysis.

METHODS

The protocol for this review was registered in PROSPERO (CRD42023393441). The last database search update was performed on November 25, 2022. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines informed methodological quality assessment, data extraction, analysis, and synthesis.

RESULTS

Twenty-seven primary studies reported the measurement properties of 16 PROMs used to assess physical and psychological symptoms in adults on hemodialysis. Results showed that most measures lacked the necessary psychometric evidence to attest their suitability for this study population, and few underwent rigorous validation procedures. Overall, caveats were found on methodological quality and evidence of content validity and structural validity, and little data was available on responsiveness, measurement error, and cross-cultural validity.

CONCLUSION

The current systematic review provides the basis for identifying PROMs with potential utility for assessing symptoms in hemodialysis care. Several recommendations are presented to help guide future research aimed at improving the rigor of validation and/or translation procedures of existing (and future) measures using COSMIN guidelines.

Exploring the influencing factors of unmet palliative care needs in Chinese patients with end-stage renal disease undergoing maintenance hemodialysis: a cross-sectional study

BACKGROUND

The role of palliative care for end-stage renal disease (ESRD) patients have been proven in some developed countries, but it is still unclear in the mainland of China. In fact, patients with ESRD experience many unmet palliative care needs, such as physical, psychological, social and spiritual needs, but the factors influencing these needs have not investigated.

METHODS

A cross-sectional study was conducted at two hemodialysis centers in the mainland of China from January to September 2022. Convenience sampling was used to collect data on the participants' socio-demographics, clinical characteristics, the Palliative Care Outcome Scale (POS), the Dialysis Symptom Index (DSI), the Karnofsky Performance Status Scale (KPS), the Patient Health Questionnaire-9 item (PHQ-9), and the Social Support Rate Scale (SSRS). Data were analyzed using latent profile analysis, Kruskal-Wallis test, one-way analysis of variance (ANOVA), the chi-square test and multinomial logistic regression analysis.

RESULTS

Three hundred five participants were included in this study, and divided palliative care needs into three categories: Class 1, mild palliative care needs (n = 154, 50.5%); Class 2, moderate palliative care needs (n = 89, 29.2%); Class 3, severe palliative care needs (n = 62, 20.3%). Based on the analysis of three profiles, the influencing factors of unmet needs were further analyzed. Compared with Class 3, senior high school education, the household per capita monthly income < 2,000, low KPS scores, high PHQ-9 scores, and low SSRS scores were less likely to be in Class 1 (OR = 0.03, P = 0.012; OR = 0.003, P < 0.001; OR = 1.15, P < 0.001; OR = 0.55, P < 0.001; OR = 1.35, P = 0.002; respectively) and Class 2 (OR = 0.03, P = 0.007; OR = 0.05, P = 0.011; OR = 1.10, P = 0.001; OR = 0.60, P = 0.001; OR = 1.32, P = 0.003; respectively), and high symptom severity were less likely to be in Class 1 (OR = 0.82, P = 0.001). Moreover, compared with Class 1, the household per capita monthly income < 2,000 (OR = 16.41, P < 0.001), high symptom severity scores (OR = 1.12, P = 0.002) and low KPS scores (OR = 0.95, P = 0.002) were more likely to be in Class 2.

CONCLUSIONS

This study showed that almost half of ESRD patients receiving MHD presented moderate to severe palliative care needs, and the unmet needs were mainly affected by education level, financial pressure, functional status, symptom burden and social support. In the future, it is important to identify the populations with the greatest need for palliative care and consider the influencing factors of unmet needs from a comprehensive perspective, so as to help them improve health-related quality of life.

Health inequity associated with financial hardship among patients with kidney failure

Financial hardship is a common challenge among patients with kidney failure and may have negative health consequences. Therefore, financial status is regarded as an important determinant of health, and its impact needs to be investigated. This cross-sectional study aimed to identify the differences in patient-reported and clinical outcomes among kidney failure patients with different financial status. A total of 354 patients with kidney failure were recruited from March to June 2017 at two hospitals in Hong Kong. The Dialysis Symptoms Index and Kidney Disease Quality of Life-36 were used to evaluate patient-reported outcomes. Clinical outcomes were retrieved from medical records and assessed using the Karnofsky Performance Scale (functional status) and Charlson Comorbidity Index (comorbidity level). Patients were stratified using two dichotomised variables, employment status and income level, and their outcomes were compared using independent sample t-tests and Mann-Whitney U-tests. In this sample, the employment rate was 17.8% and the poverty rate was 61.2%. Compared with other patients, increased distress of specific symptoms and higher healthcare utilization, in terms of more emergency room visits and longer hospital stays, were found in patients with poorer financial status. Low-income patients reported a decreased mental quality of life. Financially underprivileged patients experienced health inequity in terms of impaired outcomes. Attention needs to be paid to these patients by providing financial assessments and interventions. Additional research is warranted to confirm these findings and understand the experience of financial hardship and health equity.

Palliative care needs and symptom burden in younger and older patients with end-stage renal disease undergoing maintenance hemodialysis: A cross-sectional study

Objectives

To investigate the current situation of palliative care needs and the symptom burden in patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis (MHD), and to explore whether there are differences between younger and older patients.

Methods

This cross-sectional study was conducted in the hemodialysis centers of two tertiary hospitals from November 2021 to June 2022. Participants were selected by convenience sampling. Socio-demographics, clinical characteristics, the Palliative Care Outcome Scale (POS), the Dialysis Symptom Index (DSI), and health-related quality of life (EQ-5D-3L) were used for evaluation. Descriptive statistics, between-group comparisons, and correlation analysis were used to analyze the data.

Results

A total of 236 patients were enrolled, including 118 younger and 118 older patients. The total median (P₂₅, P₇₅) POS score was 16.0 (12.0, 23.0), and the score was higher in older patients (P < 0.01). The mean total number of symptoms in MHD patients was 15.04 ± 5.06, and the overall median symptom severity score was 59.0 (52.0, 71.0); these scores were higher in the older group (P < 0.01). The most common symptom was dry mouth (91.5%), followed by itching (83.1%), and dry skin (82.2%). Additionally, palliative care needs were significantly associated with symptom burden and health-related quality of life (HRQOL).

Conclusions

The results showed that patients with ESRD undergoing MHD have a significant symptom burden and moderate palliative care needs, which are more severe in older patients. Therefore, interdisciplinary teams should be formed to actively manage patients’ symptoms and meet the physical, psychological, social, and spiritual needs related to palliative care to improve patients’ HRQOL.

Factors influencing health-related quality of life in people with chronic kidney disease: A structural equation modelling approach

AIMS AND OBJECTIVES

To test whether the revised Wilson and Cleary model could identify which factors contribute to health-related quality of life in chronic kidney disease.

BACKGROUND

Chronic kidney disease affects a person's health-related quality of life detrimentally although nursing practice informed by theory is only beginning to emerge.

DESIGN

A cross-sectional study reported using the STROBE guidelines.

METHODS

About 886 participants with chronic kidney disease (varying grades) completed validated measures of symptoms (renal version of the Integrated Palliative care Outcome Scale), and general health perceptions and health-related quality of life (European Quality of Life five-dimension three-level). Socio-demographic and renal characteristics were also collected. Data were analysed using descriptive statistics and structural equation modelling.

RESULTS

Biological function (decreased kidney function and haemoglobin and greater number of comorbidities), directly contributed to increased symptom burden. Symptoms demonstrated strong negative relationships with both general health perceptions and health-related quality of life. General health perceptions had a direct positive relationship with health-related quality of life. As age increased, health-related quality of life decreased. The only environmental characteristic of significance was the distance between home and hospital although it was not directly associated with health-related quality of life. Overall, the model explained approximately half of the deterioration in health-related quality of life.

CONCLUSIONS

The model demonstrated how various factors influence alteration of health-related quality of life in people with chronic kidney disease. Early identification of these factors could assist nurses to introduce effective management strategies into patient care plans proactively.

RELEVANCE TO CLINICAL PRACTICE

Comprehensive symptom assessment needs to occur not only in kidney failure but in earlier chronic kidney disease grades to enable timely interventions targeted at improving people's wellbeing.

PATIENT OR PUBLIC CONTRIBUTION

Validated interviewer administered questionnaires were completed by participants with chronic kidney disease in this study.

Symptom clusters in chronic kidney disease and their association with people's ability to perform usual activities

Background

People living with a long-term condition, such as chronic kidney disease (CKD), often suffer from multiple symptoms simultaneously, making symptom management challenging. This study aimed to identify symptom clusters in adults with CKD across treatment groups and investigate their association with people’s ability to perform their usual activities.

Methods

We conducted a secondary analysis of both cross-sectional and longitudinal data collected as part of a national service improvement programme in 14 kidney centres in England, UK. This data included symptom severity (17 items, POS-S Renal) and the extent to which people had problems performing their usual activities (single item, EQ-5D-5L). We categorised data by treatment group: haemodialysis (n = 1,462), transplantation (n = 866), peritoneal dialysis (n = 127), or CKD without kidney replacement therapy (CKD non-KRT; n = 684). We used principal component analysis to identify symptom clusters per treatment group, and proportional odds models to assess the association between clusters and usual activities.

Results

Overall, clusters related to: lack of energy and mobility; gastrointestinal; skin; and mental health. Across groups, the ‘lack of energy and mobility’ clusters were associated with having problems with usual activities, with odds ratios (OR) ranging between 1.24 (95% confidence interval [CI], 1.21–1.57) for haemodialysis and 1.56 for peritoneal dialysis (95% CI, 1.28–1.90). This association was confirmed longitudinally in haemodialysis (n = 399) and transplant (n = 249) subgroups.

Implications

Our findings suggest that healthcare professionals should consider routinely assessing symptoms in the ‘lack of energy & mobility’ cluster in all people with CKD, regardless of whether they volunteer this information; not addressing these symptoms is likely to be related to them having problems with performing usual activities. Future studies should explore why symptoms within clusters commonly co-occur and how they interrelate. This will inform the development of cluster-level symptom management interventions with enhanced potential to improve outcomes for people with CKD.

Novel approach to unpleasant symptom clusters surrounding pruritus in patients with chronic kidney disease and on dialysis therapy

PURPOSE OF REVIEW

Chronic kidney disease-associated-pruritus (CKD-aP) is a common symptom in patients with end-stage kidney disease (ESKD) undergoing dialysis. CKD-aP typically occurs alongside other debilitating symptoms and may comprise so-called 'symptom clusters' which have synergistic effects that adversely impact patient health-related quality of life (HRQoL). Importantly, symptoms in a cluster may share a common biological mechanism. Here we review the clinical impact of CKD-aP and its association with other symptoms reported by dialysis patients. The clinical benefits of treating pruritus and its potential impact on other symptoms are also addressed.

RECENT FINDINGS

Studies have shown CKD-aP significantly impairs HRQoL in patients with ESKD undergoing dialysis and is associated with adverse clinical outcomes, including increased risk of infections, hospitalizations, and mortality. Despite these negative effects, CKD-aP remains underrecognized and undertreated in clinical practice. CKD-aP is frequently associated with other symptoms, including disturbed sleep/poor sleep quality, anxiety, depression, and pain. Clinical studies of antipruritic therapies show that reduction of itch intensity may also alleviate other associated symptoms, such as poor sleep quality.

SUMMARY

CKD-aP and its associated symptoms are inadequately managed in clinical practice. Greater understanding and awareness of CKD-aP and its surrounding symptom clusters in dialysis patients may improve their overall symptom management and HRQoL.

High-throughput hemodialysis on the clinical efficacy and micro-inflammatory state, calcium and phosphorus metabolism, heart and kidney function in patients with end-stage renal disease

To compare the clinical efficacy, heart and kidney function, calcium and phosphorus metabolism, serological indicators, and the effects of micro-inflammatory status after two hemodialysis treatments to evaluate the best treatment for patients with end-stage renal disease. According to the criteria for inclusion and exclusion, collected in the Department of Nephrology, third People's Hospital of Gansu Province, patients were selected and received treatment between July 2019 and July 2021. A total of 60 cases were randomized. The urea nitrogen (BUN), blood creatinine (Scr), calcium and phosphorus metabolism levels, inflammation-related factors, and serum-related indicators of the two groups of patients before and after the treatment were detected for half a year. The effective rate (83.33%) of the observation group was higher than that of the control group (66.67%). After treatment, the iPTH, β2-MG, Hcy of the observation group were lower than those of the control group, and ALB was higher than that of the control group. The inflammation-related index observation group was significantly lower than the control However, the difference in Scr and BNU index levels between the two groups of patients after treatment was not so obvious that they could not be evaluated. In terms of all indicators and parameters, high-flux hemodialysis can better treat ESRD and improve the heart and kidney function of patients.

Characterization of Symptoms and Symptom Clusters for Type 2 Diabetes Using a Large Nationwide Electronic Health Record Database

OBJECTIVE

A variety of symptoms may be associated with type 2 diabetes and its complications. Symptoms in chronic diseases may be described in terms of prevalence, severity, and trajectory and often co-occur in groups, known as symptom clusters, which may be representative of a common etiology. The purpose of this study was to characterize type 2 diabetes-related symptoms using a large nationwide electronic health record (EHR) database.

METHODS

We acquired the Cerner Health Facts, a nationwide EHR database. The type 2 diabetes cohort (n = 1,136,301 patients) was identified using a rule-based phenotype method. A multistep procedure was then used to identify type 2 diabetes-related symptoms based on International Classification of Diseases, 9th and 10th revisions, diagnosis codes. Type 2 diabetes-related symptoms and co-occurring symptom clusters, including their temporal patterns, were characterized based the longitudinal EHR data.

RESULTS

Patients had a mean age of 61.4 years, 51.2% were female, and 70.0% were White. Among 1,136,301 patients, there were 8,008,276 occurrences of 59 symptoms. The most frequently reported symptoms included pain, heartburn, shortness of breath, fatigue, and swelling, which occurred in 21-60% of the patients. We also observed over-represented type 2 diabetes symptoms, including difficulty speaking, feeling confused, trouble remembering, weakness, and drowsiness/sleepiness. Some of these are rare and difficult to detect by traditional patient-reported outcomes studies.

CONCLUSION

To the best of our knowledge, this is the first study to use a nationwide EHR database to characterize type 2 diabetes-related symptoms and their temporal patterns. Fifty-nine symptoms, including both over-represented and rare diabetes-related symptoms, were identified.

Alterations in symptoms and health-related quality of life as kidney function deteriorates: A cross-sectional study

AIMS AND OBJECTIVES

To compare symptoms and health-related quality of life and to examine the relationship between these as kidney function deteriorates.

BACKGROUND

Chronic kidney disease is a global health problem, and while knowledge of symptom burden and health-related quality of life is understood in kidney failure (previously end-stage kidney disease), there is limited understanding about symptoms and health-related quality of life across the chronic kidney disease trajectory.

DESIGN

Cross-sectional design reported using the STROBE guidelines.

METHODS

Eight hundred eighty-six adults with varying levels of kidney function (chronic kidney disease grades 3b-5 including those receiving dialysis) completed the renal version of the Integrated Palliative care Outcome Scale and the Quality of Life Short Form-36 version 2. Socio-demographic and renal characteristics were also collected. Data were analysed using descriptive and inferential statistics.

RESULTS

Participants had a mean age of 57 years and were mostly male. Regardless of chronic kidney disease grade, pain, poor mobility, weakness, anxiety and depression were the most prevalent and severe symptoms reported. Health-related quality of life was significantly associated with physical and psychological symptom scores. As kidney function deteriorated, both physical and mental health-related quality of life decreased, and prevalence and severity of symptoms increased.

CONCLUSIONS

There is substantial symptom burden irrespective of chronic kidney disease grade, which overwhelmingly affects health-related quality of life. Early identification by nurses would enable proactive management plans to be implemented.

RELEVANCE TO CLINICAL PRACTICE

Nurses, whether in specialist renal services or in primary healthcare, are ideally placed to regularly assess symptoms and health-related quality of life in those with chronic kidney disease. Timely assessment could assist in the targeting of earlier interventions designed to reduce symptom burden and to increase health-related quality of life.

A Mixed Methods Study of Symptom Experience in Patients With End-Stage Renal Disease

BACKGROUND

Patients with end-stage renal disease receiving dialysis experience a significant symptom burden. Identifying factors associated with this burden may improve symptom management. However, specific evidence about patients' experiences is lacking.

OBJECTIVES

The aim of this study was to explore factors that are associated with patients' symptom experiences.

METHODS

The convergent parallel mixed methods design was used. In the quantitative component, the Dialysis Symptom Index was used to assess the symptom burden of 271 participants to examine its associations with patient characteristics using correlation coefficients and multivariate regression analyses. In the qualitative component, associated factors reported by 10 participants were identified through semistructured interviews using content analysis. Assessments were conducted at enrollment, 6 months, and 12 months. After separate data analyses, findings were integrated using side-by-side comparison and joint display.

RESULTS

Several significant associations were identified between patient characteristics and symptom burden, and the participants described four categories of factors (i.e., treatment related, pathophysiological, situational, dietary) associated with a higher symptom burden during their interviews. Across both components of this study, three factors were consistent (i.e., employment, hyperphosphatemia, anemia). Participants described several factors not reported previously.

DISCUSSION

This study explored subjective and objective factors influencing the symptom experiences of patients with end-stage renal disease using a mixed methods design. These risk factors can be used to identify high-risk patients. Our findings suggest that participants relied on laboratory results and treatments to explain their symptom experiences. These findings suggest that assessment of both subjective and objective factors is needed to explore patients' symptom experiences.

Pain management in patients with chronic kidney disease and end-stage kidney disease

PURPOSE OF REVIEW

This review evaluates current recommendations for pain management in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) with a specific focus on evidence for opioid analgesia, including the partial agonist, buprenorphine.

RECENT FINDINGS

Recent evidence supports the use of physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management. Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and TCA may be considered based on pain cause and type, with careful dose considerations in kidney disease. NSAIDs may be used in CKD and ESKD for short durations with careful monitoring. Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/benefit discussion with the patient. Opioids that are safer to use in kidney disease include oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Buprenorphine appears to be a promising and safer option due to its partial agonism at the mu opioid receptor.

SUMMARY

Pain is poorly managed in patients with kidney disease. Nonpharmacological and nonopioid analgesics should be first-line approaches for pain management. Opioid use should be minimized with careful monitoring and dose adjustment.

Symptom-burden in people living with frailty and chronic kidney disease

Background

Frailty is independently associated with worse health-related quality of life (HRQOL) in chronic kidney disease (CKD). However, the relationship between frailty and symptom experience is not well described in people living with CKD. This study’s aim was to evaluate the relationship between frailty and symptom-burden in CKD.

Methods

This study is a secondary analysis of a cross-sectional observational study, the QCKD study (ISRCTN87066351), in which participants completed physical activity, cardiopulmonary fitness, symptom-burden and HRQOL questionnaires. A modified version of the Frailty Phenotype, comprising 3 self-report components, was created to assess frailty status. Multiple linear regression was performed to assess the association between symptom-burden/HRQOL and frailty. Logistic regression was performed to assess the association between experiencing symptoms frequently and frailty. Principal Component Analysis was used to assess the experienced symptom clusters.

Results

A total of 353 patients with CKD were recruited with 225 (64%) participants categorised as frail. Frail participants reported more symptoms, had higher symptom scores and worse HRQOL scores. Frailty was independently associated with higher total symptom score and lower HRQOL scores. Frailty was also independently associated with higher odds of frequently experiencing 9 out of 12 reported symptoms. Finally, frail participants experienced an additional symptom cluster that included loss of appetite, tiredness, feeling cold and poor concentration.

Conclusions

Frailty is independently associated with high symptom-burden and poor HRQOL in CKD. Moreover, people living with frailty and CKD have a distinctive symptom experience. Proactive interventions are needed that can effectively identify and address problematic symptoms to mitigate their impact on HRQOL.

Distinct Symptom Experience Among Subgroups of Patients With ESRD Receiving Maintenance Dialysis

CONTEXT

Patients with end-stage renal disease receiving dialysis experience multiple concurrent symptoms. A person-centered understanding of patients' symptom experiences may offer insights into individualized management.

OBJECTIVES

We identified subgroups of patients based on their symptom experiences and the characteristics that differentiated among these subgroups. Outcomes associated with these subgroups were evaluated.

METHODS

A total of 354 patients on dialysis were recruited at two regional hospitals in Hong Kong. While the Dialysis Symptom Index was adopted to assess symptoms, the Kidney Disease Quality of Life 36 and Karnofsky Performance Status Scale were used to evaluate the quality of life outcomes. Information on health care utilization and mortality were retrieved from medical records. Subgroups of patients were identified using latent class analysis based on the occurrence ratings. Differences in characteristics and outcomes were determined using Chi-squared test, analysis of variance, and Cox regression analysis.

RESULTS

Three latent classes were identified: low (37.8%), moderate physical-low psychological (29.7%), and moderate physical-high psychological (32.5%). Higher comorbidity burden and lower serum albumin levels differentiated between the low and moderate physical-low psychological classes. The moderate physical-high psychological class had the highest number of symptoms, poorest quality of life outcomes, and more unscheduled clinic visits. A shorter mean survival time (421 vs. 431 days) was also found.

CONCLUSION

Consistent with findings in other chronic conditions, subgroups of patients on dialysis have unique symptom experiences. Therefore, an individualized approach to symptom management is warranted. Our findings offer a phenotypic characterization for research on the underlying mechanisms for these symptom experiences.