Fatigue and related sleep disturbances in hemodialysis patients: prevalence, associated factors, and the influence of nutritional status

Abstract

Post-dialysis fatigue is one of the most frequent and limiting symptoms among patients undergoing hemodialysis (HD), characterized by intense physical exhaustion that may persist beyond the treatment session. Sleep disturbances frequently coexist with fatigue and may contribute to overall symptom burden. Nutritional status has been identified as a potential determinant of fatigue severity. Understanding these relationships may help identify associated factors and guide multidisciplinary interventions. Objectives: To assess the prevalence and intensity of fatigue in patients receiving HD, to describe the burden of sleep disturbances, and to analyze their association with nutritional status and various clinical, dialytic, and sociodemographic variables. Methods: A cross-sectional descriptive study was conducted between November and December 2024 in adults with chronic kidney disease undergoing maintenance HD. Fatigue and sleep disturbances were assessed using brief patient-reported outcome items adapted from PROMIS item bank concepts and analyzed as separate subscales. Nutritional status was evaluated using the Mini Nutritional Assessment–Short Form (MNA-SF). Sociodemographic, clinical, dialytic, and laboratory variables were collected. Statistical analyses were performed using SPSS v29, applying association and correlation tests (p ≤ 0.05). Results: A total of 729 patients were included (67.1% men), with a mean age of 67.7 ± 14.5 years. Clinically relevant fatigue was reported by approximately 50% of participants, with around 20% presenting severe fatigue. Sleep disturbances affected nearly 60% of patients, with severe impairment reported in approximately 30%. Regarding nutritional status, 61.9% had normal nutrition, 33.2% were at risk of malnutrition, and 4.9% were malnourished. Fatigue was significantly associated with female sex (p < 0.001), longer time on hemodialysis (p < 0.001), greater weekly dialysis exposure (p = 0.012), and poorer nutritional status (p = 0.003). The absence of residual urine output showed a borderline association with fatigue (p = 0.059) but was significantly associated with sleep disturbances (p = 0.002). Sleep disturbance scores were also significantly associated with lower levels of albumin, total proteins, and transferrin. No associations were observed between fatigue and age, BMI, comorbidity, ultrafiltration rate, or biochemical parameters. Conclusions: Fatigue is a highly prevalent and clinically relevant symptom in patients undergoing HD and is closely associated with nutritional status and dialysis-related factors. Sleep disturbances are also highly prevalent and may act as an important modulating factor, potentially amplifying fatigue, particularly in patients with greater biological vulnerability or loss of residual kidney function. The systematic use of patient-reported outcome measures (PROMs) to assess fatigue and sleep, together with nutritional evaluation, may facilitate the early identification of vulnerable patients and guide targeted strategies to reduce symptom burden and improve quality of life.