Clinical Perspectives

Fatigue in People Undergoing

Hemodialysis
Mukadder Mollaoglu, PhD

The author is with the Cumhuriyet University, High School of Nursing, Sivas, Turkey.

BACKGROUND: Fatigue, a common symptom reported by people with end-stage renal disease (ESRD), is a non-
specific 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.

D
espite advances in renal replace-
ment therapies, fatigue remains
ranked as one of the most trou-
blesome 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 fac-
tors have been associated with the fatigue
experienced in ESRD. These include: pre-
scribed medications and their side effects;
nutritional deficiencies; physiological
alterations, particularly abnormal urea and
hemoglobin (Hgb) levels; psychological
factors such as depression, sleep dysfunc-
tion; and those associated with hemodi-
alysis treatment (low dialysate sodium and
excessive ultrafiltration).3
Fatigue is a highly prevalent symptom
experienced by people who live with chron-
ic 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 pro-
fessionals. Fatigue can be conceptualized
as located on a continuum between tired-
ness 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 inter-
mittent hemodialysis treatment in 348 dial-
ysis centers, Turkey has the fifth largest
chronic hemodialysis patient population
among European countries.6 However, few
data about the fatigue of people under-
going 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 under-
standing of the phenomenon and its mean-
ing 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 spe-
cifically 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

 than 1.0, it was categorized as low. A Kt/V
TABLE I. Distribution of personal and clinical characteristics of the range between 1.0 and 1.3 was categorized as
study patients (n ⫽ 138). normal, while values >1.3 were categorized
Characteristics Data as high. For multiple regression analysis, the
Age (yrs) mean ⫾ SD 48.3 (13.4)
original continuous data for these laboratory
indicators were used.
Gender n (%)
Female 60 (43.5) Visual Analogue Scale for Fatigue
Male 78 (56.5) (VAS-F)
Educational level n (%) This 18-item scale was developed by Lee
No formal education 46 (33.4) et al in 1991.7 The scale has 2 subscales
Primary school 51 (36.9) of fatigue and energy. The VAS-F has a
Secondary school 33 (23.9) 100 mm long horizontal line with “not at
Tertiary 8 (5.8) all” written on one end and “very severe”
on the other end. The patient marks the
Marital status n (%) severity of fatigue at that moment on the
Married 90 (65.2) line between these 2 degrees. Scoring is
Single 48 (34.8) done with the help of the marked area
Employment status n (%) on the ruler. A high score on the fatigue
Employed 15 (12.5) subscale and a low score on the energy sub-
Unemployed 85 (87.5) scale indicate an excessive level of fatigue.
The VAS-F subscale goes from most posi-
Dialysis frequency (weekly) n (%)
tive items to most negative and the energy
<1 years 28 (20.3)
subscale from most negative to most posi-
1–3 years 23 (16.6) tive items. A high score from the VAS-F
>3 year 87 (63.1) scale indicates a low score from the energy
Duration of dialysis (yrs) mean ⫾ SD 4.63 (3.7) subscale and a severe level of fatigue. In
addition the scale is preferred because it is
Kt/V (M ⫽ 1.42; SD ⫽ 0.25, range ⫽ 0.61–1.97)
short and easy to use and understand. The
Hgb (g/dL) (M ⫽ 10.05; SD ⫽ 1.37, range ⫽ 6.4–14.7) validity and reliability study for the tool
URR (M ⫽ 0.75; SD ⫽ 6.48E-02, range ⫽ 0.46–0.86) in Turkey was conducted by Yurtsever.8
The Cronbach ␣ for the fatigue subscale
Albumin (g/dL) (M ⫽ 3.67; SD ⫽ 1.12, range ⫽ 0.5–4.5)
has an internal consistency coefficient of
Visual Analogue Scale mean ⫾ SD 0.90; the Cronbach ␣ value for the energy
Fatigue 60.7 (27.8) subscale was found to be 0.74. The VAS-F
Energy 42.1 (11.3) was answered by patients.8 The patients
M, median. were asked to consider their general level
of fatigue when answering the VAS-F, not
Procedures tured questionnaire included sociodemo- for any specific period of time.
graphic, hemodialysis, and physiological
Questionnaires were distributed to parti- variables.
cipants at the beginning of dialysis and Ethical Considerations
collected upon completion during dialy- Structured Questionnaire Ethical approval was obtained from both
sis treatment. The same research assistant Demographic variables included age, gen- the university and regional hospital human
interviewed participants with low literacy der, education, and employment status. research ethics committees. Participation was
skills throughout the period of data collec- Physiological factors included laboratory voluntary and participants gave informed
tion. In addition, laboratory data were col- data (Hgb, albumin, URR, Kt/V) and dura- consent prior to the commencement of data
lected from medical charts during the same tion of HD, taken from medical records. For collection. Participants were informed that if
month that the patients’ questionnaires univariate analysis, all laboratory data were they felt fatigued they could discontinue their
were completed. classified into these categories: low, normal, participation.
and high using the normal range of each indi-
Research Instruments cator given by the laboratory. Normal range
Data Analysis
of Hgb ⫽ 13.5–17.5 g/dL (male), 12–16 g/
Overall, 2 instruments were used: a struc- dL (female); for albumin ⫽ 3.5–5.5 gm/dL; Data were summarized using a descriptive
tured questionnaire and the Visual Analog for URR >65%; and for Kt/V ⫽ 1.0–1.3. For statistical method. Continuous variables
example, when the value of Kt/V was less
œ
Scale (VAS-F). The contents of the struc- with a normal distribution are reported

2 Dialysis & Transplantation June 2009

Clinical Perspectives

was used to define correlations between

TABLE II. Differences in fatigue scores by sociodemographic variables 2 parameters. A logistic regression analysis
(n ⫽ 138). was used to determine the independent fac-
Characteristics Fatigue level t Energy level t tors which had an effect on sleep quality.
Values of p < .05 were considered statisti-
mean (SD) mean (SD)
cally significant.
Age
ⱕ30 67.7 (28.9) Kruskal-Wallis ⫽
31–40 78.7 (25.2) 9.18* 23.1 (11.2) Kruskal-Wallis ⫽ Results
41–50 78.9 (25.3) p < .05 19.9 (8.7) 11.48*
The sample consisted of 78 (56.5%) male
ⱖ51 97.4 (25.6) 18.7 (7.9) p < .05
and 60 (43.5%) female patients. Ages
9.5 (7.6)
ranged from 18 to 65 with a mean of
Gender 48·3 years (SD ⫽ 7.6). Most (90) sub-
Male jects were married. Only 15 (12.5%) were
Female 65.2 (28.3) 0.013* 37.9 (1.3) 0.414* employed, 5 full-time and 1 part-time. A
83.8 (23.5) 19.9 (9.11) total of 85 (87.5%) were unemployed. Most
of the patients had normal levels of albumin
Employment status
and URR. Their Kt/V, however, was above
Employed
normal. The mean duration of HD was
Unemployed 51.9 (28.0) 27.38** 26.1 (10.7) 10.22*
4.63 years (SD ⫽ 3.71, range: 5–18 years).
82.0 (23.1) 19.2 (9.1)
In regard to situational variables, most
Hgb of the participants were female; primary
Normal (n ⫽ 66) 84.6 (26.2) school educated; not employed; and mar-
Below (n ⫽ 72) 0.014* 32.0 (1.1) 0.3.89* ried. The mean fatigue score on the VAS-F
68.1 (36.8) 18.3 (8.12) in the sample was (60.7 ⫾ 27.8), and their
mean score for the energy subscale was
Albumin
42.1 ⫾ 11.3 (Table I).
Normal (n ⫽ 107) The relationships between mean val-
Below (n ⫽ 31) 79.37 ⫾ 27.07 1.29 19.61 ⫾ 10.23 1.07 ues for the VAS-F in the sample and
72.78 ⫾ 28.30 21.62 ⫾ 9.77 the sample’s sociodemographic charac-
Kt/V teristics were analyzed. According to
Below (n ⫽ 7) Kruskal-Wallis ⫽ these analyses, as their age increased,
66.92 ⫾ 32.66 3.12 20.16 ⫾ 10.30 Kruskal-Wallis ⫽ their fatigue increased, women had
Normal (n ⫽ 45)
68.62 ⫾ 35.18 23.66 ⫾ 4.16 5.44 more fatigue than men, as educational
Above (n ⫽ 86) level decreased, fatigue increased and
68.90 ⫾ 24.48 22.62 ⫾ 8.07
energy decreased, and these differences
were found to be statistically significant
*<05; **<.001 (p < .05). In addition, unemployed par-
ticipants reported signifi cantly higher
fatigue than employed subjects for total
TABLE III. Logistic regression analysis for the factors affecting fatigue. VAS-F and the energy subscale. The rela-
tionship between fatigue and physiologi-
Covariates B Standard Error exp (B) 95% CI p
cal variables (Hgb, albumin, URR, Kt/V),
Age 0.037 0.018 1.038 1.002–1.075 .038 has been tested. Neither total VAS-F
Duration of dialysis 0.035 0.021 1.034 1.005–1.086 .023 scores nor the energy subscale differed
by the physical variables (albumin, Kt/V)
Albumin ⫺0.821 0.552 0.440 0.149–1.299 .223
except for Hgb values (Table II).
Hgb 1.332 1.092 3.787 0.445–32.201 .223 When the correlation of global fatigue
scores with other variables were assessed,
B, logistic regression. Dependent variable: fatigue. Covariates: age, duration of dialysis, albumin, and Hgb level. there was a slight but significant positive
Data in bold were significantly different from the others.
relationship between the global fatigue
score and age, duration of dialysis, and Hgb
(r ⫽ 0.28, p ⫽ .003; r ⫽ 0.24, p ⫽ .01; r ⫽
as mean ⫾ standard deviation (SD). The ␹2 not normally distributed variables), and the 0.23, p ⫽ .016, respectively). Among these
test, student’s t-test (in normally distributed Kruskal-Wallis test were used to compare variables, only age and duration of dialysis
variables), the Mann-Whitney U test (in the 2 groups. The Pearson correlation test were found to be an independent predictor

June 2009 Dialysis & Transplantation 3

 of fatigue in logistic regression analysis
(Table III).
Discussion
Fatigue was the most disturbing symptom
reported by hemodialysis patients9,10 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 expe-
rience 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 responsi-
bilities 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, mari-
tal 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 al15 and Tola et al16 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 chang-
es that occur with age as well as psychosocial
effects of a chronic illness on the individual.
Fatigue differed significantly by gen-
der. In the present study, female partici-
pants 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 Graydon18 and Chen and Ku9
found that more female patients reported
fatigue than male patients. Interestingly,
Morsch et al found the opposite in men
4 Dialysis & Transplantation June 2009
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
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.
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 deter-
mined 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 rela-
tionship, medical professionals can help
validate patients’ illness experiences and
can provide information at a level suit-
able 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 asso-
ciation 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
a job. Or, staying at home may decrease the
amount of physical activity and social sup-
port from colleagues. Thus, the unemployed
participants might report higher levels of
fatigue. The results of the present study sup-
port the findings in the literature.17
Levels of fatigue did not differ by
physiological indicators except for ane-
mia in the present study. It is not surpris-
ingly that patients with high Hgb levels
have low fatigue levels. However, this
situation is controversial and is not con-
firmed 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 relation-
ship 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 identi-
fying 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 Graydon18 and McCann and
Boore24 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,
œ
and dependency all of which may
Clinical Perspectives
have major implications for the integ-
rity 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 prob-
lem for Turkish HD patients at this time.
Age, employment, education, gender, dura-
tion of dialysis, and anemia were related to
reported levels of fatigue. Thus, identify-
ing high-risk patients such as the unem-
ployed, 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, partici-
pants were all from 1 city in Turkey, which
may limit the generalizability of the findings
to other areas nationally. Second, the VAS-
F does not address other potential factors
associated with fatigue (ie, nutritional and
sleep deficits, stress, depression) experienced
by people with ESRD. Further study should
examine the other factors associated with
fatigue in a larger sample. D&T
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