Skip to main navigation menu Skip to main content Skip to site footer


Vol. 8 No. 3 (2020): Jurnal Keperawatan Padjadjaran

Symptom Burden’s Associated Factors among Hemodialysis Patients

August 19, 2020


Many patients with chronic kidney disease undergoing hemodialysis (CKD-HD) had a high symptom burden, which can worsen their health conditions and quality of life. The known factors associated to symptom burden were age, gender, hemodialysis (HD) session duration, post dialysis recovery time, hemoglobin level, nutrition status, physical activity, depression level and social support. The aim of this study was to analyze the most dominant factor associated to symptom burden among CKD-HD patients. Using a cross-sectional design, a convenience sample of eighty-five respondents were recruited from HD unit at Adventist Bandung Hospital, who underwent HD > 3 months, HD frequency 2-3 times a week, aged ≥ 18 years, able to communicate and speak Indonesian. Data were retrieved via seven self-reported questionnaires and health records, and the symptom burden was assessed using the validated Indonesian version of the CKD-Symptom Burden Index. The data was analysed with Spearman correlation test, Chi square test, and multivariate logistic regression. Based on quartile category, most of the respondents (50.6%) had a high symptom burden (33.56±12.23). The factors significantly associated to symptom burden were age (p=0.015), post-dialysis recovery time (p=0.007) and depression level (p=0.000). In the final model, duration of HD session (OR=5.27, 95% CI 1.50-18.49) and depression level (OR=8.84, 95% CI 2.57-30.36) were the factors associated to high symptom burden. Depression level was the most dominant factor associated to high symptom burden. CKD-HD patients with depression are more at risk of experiencing a high symptom burden. Thus, symptom management may consider to modify depression level factor by screening for depression, providing assistance and nursing interventions, or developing depression-related interventions to reduce symptom burden in CKD-HD patients.

Article Matrics
Abstract views : 323 times PDF Downloads: 141


Download data is not yet available.


  1. Abrori, I., & Ahmad, R. A. (2018). Kualitas hidup penderita tuberkulosis resisten obat di kabupaten Banyumas. (Quality of life for drug resistant tuberculosis patients in Banyumas district). Berita Kedokteran Masyarakat, 34(2), 56-61.
  2. Almutary, H., Bonner, A., & Douglas, C. (2013). Review article symptom burden In chronic kidney disease : A review Of recent Literature. Journal of Renal Care, 1-11.
  3. Almutary, H., Bonner, A., & Douglas, C. (2015). Arabic translation , adaptation and modification of the dialysis symptom index for chronic kidney disease stages four and five. BMC Nephrology, 16(36), 1-8.
  4. Almutary, H., Bonner, A., & Douglas, C. (2016). Which patients with chronic kidney disease have the greatest symptom burden ? A comparative study of advanced CKD stage And Dialysis Modality. Journal of Renal Care, 42(2), 73-82.
  5. Avdal, E.U., Ayvaz, İ., Özgursoy Uran, B., Yildirim, J., Sofulu, F., & Pamuk, G. (2020). Opinions of hemodialysis and peritoneum patients regarding depression and psychological problems which they experience: A qualitative study. Journal of Infection and Public Health.
  6. Bossola, M., Di Stasio, E., Giungi, S., Rosa, F., & Tazza, L. (2015). Fatigue is associated with serum interleukin-6 levels and symptoms of depression in patients on chronic hemodialysis. Journal of Pain and Symptom Management, 49(3), 578-585.
  7. Brennan, F., Siva, B., & Crail, S. (2013). Appropriate sssessment of symptom burden and provision of patient informatio. Nephrology, n/a-n/a.
  8. Brislin, R. W. (1970). Back-Translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1(3), 185-216.
  9. Caplin, B., Kumar, S., & Davenport, A. (2011). Patients’ perspective of haemodialysis-associated symptoms. Nephrology Dialysis Transplantation, 26(8), 2656-2663.
  10. Cervantes, L., Hull, M., Keniston, A., Chonchol, M., Hasnain-Wynia, R., Fischer, S. (2018). Symptom Burden among Latino Patients with End-Stage Renal Disease and Access to Standard or Emergency-Only Hemodialysis. Journal of Palliative Medicine, XX(XX), 1-5.
  11. Chen, S. F., Wang, I. J., & Lang, H. C. (2016). Risk of major depression in patients with chronic renal failure on different treatment modalities: A matched-cohort and population-based study in Taiwan. Hemodialysis International, 20(1), 98-105.
  12. Clarke, A. L., Young, H. M. L., Hull, K. L., Hudson, N., Burton, J. O., & Smith, A. C. (2015). Motivations and barriers to exercise in chronic kidney disease : a qualitative study. Nephrol Dial Transplant, 30(June), 1885-1892.
  13. Dano, S., Zhang, J., Towes, D., Ahmed, T., Novak, M., & Musci, I. (2018). Social Support is associated with Symptom Burden. Mukci Novak Kidney Health Education and Reearch Group.
  14. Danquah, F. V. N., Zimmerman, L., Diamond, P. M., Meininger, J., & Bergstrom, N. (2010). Frequency, Severity, and Distress Of Dialysis-Related Symptoms Reported by Patients on Hemodialysis Continuing. Nephrology Nursing Journal, 37(6), 627-640.
  15. Davison, S. N. & Jhangri, G. S. (2010). Impact of Pain and Symptom Burden on the Health-Related Quality of Life of Hemodialysis Patients. Journal of Pain and Symptom Management, 39(3), 477-485.
  16. Delmas, P., Cohen, C., Loiselle, M.-C., Antonini, M., Pasquier, J., & Burnier, M. (2017). Symptoms and quality of life from patients undergoing hemodialysis in Switzerland. Clinical Nursing Studies, 6(2), 63.
  17. Desbiens, N. A., Mueller-rizner, N., Connors, A. F., Wenger, N. S., Lynn, J., & Investigators, S. (1999). The Symptom Burden of Seriously Ill Hospitalized Patients. Journal of Pain and Symptom Management, 17(4), 248-255.
  18. Gao, Y., Zhou, Y., Guo, C. X., & Zhao, J. F. (2016). The relationship among hope, symptom distress, social support, coping style and monthly income in maintenance hemodialysis patients: A structural equation model. International Journal of Clinical and Experimental Medicine, 9(10), 19717-19724.
  19. Gapstur, R. L. (2007). Symptom Burden : A Concept Analysis and Implications for Oncology Nurses. Oncology Nursing Forum, 34(3), 673-681.
  20. Farrokhi, F. (2012). Depression Among Dialysis Patients. Iranian Journal of Kidney Diseases, 6(6), 403-406.
  21. García-Llana, H., Remor, E., del Peso, G., & Selgas, R. (2014). The role of depression, anxiety, stress and adherence to treatment in dialysis patients’ health-related quality of life: a systematic review of the literature. Nefrologia, 34(5), 637-657.
  22. Hedayati, S. S., Yalamanchili, V., & Finkelstein, F. O. (2012). A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney International, 81(3), 247-255.
  23. Indonesian Renal Registry/IRR (2018). 11th Report of Indonesian Renal Registry. Retrieved March 14, 2020, from
  24. Kalantar-Zadeh, K., Kleiner, M., Dunne, E., Lee, G. H., & Luft, F. C. (1999). A modified quantitative subjective global assessment of nutrition for dialysis patients. Nephrology Dialysis Transplantation, 14(7), 1732-1738.
  25. Karasneh, R., Al, S., Shoroq, A., Osama, M. A., & Sahar, Y. A. (2020). Predictors of symptom burden among hemodialysis patients : a cross sectional study at 13 hospitals. International Urology and Nephrology.
  26. Kementrian Kesehatan RI. (2016). Pedoman Kegiatan Keafiatan di Tempat Kerja “Wellness Program at Workplaceâ€. Retrieved March 14, 2020, from
  27. Kopple, J. ., Kim, J. ., Shapiro, B. ., Zhang, M., Li, Y., Porszasz, J., … Kalantar-Zadeh, K. (2015). Factors affecting daily physical activity and physical performance in maintenance dialysis patients. J Ren Nutr., 25(2), 217-222.
  28. Kroenke, K., Spitzer, R. L., Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9): 606-613.
  29. Kustimah, K., Prathama Siswadi, A. G., Djunaidi, A., & Iskandarsyah, A. (2020). Quality of Life among Patients Undergoing Haemodialysis in Bandung: A mixed methods study. Jurnal Keperawatan Padjadjaran, 8(1).
  30. Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). Theory unpleasant symptoms. Adv Nurs Sci.
  31. Li, H., Xie, L., Yang, J., & Pang, X. (2018). Symptom burden amongst patients suffering from end-stage renal disease and receiving dialysis : A literature review. International Journal of Nursing Sciences, 5(4), 427-431.
  32. Linden, A. Van Der. (2019). Cross-cultural validation of the Patient Health Questionnaire (PHQ-9) in Bahasa Indonesia to measure depression among people affected by leprosy in Central Java [Master’s thesis, Vrije Universteit]. Vrije Universiteit, Amsterdam.
  33. Lindsay, R. M., Heidenheim, P. A., Nesrallah, G., & Garg, A. X. (2006). Minutes to recovery after a hemodialysis session : A simple health-related quality of life question that Is reliable , Valid , and Sensitive to Change, 952-959.
  34. Lopes, G. B., Silva, L. F., Pinto, G. B., Catto, L. F., Martins, M. T., Dutra, M. M., & Lopes, A. A. (2014). Patient’s response to a simple question on recovery after hemodialysis session strongly associated with scores of comprehensive tools for quality of life and depression symptoms. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 23(8), 2247-2256.
  35. Lowney, A. C., Myles, H. T., Bristowe, K., Lowney, E. L., Shepherd, K., Murphy, M., … Murtagh, F. E. M. (2015). Understanding what influences the health-related quality of life of hemodialysis patients : A collaborative study in England and Ireland. Journal of Pain and Symptom Management, 50(6), 778-785.
  36. Ng, M. S. N., So, W. K. W., Wong, C. L., Hui, Y. H., Ho, E. H. S., Choi, K. C., … Miaskowski, C. (2020). Stability and impact of symptom Clusters in Patients with end-stage renal disease undergoing dialysis. Journal of Pain and Symptom Management, 59(1), 67-76.
  37. Nur, E. I. Y. (2017). Validitas Dialysis Malnutrition Score (DMS) dan Nutritional Risk Index (NRI) Dibandingkan Dengan Subjective Global Assessment (SGA) Pada Pasien Gagal Ginjal yang Menjalani Hemodialisis. [Master’s thesis, Universitas Sebelas Maret]. Universitas Sebelas Maret, Surakarta, Indonesia.
  38. Orenstein, G. A., & Lewis, L. (2020). Eriksons Stages of Psychosocial Development. In StatPearls. StatPearls Publishing.
  39. PERNEFRI (Perhimpunan Nefrologi Indonesia) (2018). Konsensus Anemia pada Penyakit Ginjal Kronik Edisi II. (Consensus Anemia in Chronic Kidney Disease II Edition). PERNEFRI.
  40. Polit, D.F. & Beck, C.T. (2004). Nursing Research Principles and Methods. 7th ed. Philadelphia: Lippincots Williams & Wilkins.
  41. Randall, A. M., Stevenson, J., Heaney, S., Notaras, S., Hoffman, A., Choi, P., … Sud, K. (2019). Sun-102 Nutrition-Impact Symptom Burden in Patients Attending Renal Supportive Care. Kidney International Reports, 4(7), S199.
  42. Rayner, H. C., Zepel, L., Fuller, D. S., Morgenstern, H., Karaboyas, A., Culleton, B. F., … Robinson, B. M. (2014). Recovery Time, Quality of Life, and Mortality in Hemodialysis Patients: The Dialysis Outcomes and Practice Patterns Study (DOPPS). American Journal of Kidney Diseases, 1-9.
  43. Sexton, D. J., Lowney, A. C., Seaghdha, C. M. O., Murphy, M., Brien, T. O., Casserly, L. F., … Conlon, P. J. (2016). Do patient-reported measures of symptoms and health status predict mortality in hemodialysis ? An assessment of POS-S Renal and EQ-5D. Hemodialysis International 2016;, 1-13.
  44. Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and Medicine, 32(6), 705-714.
  45. Sheshadri, A., Kittiskulnam, P., & Johansen, K. L. (2019). Higher physical activity is associated with less fatigue and insomnia among patients on hemodialysis. Kidney International Reports, 4(2), 285-292.
  46. Shirazian, S., Grant, C. D., Aina, O., Mattana, J., & Khorassani, F. (2017). Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management. Kidney International Reports, 2(1), 94-107.
  47. Silva, L. F., Lopes, G. B., Matos, C. M., Brito, K. Q., Amoedo, M. K., Azevedo, M. F., … Lopes, A. A. (2012). Gastrointestinal Symptoms and Nutritional Status in Women and Men on Maintenance Hemodialysis. Journal of Renal Nutrition, 22(3), 327-335.
  48. Son, Y.-J., Choi, K.-S., Park, Y.-R., Bae, J.-S., & Lee, J.-B. (2009). Depression, Symptoms and the Quality of Life in Patients on Hemodialysis for End-Stage Renal Disease. American Journal of Nephrology, 29(1), 36-42.
  49. Song, M. K., Paul, S., Ward, S. E., Gilet, C. A., & Hladik, G. A. (2018). One-Year Linear Trajectories of Symptoms, Physical Functioning, Cognitive Functioning, Emotional Well-being, and Spiritual Well-being Among Patients Receiving Dialysis. American Journal of Kidney Diseases, 72(2), 198-204.
  50. Sugiyono. (2018). Metode Penelitian Kuantitatif. (Quantitative Research Methods). Alfabeta.
  51. Sukandar, E. (2006). Gagal Ginjal dan Panduan Terapi Dialisis Tahun 2006. (Renal Failure and Dialysis Therapy Guide, 2006.) Pusat Informasi Ilmiah (PPI) Bagian Ilmu Penyakit Dalam Fakultas Kedokteran UNPAD/RS. Dr. Hasan Sadikin.
  52. Sutinah (2020). Effect of Life Review and Cognitive Therapy on Depression in Patients with Chronic Renal Failure. Jurnal Keperawatan Padjadjaran, 8(2), 1-8.
  53. Topolski, T. D., LoGerfo, J., Patrick, D. L., Williams, B., Walwick, J., & Patrick, M. B. (2006). The Rapid Assessment of Physical Activity (RAPA) among older adults. Preventing Chronic Disease, 3(4), 1-8.
  54. Treadwell, A. A. (2017). Examining Depression in Patients on Dialysis. American Nephrology Nurses Association., 44(4), 295-307.
  55. USRDS (2018). United States Renal Data System Annual Report: Executive Summary. Retrieved March 14, 2020, from
  56. Wan Zukiman, W. Z. H., Yaakup, H., Zakaria, N. F., & Shah, S. A. Bin. (2017). Symptom Prevalence and the Negative Emotional States in End-Stage Renal Disease Patients with or without Renal Replacement Therapy: A Cross-Sectional Analysis. Journal of Palliative Medicine, 20(10), 1127-1134.
  57. Wang, L. J., Wu, M. S., Hsu, H. J., Wu, I. W., Sun, C. Y., Chou, C. C., … Chen, C. K. (2012). The relationship between psychological factors, inflammation, and nutrition in patients with chronic renal failure undergoing hemodialysis. International Journal of Psychiatry in Medicine, 44(2), 105-118.
  58. Yu, I., Huang, J., & Tsai, Y. (2012). Symptom cluster among hemodialysis patients in Taiwan. Applied Nursing Research, 25(3),190-196.