A nurse is reviewing the laboratory data of a client following a hemodialysis treatment

Medsurg Nurs. Author manuscript; available in PMC 2012 Aug 8.

Published in final edited form as:

Medsurg Nurs. 2012 May-Jun; 21(3): 158–175.

PMCID: PMC3414425

NIHMSID: NIHMS383261

Ann Horigan, MSN, RN, CNE, Doctoral Candidate, Judith Rocchiccioli, PhD, RN, Professor of Nursing, and Donna Trimm, DNS, RN, Assistant Professor of Nursing

Abstract

Fatigue is one of the most common symptoms experienced by patients receiving dialysis. When patients with chronic kidney disease (CKD) and end-stage renal disease are admitted to acute care settings, they require management of their often profound fatigue. CKD, renal pathology, and renal fatigue are examined in relation to a case study.

Caring for patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) challenges all health care providers. While a great deal of the maintenance care for patients with ESRD occurs at hemodialysis centers in the community, admission of affected patients to the hospital requires nurses to demonstrate knowledge of renal disease and renal pathology, and expertise in the identification and management of the debilitating fatigue that often impacts patients’ quality of life. Research suggests fatigue is one of the most common symptoms experienced by patients receiving dialysis (Jablonski, 2007; Weisbord et al., 2005). Prevalence of fatigue ranges from 60% to 97% (Murtaugh, Addington-Hall, & Higginson, 2007; Weisbord et al., 2005). Assessment and management of fatigue thus are important in improving clinical outcomes and quality of life for patients receiving dialysis.

Several factors may be associated with fatigue in patients receiving dialysis. These include depression (Leinau, Murphy, Bradley, & Fried, 2009; Liu, 2006), female sex (Liu, 2006; O’Sullivan & McCarthy, 2007), and anemia (Williams, Crane, & Kring, 2007). While the cause of renal fatigue remains unclear, it is clearly problematic. An understanding of how patients receiving dialysis describe and experience fatigue, the similarities and differences in fatigue experienced by patients receiving hemodialysis and peritoneal dialysis, and knowledge of the cultural differences in the experience of fatigue are critical in order to assess it accurately and intervene appropriately. Chronic kidney disease, renal pathology, and renal fatigue are discussed and related to the case of Mary R.

Overview of Renal Pathology and Renal Disease

Incidence and Prevalence of End-Stage Renal Disease

End-stage renal disease, the last stage of chronic kidney disease, is a common chronic illness that is increasing in incidence and prevalence. The incidence of ESRD in 2006 was 360 per million, an increase of 2.1% since 2005. Patients receiving dialysis now live longer, with the mortality rate decreased by 10%. Additionally, the rate of kidney transplantation has not kept pace with the incidence of ESRD, and increasing numbers of patients with failed transplants are returning to hemodialysis. In 2006, the number of new patients receiving dialysis or transplant in the United States exceeded 100,000; over 350,000 patients were receiving dialysis (National Institute of Diabetes and Digestive and Kidney Disease [NIDD KD], 2008). As the number of affected patients continues to grow and medical advances allow patients to lead longer lives, symptom management becomes an important part of care for patients receiving dialysis.

Overview of Chronic Kidney Disease

The current National Kidney Foundation (NKF) guidelines define chronic kidney disease as irreversible kidney damage or decreased kidney function for at least 3 months (Castner, 2010; Murphy, Jenkins, Chamney, McCann, & Sedgewick, 2008; NKF, 2002), which ultimately affects all kidney functions. The nephrons, the functional unit in the kidneys, lose their ability to filter wastes and extra fluid, creating fluid and electrolyte imbalances. Loss of kidney function occurs slowly, with the kidneys initially adapting well to the underlying causes of kidney damage (Castner, 2010). Symptoms of kidney failure, such as alterations in salt and fluid balance, protein-urea, and anemia, do not appear until renal function decreases significantly (Molzahn & Butera, 2006).

The severity of kidney disease is determined by the individual’s glomerular filtration rate (GFR), which is the best measure of the overall health and function of the kidneys (Kinzner & Hain, 2007). The glomerulus is a collection of capillaries in the nephron, and the glomerular membranes act as the filtering mechanism for wastes and fluid. The rate at which the glomerulus filters wastes and fluid is an indication of its health. A GFR of 90 mL/minute per 1.73 m2 or higher is considered normal. A decreasing GFR signifies increasing kidney damage. A GFR less than 60 mL/minute per 1.73 m2 indicates a loss of approximately half the kidney’s normal function in an adult. As the GFR continues to decrease in kidney failure, occurrence of complications related to kidney disease, such as anemia, bone disease, and malnutrition, increases (Castner, 2010; NKF, 2002).

Five stages of chronic kidney disease have been identified (NKF, 2002) (see Table 1). A healthy kidney is able to differentiate between protein and wastes when filtering the blood. A damaged kidney is unable to do this, and thus protein is excreted inappropriately along with the wastes in the urine. The early stages of CKD are characterized by protein-urea and decreasing GFR. Many complications, such as anemia and bone disease, become evident as CKD progresses (NKF, 2011). During the later stages of CKD, continued management of complications as well as preparation for renal replacement therapy (dialysis or transplantation) are important. When the kidneys have failed completely and irreversibly, renal replacement therapy is necessary to sustain life. At this point, most patients experience symptoms of uremia (NKF, 2002), including decreased appetite, malnutrition, drowsiness, shortness of breath, and palpitations (Murtaugh et al., 2007).

TABLE 1

Stages of Chronic Kidney Disease

Common Causes of Chronic Kidney Disease

One of the most common causes of CKD is diabetes. Other causes include hypertension and glomerulonephritis (NIDDKD, 2010). When a patient has diabetes, the glomerulus is damaged. The exact mechanism of damage is unknown, but the most likely cause is denaturization of proteins caused by high blood glucose. This leads to a thickening of the membranes of the capillaries in the glomerulus that eventually results in scarring and stenosis of the capillaries (Bakris, 2011; Redmond & McClelland, 2006). The stenosis of glomerular capillaries causes an inability to filter wastes properly, and contributes to fluid and electrolyte imbalances in the body.

Another common cause of CKD is untreated hypertension (NIDDKD, 2010). Normal regulatory processes in the kidney are compromised when the systemic blood pressure remains elevated over a long period of time, as in untreated or inadequately treated hypertension. First, untreated systemic hypertension causes damage to the systemic blood vessels by causing them to thicken and strengthen to withstand the increased pressure. These vessels become permanently narrowed due to thickening. The arteries that feed the kidneys respond to high systemic pressures by constricting, thus decreasing the amount of blood circulating through the kidneys. The kidneys in turn interpret this as a deficit in blood flow. In response, renin and aldosterone secretion are stimulated, leading to sodium and water retention in order to increase blood volume. This response only perpetuates the systemic hypertension (Hill, 2008). Over time, as the kidneys lack appropriate perfusion due to arterial constriction, nephron damage results and efficient filtration of water and wastes is lost.

Glomerulonephritis is another common cause of kidney failure (NIDDKD, 2010). Cellular, immunologic, and inflammatory factors that damage the glomerulus (capillaries in the nephron) often are triggered by changes in tissue or infections (Redmond & McClelland, 2006). Glomerulonephritis can range from mild to severe, and damage to the glomeruli differs from person to person. Nephrons are destroyed in a predictable pattern that begins with cellular infiltration and exudative reactions. Damage then progresses to macrophage infiltration with differing levels of parenchymal cell proliferation. These changes eventually lead to sclerotic structural changes in the nephron, damaging it and resulting in an inability to function properly (McCance & Huether, 2010).

Complications of Chronic Kidney Disease

As kidney function declines, multiple body systems are affected detrimentally by the accumulation of toxins in the blood (uremia) (Alper, Shenava, & Young, 2010). These symptoms usually begin to appear in stage 3 kidney disease and worsen as kidney function declines to ESRD. The kidneys lose the ability to excrete electrolytes, causing serum electrolyte imbalances. As serum phosphate increases, the additional phosphate binds with calcium and a decrease results in serum calcium levels. The body responds by pulling calcium from the bone to maintain appropriate serum calcium (McCarley & Arjomand, 2008). Bone demineralization, pain, and spontaneous fractures thus can occur as kidney disease progresses (NIDDKD, 2009a).

Serum potassium continues to rise, even to critical levels, as CKD continues. Hyperkalemia can result in muscle weakness, increased neuromuscular irritability manifested as tingling in the fingers and lips, restlessness, stomach cramping, and diarrhea. At critically high levels, potassium can cause changes in the EKG complex, often in the form of bradyarythmias. Conduction is slowed through the heart muscle, resulting in prolonged PR intervals and a widening QRS complex, often resulting in ventricular fibrillation or cardiac arrest (Putcha & Allon, 2007).

Erythropoietin secretion is controlled by the kidneys and is compromised as kidney failure progresses. Red blood cell production in the bone marrow then decreases, resulting in anemia. Additionally, the red cells that are produced have a shortened life span due to the build-up of toxins in the blood (Alper et al., 2010).

Another complication of CKD is impaired creatinine and urea clearance (Broscious & Castagnola, 2006). Creatinine is released constantly from the muscle. As the GFR decreases, the serum creatinine values increase. High serum creatinine is an indicator of kidney dysfunction (NIDDKD, 2009b). Urea, the end product of protein metabolism, also increases as the kidneys fail. Retention of urea can cause loss of appetite, nausea, vomiting, and pancreatitis (McCance & Huether, 2010).

Dialysis in Chronic Kidney Disease

Complications of CKD worsen as renal failure progresses. Eventually, hemodialysis (HD) or peritoneal dialysis (PD) must be initiated to replace kidney function in most patients. Approximately 100,000 new patients began receiving HD in the United States in 2006; over 325,000 patients received hemodialysis treatments that year. These numbers accounted for approximately 92% of the total dialysis population. Patients on PD accounted for 6.2% of new dialysis cases, and 8.2% of the total dialysis cases (NIDDKD, 2008).

The debate continues over which treatment modality is more effective and has better outcomes. No conclusive evidence indicates one form of dialysis is better than the other (Lee, Sun, & Wu, 2009). Many factors must be considered when choosing a dialysis modality, including physician recommendation, patient preference, and availability of the treatment (Shahab, Khanna, & Nolph, 2006). Dialysis modality selection often is based on the patient’s clinical and social status (Shahab et al., 2006). In general, patients who are younger and adherent to therapy; have some residual renal function, cardiovascular disease, and family or social support; and are independent in self-care are more likely to be recommended for peritoneal dialysis. Peritoneal dialysis is contraindicated in patients who have ostomies, or a ventro-peritoneal shunt. Older adults, obese persons, and individuals without social support also are less likely to be recommended for peritoneal dialysis (Shahab et al., 2006).

Fatigue in ESRD

The need to identify and assess fatigue in patients receiving dialysis is vital to patient health and quality outcomes. Fatigue frequently is unrecognized and therefore under-treated (Jhamb, Weisbord, Steel, & Unruh, 2008). Physical exercise, epoetin use, and L-carnitine infusion have all been used successfully to alleviate fatigue in patients receiving hemodialysis. Physical exercise also can help with the physiological and functional deterioration that can result from aging, illness, and sedentary lifestyle (Gordon, Doyle, & Johansen, 2011; Kosmadakis et al., 2010), all of which can contribute to dialysis-related fatigue.

Trials have shown physical exercise is safe for patients on dialysis, but exercise is not offered or recommended routinely for patients receiving dialysis. While physical exercise may be safe and help alleviate fatigue, few patients participate in these programs when offered, and many often drop out after beginning (Kosmadakis et al., 2010). Additionally, exercise may not be appropriate for a select group of patients receiving dialysis. Patients with functional limitations, poor cardiac health, or bone disease, and persons who are hemodynamically unstable during dialysis should not be considered for participation in exercise programs (Bayliss, 2006).

Epoetin is used regularly to combat anemia, a common cause of dialysis-related fatigue. Some patients do not respond well to epoetin therapy (Bamgbola, 2011) as demonstrated by no increase in their hemoglobin and hematocrit levels. Unfortunately, increasing doses of epoetin to help reduce anemia in these patients has proven detrimental, as it increases their risk for cardiovascular and cerebrovascular events (Drueke et al., 2006; Singh et al., 2006). Therefore, epoetin use may not be successful in alleviating fatigue in all patients receiving hemodialysis.

Another intervention to lessen the effects of fatigue is the use of L-carnitine, which is important for appropriate muscle function. Patients receiving hemodialysis are deficient in L-carnitine, and supplementation has proven effective in ameliorating dialysis-related fatigue, particularly in patients who are unresponsive to epoetin therapy (Lynch et al., 2008). The Centers for Medicare and Medicaid Services (CMS) only reimburses for L-carnitine used for epoetin-resistant anemia and intradialytic hypotension. Continued use of the drug is not covered if there has been no improvement in anemia or hypotension 6 months after treatment initiation (CMS, 2011).

Interventions that have been successful in alleviating fatigue may not be appropriate or safe for all patients. A significant need exists for the management of fatigue in order to reduce its impact on the lives of patients receiving hemodialysis. Nurses are in a strategic position to assess dialysis-related fatigue and help patients develop strategies to manage its effects. The following case study describes a patient admitted to the medical-surgical unit for management of hyperglycemia. The assigned nurse meets the patient for the first time immediately after her dialysis session. Patient symptoms, assessment of fatigue, evaluation of patient medications and lab results, and nursing interventions are discussed.

Case Study

Mrs. R. is a 33-year-old African-American female with type 1 diabetes, cataracts, and ESRD who has received hemodialysis for 2 years. She was admitted in the morning for hyperglycemia and management of medications, and was taken to dialysis prior to her arrival on the medical-surgical unit. After arrival to her room, she is lethargic, replies to repeated questions slowly, and slurs words at times. She demonstrates delayed response to commands with appropriate one-word answers. When asked how she feels, she responds, “I’m so tired. Please just leave me alone.” Dialysis removed 5 kg of fluid. Vital signs include oral temperature 98.3° F, blood pressure 88/40 mm Hg, pulse 96 beats per minute, respirations 12 breaths per minute, and oxygen saturation 97% on room air. See Table 2 for the patient’s routine medications, and Table 3 for current laboratory results. The patient’s height is 5′5″ and weight 145 lbs. Mrs. R.’s history includes childhood non-adherence to diabetic diet and medications, which contributed to her current health status. She lives with her mother, receives disability payments and is unemployed, and has a 9-year-old daughter. She is unable to drive due to poor vision.

TABLE 2

Current Medications

TABLE 3

Current Lab Values

Nursing Management

Fatigue Assessment

Mrs. R. presents as a typical patient with ESRD. Her fatigue is the result of both physiological and psychological influences as well as dialysis treatment inadequacy. When questioned further about her fatigue, the patient explains, “It’s ok; I’m always like this after dialysis.” Emergency interventions are not needed, but assessment of the fatigue should be completed. A simple visual analogue scale could be used to establish Mrs. R.’s baseline perception of fatigue; the scale includes a 100 mm line anchored at the left end with No Tiredness and at the right end with Complete Exhaustion. This type of measurement is a reliable assessment of fatigue in patients receiving dialysis (Brunier & Graydon, 1996; Williams et al., 2007), and can be performed quickly in the clinical setting.

Evaluate How Fatigue Impacts Patient’s Daily Living

Because fatigue can be extremely debilitating, assessing its effects on Mrs. R. is important in helping her improve her quality of life. Assessment can include asking the patient to describe her daily routine or keep a journal for review with the nurse at the dialysis unit at a later date. Mrs. R. explains that she sleeps for 4–6 hours after dialysis because she is completely exhausted. She is unable to work due to her extreme dialysis-related fatigue, and therefore receives disability payments. She lives with her mother to save rent money and receive help from her mother in caring for her 9-year-old daughter. Reviewing a time or event when fatigue was at its greatest intensity may help with planning interventions to minimize fatigue. Mrs. R. states that at times, particularly on dialysis days, she is unable to fix her daughter meals or help with her homework. The nurse can help Mrs. R. identify her support systems and collaborate with her to identify ways she can incorporate these support systems into her life. For instance, could Mrs. R.’s mother help her granddaughter with homework after school and cook evening meals? If Mrs. R. is able, making meals on her non-dialysis days and refrigerating or freezing them will help her mother and make food available when she is unable to prepare it.

Evaluating Laboratory Results and Medications

Irregularities in laboratory results and medication side effects may contribute to Mrs. R.’s fatigue. Evaluation of the patient’s laboratory results reveals serum sodium, calcium, phosphorus, and magnesium are all within normal range albeit slightly low. Her slight hypokalemia could be related to the stress of dialysis. Dialysis can return many electrolyte values to normal ranges, but also may remove insulin. Her serum glucose is elevated, which can lead to cell dehydration due to osmotic pressure in the extracellular fluid. She may need regular insulin for glucose correction. The presence of insulin affects protein (amino acids), glucose, potassium, magnesium, and phosphate uptake by the cells. Without insulin, the cells do not have the adequate glucose and amino acids to function, and weakness and/or fatigue can result. Mrs. R.’s protein and albumin values are already low, which also can cause edema. This in turn can lead to swelling and weight gain, causing tightly fitting clothes and shoes that can affect movement and increase feelings of fatigue. Dialysis removed 5 kg of fluid, which most likely included toxic levels of electrolytes, a small amount of blood, and other waste products. Mrs. R.’s hemoglobin and hematocrit are low, often typical for a patient in ESRD. With low protein and albumin, she also may lack elements to produce red blood cells. The kidney’s ability to make erythropoietin, which stimulates red blood cell production, is compromised and could contribute to Mrs. R.’s fatigue. Epoetin has been prescribed to supplement her kidneys’ failing ability to produce erythropoietin. Supplemental iron and vitamin B12 also may be given. By increasing hemoglobin, patients may experience less lethargy.

Mrs. R. also takes alprazolam (Xanax®) twice a day as needed for restless leg syndrome. This drug also may be contributing to daytime sleepiness and fatigue. The nurse should encourage Mrs. R. to investigate medications other than benzodiazapines for restless leg syndrome with her care provider to alleviate some of the fatigue. Mrs. R. also takes the anti-depressant venlafaxine (Effexor®). Depression has been associated with dialysis-related fatigue in several studies (Kim & Son, 2005; Leinau et al., 2009; Liu, 2006; McCann & Boore, 2000), and it is important that depression is identified and treated. Treating depression could help lessen fatigue levels in patients receiving dialysis. In Mrs. R.’s case, the nurse should ask if she believes her current medication is treating her depression effectively. If depression is under-treated, her fatigue may persist.

Teaching the Patient

After examining the patient’s laboratory results and medications, the nurse should teach the patient the importance of diet, exercise, and healthy sleep routines to decrease symptoms of fatigue. Diet is critically important for patients receiving dialysis. Mrs. R.’s diet should be low in potassium, sodium, and phosphate, and her fluid intake restricted. She needs adequate calories as well as moderate intake of complete protein, low fat, vitamins A and C, and carotinoids. Over time, patients affected with ESRD tend to become malnourished, so aggressively restricting their protein intake may be more detrimental to their health (Arora & Verrell, 2009). Because Mrs. R. also has diabetes, she needs high-complex, fiber-rich carbohydrates with low glycemic index and load necessary for calorie intake (Taillefer, 2008). Collaborating with a registered dietitian and designing menus for Mrs. R. may decrease the burden of planning meals.

Exercise is another essential component of patient teaching. Mrs. R. has none of the previously mentioned complications that would prevent her from participating in exercise. Collaborating with her in planning simple exercises is a must. Suggesting an exercise routine during the dialysis appointment can encourage adherence as well as socialization with others. Thirty minutes of low-intensity exercise, such as modified yoga, should be the goal (Yurtkuran, Alp, Yurtkuran, & Dilek, 2007). Some exercise plans include 30 minutes of cycling with devices adapted to the patient’s bed during dialysis (Quzouni, Kouidi, Sioulis, Grekas, & Deligiannis, 2009). Exercise can lead to significant improvements in the patient’s physical abilities, as well as decreased perception of pain, fatigue, depression, and insomnia.

Sleep disorders, such as apnea and restless leg syndrome, are common among patients receiving dialysis. In addition to management with medication, the patient may need to make behavioral changes, such as staying awake during dialysis and eliminating caffeine, nicotine, and alcohol intake. Some units provide overnight dialysis, which might be helpful. Sleep studies should be performed for sleep apnea and restless leg syndrome with the appropriate interventions of continuous positive airway pressure usage or medications (Unruh, 2008).

Evaluating this patient’s sleep and her participation in routine exercise can improve feelings of depression as well. Her loss of self, a change of status in her family, the inability to care for her daughter, her physical losses, and a loss of a social network can contribute to depression. The nurse should help the patient identify support people and local support groups, listing ways she has coped with crisis in the past. The nurse also can help her establish goals to give her a sense of hope. She may need a professional therapist, guidance in time management, and a social worker to find resources for caring for herself and daughter.

Conclusion

Fatigue is a real problem for patients receiving dialysis. While the specific cause of fatigue remains unknown, multiple conditions are associated with its occurrence. Nursing assessment of fatigue is important in the care of patients receiving dialysis in order to improve their quality of life. Nurses are in an excellent position to review patients’ medications and laboratory results, and collaborate with patients to determine how to use their support systems and individual strengths to help alleviate the effects of fatigue.

Acknowledgments

This project was supported by a grant from the National Center for Research Resources, Duke CTSA, NIH, grant number 1TL1RR024126. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.

Contributor Information

Ann Horigan, Duke University School of Nursing, Harrisonburg, VA.

Judith Rocchiccioli, James Madison University, Harrisonburg, VA.

Donna Trimm, James Madison University, Harrisonburg, VA.

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