Chronic kidney disease (CKD) has become a significant global health concern, affecting over 10% of the population. End-stage renal disease (ESRD), the advanced stage of CKD, is marked by the irreversible loss of kidney function, necessitating renal replacement therapy. As populations age, the incidence of ESRD is on the rise. The global annual incidence is approximately 146 cases per million people, and China has the highest number of affected individuals. The growing ESRD population has led to a global renal resource shortage, making hemodialysis the primary treatment for ESRD patients. Notably, an increasing number of patients undergoing maintenance hemodialysis (MHD) are older adults. In Europe, the mean age of incident MHD patients is 65.5 years, and in China, 61.2% of newly initiated dialysis patients are over 60 years old. This indicates that older adults now constitute the majority of MHD patients.
While MHD prolongs survival, it also brings high hospitalization and mortality rates, as well as significant declines in quality of life, imposing substantial psychological and financial burdens on patients and families. Among the various physical symptoms exacerbated by the disease and its treatment, fatigue is one of the most prevalent and debilitating complications, affecting 20-86% of MHD patients, with most reporting moderate to severe intensity. Recognized for its clinical significance, fatigue has been designated by the Standardized Outcomes in Nephrology–Haemodialysis (SONG-HD) initiative as a core outcome measure for MHD patients, alongside vascular access complications, cardiovascular events, and mortality. The initiative recommends its routine assessment in clinical studies.
Fatigue is a multidimensional symptom, defined as a pervasive, subjective sense of exhaustion that diminishes functional capacity and impedes daily activities, encompassing physical, mental, cognitive, emotional, and motivational fatigue. In MHD patients, fatigue is closely linked to poorer quality of life, sleep disturbances, and physical discomfort. Research shows that patients transitioning from non-fatigued to fatigued states have a 2.18-fold higher mortality risk, and each one-point increase in fatigue score corresponds to a 6% rise in mortality risk. Fatigue is also significantly associated with an increased risk of cardiovascular disease and suicidal ideation. Older adults receiving MHD are particularly susceptible to fatigue due to the compounding effects of aging and comorbidities, severely impacting their physical health and overall well-being. The World Health Organization’s Global Report on Ageing and Health emphasizes that healthy aging entails not only preserving physical function but also improving overall quality of life and well-being. Addressing fatigue in this population is, therefore, a clinical priority.
Studies have identified multiple correlates of fatigue in MHD, including age, educational attainment, sleep quality, psychological status, and social support. However, within China’s unique cultural and socioeconomic context, research specifically targeting fatigue in older adults on MHD remains limited, and tailored interventions are scarce. The Chinese sociocultural environment, deeply influenced by Confucian values such as filial piety and collectivism, places a strong emphasis on family centrality within social support systems. In this context, familial involvement becomes a cornerstone of health management, with family members frequently assuming intensive caregiving roles and providing substantial emotional and instrumental support. This culturally embedded, family-oriented ecosystem may uniquely shape the fatigue experience among older adults receiving MHD. For instance, prior research has shown that family support is associated with fatigue in patients with hepatocellular carcinoma, suggesting its potential relevance in other chronic conditions. Nevertheless, the specific role and influence of family support on fatigue in older adults undergoing MHD within China’s distinct sociocultural context have not been sufficiently explored and warrant focused investigation. Psychological factors such as anxiety and depression are also influential in MHD, yet their specific relationship with fatigue in older adults is not well defined. Additionally, low self-efficacy is common in MHD and has been associated with adverse outcomes. Given the multidimensional and complex nature of fatigue, a systematic examination of its determinants in older adults receiving MHD is warranted.
This study aims to describe the current status of fatigue in Chinese older adults receiving MHD and to analyze its determinants, providing empirical evidence to elucidate its multifactorial underpinnings and to inform the development and implementation of culturally appropriate fatigue-intervention strategies. The research hypotheses are as follows:
H1. Fatigue prevalence is high among Chinese older adults receiving MHD, with a substantial proportion experiencing moderate-to-severe levels.
H2. Fatigue severity is associated with multidomain characteristics, including psychosocial factors (e.g., self-efficacy, family functioning, depressive symptoms), physiological factors (e.g., hemoglobin, serum albumin), dialysis-related factors (e.g., dialysis vintage), and demographic factors (e.g., age, education).
The study adopted a multicenter cross-sectional research design, reported based on the Report of Observational Studies in Epidemiology (STROBE) Cross-sectional Research Inventory. The sample size was determined a priori using G*Power 3.1, assuming a medium effect size, α=0.05, power (1–β) =0.90, and 19 planned predictors. To allow for potential invalid responses to questionnaires, the target sample size was inflated by 20% to N=224. Ultimately, 279 patients undergoing MHD completed the survey.
The study found that fatigue is widespread and intense among older adults receiving MHD, with 80.3% reporting fatigue and over 60.3% experiencing moderate or severe fatigue. This outcome indicates a significant burden on patients and their families. The study also identified dialysis vintage, self-efficacy, family functioning, coping styles, depressive symptoms, hemoglobin, and serum albumin levels as independent determinants of fatigue. These findings highlight the need for routine fatigue assessment in dialysis care for older adults and the development of individualized care pathways that integrate physiological optimization, psychological support, and family support to reduce symptom burden and improve quality of life. Future research should focus on longitudinal studies to clarify causal relationships and develop culturally adapted, multifaceted management strategies tailored to this population.
