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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 4  |  Page : 729-735
Fatigue and depression and sleep problems among hemodialysis patients in a tertiary care center

1 College of Nursing, All India Institute of Medical Sciences, New Delhi, India
2 Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication9-Jul-2012


High prevalence of sleep problems, fatigue and depression are reported in maintenance hemodialysis (MHD) patients. To assess fatigue, depression, sleep problems and their co-relates among MHD patients in a tertiary care center in India, we studied 47 patients on MHD for >3 months. Patients demographic, medical and co-morbidity profile were recorded. Pittsburgh Sleep Quality Index (poor sleeper if score >5) and Epworth Sleepiness Scale (EPSS, abnormal daytime sleepiness if score >13) were used to assess sleep abnormalities and quality. Beck Depression Inventory (BDI) was used to screen for depression. Depression was classified on BDI scores as mild-moderate (score 11-30) and severe (score >30). Fatigue Severity Scale was used to assess fatigue (score ≥36 indicates fatigue). The correlations of these parameters among themselves and with social and demographic parameters were also analyzed. The mean age of the study population was 37.1 ± 13.1 (range 19-65 years) years, with 89.3% being males. The majority (68.1%) of the MHD patients was poor sleepers, but only five (10.6%) patients had borderline or abnormal daytime sleepiness. Of the patients, 44.7% reported fatigue and (72.3%) had depression (mild to moderate in 59.7% and severe in 12.6%). Fatigue scores were found to be significantly associated with lesser frequency of dialysis (P < 0.05). There was higher daytime sleepiness in patients who were working (mean EPSS score 6.2 ± 3.7) than who were unemployed (mean EPSS score 3.9 ± 2.7). Depression was found to be higher in those who were paying for the treatment themselves (mean BDI score 20 ± 11.8) as compared with those who were getting medical expenditure reimbursed (mean BDI score 12.9 ± 8.8). Fatigue positively correlated with that of daytime sleepiness (P = 0.02), poor nighttime sleep (P = 0.02) and depression (P=0.006). In the present study, there was no correlation (P <0.05) found between daytime and night time sleep and depression. We found a high prevalence of fatigue, depression and poor sleep quality in our MHD patients. These abnormalities are closely related to each other and to the socioeconomic and demographic profiles of the population.

How to cite this article:
Joshwa B, Khakha DC, Mahajan S. Fatigue and depression and sleep problems among hemodialysis patients in a tertiary care center. Saudi J Kidney Dis Transpl 2012;23:729-35

How to cite this URL:
Joshwa B, Khakha DC, Mahajan S. Fatigue and depression and sleep problems among hemodialysis patients in a tertiary care center. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 May 19];23:729-35. Available from: http://www.sjkdt.org/text.asp?2012/23/4/729/98149

   Introduction Top

End-stage renal disease (ESRD) patients suffer from psychosocial factors that are amenable to therapy and adversely affect patients outcome and quality of life (QOL), [1],[2],[3] including depres­sion, fatigue and insomnia. Sleep disturbances are extremely common among dialysis patients, with prevalence of sleep-wake complaints noted in 50-80% of the cases. Excessive daytime sleepiness and sleep disorders such as sleep apnea syndrome, restless leg syndrome and periodic limb movement disorder occur with increased frequency in these patients. [4] The sleep abnormalities appear to have significant negative effects on QOL, functional health status and outcome. [5] Fatigue is another debili­tating side-effect experienced by many patients on long-term dialysis therapy. Over 70% of dialysis patients suffer chronically from severe fatigue and tiredness. [6] This could be due to the high levels of circulating endotoxins, inflam­matory cytokine release and oxidative stress. Approximately 25-50% of the ESRD popula­tion suffers from depression, [2],[3] which increases the risk of mortality, [7] and ranges from mild to severe. [8]

Fatigue, sleep problems and depressive mood affect the QOL of the dialysis patients. The patient population on dialysis in our country is significantly different from the developed coun­tries in age of patients entering ESRD. [9] Also, the majority of our patients pay for the cost of dialysis therapy and receive less frequency of dialysis. [9] However, no study from our sub­continent has looked into these problems in maintenance hemodialysis (MHD) patients.

The aim of our study was therefore to deter­mine the prevalence of fatigue, depression and sleep problems and their association among our MHD patients in addition to the corre­lation of fatigue, sleep and depression scores with frequency and duration of HD, employ­ment status and blood metabolic profile.

   Materials and Methods Top

Patients who were on MHD for more than three months, aged more than 18 years, were included in the study; patients with known psychiatric illness, in-hospital admission with­in four weeks of the study and those not wil­ling to participate were excluded. The study was conducted in a hemodialysis unit of a state-run tertiary care hospital in North India, which gets referred patients belonging to various social and economic profiles. Our hos­pital is a transplant-oriented center and we accept, for dialysis, only those patients who have available related kidney donors. Dialysis is provided at a nominal cost, but patients pay for the disposables and medicines, including erythropoietin. Some of the patients were re­imbursed the medical expenses by their emplo­yers or by insurance (reimbursable), while others paid for their medical expenses (non-reim­bursable). A convenience sample of 47 pa­tients was studied from June 2008 to Novem­ber 2008. The demographic and medical pro­file of the study population was representative of the dialysis population at our center.

The tools used in the study were Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepi­ness Scale (EPSS), Beck Depression Inventory (BDI) and Fatigue Severity Scale (FSS).

PSQI is a standardized tool used for assessing the quality of sleep. It measures seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep dis­turbances, use of sleeping medication and daytime dysfunction. The tool has four items, which are open-ended questions, and the other five items are on a rating scale (from 0 to 3), where 0 represents no trouble in sleeping over the past week, 1 refers to presence of trouble once, 2 is presence of trouble twice and 3 is presence of trouble thrice over the past week. A global sum of "5" or greater indicates a "poor" sleeper.

The Epworth Sleepiness Scale (EPSS) is a tool used for assessing daytime sleepiness. It is a standardized tool and the items are related to the likelihood of the person to doze off in different situations. Responses are provided on a scale from 0 to 3, where 0 refers to no chance of dozing, 1 refers to slight chance of dozing, 2 refers to moderate chance of dozing and 3 refers to high chance of dozing. The to­tal scores are then categorized to three groups: normal (0-9), borderline (10-12) and abnormal (13-29).

BDI is a standardized tool used for assessing depression. It consists of 21 questions about how the subject has been feeling in the last week. Each question has a set of at least four possible answer choices, ranging in intensity. When the test is scored, a value of 0-3 is assigned for each answer and then the total score is compared with a key to determine the severity of depression. The patients were clas­sified as being normal (BDI score <10), having mild to moderate depression (BDI score 11- 30) or having severe depression (BDI score >30).

FSS is a standardized tool used for assessing fatigue. It contains nine statements rated from 1 to 7, where a low value (e.g., 1) indicates strong disagreement with the statement, whereas a high value (e.g., 7) indicates strong agree­ment. A total score of <36 means no fatigue and ≥36 means presence of fatigue.

The patients either filled the entire question­naires themselves or it was read out to them in case of poor vision or if they were illiterate. Ethical clearance was obtained from the ethics committee of the institute and all the related consent was obtained.

   Statistical Analysis Top

The data obtained was analyzed using STATA package. Both descriptive and inferential sta­tistics were used. Descriptive statistics used in the study were frequencies, percentage, median, mean and standard deviation. For inferential statistics, Mann Whitney test, two sample t test and Spearman correlation were used where appropriate.

   Results Top

[Table 1] shows the study parameters in the population. The mean age of the study popu­lation was 37.1 ± 13.1 years (range 19-65 years, median 34 years); 89.3% were male, 51% were graduates, 53.2% were employed, 36.1% received medical reimbursement and 42.5% resided in villages, while the rest were city dwellers. Chronic interstitial nephritis was the most common cause of ESRD (34.7%), while in 31.7% no cause could be ascertained from history and/or investigations. Diabetes as a cause of renal failure was present in 6.4% of the cases. Although the patient has to pay a nominal cost for dialysis at our center (appro­ximately USD 12 per session including dispo­sables) and most of them are encouraged to have three dialysis sessions per week, still, 35 (74.4%) of them were dialyzed twice a week and only 12 (25.6%) were dialyzed thrice a week. This pattern is representative of dialysis population at our center and nearly universal in our country due to lack of finances and dia­lysis slots. [9] The mean duration of dialysis was 7.2 ± 3.5 months and the mean body mass index was 20.3 ± 3.0. The metabolic profile of the study population is also tabulated in [Table 1].
Table 1: Baseline profile of study population (n = 47).

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[Table 1] also shows the reported quality of sleep, daytime sleepiness, depression and fa­tigue in the study population. The mean PSQI scores were 6.5 ± 2.9 (median, 6), and the majority (68.1%) was poor sleepers. Mean EPSS score was 5.6 ± 3.4 (median, 4), with only 10.6% reporting borderline to abnormal daytime sleepiness. The mean of the BDI scores was 21.9 ± 10.5 (median, 18), and de­pression was reported by 72.3% of the patients (mild to moderate depression in 59.7%, severe depression in 12.6%). The mean of the fatigue scores was 31 ± 13.2 (median, 34), and was reported by 44.7% of the patients. This is also graphically represented in [Figure 1].
Figure 1: Percentage of the study patients reporting poor sleep quality, daytime sleepiness, depression and fatigue.

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Among the demographic parameters studied, fatigue was significantly associated with that of the frequency of dialysis, i.e. the subjects who were dialyzed twice a week had higher fatigue than those who were dialyzed thrice a week (mean FSS scores 35.1 ± 15.1 and 29.1 ± 9.01, respectively, P < 0.05). Daytime sleepiness was found to be higher in employed than in unemployed patients (mean EPSS scores 6.2 ± 3.7 and 3.9 ± 2.7, respectively, P <0.05). Dep­ression was found to be higher in non­reimbursable compared with reimbursable pa­tients (mean BDI scores 20 ± 11.8 and 12.9 ± 8.8, respectively, P < 0.05).

Fatigue positively correlated with that of day­time sleep (r = 0.59, P = 0.02), night time sleep (r = 0.81, P = 0.02) and depression (r = 0.45, P = 0.006). In the present study, there was no correlation found between daytime sleep and depression, night time sleep and depression, and daytime sleep and nighttime sleep.

Among all the pre-dialysis blood biochemical parameters studied, viz. hemoglobin, blood urea nitrogen, creatinine, calcium, phosphorus and albumin, only depression was found to be significantly associated with creatinine (r = 0.33, P = 0.02). No correlation was found bet­ween fatigue, sleep quality and daytime sleepi­ness with any of the serum chemistry values.

   Discussion Top

We document for the first time the prevalence of fatigue, depression and sleep disturbances problems in our patient population.

The reported incidence of fatigue in MHD patients and its correlates varies significantly in the literature. In a study among 36 African American women undergoing MHD, 75% re­ported fatigue, [10] which correlated with anemia, malnutrition, social support and mood disor­ders. McCann and Boore [11] from Ireland found that all of their 39 dialysis patients reported fatigue and low vitality, which correlated sig­nificantly with sleep problems and depression only. Bonner et al from Queensland reported significant fatigue in all of their 42 MHD patients, with a mean FSS score of 45. [12] Kim and Son [13] from Korea noted fatigue in 77.9% of MHD patients, and this strongly correlated with depresssion. Two recent studies however have reported a lower incidence of fatigue le­vels in different communities. Liu et al, [6] from Taiwan found fatigue in 45% of their HD pa­tients, with females, unemployed and depressed patients reporting higher depression. Bossola et al from Italy [14] noted that that 26 of their 62 HD patients (41.8%) reported fatigue as as­sessed by SF 36 vitality score, with symptoms of anxiety and depression being significantly higher in the fatigued group. We found that 44.1% of our patients felt fatigued, which is lower than most of the previously reported studies and in tune with recent findings. We also found that fatigue correlated positively with sleep disorders and depression, as has also been borne out by most of the previous studies. In addition, for the first time, we documented association of fatigue with lesser frequency of dialysis. As already highlighted, most of our patients received 2-4-h dialysis sessions per week due to financial constraints. This is not a selection bias, but inherent characteristic of dialysis patients at our center as well as in other centers of India. [9] Inadequate correction of the uremic milieu could result in symptoms of fatigue as observed in our study.

Depression is recognized as the most com­mon psychological problem encountered among patients with ESRD. [1],[2],[3] Studies have suggested that depressive symptoms occur in 25-50% of patients maintained on dialysis therapy. [2],[3] In the present study, we found that 72.3% of our patients were depressed, with 12.6% having severe depression. In dialysis patients, the asso­ciation between depression, demographic pro­file and co-morbidities such as DM, coronary artery disease (CAD) and peripheral vascular disease (PVD) is not certain. Some other studies have not found any demographic factor to be significantly associated with depression, [15],[16] while Einwohner et al, [17] have found increasing age as a significant factor affecting depression. Among the social and demogra­phic parameters, we found that only lack of facility of medical reimbursement correlated with depressive symptoms. Of the initial me­dical profile, we found that depression posi­tively correlated with high serum creatinine concentrations again indicating association of poor correction of uremia with psychological symptoms. Although the association between depression and nutritional parameters in dia­lysis patients is more consistent, we did not find any correlation between serum albumin and the levels of depression. The reported incidence of "poor sleep" among MHD patients in previous studies has been 45-80%. [18] In fact, Iliescu et al in a study among CKD patients not requiring dialysis found that using PSQI, 53% of their 120 pa­tients reported poor sleep quality, indicating that sleep disorders set early among CKD patients. [18] Mucsi et al from Hungary in 78 MHD patients found that 65% had sleep problems, with insomnia being the most common in 49%. [19] In another study, Iliescu et al from Canada [20] evaluated 89 HD patients with PSQI and found that 71% were poor sleepers and that PSQI scores correlated significantly with depression, increased age, co-morbidities and poor QOL. Multinational DOPPS trial reported that 49% of MHD patients had poor sleep quality. They also observed that poor sleep quality was independently associated with poor QOL and increased mortality. [21] Merlino et al in a multi-centric trial from Italy found that 69.1% of their patients had insomnia and that advancing age correlated with sleep disturbances. [22] In a study among Taiwanese patients, Chen et al, [23] found a mean PSQI score of 5.4 ± 4.4, with 66.6% reporting insomnia. We also found a mean PSQI score of 6.5, and 68.1% of our patients were "poor sleepers." However, none of the demographic and metabolic para­meters in our study correlated with sleep qua­lity. Daytime sleepiness is, however, only anecdotally reported in MHD patients. Mucsi et al found daytime sleepiness in 31% patients using ESS. [19] Parker et al found that 30% of their 46 MHD patients reported daytime slee­piness by using ESS, and no correlation was found with any of the demographic or clinical parameters. [24] However, Merlino et al found daytime sleepiness in only 11.8% of the patients. [22] Similarly, Chen et al in Taiwanese patients found daytime sleepiness in only 17.8% of the patients and correlated this with decreased dialysis dose and older age. [23] In accordance with these later reports, we also found reported daytime sleepiness in only 10.6% of the cases, which was significantly higher in those patients who were working.

Our study, however, has some limitations. Because our hospital is predominantly a trans­plant-oriented center, our MHD patients are predominantly young males and have short duration of dialysis and low co-morbidities. Therefore, the results might not be repre­sentative of all the dialysis patients in our country. However, the high incidence of fa­tigue, depression and poor sleep found in these patients suggests that the problem would be of larger magnitude in the overall dialysis popu­lation. Secondly, although the demographic and medical profile of the study population was representative of the dialysis population at our center, convenience sampling used may lead to bias as final sample may not be typical of the population. Also, the cross-sectional de­sign of the study and small patient numbers limits the establishment of a cause-effect rela­tionship between the study parameters, which highlights the need for multi-center prospec­tive studies.

To conclude, our study suggests a high pre­valence of self-reported fatigue, depression and poor sleep quality among Indian hemodialysis patients. Considering the negative impact of these symptoms on QOL and patient outcomes, further prospective and multi-center studies are required to delineate these problems.

   References Top

1.Finkelstein FO, Finkelstein SH. Psychological adaptation and quality of life of the patient with end-stage renal disease. In: Brown E, Parfrey P, eds. Complications of Long Term Dialysis, Oxford: Oxford University Press; 1999. p. 168-87.  Back to cited text no. 1
2.Kimmel PL. Psychosocial factors in dialysis patients. Kidney Int 2001;59:1599-13.  Back to cited text no. 2
3.Finkelstein FO, Finkelstein SH. Depression in chronic dialysis patients: Assessment and treat­ment. Nephrol Dial Transplant 2000;15:1911-3.  Back to cited text no. 3
4.Perl J, Unruh ML, Chan CT. Sleep disorders in end stage renal disease: Markers of inadequate dialysis. Nephrol Dial Transplant 2005;20:571-7.  Back to cited text no. 4
5.Parker KP. Sleep disturbances in dialysis patients. Sleep Med 2003;7:131-43.  Back to cited text no. 5
6.Liu HE. Fatigue and associated factors in hemodialysis patients in Taiwan. Res Nurs Health 2006;29:40 - 50.  Back to cited text no. 6
7.Chilcot J, Wellsted D, Gane MD, Farrington K. Depression on Dialysis. Nephron Clin Pract 2008;108:256-64.  Back to cited text no. 7
8.Upadhyaya BK, Khaira A, Khatri P, et al. Comparison of factors affecting depression in patients on hemodialysis and continuous am­bulatory peritoneal dialysis. Indian J Nephrol 2007;17:153-63.  Back to cited text no. 8
9.Sakhuja V, Sud K. End-stage renal disease in India and Pakistan: Burden of disease and management issues. Kidney Int 2003;63(Suppl 83):S115-8.  Back to cited text no. 9
10.Williams AG, Crane PB, Kring D. Fatigue in African American women on hemodialysis. Nephrol Nurs J 2007;34:610-7.  Back to cited text no. 10
11.McCann K, Boore JR. Fatigue in persons with renal failure who require maintenance haemodialysis. J Adv Nurs 2000;32:1132-42.  Back to cited text no. 11
12.Bonner A, Wellard S, Caltabiano M. Levels of fatigue in people with ESRD living in far North Queensland. J Clin Nurs 2008;17:90-8.  Back to cited text no. 12
13.Kim HR, Son GR. Fatigue and its related factors in Korean patients on hemodialysis. Taehan Kanho Hakhoe Chi 2005;35:701-8.  Back to cited text no. 13
14.Bossola M, Luciani G, Tazza L. Fatigue and its correlates in chronic hemodialysis patients. Blood Purif 2009;28:245-52.  Back to cited text no. 14
15.Troidle L, Watnick S, Wuerth DB, et al. Depression and its association with peritonitis in long-term peritoneal dialysis patients. Am J Kidney Dis 2003;42:350-4.  Back to cited text no. 15
16.Wuerth D, Finkelstein SH, Ciarcia J, Peterson RA, Kliger AS, Finkelstein FO. Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis. Am J Kidney Dis 2001;37:1011-7.  Back to cited text no. 16
17.Einwohner R, Bernardini J, Fried L, Piraino B. The effect of depressive symptoms on survival in peritoneal dialysis patients. Perit Dial Int 2004;24:256-63.  Back to cited text no. 17
18.Iliescu EA, Yeates KE, Holland DC. Quality of sleep in patients with chronic kidney disease. Nephrol Dial Transplant 2004;19:95-9.  Back to cited text no. 18
19.Mucsi I, Molnar MZ, Rethelyi J, et al. Sleep disorders and illness intrusiveness in patients on chronic dialysis. Nephrol Dial Transplant. 2004;19:1815-22.  Back to cited text no. 19
20.Iliescu EA, Coo H, McMurray MH, et al. Quality of sleep and health-related quality of life in haemodialysis patients. Nephrol Dial Transplant 2003;18:126-32.  Back to cited text no. 20
21.Elder SJ, Pisoni RL, Akizawa T, et al. Sleep quality predicts quality of life and mortality risk in haemodialysis patients: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2008;23: 998-1004.  Back to cited text no. 21
22.Merlino G, Piani A, Dolso P, et al. Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy. Nephrol Dial Transplant 2006;21:184-90.  Back to cited text no. 22
23.Chen WC, Lim PS, Wu WC, et al. Sleep behavior disorders in a large cohort of Chinese (Taiwanese) patients maintained by long-term hemodialysis. Am J Kidney Dis 2006;48:277-84.  Back to cited text no. 23
24.Parker KP, Bliwise DL, Bailey JL, Rye DB. Daytime sleepiness in stable hemodialysis patients. Am J Kidney Dis 2003;41:394-402.  Back to cited text no. 24

Correspondence Address:
Sandeep Mahajan
Department of Nephrology, All India Institute of Medical Sciences, New Delhi - 110 029
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DOI: 10.4103/1319-2442.98149

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