Post-Dialysis Syndrome: A Narrative Review

Abstract

Use of the term post-dialysis syndrome (PDS) was recently recommended to refer to the exacerbation of a debilitating, under-recognized cluster of physical, cognitive, psychological, and behavioral symptoms commonly affecting patients on maintenance dialysis after treatment sessions. This narrative review synthesizes existing and emerging literature to provide an overview of the characterization, pathophysiology, measurement, and management of post-dialysis syndrome. Commonly referred to as post-dialysis fatigue, the term PDS more accurately captures the multidimensional nature and true burden of the condition and may minimize patient stigma. Its pathophysiology is multifactorial, and the evidence suggests that inflammation, nutritional status, and dialysis-related, clinical, socio-demographic, and psychiatric factors are significant contributors. Although a number of measurement tools and interventions targeting individual symptoms have been studied, there are no established methods or guidelines to define, diagnose, and manage PDS in its entirety. Existing quantitative instruments include time to recovery from dialysis, self-report scales, and ecological momentary assessments, but they differ in their ability to capture the heterogeneity of and variations in PDS symptoms and in psychometric properties. Qualitative and mixed-methods approaches may provide more in-depth information on the scope and impact of PDS and can be useful for future development of better measurement tools. Potential interventions for PDS include adjustment of dialysis prescription, exercise and physical activity, and cognitive behavioral therapy. Studies examining these interventions have focused on a narrow range of post-dialysis symptoms, however, and given the lack of PDS management guidelines, patients strongly advocate for further research into treatments. In the interim, we recommend a pragmatic approach to address PDS in dialysis patients involving: collection of a detailed medical history to understand the range, severity, and impact of post-dialysis symptoms; use of patient-reported outcome measures to quantify symptoms and treatment effects; and engagement in shared decision-making with patients when selecting among interventions.