Fatigue in Patients Receiving Maintenance Hemodialysis: A Review

Fatigue surrounding hemodialysis treatments is a common and often debilitating symptom that impacts patients' quality of life. Intradialytic fatigue develops or worsens immediately before hemodialysis and persists through the dialysis treatment. Little is known about associated risk factors or pathophysiology, although it may relate to a classic conditioning response. Postdialysis fatigue (PDF) develops or worsens after hemodialysis and may persist for hours. There is no consensus on how to measure PDF. Estimates for the prevalence of PDF range from 20%-86%, likely due to variation in methods of ascertainment and participant characteristics. Several hypotheses seek to explain the pathophysiology of PDF, including inflammation, hypothalamic-pituitary-adrenal axis dysregulation, and osmotic and fluid shifts, but none is currently supported by compelling or consistent data. PDF is associated with several clinical factors, including cardiovascular and hemodynamic effects of the dialysis procedure, laboratory abnormalities, depression, and physical inactivity. Clinical trials have reported hypothesis-generating data about the utility of cold dialysate, frequent dialysis, clearance of large middle molecules, treatment of depression, and exercise as potential treatments. Existing studies are often limited by sample size, lack of a control group, observational design, or short intervention duration. Robust studies are needed to establish the pathophysiology and management of this important symptom. Fatigue surrounding hemodialysis treatments is a common and often debilitating symptom that impacts patients' quality of life. Intradialytic fatigue develops or worsens immediately before hemodialysis and persists through the dialysis treatment. Little is known about associated risk factors or pathophysiology, although it may relate to a classic conditioning response. Postdialysis fatigue (PDF) develops or worsens after hemodialysis and may persist for hours. There is no consensus on how to measure PDF. Estimates for the prevalence of PDF range from 20%-86%, likely due to variation in methods of ascertainment and participant characteristics. Several hypotheses seek to explain the pathophysiology of PDF, including inflammation, hypothalamic-pituitary-adrenal axis dysregulation, and osmotic and fluid shifts, but none is currently supported by compelling or consistent data. PDF is associated with several clinical factors, including cardiovascular and hemodynamic effects of the dialysis procedure, laboratory abnormalities, depression, and physical inactivity. Clinical trials have reported hypothesis-generating data about the utility of cold dialysate, frequent dialysis, clearance of large middle molecules, treatment of depression, and exercise as potential treatments. Existing studies are often limited by sample size, lack of a control group, observational design, or short intervention duration. Robust studies are needed to establish the pathophysiology and management of this important symptom. Patients with end-stage kidney disease (ESKD) receiving hemodialysis (HD) suffer a high burden of symptoms during and after dialysis treatments that adversely impact their quality of life. One of the most common, distressing, and debilitating symptoms is fatigue.1De Rooij E.N.M. Meuleman Y. de Fijter J.W. et al.Symptom burden before and after dialysis initiation in older patients.Clin J Am Soc Nephrol. 2022; 17: 1719-1729https://doi.org/10.2215/CJN.09190822Crossref PubMed Scopus (4) Google Scholar Fatigue is a complex phenomenon that involves physical, psychological, and emotional components.2Gregg L.P. Bossola M. Ostrosky-Frid M. Hedayati S.S. Fatigue in CKD: epidemiology, pathophysiology, and treatment.Clin J Am Soc Nephrol. 2021; 16: 1445-1455https://doi.org/10.2215/CJN.19891220Crossref PubMed Scopus (32) Google Scholar Although unrelenting chronic fatigue is common among patients with ESKD, there are 2 additional patterns of fatigue in this patient population related to the timing of dialysis sessions: (1) intradialytic fatigue (IDF), which develops or worsens immediately before the dialysis session and persists for the duration of the treatment,3Brys A.D.H. Lenaert B. Van Heugten C.M. Gambaro G. Bossola M. Exploring the diurnal course of fatigue in patients on hemodialysis treatment and its relation with depressive symptoms and classical conditioning.J Pain Symptom Manage. 2019; 57: 890-898.e4https://doi.org/10.1016/j.jpainsymman.2019.02.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar and (2) postdialysis fatigue (PDF), which develops or worsens after the end of the dialysis session and may persist for hours.4Bossola M. Tazza L. Postdialysis fatigue: a frequent and debilitating symptom.Semin Dial. 2016; 29: 222-227https://doi.org/10.1111/sdi.12468Crossref PubMed Scopus (47) Google Scholar This review consolidates known information about the measurement, epidemiology, pathophysiology, and potential management of IDF and PDF in patients with ESKD on maintenance HD. It is controversial whether IDF and PDF should be considered unique entities or as parts of a cumulative experience of chronic fatigue.5Ju A. Unruh M. Davison S. et al.Establishing a core outcome measure for fatigue in patients on hemodialysis: a Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop report.Am J Kidney Dis. 2018; 72: 104-112https://doi.org/10.1053/j.ajkd.2017.12.018Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar For affected patients, these nuances about the timing of fatigue may be less important than the degree to which fatigue limits participation in their daily lives.5Ju A. Unruh M. Davison S. et al.Establishing a core outcome measure for fatigue in patients on hemodialysis: a Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop report.Am J Kidney Dis. 2018; 72: 104-112https://doi.org/10.1053/j.ajkd.2017.12.018Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Clinically, it may be difficult to distinguish between IDF, PDF, and chronic fatigue in patients who experience some overlap between these loosely defined categories. Consequently, much of the existing research about fatigue in patients with ESKD either ascertained chronic fatigue or did not specify the timing of symptoms relative to the HD treatment.5Ju A. Unruh M. Davison S. et al.Establishing a core outcome measure for fatigue in patients on hemodialysis: a Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop report.Am J Kidney Dis. 2018; 72: 104-112https://doi.org/10.1053/j.ajkd.2017.12.018Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 6Ju A. Teixeira-Pinto A. Tong A. et al.Validation of a core patient-reported outcome measure for fatigue in patients receiving hemodialysis: the SONG-HD fatigue instrument.Clin J Am Soc Nephrol. 2020; 15: 1614-1621https://doi.org/10.2215/CJN.05880420Crossref PubMed Scopus (26) Google Scholar, 7Jhamb M. Weisbord S.D. Steel J.L. Unruh M. Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors.Am J Kidney Dis. 2008; 52: 353-365https://doi.org/10.1053/j.ajkd.2008.05.005Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar Such studies may encompass IDF and PDF without identifying them specifically. However, the pathogenesis of fatigue in patients with kidney disease is likely multifactorial but remains poorly understood,2Gregg L.P. Bossola M. Ostrosky-Frid M. Hedayati S.S. Fatigue in CKD: epidemiology, pathophysiology, and treatment.Clin J Am Soc Nephrol. 2021; 16: 1445-1455https://doi.org/10.2215/CJN.19891220Crossref PubMed Scopus (32) Google Scholar and the timing of fatigue relative to the HD treatment may offer some insights into mechanisms and potential treatments. Fatigue that develops or worsens during or after the HD treatment raises the question of whether factors related to dialysis itself may contribute to the increased symptom burden for some patients. Ultimately, whether IDF and PDF have unique underlying contributing factors or represent heterogeneous manifestations of generalized fatigue, summarizing and organizing what is known about these entities may generate new hypotheses to more effectively manage fatigue in patients with ESKD. Each HD session is a physiologically and psychologically demanding event that affects mental well-being, metabolism, cardiovascular function, and perfusion. IDF is characterized by fatigue that develops or worsens immediately before the start of the HD treatment and persists for the duration of the treatment.3Brys A.D.H. Lenaert B. Van Heugten C.M. Gambaro G. Bossola M. Exploring the diurnal course of fatigue in patients on hemodialysis treatment and its relation with depressive symptoms and classical conditioning.J Pain Symptom Manage. 2019; 57: 890-898.e4https://doi.org/10.1016/j.jpainsymman.2019.02.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Fatigue is the most common symptom during the HD procedure, reported by 60%-80% of patients,8Alvarez L. Brown D. Hu D. Chertow G.M. Vassalotti J.A. Prichard S. Intradialytic symptoms and recovery time in patients on thrice-weekly in-center hemodialysis: a cross-sectional online survey.Kidney Med. 2020; 2: 125-130https://doi.org/10.1016/j.xkme.2019.10.010Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,9Caplin B. Kumar S. Davenport A. Patients' perspective of haemodialysis-associated symptoms.Nephrol Dial Transplant. 2011; 26: 2656-2663https://doi.org/10.1093/ndt/gfq763Crossref PubMed Scopus (137) Google Scholar and appears to be more severe immediately before or during the HD procedure than on nondialysis days.3Brys A.D.H. Lenaert B. Van Heugten C.M. Gambaro G. Bossola M. Exploring the diurnal course of fatigue in patients on hemodialysis treatment and its relation with depressive symptoms and classical conditioning.J Pain Symptom Manage. 2019; 57: 890-898.e4https://doi.org/10.1016/j.jpainsymman.2019.02.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,10Debnath S. Rueda R. Bansal S. Kasinath B.S. Sharma K. Lorenzo C. Fatigue characteristics on dialysis and non-dialysis days in patients with chronic kidney failure on maintenance hemodialysis.BMC Nephrol. 2021; 22: 112https://doi.org/10.1186/s12882-021-02314-0Crossref PubMed Scopus (13) Google Scholar,11Lenaert B. Boddez Y. Vlaeyen J.W.S. van Heugten C.M. Learning to feel tired: a learning trajectory towards chronic fatigue.Behav Res Ther. 2018; 100: 54-66https://doi.org/10.1016/j.brat.2017.11.004Crossref PubMed Scopus (21) Google Scholar To further assess the relationship of fatigue severity with the timing of HD, one study showed that fatigue increased significantly during the HD treatment as compared with 1 hour before the treatment (Fig 1A). This pattern was particularly pronounced in individuals without depressive symptoms, in whom symptoms of fatigue increased significantly from 1 hour before HD to both immediately before HD and immediately after the HD treatment (Fig 1B). Individuals with depressive symptoms, on the other hand, reported persistently high levels of fatigue on the dialysis day that were not temporally associated with the HD procedure (Fig 1B).3Brys A.D.H. Lenaert B. Van Heugten C.M. Gambaro G. Bossola M. Exploring the diurnal course of fatigue in patients on hemodialysis treatment and its relation with depressive symptoms and classical conditioning.J Pain Symptom Manage. 2019; 57: 890-898.e4https://doi.org/10.1016/j.jpainsymman.2019.02.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Data that patient-reported fatigue was higher immediately before HD than on nondialysis days suggest a possible classical conditioning response to the HD procedure or environment.3Brys A.D.H. Lenaert B. Van Heugten C.M. Gambaro G. Bossola M. Exploring the diurnal course of fatigue in patients on hemodialysis treatment and its relation with depressive symptoms and classical conditioning.J Pain Symptom Manage. 2019; 57: 890-898.e4https://doi.org/10.1016/j.jpainsymman.2019.02.010Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,10Debnath S. Rueda R. Bansal S. Kasinath B.S. Sharma K. Lorenzo C. Fatigue characteristics on dialysis and non-dialysis days in patients with chronic kidney failure on maintenance hemodialysis.BMC Nephrol. 2021; 22: 112https://doi.org/10.1186/s12882-021-02314-0Crossref PubMed Scopus (13) Google Scholar,11Lenaert B. Boddez Y. Vlaeyen J.W.S. van Heugten C.M. Learning to feel tired: a learning trajectory towards chronic fatigue.Behav Res Ther. 2018; 100: 54-66https://doi.org/10.1016/j.brat.2017.11.004Crossref PubMed Scopus (21) Google Scholar A similar phenomenon has been described in patients with breast cancer, whose experience of fatigue in anticipation of chemotherapy treatments is associated with their experience of fatigue during previous chemotherapy sessions.12Bovbjerg D.H. Montgomery G.H. Raptis G. Evidence for classically conditioned fatigue responses in patients receiving chemotherapy treatment for breast cancer.J Behav Med. 2005; 28: 231-237https://doi.org/10.1007/s10865-005-4659-9Crossref PubMed Scopus (12) Google Scholar Other studies have also supported the important role of illness beliefs and behaviors in a patient's experience of fatigue, although less is known about how these factors may affect IDF specifically.13Picariello F. Moss-Morris R. Macdougall I.C. Chilcot A.J. The role of psychological factors in fatigue among end-stage kidney disease patients: a critical review.Clin Kidney J. 2017; 10: 79-88https://doi.org/10.1093/ckj/sfw113Crossref PubMed Scopus (42) Google Scholar At this time, few studies have evaluated IDF, its risk factors, or its pathophysiology. Further research should investigate physical and psychological components to further elucidate this question of a classical conditioning response or other factors that may contribute to IDF. Fatigue occurring after dialysis has been better studied than IDF. In qualitative studies, patients have identified PDF as a unique and debilitating form of fatigue, with a consistent theme across studies of feeling "worn out" or "exhausted" after treatment, and the need to "collapse" after HD, with gradual recovery just in time to return for another HD treatment and develop fatigue again.14Jacobson J. Ju A. Baumgart A. et al.Patient perspectives on the meaning and impact of fatigue in hemodialysis: a systematic review and thematic analysis of qualitative studies.Am J Kidney Dis. 2019; 74: 179-192https://doi.org/10.1053/j.ajkd.2019.01.034Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar There is currently no consensus on how to define or measure PDF (Table 1).15Sklar A. Newman N. Scott R. Semenyuk L. Schultz J. Fiacco V. Identification of factors responsible for postdialysis fatigue.Am J Kidney Dis. 1999; 34: 464-470https://doi.org/10.1016/s0272-6386(99)70073-9Abstract Full Text Full Text PDF PubMed Google Scholar, 16Sklar A.H. Beezhold D.H. Newman N. Hendrickson T. Dreisbach A.W. Postdialysis fatigue: lack of effect of a biocompatible membrane.Am J Kidney Dis. 1998; 31: 1007-1010https://doi.org/10.1053/ajkd.1998.v31.pm9631846Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 17Sklar A.H. Riesenberg L.A. Silber A.K. Ahmed W. Ali A. Postdialysis fatigue.Am J Kidney Dis. 1996; 28: 732-736https://doi.org/10.1016/s0272-6386(96)90256-5Abstract Full Text PDF PubMed Google Scholar, 18Gordon P.L. Doyle J.W. Johansen K.L. Postdialysis fatigue is associated with sedentary behavior.Clin Nephrol. 2011; 75: 426-433PubMed Google Scholar, 19Dubin R.F. Teerlink J.R. Schiller N.B. Alokozai D. Peralta C.A. Johansen K.L. Association of segmental wall motion abnormalities occurring during hemodialysis with post-dialysis fatigue.Nephrol Dial Transplant. 2013; 28: 2580-2585https://doi.org/10.1093/ndt/gft097Crossref PubMed Scopus (26) Google Scholar, 20Guerraoui A. Prezelin-Reydit M. Kolko A. et al.Patient-reported outcome measures in hemodialysis patients: results of the first multicenter cross-sectional ePROMs study in France.BMC Nephrol. 2021; 22: 357https://doi.org/10.1186/s12882-021-02551-3Crossref PubMed Scopus (4) Google Scholar, 21Zu Y. Lu X. Yu Q. Yu L. Li H. Wang S. Higher postdialysis lactic acid is associated with postdialysis fatigue in maintenance of hemodialysis patients.Blood Purif. 2020; 49: 535-541https://doi.org/10.1159/000505612Crossref PubMed Scopus (7) Google Scholar, 22Bossola M. Monteburini T. Parodi E. et al.Post-dialysis fatigue: comparison of bicarbonate hemodialysis and online hemodiafiltration.Hemodial Int. 2023; 27: 55-61https://doi.org/10.1111/hdi.13058Crossref PubMed Scopus (1) Google Scholar One of the more consistently used measures quantifies PDF by the duration, frequency, and intensity of fatigue.15Sklar A. Newman N. Scott R. Semenyuk L. Schultz J. Fiacco V. Identification of factors responsible for postdialysis fatigue.Am J Kidney Dis. 1999; 34: 464-470https://doi.org/10.1016/s0272-6386(99)70073-9Abstract Full Text Full Text PDF PubMed Google Scholar, 16Sklar A.H. Beezhold D.H. Newman N. Hendrickson T. Dreisbach A.W. Postdialysis fatigue: lack of effect of a biocompatible membrane.Am J Kidney Dis. 1998; 31: 1007-1010https://doi.org/10.1053/ajkd.1998.v31.pm9631846Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 17Sklar A.H. Riesenberg L.A. Silber A.K. Ahmed W. Ali A. Postdialysis fatigue.Am J Kidney Dis. 1996; 28: 732-736https://doi.org/10.1016/s0272-6386(96)90256-5Abstract Full Text PDF PubMed Google Scholar, 18Gordon P.L. Doyle J.W. Johansen K.L. Postdialysis fatigue is associated with sedentary behavior.Clin Nephrol. 2011; 75: 426-433PubMed Google Scholar,22Bossola M. Monteburini T. Parodi E. et al.Post-dialysis fatigue: comparison of bicarbonate hemodialysis and online hemodiafiltration.Hemodial Int. 2023; 27: 55-61https://doi.org/10.1111/hdi.13058Crossref PubMed Scopus (1) Google Scholar, 23Bossola M. Marzetti E. Di Stasio E. et al.Prevalence and associated variables of post-dialysis fatigue: results of a prospective multicentre study.Nephrology (Carlton). 2018; 23: 552-558https://doi.org/10.1111/nep.13059Crossref PubMed Scopus (24) Google Scholar, 24Bossola M. Di Stasio E. Monteburini T. et al.Intensity, duration, and frequency of post-dialysis fatigue in patients on chronic haemodialysis.J Ren Care. 2020; 46: 115-123https://doi.org/10.1111/jorc.12315Crossref PubMed Scopus (10) Google Scholar The most commonly used measure is time to recovery from dialysis (TIRD), a validated indirect measure of PDF in which patients report the time required to recover from an HD session.20Guerraoui A. Prezelin-Reydit M. Kolko A. et al.Patient-reported outcome measures in hemodialysis patients: results of the first multicenter cross-sectional ePROMs study in France.BMC Nephrol. 2021; 22: 357https://doi.org/10.1186/s12882-021-02551-3Crossref PubMed Scopus (4) Google Scholar,25Lindsay R.M. Heidenheim P.A. Nesrallah G. Garg A.X. Suri R. Daily Hemodialysis Study Group London Health Sciences Centre. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change.Clin J Am Soc Nephrol. 2006; 1: 952-959https://doi.org/10.2215/CJN.00040106Crossref PubMed Scopus (169) Google Scholar, 26Brys A. Stasio E.D. Lenaert B. et al.Peridialytic serum cytokine levels and their relationship with postdialysis fatigue and recovery in patients on chronic haemodialysis: a preliminary study.Cytokine. 2020; 135155223https://doi.org/10.1016/j.cyto.2020.155223Crossref PubMed Scopus (9) Google Scholar, 27Bossola M. Di Stasio E. Antocicco M. Silvestri P. Tazza L. Variables associated with time of recovery after hemodialysis.J Nephrol. 2013; 26: 787-792https://doi.org/10.5301/jn.5000198Crossref PubMed Scopus (20) Google Scholar, 28Awuah K.T. Afolalu B.A. Hussein U.T. Raducu R.R. Bekui A.M. Finkelstein F.O. Time to recovery after a hemodialysis session: impact of selected variables.Clin Kidney J. 2013; 6: 595-598https://doi.org/10.1093/ckj/sft120Crossref PubMed Scopus (22) Google Scholar, 29Rayner H.C. Zepel L. Fuller D.S. et al.Recovery time, quality of life, and mortality in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS).Am J Kidney Dis. 2014; 64: 86-94https://doi.org/10.1053/j.ajkd.2014.01.014Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 30Davenport A. Guirguis A. Almond M. et al.Postdialysis recovery time is extended in patients with greater self-reported depression screening questionnaire scores.Hemodial Int. 2018; 22: 369-376https://doi.org/10.1111/hdi.12642Crossref PubMed Scopus (20) Google Scholar, 31Hussein W.F. Arramreddy R. Sun S.J. Reiterman M. Schiller B. Higher ultrafiltration rate is associated with longer dialysis recovery time in patients undergoing conventional hemodialysis.Am J Nephrol. 2017; 46: 3-10https://doi.org/10.1159/000476076Crossref PubMed Scopus (30) Google Scholar To address the heterogeneity of existing fatigue measures, the Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) work group developed and validated a 3-item measure to consistently assess fatigue in research and clinical practice.5Ju A. Unruh M. Davison S. et al.Establishing a core outcome measure for fatigue in patients on hemodialysis: a Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop report.Am J Kidney Dis. 2018; 72: 104-112https://doi.org/10.1053/j.ajkd.2017.12.018Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar,6Ju A. Teixeira-Pinto A. Tong A. et al.Validation of a core patient-reported outcome measure for fatigue in patients receiving hemodialysis: the SONG-HD fatigue instrument.Clin J Am Soc Nephrol. 2020; 15: 1614-1621https://doi.org/10.2215/CJN.05880420Crossref PubMed Scopus (26) Google Scholar Patients are asked if, in the last week, they felt tired, lacked energy, or if fatigue limited their usual activities.6Ju A. Teixeira-Pinto A. Tong A. et al.Validation of a core patient-reported outcome measure for fatigue in patients receiving hemodialysis: the SONG-HD fatigue instrument.Clin J Am Soc Nephrol. 2020; 15: 1614-1621https://doi.org/10.2215/CJN.05880420Crossref PubMed Scopus (26) Google Scholar Notably, this measure does not distinguish PDF, IDF, and chronic fatigue but reflects a cumulative experience of fatigue. Existing measurement instruments assess symptom burden retrospectively, so they may overestimate fatigue due to recall bias.32Brys A.D.H. Stifft F. Van Heugten C.M. Bossola M. Gambaro G. Lenaert B. Unraveling fatigue in hemodialysis patients: comparing retrospective reports to real-time assessments with an mhealth experienced sampling method.J Pain Symptom Manage. 2020; 60: 1100-1108.e2https://doi.org/10.1016/j.jpainsymman.2020.06.042Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Novel fatigue assessment methods combining a validated patient-reported outcome measure for fatigue with a real-time digital experience sampling methodology may overcome this limitation and provide more nuanced insight into the relationships of fatigue with clinical, psychological, and behavioral factors, but such tools need to be further studied.32Brys A.D.H. Stifft F. Van Heugten C.M. Bossola M. Gambaro G. Lenaert B. Unraveling fatigue in hemodialysis patients: comparing retrospective reports to real-time assessments with an mhealth experienced sampling method.J Pain Symptom Manage. 2020; 60: 1100-1108.e2https://doi.org/10.1016/j.jpainsymman.2020.06.042Abstract Full Text Full Text PDF PubMed Scopus (2) Google ScholarTable 1Measures of PDFStudyMeasureBenefitsLimitationsLindsay et al 200625Lindsay R.M. Heidenheim P.A. Nesrallah G. Garg A.X. Suri R. Daily Hemodialysis Study Group London Health Sciences Centre. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change.Clin J Am Soc Nephrol. 2006; 1: 952-959https://doi.org/10.2215/CJN.00040106Crossref PubMed Scopus (169) Google ScholarAwuah et al 201328Awuah K.T. Afolalu B.A. Hussein U.T. Raducu R.R. Bekui A.M. Finkelstein F.O. Time to recovery after a hemodialysis session: impact of selected variables.Clin Kidney J. 2013; 6: 595-598https://doi.org/10.1093/ckj/sft120Crossref PubMed Scopus (22) Google ScholarBossola et al 201327Bossola M. Di Stasio E. Antocicco M. Silvestri P. Tazza L. Variables associated with time of recovery after hemodialysis.J Nephrol. 2013; 26: 787-792https://doi.org/10.5301/jn.5000198Crossref PubMed Scopus (20) Google ScholarRayner et al 201429Rayner H.C. Zepel L. Fuller D.S. et al.Recovery time, quality of life, and mortality in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS).Am J Kidney Dis. 2014; 64: 86-94https://doi.org/10.1053/j.ajkd.2014.01.014Abstract Full Text Full Text PDF PubMed Scopus (142) Google ScholarHussein et al 201731Hussein W.F. Arramreddy R. Sun S.J. Reiterman M. Schiller B. Higher ultrafiltration rate is associated with longer dialysis recovery time in patients undergoing conventional hemodialysis.Am J Nephrol. 2017; 46: 3-10https://doi.org/10.1159/000476076Crossref PubMed Scopus (30) Google ScholarDavenport et al 201830Davenport A. Guirguis A. Almond M. et al.Postdialysis recovery time is extended in patients with greater self-reported depression screening questionnaire scores.Hemodial Int. 2018; 22: 369-376https://doi.org/10.1111/hdi.12642Crossref PubMed Scopus (20) Google ScholarAlvarez et al 20208Alvarez L. Brown D. Hu D. Chertow G.M. Vassalotti J.A. Prichard S. Intradialytic symptoms and recovery time in patients on thrice-weekly in-center hemodialysis: a cross-sectional online survey.Kidney Med. 2020; 2: 125-130https://doi.org/10.1016/j.xkme.2019.10.010Abstract Full Text Full Text PDF PubMed Scopus (11) Google ScholarBrys et al 202026Brys A. Stasio E.D. Lenaert B. et al.Peridialytic serum cytokine levels and their relationship with postdialysis fatigue and recovery in patients on chronic haemodialysis: a preliminary study.Cytokine. 2020; 135155223https://doi.org/10.1016/j.cyto.2020.155223Crossref PubMed Scopus (9) Google ScholarGuerraoui et al 202120Guerraoui A. Prezelin-Reydit M. Kolko A. et al.Patient-reported outcome measures in hemodialysis patients: results of the first multicenter cross-sectional ePROMs study in France.BMC Nephrol. 2021; 22: 357https://doi.org/10.1186/s12882-021-02551-3Crossref PubMed Scopus (4) Google Scholar•Time to recovery from dialysis•Patients were asked, "How long does it take you to recover from a dialysis session?"•No consensus between studies of how to report this, either as a continuous or a categorical measure•Easily interpreted, elicits a clear response, and stable on test-retest25Lindsay R.M. Heidenheim P.A. Nesrallah G. Garg A.X. Suri R. Daily Hemodialysis Study Group London Health Sciences Centre. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change.Clin J Am Soc Nephrol. 2006; 1: 952-959https://doi.org/10.2215/CJN.00040106Crossref PubMed Scopus (169) Google Scholar•Has been used across several studies•Does not incorporate multiple dimensions of fatigue such as severity or frequency•No consensus on how to report values•Moderately associated with fatigue severity, quality of life, other dialysis-associated symptoms, psychosocial stressors, and ability to engage in social-leisure activity25Lindsay R.M. Heidenheim P.A. Nesrallah G. Garg A.X. Suri R. Daily Hemodialysis Study Group London Health Sciences Centre. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change.Clin J Am Soc Nephrol. 2006; 1: 952-959https://doi.org/10.2215/CJN.00040106Crossref PubMed Scopus (169) Google ScholarSklar et al 199617Sklar A.H. Riesenberg L.A. Silber A.K. Ahmed W. Ali A. Postdialysis fatigue.Am J Kidney Dis. 1996; 28: 732-736https://doi.org/10.1016/s0272-6386(96)90256-5Abstract Full Text PDF PubMed Google ScholarSklar et al 199816Sklar A.H. Beezhold D.H. Newman N. Hendrickson T. Dreisbach A.W. Postdialysis fatigue: lack of effect of a biocompatible membrane.Am J Kidney Dis. 1998; 31: 1007-1010https://doi.org/10.1053/ajkd.1998.v31.pm9631846Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarSklar et al 199915Sklar A. Newman N. Scott R. Semenyuk L. Schultz J. Fiacco V. Identification of factors responsible for postdialysis fatigue.Am J Kidney Dis. 1999; 34: 464-470https://doi.org/10.1016/s0272-6386(99)70073-9Abstract Full Text Full Text PDF PubMed Google Scholar Gordon et al 201118Gordon P.L. Doyle J.W. Johansen K.L. Postdialysis fatigue is associated with sedentary behavior.Clin Nephrol. 2011; 75: 426-433PubMed Google ScholarBossola et al 201823Bossola M. Marzetti E. Di Stasio E. et al.Prevalence and associated variables of post-dialysis fatigue: results of a prospective multicentre study.Nephrology (Carlton). 2018; 23: 552-558https://doi.org/10.1111/nep.13059Crossref PubMed Scopus (24) Google ScholarBossola et al 202024Bossola M. Di Stasio E. Monteburini T. et al.Intensity, duration, and frequency of post-dialysis fatigue in patients on chronic haemodialysis.J Ren Care. 2020; 46: 115-123https://doi.org/10.1111/jorc.12315Crossref PubMed Scopus (10) Google ScholarBossola et al 202322Bossola M. Monteburini T. Parodi E. et al.Post-dialysis fatigue: comparison of bicarbonate hemodialysis and online hemodiafiltration.Hemodial Int. 2023; 27: 55-61https://doi.org/10.1111/hdi.13058Crossref PubMed Scopus (1) Google Scholar•Quantify duration, frequency, and intensity of fatigue on 5-point Likert scales•If the average of these was ≥4, the patient was considered to have PDF.•Incor