Extracellular Water Excess and Increased Self‐Reported Fatigue in Chronic Hemodialysis Patients

Abstract

Hemodialysis patients (HD) commonly report fatigue. Muscle wasting (sarcopenia) and extracellular water (ECW) excess have been reported to be associated with fatigue in other conditions. We wished to determine whether muscle loss and ECW excess were associated with fatigue in HD patients. Patients completed the Multidimensional Fatigue Inventory (MFI), Beck Depression Inventory-II (BDI-II), Patient Health Questionnaires (PHQ-9) and recorded their post-dialysis recovery time. Sessional dialysis data were recorded along with pre- and post-dialysis multi-frequency bioimpedance assessments (MFBIA). One hundred and ten patients, median age 64 (52-79) years, 67% male, 35% diabetic completed questionnaires and had pre- and post-HD MFBIAs. Median total MFI score was 60 (48-72), with the physical domain having the highest score. Modal (30.8%) recovery time post-dialysis was 1-4 h. Of the participants, 35% and 34% had increased BDI-II and PHQ-9 scores, respectively. Total MFI score was associated with increased BDI-II (>16) (standardized (Std) β 0.54, P < 0.001), PHQ-9 (>10) scores (Std β 0.49, P < 0.001, past history of depression (Std β 0.28, P = 0.003), post-HD ECW/total body water ratio (Std β 0.25, P = 0.002), recovery time > 8 h (Std β 0.26, P = 0.001), post dialysis mean arterial pressure (MAP) (Std β -0.19, P = 0.02), and muscle wasting (Std β -0.15, P = 0.05). Self-reported fatigue in HD patients is associated with self-reported depression, but also dialysis-related factors including increased ECW post HD, low MAP, and longer recovery times. Patients with reduced muscle mass were less likely to report fatigue, possibly accepting physical limitations. As such, interventions to reduce fluid overload and improve dialysis experience may help improve fatigue.

A new assessment scale for post-dialysis fatigue in hemodialysis patients

“…In a previous study, a longer recovery time was associated with a greater intradialytic weight loss [15], suggesting that the ultrafiltration volume may play a role in causing PDF. In addition, selfreported fatigue was associated with a particularly low mean arterial blood pressure post-dialysis [20]. The "stress" reaction accompanying intradialytic hypotension may also contribute to the development of PDF [1].…”

“…Fatigue negatively impacts the health-related quality of life and is associated with both increased morbidity and mortality in patients suffering from many chronic illnesses [20]. However, only a few studies have been specifically designed and conducted to evaluate treatments for PDF.…”

Subjective global assessment of nutrition, dialysis quality, and the theory of the scientific method in Nephrology practice

“…Nevertheless, BIS seems to be a promising tool to assess nutritional status by its ability to measure lean body mass, fat body mass, and their ratio in maintenance dialysis patients. 66,67,68 Assessment of lean body mass and lean-to-fat body mass ratio 66 may prove to be a good surrogate marker for maintenance of muscle mass and therefore the ability to prevent uremia-induced catabolism, a major goal for renal replacement therapy. In summary, while the ability of SGA is well documented and correlated with clinical outcomes, more research is needed to better estimate the relative merits of bioimpedance-based assessments.…”

The relationship of volume overload and its control to hypertension in hemodialysis patients

“…Beyond these “hard” outcomes, volume overload has substantial implications for patients. Hypervolemia, measured by BIS, is associated with fatigue while a high UF rate, often used in the setting of volume overload, is a predictor of prolonged recovery time after HD . Patients also report a substantial life impact from debilitating volume‐related symptoms such as shortness of breath.…”