Author Interview: Sebnem Karakan, MD
University of Baskent School of Medicine
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Publication:
Author Interview: Sebnem Karakan, MD
Factors related to fatique and subgroups of fatique in patients with end-stage renal disease
Sebnem Karakan, Siren Sezer, Fatma Nurhan Ozdemir
Clin Nephrol. 2011 Nov;76(5):358-64.
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What are the main findings of the study? |
This is a cross sectional study that found a positive association between quality of life and critical outcome for undergoing hemodialysis patients; it has been associated with clinical indicators, fatigue, morbidity and survival in HD patients. Uremic syndrome may manifest as fatigue and social-demographic factors and biochemical parameters may also play a role in experience of fatigue in dialysis patient.
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Were any of the findings unexpected? |
We have to know that there are significant associations among fatigue and biochemical variables including serum calcium level. Biochemical derangements incluiding electrolytes in patients with uremia may cause fatigue. Subgroup analysis clearly indicates the divergent etiological factors of underlying fatigue in patients with ESRD. This divergence also reflects the need for subgroup specific therapeutic approach according to the type of fatigue (eg. mainly behavioral, affective, sensory or cognitive).
Another unexpected finding is fatigue score is not affected by sleep disorders in our study. The lack of any sleep disorders in our patients further improved reliability of fatigue scores.
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What should clinicians and patients take away from this study? |
Fatigue and depression are closely interrelated, and depression may manifest as feelings of tiredness and lack of energy.
Depression has been strongly correlated with overall symptom burden and severity, including fatigue in dialysis patients. Fatigue management was critically important in this depressed hemodialysis population.
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What recommendations do you have for nephrology health care providers as a result of your study? |
We have to analyse depression and quality of sleep when studying fatigue and relationship between depressive symptoms, fatigue subgroups, sleep disturbances and biochemical parameters. If there are different etiological factors for each subgroup of fatigue, the treatment modalities may also target these individual factors. A proper management of fatigue, according to subgroups of fatigue, might further improve survival of ESRD patients.
We suggest that because of the complexity of fatigue, a multidisciplinary approach to treatment should be adopted. According to the subgroup analysis, the physician should improve nutritional status for low albumin levels and fight against inflammation and hypoglycemia in order to improve cognitive functions.
This novel hypothetical approach should be investigated in larger prospective trials. Identifying high-risk patients such as the unemployed, the depressed patients, or electrolyte imbalance may enable the development of specific strategies to decrease levels of fatigue and discomfort associated with these conditions. Further strategies may be planned according to specific subgroups, such as anti-inflammatory therapy in cognitive dysfunction and psychological support for affective dysfunction. Possible interventions for minimizing fatigue in patients on long-term dialysis therapy should aim at managing known contributing factors.
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| Abstract: |
Introduction and aims: Fatigue is a major determinant for quality of life for patients undergoing chronic hemodialysis (HD) treatment. The aim of this study was to determine the severity and contributing factors of fatigue in patients under chronic HD treatment.
Methods: 154 end-stage renal disease (ESRD) patients under HD treatment (92 M, 62 F, mean age 53 ± 15 y, mean duration of HD treatment 92 ± 65 months) were enrolled. Patients were given Piper's fatigue scale (PFS), Epworth sleepiness scale (ESS) and Beck depression test (BDT). Study participants were evaluated at the end of the HD session.
Results: ESS score was above 10 (indicating daytime sleepiness) in only 6 (3.9%) patients. The overall PFS scores were normal-to-mild in 25 (16.2%), moderate in 63 (40.9%) and severe in 66 (42.9%) patients. Total PFS score was correlated with presence of depression (OR: 2.48), employment status (OR: 2.25), calcium (OR: 2.64) and phosphate (OR: 3.70) concentration. PFS behavior score was correlated with employment status (OR: 2.29) and phosphate (OR: 1.96). PFS affective score was correlated with presence of depression (OR: 2.56), employment status (OR: 2.72) and creatinine (OR: 2.25) concentration. PFS sensory score was correlated with advanced age (OR: 1.95), presence of depression (OR: 2.90), albumin (nutritional status) (OR: 0.17), postdialysis serum urea level (OR: 2.37), hemoglobin (anemia) (OR: 0.21).
Conclusion: Daytime sleepiness is not prevalent; however, fatigue is closely related to presence of depression, employment status, and calcium and phosphate levels.
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WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
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Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
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