What are the guidelines for managing chronic fatigue in a patient with End-Stage Renal Disease (ESRD) undergoing hemodialysis?

Management of Chronic Fatigue in Hemodialysis Patients

Fatigue is the most common symptom in hemodialysis patients, and you should prioritize aerobic exercise as the primary intervention, followed by cognitive behavioral therapy, while optimizing dialysis adequacy and correcting anemia—SSRIs should not be used as first-line treatment due to lack of consistent benefit and increased adverse effects. 1, 2

Routine Assessment and Recognition

• Implement routine symptom screening every 1-3 months using validated tools to identify fatigue early, as it affects at least half of patients on long-term dialysis and is associated with higher mortality. 1
• Recognize that fatigue status fluctuates significantly—approximately 42-47% of hemodialysis patients change their fatigue status over 6-month intervals, requiring frequent reassessment. 3
• Document fatigue in the medical record and integrate it into the overall clinical assessment, as treatment is initiated infrequently even when symptoms are identified. 1

First-Line Non-Pharmacologic Interventions

Exercise (Primary Intervention)

• Prescribe moderate-intensity aerobic exercise for at least 150 minutes per week as the primary intervention, as moderate-quality evidence demonstrates this reduces fatigue and depressive symptoms in hemodialysis patients. 1, 2
• Aerobic exercise provides dual benefit by simultaneously addressing fatigue and the 40% prevalence of depression in dialysis patients, which often coexist and compound each other. 1

Cognitive Behavioral Therapy

• Refer patients for cognitive behavioral therapy (CBT) as it has proven efficacy in reducing depression, which frequently contributes to fatigue in hemodialysis patients. 1, 2, 4
• CBT offers advantages over pharmacologic approaches by avoiding adverse effects, drug interactions, and the burden of polypharmacy. 1

Additional Non-Pharmacologic Options

• Consider manual acupressure as an adjuvant intervention, as limited evidence suggests short-term benefits for fatigue and depression. 1
• Implement music therapy during dialysis sessions, as small-scale studies indicate it may reduce depressive symptoms and pain perception during vascular access cannulation. 1, 5
• Explore mindfulness and meditation interventions, which may reduce depressive symptom prevalence without adverse effects. 1

Optimize Dialysis Prescription

Adequacy and Frequency

• Ensure adequate dialysis delivery with minimum three times weekly sessions, as inadequate dialysis contributes to uremic symptoms including fatigue. 4
• Consider offering in-center short frequent hemodialysis (more than 3 times weekly) or home long hemodialysis (6-8 hours, 3-6 nights per week) after discussing individual patient preferences, as these regimens improve blood pressure control, anemia management, and quality of life in selected patients. 1
• Inform patients that frequent hemodialysis carries risks including increased vascular access procedures and potential hypotension during dialysis. 1

Intradialytic Symptom Management

• Optimize ultrafiltration rates by reassessing estimated dry weight, especially in patients showing signs of improving nutrition, to prevent intradialytic symptoms that worsen fatigue. 2
• Extend treatment duration rather than accepting inadequate fluid removal to slow ultrafiltration rate and minimize hypotensive episodes. 2
• Increase dialysate sodium concentration to 148 mEq/L with sodium ramping to reduce intradialytic hypotension frequency. 2
• Reduce dialysate temperature to minimize hypotensive episodes and improve patient comfort. 2
• Switch to bicarbonate-buffered dialysate if using acetate-based solutions to reduce intradialytic symptoms. 2

Correct Underlying Medical Factors

Anemia Management

• Evaluate iron status before and during treatment, administering supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation is <20%, as the majority of patients require supplemental iron during ESA therapy. 6
• Initiate erythropoiesis-stimulating agents (ESAs) when hemoglobin is <10 g/dL, using the lowest dose sufficient to reduce transfusion need, as correcting anemia directly impacts fatigue and treatment tolerance. 2, 6
• For adult hemodialysis patients, start darbepoetin alfa at 0.45 mcg/kg intravenously weekly or 0.75 mcg/kg every 2 weeks, monitoring hemoglobin weekly until stable. 6
• Reduce or interrupt ESA dose if hemoglobin approaches or exceeds 11 g/dL, as targeting hemoglobin >11 g/dL increases risks of death, serious cardiovascular reactions, and stroke. 6
• Avoid increasing ESA dose more frequently than once every 4 weeks; if hemoglobin has not increased by >1 g/dL after 4 weeks, increase dose by 25%. 6

Other Contributing Factors

• Review medications for side effects that may contribute to fatigue. 4
• Achieve target dry weight, as volume overload contributes to symptoms. 4
• Evaluate for sleep disorders, as poor sleep quality is significantly associated with fatigue (59.1% of fatigued patients have poor sleep quality). 7

Pharmacologic Approaches: Use With Extreme Caution

• Do not use SSRIs as first-line treatment for fatigue, as existing small randomized placebo-controlled trials have not shown consistent benefit over placebo in hemodialysis patients. 1, 2, 4
• SSRIs have documented increased adverse effects, particularly gastrointestinal symptoms, with nausea occurring 2.67 times more frequently than placebo. 4
• No randomized controlled trials address pharmacologic management of anxiety in kidney failure populations, making non-pharmacological approaches particularly valuable. 1, 5
• If pharmacologic treatment for depression is necessary after optimizing dialysis adequacy and attempting non-pharmacological interventions, consider selective serotonin reuptake inhibitors or atypical antidepressants (nefazodone, bupropion) with careful monitoring. 4

Address Psychosocial Factors

• Recognize that fatigue is independently associated with lower quality of life in physical and general health domains, and 65.9% of fatigued hemodialysis patients have depression. 7
• Provide iterative, culturally sensitive education and emotional support, recognizing that emotional preparedness is as important as educational preparedness. 2, 4
• Consider mental health professional input for emotional support to address the psychological burden of fatigue. 2
• Address socioeconomic factors such as food and housing insecurity, as these contribute to symptom burden. 1

High-Risk Patient Identification

• Identify high-risk patients for more intensive monitoring: those who are unemployed, have low educational level, reside in urban areas, and those with higher comorbidity burden. 8
• Recognize that fatigue is a "debilitating and exhausting burden" that causes bodily depletion, traps patients in a vicious cycle of post-dialysis exhaustion, and restricts life participation. 9
• Understand that fatigued patients often feel vulnerable to misunderstanding, being criticized for needing rest and failing to meet expectations, which compounds the psychological burden. 9

Common Pitfalls to Avoid

• Do not dismiss fatigue as an expected part of dialysis—it is a treatable symptom that significantly impacts mortality and quality of life. 1, 9
• Avoid prescribing SSRIs without first optimizing dialysis adequacy, correcting anemia, and attempting non-pharmacological interventions. 4
• Do not assume fatigue status is stable—reassess frequently as nearly half of patients change fatigue status over 6-month periods. 3
• Avoid adding to polypharmacy burden in an already medically complex population by prioritizing interventions without drug interactions. 4
• Do not overlook the impact on caregivers, as symptom burden extends beyond the patient to family members and can lead to caregiver burnout. 1, 2