Fatigue in People Undergoing Hemodialysis. The author is with the Cumhuriyet University, High School of Nursing, Sivas, Turkey.

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1 Fatigue in People Undergoing Hemodialysis Mukadder Mollaoglu, PhD The author is with the Cumhuriyet University, High School of Nursing, Sivas, Turkey. Clinical Perspectives BACKGROUND: Fatigue, a common symptom reported by people with end-stage renal disease (ESRD), is a nonspecifi c and invisible symptom and is a phenomenon that is poorly understood by healthcare professionals. There is limited understanding of the level of fatigue experienced by people with ESRD, with research currently limited to people treated with hemodialysis. AIM: Levels of fatigue as experienced by people undergoing hemodialysis (HD) were assessed using the Visual Analog Scale for Fatigue (VAS-F). METHOD: The VAS-F was completed by 138 people with ESRD who were patients of HD units in Sivas, Turkey. Demographic and renal health history data were also collected with a structured questionnaire. The statistical analyses used in order to evaluate the data include: student s t-test, Kruskal-Wallis test, Pearson correlation test, and logistic regression analysis. RESULTS: The level of fatigue experienced by people with HD in our study was high, and their energy level was low. Univariate analysis showed that levels of fatigue differed by gender, age, education, employment, and presence of anemia. However, logistic regression analysis, age, and duration of dialysis were found to be the independent predictors of fatigue. CONCLUSIONS: The results of the study indicated that high levels of fatigue are experienced. In order to improve patient care and promote patient s quality of life, nephrology professionals should understand the comprehensive assessment of fatigue and work with patients to initiate a range of strategies and interventions to address it. Despite advances in renal replacement therapies, fatigue remains ranked as one of the most troublesome symptoms for people with ESRD; physical fatigue is one of the most frequently experienced symptoms with >90% of patients reporting a lack of energy and feeling tired. 1,2 Several factors have been associated with the fatigue experienced in ESRD. These include: prescribed medications and their side effects; nutritional deficiencies; physiological alterations, particularly abnormal urea and hemoglobin (Hgb) levels; psychological factors such as depression, sleep dysfunction; and those associated with hemodialysis treatment (low dialysate sodium and excessive ultrafiltration). 3 Fatigue is a highly prevalent symptom experienced by people who live with chronic illness, including those with renal failure who require maintenance hemodialysis. Fatigue, however, is a non-specific and invisible symptom, and is a phenomenon that is poorly understood by healthcare professionals. Fatigue can be conceptualized as located on a continuum between tiredness and exhaustion at one end and with vitality being full of life and energy at the opposite end of this continuum. 4,5 With 18,063 patients undergoing intermittent hemodialysis treatment in 348 dialysis centers, Turkey has the fifth largest chronic hemodialysis patient population among European countries. 6 However, few data about the fatigue of people undergoing HD in Turkey are available, and basic demographic information, such as prevalence and incidence rates, are not completely known. As fatigue can have a negative effect on hemodialysis patients, it is important to develop a deeper understanding of the phenomenon and its meaning for the hemodialysis patients. Thus, this study examined the level of fatigue and the relationship between the affected factors discussed by people with HD in Sivas, Turkey. Understanding the level of the experience of fatigue among people undergoing HD will guide the development of nursing interventions and practices specifically targeted at symptom identification and management of fatigue. Methods and Materials Participants We consecutively identified 138 ESRD patients who were treated at HD units at the Sivas hospitals. All participants were 18 years of age or older, able to understand Turkish, and able to give informed consent and participate in the study. Subjects with an acute illness or who were hospitalized and those who reported psychological or cognitive disorders or physical limitations in self-care were excluded. June 2009 Dialysis & Transplantation 1

2 TABLE I. Distribution of personal and clinical characteristics of the study patients (n 138). Characteristics Procedures Questionnaires were distributed to participants at the beginning of dialysis and collected upon completion during dialysis treatment. The same research assistant interviewed participants with low literacy skills throughout the period of data collection. In addition, laboratory data were collected from medical charts during the same month that the patients questionnaires were completed. Research Instruments Data Age (yrs) mean SD 48.3 (13.4) Gender n (%) Female Male Educational level n (%) No formal education Primary school Secondary school Tertiary Marital status n (%) Married Single Employment status n (%) Employed Unemployed Dialysis frequency (weekly) n (%) <1 years 1 3 years >3 year 60 (43.5) 78 (56.5) 46 (33.4) 51 (36.9) 33 (23.9) 8 (5.8) 90 (65.2) 48 (34.8) 15 (12.5) 85 (87.5) 28 (20.3) 23 (16.6) 87 (63.1) Duration of dialysis (yrs) mean SD 4.63 (3.7) Kt/V (M 1.42; SD 0.25, range ) Hgb (g/dl) (M 10.05; SD 1.37, range ) URR (M 0.75; SD 6.48E-02, range ) Albumin (g/dl) (M 3.67; SD 1.12, range ) Visual Analogue Scale mean SD Fatigue Energy M, median (27.8) 42.1 (11.3) Overall, 2 instruments were used: a structured questionnaire and the Visual Analog Scale (VAS-F). The contents of the structured questionnaire included sociodemographic, hemodialysis, and physiological variables. Structured Questionnaire Demographic variables included age, gender, education, and employment status. Physiological factors included laboratory data (Hgb, albumin, URR, Kt/V) and duration of HD, taken from medical records. For univariate analysis, all laboratory data were classified into these categories: low, normal, and high using the normal range of each indicator given by the laboratory. Normal range of Hgb g/dl (male), g/ dl (female); for albumin gm/dl; for URR >65%; and for Kt/V For example, when the value of Kt/V was less than 1.0, it was categorized as low. A Kt/V range between 1.0 and 1.3 was categorized as normal, while values >1.3 were categorized as high. For multiple regression analysis, the original continuous data for these laboratory indicators were used. Visual Analogue Scale for Fatigue (VAS-F) This 18-item scale was developed by Lee et al in The scale has 2 subscales of fatigue and energy. The VAS-F has a 100 mm long horizontal line with not at all written on one end and very severe on the other end. The patient marks the severity of fatigue at that moment on the line between these 2 degrees. Scoring is done with the help of the marked area on the ruler. A high score on the fatigue subscale and a low score on the energy subscale indicate an excessive level of fatigue. The VAS-F subscale goes from most positive items to most negative and the energy subscale from most negative to most positive items. A high score from the VAS-F scale indicates a low score from the energy subscale and a severe level of fatigue. In addition the scale is preferred because it is short and easy to use and understand. The validity and reliability study for the tool in Turkey was conducted by Yurtsever. 8 The Cronbach for the fatigue subscale has an internal consistency coefficient of 0.90; the Cronbach value for the energy subscale was found to be The VAS-F was answered by patients. 8 The patients were asked to consider their general level of fatigue when answering the VAS-F, not for any specific period of time. Ethical Considerations Ethical approval was obtained from both the university and regional hospital human research ethics committees. Participation was voluntary and participants gave informed consent prior to the commencement of data collection. Participants were informed that if they felt fatigued they could discontinue their participation. Data Analysis Data were summarized using a descriptive statistical method. Continuous variables with a normal distribution are reported œ 2 Dialysis & Transplantation June 2009

3 Clinical Perspectives TABLE II. Differences in fatigue scores by sociodemographic variables (n 138). Characteristics Age Fatigue level mean (SD) 67.7 (28.9) 78.7 (25.2) 78.9 (25.3) 97.4 (25.6) Gender Male Female 65.2 (28.3) 83.8 (23.5) Employment status Employed Unemployed 51.9 (28.0) 82.0 (23.1) Hgb Normal (n 66) Below (n 72) 84.6 (26.2) 68.1 (36.8) Albumin Normal (n 107) Below (n 31) Kt/V Below (n 7) Normal (n 45) Above (n 86) *<05; **< TABLE III. Logistic regression analysis for the factors affecting fatigue. Covariates B Standard Error exp (B) 95% CI p Age Duration of dialysis Albumin Hgb B, logistic regression. Dependent variable: fatigue. Covariates: age, duration of dialysis, albumin, and Hgb level. Data in bold were signifi cantly different from the others. as mean standard deviation (SD). The 2 test, student s t-test (in normally distributed variables), the Mann-Whitney U test (in t 9.18* p <.05 Energy level mean (SD) 23.1 (11.2) 19.9 (8.7) 18.7 (7.9) 9.5 (7.6) 0.013* 37.9 (1.3) 19.9 (9.11) 27.38** 26.1 (10.7) 19.2 (9.1) 0.014* 32.0 (1.1) 18.3 (8.12) not normally distributed variables), and the Kruskal-Wallis test were used to compare the 2 groups. The Pearson correlation test t 11.48* p < * 10.22* * was used to define correlations between 2 parameters. A logistic regression analysis was used to determine the independent factors which had an effect on sleep quality. Values of p <.05 were considered statistically significant. Results The sample consisted of 78 (56.5%) male and 60 (43.5%) female patients. Ages ranged from 18 to 65 with a mean of 48 3 years (SD 7.6). Most (90) subjects were married. Only 15 (12.5%) were employed, 5 full-time and 1 part-time. A total of 85 (87.5%) were unemployed. Most of the patients had normal levels of albumin and URR. Their Kt/V, however, was above normal. The mean duration of HD was 4.63 years (SD 3.71, range: 5 18 years). In regard to situational variables, most of the participants were female; primary school educated; not employed; and married. The mean fatigue score on the VAS-F in the sample was ( ), and their mean score for the energy subscale was (Table I). The relationships between mean values for the VAS-F in the sample and the sample s sociodemographic characteristics were analyzed. According to these analyses, as their age increased, their fatigue increased, women had more fatigue than men, as educational level decreased, fatigue increased and energy decreased, and these differences were found to be statistically significant (p <.05). In addition, unemployed participants reported significantly higher fatigue than employed subjects for total VAS-F and the energy subscale. The relationship between fatigue and physiological variables (Hgb, albumin, URR, Kt/V), has been tested. Neither total VAS-F scores nor the energy subscale differed by the physical variables (albumin, Kt/V) except for Hgb values (Table II). When the correlation of global fatigue scores with other variables were assessed, there was a slight but significant positive relationship between the global fatigue score and age, duration of dialysis, and Hgb (r 0.28, p.003; r 0.24, p.01; r 0.23, p.016, respectively). Among these variables, only age and duration of dialysis were found to be an independent predictor June 2009 Dialysis & Transplantation 3

4 of fatigue in logistic regression analysis (Table III). Discussion Fatigue was the most disturbing symptom reported by hemodialysis patients 9,10 and nearly half of all hemodialysis patients experience a certain degree of fatigue and lack of energy. 2 It has been shown that 50.6% to 58.3% of dialysis patients experience fatigue. 11,12,13 The results of the present study indicated that high levels of fatigue are experienced. Determining patients level of fatigue and then ensuring that particular activities are planned for patients are clearly important responsibilities for medical professionals. They can also assist patients in developing strategies for both conserving and building energy, such as regular mild exercise, spacing activities between rest periods, and so forth. Theoretically, these interventions can improve physical symptoms and maintain the patients blood levels at normal degrees to relieve fatigue. 14 Univariate analysis showed that levels of fatigue differed by gender, age, marital status, employment, and the physical variables (Kt/V, URR, Hgb). However, the multivariate analysis showed that only age and duration of dialysis could predict levels of fatigue reported by HD participants. In the study, it was determined that as HD patients age increased, their fatigue level mean score increased and their energy level mean score decreased. In studies by Colosimo et al 15 and Tola et al 16 it was also determined that as a patients age increased they experienced more fatigue. At the same time, in a study by Cardenas and Kutner, a positive relationship was found between fatigue level and age. 11 The reason for this result is probably due to physiological changes that occur with age as well as psychosocial effects of a chronic illness on the individual. Fatigue differed significantly by gender. In the present study, female participants reported higher levels of fatigue than males. This finding is consistent with Liu who found that women hemodialysis patients reported more fatigue. 17 Similarly, Brunier and Graydon 18 and Chen and Ku 9 found that more female patients reported fatigue than male patients. Interestingly, Morsch et al found the opposite in men who were receiving hemodialysis therapy and who rated lack of physical energy and fatigue as impacting more significantly on their health related quality of life. 19 Gender and reporting of symptoms in HD patients are interesting. For instance, men with ESRD have been found to be less willing to report symptoms including fatigue. 20 Among the reasons why the high level of fatigue in female patients may be more severe than in male patients is that, in the Turkish culture, women can talk more easily than men about their illness and the problems associated with it. In Turkish society, men perceive illness as a loss of their power. For this reason, men may avoid talking about the problems they experience. In addition, in Turkish society, women have greater responsibilities within the home, which may be another reason why their fatigue level is higher. In addition, in this study it was determined that as educational level increased, fatigue decreased. In a study by Lerdal et al, 60.1% of patients experienced fatigue and as educational level decreased their fatigue level increased. 21 That is to say, the patients with a low educational level seemed to cope inadequately with fatigue and experienced more severe fatigue. Thus, individuals with a high level of education may be better able to manage their fatigue. In future studies, causes of this finding should be assessed using more specific questions. Professionals must be aware of fatigue and related factors, take it seriously, and assist patients in developing coping strategies to prevent and respond to it. By establishing a therapeutic relationship, medical professionals can help validate patients illness experiences and can provide information at a level suitable to the patients understanding of fatigue. 22 In this study, unemployed subjects reported higher fatigue for both the total VAS-F and the energy subscales. The association between employment status and HD treatment is unclear in the present study. Participants with higher frequencies of uncomfortable symptoms of fatigue might lack the energy to endure the requirements of It s important for medical professionals to determine their patients levels of fatigue and assist them in developing strategies for both conserving and building energy. a job. Or, staying at home may decrease the amount of physical activity and social support from colleagues. Thus, the unemployed participants might report higher levels of fatigue. The results of the present study support the findings in the literature. 17 Levels of fatigue did not differ by physiological indicators except for anemia in the present study. It is not surprisingly that patients with high Hgb levels have low fatigue levels. However, this situation is controversial and is not confirmed in all studies. A number of studies investigating fatigue in HD patients have failed to show a relationship between Hgb levels and fatigue. 18,23,24 However, several previous studies conducted with HD patients have indicated a relationship between a low level of Hgb and fatigue. 25,26,27,28,29 In our patients, there was relationship between Hgb levels and fatigue. Our findings suggest that identifying the existence of anemia routinely and providing adequate treatment for anemia might be an effective strategy for decreasing levels of fatigue. In this study, there were 2 significant predictors for fatigue identified by logistic regression analysis: duration of dialysis and age. Duration of dialysis is a factor that positively correlates with fatigue. 11,30 Cardenas and Kutner found that fatigue is a more serious problem for patients receiving dialysis for less than 4 years. 11 However, further research is needed, as Brunier and Graydon 18 and McCann and Boore 24 found that the duration of HD had no impact on fatigue in a person with renal failure who required maintenance hemodialysis. We also found that fatigue increased and the global score rose with advanced age. The patients must adapt to changes in lifestyle, relationships, status, and dependency all of which may œ 4 Dialysis & Transplantation June 2009

5 Clinical Perspectives have major implications for the integrity of the individual. No associations between fatigue and other situational and biochemical variables were identified by logistic regression analysis. Further examination of the data revealed complex relationships between the physiological factors examined. In conclusion, the findings of this study indicate that fatigue is a severe problem for Turkish HD patients at this time. Age, employment, education, gender, duration of dialysis, and anemia were related to reported levels of fatigue. Thus, identifying high-risk patients such as the unemployed, females, or the elderly, may enable the development of specific strategies to decrease levels of fatigue and discomfort associated with these conditions. Study Limitations There are some limitations to this study which must be acknowledged. First, participants were all from 1 city in Turkey, which may limit the generalizability of the findings to other areas nationally. 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