A prospective study of fatigue trajectories among in-centre haemodialysis patients, 2020, Picariello, Moss-Morris et al

Andy

Retired committee member
Objectives

Fatigue is common and debilitating among dialysis patients. The aim of this study was to understand the longitudinal trajectory of fatigue and consider sociodemographic, clinical, and psychological factors that are related to variation in fatigue levels over time.

Design
A prospective study of fatigue with yearly assessments over 3 years among prevalent in‐centre haemodialysis (HD) patients.

Methods
Fatigue severity was measured using the Chalder Fatigue Questionnaire and fatigue‐related functional impairment using the Work and Social Adjustment Scale. The trajectories of fatigue outcomes were examined using piecewise growth models, using length of time on dialysis as time. Sociodemographic, clinical, and psychological predictors of fatigue were assessed using linear growth models, using follow‐up time.

Results
One hundred and seventy‐four prevalent HD patients completed baseline measures, 118 at 12 months, 84 at 24 months, and 66 at 36 months. Fatigue severity scores decreased by 0.15 each year. Fatigue‐related functional impairment increased by 1.17 each year. In adjusted linear growth models, non‐white ethnicity was a significant predictor of lower initial fatigue severity (B = −2.95, 95% CI −5.51 to −0.40) and a greater reduction in fatigue severity of 1.60 each year (95% CI 0.35–2.36). A one‐point increase in damage beliefs was associated with a 0.36 increase in fatigue‐related functional impairment each year (95% CI −0.61 to −0.01).

Conclusion
Damage beliefs predicted an increase in fatigue‐related functional impairment over time. However, the data strongly suggested that fatigue outcomes vary by length of time on dialysis.
Open access, https://bpspsychub.onlinelibrary.wiley.com/doi/full/10.1111/bjhp.12395
 
A survival analysis from this study cohort indicated that fatigue severity and fatigue‐related functional impairment were significantly associated with an increased risk of death
Psychological factors did not appear to play a significant role in fatigue severity, after controlling for sociodemographic and clinical factors.
Psychological factors being 'fear avoidance', catastrophising, 'symptom focusing', 'damage beliefs', 'embarrassment avoidance', 'all or nothing behaviours' and 'avoidance behaviours'.

So, the association of death with fatigue suggests that the patients might have been perceiving things correctly. And the lack of associations between measured psychological factors and fatigue severity suggests that changing psychological factors probably isn't the answer.



The mean CFQ numbers (lower is less fatigued; >18 is regarded as 'fatigued') were:
Baseline: 17.34
12 months: 17.37
24 months: 18.26
36 months: 16.49

Much was made of a trend to less fatigue over time, and changes in the percentages of patients who were 'fatigued'. But the cohort was changing at each measurement, with some dying, some receiving a transplant and some dropping out of the study. And the scores were hovering around that fatigue threshold of 18. Really, there is no evidence for fatigue changing over time in any systematic way.

But here's the conclusion:
In conclusion, changes in fatigue outcomes over time may be more complex than originally anticipated, varying by the length of time on dialysis, as the data suggested here. This provides some indication of when treatment for fatigue may be effectively delivered, yet the targets of treatment need to be explored further using a sample of incident dialysis patients.
So, the researchers aren't sure what psychological deficiencies in dialysis patients need to be fixed, but they suggest the study has identified when the fixing should be done - although they don't say in the conclusion when that is.

Scrolling through the study trying to find out when they think the intervention should be delivered, I could only find this:

According to the findings here, the timing of intervention delivery may be of relevance for patients on dialysis, as 24 months from dialysis initiation marked a change in the trajectory of fatigue severity. There is accumulating evidence in support of psychological interventions, such as cognitive‐behavioural therapy for the management of fatigue in physical LTCs (van den Akker et al., 2016) and promising preliminary evidence is available in kidney failure (Picariello et al., 2017). However, what modifiable cognitive and behavioural factors are associated with fatigue trajectories over the span of dialysis vintage is yet to be defined.

So, they say that at 24 months there is 'a change in the trajectory of fatigue severity'. Are they suggesting that the CBT for some yet to be identified psychological failing should be delivered at this point i.e. when the fatigue scores appear to naturally improve?

The paper is full of logical holes. And a lot of rather nasty patient blaming.

For example, once fatigue develops as a consequence of underlying disease processes, interpretations of fatigue as uncontrollable and lasting, and unhelpful thinking styles in response to fatigue, such as catastrophizing, symptom focusing, or perceiving fatigue as a sign of bodily damage (damage beliefs), may lead to increased anxiety and low mood and subsequently unhelpful behavioural responses, such as excessive rest in an attempt to control fatigue and reduce the damage perceived it is doing to their body. Excessive rest may in turn lead to deconditioning, poor sleep and physiological arousal related to anxious mood, and lead to the perpetuation of fatigue
 
I feel sorry for patients already suffering from life changing and very unpleasant kidney problems needing dialysis being subjected to this nonsense. Can't someone stop them in their never ending quest to psychologise in such a negative way, and with so little evidence, every patient who dares to admit to fatigue.
 
For example, once fatigue develops as a consequence of underlying disease processes, interpretations of fatigue as uncontrollable and lasting, and unhelpful thinking styles in response to fatigue, such as catastrophizing, symptom focusing, or perceiving fatigue as a sign of bodily damage (damage beliefs), may lead to increased anxiety and low mood and subsequently unhelpful behavioural responses, such as excessive rest in an attempt to control fatigue and reduce the damage perceived it is doing to their body. Excessive rest may in turn lead to deconditioning, poor sleep and physiological arousal related to anxious mood, and lead to the perpetuation of fatigue

Blissfully unconstrained by evidence, as always.
 
For example, once fatigue develops as a consequence of underlying disease processes, interpretations of fatigue as uncontrollable and lasting, and unhelpful thinking styles in response to fatigue, such as catastrophizing, symptom focusing, or perceiving fatigue as a sign of bodily damage (damage beliefs), may lead to increased anxiety and low mood and subsequently unhelpful behavioural responses, such as excessive rest in an attempt to control fatigue and reduce the damage perceived it is doing to their body. Excessive rest may in turn lead to deconditioning, poor sleep and physiological arousal related to anxious mood, and lead to the perpetuation of fatigue

This is not how it works. It's just marketing for CBT.
 
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Kidney disease, serious enough to require Haemodialysis (HD) is dreadful. The waste products you normally excrete build up until your next session, typically 3 times a week.
Your fluid intake and diet are hugely restricted.
These patients have every right to feel dreadful.

What is it with these Psychs and how are they continually accessing the funds for this this drivel!
 
I worked as a nurse with chronic dialysis patients for twenty years.

A large chunk of the dialysis population is over 65, which can account for some increase in fatigue.

My observations always concluded that the more uremic (abnormal levels of nitrogen waste products the blood---this corresponds to how much residual kidney function a dialysis patient has and also how strictly they follow their limiting of protein in their diets) a patient is, the more fatigue they have.

The higher level of nitrogen wastes in the blood make them feel sicker, thus more fatigued. Those levels have a direct effect on the brain.

Also, when potassium levels are high (almost every patient has higher than normal potassium levels just before dialysis) muscles feel and are weak. Thus, fatigue.

And almost all have some degree of depression. They know that their livespans are greatly reduced once they get to the end stage renal failure.

Edited to add: Kidney function continues to deteriorate with time on dialysis. So, fatigue will increase for that reason, too.
 
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Copy-paste research with copy-paste conclusions written from the start. Zero value, this informs nothing.

What this really shows is how completely arbitrary their stuff is, that whatever you put in, you always get the exact same thing out: the thing they believe. It also shows that patient predictions about their own course are generally reliable enough to serve as prognosis, probably not on a per-case basis but significantly more accurate than anything these fools have been trying for decades anyway. In a way, this is a massive ongoing self-own. But evidence does not matter in evidence-based medicine so whatever.
 
I find it totally amazing that researchers looking at dialysis patients can completely neglect to actually think about the medical side of needing dialysis. And that this piece of rubbish can get through peer review and publication.....
this trash is published for profit the publishing houses make in excess of two and a half billion every year the ridiculous prices they charge to read texts that they get for free guarantees that considerable amounts of copy pasted drivel will be published . i wish the law makers would get of their collective buts and bring an end to these hugely fraudulent practices .
 
this trash is published for profit the publishing houses make in excess of two and a half billion every year the ridiculous prices they charge to read texts that they get for free guarantees that considerable amounts of copy pasted drivel will be published . i wish the law makers would get of their collective buts and bring an end to these hugely fraudulent practices .

Agreed, except that it's not fraud til after the lawmakers do the right thing. Until then it's merely creepily unethical. And stands as one of the pillars that will bring us into a dark age where everything anyone says is science. Because they said so. And they're an expert.
 
For example, once fatigue develops as a consequence of underlying disease processes, interpretations of fatigue as uncontrollable and lasting, and unhelpful thinking styles in response to fatigue, such as catastrophizing, symptom focusing, or perceiving fatigue as a sign of bodily damage (damage beliefs), may lead to increased anxiety and low mood and subsequently unhelpful behavioural responses, such as excessive rest in an attempt to control fatigue and reduce the damage perceived it is doing to their body. Excessive rest may in turn lead to deconditioning, poor sleep and physiological arousal related to anxious mood, and lead to the perpetuation of fatigue

If doctors read these things at all the constant repetition will make this story sound true. We notice all the "mays" and "mights" but they are easy to miss. They are also an admission that there is no evidence for their theory. Obviously because they never test it just twist everything to make it sound true.
 
I find it totally amazing that researchers looking at dialysis patients can completely neglect to actually think about the medical side of needing dialysis. And that this piece of rubbish can get through peer review and publication.....
I used to maintain dialysis machines, including in people's homes.

Those patients are tired and unwell at least 50-60% of the time, are never 100% well, and have a bunch of serious complications from the kidney disease.

I wouldn't wish it on anybody.
 
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