Abstract

Patient-reported outcome metrics are critical to establishing a more patient-centered dialysis delivery care model. Dialysis recovery time after a hemodialysis session impacts patients’ well-being. This pilot project examined easy-to-implement hemodialysis prescription changes in patients undergoing in-center hemodialysis with a dialysis recovery time of 12 hours or more to understand if any of the interventions improve dialysis recovery times. Thirteen patients received stepwise prescription interventions of adjusted dialysate sodium, reduced blood flow rate, and decreased dialysate temperature. Individual patient results, reduced blood flow rates in particular, suggested some benefit in reducing dialysis recovery time.

Background

Post-dialysis fatigue is a frequent symptom following maintenance hemodialysis (HD) treatments that can affect the normal activities of daily living, reducing quality of life. 1 Post-dialysis fatigue has been associated with long-term fatigue, 2 depression, 3,4 sedentary behavior, 5 and mortality, 6 and can reduce exercise and participation in social activities. 7 Potential contributing factors to post-dialysis fatigue are high ultrafiltration rates, 8,9 disequilibrium syndrome, 10 and elevated tumor necrosis factor. 11 However, the cause or causes of post-dialysis fatigue have not been clearly established and, therefore, a tendency to consider post-dialysis fatigue as an uncontrollable adverse event of conventional HD therapy in some patients is widespread.

Dialysis recovery time (DRT), also known as time to recover from hemodialysis (TIRD), is the quantifiable, validated measure of post-dialysis fatigue. 7 Globally, 27% of patients have reported 6 hours and longer DRT while 68% of patients reported taking longer than 2 hours to recover from a dialysis session. 12 In the US, approximately 86% of patients experience post-dialysis fatigue ranging from mild-to-severe, 13 and a recent report suggested 29% of patients experience greater than 6 hours DRT. 9 Similar findings were seen in evaluations in our patient population, with 29% of patients experiencing a more than six-hour-long dialysis recovery time, and 20% reporting 12 hours or longer. 9

The most dramatic improvements of prolonged DRT have been achieved with increased dialysis frequency and longer-time nocturnal dialysis. 7,14 However, other, less ‘intrusive’ interventions attempting to decrease post-dialysis fatigue and improve DRT have included decreased dialysate temperature, 14 physical exercise, 15 sodium modeling, 8,16 increased dialysis glucose, 17,18 hemodialysis biofeedback technologies, 19 and hemodiafiltration. 20 Other associated factors that may influence post-dialysis fatigue are intradialytic blood flow rate 12 and ultrafiltration rates. 8,12

The aim of this quality improvement project was to test the hypothesis that a stepwise approach of minimally invasive, pragmatic interventions can reduce dialysis recovery time. The emphasis was on pragmatic interventions with minimal interference to patients’ schedules.

Methods

Dialysis recovery time survey

This project commenced with a cross-sectional descriptive survey. Convenience sampling was used from the patients cared for by 15 nephrologists in 8 outpatient hemodialysis centers. Firstly, the question, “How long does it takes you to recover from a dialysis session?” was asked to each patient at two time points, one month apart. As per Lindsay et al., this question is “reliable, valid, and subject to change.” 7 Responses indicating that recovery time was just minutes were recorded directly, answers in hours were multiplied by 60, answers of half a day, including the next day, were given a value of 720 minutes and variants of  “one day,” were given a value of 1,440 minutes. Variants of “more than a day” were given a value of 2,160 minutes. Patients with a response greater than or equal to 720 minutes (12 hours) at both time points were included in the intervention pathway. Recruitment and inclusion details are summarized in Figure 1.

Intervention pathway

The second part of this project consisted of three stepwise interventions for patients who reported greater than or equal to 12 hours DRT on two different occasions at least 2 weeks apart. The chosen interventions (see Figure 2) consisted of:

  • Adjustment to dialysate sodium gradient to within 2 mEq/L of the patient’s serum sodium (Na gradient ± 2)
  • Decreasing blood flow rate (Qb) by a mean of 20%
  • Decreasing dialysate temperature by 0.5° Celsius

These three interventions were chosen by the clinical team with the goal to minimize the effect on each patient’s treatment regimen and thus get easy buy-in and potentially wider applicability as feasible. The three interventions had been reported in the literature as potential antecedents of dialysis recovery time. 6 Following the implementation of interventions, patients were asked the DRT question approximately two weeks and four weeks after start of the intervention to properly assess for any changes in DRT.

Results

Dialysis recovery time screening

From a sample of 327 patients, 147 (45%) patients were excluded due to schedule changes, inability to respond (as a result of cognitive or language barriers and misinterpretation of the project question), refusal to respond, or being absent on the day of evaluation, leaving 180 who were asked the question, “How long does it take you to recover from a dialysis session?” At two weeks, 131 (72%) patients responded again, with 49 lost to follow up (see Figure 1).

Twenty-seven patients reported a DRT greater than 720 minutes (12 hours) at both time points and were targeted for intervention. Ten patients were excluded due to medical reasons (access, hospitalizations, and hemodynamic instability during HD), two patient refused prescription changes, and two patient transferred (see Figure 1).

Intervention pathway

Demographic data of the remaining thirteen patients is listed in Table 1. Of the 13 patients enrolled, three patients were unable to follow the full algorithm due to reasons outlined in Figure 3. Only two of the remaining 10 patients qualified for a dialysate sodium adjustment to an optimal gradient of ≤ 2 mEq/L (all other patients were already dialyzing at this desired gradient). In one of these patients, the decrease of Qb was missed and a dialysate temperature reduction followed as the next step without impacting DRT. Eight patients had their blood flow rate decreased by a mean of 20% (range 11-33%); Qb = 400 to 450 mL/min were reduced to 300 or 350 mL/min based on individual prescription and treatment time. Adequate Kt/V defined as greater than 1.4 was maintained. Of these eight patients, four achieved reduced DRT after the decrease in blood flow rate only. Another four patients continued through the pathway to receive a reduction in dialysate temperature; however, one of these patients was dialyzing at 36°C and no further decrease was attempted.

Of the 10 patients, eight patients underwent conventional thrice weekly hemodialysis and two patients dialyzed four times per week. Of these two patients dialyzing four times per week, one patient’s DRT improved post Qb reduction and one patient’s DRT remained unchanged despite interventions.

For seven out of the ten patients, these interventions resulted in a decrease of their reported DRT. One patient benefited from a dialysate sodium reduction, four benefited from a decreased blood flow rate of between 50 to 150 mL/min. (median: 100 mL/min), and two patients reported a lower DRT after reductions in dialysate temperature.

Three patients reported no change in DRT. One was prescribed a lower blood flow only, as dialysate sodium and dialysate temperature were at the lowest level per the intervention plan. One patient was dialyzed at a lower blood flow and subsequent lower dialysate temperature. One patient missed Qb intervention and therefore received only a lowered sodium prescription and temperature reduction without success.

Three patients were removed from the project after the first round of interventions due to an access issue, hospitalization, or an inability to determine DRT (see Figure 3).

Discussion

Results from this quality improvement pilot project indicate that a reduction in dialysis blood flow rate may present an opportunity to decrease dialysis recovery time in some patients, as four out of 10 patients benefited from a lowered Qb alone.

Reducing blood flow

Concerns as to whether decreased blood flow would decrease Kt/V were not realized as no patient’s Kt/V fell below 1.4. Thus, implementation of lower blood flow rate for people with high DRT may present an opportunity for improvement in post-dialysis fatigue. However, this will require a change in common US practice given the median US blood flow rates are 450 mL/min compared to 350 mL/min in Belgium, France, Sweden and the UK, 300 mL/min in Australia, Germany and Italy, and 200 mL/min in Japan. 21 The current culture of high blood flow rates reflects a historical focus on achieving adequate dialysis measures for Kt/V of ≥ 1.2 22 while accommodating shorter dialysis sessions often perceived by clinicians and patients as preferable compared to longer times in the dialysis chair.

Longer dialysis

Improved post-dialysis fatigue as defined by DRT can certainly be achieved through longer dialysis sessions. Lindsay et al.7 have clearly demonstrated that extending dialysis treatment time through more frequent and nocturnal dialysis is associated with both increased Kt/V and decreased DRT. These results were confirmed in a FREEDOM study in patients undergoing short daily home-hemodialysis therapy. 23 However, for those unable to access or unwilling to undergo these treatment options, decreasing Qb may be an alternative option to improve DRT. While this may be an underutilized opportunity, a challenge exists in finding a proper balance between decreasing DRT through blood flow rate reductions and maintaining Kt/V, while minimizing treatment length changes. However, lower Qb may present a very intriguing reason for patients to embrace longer treatment times, if needed, with the prospect of better quality of life. Faster recovery time holds a promise worth the additional time spent on dialysis, when weighed against the reduced time of feeling drained after treatment.

Through the observational studies of the DOPPS group, Rayner et al. 12 did not find a significant association between blood flow rate and DRT. However, of interest was their finding that Japanese patients had the shortest DRTs while also having the lowest Qb. Reasons for the Japanese results are not clear, as blood flow rate variations are one of many differences in international dialysis practices. Blood flow adjustments could still prove to be a simple yet practical first step in addressing some patients’ high DRT because of the association with gentler toxin removal and hemodynamic stability. Further research measuring the effects of decreased Qb on DRT by testing its impact on the intra-extracellular shift of toxins and electrolytes are difficult, but would assist in clarifying the role of blood flow rate and time on dialysis in these situations.

Dialysate sodium

Dialysate sodium has been reported to play a role in DRT. 24 Other positive effects have been shown by maintaining a gradient of < 2 mEq/L within the patient’s serum sodium mainly thought to be due to the decreased intradialytic fluid gain. 24 Lowering dialysate sodium to achieve this gradient resulted in lowering post-dialysis recovery time in one patient/two patients who were subjected to this intervention. All other patients were already dialyzing at the desired gradient of ≤ 2 mEq/L. Although only measured for a limited period, the decreased DRT was independent of the patient’s interdialytic fluid gains.

Dialysate temperature

Cooling dialysate temperature to below 37°C can improve hemodynamic stability in patients on dialysis and decrease post-dialysis fatigue. 14 As a pragmatic approach, we reduced dialysate temperature by 0.5°C to a minimum of 36°C to monitor whether more subtle changes in prescription can impact dialysis recovery time. This intervention, however, brought mixed results. Thus, it is difficult to properly assess its impact on DRT in our small sample size. Our project was consistent with Azar’s 14 in that temperature can play a role in DRT, and therefore deserves consideration to be explored in patients with prolonged DRT.

The implementation of the interventions in this project required nephrologist, staff and patient education. Education may assist in increasing patient adherence in particular, decreasing Qb from 450 mL/min. In addition to changing blood flow rate, decreasing dialysate temperature was difficult due to the logistics of prescription documentation and dialysis machine default settings. Given that dialysate temperature changes were not standard practice in the center’s care models, the prescription change may risk not being consistently implemented.

There has been increased interest in the possible hemodialysis treatment causes of DRT. In a homogenous group of US patients, no significant relationships with DRT were found between age, gender, comorbidity, dialysis vintage, ultrafiltration, HD treatment time, and intradialytic hypotension incidence. 25 In a larger more global group, treatment associations included intradialytic weight loss, session length, and lower dialysate sodium concentration. 12 However, asking the global dialysis audience the one DRT question highlights the challenges of the DOPPS approach given the differences in populations (even when complex adjustments are implemented). The challenge of validity following the one question translation requires discussion, as the question was originally validated in a North American population and not an international group. Furthermore, when patients are asked a personal experience question, some cultures may not want to complain or report problems, with the opposite being true for other cultures who express their emotions far more. This, rather than any other variable, may account for differences, or non-differences, in varying international responses to the DRT question.

While the recovery time question is simple enough to integrate into clinical practice and has been validated comparing home and in-center patients, a limitation exists in its ability to accurately assess patients who dialyze on the late afternoon or evening shift. The recovery time is complicated by the reality that many of these patients go to sleep following their evening hemodialysis, at a relatively normal time, making it difficult to assess whether they have actually recovered or not. These patients may benefit from the approach offered by Sklar et al.8 and Gordon et al.13 who explored duration, frequency, and intensity that generated a fatigue index. The approach of Dubin et al. 26 of simply asking, “After most dialysis sessions, do you have fatigue of two hours or less…or greater than two hours?” may also have been more applicable to this group of patients. Hence, the context in which the one question approach is asked may need to be considered prior to evaluating DRT.

Limitations

Given the case study approach using a small sample size for this pilot project, broader investigation is necessary to more accurately determine the effects of the stepped approach in the effort to improve DRT.

Conclusion

Post dialysis fatigue is a complex set of symptoms that affects people in different ways, thus requiring an individualized management approach. A one size fits all approach, in the US context, is unlikely to decrease all patients’ DRT given its multifactorial complexity. This pilot indicates that some patients experiencing a high DRT may benefit from decreased blood flow rate and/or lower sodium dialysate, and possibly decreased dialysate temperature. Thus, individualized prescriptions in patients undergoing thrice weekly hemodialysis may present an opportunity for nephrologists to decrease dialysis recovery time in some of their patients, impacting quality of life in a meaningful way.

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