Abstract
KEY POINTS: Patients treated with maintenance hemodialysis report a higher symptom burden on the days they receive hemodialysis treatment, compared with non-hemodialysis days. The severity of physical, cognitive, and mood symptoms can vary diurnally, and the pattern of this variation may differ between hemodialysis and non-hemodialysis days. Ecological momentary assessment can provide insights into the complex, dynamic symptom experiences of patients on hemodialysis. BACKGROUND: Patients with ESKD on hemodialysis experience a high symptom burden, which is compounded by unpredictable fluctuations in symptom severity. Few studies have used ecological momentary assessment to determine how symptoms vary over time. This study aimed to characterize the diurnal and day-to-day variability in symptoms among patients receiving hemodialysis. METHODS: Patients enrolled in the Technology-Assisted Collaborative Care trial rated the intensity of physical, cognitive, and mood symptoms using an automated telephone-administered version of the Daytime Insomnia Symptom Scale at four time points (morning, early afternoon, late afternoon, evening) for seven consecutive days at baseline. Confirmatory factor analysis was used to verify the original four-factor solution for the Daytime Insomnia Symptom Scale: sleepiness/fatigue (SF), alert cognition (AC), positive mood (PM), and negative mood (NM). Symptom domain scores were calculated for each time point, and mixed modeling with random patient effects was used to examine differences in daily symptoms at daily time points between hemodialysis and non-hemodialysis days after controlling for age, sex, race, and comorbidity burden. RESULTS: One hundred sixty patients were enrolled (mean±SD age 58±14 years, 45% women, 52% White). Diurnal symptom variation existed; trends were nonlinear and differed by hemodialysis versus non-hemodialysis days. Day-to-day symptom variation also existed; patients endorsed better physical, cognitive, and mood states (i.e., higher AC and PM) as well as lower symptom burden (i.e., lower SF and NM) on non-hemodialysis days compared with hemodialysis days at all time points. The greatest day-to-day mean differences (MDs) were observed in the early afternoon for all symptom domains: AC (MD=0.17 P < 0.001), PM (MD=0.28, P < 0.001), SF (MD=−0.66, P < 0.001), and NM (MD=−0.26, P < 0.001). CONCLUSIONS: Patients with ESKD demonstrate diurnal variation in symptoms and greater symptom burden on hemodialysis days compared with non-hemodialysis days, with the most extreme differences in symptom severity occurring in the early afternoon. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03440853.