What are the management strategies for tiredness in a patient undergoing hemodialysis (HD) at home?

Management of Tiredness in Home Hemodialysis Patients

Address dialysis adequacy first by optimizing ultrafiltration rates and preventing intradialytic symptoms, as these directly impact treatment adherence and quality of life, then implement aerobic exercise and cognitive behavioral therapy as primary non-pharmacologic interventions for fatigue. 1

Optimize the Dialysis Prescription

The most critical step is ensuring adequate dialysis delivery without causing intradialytic symptoms that lead to premature treatment termination or missed sessions. 1

Prevent Intradialytic Hypotension and Cramps

• Avoid excessive ultrafiltration by reassessing estimated dry weight (EDW), especially if patients show signs of improving nutrition (increasing serum albumin, creatinine, or normalized protein catabolic rate) 1
• Slow the ultrafiltration rate by extending treatment duration rather than accepting inadequate fluid removal 1
• Increase dialysate sodium concentration (148 mEq/L) with sodium ramping—higher concentration early in treatment followed by stepwise decrease 1
• Reduce dialysate temperature to minimize hypotensive episodes 1
• Switch to bicarbonate-buffered dialysate if using acetate-based solutions 1
• Correct anemia to NKF-K/DOQI recommended ranges, as this directly impacts fatigue and treatment tolerance 1

Consider Pharmacologic Adjuncts for Intradialytic Symptoms

• Administer midodrine predialysis for recurrent hypotension (avoid with supine hypertension or concurrent use with other alpha-adrenergic agents) 1
• Consider intravenous L-carnitine at 20 mg/kg into the venous port with each dialysis session, which reduces intradialytic hypotension frequency from 44% to 18% 1
• Sertraline may improve hemodynamic parameters in resistant intradialytic hypotension, though side effects include dizziness, fatigue, and somnolence 1

Implement Non-Pharmacologic Interventions for Fatigue

Exercise therapy provides the strongest evidence for reducing fatigue in dialysis patients and should be the primary intervention. 1

Exercise Prescription

• Aerobic exercise has moderate-quality evidence for reducing fatigue in chronic kidney disease patients 1
• Target moderate-intensity physical activity for at least 150 minutes per week according to patient ability 1
• Aerobic exercise also decreases depressive symptom burden in hemodialysis patients, which often coexists with fatigue 1

Psychological Interventions

• Cognitive behavioral therapy has proven efficacy in reducing depression, which frequently contributes to fatigue 1
• Mindfulness and meditation lack adverse effects and medication interactions, making them ideal for home dialysis patients 1
• Manual acupressure shows short-term benefits as an adjuvant intervention for fatigue and depression 1

Music Therapy

• Music therapy with calming and uplifting lyrics can reduce stress, anxiety, and depressive symptoms that contribute to fatigue 2
• Music interventions offer flexibility in delivery mode and accessibility, even during intradialytic intervals 2
• This approach avoids adverse effects and polypharmacy burden 2

Address Caregiver Burden and Support

Patients and families can become fatigued with long-term home care, which directly impacts treatment adherence and patient outcomes. 1

• Recognize that emotional preparedness and support are as important as educational preparedness 1
• Provide iterative, culturally sensitive education from dedicated team members 1
• Consider mental health professional input for emotional support 1
• Acknowledge that home dialysis should not be limited to patients with high levels of activation, as these can be developed with appropriate support 1

Pharmacologic Approaches: Use With Caution

SSRIs have NOT shown consistent benefit over placebo in hemodialysis patients and have documented increased adverse effects, particularly gastrointestinal. 1

• No randomized controlled trials address SSRI use in peritoneal dialysis or pharmacologic management of anxiety in kidney failure populations 1
• If prescribing psychotropic medications, uptitrate from subtherapeutic doses with care, considering QT prolongation and altered pharmacokinetics in kidney failure 1
• Prioritize non-pharmacologic approaches to avoid polypharmacy burden 1, 2

Common Pitfalls to Avoid

• Do not decrease blood flow and ultrafiltration rates in response to intradialytic symptoms without first optimizing the dialysis prescription, as this compromises delivered dose 1
• Do not assume fatigue is purely psychological—assess for inadequate dialysis, anemia, and intradialytic symptoms that cause treatment nonadherence 1
• Do not overlook caregiver fatigue in home dialysis patients, as this impacts long-term sustainability 1
• Do not default to pharmacologic management when exercise and cognitive behavioral therapy have stronger evidence and fewer adverse effects 1