Symptoms Worsen Before Dialysis, Ease After, in Older Patients With CKD

Marlene Busko

November 28, 2022

Among older patients with advanced kidney disease, the mean number of kidney failure–related symptoms and symptom burden worsened considerably in the year before they started dialysis but generally stabilized in the following year, researchers report.

The findings are from close to 500 patients aged 65 and older with kidney failure in six European countries who took part in the European Quality (EQUAL) study.  

The study by Esther N.M. de Rooij, MD, Leiden University, the Netherlands, and colleagues, was recently published online in the Clinical Journal of the American Society of Nephrology.

Patients replied to a questionnaire asking if they had any of 30 kidney failure-related symptoms, and if so, how much they were bothered by each symptom. Each symptom burden was scored from 1 for "not at all" to 5 for "very much."

The highest mean symptom prevalence and burden during the 30 days before starting dialysis were "fatigue" (81% of patients, burden 2.7), "decreased interest in sex" (69%, burden 2.4), and "difficulty becoming sexually aroused" (68%, burden 2.3), in the 278 patients with these data. 

In the 30 days after dialysis initiation, fatigue improved somewhat, but the prevalence and burden of sexual symptoms worsened.

"The change in symptoms before and after start of dialysis in older patients has not been studied before," de Rooij noted in a press release from the American Society of Nephrology.

"We hope these results could help inform older patients with kidney failure who decide to start dialysis on what to expect regarding the development of their symptom burden," said de Rooij.

"Our results emphasize the importance of identifying and discussing kidney failure–related symptoms in routine clinical care and considering their differing patterns of evolution before and after dialysis initiation," de Rooij and her colleagues write.

Cardiopulmonary Symptoms Improved, Others Stabilized or Worsened

EQUAL is an ongoing prospective study of patients in Germany, Italy, Poland, Sweden, the Netherlands, and the United Kingdom aged 65 and older, with an estimated glomerular filtration rate (eGFR) ≤ 20 mL/min/1.73m2, who were initiated on dialysis and given a dialysis symptom index questionnaire to complete every 3 to 6 months from 2012 to December 2021.

The current study included 456 patients who had filled out at least one dialysis symptom index questionnaire in the year before starting dialysis and/or the following year.

Patients were a mean age of 76 and 75% were men. They had a mean eGFR of 8 mL/min/1.73m2, 44% had diabetes, and 46% had cardiovascular disease.

On average, in the year before starting dialysis, symptom number increased by 3.6 and total symptom burden score increased by 13.3.

In the year after starting dialysis, symptom number decreased by 0.9 and symptom burden decreased by 5.9.

In the 278 patients with data from 30 days before and 30 days after starting dialysis, the most common symptoms prior to dialysis, in decreasing order, were fatigue, decreased interest in sex and difficulty becoming sexually aroused, trouble staying asleep, muscle cramps, dry skin, leg swelling, dry mouth, itch, bone or joint pain, decreased appetite, shortness of breath, worrying, trouble falling asleep, difficulty concentrating, feeling irritable, feeling sad, feeling nervous, nausea, muscle soreness, feeling anxious, constipation, dizziness, diarrhea, cough, restless leg, tingling in the feet, headache, chest pain, and vomiting,

After dialysis initiation, "although some of the 30 symptoms improved, almost half (eg, 'cough,' 'itch,' 'tingling in feet,' 'diarrhea,' and sexual symptoms) only stabilized or further worsened," the researchers point out.

Cardiopulmonary symptoms, such as "leg swelling" and "shortness of breath," "clearly improved after dialysis initiation, as could be expected after a better control of fluid overload due to dialysis treatment," they note.

"In contrast, the burden of itch, a classic uremic symptom, did not improve after dialysis initiation."

Dialysis treatment itself can induce symptoms, the researchers note, such as pain from vascular access cannulation and muscle cramps or headache from excess volume removal and electrolyte fluctuations.

They found no change in muscle cramps and headache after the start of dialysis, although these symptoms were stable in the year preceding dialysis.  

The burden of emotional symptoms increased in the year before dialysis, possibly partly due to fear of dialysis, the researchers suggest, because "worrying" decreased somewhat after dialysis was started.

"Our results emphasize the importance of identifying and discussing kidney failure–related symptoms in routine clinical care and considering their differing patterns of evolution before and after dialysis initiation," de Rooij and colleagues write.

"Inquiring about sexual symptoms may help patients to address these sensitive but burdensome symptoms," they suggest.

Moreover, "routine use of symptom questionnaires might help clinicians in addressing symptoms important to the individual patient. However, considering multifactorial causes or limited effective treatment options, adequate management of identified symptoms may remain a challenge."  

This study was mainly funded by the European Renal Association, with contributions from the Swedish Medical Association; Stockholm County Council ALF Medicine and Center for Innovative Research; Italian Society of Nephrology; Dutch Kidney Foundation; Young Investigators Grant in Germany; and UK National Institute for Health Research. De Rooij has reported no relevant financial relationships. Disclosures for the other authors are listed with the article.

Clin J Am Soc Nephrol. Published online November 10, 2022. Full text

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