Symptom burden before and after dialysis initiation in older patients

Background and objectives. For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients.
Design, setting, participants, and measurements. The European Quality (EQUAL) study is an ongoing prospective multicenter study in patients ≥65 years with an incident eGFR ≤20 mL/min/1.73m2. Using the dialysis symptom index (DSI), 30 symptoms were assessed every 3-6 months between 2012 and 2021. Scores for symptom number range from 0-30 and for burden from 0-150, with higher scores indicating more severity. Using mixed-effects models we studied symptoms during the year preceding and the year following dialysis initiation.
Results. We included 456 incident dialysis patients who filled out at least one DSI during the year before or after dialysis. At dialysis initiation, mean(SD) age was 77(6) years, 75% were men, eGFR was 8(3) ml/min/1.73m2, 44% had diabetes and 46% had cardiovascular disease. In the year before dialysis initiation, symptom number increased +3.6 (95%CI: +2.5;+4.6) and symptom burden +13.3 (95%CI: +9.5;+17.0). In the year after, symptom number changed -0.9 (95%CI: -3.4;+1.5) and burden decreased -5.9 (95%CI: -14.9;-3.0). At dialysis initiation, “fatigue”, “decreased interest in sex” and “difficulty becoming sexually aroused” had the highest prevalence of 81%, 69% and 68%, with a burden of 2.7, 2.4 and 2.3, respectively. “Fatigue” somewhat improved after dialysis initiation, whereas the prevalence and burden of sexual symptoms further increased.
Conclusions. Symptom burden worsened considerably before and stabilized after dialysis initiation. “Fatigue”, “decreased interest in sex” and “difficulty becoming sexually aroused” were considered most burdensome, of which only “fatigue” somewhat improved after dialysis initiation.