Background: Little is known about the correlation between fatigue and survival in patients on chronic hemodialysis and whether fatigue is an independent predictor of outcome above and beyond the effects of depression. The aim of the present study was to determine if fatigue is a predictor of mortality in patients on chronic hemodialysis (CHP) and if this occurs independently of the symptoms of depression. Methods: CHP referring to the Hemodialysis Service of the Università Cattolica of Rome, Italy between November 2007 and January 2015 were studied. Demographic, clinical, and laboratory data were recorded for each patient at the moment of the inclusion in the study. Fatigue levels were assessed in patients using the Vitality Scale of SF-36 (SF-36 VS), functional ability by the activities of daily living (ADL) and instrumental activities of daily living (IADL), depressive symptoms through the Geriatric Depression Scale (GDS), cognitive function using the Mini Mental State Examination (MMSE), and comorbidity through the Charlson Comorbidity Index (CCI). Patients were grouped into four groups (quartiles): Quartile 1 (Q1), >65; Q2, ≥50 to <65; Q3, ≥35 to <50; Q4, <35. Results: We studied 126 patients: 11 were transplanted and 53 died. Patients who later died were older and had a worse cognitive performance, higher CCI and GDS scores, lower ADL, IADL and SF-36 VS scores, lower serum creatinine and albumin levels. Kaplan-Meier survival was significantly lower in Q4 than in Q1 (p = 0.0001). According to Cox regression analysis, higher fatigue (Q4) was associated with a higher risk of mortality (HR, 95% CI: 5.29, 2.2-12.73). Conclusion: Fatigue is associated with an increased risk of mortality in CHP, with the relationship independent of symptoms of depression. Fatigue should be assessed routinely and may be a potential target of interventions that aim to reduce mortality in CHP.

Keywords:
Hemodialysis, Mortality, Survival, Fatigue, Depression, SF-36 Vitality Scale
1.
Jhamb M, Weisbord SD, Steel JL, Unruh M: Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors. Am J Kidney Dis 2008;52:353-365.
2.
Bossola M, Vulpio C, Tazza L: Fatigue in chronic dialysis patients. Semin Dial 2011;24:550-555.
3.
Artom M, Moss-Morris R, Caskey F, Chilcot J: Fatigue in advanced kidney disease. Kidney Int 2014;86:497-505.
4.
Bonner A, Caltabiano M, Berlund L: Quality of life, fatigue, and activity in Australians with chronic kidney disease: a longitudinal study. Nurs Health Sci 2013;15:360-367.
5.
Bonner A, Wellard S, Caltabiano M: The impact of fatigue on daily activity in people with chronic kidney disease. J Clin Nurs 2010;19:3006-3015.
6.
Davison SN, Jhangri GS: Impact of pain and symptom burden on the health-related quality of life of hemodialysis patients. J Pain Symptom Manage 2010;39:477-485.
7.
Perez-Moreno AC, Jhund PS, Macdonald MR, Petrie MC, Cleland JG, Böhm M, van Veldhuisen DJ, Gullestad L, Wikstrand J, Kjekshus J, Lewsey JD, McMurray JJ: Fatigue as a predictor of outcome in patients with heart failure: analysis of CORONA (controlled rosuvastatin multinational trial in heart failure). JACC Heart Fail 2014;2:187-197.
8.
Bower JE: Cancer-related fatigue - mechanisms, risk factors, and treatments. Nat Rev Clin Oncol 2014;11:597-609.
9.
Peters KB, West MJ, Hornsby WE, Waner E, Coan AD, McSherry F, Herndon JE 2nd, Friedman HS, Desjardins A, Jones LW: Impact of health-related quality of life and fatigue on survival of recurrent high-grade glioma patients. J Neurooncol 2014;120:499-506.
10.
Innominato PF, Giacchetti S, Moreau T, Bjarnason GA, Smaaland R, Focan C, Garufi C, Iacobelli S, Tampellini M, Tumolo S, Carvalho C, Karaboué A, Poncet A, Spiegel D, Lévi F; International Association for Research on Time in Biology and Chronotherapy (ARTBC) Chronotherapy Group: Fatigue and weight loss predict survival on circadian chemotherapy for metastatic colorectal cancer. Cancer 2013;119:2564-2573.
11.
Naess H, Nyland H: Poststroke fatigue and depression are related to mortality in young adults: a cohort study. BMJ Open 2013;3:e002404.
12.
Naess H, Lunde L, Brogger J, Waje-Andreassen U: Fatigue among stroke patients on long-term follow-up. The Bergen stroke study. J Neurol Sci 2012;312:138-141.
13.
Jhamb M, Pike F, Ramer S, Argyropoulos C, Steel J, Dew MA, Weisbord SD, Weissfeld L, Unruh M: Impact of fatigue on outcomes in the hemodialysis (HEMO) study. Am J Nephrol 2011;33:515-523.
14.
Jhamb M, Argyropoulos C, Steel JL, Plantinga L, Wu AW, Fink NE, Powe NR, Meyer KB, Unruh ML; Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study: Correlates and outcomes of fatigue among incident dialysis patients. Clin J Am Soc Nephrol 2009;4:1779-1786.
15.
Koyama H, Fukuda S, Shoji T, Inaba M, Tsujimoto Y, Tabata T, Okuno S, Yamakawa T, Okada S, Okamura M, Kuratsune H, Fujii H, Hirayama Y, Watanabe Y, Nishizawa Y: Fatigue is a predictor for cardiovascular outcomes in patients undergoing hemodialysis. Clin J Am Soc Nephrol 2010;5:659-666.
16.
Bossola M, Di Stasio E, Giungi S, Rosa F, Tazza L: Fatigue is associated with serum interleukin-6 levels and symptoms of depression in patients on chronic hemodialysis. J Pain Symptom Manage 2015;49:578-585.
17.
Di Iorio B, Cillo N, Cirillo M, De Santo NG: Charlson Comorbidity Index is a predictor of outcomes in incident hemodialysis patients and correlates with phase angle and hospitalization. Int J Artif Organs 2004;27:330-336.
18.
Bossola M, Vulpio C, Colacicco L, Scribano D, Zuppi C, Tazza L: Reactive oxygen metabolites (ROMs) are associated with cardiovascular disease in chronic hemodialysis patients. Clin Chem Lab Med 2012;50:1447-1453.
19.
Mingardi G, Cornalba L, Cortinovis E, Ruggiata R, Mosconi P, Apolone G: Health-related quality of life in dialysis patients. A report from an Italian study using the SF-36 health survey. DIA-QOL Group. Nephrol Dial Transplant 1999;14:1503-1510.
20.
Collado-Hidalgo A, Bower JE, Ganz PA, Cole SW, Irwin MR: Inflammatory biomarkers for persistent fatigue in breast cancer survivors. Clin Cancer Res 2006;12:2759-2766.
21.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW: Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185:914-919.
22.
Lawton MP, Brody EM: Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-186.
23.
Folstein MF, Folstein SE, McHugh PR: ‘Mini-mental state'. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
24.
Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza L, Rosa F, Onder G: Mini mental state examination over time in chronic hemodialysis patients. J Psychosom Res 2011;71:50-54.
25.
Nardi B, De Rosa M, Paciaroni G, Marchesi GF, Bonaiuto S, Luciani P, Turtù F, Giannandrea E: Clinical investigation on depression on a randomized and stratified sample in an elderly population. Minerva Psichiatr 1991;32:135-144.
26.
Lindsay RM, Heidenheim PA, Nesrallah G, Garg AX, Suri R; Daily Hemodialysis Study Group London Health Sciences Centre: Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change. Clin J Am Soc Nephrol 2006;1:952-959.
27.
Chang Y, Cheng SY, Lin M, Gau FY, Chao YF: The effectiveness of intradialytic leg ergometry exercise for improving sedentary life style and fatigue among patients with chronic kidney disease: a randomized clinical trial. Int J Nurs Stud 2010;47:1383-1388.
28.
Storer TW, Casaburi R, Sawelson S, Kopple JD: Endurance exercise training during haemodialysis improves strength, power, fatigability and physical performance in maintenance haemodialysis patients. Nephrol Dial Transplant 2005;20:1429-1437.
29.
Cho H, Sohng KY: The effect of a virtual reality exercise program on physical fitness, body composition, and fatigue in hemodialysis patients. J Phys Ther Sci 2014;26:1661-1665.
30.
Maniam R, Subramanian P, Singh SK, Lim SK, Chinna K, Rosli R: Preliminary study of an exercise programme for reducing fatigue and improving sleep among long-term haemodialysis patients. Singapore Med J 2014;55:476-482.
31.
Farrokhi F, Abedi N, Beyene J, Kurdyak P, Jassal SV: Association between depression and mortality in patients receiving long-term dialysis: a systematic review and meta-analysis. Am J Kidney Dis 2014;63:623-635.
32.
Vestergaard S, Nayfield SG, Patel KV, Eldadah B, Cesari M, Ferrucci L, Ceresini G, Guralnik JM: Fatigue in a representative population of older persons and its association with functional impairment, functional limitation, and disability. J Gerontol A Biol Sci Med Sci 2009;64:76-82.
33.
Bossola M, Laudisio A, Antocicco M, Tazza L: Functional disability predicts mortality in patients on chronic hemodialysis. International Conference on Frailty and Sarcopenia (April 24-26, 2015). Boston, Poster 4.
34.
DeOreo PB: Hemodialysis patient-assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance. Am J Kidney Dis 1997;30:204-212.
35.
Ifudu O, Paul HR, Homel P, Friedman EA: Predictive value of functional status for mortality in patients on maintenance hemodialysis. Am J Nephrol 1998;18:109-116.
© 2015 S. Karger AG, Basel
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.