Fatigue is a predictor for cardiovascular outcomes in patients undergoing hemodialysis

The lived experiences of fatigue among patients receiving haemodialysis in Oman: a qualitative exploration

BACKGROUND

Fatigue among patients with end-stage kidney disease (ESKD) receiving haemodialysis imposes a substantial burden on patients' quality of life and expected treatment outcomes. This study explores the perspective on ESKD-related fatigue and contributing factors among Omani patients receiving haemodialysis.

METHODS

An exploratory qualitative design was used. Participants (N = 25) were recruited from two Omani haemodialysis centres, and data were collected through semi-structured interviews, which were transcribed and analysed using a thematic analysis approach. NVivo 11 is used to manage qualitative data and create memos, nodes, and codes.

RESULTS

Findings highlighted three themes: (i)"Inevitability of fatigue," (ii)"Contributors to physical fatigue," and (iii)"Contributors to mental fatigue." Theme one alluded to the inevitability of fatigue and the unique experience encountered by patients. Theme two addressed the physical fatigue associated with ESKD-related factors, such as chronically low haemoglobin levels, and the exhausting impact caused by the frequency and travelling distance for treatment sessions. Theme three, mental fatigue, was notably driven by heightened emotional disturbance, encompassing frustration, guilt, anxiety, and distress, that in turn impacted family interactions, frequently triggering anger and remorse. Moreover, mental fatigue is a result of disturbances in expressing physical sexuality in marriage, as physical fatigue was found to be a significant contributor to unsatisfactory sexual experiences and, thus, straining the relationships between couples.

CONCLUSIONS

This study offers an explanation of fatigue among Omani patients with ESKD who are receiving haemodialysis. The study emphasises close links between physiological change, the haemodialysis process, and mental tiredness, together with their contribution to supporting the need for a holistic approach and care strategies in managing these patients and promoting patient and family well-being.

Post-dialysis fatigue predicts all-cause mortality in patients on chronic hemodialysis

INTRODUCTION

Fatigue is reportedly associated with a poor prognosis in dialysis patients. The aim of the present study was to investigate whether fatigue on dialysis days or non-dialysis days is associated with mortality in patients on chronic hemodialysis.

METHODS

This was a prospective study of 134 hemodialysis patients. The level of fatigue was evaluated using a visual analog scale (VAS). The association between high fatigue evaluated by the highest quartile of the VAS value and all-cause death was investigated.

RESULTS

The fatigue scale score was significantly higher on dialysis than on non-dialysis days. During the follow-up period (median 6.8 years), 42 patients died. Patients with high post-dialysis fatigue in the higher quartiles died more frequently compared to those with in the lower quartiles (p = 0.012). Multivariate Cox regression analysis showed that high post-dialysis fatigue was an independent predictor of all-cause death (adjusted hazard ratio 2.12, 95% confidence interval 1.10-4.07).

CONCLUSION

Higher post-dialysis fatigue is related to increased mortality.

Development and validation of a nomogram model for accurately predicting severe fatigue in maintenance hemodialysis patients: A multicenter cross-sectional study in China

INTRODUCTION

This study aims to analyze the risk factors for severe fatigue in maintenance hemodialysis (MHD) patients and develop a clinical prediction model to help doctors and patients prevent severe fatigue.

METHODS

Multicentre MHD patients were included in this study. The objective was to investigate the risk factors for severe fatigue in MHD patients and develop a prediction model.

RESULTS

A total of 243 MHD patients were included in the study, and the incidence of severe fatigue was found to be 20.99%. Using age, body mass index, total cholesterol, and albumin levels, a predictive nomogram for fatigue was constructed. In the training set, the nomogram had an area under the curve of 0.851, sensitivity of 82.86%, specificity of 81.76%, and c-index of 0.851. The nomogram was accurate in calibration and proved to be clinically useful.

CONCLUSION

The nomogram developed in this study is a practical and reliable tool for quickly identifying severe fatigue in MHD patients.

Psychosocial and Clinical Associations of Fatigue Severity and Fatigue-Related Impairment in Kidney Transplant Recipients

Debilitating fatigue is common in people living with kidney disease and often persists after a kidney transplant. Current understanding of fatigue is centered around pathophysiological processes. Little is known about the role of cognitive and behavioral factors. The aim of this study was to evaluate the contribution of these factors to fatigue among kidney transplant recipients (KTRs). A cross-sectional study of 174 adult KTRs who completed online measures of fatigue, distress, illness perceptions, and cognitive and behavioral responses to fatigue. Sociodemographic and illness-related information was also collected. 63.2% of KTRs experienced clinically significant fatigue. Sociodemographic and clinical factors explained 16.1% and 31.2% of the variance in the fatigue severity and fatigue impairment, respectively, increasing by 28% and 26.8% after adding distress. In adjusted models, all the cognitive and behavioral factors except for illness perceptions were positively associated with increased fatigue-related impairment, but not severity. Embarrassment avoidance emerged as a key cognition. In conclusion, fatigue is common following kidney transplantation and associated with distress and cognitive and behavioral responses to symptoms, particularly embarrassment avoidance. Given the commonality and impact of fatigue in KTRs, treatment is a clinical need. Psychological interventions targeting distress and specific beliefs and behaviors related to fatigue may be beneficial.

Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps?

Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.

Examining the safety and effectiveness of a 4-week supervised exercise intervention in the treatment of frailty in patients with chronic kidney disease

Background

The optimal duration of antifrailty interventions and how best to deliver them to patients with chronic kidney disease (CKD) is unknown. The aim of this study was to examine the safety, feasibility and preliminary efficacy of a 4-week supervised exercise intervention on frailty in patients with CKD.

Methods

We conducted a prospective feasibility study involving patients with ≥stage 3 CKD (1 patient with stage 3 CKD, 7 patients with stage 4 CKD and 17 patients with stage 5 CKD) who were either frail or prefrail according to the physical frailty phenotype and/or had a Short Physical Performance Battery (SPPB) score ≤10. The exercise intervention consisted of two supervised outpatient sessions per week for 4 weeks (eight total sessions). Frailty and other study measures were assessed at baseline and after 4 weeks of exercise.

Results

Of the 34 participants who completed the baseline assessment and were included in the analyses, 25 (73.5%) completed the 4-week assessment. Overall, 64.0% of patients were on dialysis and 64.0% had diabetes mellitus. After 4 weeks of exercise, frailty prevalence, total SPPB scores and energy/fatigue scores improved. No adverse study-related outcomes were reported.

Conclusions

The 4 weeks of supervised exercise was safe, was associated with an excellent completion rate and improved frailty parameters in CKD patients with CKD. This study provides important preliminary data for a future larger prospective randomized study.

Clinical Trialgov

registration: NCT03535584.

Causal association between self-reported fatigue and coronary artery disease: a bidirectional two-sample Mendelian randomization analysis

Background

Observational studies have reported the association between fatigue and coronary artery disease (CAD), but the causal association between fatigue and CAD is unclear.

Method

We conducted a bidirectional Mendelian randomization (MR) study using publicly available genome-wide association studies (GWAS) data. The inverse-variance weighted (IVW) method was used as the primary analysis. We performed three complementary methods, including weighted median, MR-Egger regression, and MR pleiotropy residual sum and outlier (MR-PRESSO) to evaluate the sensitivity and horizontal pleiotropy of the results.

Result

Self-reported fatigue had a causal effect on coronary artery atherosclerosis (CAA) (OR 1.047, 95%CI 1.033-1.062), myocardial infarction (MI) (OR 1.027 95%CI 1.014-1.039) and coronary heart disease (CHD) (OR 1.037, 95%CI 1.021-1.053). We did not find a significant reverse causality between self-reported fatigue and CAD. Given the heterogeneity revealed by MR-Egger regression, we employed the IVW random effect model. For the examination of fatigue on CHD and the reverse analysis of CAA, and MI on fatigue, the MR-PRESSO test found horizontal pleiotropy. No significant outliers were found.

Conclusion

The MR analysis reveals a causal relationship between self-reported fatigue and CAD. The results should be interpreted with caution due to horizontal pleiotropy.

The relationship between fatigue and sickness absence from work

Background

Although many studies have been conducted on worker fatigue and sickness absence, the association between fatigue and sickness absence is unclear in Korean workers. This study was conducted to investigate the effect of worker fatigue on future sickness absence.

Methods

The study was conducted on workers who received medical check-ups at a university hospital for two consecutive years (2014-2015). During check-ups in the first year, the Fatigue Severity Scale (FSS) was used to assess fatigue levels, and during check-ups in the second year, sickness absence was surveyed to determine whether they had been absent from work due to physical or mental illness during previous 12 months. The χ2 test was used to analyze relationships between sociodemographic and occupational characteristics, fatigue levels, and sickness absence. Odds ratios (ORs) were calculated by logistic regression analysis controlled for confounding factors.

Results

A total of 12,250 workers were included in the study, and 396 (3.2%) workers experienced more than one day of sickness absence during the study period. Adjusted ORs for sickness absence were 3.35 (95% confidence interval [CI]: 2.64-4.28) in the moderate-fatigue group and 6.87 (95% CI: 4.93-9.57) in the high-fatigue group versus the low-fatigue group. For men in the moderate- and high-fatigue groups, adjusted ORs for sickness absence were 3.40 (95% CI: 2.58-4.48) and 8.94 (95% CI: 6.12-13.07), and for women in the moderate- and high-fatigue groups, adjusted ORs for sickness absence were 2.93 (95% CI: 1.68-5.10) and 3.71 (95% CI: 1.84-7.49), respectively.

Conclusions

Worker fatigue is associated with sickness absence during the following 12 months, and this association appears to be stronger for men than women. These results support the notion that sickness absence can be reduced by evaluating and managing work-related fatigue.

Association between corrected serum calcium levels after dialysis and post-dialysis fatigue risk: a hospital-based case-control study

OBJECTIVE

Post-dialysis fatigue (PDF) is an important problem in patients undergoing maintenance hemodialysis (MHD); however, evidence of the association between serum calcium after dialysis and the risk of PDF is limited and controversial. We explored this association among patients receiving MHD.

METHODS

We carried out a case-control study of patients in the dialysis unit of Dalian Municipal Central Hospital between December 2019 and January 2020, including 340 patients with PDF and 270 patients without PDF. PDF was assessed by a \validated self-administered questionnaire. Clinical variables were tested for multicollinearity using variance inflation factor analysis. Corrected serum calcium levels were categorized into three groups, with the lowest tertile used as the reference category. The odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for PDF risk were estimated using an unconditional logistic regression model.

RESULT

After adjusting for potential confounders, corrected serum calcium levels showed a significant positive association with the risk of PDF (OR_T3vs.T1 = 1.61, 95% CI = 1.01-2.58). Notably, after stratification by age, corrected serum calcium was also positively associated with the risk of PDF in patients aged ≥ 65 years (OR_T3vs.T1  = 4.25, 95% CI 1.66-11.46). Furthermore, a significant linear trend and interaction were also observed (P < 0.05).

DISCUSSION

Higher corrected serum calcium levels after dialysis might increase the risk of PDF among MHD patients. However, further studies are warranted to confirm these findings.

Association of alcohol consumption and fatigue in SLE: A cross-sectional study from Lupus Registry of Nationwide Institution (LUNA) cohort

OBJECTIVE

Fatigue is one of the most common complaints and is a potentially modifiable issue in systemic lupus erythematosus (SLE). Studies suggest that alcohol consumption has a protective effect against the development of SLE; however, an association between alcohol consumption and fatigue in patients with SLE has not been studied. Here, we assessed whether alcohol consumption was associated with fatigue using lupus patient-reported outcomes (LupusPRO).

METHODS

This cross-sectional study, conducted between 2018 and 2019, included 534 patients (median age, 45 years; 87.3% female) from 10 institutions in Japan. The main exposure was alcohol consumption, which was defined as the frequency of drinking [<1 day/month (none group), ≤1 day/week (moderate group), and ≥2 days/week (frequent group)]. The outcome measure was the Pain Vitality domain score in LupusPRO. Multiple regression analysis was performed as the primary analysis after adjusting for confounding factors, such as age, sex, and damage. Subsequently, the same analysis was performed as a sensitivity analysis after multiple imputations (MIs) for missing data (n = 580).

RESULTS

In total, 326 (61.0%) patients were categorized into the none group, 121 (22.7%) into the moderate group, and 87 (16.3%) into the frequent group. The frequent group was independently associated with less fatigue compared with none group [β = 5.98 (95% CI 0.19-11.76), p = 0.04], and the results did not substantially deviate after MI.

CONCLUSIONS

Frequent drinking was associated with less fatigue, which highlights the need for further longitudinal studies focusing on drinking habits in patients with SLE.

The impact of nurse-led nonpharmacological multidisciplinary holistic nursing care on fatigue patients receiving hemodialysis: a randomized, parallel-group, controlled trial

BACKGROUND

Fatigue is a symptom characterized by an elevated prevalence in patients undergoing hemodialysis, which may cause extreme mental and muscular debilitation, significantly influencing social interaction, life quality and well-being. However, the significance of fatigue to patients undergoing hemodialysis has not been recognized yet, and prevention and management of fatigue in this population have not been thoroughly investigated. Additionally, previous studies mainly focused on muscular fatigue, while mental fatigue has been seldom discussed. This study aims to investigate the interaction between nurses and multidisciplinary of nonpharmacological integrated care interventions (NICIs) and assess the impact of fatigue on patients undergoing hemodialysis.

METHODS

The integrative nonpharmacological care interventions in this study included walking, motivational interviewing (MI) and health education regarding behavioral self-management. A single-center randomized controlled trial was conducted in the dialysis center of the nephrological department in a tertiary affiliated hospital of medical university from January to June 2019. A total of 118 patients were selected and randomly divided into the intervention group (IG) and the control group (CG). Four patients dropped out during the study, and 114 patients were enrolled for the eventual analysis. The 60 patients in the IG received routine nursing combined with integrated care interventions, while the 54 patients in the CG received routine nursing only. This study lasted for six months.

RESULTS

The experimental group exhibited significant reductions of overall fatigue (2.26 vs. 0.48), mental fatigue (1.41 vs. 0.54), muscular fatigue (2.13 vs. 0.75), and some biochemical indicators (e.g., serum urea) (P<0.05), compared with the CG.

CONCLUSIONS

Nurses and multidisciplinary teams have been demonstrated to play a key role and interplay function in chronic disease management. Hence, the nurse-led multidisciplinary NICIs significantly alleviated total fatigue (muscular fatigue and mental fatigue) and improved other parameters.

TRIAL REGISTRATION

ChiCTR-IOR-16008621 (March 18, 2016).

Carnitine supplements for people with chronic kidney disease requiring dialysis

BACKGROUND

Carnitine deficiency is common in patients with chronic kidney disease (CKD) who require dialysis. Several clinical studies have suggested that carnitine supplementation is beneficial for dialysis-related symptoms. However, the clinical effectiveness and potential adverse effects of carnitine supplementation in dialysis patients have not been determined.

OBJECTIVES

This review aimed to evaluate the effectiveness and safety of carnitine supplementation for the treatment of dialysis-related complications in CKD patients requiring dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 16 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth, or other predictable methods) that compared carnitine supplements with placebo or standard care in people with CKD requiring dialysis.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted study data and assessed study quality. We used a random-effects model to perform a quantitative synthesis of the data.  We used the I² statistic to measure heterogeneity amongst the studies in each analysis. We indicated summary estimates as a risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, or standardised mean differences (SMD) if different scales were used, with 95% confidence intervals (CI). We assessed the certainty of the evidence for each of the main outcomes using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach.

MAIN RESULTS

We included 52 studies (47 parallel RCTs and five cross-over RCTs) (3398 randomised participants). All studies compared L-carnitine with a placebo, other treatment, or no treatment. Standard care was continued as co-interventions in each group. Most studies were judged to have an unclear or high risk of bias. L-carnitine may have little or no effect on the quality of life (QoL) SF-36 physical component score (PCS) (4 studies, 134 participants: SMD 0.57, 95% CI -0.15 to 1.28; I² = 73%; low certainty of evidence), and the total QoL score (Kidney Disease Quality of Life (KDQOL), VAS (general well-being), or PedsQL) (3 studies, 230 participants: SMD -0.02, 95% CI -0.29 to 0.25; I² = 0%; low certainty of evidence). L-carnitine may improve SF-36 mental component score (MCS) (4 studies, 134 participants: SMD 0.70, 95% CI 0.22 to 1.18; I² = 42%; low certainty of evidence). L-carnitine may have little or no effect on fatigue score (2 studies, 353 participants: SMD 0.01, 95% CI -0.20 to 0.23; I² = 0%; low certainty of evidence), adverse events (12 studies, 1041 participants: RR, 1.14, 95% CI 0.86 to 1.51; I² = 0%; low certainty of evidence), muscle cramps (2 studies, 102 participants: RR, 0.44, 95% CI 0.18 to 1.09; I² = 23%; low certainty of evidence), and intradialytic hypotension (3 studies, 128 participants: RR, 0.76, 95% CI 0.34 to 1.69; I² = 0%; low certainty of evidence). L-carnitine may improve haemoglobin levels (26 studies, 1795 participants: MD 0.46 g/dL, 95% CI 0.18 to 0.74; I² = 86%; low certainty of evidence) and haematocrit values (14 studies, 950 participants: MD 1.78%, 95% CI 0.38 to 3.18; I² = 84%; low certainty of evidence).

AUTHORS' CONCLUSIONS

The available evidence does not currently support the use of carnitine supplementation in the treatment of dialysis-related carnitine deficiency. Although carnitine supplementation may slightly improve anaemia-related markers, carnitine supplementation makes little or no difference to adverse events. However, these conclusions are based on limited data and, therefore, should be interpreted with caution.

Prevalence and Risk Factors of Postdialysis Fatigue in Patients Under Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

PURPOSE

Despite the high prevalence of postdialysis fatigue (PDF) in maintenance hemodialysis patients, no meta-analysis on the prevalence and risk factors of PDF has yet been published. This study aimed to identify the prevalence of PDF and explore its related factors.

METHODS

PubMed, Embase, CENTRAL, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the four Chinese databases (National Knowledge Infrastructure [CNKI], Chinese Biomedical Literature database [SinoMed], Wanfang Digital Periodicals [WANFANG], and Chinese Science and Technology Periodicals [VIP] database) were searched from inception up to July 2022. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The articles were independently searched by two reviewers, and the relevant data were extracted. The Agency for Healthcare Research and Quality was used to assess the quality of the included studies.

RESULTS

Thirteen articles with 2,118 participants were included. The pooled prevalence was 60.0%. The meta-analysis results revealed that the ultrafiltration volume, mean arterial pressure after dialysis, and good sleep quality were potentially associated with PDF, whereas only good sleep quality (odds ratio 0.24, 95% confidence interval 0.19-0.30) was significantly associated with PDF.

CONCLUSION

PDF is common in maintenance hemodialysis patients, which is related to the ultrafiltration volume, sleep quality, and mean arterial pressure after dialysis. However, the mechanism underlying the risk factors and PDF remains unknown. Further research is warranted to investigate the risk factors, intervention, treatment, and mechanism in maintenance hemodialysis patients.

Impact of hemodialysis solutions containing different levels of molecular hydrogen (H2) on the patient-reported outcome of fatigue

Background

Reportedly, dialysis solutions containing molecular hydrogen (H2) might ameliorate patient-reported fatigue in hemodialysis (HD) patients. However, it is unknown whether its impact might differ with different H2 levels.

Method

This single-arm, prospective observational study examined 105 patients on chronic HD (62 males; mean age, 66 years; mean HD duration, 117 months). All patients were originally treated with an HD solution with 47 ppb (mean) H2 for more than 12 months, followed by an HD solution with 154 ppb (mean) H2 for 8 weeks. Baseline and changes in subjective fatigue status rated on a numerical rating scale (NRS) were assessed before the start of the study (baseline) and 8th week of the study.

Results

Patients were classified into three groups according to the presence of subjective fatigue at baseline: Group A (15.2%), presence of fatigue on both HD and HD-free days; Group B (28.6%), fatigue only on HD days; and Group C (56.2%), freedom from fatigue. In Group A, NRS scores during the 8-week period were significantly decreased as compared with 0 week, at the 4th and 8th week on HD days, and at the 8th week on HD-free day, respectively. While no consistent changes were found in other groups. At the 8th week, 64 patients (61%) presented absence of or decrease in the NRS score of fatigue, while the rest of patients did not present the decrease in NRS (the non-improved: 39%). Regarding the factors related to the non-improved, prescription of antihypertensive agents was a significant independent risk factor by multivariate analysis, indicating the possible involvement of excess fall in blood pressure (BP) in those patients.

Conclusion

Amelioration of the patient-reported outcome of fatigue might be influenced by H2 levels in the HD solution, and the optimal H2 level in the dialysate needs to be elucidated in consideration of clinical type of fatigue and BP control status.

Association between sleep duration and sleep quality with arterial stiffness: A systematic review and meta-analysis

BACKGROUND

Altered sleep parameters, such as duration and quality, play an important role in the pathogenesis and progression of cardiovascular diseases, as well as in all-cause morbidity and mortality. It has been suggested that the specific mechanisms underlying this association could be through the influence of sleep parameters on vascular markers, such as arterial stiffness (AS), although this remains unclear. Thus, in this meta-analysis, we aimed to assess the association between sleep duration and sleep quality with AS in adults.

METHODS

PubMed, Scopus, Web of Science and Cochrane Library databases were searched from inception to July 30, 2021. The DerSimonian and Laird method was used to compute pooled effect size estimates and their respective 95% confidence intervals (95% CIs) of the association of sleep duration and sleep quality with AS. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the United States National Institute of Health National Heart, Lung, and Blood Institute was used to assess the risk of bias.

RESULTS

Finally, 14 studies (8 cross-sectional studies and baseline data from 6 prospective longitudinal studies) involving 97,837 individuals between 18 and 92 years of age were included. Our results showed that increased sleep duration, as continuous values, does not influence AS (effect size [ES]: 0.00; 95% CIs: -0.15, 0.15) in the general population. However, when sleep duration was longer than 8 hours (ES: 0.21; 95% CIs: 0.06, 0.36), according to sleep categories, a significant increase in pulse wave velocity was shown. Poor sleep quality was associated with increased AS (ES: 0.13; 95% CIs: 0.04, 0.21) in the general population. The overall risk of bias for studies examining sleep duration was fair in 77.8% of the included studies and the overall risk of bias for studies examining sleep quality was fair in 55.6%.

CONCLUSIONS

Our findings showed that both long sleep duration and poor sleep quality were associated with AS in adults. These findings underscore the influence of sleep on vascular health markers, specifically AS, as a possible pathway to explain the increased cardiovascular morbidity and mortality associated with sleep disorders.

The Effect of Nonpharmacological Integrated Care Protocols on Patients with Fatigue Undergoing Hemodialysis: A Randomized Controlled Trial

This study was designed to investigate the effects of nonpharmacological integrated care protocols on fatigue in patients with hemodialysis. This parallel randomized controlled trial was conducted on patients undergoing hemodialysis from May to October 2020 at the Dialysis Center of the Fifth Affiliated Hospital of Zunyi Medical University. The patients were randomized into an intervention group (accepting nonpharmacological integrated care protocols and standard care) or a control group (accepting standard care only) using a computer-generated random number. The nonpharmacological holistic care intervention used in this study involved a well-rounded multidisciplinary team that worked together to improve dietary compliance, medication adherence, and self-management to improve patients' care and promote self-management. From the 120 evaluated patients, 116 cases were eligible and analyzed. The results showed that patients from the intervention group had obviously reduced overall fatigue, mental fatigue, and muscular fatigue relative to the control group. The nonpharmacological integrated care protocols were interactive and promotive to each other. Meanwhile, the role and function of nurses in the management of chronic disease were demonstrated to be crucial.

New perspective on fatigue in hemodialysis patients with preserved ejection fraction: diastolic dysfunction : Fatigue and diastolic dysfunction

The relationship between diastolic dysfunction and fatigue in hemodialysis patients with preserved ejection fraction is unknown. In this context, the objective of this study is to assess fatigue using the relevant scales and to demonstrate its relationship with diastolic dysfunction. The patients who underwent hemodialysis were evaluated prospectively. Patients' fatigue was assessed using the Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F). The echocardiographic works were performed as recommended in the American Society of Echocardiography guidelines. A total of 94 patients [mean age 64.7 ± 13.5 years, 54 males (57.4%)] were included in the study. The median VAS-F score of these patients was 68.5 (33.25-91.25), and they were divided into two groups according to this value. Peak myocardial velocities during early diastole (e') and tricuspid annular plane systolic excursion (TAPSE) values were found to be significantly lower in the group with high VAS-F scores, whereas the early diastolic flow velocities (E)/e' ratio and pulmonary artery peak systolic pressures (PAP) were found to be significantly higher (p < 0.05, for all). E/e' ratio (r 0.311, p 0.002) and PAP (r 0.281, p 0.006) values were found to be positively correlated with the VAS-F score, as opposed to the TAPSE (r - 0.257, p 0.012) and e' (r - 0.303, p 0.003) values, which were found to be negatively correlated with the VAS-F score. High fatigue scores in hemodialysis patients may be associated with diastolic dysfunction. In addition, in our study, we determined the correlation of VAS-F score with E/e' ratio, PAP and TAPSE.

Dialysis recovery time: associated factors and its association with quality of life of hemodialysis patients

Introduction

Post-dialysis fatigue is a common and distressing complaint in patients on hemodialysis (HD). The dialysis recovery time (DRT) is a recent and reliable method of Post-dialysis fatigue assessment. We aimed to identify factors affecting the DRT and its relation with HD patients’ quality of life.

Material and methods

This is a cross-sectional study carried out on end-stage renal disease patients on regular HD. All participants underwent detailed history taking and complete physical examination, and data on dialysis and laboratory investigations were also collected. Patients were asked “How long does it take you to recover from a dialysis session?” to calculate the DRT. We used the Malnutrition-Inflammation Score (MIS) and KDQOL-36 questionnaire to assess patients’ nutritional status and quality of life, respectively.

Results

Two hundred and ten patients were screened and 191, with a median age of 47 years, completed the study. Patients had a median DRT of 300 minutes (range: 0.0–2880.0), with 55% of patients reporting a DRT of > 240 minutes and 22.5% of them reporting a DRT of < 30 minutes. Patients had a median MIS score of 7 (range: 0–17). There was a statistically significant negative relation between the DRT and symptom/ problem list (p < 0.001), effects of kidney disease (p < 0.001), burden of kidney disease (p < 0.001), SF-12 physical composite (p = 0.001), and SF-12 mental composite (p < 0.001) of KDQOL. The results of multivariate analyses showed that dialysate Na (p = 0.003), and the number of missed sessions (p < 0.001) were independently correlated with the DRT.

Conclusions

Decreased dialysate Na, and increased number of missed sessions were predictors of prolonged DRT. Patients with prolonged DRT were associated with poorer quality of life. Further randomized clinical trials are needed to assess strategies to minimize the DRT and, perhaps, enhance clinical outcomes.

Trials registration

ClinicalTrials.gov Identifier: NCT04727281. First registration date: 27/01/2021.

New polymethylmethacrylate membrane, NF-U, improves nutritional status and reduces patient-reported symptoms in older dialysis patients

Introduction

We previously reported the nutritional advantage of polymethylmethacrylate (PMMA) membranes to prevent the progression of malnutrition in dialysis patients. In this study, we examined whether a new PMMA dialyzer, NF-U, has advantages to improve the nutritional condition, patient-reported symptoms, and other clinical parameters in older dialysis patients.

Methods

We selected ten older chronic dialysis patients who were treated with NF-U for improving their worsening nutritional parameters and retrospectively evaluated nutrition and patient-reported symptoms. Patient-reported symptoms were surveyed by our original questionnaire including 20 items of symptom.

Results

Serum albumin concentration, geriatric nutritional risk index, and percent creatinine generation rate increased from 3.01 ± 0.16 to 3.25 ± 0.17 g/dL, 87.7 ± 5.8 to 91.4 ± 6.2, 100.2 ± 21.6 to 111.9 ± 20.9% at 1 and 4 months after switching to NF-U, respectively. For patient-reported outcomes, fatigue and the total score of patient-reported outcomes were improved after switching to NF-U.

Conclusion

Our results suggest that NF-U is a good choice for older dialysis patients to ameliorate their nutritional status and patient-reported outcomes.

Experiences of a cognitive behavioural therapy (CBT) intervention for fatigue in patients receiving haemodialysis

BACKGROUND

A feasibility randomised-controlled trial found that a cognitive-behavioural therapy intervention for renal fatigue has the potential to reduce fatigue in patients receiving haemodialysis, but uptake was low.

OBJECTIVES

Nested in the randomised-controlled trial (RC) qualitative interviews were undertaken to understand the acceptability of renal fatigue, the facilitators of, and barriers to, engagement, and the psychosocial processes of change.

DESIGN

The trial included 24 participants at baseline. Semi-structured interviews were conducted with nine participants from the intervention arm (n = 12). Approach Interviews were carried out immediately following treatment (3 months post-randomisation). Data were analysed using inductive thematic analysis.

FINDINGS

Five main themes were formulated. The overarching theme was a sense of coherence (whether the illness, symptoms and treatment made sense to individuals), which appeared to be central to acceptability and engagement. Two themes captured the key barriers and facilitators to engagement, cognitive and illness/treatment burdens and collaboration with the therapist. Participants described changes related to their activity, thoughts and social identity/interactions, which shaped perceptions of change in fatigue. Lastly, participants discussed the optimal delivery of the intervention.

CONCLUSIONS

This study revealed the importance of patients' understanding of fatigue and acceptance of the treatment model for the acceptability of and engagement with a cognitive-behavioural therapy-based intervention for fatigue. Overall, there was an indication that such an intervention is acceptable to patients and the mechanisms of change align with the proposed biopsychosocial model of fatigue. However, it needs to be delivered in a way that is appealing and practical to patients, acknowledging the illness and treatment burdens.

Fatigue Is Not Associated with Phase Angle in Hemodialysis Patients

PURPOSE

The aim of this study was to investigate the association between fatigue and phase angle (PA) in patients with chronic kidney disease (CKD) on hemodialysis (HD).

METHODS

A cross-sectional study with older patients than 18 years diagnosed with CKD undergoing HD. From 160 (58.36±15.05 years) patients, (n=96; 60%) are men. Body mass and height were assessed using a portable scale and stadiometer, followed by body mass index (BMI) calculus. The bioimpedance electrical analysis was performed using the Bodystat QuadScan 4000. The sample size was dichotomized in two groups, using the median of our sample, either normal when PA ≥5.4º, or low when the PA <5.4º. The Chalder fatigue questionnaire was used the assess the fatigue. The multiple regression was applied to assess the association between fatigue questionnaire and PA.

RESULTS

Were considered normal PA≥5.4º (n=78, 48.8%) and low PA<5.4º (n=82, 51.2%). The patients of the PA<5.4º group are older compared to the PA≥5.4º group (63.1±15.1 vs. 53.3±13.4 years, p<0.001). There was no association between PA and fatigue score in the crude model (OR: 1.02, 95%CI: 0.96-1.08, p=0.47) and after confounding variables (OR: 1.03, CI: 0.95-1.12, p=0.43).

CONCLUSIONS

In HD patients, we found that patients with lower PA values are older. In addition, we did not find association between fatigue and PA.

The reliability and validity of the Turkish version of the postdialysis fatigue scale

AIM

Haemodialysis (HD) commonly leads to postdialysis fatigue (PDF) and, thus, worsens the quality of life and the clinical outcomes. The aim of this study was to translate, linguistically validate and determine the psychometric properties of the "Postdialysis Fatigue" Scale for Turkish patients with HD.

STUDY DESIGN

A methodological study.

METHODS

The standard lingual translation and validation methods for the initial translation of the PDF Scale and then assessed the psychometric properties of reliability and validity of the translated scale. Visual analogue scale (VAS) and Piper Fatigue Scale were used to assess concurrent and construct validity. In addition, postdialysis recovery time was used it as an indirect measurement method for PDF.

RESULTS

A total of 93 patients participated in the study. The Cronbach's alpha coefficient of PDF was 0.773. There was a statistically significant relationship between the test and retest scores (ICC: 0.973; P < .001). PDF Scale was acceptable with 11 items. There was a positive correlation with a statistically significant relationship was present between the PDF scores and Piper Fatigue Scale (r = .488; P < .001) and VAS score (r = .656; P < .001). There was a statistically significant positive correlation between the PDF Scale and the postdialysis recovery time (r = .270; P = .009), CONCLUSION: The study results have shown that the Turkish form of the PDF Scale is a valid and reliable tool in patients undergoing HD treatment. Postdialysis recovery time may be used as an indirect measurement method to evaluate PDF.

Amelioration of fatigue in chronic dialysis patients with dialysis solution employing electrolyzed water containing molecular hydrogen (H2) and its association with autonomic function balance

Background

Enhanced oxidative stress is involved with fatigue in hemodialysis (HD) patients. Molecular hydrogen (H2) could improve the redox status. Thus, the study examines whether HD solution rendered by electrolyzed water containing H2 (E-HD) could impact the fatigue and autonomic balance of patients.

Methods

This single-arm, prospective observational study examined 95 patients on chronic HD (54 males; mean age and HD duration; 71.4 years and 10.6 years). Fatigue status on HD and HD-free days was compared between control HD (CHD) and 8 weeks after commencement of E-HD, using a visual analog scale (VAS) and an original scale. Autonomic balance was analyzed with the degree of activities of the sympathetic and parasympathetic nervous system via frequency analysis of a continuous beat interval.

Results

Patients were classified into three groups according to the presence of subjective fatigue during the period of CHD: Group A (40.0%), fatigue only on HD days; Group B (11.6%), presence of fatigue on both HD and HD-free days; and Group C (48.4%), freedom from fatigue. During the 8-week observation period of E-HD, VAS scores were significantly decreased on HD days in Group A, while Group B showed no significant changes in VAS on HD days, but significant decreases on HD-free days. No consistent changes were found in Group C. Significant increases in percentages of patients who reported absence of fatigue were seen in Group A on HD days and in Group B on HD-free days in week 8. Regarding changes in autonomic balance parameters after E-HD commencement, a positive correlation was identified between changes in VAS and autonomic balance in Group A.

Conclusion

E-HD may ameliorate fatigue in patients with subjective symptoms on HD and HD-free days. The influence of autonomic balance by E-HD and its impact on fatigue needs to be elucidated.

Amelioration of hemodialysis-induced oxidative stress and fatigue with a hemodialysis system employing electrolyzed water containing molecular hydrogen

Background

A novel hemodialysis (HD) system employing electrolyzed water containing molecular hydrogen (E-HD) has been developed to improve the bio-compatibility of HD. This study examined the impact of E-HD on changes in redox state during HD and HD-related fatigue.

Method

This single-arm, prospective observational study examined 63 patients on chronic HD (41 males; mean age, 72 ± 9 years; median duration of HD, 7 years). Redox parameters (serum myeloperoxidase [MPO], malondialdehyde-protein adduct [MDA-a], thioredoxin 1 [TRX]) during HD were compared between control HD (C-HD) and E-HD after 8 weeks. Fatigue was evaluated using a numerical rating scale (NRS) during the 8-week course.

Results

In C-HD, an increase in serum MPO accompanied increases in both oxidative products (MDA-a) and anti-oxidant molecules (TRX). In E-HD, although increases in MPO were accentuated during HD, changes in MDA-a and TRX were ameliorated as compared with C-HD. In patients who showed HD-related fatigue (47%) during C-HD, change in MDA-a by HD was a risk factor for the presence of fatigue. During the 8 weeks of observation on E-HD, those patients displayed significant decreases in fatigue scores.

Conclusion

E-HD ameliorates oxidative stress and supports anti-oxidation during HD, suggesting improved bio-compatibility of the HD system. E-HD may benefit patients with HD-related fatigue, but the mechanisms underlying changes to oxidative stress have yet to be clarified.

Exercise intolerance in kidney diseases: physiological contributors and therapeutic strategies

Exertional fatigue, defined as the overwhelming and debilitating sense of sustained exhaustion that impacts the ability to perform activities of daily living, is highly prevalent in chronic kidney disease (CKD) and end-stage renal disease (ESRD). Subjective reports of exertional fatigue are paralleled by objective measurements of exercise intolerance throughout the spectrum of the disease. The prevalence of exercise intolerance is clinically noteworthy, as it leads to increased frailty, worsened quality of life, and an increased risk of mortality. The physiological underpinnings of exercise intolerance are multifaceted and still not fully understood. This review aims to provide a comprehensive outline of the potential physiological contributors, both central and peripheral, to kidney disease-related exercise intolerance and highlight current and prospective interventions to target this symptom. In this review, the CKD-related metabolic derangements, cardiac and pulmonary dysfunction, altered physiological responses to oxygen consumption, vascular derangements, and sarcopenia are discussed in the context of exercise intolerance. Lifestyle interventions to improve exertional fatigue, such as aerobic and resistance exercise training, are discussed, and the lack of dietary interventions to improve exercise tolerance is highlighted. Current and prospective pharmaceutical and nutraceutical strategies to improve exertional fatigue are also broached. An extensive understanding of the pathophysiological mechanisms of exercise intolerance will allow for the development of more targeted therapeutic approached to improve exertional fatigue and health-related quality of life in CKD and ESRD.

Validation of a Core Patient-Reported Outcome Measure for Fatigue in Patients Receiving Hemodialysis: The SONG-HD Fatigue Instrument

BACKGROUND AND OBJECTIVES

Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy-Fatigue were used.

RESULTS

In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81-0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68-0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy-Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model.

CONCLUSIONS

SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.

Branched-Chain Amino Acids Depletion during Hemodialysis Is Associated with Fatigue

BACKGROUND

Fatigue is one of the most debilitating symptoms reported by maintenance hemodialysis (MHD) patients. Hemodialysis causes marked depletion in plasma essential amino acids. We studied the cross-sectional relationship of pre- and post-hemodialysis branched-chain amino acids (BCAAs) concentrations with fatigue in MHD patients.

METHODS

MHD patients self-reported fatigue during a dialysis session using the Brief Fatigue Inventory. Pre- and post-dialysis plasma levels of BCAAs (valine, leucine, and isoleucine) were measured using HPLC-mass spectrometry.

RESULTS

The mean age of study participants (n = 114) was 54.8 ± 12.8 years. Plasma levels of BCAAs decreased significantly post-dialysis compared to pre-dialysis (303.8 ± 9.4 vs. 392.1 ± 9.4 μM/L, p < 0.0001). Fatigue score increased as a function of age (p = 0.015). There was no association between pre-dialysis plasma levels of BCAAs and fatigue. A significant negative correlation was found between post-dialysis plasma levels of BCAAs and fatigue (p < 0.05).

CONCLUSIONS

These preliminary findings suggest that disruption in BCAAs homeostasis may play a role in precipitating fatigue.

Fatigue in Peritoneal Dialysis Patients and an Exploration of Contributing Factors: A Cross-Sectional Study

CONTEXT

Fatigue is a common and detrimental symptom in dialysis patients; however, our understanding of it and investigation of its contributing factors is still very limited, especially in peritoneal dialysis (PD) patients.

OBJECTIVES

To assess fatigue in PD patients and identify contributing factors.

METHODS

One hundred eight PD patients in a comprehensive hospital in China were recruited. The fatigue severity of the participants was assessed using the Chalder Fatigue Scale 11. Demographic factors and results of physiological tests were collected. Quality of sleep, mental health, and social support were assessed with the Pittsburgh Sleep Quality Index, Symptom Checklist 90, and Social Support Rating Scale, respectively. Multiple linear regression models were conducted with candidate variables with a P-value of less than 0.1 on univariate analysis and variables that were clinically relevant to identify contributing factors for fatigue.

RESULTS

The fatigue level in PD patients was significantly higher than the community population, and 78.7% of them were suffering from fatigue. The factors that were significantly associated with fatigue were quality of sleep, normalized protein nitrogen appearance, transferrin, alkaline phosphatase, and total cholesterol (adjusted R squared 0.86). Among them, quality of sleep, transferrin, alkaline phosphatase, and total cholesterol were significant contributors for physical fatigue, whereas the quality of sleep and normalized protein nitrogen appearance were contributing factors for mental fatigue.

CONCLUSION

Fatigue is a common symptom in PD patients, suggesting that increased awareness of this symptom is required. The identification of correlates by extensive exploration of multidimensional factors in this study may help practitioners to identify patients at higher risk and to develop a multidimensional and targeted intervention plan.

A prospective study of fatigue trajectories among in-centre haemodialysis patients

Objectives

Fatigue is common and debilitating among dialysis patients. The aim of this study was to understand the longitudinal trajectory of fatigue and consider sociodemographic, clinical, and psychological factors that are related to variation in fatigue levels over time.

Design

A prospective study of fatigue with yearly assessments over 3 years among prevalent in‐centre haemodialysis (HD) patients.

Methods

Fatigue severity was measured using the Chalder Fatigue Questionnaire and fatigue‐related functional impairment using the Work and Social Adjustment Scale. The trajectories of fatigue outcomes were examined using piecewise growth models, using length of time on dialysis as time. Sociodemographic, clinical, and psychological predictors of fatigue were assessed using linear growth models, using follow‐up time.

Results

One hundred and seventy‐four prevalent HD patients completed baseline measures, 118 at 12 months, 84 at 24 months, and 66 at 36 months. Fatigue severity scores decreased by 0.15 each year. Fatigue‐related functional impairment increased by 1.17 each year. In adjusted linear growth models, non‐white ethnicity was a significant predictor of lower initial fatigue severity (B = −2.95, 95% CI −5.51 to −0.40) and a greater reduction in fatigue severity of 1.60 each year (95% CI 0.35–2.36). A one‐point increase in damage beliefs was associated with a 0.36 increase in fatigue‐related functional impairment each year (95% CI −0.61 to −0.01).

Conclusion

Damage beliefs predicted an increase in fatigue‐related functional impairment over time. However, the data strongly suggested that fatigue outcomes vary by length of time on dialysis.

Fatigue in Individuals with End Stage Renal Disease

Fatigue is a subjective overwhelming feeling of tiredness at rest, exhaustion with activity, lack of energy that impedes daily tasks, lack of endurance, or a loss of vigor. Individuals with end stage renal disease (ESRD) experience a high rate and severity of fatigue. Symptom management of fatigue in this population is critical, since fatigue has been linked with lower quality of life and higher mortality rates. In this article, we present a definition and overview of fatigue, a review of factors contributing to fatigue, and ways to manage fatigue in individuals with ESRD.

Fatigue in Nondialysis Chronic Kidney Disease: Correlates and Association with Kidney Outcomes

BACKGROUND

Fatigue, although common and associated with outcomes in dialysis-dependent chronic kidney disease (CKD), has not been studied in nondialysis chronic kidney disease (CKD-ND) patients.

METHODS

In this longitudinal cohort of 266 outpatients with CKD-ND stages 2-5, we measured self-reported fatigue on 3 scales-Quick Inventory of Depression Symptomatology-Self Report (QIDS-SR16), Beck Depression Inventory-I (BDI-I), and short form 12 health survey (SF-12) questionnaires and evaluated the prespecified composite of progression to dialysis initiation, death, or hospitalization after 12 months. Logistic and linear regression assessed characteristics associated with fatigue. Survival analysis measured associations of fatigue with outcomes.

RESULTS

Mean age was 64.4 ± 12.0 years, and mean estimated glomerular filtration rate (eGFR) was 31.6 ± 16.7 mL/min/1.73 m2. Fatigue was common, with 69.2% reporting fatigue on QIDS-SR16 and 77.7% on BDI-I. Unemployment, comorbidities, use of antidepressant medications, and lower hemoglobin correlated with fatigue. There were 126 outcome events. Participants that reported any versus no fatigue on QIDS-SR16 were more likely to reach the composite, hazard ratio (HR) 1.70 (95% CI 1.11-2.59), which persisted after adjusting for demographics, comorbidities, substance abuse, hemoglobin, albumin, eGFR, and calcium-phosphorus product, HR 1.63 (1.05-2.55). Fatigue severity by the SF-12 was also associated with outcomes independent of demographics, comorbidities, and substance abuse, HR per unit increase 1.18 (1.03-1.35). No association was observed with fatigue on the BDI-I.

CONCLUSION

Fatigue affected about 2/3 of CKD-ND patients and associated with unemployment, comorbidities, antidepressant medication use, and anemia. Fatigue measured by the QIDS-SR16 and SF-12 independently predicted outcomes in CKD patients. Eliciting the presence of fatigue may be a clinically significant prognostic assessment in CKD patients.

Physical Exhaustion Induced Variations in Event-Related Potentials and Cognitive Task Performance in Young Adults

Background/Aims

Physical exhaustion is not always peripheral, and it is the brain that causes the sensation of fatigue either due to decrease of metabolic resources or due to central activation process that regulates attention and performance. This study was undertaken to observe the variations in event-related potentials (ERPs) and cognitive performance after an exhausting physical exercise.

Methods

A total of 60 healthy young adult subjects were included in the study. The study was conducted in 2 phases with at least a week gap between the phases. The participants answered a Multidimensional Fatigue Inventory (MFI-20) questionnaire before and after trials in each phase to measure the induced physical exhaustion. In phase I (control trial), the ERP data were processed using P300, Standard auditory "oddball paradigm," on computerized evoked potential recorder (RMS EMG MK-2) using 10/20 system to know the engagement of attention after which participants were given to perform cognitive tasks such as "Stroop Test, Trial Making Test and Mini Mental State Examination." In Phase II (exercise trial), the participants were instructed to cycle as hard as they could, till they could not continue anymore, which was followed by recording of P300-evoked potentials and performance of cognitive tasks as in Phase I. Paired t test was used to compare between any dependent variables.

Results

Fatigue-related subjective measures (MFI-20) showed that both mental and physical exhaustion were significantly greater in the exercise-involved cognitive trial than in the control trial. Lower P300 latencies reflect faster reaction time; however, their response accuracies were poorer resulting in poorer cognitive performances. Participants subjected to control trial performed better in terms of higher percentage accuracy but with slow reaction time.

Conclusion

The participants experienced more fatigue physically and mentally during the exercise that involved cognitive tasks. An apparent decrease in attention based on decreased percentage accuracy of response was evident, implying that fatigue, performance, and attention are interdependent.

Sleep, Autonomic Nervous Function and Atherosclerosis

Behavioral and psychosocial factors related to development of cardiovascular disease have been gaining increased attention. Notably, sleep is considered to be one of the most important behavioral factors involved in progression of atherosclerosis and cardiovascular events, with autonomic nervous function a potential mechanism. Several studies have shown associations of sleep and autonomic dysfunction with major surrogate markers of atherosclerosis, such as carotid intima-media thickness and arterial stiffness. Endocrinological, immunological, oxidative, inflammatory, and metabolic responses, as well as endothelial dysfunction may mediate the effects of the autonomic nervous system. For this review, we examined recent findings related to sleep, autonomic nervous dysfunction, and atherosclerosis, with the aim of understanding the involved pathophysiological mechanisms.

Vitality Measured as Self-reported Energy Level and Clinical Outcomes in Hemodialysis Patients: The Japanese Dialysis Outcomes and Practice Pattern Study (J-DOPPS)

RATIONALE & OBJECTIVE

The infrequent assessment of vitality in clinical practice may be partially due to an inadequate understanding of vitality and the lack of a concise method of assessing it. This study aimed to examine the association of a simple 1-item "vitality" question measuring self-reported energy level with clinical outcomes.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

3,667 hemodialysis patients participating in the Japanese Dialysis Outcomes and Practice Pattern Study (J-DOPPS), phases 3 to 4 (2005-2011).

PREDICTOR

Responses to a single question from the 12-item Medical Outcomes Study Short Form survey, version 2.0: "How much time during the past 4 weeks did you have a lot of energy?," recorded using a 5-level Likert scale.

OUTCOMES

All-cause mortality and a composite of cardiovascular hospitalizations and all-cause mortality.

ANALYTICAL APPROACH

A pooled ordered logit model was fit to examine correlates of self-reported energy level. Cox and mixed-effects negative binomial regression models were fit for mortality and the composite outcome.

RESULTS

Lower self-reported energy level was associated with tachycardia and use of benzodiazepines, hypnotics, and antidepressants. In contrast, higher energy was associated with higher single-pool Kt/V, serum albumin concentration, and body mass index. Compared to the lowest energy level, the second-highest and middle levels were associated with lower all-cause mortality (adjusted HRs [aHRs] of 0.66 [95% CI, 0.47-0.93] and 0.75 [95% CI, 0.59-0.96], respectively). Each 1-level higher self-reported energy was associated with lower mortality (aHR, 0.86; 95% CI, 0.78-0.96). Associations between self-reported energy level and multiple cardiovascular hospitalizations and mortality were similar to those between self-reported energy and mortality.

LIMITATIONS

No psychometric assessments were done for the Short Form survey.

CONCLUSIONS

The response to a single "vitality" question addressing self-reported energy level is associated with adverse clinical outcomes and correlated with potentially modifiable factors.

How Physical Activities Affect Mental Fatigue Based on EEG Energy, Connectivity, and Complexity

Many studies have verified that there is an interaction between physical activities and mental fatigue. However, few studies are focused on the effect of physical activities on mental fatigue. This study was to analyze the states of mental fatigue based on electroencephalography (EEG) and investigate how physical activities affect mental fatigue. Fourteen healthy participants participated in an experiment including a 2-back mental task (the control) and the same mental task with cycling simultaneously (physical-mental task). Each experiment consisted of three 20 min fatigue-inducing sessions repeatedly (mental fatigue for mental tasks or mental fatigue plus physical activities for physical-mental tasks). During the evaluation sessions (before and after the fatigue-inducing sessions), the states of the participants were assessed by EEG parameters. Wavelet Packet Energy (WPE), Spectral Coherence Value (SCV), and Lempel-Ziv Complexity (LZC) were used to indicate mental fatigue from the perspectives of activation, functional connectivity, and complexity of the brain. The indices are the beta band energy E_β, the energy ratio E_α/β, inter-hemispheric SCV of beta band SCV_β and LZC. The statistical analysis shows that mental fatigue was detected by E_β, E_α/β, SCV_β, and LZC in physical-mental task. The slopes of the linear fit on these indices verified that the mental fatigue increased more fast during physical-mental task. It is concluded form the result that physical activities can enhance the mental fatigue and speed up the fatigue process based on brain activation, functional connection, and complexity. This result differs from the traditional opinion that physical activities have no influence on mental fatigue, and finds that physical activities can increase mental fatigue. This finding helps fatigue management through exercise instruction.

Assessment of Fatigue in End Stage Renal Disease Patients Undergoing Hemodialysis: Prevalence and Associated Factors

Background:

Fatigue is a common symptom referred by many patients undergoing hemodialysis. Fatigue is associated with poor health-related quality of life (HRQoL) and is an important predictor for survival of hemodialysis patients.

Aim:

To assess the levels of fatigue and demographic factors affecting it among patients with End Stage Renal Disease undergoing hemodialysis.

Methods:

This quantitative study was carried out in two Dialysis Units of Hospitals in Athens Region. Between January 2015 and June 2015, 129 hemodialysis patients completed the Greek Version of the Fatigue Assessment Scale (FAS). Demographic data of patients was recorded. For the statistical analysis IBM SPSS Statistics version 20 was used.

Results:

The mean FAS score was 24.99. 49 patients (38.0%) were non fatigued, 61 patients (47.3%) were fatigued, and 19 patients (13.7%) were extremely fatigued. Higher levels of fatigue were reported among hemodialysis patients residing in urban areas, in those with low educational level and unemployed.

Conclusion:

The findings of this study can be used in the assessment of fatigue and early identification of high-risk patients (especially of the unemployed, those who occupy with domestic works, those with low educational level and of urban citizens). Use of this knowledge by hemodialysis nurses may lead to a better understanding of the factors of fatigue in ESRD, which in turn may lead to a more effective treatment.

Fatigue is associated with high prevalence and severity of physical and emotional symptoms in patients on chronic hemodialysis

PURPOSE

The symptom burden of fatigued hemodialysis patients is poorly known. We aimed to investigate possible differences in the prevalence and severity of symptoms between fatigued and not fatigued patients on chronic hemodialysis.

METHODS

All prevalent patients on chronic hemodialysis referring to the Hemodialysis Service between January 2016 and June 2017 were considered eligible. The Dialysis Symptom Index (DSI) questionnaire was performed during the dialysis treatment. Patients underwent assessment of fatigue using the Italian version of the vitality scale of the SF-36 (SF-36VS).

RESULTS

We studied 137 patients: 107 (78.1%) were fatigued and 30 (31.9%) were non-fatigued. The median [95% CI] number of symptoms was 15 [14-16] for patients who reported fatigue and 9 [8-19] for the non-fatigued (P < 0.0001). In fatigued patients, with respect to non-fatigued ones, the prevalence of dry skin, itching, muscle soreness, bone or joint pain, restless legs, shortness of breath, feeling sad, feeling anxious, difficulty concentrating, and difficulty becoming sex aroused was significantly higher. Restless legs, feeling sad, difficulty concentrating, and difficulty becoming sex aroused were symptoms independently associated with fatigue. The severity of dry skin, trouble staying asleep, and bone/joint pain was higher in fatigued patients.

CONCLUSION

Fatigued hemodialysis patients report suffering from physical and emotional symptoms more frequently than non-fatigued patients. This finding suggests the need to accurately and routinely define the symptom burden of chronic hemodialysis patients and may help to investigate eventually common underlying pathogenic mechanisms of symptoms in these patients.

Relationship between fatigue symptoms and subjective and objective indicators in hemodialysis patients

PURPOSE

The purpose of the study was to investigate the major factors affecting fatigue symptoms and to examine the relationships between fatigue symptoms and subjective and objective indicators in patients on hemodialysis (HD).

METHODS

Patients on HD who met the inclusion criteria were chosen from two grade A tertiary general hospitals by convenience sampling and cross-sectional survey methods.

RESULTS

A total of 511 patients were included in the study. The morbidity rate of fatigue in patients on HD was 61.6%, and the median fatigue level was 3.91. Fatigue and subjective indicators showed a mild-moderate relationship (0.3 < all |r| < 0.6, all P < 0.001), whereas a weak correlation was found between fatigue and objective indicators (all |r| < 0.2, all P < 0.05). Multivariate analysis showed that subjective indicators, including employment, exercise time, appetite, the vitality of 36-item Short Form Health Survey, perceived social support, intrafamilial support, cramping, headache, chest tightness, and whole-body pain, as well objective indicator, such as serum intact parathyroid hormone levels, were the influence factors of fatigue in patients on HD.

CONCLUSION

The prevalence of fatigue symptoms was high and the level of fatigue was moderate in patients on HD. Subjective and objective indicators can both affect fatigue symptoms in patients on HD.

'It's when you're not doing too much you feel tired': A qualitative exploration of fatigue in end-stage kidney disease

BACKGROUND

Fatigue is commonly experienced in end-stage kidney disease (ESKD) patients. In order to develop patient-centred psychosocial interventions to help patients manage fatigue symptoms, a more in-depth understanding regarding the experience of fatigue is needed.

OBJECTIVE

The objective of this study was to explore renal patients' experiences of fatigue, across renal replacement therapy (RRT) modalities.

METHODS

Twenty-five in-depth semi-structured interviews were conducted. Interviews were audio-taped, transcribed, and analysed using inductive thematic analysis.

RESULTS

Main themes included the strong role of the illness and treatment in the aetiology of fatigue. Two contrasting streams of illness-fatigue interpretations emerged: catastrophizing versus normalizing. Participants emphasized the importance of having a sense of purpose in facilitating active management of fatigue. Many participants described the consequences of fatigue on their functioning. Low mood, frustration, and anger were common emotional consequences of fatigue. Three dominant fatigue management strategies emerged: one related to accommodation of activities around fatigue, another on increasing activities to counteract fatigue, and the third one revolved around self-compassion. Social support emerged as an important aspect of the fatigue experience, serving as a source of motivation, yet participants were wary of becoming a burden to others.

CONCLUSION

Findings identify casual attributions, behavioural and emotional reactions, management strategies, and facilitators of active management of fatigue in ESKD. Untying fatigue from the illness and treatment may help patients to develop alternative less catastrophic perceptions of fatigue, increase their perception of control over fatigue, and facilitate active fatigue management. Statement of contribution What is already known on this subject? Fatigue is persistent and debilitating in end-stage kidney disease (ESKD), with no consistent treatment model. Promising evidence is available for psychological fatigue interventions in other chronic conditions. There is a gap in studies looking at the fatigue experiences of patients with ESKD across renal replacement therapies. What does this study add? Fatigue is not inherently negative, but shaped by patients' beliefs and behaviours. Findings provide novel insights, for example, on the important role social support seems to play in fatigue. An in-depth understanding of fatigue may help to inform a future patient-centred intervention in ESKD.

A Systematic Review of Biological Mechanisms of Fatigue in Chronic Illness

Fatigue, a commonly reported symptom, is defined as an overwhelming, debilitating, and sustained sense of exhaustion that decreases the ability to function and carry out daily activities. To date, cancer researchers have been in the forefront in investigating the possible biological mechanisms of fatigue, identifying inflammation, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, and activation of the autonomic nervous system. The purpose of this systematic review is to describe fatigue and what is known about the biological mechanisms described in cancer in five chronic, noninfectious illnesses: heart failure, multiple sclerosis, chronic kidney disease, rheumatoid arthritis, and chronic obstructive pulmonary disease. We searched PubMed and EMBASE using fatigue as a major Medical subject headings (MeSH) heading with each individual disease added as a search term followed by each biological mechanism. We included only primary research articles published in English between 1996 and 2016 describing studies conducted in adult humans. We identified 26 relevant articles. While there is some evidence that the biological mechanisms causing fatigue in cancer are also associated with fatigue in other chronic illnesses, more research is needed to explore inflammation, the HPA axis, and the autonomic nervous system, and other mechanisms in relation to fatigue in a variety of chronic illnesses.

Cognitive-behavioural therapy (CBT) for renal fatigue (BReF): a feasibility randomised-controlled trial of CBT for the management of fatigue in haemodialysis (HD) patients

INTRODUCTION

Fatigue is one of the most common and disabling symptoms in end-stage kidney disease, particularly among in-centre haemodialysis patients. This two-arm parallel group feasibility randomised controlled trial will determine whether a fully powered efficacy trial is achievable by examining the feasibility of recruitment, acceptability and potential benefits of a cognitive-behavioural therapy (CBT)-based intervention for fatigue among in-centre haemodialysis patients.

METHODS

We aim to recruit 40 adult patients undergoing in-centre haemodialysis at secondary care outpatient dialysis units, who meet clinical levels of fatigue. Patients will be randomised individually (using a 1:1 ratio) to either a 4-6 weeks' CBT-based intervention (intervention arm) or to a waiting-list control (control arm). The primary feasibility outcomes include descriptive data on numbers within each recruiting centre meeting eligibility criteria, rates of recruitment, numbers retained postrandomisation and treatment adherence. To assess the potential benefits of the cognitive-behavioural therapy for renal fatigue intervention, secondary self-report outcomes include measures of fatigue severity (Chalder Fatigue Questionnaire), fatigue-related functional impairment (Work and Social Adjustment Scale), sleep quality (Pittsburgh Sleep Quality Index), depression (Patient Health Questionnaire-9) and anxiety (Generalised Anxiety Disorder-7). Changes in fatigue perceptions (Brief Illness Perception Questionnaire), cognitive and behavioural responses to fatigue (Cognitive and Behavioural Responses to Symptoms Questionnaire), sleep hygiene behaviours (Sleep Hygiene Index) and physical activity (International Physical Activity Questionnaire-short form) will also be explored. These self-report measures will be collected at baseline and 3 months postrandomisation. Nested qualitative interviews will be conducted postintervention to explore the acceptability of the intervention and identify any areas in need of improvement. The statistician and assessor will be blinded to treatment allocation.

ETHICS AND DISSEMINATION

A National Health Service (NHS) Research Ethics Committee approved the study. Any amendments to the protocol will be submitted to the NHS Committee and study sponsor.

TRIAL REGISTRATION NUMBER

ISRCTN91238019;Pre-results.