Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis

Abstract

Background Quality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms. Methods We reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW). Results We studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times. We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times. Conclusion We found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.

Delayed post‐dialysis recovery times are associated with relative changes in intracellular and extracellular fluid ratios between different body compartments

“…We found no difference in predialysis clinical status, medications, blood pressure, volume status, or pre-dialysis laboratory investigations, in keeping with several previous reports [4,[18][19][20]. Similarly, there were no statistically significant differences in the prescribed dialysis prescription between the two sessions, in terms of dialysate composition, dialyzer, peridialytic changes in blood pressure, or ultrafiltration rates, supporting earlier studies [4,[18][19][20][21]. However, longer recovery times were reported more frequently with high flux hemodialysis sessions compared to those with hemodiafiltration.…”

“…This relative difference in the change in ECW could potentially lead to a more pronounced effect in terms of reducing cerebral oxygenation in this older cohort of patients [34], and so possibly induce greater cytotoxic cerebral edema [35], consequently increasing the sensation of post-dialysis fatigue. This greater fall in ECW would support earlier reports that patients who start dialysis closer to their target weight, with lower ultrafiltration rates are more vulnerable to delayed post-dialysis recovery and fatigue [4,21], and equally excessive ultrafiltration rates could also reduce ECW and increase intercompartmental disequilibrium [11,18]. Although not statistically different, the median ultrafiltration rate adjusted for body weight, and percentage body weight change were slightly greater for those sessions with longer recovery times which would support a greater compartmental disequilibrium leading to patients reporting a longer recovery time.…”

“…There appears to be little or no consensus on the drivers to the cause of post-dialysis fatigue, with some studies reporting an association with patient factors such as female gender, age, frailty, comorbidity, and depression [9][10][11][12]; and dialysis factors including higher ultrafiltration rates, lower dialysate sodium, intra-dialytic hypotension, dialysis modality, session duration, and frequency [11,[13][14][15][16][17], whereas other observational reports failed to confirm these associations [8,[18][19][20][21]. As most of these studies either reported on a single session or asked patients to reflect on a period of dialysis treatment, it is unclear as to which specific factors associated with a dialysis session may contribute to post-dialysis fatigue.…”

Do patients dialysing with higher ultrafiltration rates report more intradialytic symptoms and longer postdialysis recovery times?

“…Some studies have even reported that peridialytic symptoms were associated with lower UFRs 20 . This association with very low UFRs could possibly be explained in that fluid removal in patients attending for dialysis with little or no fluid to be removed, so closer to the postdialysis target weight could be at greater risk of developing symptomatic hypovolemia 31 . Other studies have highlighted that dialysis patients have greater self‐reported depression, 9 and those reporting more peridialytic symptoms and longer recovery times also reported greater psychological distress 5,32 .…”

Characteristics of Frailty in Haemodialysis Patients

“…Other studies have used the Fatigue questionnaire (FACIT-F) ( McKeaveney et al, 2021 ), a 40-item measure that assesses self-reported fatigue and its impact upon daily activities and function. However, the results of this questionnaire can be confounded by fatigue secondary to anaemia and volume overload ( Yoowannakul et al, 2021 ), and psychological distress. In our cohort distress thermometer scores were similar for both frail and non-frail patients, and previous studies have not shown an effect of psychological distress on muscle strength in dialysis patients ( Camilleri et al, 2017 ).…”