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Description
Chronic kidney disease affects approximately 7 million people in the United States (Coresh et al., 2005), and many of these progress to end stage renal disease (ESRD) which requires transplant or some form of dialysis to sustain life with the majority receiving hemodialysis. African Americans are burdened more by ESRD than any other racial group in America and account for approximately 32% of patients diagnosed with ESRD (United States Renal Data System [USRDS], 2007).
Patients on hemodialysis experience many side effects due both to the disease process and the treatment regimen. Fatigue is one of the most common side effects and has been shown to be a common stressor for those on hemodialysis (Curtin, Bultman, Thomas-Hawkins, Walters, & Schatell, 2002; Lok, 1996; McCann & Boore, 2000; Sklar, Riesenberg, Silber, Ahmed, & Ali, 1996). The fatigue experienced by individuals with ESRD has been described as common and incapacitating (Evans, 1999). Increased effort is required for those with fatigue to carry out cognitive and physical activities, and fatigue also affects role performance and functional status (McCann & Boore, 2000). Fatigue has been related to depression, anxiety, and significant problems with work and other activities (McCann & Boore, 2000; Sklar et al., 1996). Thus, fatigue experienced by women with ESRD has the potential to alter roles, relationships, and negatively affect quality of life (DeNour, 1982; White & Grenyer, 1999). The majority of the studies on fatigue in ESRD relate to the prevalence of fatigue. Outcomes associated with this unpleasant symptom include mental and physical function, role performance, depression, and anxiety (Curtin et al., 2002; Lok, 1996; McCann & Boore, 2000; Sklar et al., 1996). Most studies have not explored factors contributing to fatigue. Studies examining the correlates of fatigue are imperative for nurses who desire to develop interventions to improve the quality of life of African American women with ESRD. Therefore, the purpose of this study was to examine fatigue and factors contributing to fatigue in African American women on hemodialysis as a basis for developing interventions to decrease fatigue and improve quality of life.
Conceptual Framework
The theory of unpleasant symptoms served as the guiding framework for the study (Lenz, Pugh, Milligan, Gift, & Suppe, 1997). The symptom the individual experiences, the factors affecting the symptom, and the consequence of the symptom are the three major components of the theory. This study focused on factors affecting fatigue.
Factors influencing the unpleasant symptom of fatigue in patients on hemodialysis are physiologic, psychological, and situational (Lenz et al., 1997). The physiologic factors examined in this study were related to the pathology of ESRD and included uremic malnutrition and anemia. Mood disorder was the psychological variable chosen for study. Social support was the situational variable studied.
Physiologic Variables: Anemia and Uremic Malnutrition
Anemia
Those affected with ESRD have many physiologic changes related to their disease and treatment. Anemia is one of the most debilitating consequences of ESRD, with manifestations ranging from compromised quality of life and increased hospitalizations to increased mortality (Hong, Ebben, Ma, & Collins, 1999; Kammerer, Ratican, Elzein, & Mapes, 2002; Pickett, Theberge, Brown, Schweitzer, & Nissenson, 1999). Anemia in patients with ESRD is a result of dialysis and inadequate erythropoietin production. Iron is vital in erythropoiesis, and because blood is lost in dialysis and iron is restricted in the diet, iron stores are depleted as well. McCann and Boore (2000) and Sklar et al. (1996) examined the direct relationship of hemoglobin and hematocrit levels to fatigue, but no significant associations were found in either study. The National Kidney Foundation recommends a target range of hemoglobin of 11-12.5 grams per deciliter with a gender specific and menopausal approach to diagnosis and treatment (National Kidney Foundation, 2002). Patients in this range are reported to have improved cognitive function, quality of life, and exercise capacity (Hong et al., 1999; Kammerer et al., 2002; Pickett et al., 1999). Studies of patients with ESRD (Hong et al., 1999, Kammerer et al., 2002), however, have not taken into account differences in hemoglobin levels based on gender or explained what indicator was used for anemia.
Uremic Malnutrition
Patients on dialysis also have problems with malnutrition. Factors such as decreased dietary protein, inadequate dialysis dose, decreased caloric intake, nutrient loss during dialysis, and symptoms such as anorexia and nausea contribute to the condition known as uremic malnutrition (Caglar, Hakim, & Ikizler, 2002). Uremic malnutrition is a unique form of protein-calorie malnutrition leading to decreased tissue function and loss of body mass (Caglar et al., 2002; Pupim & Ikizler, 2004). It is reported to be present in 20%-50% of patients on dialysis (Caglar et al., 2002) and is associated with poor clinical outcomes in ESRD (Churchill et al., 1992; Pupim, Evanson, Hakim, & Ikizler, 2003; Pupim & Ikizler, 2004), including increased inflammation, infection, cardiac disease, hospitalization, and mortality.
Churchill et al. (1992) examined survival and morbidity in 496 people on hemodialysis for a year and a half, approximately 42% of whom were women. Since albumin correlated well with other measures of malnutrition, serum albumin was used as the nutritional marker. The probability of hospitalization for any cause was greater for those with a serum albumin of 30 grams per liter or less. Hospitalization due to circulatory disease and infections, including pneumonia, was also more likely in those with lower albumin levels. There was also a higher death rate among those with a serum albumin of 30 grams per liter or less than among those with higher albumin levels (13.8% vs. 7.8%). However, this study did not explore how malnutrition is related to the fatigue experienced by those on hemodialysis.
Sklar et al. (1996) examined the relationship of nutritional status to fatigue in patients on hemodialysis using chart reviews to obtain recent albumin levels. Albumin level was not associated with fatigue. McCann and Boore (2000) also investigated the role of nutrition in fatigue, again, using albumin. Consistent with Sklar et al., no significant associations were found between nutrition and fatigue. Both studies, however, had small samples and nutrition... |
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