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Evidence-based strategies for improving dialysis recovery time and managing post-dialysis fatigue.


Learning outcomes

On completion of this continuing professional development (CPD) activity participants should be able to:

* Describe the Joanna Briggs Institute's levels of evidence for effectiveness hierarchy

* Summarise symptoms comprising post-dialysis fatigue (PDF)

* Summarise existing evidence suggesting strategies to improve time to recovery

* Summarise existing evidence outlining assessment strategies for PDF recognition

* Summarise existing evidence that may help haemodialysis patients manage PDF

* Outline best practice recommendations related to PDF strategies for nurses and patients


Evidence-based summaries, post-dialysis fatigue, haemodialysis, best practice, dialysis recovery time.


Fatigue is one of the most common symptoms reported by haemodialysis (HD) patients, with prevalence ranging from 60 to 97% (Caplin et al., 2011; Horigan, 2012). Post-dialysis fatigue (PDF), also referred to as dialysis recovery time, is a distinct phenomenon and is a frequent complaint of HD patients following a dialysis session (Caplin et al., 2011; Horigan, 2012). One study found that 32% of patients reported recovery time shorter than 2 hours, 41% recovered in 2-6 hours, 17% in 7-12 hours, and 10% reported taking longer than 12 hours to recover (Rayner et al., 2014). It is important to note that PDF refers specifically to fatigue that occurs following an HD session, that is above any baseline level of general fatigue (Horigan & Barroso, 2016). Considering that in Australia there are over 10,000 people receiving HD, either in-centre or at home, PDF or feeling "washed out" could potentially affect thousands of patients (ANZDATA Registry, 2016).

The causes of PDF are not well understood; however, research suggests that PDF may be part of a symptom complex including nausea, muscle cramps and headache, possibly resulting from the fluid shifts and electrolytic disturbances that occur during HD (Horigan, 2012). Factors that have been implicated in the pathogenesis of PDF include ultrafiltration, diffusion, osmotic disequilibrium, changes in blood pressure, blood membrane interactions, higher levels of tumour necrosis factor and psychological factors such as depression (Jhamb et al., 2008). In addition, PDF may be associated with cardiac ischaemia occurring during HD in some patients (Dubin et al., 2013). Time to recovery following HD may be reduced with more frequent treatments and PDF is less prevalent in daily HD patients than in patients receiving HD three times per week (Jhamb et al., 2008).

This is the second continuing professional development (CPD) paper developed to report on an ongoing nephrology issue, offering here the evidence associated with strategies concerning the management of PDF. It comprises an evidence summary from the Joanna Briggs Institute (JBI) Renal Care node. The JBI is based at the University of Adelaide and has a well-established reputation in evidence-based clinical decision support and practice improvement. This evidence summary is based on a structured search of the literature and selected evidence-based health care databases. The characteristics and key points arising from the evidence as reported in the literature are listed within each study, along with the evidence level. Figure 1 shows the JBI levels of evidence for effectiveness and levels for other evidence types may be found at Best practice recommendations are reported separately within this report, with Grade A suggesting a "strong" recommendation and Grade B a "weak" recommendation.


What is the best available evidence regarding dialysis recovery time and management of PDF in patients undergoing haemodialysis?

Key points from the evidence

Factors associated with dialysis recovery time

* The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a prospective cohort study of 6,040 patients from 12 countries (Rayner et al., 2014). This study found shorter recovery time was associated with male gender, full-time employment, and higher serum albumin. Longer recovery time was associated with older age, dialysis vintage (length of time on dialysis), body mass index (BMI), diabetes, psychiatric disorders, higher ultrafiltration goals, longer session time, and lower dialysate sodium concentration. Recovery time can be used to identify patients with poorer health-related quality of life (HRQoL) and higher risks of hospitalisation and mortality. Longer recovery times were significantly associated with time to first hospitalisation and higher mortality, with patients who take more than 12 hours to recover at 30-60% higher risk of dying than those who take 2-6 hours. (Level 3)

* A cross-sectional study including 267 patients in the United States assessed whether a range of demographic and clinical factors were associated with time to recovery after an HD session (Awuah et al., 2013). It was found that age, gender, number of comorbidities, months on renal replacement therapy, occurrence of hypotension during dialysis, amount of ultrafiltration and duration of dialysis session were not significantly associated with time to recovery. (Level 4)

* A prospective multi-centre study of 288 patients was conducted in the United Kingdom and compared HD in the home versus hospital dialysis centre (Jayanti et al., 2015). The study involved asking patients the question "How long does it take for you to recover from a haemodialysis session?" Results showed that recovery time was considerably longer amongst in-centre patients (mean 193 min; standard deviation [SD] 295.37) compared to home dialysis patients (mean 67.3 min; standard deviation [SD] 86.8). Amongst the home HD cohort, there was no difference in recovery time between those receiving conventional HD (3 times per week) or intensive HD (> 3 times per week), indicating that dialysis locality rather than intensity was significant (p=0.001). (Level 3)

* A survey of 100 HD patients in Italy utilised a combination of several quality of life (QoL) indicators, including the Charlson Comorbidity Index (CCI), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS) (Bossola et al., 2013). In addition, laboratory variables and five fatigue quality (FQ) questions regarding tiredness, emotion, cognition, weakness and energy levels related to time of recovery after HD (TIRD) were utilised. Multiple regression analysis indicated that the number of FQs was related to TIRD and this was independently associated with the GDS. (Level 4)

* A cross-sectional study including 104 HD patients in Korea assessed the duration of PDF (mean duration 3.8 hours; SD 5.3; range 0 to 24) (Kim & Son, 2005). Depression (beta = 0.43; p<0.00) and interdialytic weight gain (beta = 0.25; p<0.05) were statistically significantly associated with fatigue. The authors suggested that nursing interventions for patients that experience fatigue while on HD should focus on psychological problems, such as depression, and physiological problems, such as interdialytic weight gain. (Level 4)

Assessment of PDF

* Two studies--an observational study including 23 patients treated by regular HD (five to seven times a week) and 22 control subjects treated by thrice-weekly HD (Lindsay et al., 2006) and a cross-sectional study of 800 Brazilian patients enrolled in the Prospective Study of the Prognosis of Chronic Haemodialysis Patients (PROHEMO) (Lopes et al., 2014)--found that the simple question asking patients how long it takes them to recover from a dialysis session is a reliable and valid method to assess HRQoL. Scores for this simple "time to recovery" question were associated with scores of several other comprehensive tools for assessing HRQoL, suggesting that this question could serve as a proxy for more complex instruments. (Levels 3 and 4)

* Instruments for assessing fatigue that have been used in chronic HD patients include the Brief Fatigue Inventory (BFI), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Fatigue Severity Scale (FSS), Lee Fatigue Scale (LFS), Fatigue Questionnaire (FQ), Fatigue Symptom Inventory (FSI), and Short-Form 36-Vitality (SF36-V) (Chao et al., 2016). (Level 4)

Strategies for nursing management of PDF

* A case study analysis suggested several steps in the nursing management of fatigue following an HD session (Horigan et al., 2012). These include: (Level 4)

** Fatigue assessment: using a scale that can be performed quickly in the clinical setting, such as a simple visual analogue scale.

** Evaluate how fatigue impacts the patient's daily living: Enquire about the patient's daily routines and assist the patient to plan self-management strategies to minimise the impact of fatigue. Help identify support systems for the patient and ways to incorporate these.

** Evaluating laboratory results and medications: Check for irregularities in laboratory results or medication side effects that may contribute to the patient's fatigue.

** Teach the patient: educate about the importance of diet (in collaboration with dietitian), exercise and healthy sleep routines to decrease symptoms of fatigue.

* A qualitative study including 14 adult in-centre HD patients investigated the experience and self-management of fatigue in HD patients (Horigan et al., 2013). Participants reported that fatigue negatively affected their socialisation, compromised time spent with children and made participation in activities difficult. Regarding self-management techniques, participants indicated they had to rest after dialysis and adjust or adapt their routine (timing and intensity of their activities) to accommodate their fatigue. Participants also reported that appropriate management of comorbidities and related symptoms left them with higher energy levels. However, none of the management techniques were consistently successful and patients were not satisfied with the degree of relief the techniques provided. In the implications for practice arising from the study, the authors highlighted several areas to assist renal nurses to support HD patients with fatigue.

These included: (Level 3)

** Education for renal nurses regarding symptom assessment and management, to provide nurses with the tools needed to positively affect HD patients' QoL.

** Enhanced patient and family education by renal nurses regarding HD-related fatigue and the management of comorbidities.

** Education of patients and families about fatigue prior to them being faced with the symptom to help them identify and prepare for future needs.

** Nurses may also assist in promoting healthy sleep routines by keeping patients awake and active while receiving HD treatments.

Effectiveness of interventions

* Some randomised controlled trials (RCTs) and quasi-experimental studies have investigated the effect of interventions on general fatigue in patients undergoing HD (Astroth et al., 2013; Cho & Sohng, 2014; Maniam et al., 2014; Motedayen et al., 2014; Soliman, 2015; Thejaswi et al., 2016). These studies suggest that low to moderate intensity exercise, performed before or during an HD session, may reduce general fatigue. (Levels 1 and 2)

* However, there is very limited evidence on the effect of interventions on dialysis recovery time or PDF specifically. One quasi-experimental study including 31 dialysis patients divided participants into exercise (n=17) and control groups (n=14) (Malagoni et al., 2008). The exercise group was prescribed a six-month walking programme, which involved 10-minute home walking sessions to be performed twice-daily on non-dialysis days. The control group was not prescribed any exercise. The self-reported intensity of PDF was evaluated by a scale (0=absent to 5=severe) and the recovery time necessary to overcome the fatigue was also reported. The mean PDF score was significantly decreased in the exercise group (baseline 2.8 [+ or -] 1.4, 6-months 2.3 [+ or -] 1.6; p=0.039) and unchanged in the control group (baseline 2.6 [+ or -] 0.6, 6-months 2.6 [+ or -] 1.1). In addition, recovery time (hours) was significantly reduced in the exercise group (baseline 3.4 [+ or -] 2.8, 6-months 2.6 [+ or -] 3.05; p=0.025) and unchanged in the control group (4.6 [+ or -] 5.2 at baseline and 6-months). (Level 2)

Best practice recommendations

* Renal nurses should receive education regarding symptom assessment and management of PDF. (Grade A)

* HD patients (and carers) should receive education regarding PDF as part of pre-dialysis and ongoing education, including education about the importance of controlling interdialytic weight gain, management of comorbidities, and strategies to decrease symptoms of fatigue (such as exercise, diet and healthy sleep routines). (Grade A)

* Laboratory results and medications should be checked for any irregularities that may contribute to PDF. (Grade A)

* The impact of fatigue on patients' functional abilities and activities of daily living should be evaluated and patients assisted to develop self-management strategies. (Grade A)

* It may be recommended to keep patients awake and active while receiving HD treatment to promote healthy sleep routines. (Grade B)

* It may be recommended to assess patients for PDF using a standardised time to recovery question or a validated tool, such as the SF-36 vitality subscale or visual analogue scale for fatigue (VAS-F). (Grade B)

* For HD patients who experience significant PDF, it may be recommended to screen for psychosocial disorders, such as depression, using a validated tool. (Grade B)


The causes of PDF remain poorly understood. Evidence highlights several factors that may be associated with dialysis recovery time, with longer recovery time linked to higher BMI, diabetes, psychiatric disorders such as depression, higher ultrafiltration goals, increased interdialytic weight gain, and longer session time. Patients undergoing home HD have reported shorter recovery times than in-centre patients. While several studies have investigated the effect of interventions such as exercise on general fatigue in HD patients, there is limited evidence reporting on the effect of interventions on dialysis recovery time or PDF specifically. This is an important area for future research, with high-quality RCTs needed to establish effective interventions to reduce recovery time and improve outcomes for patients that suffer from PDF.


ANZDATA Registry. (2016). 38th Report, Chapter 4: Haemodialysis. Australia and New Zealand Dialysis and Transplant Registry, Available at:

Astroth, K. S., Russell, C. L., & Welch, J. L. (2013). Non-pharmaceutical fatigue interventions in adults receiving hemodialysis: a systematic review. Nephrology Nursing Journal, 40(5), 407-427; quiz 428.

Awuah, K. T., Afolalu, B. A., Hussein, U. T., Raducu, R. R., Bekui, A. M., & Finkelstein, F. O. (2013). Time to recovery after a hemodialysis session: impact of selected variables. Clinical Kidney Journal, 6(6), 595-598.

Bossola, M., Di Stasio, E., Antocicco, M., Silvestri, P., & Tazza, L. (2013). Variables associated with time of recovery after hemodialysis. Journal of Nephrology, 26(4), 787-792.

Caplin, B., Kumar, S., & Davenport, A. (2011). Patients' perspective of haemodialysis-associated symptoms. Nephrology, Dialysis, Transplantation, 26(8), 2656-2663.

Chao, C. T., Huang, J. W., & Chiang, C. K. (2016). Functional assessment of chronic illness therapy-the fatigue scale exhibits stronger associations with clinical parameters in chronic dialysis patients compared to other fatigue-assessing instruments. PeerJ, 4, e1818.

Cho, H., & Sohng, K. Y. (2014). The effect of a virtual reality exercise program on physical fitness, body composition, and fatigue in hemodialysis patients. Journal of Physical Therapy Science, 26(10), 1661-1665.

Dubin, R. F., Teerlink, J. R., Schiller, N. B., Alokozai, D., Peralta, C. A., & Johansen, K. L. (2013). Association of segmental wall motion abnormalities occurring during hemodialysis with post-dialysis fatigue. Nephrology, Dialysis, Transplantation, 28(10), 2580-2585.

Horigan, A., Rocchiccioli, J., & Trimm, D. (2012). Dialysis and fatigue: implications for nurses--a case study analysis. Medsurg Nursing, 21(3), 158-163, 175.

Horigan, A. E. (2012). Fatigue in hemodialysis patients: a review of current knowledge. Journal of Pain and Symptom Management, 44(5), 715-724.

Horigan, A. E., & Barroso, J. V. (2016). A comparison of temporal patterns of fatigue in patients on hemodialysis. Nephrology Nursing Journal, 43(2), 129-138, 148; quiz 139.

Horigan, A. E., Schneider, S. M., Docherty, S., & Barroso, J. (2013). The experience and self-management of fatigue in patients on hemodialysis. Nephrology Nursing Journal, 40(2), 113-122; quiz 123.

Jayanti, A., Foden, P., Morris, J., Brenchley, P., & Mitra, S. (2015). Time to recovery from haemodialysis--location, intensity and beyond. Nephrology (Carlton).

Jhamb, M., Weisbord, S. D., Steel, J. L., & Unruh, M. (2008). Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors. American Journal of Kidney Diseases, 52(2), 353-365.

Kim, H. R., & Son, G. R. (2005). Fatigue and its related factors in Korean patients on hemodialysis. Taehan Kanho Hakhoe Chi, 35(4), 701-708.

Lindsay, R. M., Heidenheim, P. A., Nesrallah, G., Garg, A. X., & Suri, R. (2006). Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change. Clinical Journal of the American Society of Nephrology, 1(5), 952-959.

Lopes, G. B., Silva, L. F., Pinto, G. B., Catto, L. F., Martins, M. T., Dutra, M. M. et al. (2014). Patient's response to a simple question on recovery after hemodialysis session strongly associated with scores of comprehensive tools for quality of life and depression symptoms. Quality of Life Research, 23(8), 2247-2256.

Malagoni, A. M., Catizone, L., Mandini, S., Soffritti, S., Manfredini, R., Boari, B. et al. (2008). Acute and long-term effects of an exercise program for dialysis patients prescribed in hospital and performed at home. Journal of Nephrology, 21(6), 871-878.

Maniam, R., Subramanian, P., Singh, S. K., Lim, S. K., Chinna, K., & Rosli, R. (2014). Preliminary study of an exercise programme for reducing fatigue and improving sleep among long-term haemodialysis patients. Singapore Medical Journal, 55(9), 476-482.

Motedayen, Z., Nehrir, B., Tayebi, A., Ebadi, A., & Einollahi, B. (2014). The effect of the physical and mental exercises during hemodialysis on fatigue: a controlled clinical trial. Nephro-urology Monthly, 6(4), e14686.

Oliver, V., & Stephenson, M. (2016). Prevention, assessment and management of post dialysis fatigue for patients attending in-center hemodialysis: a best practice implementation project. JBI Database of Systematic Reviews and Implementation Reports, 14(11), 278-88.

Rayner, H. C., Zepel, L., Fuller, D. S., Morgenstern, H., Karaboyas, A., Culleton, B. F. et al. (2014). Recovery time, quality of life, and mortality in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). American Journal of Kidney Diseases, 64(1), 86-94.

Soliman, H. (2015). Effect of intradialytic exercise on fatigue, electrolytes level and blood pressure in haemodialysis patients: A randomized controlled trial. Journal of Nursing Education & Practice, 5(11), 16-28.

Thejaswi, V., Latha, A., Indira, A., & Radhika, M. (2016). Effectiveness of leg stretch exercises on fatigue among patients undergoing haemodialysis. International Journal of Applied Research, 2(6), 74-76.

Submitted: 23 September 2016, Accepted: 7 December 2016

Matthew Stephenson, BBiotech (Hons), PhD, Joanna Briggs Institute, The University of Adelaide, SA, Australia

Veronica Oliver, RN, MN PractSt, Princess Alexandra Hospital, Brisbane, QLD, Australia

Wendi Bradshaw, RN, MN, Monash Health, VIC, Australia

Correspondence to: Veronica Oliver, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD 4102, Australia Email:
Table 1: Strategies for clinical practice

Improving dialysis recovery time:
* Provide pre-dialysis and ongoing education to patients
  and their carers, including education about the
  importance of controlling interdialytic weight (fluid) gains.
* Offer strategies to patients to assist them to remain
  awake/active while receiving HD treatment, such as
  reading, watching television, craft, or gentle exercise.
* Check laboratory results and medications for any
  irregularities that may contribute to PDF.
Assessment of PDF:
* At appropriate intervals, ask patients: "How long does it
  take you to recover from dialysis?"
  ** 0 hour
  ** <2 hours
  ** 2-6 hours
  ** 6-12 hours
  ** >12 hours
Note: Evidence suggests that asking a patient how long it takes them to
recover from a dialysis session is a reliable and valid method to
assess HRQoL in relation to PDF. Alternatively, patients may be
assessed for PDF using a validated tool, such as the SF36-V or VAS-F,
at appropriate intervals.
Management of PDF:
* Provide pre-dialysis and ongoing education to patients
  and carers about management of comorbidities to
  minimise the impact of PDF and strategies to decrease
  symptoms of fatigue, such as remaining awake/active
  during HD sessions, exercise, diet and healthy sleep
* Enquire about the patient's daily routines to assess
  the impact of PDF on the patient's functional abilities/activities
  of daily living at appropriate intervals.
* Assist the patient to develop self-management strategies
  to minimise the impact of PDF.
* Help identify support systems for the patient and ways
  to incorporate these.
* Review the patient for psychosocial disorders, such
  as depression, using a validated tool (e.g. the Hospital
  Anxiety and Depression Scale [HADS]) at appropriate

Table 2: Extra resources

For an example regarding implementation of best practice
strategies for PDF, see:
Oliver, V., & Stephenson, M. (2016). Prevention,
assessment and management of post dialysis fatigue for
patients attending in-center hemodialysis: a best practice
implementation project. JBI Database of Systematic
Reviews and Implementation Reports, 14(11), 278-88.
Use the link below for information about sleep hygiene.
Use the link below for the Hospital Anxiety and Depression
Use the link below for National Activity Guidelines.
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Article Details
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Author:Stephenson, Matthew D; Oliver, Veronica; Bradshaw, Wendi
Publication:Renal Society of Australasia Journal
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2017
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