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Open Access Highly Accessed Research article

Ecological momentary assessment of fatigue, sleepiness, and exhaustion in ESKD

Khaled Abdel-Kader1*, Manisha Jhamb2, Lee Anne Mandich3, Jonathan Yabes4, Robert M Keene5, Scott Beach5, Daniel J Buysse6 and Mark L Unruh7

Author Affiliations

1 Division of Nephrology and Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, MCN S-3223, Nashville, TN 37232-2372, USA

2 Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA

3 Renal Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

4 Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA

5 University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, USA

6 Department of Psychiatry, Sleep Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA

7 Division of Nephrology, University of New Mexico, Albuquerque, NM, USA

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BMC Nephrology 2014, 15:29  doi:10.1186/1471-2369-15-29

Published: 6 February 2014



Many patients on maintenance dialysis experience significant sleepiness and fatigue. However, the influence of the hemodialysis (HD) day and circadian rhythms on patients’ symptoms have not been well characterized. We sought to use ecological momentary assessment to evaluate day-to-day and diurnal variability of fatigue, sleepiness, exhaustion and related symptoms in thrice-weekly maintenance HD patients.


Subjects used a modified cellular phone to access an interactive voice response system that administered the Daytime Insomnia Symptom Scale (DISS). The DISS assessed subjective vitality, mood, and alertness through 19 questions using 7- point Likert scales. Subjects completed the DISS 4 times daily for 7 consecutive days. Factor analysis was conducted and a mean composite score of fatigue-sleepiness-exhaustion was created. Linear mixed regression models (LMM) were used to examine the association of time of day, dialysis day and fatigue, sleepiness, and exhaustion composite scores.


The 55 participants completed 1,252 of 1,540 (81%) possible assessments over the 7 day period. Multiple symptoms related to mood (e.g., feeling sad, feeling tense), cognition (e.g., difficulty concentrating), and fatigue (e.g., exhaustion, feeling sleepy) demonstrated significant daily and diurnal variation, with higher overall symptom scores noted on hemodialysis days and later in the day. In factor analysis, 4 factors explained the majority of the observed variance for DISS symptoms. Fatigue, sleepiness, and exhaustion loaded onto the same factor and were highly intercorrelated. In LMM, mean composite fatigue-sleepiness-exhaustion scores were associated with dialysis day (coefficient and 95% confidence interval [CI] 0.21 [0.02 – 0.39]) and time of day (coefficient and 95% CI 0.33 [0.25 – 0.41]. Observed associations were minimally affected by adjustment for demographics and common confounders.


Maintenance HD patients experience fatigue-sleepiness-exhaustion symptoms that demonstrate significant daily and diurnal variation. The variability in symptoms may contribute to poor symptom awareness by providers and greater misclassification bias of fatigue related symptoms in clinical studies.

End-stage renal disease; Alertness; Fatigue; Symptoms; Ecological momentary assessment