FC093: Symptom Burden and Individual Symptoms Before and After Dialysis Initiation in Older Patients
Authors: De Rooij Esther , Meuleman Yvette , De Fijter Johan W , Jager Kitty J , Chesnaye Nicholas , Evans Marie , Pagels Agneta , Caskey Fergus , Torino Claudia , Porto Gaetana , Szymczak Maciej , Drechsler Christiane , Wanner Christoph , Dekker Friedo W , Hoogeveen Ellen 
Published: May 2022

Abstract

BACKGROUND AND AIMS
In older people with end-stage kidney disease (ESKD), lowering symptom burden is likely more important than solely the prolongation of life. ESKD-related symptoms are multifactorial and dialysis initiation may affect distinct symptoms differently [1]. Symptoms caused by fluid overload (e.g. leg swelling) may be expected to improve, whereas those related to uremic toxins (e.g. itch) may remain. This, since protein-bound uremic toxins are dependent on tubular secretion and thus not sufficiently removed by dialysis treatment [2]. Furthermore, dialysis treatment itself may cause additional symptoms (e.g. fatigue). Therefore, we investigated the evolution of symptom burden and individual symptoms before and after starting dialysis in older ESKD patients.

METHOD
The European Quality (EQUAL) study is an ongoing prospective multicenter study in late stage 4/5 chronic kidney disease patients aged ≥65 years. Between April 2012 and December 2021, 30 kidney disease-related symptoms were assessed every 3–6 months using the dialysis symptom index (DSI). The sum score for symptom number ranges from 0 to 30 and for symptom severity from 0 to 150, with higher scores indicating a higher burden. We used mixed-effects models to study symptom burden and individual symptoms during the year preceding and following dialysis initiation.

RESULTS
In total, 456 incident dialysis patients were included. At baseline, dialysis initiation, mean (SD) age was 77 (6) years, eGFR 8 (4) mL/min/1.73 m2 75% were men, 45% had diabetes, 9% smoked and 45% had a history of cardiovascular disease. Mean (SD) number of symptoms was 15 (7) with a symptom severity of 46 (24). During the year preceding dialysis, symptom number increased by +3.4 [95% confidence interval (95% CI): +2.4 to +4.4] and severity by +13.9 (95% CI: +10.1 to +17.6). In the year following dialysis, symptom number decreased by –1.0 (95% CI: −2.1 to + 0.0) and symptom severity by –6.9 (95% CI: −10.8 to −3.0) (Figure 1). At start of dialysis, fatigue, decreased interest in sex and difficulty becoming sexually aroused had the highest prevalence of 81%, 69% and 68%, respectively, and highest burden with a mean severity of 2.7, 2.4 and 2.3, respectively. We observed three separate patterns in prevalence and severity of individual symptoms: (1) increase in the year before dialysis initiation and decrease in the year after (fatigue, trouble staying asleep, leg swelling, decreased appetite, shortness of breath, worrying, trouble falling asleep, difficulty concentrating, feeling irritable, feeling sad, feeling nervous, nausea, feeling anxious, constipation, restless legs and chest pain); (2) increase in the year before dialysis initiation and no change or continued increase in the year after (decreased interest in sex, difficulty becoming sexually aroused, itch, bone or joint pain, dizziness, diarrhea, tingling in feet and vomiting); and (3) no change in the year before or after dialysis initiation (muscle cramps, dry skin, dry mouth, muscle soreness, cough and headache) (Figure 2).

CONCLUSION
Symptom burden worsened considerably before dialysis initiation, and halted afterwards. Fatigue was the most common and burdensome symptom. Our results may emphasize the importance of discussing kidney-disease related symptoms in routine clinical care and considering their differing patterns of evolution before and after dialysis initiation. Increased physician awareness may lead to better symptom control and has been shown to improve total symptom burden [3].