American Journal of Kidney Diseases

Patient-Reported Outcome Measures for Fatigue in Patients on Hemodialysis: A Systematic Review

Published:November 29, 2017DOI:


      Fatigue is a prevalent and debilitating symptom in patients receiving hemodialysis. We aimed to identify and evaluate the characteristics and psychometric properties of patient-reported outcome measures for fatigue in patients receiving hemodialysis, to inform the selection of a robust and feasible measure for use in randomized trials in hemodialysis.

      Study Design

      Systematic review of outcome measures for fatigue.

      Setting & Population

      Patients receiving hemodialysis.

      Search Strategy & Sources

      MEDLINE, Embase, PsycINFO, and CINAHL from inception to April 2017 were searched for all studies that reported fatigue in patients receiving hemodialysis.

      Analytical Approach

      With a focus on addressing methods, items (individual questions) from all measures were categorized into content and measurement dimensions of fatigue. We assessed the general characteristics (eg, number of items and cost) and psychometric properties of all measures.


      From 123 studies, we identified 43 different measures: 24 (55%) were developed specifically for the hemodialysis population (of which 18 were nonvalidated author-developed measures for use in their study only), 17 (40%) for other populations, and 2 (5%) for chronic kidney disease (all stages). The measures assessed 11 content dimensions of fatigue, the 3 most frequent being level of energy (19 [44%]), tiredness (15 [35%]), and life participation (14 [33%]); and 4 measurement dimensions: severity (34 [79%]), frequency (10 [23%]), duration (4 [9%]), and change (1 [2%]). The vitality subscale of the 36-Item Short Form Health Survey (SF-36) was the most frequently used (19 [15%] studies), but has only been tested for reliability in hemodialysis. Of the fatigue-specific measures, the Chalder Fatigue Scale was the only one evaluated in hemodialysis, but the full psychometric robustness remains uncertain.


      For feasibility, we searched for validation studies in the hemodialysis population using the names of measures identified in the primary search strategy.


      A very wide range of measures have been used to assess fatigue in patients receiving hemodialysis, each varying in content and length. Many have limited validation data available in this population. A standardized and psychometrically robust measure that captures dimensions of fatigue that are important to patients is needed to estimate and improve this disabling complication of hemodialysis.

      Index Words

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        • Evangelidis N.
        • TA
        • Manns B.
        • et al.
        Developing a set of core outcomes for trials in hemodialysis: an international Delphi survey.
        Am J Kidney Dis. 2017; 70: 464-475
        • Jhamb M.
        • Weisbord S.D.
        • Steel J.L.
        • et al.
        Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors.
        Am J Kidney Dis. 2008; 52: 353-365
        • Tong A.
        • Manns B.
        • Hemmelgarn B.
        • et al.
        Establishing core outcome domains in hemodialysis: report of the Standardized Outcomes in Nephrology; Hemodialysis (SONG-HD) Consensus Workshop.
        Am J Kidney Dis. 2017; 69: 97-107
        • Urquhart-Secord R.
        • Craig J.C.
        • Hemmelgarn B.
        • et al.
        Patient and caregiver priorities for outcomes in hemodialysis: an international nominal group technique study.
        Am J Kidney Dis. 2016; 68: 444-454
        • Artom M.
        • Moss-Morris R.
        • Caskey F.
        • et al.
        Fatigue in advanced kidney disease.
        Kidney Int. 2014; 86: 497-505
        • Fatigue
        Wilson LJFaJ. The Gale Encyclopedia of Mental Health. 2nd ed. Gale Virtual Reference Library, Detroit, MI2008: 462-466
        • Ryan R.
        • Hill S.
        • Broclain D.
        • Horey D.
        • Oliver S.
        • Prictor M.
        Cochrane Consumers and Communication Review Group.
        Study Design Guide. June 2013; ( Accessed January 16 2017)
        • Beaton D.E.
        • Bombardier C.
        • Katz J.N.
        • et al.
        A taxonomy for responsiveness.
        J Clin Epidemiol. 2001; 54: 1204-1217
        • Shen J.
        • Barbera J.
        • Shapiro C.M.
        Distinguishing sleepiness and fatigue: focus on definition and measurement.
        Sleep Med Rev. 2006; 10: 63-76
        • Sakkas G.K.
        • Karatzaferi C.
        Hemodialysis fatigue: just “simple” fatigue or a syndrome on its own right?.
        Front Physiol. 2012; 3: 306
        • Cook K.F.
        • Jensen S.E.
        • Schalet B.D.
        • et al.
        PROMIS(®) measures of pain, fatigue, negative affect, physical function, and social function demonstrate clinical validity across a range of chronic conditions.
        J Clin Epidemiol. 2016; 73: 89-102
        • Prinsen C.A.C.
        • Vohra S.
        • Rose M.R.
        • et al.
        How to select outcome measurement instruments for outcomes included in a “Core Outcome Set” – a practical guideline.
        Trials. 2016; 17: 449
        • Picariello F.
        • Moss-Morris R.
        • Macdougall I.C.
        • et al.
        Measuring fatigue in haemodialysis patients: the factor structure of the Chalder Fatigue Questionnaire (CFQ).
        J Psychosom Res. 2016; 84: 81-83
        • Lin C.C.
        • Lee Y.H.
        • Hung C.C.
        • et al.
        Development of a novel fatigue scale for hemodialysis patients.
        Formos J Med. 2006; 10: 422-428
        • Davison S.N.
        • Jhangri G.S.
        • Johnson J.A.
        Longitudinal validation of a modified Edmonton symptom assessment system (ESAS) in haemodialysis patients.
        Nephrol Dial Transplant. 2006; 21: 3189-3195
        • Davison S.N.
        • Jhangri G.S.
        • Johnson J.A.
        Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: a simple assessment of symptom burden.
        Kidney Int. 2006; 69: 1621-1625
        • Wang S.-Y.
        • Zang X.-Y.
        • Liu J.-D.
        • et al.
        Psychometric properties of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue) in Chinese patients receiving maintenance dialysis.
        J Pain Symptom Manage. 2015; 49: 135-143
        • Yang S.-C.
        • Kuo P.-W.
        • Su S.
        • et al.
        Development and psychometric properties of the dialysis module of the WHOQOL-BREF Taiwan version.
        J Formos Med Assoc. 2006; 105: 299-309
        • Chilcot J.
        • Moss-Morris R.
        • Artom M.
        • et al.
        Psychosocial and clinical correlates of fatigue in haemodialysis patients: the importance of patients' illness cognitions and behaviours.
        Int J Behav Med. 2016; 23: 271-281
        • Elbers R.G.
        • Rietberg M.B.
        • van Wegen E.E.
        • et al.
        Self-report fatigue questionnaires in multiple sclerosis, Parkinson's disease and stroke: a systematic review of measurement properties.
        Qual Life Res. 2012; 21: 925-944
        • Hofman M.
        • Ryan J.L.
        • Figueroa-Moseley C.D.
        • et al.
        Cancer-related fatigue: the scale of the problem.
        Oncologist. 2007; 12: 4-10
        • Minton O.
        • Stone P.
        A systematic review of the scales used for the measurement of cancer-related fatigue (CRF).
        Ann Oncol. 2009; 20: 17-25
        • Drennan J.
        Cognitive interviewing: verbal data in the design and pretesting of questionnaires.
        J Adv Nurs. 2003; 42: 57-63
        • Nikolaus S.
        • Bode C.
        • Taal E.
        • et al.
        Which dimensions of fatigue should be measured in patients with rheumatoid arthritis? A Delphi study.
        Musculoskel Care. 2012; 10: 13-17
        • Hewlett S.
        • Hehir M.
        • Kirwan J.R.
        Measuring fatigue in rheumatoid arthritis: a systematic review of scales in use.
        Arthritis Rheum. 2007; 57: 429-439
        • Crichton A.
        • Knight S.
        • Oakley E.
        • et al.
        Fatigue in child chronic health conditions: a systematic review of assessment instruments.
        Pediatrics. 2015; 135: e1015-e1031
        • Ahlberg K.
        • Ekman T.
        • Gaston-Johansson F.
        Fatigue, psychological distress, coping resources, and functional status during radiotherapy for uterine cancer.
        Oncol Nurs Forum. 2005; 32: 633-640
        • Chen R.C.
        • Chang P.
        • Vetter R.J.
        • et al.
        Recommended patient-reported core set of symptoms to measure in prostate cancer treatment trials.
        J Natl Cancer Inst. 2014; 106
        • Nicklin J.
        • Cramp F.
        • Kirwan J.
        • et al.
        Collaboration with patients in the design of patient-reported outcome measures: capturing the experience of fatigue in rheumatoid arthritis.
        Arthritis Care Res. 2010; 62: 1552-1558
        • Nikolaus S.
        • Bode C.
        • Taal E.
        • et al.
        Selection of items for a computer-adaptive test to measure fatigue in patients with rheumatoid arthritis: a Delphi approach.
        Qual Life Res. 2012; 21: 863-872
        • Lai J.-S.
        • Stucky B.D.
        • Thissen D.
        • et al.
        Development and psychometric properties of the PROMIS® pediatric fatigue item banks.
        Qual Life Res. 2013; 22: 2417-2427
        • Cella D.
        • Lai J.S.
        • Jensen S.E.
        • et al.
        PROMIS fatigue item bank had clinical validity across diverse chronic conditions.
        J Clin Epidemiol. 2016; 73: 128-134
        • Mokkink L.B.
        • Terwee C.B.
        • Patrick D.L.
        • et al.
        The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study.
        Qual Life Res. 2010; 19: 539-549
        • Fitzpatrick R.
        • Davey C.
        • Buxton M.J.
        • et al.
        Evaluating patient-based outcome measures for use in clinical trials.
        Health Technol Assess. 1998; 2 (1-74): i-iv
        • Mendoza T.R.
        • Wang X.S.
        • Cleeland C.S.
        • et al.
        The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory.
        Cancer. 1999; 85: 1186-1196
        • Chalder T.
        • Berelowitz G.
        • Pawlikowska T.
        • et al.
        Development of a fatigue scale.
        J Psychosom Res. 1993; 37: 147-153
        • Buysse D.J.
        • Thompson W.
        • Scott J.
        • et al.
        Daytime symptoms in primary insomnia: a prospective analysis using ecological momentary assessment.
        Sleep Med. 2007; 8: 198-208
        • Weisbord S.D.
        • Fried L.F.
        • Arnold R.M.
        • et al.
        Development of a symptom assessment instrument for chronic hemodialysis patients: the Dialysis Symptom Index.
        J Pain Symptom Manage. 2004; 27: 226-240
        • Bruera E.
        • Kuehn N.
        • Miller M.J.
        • et al.
        The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients.
        J Palliat Care. 1991; 7: 6-9
        • Yellen S.B.
        • Cella D.F.
        • Webster K.
        • et al.
        Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system.
        J Pain Sympt Manage. 1997; 13: 63-74
        • Fisk J.D.
        • Ritvo P.G.
        • Ross L.
        • et al.
        Measuring the functional impact of fatigue: initial validation of the Fatigue Impact Scale.
        Clin Infect Dis. 1994; 18: S79-S83
        • Fukuda S.
        • Takashima S.
        • Iwase M.
        • et al.
        Development and validation of a new fatigue scale for fatigued subjects with and without chronic fatigue syndrome.
        in: Watanabe Y. Evengård B. Natelson B.H. Fatigue Science for Human Health. Springer Japan, Tokyo, Japan2008: 89-102
        • Krupp L.B.
        • LaRocca N.G.
        • Muir-Nash J.
        • et al.
        The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus.
        Arch Neurol. 1989; 46: 1121-1123
        • Hann D.M.
        • Jacobsen P.B.
        • Azzarello L.M.
        • et al.
        Measurement of fatigue in cancer patients: development and validation of the Fatigue Symptom Inventory.
        Qual Life Res. 1998; 7: 301-310
        • Murphy S.
        • Powers M.
        • Jalowiec A.
        Psychometric evaluation of the Hemodialysis Stressor Scale.
        Nurs Res. 1985; 34: 368-371
        • Hays R.D.
        • Kallich J.
        • Mapes D.
        • et al.
        Kidney Disease Quality of Life Short Form (KDQOL-SF ™), Version 1.3: A Manual for Use and Scoring.
        Santa Monica, CA: RAND Corporation. 1997; (
        • Laupacis A.
        • Muirhead N.
        • Keown P.
        • et al.
        A disease-specific questionnaire for assessing quality of life in patients on hemodialysis.
        Nephron. 1992; 60: 302-306
        • Belza B.L.
        Comparison of self-reported fatigue in rheumatoid arthritis and controls.
        J Rheumatol. 1995; 22: 639-643
        • Smets E.M.
        • Garssen B.
        • Bonke B.
        • et al.
        The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue.
        J Psychosom Res. 1995; 39: 315-325
      1. Palliative Care Outcome Scale. POS: a resource for palliative care 2012. Accessed June 4, 2017.

        • Aaronson N.K.
        • Ahmedzai S.
        • Bergman B.
        • et al.
        The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology.
        J Natl Cancer Inst. 1993; 85: 365-376
        • McHorney C.A.
        • Ware Jr., J.E.
        • Raczek A.E.
        The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.
        Med Care. 1993; 31: 247-263
        • Lee K.A.
        • Hicks G.
        • Nino-Murcia G.
        Validity and reliability of a scale to assess fatigue.
        Psychiatry Res. 1991; 36: 291-298
        • The WHOQOL Group
        Development of the World Health Organization WHOQOL-BREF quality of life assessment.
        Psychol Med. 1998; 28: 551-558
        • Bilal M.
        • Khan R.A.
        • Danial K.
        Hijama improves overall quality of life in chronic renal failure patients: a pilot study.
        Pak J Pharm Sci. 2015; 28: 1731-1735
        • Bossola M.
        • Di Stasio E.
        • Antocicco M.
        • et al.
        Qualities of fatigue in patients on chronic hemodialysis.
        Hemodial Int. 2013; 17: 32-40
        • Bugeja A.
        • Dacouris N.
        • Thomas A.
        • et al.
        In-center nocturnal hemodialysis: another option in the management of chronic kidney disease.
        Clin J Am Soc Nephrol. 2009; 4: 778-783
        • Curtin R.B.
        • Bultman D.C.
        • Thomas-Hawkins C.
        • et al.
        Hemodialysis patients' symptom experiences: effects on physical and mental functioning.
        Nephrol Nurs J. 2002; 29 (discussion 575, 598): 562-574
        • Dubin R.F.
        • Teerlink J.R.
        • Schiller N.B.
        • et al.
        Association of segmental wall motion abnormalities occurring during hemodialysis with post-dialysis fatigue.
        Nephrol Dial Transplant. 2013; 28: 2580-2585
        • Horigan A.
        • Rocchiccioli J.
        • Trimm D.
        Dialysis and fatigue: implications for nurses–a case study analysis.
        Medsurg Nurs. 2012; 21 (175): 158-163
        • Jablonski A.
        The multidimensional characteristics of symptoms reported by patients on hemodialysis.
        Nephrol Nurs J. 2007; 34 (quiz 38): 29-37
        • Kocak R.
        • Can F.
        The effect of rehabilitation on activities of daily living and fatigue level in hemodialysis patients [Turkish].
        Fizyoterapi Rehabilitasyon. 2003; 14: 80-86
        • Malagoni A.M.
        • Catizone L.
        • Mandini S.
        • et al.
        Acute and long-term effects of an exercise program for dialysis patients prescribed in hospital and performed at home.
        J Nephrol. 2008; 21: 871-878
        • Merkus M.P.
        • Jager K.J.
        • Dekker F.W.
        • et al.
        Physical symptoms and quality of life in patients on chronic dialysis: results of The Netherlands Cooperative Study on Adequacy of Dialysis (NECOSAD).
        Nephrol Dial Transplant. 1999; 14: 1163-1170
        • Merlin M.D.
        • Gallant G.
        [Impact of a fatigue management program in patients on hemodialysis].
        CANNT J. 2010; 20: 43-48
        • Sklar A.H.
        • Riesenberg L.A.
        • Silber A.K.
        • et al.
        Postdialysis fatigue.
        Am J Kidney Dis. 1996; 28: 732-736
        • Sklar A.
        • Newman N.
        • Scott R.
        • et al.
        Identification of factors responsible for postdialysis fatigue.
        Am J Kidney Dis. 1999; 34: 464-470
        • Sklar A.H.
        • Beezhold D.H.
        • Newman N.
        • et al.
        Postdialysis fatigue: lack of effect of a biocompatible membrane.
        Am J Kidney Dis. 1998; 31: 1007-1010
        • Su L.H.
        • Wu K.D.
        • Lee L.S.
        • et al.
        Effects of far infrared acupoint stimulation on autonomic activity and quality of life in hemodialysis patients.
        Am J Chin Med. 2009; 37: 215-226
        • Suet-Ching W.L.
        The quality of life for Hong Kong dialysis patients.
        J Adv Nurs. 2001; 35: 218-227
        • Trbojevic J.
        • Nesic D.
        • Stojimirovic B.
        [Effect of various methods of treatment in chronic renal insufficiency on the quality of life in patients].
        Srp Arh Celok Lek. 1998; 126: 374-378
        • Yong D.S.
        • Kwok A.O.
        • Wong D.M.
        • et al.
        Symptom burden and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care.
        Palliat Med. 2009; 23: 111-119

      Linked Article

      • Assessing Fatigue in the ESRD Patient: A Step Forward
        American Journal of Kidney DiseasesVol. 71Issue 3
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          Patient-reported outcome measures (PROMs) as a way of assessing the health-related quality of life (HRQoL) of patients are now recognized as key outcome measures in clinical trials evaluating the impact of different renal replacement therapies for patients with end-stage renal disease (ESRD).1-6 Thus, recent studies comparing more frequent hemodialysis (HD) to conventional HD, home HD to center HD, extended HD to conventional treatments, and home peritoneal dialysis to center HD have all incorporated PROMs as important outcome measures.
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