JMERC
Owner
Janbazan Medical and Engineering Research Center (JMERC) is the owner of IJWPH.
0.5
Cite Score
SJR: 0.129 / SNIP: 0.140
Volume 17, Issue 3 (2025)
Iran J War Public Health 2025, 17(3): 223-228 |
Back to browse issues page
Article Type:
Subject:
History
Received: 2025/05/1 | Accepted: 2025/07/5 | Published: 2025/07/19
Received: 2025/05/1 | Accepted: 2025/07/5 | Published: 2025/07/19
How to cite this article
Qaed A, Atiyah H. Comfort Level in Hemodialysis Patients and Its Relationship with Symptom Burden. Iran J War Public Health 2025; 17 (3) :223-228
URL: http://ijwph.ir/article-1-1621-en.html
URL: http://ijwph.ir/article-1-1621-en.html
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Rights and permissions
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Authors
A.R. Qaed *1, H.H. Atiyah2
1- Ministry of Health, Al-Diwaniyah Health Directorate, Al-Diwaniyah, Iraq
2- Department of Adult Nursing, College of Nursing, University of Baghdad, Baghdad, Iraq
2- Department of Adult Nursing, College of Nursing, University of Baghdad, Baghdad, Iraq
Full-Text (HTML) (58 Views)
Introduction
The global community involved in dialysis is growing rapidly, with an estimated 2.5 million people receiving dialysis treatment in 2020, and this number is expected to rise to 5.4 million by 2030 [1, 2]. This increase underscores the urgent need for healthcare systems to adapt and expand their resources to accommodate the growing patient population. As the number of individuals requiring dialysis continues to rise, healthcare facilities must ensure that they have the necessary infrastructure, including sufficient dialysis machines, trained personnel, and adequate space to meet patient demand. Additionally, there is a pressing need for healthcare policies that prioritize access to dialysis treatment, particularly in underserved regions where resources may be limited. Investment in technology and telemedicine could also play a crucial role in providing support and monitoring for patients, making treatment more accessible and efficient.
Dialysis is characterized as a significant and resource-intensive medical intervention that places substantial financial, physical, and psychological demands on patients and their caregivers [3]. The financial burden often includes not only the cost of the dialysis treatment itself but also associated expenses, such as transportation to treatment facilities, nutritional supplements, and medications. Many patients must navigate complex insurance policies or face out-of-pocket expenses that can strain their financial resources, leading to anxiety and stress about their economic stability. Furthermore, some patients may experience a loss of income due to their health condition, as frequent treatments can limit their ability to work, adding an additional layer of financial insecurity. Individuals undergoing dialysis frequently endure profound symptoms, diminished psychological health, and heightened levels of stress [4]. The psychological health of dialysis patients is often compromised, with many experiencing feelings of anxiety and depression as they grapple with the realities of a chronic illness. The burden of managing a demanding treatment regimen, along with fears about health deterioration and potential complications, can lead to a pervasive sense of hopelessness. Heightened levels of stress are common among dialysis patients and their families, as they navigate not only the physical demands of treatment but also the emotional and financial strains that accompany it. Caregivers may also experience significant stress as they balance their own needs with those of the patient, often sacrificing their well-being to provide support.
Research indicates that sleep disturbances represent the predominant burden symptom experienced by hemodialysis patients. Moreover, an additional study indicated that a significant percentage of patients (exceeding 70%) report the presence of fatigue and dry mouth. In contrast, symptoms, such as myalgia and pruritus, are noted in approximately 40-60% of the patient population [5, 6]. This symptomatology adversely influences overall quality of life and frequently results in discomfort between or during dialysis sessions [7].
Burden symptoms, including fatigue, pruritus, sexual dysfunction, sleep disturbances, and pain, markedly affect patients’ daily activities and overall well-being. These distressing symptoms may persist throughout and after dialysis treatments, ultimately influencing patients’ daily existence, interpersonal relationships, and general quality of life [8, 9]. For instance, fatigue can lead to reduced participation in social activities, making it difficult for patients to maintain connections with friends and family, which can further exacerbate feelings of isolation and depression. Similarly, sexual dysfunction can strain intimate relationships, creating additional emotional stress and contributing to the overall burden of the illness. The management of pruritic symptoms is critical for enhancing quality of life and alleviating sleep disturbances in individuals with renal failure [10]. Persistent itching can disrupt sleep patterns, leading to a cycle of sleep deprivation that exacerbates fatigue and impairs cognitive function during waking hours. Effective treatment strategies, such as topical therapies or medications, are essential for addressing pruritus and promoting better sleep hygiene, which can significantly improve patients’ overall sense of well-being.
These patients face challenges that severely impact their independence and restrict various aspects of their daily lives [11, 12]. These difficulties adversely affect their quality of life and sense of comfort [13]. Therefore, it is important to regularly evaluate the comfort levels of dialysis patients [14]. A study found that patients undergoing hemodialysis reported a medium level of comfort [15]. Focusing on patient comfort is one of the key goals and responsibilities of nurses. Nurses play a crucial role in providing care for individuals with long-term kidney failure undergoing hemodialysis [16, 17].
Effective hemodialysis procedures for individuals with kidney failure rely on patients adhering to their prescribed treatment plans [18]. Consistent compliance is essential not only for optimizing the effectiveness of the dialysis sessions but also for preventing complications that can arise from missed treatments or inadequate fluid and dietary restrictions. When patients fail to adhere to their treatment schedules, they may experience a buildup of toxins and excess fluid in their bodies, leading to severe health issues such as hypertension, heart problems, and increased fatigue. Noncompliance may lead to increased discomfort for patients between their hemodialysis sessions [9, 19]. As a result, patients may endure heightened symptoms, including swelling, shortness of breath, and general malaise, which can significantly impair their overall quality of life. Moreover, the physical discomfort often translates into emotional distress, as patients may feel frustrated and hopeless about their condition, further perpetuating a cycle of noncompliance. Addressing the barriers to adherence, such as a lack of understanding about the treatment process or difficulties in accessing care, is crucial for healthcare providers.
The accumulation of these symptoms can affect physical comfort and mental well-being, further decreasing overall life satisfaction [20]. Research highlights that symptom management should be a core focus for improving patient comfort levels, as symptoms such as fatigue, pain, and sleep issues are linked to higher rates of depression and anxiety in patients [21, 22].
Globally, symptom burden has been recorded and measured in various chronic disease populations, such as those with heart disease [23, 24], diabetes [25, 26], renal failure [27, 28], and even dialysis [29, 30]. However, only a few studies have been conducted to assess symptom burden [31], especially among CKD patients or dialysis populations in Iraq.
This study aimed to assess the comfort level of hemodialysis patients and its relationship with symptom burden.
Instrument and Methods
Study design and Sample
This descriptive cross-sectional study was conducted in three governorates, Najaf, Karbala, and Diwaniyah, in Iraq from October 28, 2024, to June 7, 2025. The kidney dialysis centers in these areas are Fatima Al-Zahra and Al-Hayat in Al-Diwaniyah, Al-Hakeem and Al-Sadr in Al-Najaf, and Habib Bin Mazahir Al-Asadi and Dr. Adel Al-Sabbah in Karbala.
The study sample was selected using a non-probability (purposive) sampling method, which included 257 patients from the dialysis centers. The sample was collected based on the inclusion and exclusion criteria. The participants consisted of adults diagnosed with renal failure who were undergoing hemodialysis, at least 18 years old, of both sexes, who agreed to participate, and were able to read and write. Participation in this study was voluntary. Patients with cognitive impairments that would affect their ability to complete questionnaires, those who were unable to read or write, or those who refused to participate were excluded.
Research tools
Demographic data form
This form collected demographic information from the patients, including age, sex, level of education, occupation, marital status, the presence of chronic diseases, household composition, family monthly income, and duration of dialysis.
Chronic Kidney Disease Symptom Burden Index (CKD-SBI)
The CKD-SBI, an Arabic version developed by Almutary et al. in 2015, is a tool designed to evaluate the symptoms experienced by individuals with CKD. To compute the total CKD-SBI score, the scores from each of the CKD-SBI subscales (prevalence, distress, severity, and frequency) are summed and then multiplied by 0.1008 (a constant). Consequently, the total score for the CKD-SBI scale ranges from 0 to 100, where a score of 100 signifies the highest possible symptom burden [32]. The severity levels were defined as follows: minimal (0-20), mild (21-40), moderate (41-60), moderate-severe (61-80), and severe (81-100).
Hemodialysis Comfort Questionnaire
In 2018, Estridge et al. adapted the General Comfort Questionnaire specifically for hemodialysis patients from the original Kolcaba scale. The GCQ for hemodialysis patients consists of 48 items and utilizes a six-point Likert-type scale designed to measure comfort in patients undergoing hemodialysis, with higher scores reflecting greater comfort [9].
The instrument employed encompasses both positively and negatively framed items. The items within the instrument are systematically arranged in an interspersed manner, incorporating both positive and negative phrasing. Twenty-five negatively framed questions were included in the instrument to mitigate potential response bias [9]. The instrument was administered at the commencement of the study to assess each participant’s comfort level.
Data analysis
SPSS 26 was utilized for coding and analyzing the data. The distribution of the data was not normal; consequently, non-parametric statistical methods were applied. The Spearman’s rho correlation, Mann-Whitney U test, and Kruskal-Wallis test were employed to analyze the data.
Findings
The mean age of patients was 38.66±10.63 years (range: 22-60 years), and 90.7% were male. Education levels ranged from illiteracy to university education, while 47.5% were unemployed. The majority were married (91.8%), and more than half (55.6%) suffered from chronic diseases. Regarding monthly income, 48.2% earned less than 300,000 Iraqi dinars. In terms of the duration of dialysis, 49.4% underwent treatment for one year (Table 1).
Table 1. Frequency of patients’ socio-demographic characteristics
The total comfort level scores ranged from 129 to 166, with a mean of 144.75±7.70. All patients (100%) had a moderate comfort level, with no cases recorded in the “good” or “poor” comfort categories.
The mean symptom burden score was 44.47±4.93 (range: 34.88-57.96). The majority of patients (193, 75.1%) had moderate levels of symptom burden, while 64 cases (24.9%) reported mild symptom burden.
There was a significant negative relationship between symptom burden and comfort level among the patients (r=-0.610; p=0.01).
Discussion
This study aimed to assess the comfort level of hemodialysis patients and its relationship with symptom burden. The average age of samples was 38.66±10.63 years, and the cohort consisted of 90.7% males. Among them, 31.9% were literate, while 22.2% had attained an intermediate level of education. Nearly half of the patients, specifically 47.5%, were unemployed. Regarding monthly family income, the largest segment, comprising 48.2% of the patients, earned less than 300,000 Iraqi dinars. These findings are consistent with previous studies on dialysis patients, showing that most are male, married, possess a low level of education (either literate or at the intermediate level), and are either jobless or engaged in freelance work [33]. A report published in the Iraqi National Journal of Medicine found that the majority (34.4%) of hemodialysis patients are jobless [34]. In light of these findings, it is evident that a considerable proportion of hemodialysis patients face substantial financial constraints. The high levels of unemployment and precarious work among this patient group have significant implications for their financial stability, access to healthcare, and overall well-being.
Concerning the duration of dialysis, 49.4% of patients had been undergoing treatment for one year, while 27.2% had been treated for two years. This distribution indicates that the majority of them (one year) had a shorter duration compared to Iraqi hemodialysis patients in previous studies, reporting durations of 2 to 8 years [34, 35]. These results suggest an increasing number of patients with chronic kidney failure in recent years.
A moderate patient comfort level was found. Comfort level scores varied between 129 and 166, with a mean of 144.75, indicating that all patients (100%) experienced moderate comfort. In comparison, the study by Bilgiç et al. noted that hemodialysis patients have a moderate perception of stressors [36].
In contrast, their comfort levels exceeded the average. Furthermore, Özdemir highlights that both post-dialysis fatigue and comfort levels are above average, with post-dialysis fatigue negatively impacting patient comfort [8]. It is imperative that healthcare teams, the responsible hospitals, and the patients themselves exert considerable effort to ensure optimal comfort both prior to and throughout the hemodialysis procedure [8, 37].
Most patients had moderate symptom burden, consistent with the most common category on the scale. Notably, these results align with those obtained from prior studies, reporting that the symptoms experienced by hemodialysis patients are generally moderate in severity [38, 39]. Proactive interventions are necessary to effectively manage these symptoms, thereby lessening their impact on health-related quality of life [40].
There was a significant negative relationship between symptom burden and comfort level among the patients. Notably, these results are consistent with those obtained from a prior study, which shows that symptoms related to hemodialysis treatment negatively influence patients’ comfort levels [37].
Moreover, a study by Huiskes et al. reported that increased comfort and reduced symptom burden significantly improve health-related quality of life [41]. By enhancing the factors that influence comfort and quality of life, it is possible to improve patients’ overall comfort and increase their quality of life [42].
These symptoms significantly affect patients’ daily routines and overall comfort. They can persist both during and after dialysis, ultimately harming patients’ daily lives, their relationships, and their overall comfort levels [8, 9]. The accumulation of these symptoms can impact physical comfort and mental well-being, further decreasing overall life satisfaction. Research highlights that symptom management should be a core focus and routinely evaluated by nurses in patients receiving hemodialysis treatment to improve patient comfort levels [8, 21].
As symptom burden increases, physical and mental health quality of life scores decrease [43]. The prevalence and severity of symptoms such as restless legs, muscle cramps, fatigue, and leg swelling indicate the need for better symptom management strategies. Other research shows that the lack of effective interventions for symptoms, like insomnia and restless leg syndrome, further impacts patients’ overall comfort, stressing the need for more targeted therapies [44].
Fatigue experienced by individuals undergoing hemodialysis arises from a multitude of determinants, including nutritional inadequacies, physiological alterations, hemoglobin concentrations, urea levels, and disturbances in sleep patterns [45]. Additionally, symptoms, such as pain, muscle cramps, and dry mouth, may become chronic. The continuous experience of these symptoms may negatively affect patients’ daily lives, relationships with their environment, and comfort levels [38].
It is recommended to develop treatment protocols that target alleviating the most common and recurring symptoms (such as leg restlessness, muscle cramps, fatigue, and leg swelling) by providing physical therapy sessions to improve blood circulation and prescribing nutritional supplements or medications to reduce cramps after a medical consultation. It is also suggested to provide psychological support sessions for patients and their families, especially since the majority are married and young, which may increase family and work pressures. We also recommend enhancing cross-sectoral cooperation, such as partnerships between the Ministries of Health and Labor and charitable organizations, to create integrated programs to support dialysis patients.
Conclusion
There is a significant negative relationship between symptom burden and comfort level in dialysis patients.
Acknowledgments: I sincerely thank the patients who participated in this study and all those who provided scientific support and assistance in completing this research.
Ethical Permissions: The authors obtained permission from the scientific committee in the College of Nursing at the University of Baghdad (Code: 12-28/10/2024) in Baghdad.
Conflicts of Interests: There are no conflicts of interests.
Authors' Contribution: Qaed AR (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (70%); Atiyah HH (Second Author), Introduction Writer/Assistant Researcher/Discussion Writer (30%)
Funding/Support: No funding was received.
The global community involved in dialysis is growing rapidly, with an estimated 2.5 million people receiving dialysis treatment in 2020, and this number is expected to rise to 5.4 million by 2030 [1, 2]. This increase underscores the urgent need for healthcare systems to adapt and expand their resources to accommodate the growing patient population. As the number of individuals requiring dialysis continues to rise, healthcare facilities must ensure that they have the necessary infrastructure, including sufficient dialysis machines, trained personnel, and adequate space to meet patient demand. Additionally, there is a pressing need for healthcare policies that prioritize access to dialysis treatment, particularly in underserved regions where resources may be limited. Investment in technology and telemedicine could also play a crucial role in providing support and monitoring for patients, making treatment more accessible and efficient.
Dialysis is characterized as a significant and resource-intensive medical intervention that places substantial financial, physical, and psychological demands on patients and their caregivers [3]. The financial burden often includes not only the cost of the dialysis treatment itself but also associated expenses, such as transportation to treatment facilities, nutritional supplements, and medications. Many patients must navigate complex insurance policies or face out-of-pocket expenses that can strain their financial resources, leading to anxiety and stress about their economic stability. Furthermore, some patients may experience a loss of income due to their health condition, as frequent treatments can limit their ability to work, adding an additional layer of financial insecurity. Individuals undergoing dialysis frequently endure profound symptoms, diminished psychological health, and heightened levels of stress [4]. The psychological health of dialysis patients is often compromised, with many experiencing feelings of anxiety and depression as they grapple with the realities of a chronic illness. The burden of managing a demanding treatment regimen, along with fears about health deterioration and potential complications, can lead to a pervasive sense of hopelessness. Heightened levels of stress are common among dialysis patients and their families, as they navigate not only the physical demands of treatment but also the emotional and financial strains that accompany it. Caregivers may also experience significant stress as they balance their own needs with those of the patient, often sacrificing their well-being to provide support.
Research indicates that sleep disturbances represent the predominant burden symptom experienced by hemodialysis patients. Moreover, an additional study indicated that a significant percentage of patients (exceeding 70%) report the presence of fatigue and dry mouth. In contrast, symptoms, such as myalgia and pruritus, are noted in approximately 40-60% of the patient population [5, 6]. This symptomatology adversely influences overall quality of life and frequently results in discomfort between or during dialysis sessions [7].
Burden symptoms, including fatigue, pruritus, sexual dysfunction, sleep disturbances, and pain, markedly affect patients’ daily activities and overall well-being. These distressing symptoms may persist throughout and after dialysis treatments, ultimately influencing patients’ daily existence, interpersonal relationships, and general quality of life [8, 9]. For instance, fatigue can lead to reduced participation in social activities, making it difficult for patients to maintain connections with friends and family, which can further exacerbate feelings of isolation and depression. Similarly, sexual dysfunction can strain intimate relationships, creating additional emotional stress and contributing to the overall burden of the illness. The management of pruritic symptoms is critical for enhancing quality of life and alleviating sleep disturbances in individuals with renal failure [10]. Persistent itching can disrupt sleep patterns, leading to a cycle of sleep deprivation that exacerbates fatigue and impairs cognitive function during waking hours. Effective treatment strategies, such as topical therapies or medications, are essential for addressing pruritus and promoting better sleep hygiene, which can significantly improve patients’ overall sense of well-being.
These patients face challenges that severely impact their independence and restrict various aspects of their daily lives [11, 12]. These difficulties adversely affect their quality of life and sense of comfort [13]. Therefore, it is important to regularly evaluate the comfort levels of dialysis patients [14]. A study found that patients undergoing hemodialysis reported a medium level of comfort [15]. Focusing on patient comfort is one of the key goals and responsibilities of nurses. Nurses play a crucial role in providing care for individuals with long-term kidney failure undergoing hemodialysis [16, 17].
Effective hemodialysis procedures for individuals with kidney failure rely on patients adhering to their prescribed treatment plans [18]. Consistent compliance is essential not only for optimizing the effectiveness of the dialysis sessions but also for preventing complications that can arise from missed treatments or inadequate fluid and dietary restrictions. When patients fail to adhere to their treatment schedules, they may experience a buildup of toxins and excess fluid in their bodies, leading to severe health issues such as hypertension, heart problems, and increased fatigue. Noncompliance may lead to increased discomfort for patients between their hemodialysis sessions [9, 19]. As a result, patients may endure heightened symptoms, including swelling, shortness of breath, and general malaise, which can significantly impair their overall quality of life. Moreover, the physical discomfort often translates into emotional distress, as patients may feel frustrated and hopeless about their condition, further perpetuating a cycle of noncompliance. Addressing the barriers to adherence, such as a lack of understanding about the treatment process or difficulties in accessing care, is crucial for healthcare providers.
The accumulation of these symptoms can affect physical comfort and mental well-being, further decreasing overall life satisfaction [20]. Research highlights that symptom management should be a core focus for improving patient comfort levels, as symptoms such as fatigue, pain, and sleep issues are linked to higher rates of depression and anxiety in patients [21, 22].
Globally, symptom burden has been recorded and measured in various chronic disease populations, such as those with heart disease [23, 24], diabetes [25, 26], renal failure [27, 28], and even dialysis [29, 30]. However, only a few studies have been conducted to assess symptom burden [31], especially among CKD patients or dialysis populations in Iraq.
This study aimed to assess the comfort level of hemodialysis patients and its relationship with symptom burden.
Instrument and Methods
Study design and Sample
This descriptive cross-sectional study was conducted in three governorates, Najaf, Karbala, and Diwaniyah, in Iraq from October 28, 2024, to June 7, 2025. The kidney dialysis centers in these areas are Fatima Al-Zahra and Al-Hayat in Al-Diwaniyah, Al-Hakeem and Al-Sadr in Al-Najaf, and Habib Bin Mazahir Al-Asadi and Dr. Adel Al-Sabbah in Karbala.
The study sample was selected using a non-probability (purposive) sampling method, which included 257 patients from the dialysis centers. The sample was collected based on the inclusion and exclusion criteria. The participants consisted of adults diagnosed with renal failure who were undergoing hemodialysis, at least 18 years old, of both sexes, who agreed to participate, and were able to read and write. Participation in this study was voluntary. Patients with cognitive impairments that would affect their ability to complete questionnaires, those who were unable to read or write, or those who refused to participate were excluded.
Research tools
Demographic data form
This form collected demographic information from the patients, including age, sex, level of education, occupation, marital status, the presence of chronic diseases, household composition, family monthly income, and duration of dialysis.
Chronic Kidney Disease Symptom Burden Index (CKD-SBI)
The CKD-SBI, an Arabic version developed by Almutary et al. in 2015, is a tool designed to evaluate the symptoms experienced by individuals with CKD. To compute the total CKD-SBI score, the scores from each of the CKD-SBI subscales (prevalence, distress, severity, and frequency) are summed and then multiplied by 0.1008 (a constant). Consequently, the total score for the CKD-SBI scale ranges from 0 to 100, where a score of 100 signifies the highest possible symptom burden [32]. The severity levels were defined as follows: minimal (0-20), mild (21-40), moderate (41-60), moderate-severe (61-80), and severe (81-100).
Hemodialysis Comfort Questionnaire
In 2018, Estridge et al. adapted the General Comfort Questionnaire specifically for hemodialysis patients from the original Kolcaba scale. The GCQ for hemodialysis patients consists of 48 items and utilizes a six-point Likert-type scale designed to measure comfort in patients undergoing hemodialysis, with higher scores reflecting greater comfort [9].
The instrument employed encompasses both positively and negatively framed items. The items within the instrument are systematically arranged in an interspersed manner, incorporating both positive and negative phrasing. Twenty-five negatively framed questions were included in the instrument to mitigate potential response bias [9]. The instrument was administered at the commencement of the study to assess each participant’s comfort level.
Data analysis
SPSS 26 was utilized for coding and analyzing the data. The distribution of the data was not normal; consequently, non-parametric statistical methods were applied. The Spearman’s rho correlation, Mann-Whitney U test, and Kruskal-Wallis test were employed to analyze the data.
Findings
The mean age of patients was 38.66±10.63 years (range: 22-60 years), and 90.7% were male. Education levels ranged from illiteracy to university education, while 47.5% were unemployed. The majority were married (91.8%), and more than half (55.6%) suffered from chronic diseases. Regarding monthly income, 48.2% earned less than 300,000 Iraqi dinars. In terms of the duration of dialysis, 49.4% underwent treatment for one year (Table 1).
Table 1. Frequency of patients’ socio-demographic characteristics
The total comfort level scores ranged from 129 to 166, with a mean of 144.75±7.70. All patients (100%) had a moderate comfort level, with no cases recorded in the “good” or “poor” comfort categories.
The mean symptom burden score was 44.47±4.93 (range: 34.88-57.96). The majority of patients (193, 75.1%) had moderate levels of symptom burden, while 64 cases (24.9%) reported mild symptom burden.
There was a significant negative relationship between symptom burden and comfort level among the patients (r=-0.610; p=0.01).
Discussion
This study aimed to assess the comfort level of hemodialysis patients and its relationship with symptom burden. The average age of samples was 38.66±10.63 years, and the cohort consisted of 90.7% males. Among them, 31.9% were literate, while 22.2% had attained an intermediate level of education. Nearly half of the patients, specifically 47.5%, were unemployed. Regarding monthly family income, the largest segment, comprising 48.2% of the patients, earned less than 300,000 Iraqi dinars. These findings are consistent with previous studies on dialysis patients, showing that most are male, married, possess a low level of education (either literate or at the intermediate level), and are either jobless or engaged in freelance work [33]. A report published in the Iraqi National Journal of Medicine found that the majority (34.4%) of hemodialysis patients are jobless [34]. In light of these findings, it is evident that a considerable proportion of hemodialysis patients face substantial financial constraints. The high levels of unemployment and precarious work among this patient group have significant implications for their financial stability, access to healthcare, and overall well-being.
Concerning the duration of dialysis, 49.4% of patients had been undergoing treatment for one year, while 27.2% had been treated for two years. This distribution indicates that the majority of them (one year) had a shorter duration compared to Iraqi hemodialysis patients in previous studies, reporting durations of 2 to 8 years [34, 35]. These results suggest an increasing number of patients with chronic kidney failure in recent years.
A moderate patient comfort level was found. Comfort level scores varied between 129 and 166, with a mean of 144.75, indicating that all patients (100%) experienced moderate comfort. In comparison, the study by Bilgiç et al. noted that hemodialysis patients have a moderate perception of stressors [36].
In contrast, their comfort levels exceeded the average. Furthermore, Özdemir highlights that both post-dialysis fatigue and comfort levels are above average, with post-dialysis fatigue negatively impacting patient comfort [8]. It is imperative that healthcare teams, the responsible hospitals, and the patients themselves exert considerable effort to ensure optimal comfort both prior to and throughout the hemodialysis procedure [8, 37].
Most patients had moderate symptom burden, consistent with the most common category on the scale. Notably, these results align with those obtained from prior studies, reporting that the symptoms experienced by hemodialysis patients are generally moderate in severity [38, 39]. Proactive interventions are necessary to effectively manage these symptoms, thereby lessening their impact on health-related quality of life [40].
There was a significant negative relationship between symptom burden and comfort level among the patients. Notably, these results are consistent with those obtained from a prior study, which shows that symptoms related to hemodialysis treatment negatively influence patients’ comfort levels [37].
Moreover, a study by Huiskes et al. reported that increased comfort and reduced symptom burden significantly improve health-related quality of life [41]. By enhancing the factors that influence comfort and quality of life, it is possible to improve patients’ overall comfort and increase their quality of life [42].
These symptoms significantly affect patients’ daily routines and overall comfort. They can persist both during and after dialysis, ultimately harming patients’ daily lives, their relationships, and their overall comfort levels [8, 9]. The accumulation of these symptoms can impact physical comfort and mental well-being, further decreasing overall life satisfaction. Research highlights that symptom management should be a core focus and routinely evaluated by nurses in patients receiving hemodialysis treatment to improve patient comfort levels [8, 21].
As symptom burden increases, physical and mental health quality of life scores decrease [43]. The prevalence and severity of symptoms such as restless legs, muscle cramps, fatigue, and leg swelling indicate the need for better symptom management strategies. Other research shows that the lack of effective interventions for symptoms, like insomnia and restless leg syndrome, further impacts patients’ overall comfort, stressing the need for more targeted therapies [44].
Fatigue experienced by individuals undergoing hemodialysis arises from a multitude of determinants, including nutritional inadequacies, physiological alterations, hemoglobin concentrations, urea levels, and disturbances in sleep patterns [45]. Additionally, symptoms, such as pain, muscle cramps, and dry mouth, may become chronic. The continuous experience of these symptoms may negatively affect patients’ daily lives, relationships with their environment, and comfort levels [38].
It is recommended to develop treatment protocols that target alleviating the most common and recurring symptoms (such as leg restlessness, muscle cramps, fatigue, and leg swelling) by providing physical therapy sessions to improve blood circulation and prescribing nutritional supplements or medications to reduce cramps after a medical consultation. It is also suggested to provide psychological support sessions for patients and their families, especially since the majority are married and young, which may increase family and work pressures. We also recommend enhancing cross-sectoral cooperation, such as partnerships between the Ministries of Health and Labor and charitable organizations, to create integrated programs to support dialysis patients.
Conclusion
There is a significant negative relationship between symptom burden and comfort level in dialysis patients.
Acknowledgments: I sincerely thank the patients who participated in this study and all those who provided scientific support and assistance in completing this research.
Ethical Permissions: The authors obtained permission from the scientific committee in the College of Nursing at the University of Baghdad (Code: 12-28/10/2024) in Baghdad.
Conflicts of Interests: There are no conflicts of interests.
Authors' Contribution: Qaed AR (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (70%); Atiyah HH (Second Author), Introduction Writer/Assistant Researcher/Discussion Writer (30%)
Funding/Support: No funding was received.
Keywords:
References
1. Bello AK, Okpechi IG, Osman MA, Cho Y, Htay H, Jha V, et al. Epidemiology of haemodialysis outcomes. Nat Rev Nephrol. 2022;18(6):378-95. [Link] [DOI:10.1038/s41581-022-00542-7]
2. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020;395(10225):709-33. [Link] [DOI:10.1016/S0140-6736(19)32977-0]
3. Yaseen AKM, AL-Fayyadh S. Effect of social support and spiritual well-being on the quality of life of patients undergoing hemodialysis. South East Eur J Public Health. 2024;XXIV:760-77. [Link] [DOI:10.70135/seejph.vi.1332]
4. Qi S, Yang Q, Hu S, Wang Y, Yang J, Li J, et al. The benefits of virtual reality travel on symptom burden and mental health of hemodialysis patients. J Pain Symptom Manage. 2025;69(3):e247-56. [Link] [DOI:10.1016/j.jpainsymman.2024.11.018]
5. Bossola M, Mariani I, Piccinni CP, Spoliti C, Di Stasio E. Symptom burden in patients on maintenance hemodialysis: Prevalence and severity 17 years apart. J Clin Med. 2024;13(18):5529. [Link] [DOI:10.3390/jcm13185529]
6. You AS, Kalantar SS, Norris KC, Peralta RA, Narasaki Y, Fischman R, et al. Dialysis symptom index burden and symptom clusters in a prospective cohort of dialysis patients. J Nephrol. 2022;35(5):1427-36. [Link] [DOI:10.1007/s40620-022-01313-0]
7. Zhou K, Ning F, Wang W, Li X. The mediator role of resilience between psychological predictors and health-related quality of life in breast cancer survivors: A cross-sectional study. BMC Cancer. 2022;22(1):57. [Link] [DOI:10.1186/s12885-022-09177-0]
8. Özdemir Ö. Postdialysis fatigue and comfort levels of patients receiving hemodialysis treatment. BANDIRMA ONYEDI EYLÜL ÜNIVERSITESI SAĞLIK BILIM VE ARAŞTIRMALARI DERGISI. 2024;6(2):356-65. [Link] [DOI:10.46413/boneyusbad.1439000]
9. Estridge KM, Morris DL, Kolcaba K, Winkelman C. Comfort and fluid retention in adult patients receiving hemodialysis. Nephrol Nurs J. 2018;45(1):25-60. [Link]
10. Aliwy NH, Mohammed WK. Effectiveness of an education program on hemodialysis patient's toward alleviate of itching at Al-Hussein Teaching Hospital in al-Nasiriyah City. Indian J Public Health Res Dev. 2018;9(10):617. [Link] [DOI:10.5958/0976-5506.2018.01201.9]
11. Kadhum I, Mohammed W. Nutritional status of adult hemodialysis patients in Al-Najaf al-Ashraf governorate. Iraqi Natl J Nurs Spec. 2012;25(1):64-78. [Link] [DOI:10.58897/injns.v25i1.119]
12. Jawad A, Okab A. Assessment of risk factors among renal failurepatients in Baghdad teaching hospital. Iraqi Natl J Nurs Spec. 2017;30(2):63-71. [Link] [DOI:10.58897/injns.v30i2.281]
13. Aktürk Ü, Erci B, Dural G. Comparison of quality of life and comfort levels in patients with three different chronic diseases. J Samsun Health Sci. 2023;8(1):113-28. [Link] [DOI:10.47115/jshs.1120474]
14. Yanmiş S, Molllaoğlu M. Comfort level of patients undergoing hemodialysis and associated factors in Turkey: A cross-sectional study. Niger J Clin Pract. 2024;27(6):779-84. [Link] [DOI:10.4103/njcp.njcp_890_23]
15. Gülay T, Özdemir Eler Ç, Ökdem Ş, Akgün Çitak E. Examining the comfort level of hemodialysis patients. HACETTEPE ÜNIVERSITESI HEMŞIRELIK FAKÜLTESI DERGISI. 2020;7(2):122-9. [Turkish] [Link] [DOI:10.31125/hunhemsire.763155]
16. Zarurati M, Pishgooie SA, Farsi Z, Karbaschi K. The effect of music therapy on comfort level and some vital signs of patients undergoing hemodialysismodialysis. Mil Caring Sci. 2016;3(4):221-32. [Persian] [Link] [DOI:10.18869/acadpub.mcs.3.4.221]
17. Bakey SJ. Hemodialysis nurses' practices toward hand hygiene performance at Baghdad Teaching Hospitals. Indian J Public Health Res Dev. 2019;10(4):615-21. [Link] [DOI:10.5958/0976-5506.2019.00768.X]
18. Hermis AH, Abed RI. Effectiveness of self-regulation fluid program on patients with hemodialysis self-efficacy for fluid adherence in Al-Diwaniyah Teaching Hospital. Iraqi Natl J Nurs Spec. 2021;34(2):74-88. [Link] [DOI:10.58897/injns.v34i2.577]
19. Al-Jubouri MB, Jaafar SA, Abbas MK, Gazi IN, Shawwat MA, Karmoud KF, et al. Using cryotherapy, EMLA (eutectic lidocaine/prilocaine) cream, or lidocaine spray to reduce pain during arteriovenous fistula puncture: A randomized controlled trial. Hemodial Int. 2024;28(3):270-7. [Link] [DOI:10.1111/hdi.13152]
20. Al-Juboori AKK, Khudhur IAG, Faris SH. Depression among patients with renal failure undergoing haemodialysis treatment in holy Kerbala City in Iraq. Medico Leg Update. 2020;20(1):1002-7. [Link]
21. Hnynn Si PE, Gair R, Barnes T, Dunn L, Lee S, Ariss S, et al. Symptom burden according to dialysis day of the week in three times a week haemodialysis patients. PLoS One. 2022;17(9):e0274599. [Link] [DOI:10.1371/journal.pone.0274599]
22. Hameed Z, Sachit K. Spiritual coping strategies for patients with chronic renal failure. Iraqi Natl J Nurs Spec. 2018;31(2):103-16. [Link] [DOI:10.58897/injns.v31i2.311]
23. Reynolds HR, Shaw LJ, Min JK, Spertus JA, Chaitman BR, Berman DS, et al. Association of sex with severity of coronary artery disease, ischemia, and symptom burden in patients with moderate or severe ischemia: Secondary analysis of the ISCHEMIA randomized clinical trial. JAMA Cardiol. 2020;5(7):773-86. [Link] [DOI:10.1001/jamacardio.2020.0822]
24. Tan W, Aboulhosn J. The cardiovascular burden of coronavirus disease 2019 (COVID-19) with a focus on congenital heart disease. Int J Cardiol. 2020;309:70-7. [Link] [DOI:10.1016/j.ijcard.2020.03.063]
25. Tomic D, Shaw JE, Magliano DJ. The burden and risks of emerging complications of diabetes mellitus. Nat Rev Endocrinol. 2022;18(9):525-39. [Link] [DOI:10.1038/s41574-022-00690-7]
26. Dugani SB, Mielke MM, Vella A. Burden and management of type 2 diabetes in rural United States. Diabetes Metab Res Rev. 2021;37(5):e3410. [Link] [DOI:10.1002/dmrr.3410]
27. Ng MSN, Wong CL, Ho EHS, Hui YH, Miaskowski C, So WKW. Burden of living with multiple concurrent symptoms in patients with end-stage renal disease. J Clin Nurs. 2020;29(13-14):2589-601. [Link] [DOI:10.1111/jocn.15282]
28. Lu Y, Zhai S, Liu Q, Dai C, Liu S, Shang Y, et al. Correlates of symptom burden in renal dialysis patients: A systematic review and meta-analysis. Ren Fail. 2024;46(2):2382314. [Link] [DOI:10.1080/0886022X.2024.2382314]
29. Limbong EO, Pahria T, Pratiwi SH. Symptom burden's associated factors among hemodialysis patients. JURNAL KEPERAWATAN PADJADJARAN. 2020;8(3):208-20. [Link] [DOI:10.24198/jkp.v8i3.1448]
30. Song YY, Chen L, Yu WW, Wang WX, Yang DJ, Jiang XL. Correlates of symptom burden of hemodialysis patients. West J Nurs Res. 2021;43(5):459-67. [Link] [DOI:10.1177/0193945920957229]
31. Hussain AM, Lafta RK. Burden of non-communicable diseases in Iraq after the 2003 war. Saudi Med J. 2019;40(1):72-8. [Link] [DOI:10.15537/smj.2019.1.23463]
32. Almutary H, Bonner A, Douglas C. Arabic translation, adaptation and modification of the dialysis symptom index for chronic kidney disease stages four and five. BMC Nephrol. 2015;16:36. [Link] [DOI:10.1186/s12882-015-0036-2]
33. Abid MA, Mohammed TR. Hardiness shields against depression in Iraqi dialysis patients. Acad Open. 2024;9(2). [Link] [DOI:10.21070/acopen.9.2024.9281]
34. ALkhaqani A. Effectiveness of resistance exercise therapy on patients' physiological status during hemodialysis: A randomized controlled trial. Iraqi Natl J Med. 2022;4(2):177-94. [Link] [DOI:10.37319/iqnjm.4.2.3]
35. Jassem ZA, Al-Ashour IA. Health literacy among patients undergoing hemodialysis: A descriptive study. Iraqi Natl J Nurs Spec. 2023;36(2):41-8. [Link] [DOI:10.5455/rmj.20230602053431]
36. Bilgiç Ş, Pamuk Cebeci S. Relationship between stressors and comfort level in hemodialysis patients. Arch Health Sci Res. 2022;9(2):105-9. [Link] [DOI:10.54614/ArcHealthSciRes.2022.21146]
37. Borzou SR, Anosheh M, Mohammadi E, Kazemnejad A. Patients' perception of comfort facilitators during hemodialysis procedure: A qualitative study. Iran Red Crescent Med J. 2014;16(7):e19055. [Link] [DOI:10.5812/ircmj.19055]
38. Dikmen RD, Aslan H. The effects of the symptoms experienced by patients undergoing hemodialysis treatment on their comfort levels. J Clin Nephrol Ren Care. 2020;6(2):2-9. [Link] [DOI:10.23937/2572-3286.1510060]
39. Yang N, Ornstein KA, Reckrey JM. Association between symptom burden and time to hospitalization, nursing home placement, and death among the chronically ill urban homebound. J Pain Symptom Manage. 2016;52(1):73-80. [Link] [DOI:10.1016/j.jpainsymman.2016.01.006]
40. Nixon AC, Wilkinson TJ, Young HML, Taal MW, Pendleton N, Mitra S, et al. Symptom-burden in people living with frailty and chronic kidney disease. BMC Nephrol. 2020;21(1):411. [Link] [DOI:10.1186/s12882-020-02063-6]
41. Huiskes BL, Heywood JT, Dracup K. Comfort and symptom burden associated with health-related quality of life in older women with advanced heart failure and preserved systolic function. J Card Fail. 2011;17(8):S5. [Link] [DOI:10.1016/j.cardfail.2011.06.015]
42. Demir Erbaş Ş, Akman Yılmaz A, Gençer Şendur E. Comfort and quality of life of older cardiac patients: A cross-sectional study. Eur J Geriatr Gerontol. 2023;5(2):116-23. [Link] [DOI:10.4274/ejgg.galenos.2023.2022-12-3]
43. Speyer E, Tu C, Zee J, Sesso R, Lopes AA, Moutard E, et al. Symptom burden and its impact on quality of life in patients with moderate to severe CKD: The international chronic kidney disease outcomes and practice patterns study (CKDopps). Am J Kidney Dis. 2024;84(6):696-707. [Link] [DOI:10.1053/j.ajkd.2024.06.011]
44. Bossola M, Pepe G, Picca A, Calvani R, Marzetti E. Treating symptoms to improve the quality of life in patients on chronic hemodialysis. Int Urol Nephrol. 2019;51(5):885-7. [Link] [DOI:10.1007/s11255-019-02121-5]
45. Ahmady S, Rezaei M, Khatony A. Comparing effects of aromatherapy with lavender essential oil and orange essential oil on fatigue of hemodialysis patients: A randomized trial. Complement Ther Clin Pract. 2019;36:64-8. [Link] [DOI:10.1016/j.ctcp.2019.05.005]