Undertreatment of symptoms in patients on maintenance hemodialysis

Context: Hemodialysis patients suffer a large symptom burden, and little is known about how effectively symptoms are treated.

Objectives: To assess the management of treatable symptoms in hemodialysis patients, we administered a 30-item questionnaire on physical and emotional symptoms to patients receiving outpatient hemodialysis at the University of Virginia.

Methods: We asked patients whether they were prescribed therapy for potentially treatable symptoms and assessed who prescribed the therapy. By means of chart review, we also documented whether medications were prescribed for these symptoms.

Results: We approached 87 patients and enrolled 62 (71%). The most commonly reported, potentially treatable symptoms included bone/joint pain, insomnia, mood disturbance, sexual dysfunction, paresthesia, and nausea. Only 45% of patients with bone/joint pain reported receiving an analgesic medication. Twenty-three percent of patients with trouble falling asleep and 53% of patients with nausea reported receiving a medication to alleviate this symptom. Chart review revealed that 58% of patients who reported the presence of bone/joint pain were prescribed an analgesic, 23% of patients with trouble falling asleep were prescribed a sleep aid, and 42% of patients with nausea received an antiemetic. Primary care providers were more likely than nephrologists to provide for all symptoms except nausea and numbness or tingling in the feet, and this difference was significant for the treatment of worrying (3/3 vs. 0/3, P=0.05) and nervousness (4/5 vs. 0/5, P=0.02).

Conclusion: Potentially treatable symptoms in hemodialysis are undertreated. Pharmacologic therapy, particularly for emotional symptoms, was more commonly prescribed by primary care providers than nephrologists. Additional study of the barriers to symptom treatment and interventions that increase nephrologist and primary care provider symptom management are needed.