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The relationship between fatigue,
pruritus, and thirst distress
with quality of life among patients
receiving hemodialysis: a mediator
model to test concept of treatment
adherence
Hamid Sharif‑Nia
1,2, João Marôco
3, Erika Sivarajan Froelicher
4,5, Saeed Barzegari
6,
Niloofar Sadeghi
6 & Reza Fatehi
7*
Hemodialysis is a conservative treatment for end‑stage renal disease. It has various complications
which negatively aect quality of life (QOL). This study aimed to examine the relationship between
fatigue, pruritus, and thirst distress (TD) with QOL of patients receiving hemodialysis, while also
considering the mediating role of treatment adherence (TA). This cross‑sectional study was carried
out in 2023 on 411 patients receiving hemodialysis. Participants were consecutively recruited from
several dialysis centers in Iran. Data were collected using a demographic information form, the Fatigue
Assessment Scale, the Thirst Distress Scale, the Pruritus Severity Scale, the 12‑Item Short Form
Health Survey, and the modied version of the Greek Simplied Medication Adherence Questionnaire
for Hemodialysis Patients. Covariance‑based structural equation modeling was used for data analysis.
The structural model and hypothesis testing results showed that all hypotheses were supported in
this study. QOL had a signicant inverse association with fatigue, pruritus, and TD and a signicant
positive association with TA. TA partially mediated the association of QOL with fatigue, pruritus,
and TD, denoting that it helped counteract the negative association of these complications on QOL.
This model explained 68.5% of the total variance of QOL. Fatigue, pruritus, and TD have a negative
association with QOL among patients receiving hemodialysis, while TA reduces these negative
associations. Therefore, TA is greatly important to manage the associations of these complications
and improve patient outcomes. Healthcare providers need to assign high priority to TA improvement
among these patients to reduce their fatigue, pruritus, and TD and improve their QOL. Further studies
are necessary to determine the most eective strategies for improving TA and reducing the burden of
complications in this patient population.
Keywords Fatigue, Hemodialysis, Pruritus, Quality of life, irst distress, Treatment adherence
Chronic kidney disease (CKD) is one of the most prevalent chronic illnesses throughout the world. It involves
structural injuries to the kidney and a glomerular ltration rate (GFR) below 60mL/min/1.73 m2 persisting
for at least 3 months1. e global prevalence of CKD is as high as 10% or 800 million people2. Its prevalence is
OPEN
1Psychosomatic Research Center, Mazandaran University of Medical Sciences, Sari, Iran. 2Department of Nursing,
Amol School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran. 3William James
Centre for Research ISPA–Instituto Universitário, Lisbon, Portugal. 4Department of Physiological Nursing,
School of Nursing, University of California San Francisco, San Francisco, CA, USA. 5Department of Epidemiology
& Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA. 6Department
of Paramedicine, Amol School of Paramedical Sciences, Mazandaran University of Medical Sciences, Sari,
Iran. 7Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran. *email: r3fatehi@
gmail.com
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8–16% in the world3 and almost 20% in Iran4. Predictions show that CKD will be the h leading cause of death
in the world by 20405.
Currently, hemodialysis is the most common treatment option for CKD before kidney transplantation6.
Hemodialysis is a procedure that lters a patient’s blood through a machine, removing waste substances and
excess water by passing them across a semi-permeable membrane7. Almost 69% of all patients with CKD8 and
49% of them in Iran receive hemodialysis9. A study reported that in 2016, around 30,000 patients in Iran received
hemodialysis6.
CKD and hemodialysis cause dierent complications10, including fatigue. By denition, fatigue is a feeling of
a lack of energy that interferes with the performance of daily activities11. Its prevalence among patients receiving
hemodialysis is 60–80%12. e contributing factors to fatigue among these patients include anemia, uremia, inap-
propriate diet, hemodialysis ineciency, sedentary lifestyle, sleep pattern disorders, uid restriction, dehydration,
and other comorbid conditions13,14. Fatigue can lead to mental and physical weakness, non-adherence to medica-
tions, absence from hemodialysis sessions, depression, and heavy costs for patients and societies15,16. Fatigue-
induced depression and altered immunity can also lead to skin inammation, skin infections, and pruritus17,18.
Pruritus is very common among patients who receive hemodialysis. Uremic pruritus is attributed to CKD and
end-stage renal disease in the absence of primary dermatologic ndings and other pruritus-inducing disorders
such as eczema19. With a prevalence of 20%–50%, pruritus is one of the most common contributing factors to
discomfort in CKD20. e major causes of pruritus in CKD are cytokines, hyperparathyroidism, hyperkalemia,
hyperphosphatemia, uremia, anemia21, and waste product accumulation in the skin22. Pruritus can lead to ero-
sion at the vascular access site and loss of the hemodialysis session19.
irst distress (TD) is another very common complication of CKD and hemodialysis with a prevalence of
67–97%23. TD is a subjective perception dened as a sense of mouth dryness with a desire for uid intake24.
Patients with CKD suer from impaired urine production and hence the intake of foodstus and uids can lead
to uid overload and hypoosmolality. Hence, increased desire for salt intake which is associated with TD. TD
can also lead to dryness in the mouth, reduced energy, and fatigue25,26. ese complications may interact with
each other, leading to a harmful cycle of negative physical and mental health outcomes.
Fatigue13, pruritus21, and TD25 among patients receiving hemodialysis can negatively aect their QOL. QOL
among these patients refers to general well-being, satisfaction, and ability to perform daily activities while receiv-
ing hemodialysis, and includes physical health, psychoemotional well-being, social functioning, and general
satisfaction with life27. Fatigue can reduce patients’ QOL by reducing their motivation for treatment continua-
tion, impairing their social relationships, and reducing their sleep quality11. Pruritus also reduces their QOL by
disturbing the patient’s social balance, causing them fatigue, increasing their anxiety, and impairing their daily
activities19. TD also negatively aects their QOL because the necessity of uid restriction causing them to feel
thirsty, which in turn leads to negative emotions such as guilt, anxiety, and discomfort25. A systematic review
of 45 studies with a total population of 17,000 patients with CKD reported that they had poor QOL10. Several
other studies also reported low to moderate QOL among these patients28–32.
Treatment adherence (TA) is one of the factors with a potentially positive impact on CKD and hemodialy-
sis complications, patient’ QOL33, and hemodialysis outcomes34. It consists of adherence to dietary regimen,
medications, uid restriction, and regular attendance at hemodialysis sessions34. By denition, TA refers to
patients’ active engagement in a course of acceptable health-related behaviors which lead to positive treatment
outcomes35. As hemodialysis is not a perfect substitute for kidneys, TA is of great importance to maintaining
the patient’s health36, so hemodialysis has limited eciency in the absence of TA37. Patients receiving hemodi-
alysis need to restrict phosphorus intake while they need to receive adequate protein to prevent malnutrition38.
Moreover, their adherence to salt restriction can reduce their TD39. Close adherence to pharmacological and
non-pharmacological therapies such as nutrition therapy, sleep improvement modalities, stress management,
physical exercise, and yoga can reduce fatigue among these patients40. Moreover, adherence to treatments for
anemia can increase hemoglobin levels and oxygen transport and thereby, reduce fatigue41. Nonetheless, a study
reported that poor TA among patients receiving hemodialysis is as high as 50%42. Another study showed that
86% of patients receiving hemodialysis had poor adherence to dietary regimens and 86% of them did not adhere
to some dietary restrictions43. Similarly, a study revealed that 33% of these patients had poor adherence to uid
restriction44. Another study also found that one-fourth of patients with end-stage renal disease had a history of
absence from hemodialysis sessions during the past month45. Generally speaking, estimations show that non-
adherence to medication regimens among these patients varies from 3 to 80%46. Such poor TA can increase the
complications of hemodialysis42,47. Moreover, the absence of hemodialysis sessions increases waste products in
the body48 and increases the mortality rate42. Contributing factors to poor TA include the large number and
unpleasant taste of some medications, the complexity of treatments49, and the side eects of medications50,51.
Literature review
Previous studies on patients receiving hemodialysis reported the inverse relationship of their QOL with their
fatigue52,53, pruritus18,54,55, and TD25,49,56. e QOL of these patients is also aected by factors such as the long-
term course of their treatment, complex treatment regimens, dermatologic manifestations, and lifestyle changes57.
ese ndings denote that the eective management of these problems may improve patients’ QOL. Respecting
TA, dierent studies found a positive correlation with the QOL of patients receiving hemodialysis58–61. However,
some studies reported no signicant relationship between TA and QOL62. Moreover, there is limited data about
the combined association of fatigue, pruritus, TD, and TA with QOL. erefore, the current study was conducted
in order to examine the inter-relationships of fatigue, pruritus, and TD with QOL and the potential mediating
role of TA among patients receiving hemodialysis.
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Conceptual framework of the study
e conceptual framework of this study was the symptom management theory (SMT). is theory emphasizes
the importance of symptom management to improve QOL63. e four components of this theory are symptom
experience, symptom management strategies, outcomes, and inuential factors on symptom management. is
theory focuses on the perception and management of the symptoms that patients experience with chronic
illnesses. It focuses on the dynamic and multidimensional characteristics of the symptoms while considering
the complex interaction of biological, psychological, and social factors that inuence symptom experience. It
also provides a comprehensive approach to evaluate, measure, and manage symptoms to improve QOL among
dierent patient populations. is theory considers symptom management as a complex and multidisciplinary
phenomenon that needs the collaboration and interaction of healthcare providers, patients, and families64,65.
SMT is a critical approach that aims to address and alleviate symptoms experienced by patients to enhance their
QOL66. Specically in the context of hemodialysis, this theory plays a crucial role in controlling common side
eects such as fatigue, pruritus, and TD. By understanding the interconnected nature of symptoms and their
impact on patient’s well-being, healthcare providers can develop personalized interventions to eectively manage
these symptoms. e theory underscores the signicance of tailored and precise symptom management strate-
gies to enhance patient outcomes67–69.
By utilizing the SMT, healthcare providers can implement comprehensive symptom management programs
that address these side eects holistically. rough a systematic approach that takes into account the synergy
between symptoms, providers can eectively classify and manage symptom clusters. is shi in focus from
individual symptoms to interconnected symptom clusters allows for a more targeted and comprehensive man-
agement strategy69,70.
By understanding the relationships between symptoms such as fatigue, pruritus, and TD, healthcare providers
can develop interventions that not only alleviate these side eects but also enhance treatment adherence. TA may
serve as a mediating factor that helps mitigate the negative eects of symptoms on QOL. erefore, by integrat-
ing the principles of SMT into practice, healthcare providers can optimize patient care by eectively controlling
common side eects associated with hemodialysis, ultimately leading to improved patient outcomes68,71.
Research problems
Based on the literature and proposed conceptual model, the following hypotheses are raised:
1. Fatigue reduces the QOL of patients undergoing hemodialysis.
2. Pruritus reduces the QOL of patients undergoing hemodialysis.
3. TD reduces the QOL of patients undergoing hemodialysis.
4. TA increases the QOL of patients undergoing hemodialysis.
5. e mediating role of TA may explain the relationship between fatigue and QOL of patients undergoing
hemodialysis.
6. e mediating role of TA may explain the relationship between pruritus and QOL of patients undergoing
hemodialysis.
7. e mediating role of TA may explain the relationship between TD and QOL of patients undergoing hemo-
dialysis.
Responding to these problems can help clarify if addressing adherence is crucial for improving patients’ well-
being beyond managing only the complications.
Methods
Design and participants
is cross-sectional study was carried out using structural equation modeling between September to October
2023.
e population of the study consisted of all patients with CKD who received hemodialysis. Participants were
consecutively selected from four hospitals in Amol, Iran. Inclusion criteria were to be above eighteen years old
and to have received hemodialysis for at least one year before the study. Exclusion criteria were peritoneal dialysis,
kidney transplantation, emergency hemodialysis, and acute renal failure during the study. e sample size was
calculated for structural equation modeling72 with a moderate eect size of 0.2573, a power of 0.80, a condence
level of 0.95, ve latent factors, and 48 items of the data collection instruments. Calculations showed that 229
participants were necessary. Nonetheless, considering an attrition rate of at least 10% due to missing data, the
sample size was increased to 252 and nally, 411 patients were recruited to the study.
Data collection instruments
e instruments for data collection were as follows.
Demographic information form
is data collection form included items on age, gender, employment status, level of education, marital status,
social support, duration of hemodialysis sessions, time on hemodialysis, and aiction by comorbid chronic
illnesses.
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Fatigue Assessment Scale (FAS)
Michielsen etal. developed this 10-item scale in 2003. It has ve items on physical fatigue and ve items on
mental fatigue. e items are scored on a ve-point Likert scale from 1 (“Never”) to 5 (“Always”). Items 4 and 10
are reversely scored. e possible total score of the scale ranges from 10 to 50, with scores less than 22 showing
no fatigue and scores 22 and more showing fatigue. In other words, higher scores show greater fatigue74. e
reliability and validity of this scale for patients with sarcoidosis in Iran have been conrmed, with a Cronbach’s
alpha coecient of 0.92775. e reliability of this scale in the present study was conrmed with a Cronbach’s
alpha of 0.807, a McDonald’s omega of 0.816, and an average inter-item correlation coecient (AIC) of 0.293.
irst Distress Scale (TDS)
Welch and Molzahn developed this scale in 2002 for patients receiving hemodialysis. It has six items scored on
a ve-point Likert scale from 5 (“Strongly agree”) to 1 (“Strongly disagree”). Its possible total score is 6–30 and
higher scores show greater TD76. e Cronbach’s alpha, McDonald’s omega, and an AIC of this scale in the present
study were respectively 0.891, 0.967, and 0.574, which conrmed its acceptable reliability.
e 12‑Item Pruritus Severity Scale (12‑PSS)
is scale was developed in 2017 by Reich etal. for patients with chronic pruritus. It has twelve items on the ve
main dimensions of pruritus, namely pruritus intensity, pruritus frequency, pruritus duration, pruritus inuence
on daily activities and mood, and scratching as a response to pruritus. Items are scored dierently (including yes/
no items and items with dierent Likert scales) and the possible total score of the scale ranges from 3 (minimum
pruritus) to 22 (maximum pruritus). e total score is categorized as follows: scores 3–6: mild pruritus; scores
7–11: moderate pruritus; and scores 12–22: severe pruritus77. e reliability of this scale for hemodialysis patients
in Iran has been examined and conrmed, with a Cronbach’s alpha of 0.89078. e reliability of the scale was con-
rmed in the present study with a Cronbach’s alpha of 0.850, a McDonald’s omega of 0.862, and an AIC of 0.341.
e 12‑ItemShort Form Health Survey (SF‑12)
Ware etal. developed this twelve-item scale for QOL assessment based on the original 36-item Health Survey. It
predicts 90% of the variance of the 36-item Health Survey79. It has two main dimensions, namely physical health
and mental health, with the eight subscales of general health perception, physical functioning, role limitations
due to physical health, bodily pain, role limitations due to emotional problems, social functioning, vitality, and
mental health. Two items are Yes/No questions and ten items are scored using various Likert scales. Items 1, 8,
10, and 11 are reversely scored. e possible range of the total score is 12–48, with higher scores standing for
better QOL. Scores 12–24, 25–36, and 37–48 show poor, moderate, and good QOL, respectively. e reliability
of this survey in Iran for the general population has been thoroughly examined and conrmed. e Cronbach’s
alpha for the physical and mental components was found to be 0.730 and 0.720, respectively. is indicates a high
level of internal consistency and reliability in the survey results80. e Cronbach’s alpha, McDonald’s omega, and
an AIC of the scale in the present study were 0.803, 0.836, and 0.312, respectively.
A modied version of the Greek simplied medication adherence questionnaire for hemodialysis patients
(GR‑SMAQ‑HD)
Alikari etal. developed this eight-item questionnaire in 2017 for patients receiving hemodialysis. ree items
are Yes/No questions and ve items are scored on a ve-point Likert scale. Items are on the dierent aspects of
TA, namely medication adherence, attendance at hemodialysis sessions, and uid/diet restrictions. Items are
scored either zero or 1 and hence, the possible range of the total score of the questionnaire is 0–8, where higher
scores show greater TA81. In the present study, the Cronbach’s alpha, McDonald’s omega, and an AIC of items
1–4 were 0.734, 0.744, and 0.389, the Cronbach’s alpha and an AIC of items 5 and 6 were 0.894 and 0.810, and
the Cronbach’s alpha and an AIC of items 7 and 8 were 0.582 and 0.412, respectively.
Data analysis
e Kaiser–Meyer–Olkin and Bartlett’s tests were used to determine sampling adequacy and model appropri-
ateness in factor analysis. Kaiser–Meyer–Olkin test values of more than 0.7 show model appropriateness82. e
Mahalanobis distance was also used to nd multivariate outliers83. Univariate normality was tested via skewness
(± 3) and kurtosis (± 7) measures and multivariate normality was tested via the Mardia’s coecient (< 8)83. Finally,
structural equation modeling was performed to assess the mediating role of TA in the relationship of fatigue,
pruritus, and TD with QOL. Bootstrapping with 2000 repetitions was also employed for hypothesis testing in
structural modeling84. Model t indices were root mean square error of approximation (RMSEA; < 0.08), Stand-
ardized Root Mean Square Residual (SRMR; < 0.10), comparative t index (CFI; > 0.90), incremental t index
(IFI; > 0.90), and Tucker-Lewis index (TLI; > 0.90)83. e Internal consistency was tested using Cronbach’s alpha,
McDonald’s omega, AIC, and composite reliability (CR), where Cronbach’s alpha, McDonald’s omega, and CR
values of more than 0.7, and AIC values of 0.2–0.4 were interpreted as acceptably reliability83. Statistical analyses
were conducted using the SPSS (v. 26.0), AMOS (v. 27.0), and RStudio Integrated Development Environment
(v. 4.1.0) soware. All statistical hypotheses were two-tailed and the signicance levels were set at less than 0.05.
Ethics
is study obtained approval from the Ethics Committee of Mazandaran University of Medical Sciences, Sari,
Iran (code: IR.MAZUMS.REC.1402.344). Data collection took place aer explaining the study’s purpose to par-
ticipants, ensuring their voluntary participation and data condentiality. Written Informed consent was obtained
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from all subjects and/or their legal guardian(s). Permissions to use the data collection tools were acquired from
their developers. All procedures adhered to the appropriate guidelines and regulations.
Results
None of the participants were excluded from the study and the data of all 411 recruited participants were ana-
lyzed. e participants’ mean age was 59.37 (SD = ± 12.99) years (95% condence interval: 58.11–60.63) and the
percentage of men and women participants was almost equal (50.1% vs. 49.9%). Most participants reported that
they had social support (78.10%). Table1 shows participants’ characteristics.
Structural equation modeling with bias-corrected bootstrapping and 2000 repetitions showed that the model
t indices were appropriate (CFI = 0.99, TLI = 0.99, IFI = 0.99, RMSEA = 0.09, and SRMR = 0.11). e mediation
model was tested by controlling the eects of gender, age, level of education, marital status, social support, time
on hemodialysis and duration of hemodialysis sessions, employment status, and aiction by chronic illnesses.
e results of the direct eects showed a signicant inverse relationship between fatigue and QOL (b = −0.584,
r = −0.798, p-va lue < 0.001), between pruritus and QOL (b = −0.240, r = −0.563, p-value < 0.001), and between
TD and QOL (b = –0.222, r = 0.615, p-value < 0.001). Moreover, there was a signicant positive relationship
between TA and QOL (b = 0.807, r = 0.568, p-value < 0.001) (Table2 and Fig.1).
Findings revealed a signicant indirect eect of TA in the relationships between fatigue and QOL (b = −0.087,
p-value < 0.001), between pruritus and QOL (b = −0.305, p-value < 0.001), and between TD and QOL (b = −0.208,
p-value < 0.001) (Table2 and Fig.1). Figure1 shows the full eect and depicts the results of the structural model
assessment, in which the mediation model accounted for 35.4% of the variance of TA and 68.5% of the total
variance of QOL.
Table3 displays the reliability of the scales, and questionnaires, along with the factor loading of each item.
Instruments showed acceptable reliability. Items 8 of the FAS, 5 of the 12-PSS, 2 and 5 of the TDS, and 3 of the
GR-SMAQ-HD for hemodialysis patients were removed.
Discussion
e relationship between fatigue, pruritus, TD, and QOL among patients undergoing hemodialysis can be better
understood through SMT, with TA playing a crucial role as a mediating variable. Fatigue, pruritus, and TD are
common complications experienced by hemodialysis patients, signicantly associated with their QOL. Research
ndings indicate that higher levels of fatigue, pruritus, and TD are linked to lower QOL scores, highlighting the
detrimental impact of these complications on overall well-being. However, the positive correlation between TA
Table 1. Demographic proles of the participants (n = 411).
Variables Mean (SD)
Age 59.37 (± 12.99)
Duration of hemodialysis (year) 4.90 (± 4.01)
Variables n (%)
Gender Men 206 (50.1)
Wom en 205 (49.9)
Marital status Single 38 (9.2)
Married 373 (90.8)
Social support Yes 321 (78.1)
No 90 (21.9)
Time on hemodialysis
Morning 160 (38.9)
Evening 140 (34.1)
Night 111 (27.0)
Level of education
Below diploma 232 (56.4)
Diploma 62 (15.1)
University 117 (28.5)
Employment status
Housewife 183 (44.5)
Manual worker 20 (4.9)
Employee 25 (6.1)
Self-employed 93 (22.6)
Unemployed 34 (8.3)
Retired 56 (13.6)
Chronic disease
Diabetes mellitus 240 (58.4)
Heart disease 219 (53.3)
Respiratory disease 47 (11.4)
Anemia 282 (68.6)
yroid disease 107 (26.0)
Blood Pressure 317 (77.1)
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and QOL suggests that following treatment plans can help alleviate the negative eects of these complications
on QOL. TA acts as a protective factor, reducing the adverse impact of complications and improving patient
outcomes.
e nding revealed a signicant negative relationship between fatigue and QOL. In line with this nding,
patients receiving hemodialysis in a previous study reported impaired QOL due to the loss of energy, reduced
cognitive and motor functioning, increased dependence, and reduced self-esteem13. Fatigue is a mental state of
burnout with reduced motivation, altered social relationships, and reduced sleep quality and thereby, can reduce
QOL among patients receiving hemodialysis. Chronic fatigue in hemodialysis patients may be attributed to
anxiety, depression, and poor sleep quality. ese factors can result in decreased motivation, changes in social
interactions, and a diminished overall QOL for individuals undergoing hemodialysis treatment85.
Table 2. e mediation model assessment. ***p < 0.001, **p < 0.01, *p < 0.05, , two-tailed test.
SEM b p-value
95% condence level
rLower bound Upper bound
Direct eects
Fatigue → quality of life −0.584 *** −0.805 −0.695 −0.798
Pruritus → quality of life −0.240 *** −1.149 −0.862 −0.563
irst distress → quality of life −0.222 *** −1.014 −0.789 −0.615
Treatment adherence → quality of life 0.807 *** 2.204 2.926 0.568
Fatigue → treatment adherence −0.034 0.006 −0.122 −0.087
Pruritus → treatment adherence −0.119 *** −0.232 −0.166
irst distress → treatment adherence −0.081 *** −0.185 −0.130
Indirect eects
Fatigue → quality of life −0.087 *** −0.705 −0.585
Pruritus → quality of life −0.305 *** −0.815 −0.510
irst distress → quality of life −0.208 *** −0.769 −0.532
Full eects
Fatigue → quality of life −0.556 *** −0.633 −0.480
Pruritus → quality of life −0.143 0.025 −0.270 −0.017
irst distress → quality of life −0.156 0.005 −0.265 −0.047
Figure1. e results of the mediation model assessment; ***p < 0.001, **p < 0.01, *p < 0.05.
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Table 3. e factor loading values and reliability parameters of the study instruments. α: Cronbach’s alpha;
Ω: McDonald’s omega; AIC: average inter-item correlation; CR: composite reliability; AVE: average variance
extracted.
Construct Factor loading Reliability CR AVE
Fatigue
Item 1: I am bothered by fatigue 0.807
α = 0.807,Ω = 0.816
AIC = 0.293 0.819 0.455
Item 2: I get tired very quickly 0.766
Item 3: I don’t do much during the day 0.240
Item 4: I have enough energy for everyday life 0.619
Item 5: Physically, I feel exhausted 0.679
Item 6: I have problems to start things 0.505
Item 7: I have problems to think clearly 0.667
Item 8: I feel no desire to do anything 0.290
Item 9: Mentally, I feel exhausted 0.629
Item 10: When I am doing something, I can concentrate quite well 0.458
Pruritus
Item 1: How oen did you feel pruritus within the last 3 days? 0.738
α = 0.850,Ω= 0.862
AIC = 0.341 0.873 0.804
Item 2: Did pruritus hinder your ability to do simply things, like watching TV, hearing music, etc.? 0.977
Item 3: Did you feel irritated or nervous because of your itching? 0.923
Item 4: Did your pruritus cause you depressed? 0.914
Item 5: Did your pruritus impede your work or learning abilities? 1.003
Item 6: Did you scratch your skin because of itching? 0.790
Item 7: Did scratching bring you relief ? 0.156
Item 8: Were you able to refrain from scratching? 0.653
Item 9: Did you wake up during last night because of pruritus? 0.712
Item 10: Could you assess the severity of your pruritus within last 3 days? 0.544
Item 11: Could you indicate pruritus location? 0.559
Item 12: Are excoriations or other scratch lesions present? 0.299
irst distress
Item 1: My thirst causes me discomfort 0.967
α = 0.891, Ω= 0.967
AIC = 0.574 0.967 0.877
Item 2: My thirst bothers me a lot 1.004
Item 3: I am very uncomfortable when I am thirsty 0.994
Item 4: My mouth feels really dry when I am thirsty 0.989
Item 5: My saliva is very thick when I am thirsty 1.000
Item 6: Did you scratch your skin because of itching? 0.593
Quality of life
Item 1: In general, would you say your health is: 0.520
α = 0.803,Ω= 0.836
AIC = 0.312 0.837 0.493
Item 2: Moderate Activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf: 0.654
Item 3: Climbing Several ights of stairs: 0.616
Item 4: Accomplished Less than you would like: 0.623
Item 5: Were limited in the Kind of work or other activities: 0.510
Item 6: accomplished Less than you would like: 0.962
Item 7: Didn’t do work or other activities as Carefully as usual: 0.944
Item 8: how much did Pain interfere with your normal work (including both work outside the home? 0.504
Item 9: how much of the time have your physical or emotional problems interfered with your social activities? 0.482
Item 10: Have you felt calm and peaceful? 0.820
Item 11: Did you have a lot of energy? 0.900
Item 12: Have you felt downhearted and blue? 0.632
Treatment adherence
Item 1:When you feel bad, have you ever stopped taking your medications? 0.497
α = 0.734,Ω= 0.744 AIC = 0.389
0.846 0.665
Item 2: Have you ever forgotten to take your medications? 0.977
Item 3: Have you ever forgotten to take your medications on the days between the two dialysis sessions? 1.007
Item 4: In the last week, how many times have you not taken your medications? 0.666
Item 5: Last month, how many times was the session shortened on your own initiative? 0.908 α = 0.894
AIC = 0.810
Item 6: Last month, on average, how many minutes was the session cut o on your own initiative? 0.893
Item 7: During the past week, how many times did you follow uid restrictions? 0.519 α = 0.582
AIC = 0.412
Item 8: During the past week, how many times did you follow dietary recommendations? 0.746
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A study on patients receiving hemodialysis reported that anxiety and depression had a signicant relationship
with fatigue86. Anxiety and depression are prevalent among hemodialysis patients, signicantly impacting their
QOL. ese conditions are closely linked to fatigue, demonstrating their collective inuence on patient well-
being. Individuals suering from anxiety and depression are more prone to experiencing fatigue, highlighting
the interconnected nature of these factors and their combined eect on QOL87.
Increased levels of the metabolites of tryptophan and the precursors of serotonin and melatonin among
patients receiving hemodialysis are associated with depression and fatigue88. Moreover, sleep disorders among
these patients threaten their general health, mental health, and physical capacity, and cause them fatigue. A study
indicated a signicant relationship between sleep disorders and fatigue among patients receiving hemodialysis
and noted that the eective management of sleep disorders can reduce their fatigue and improve their QOL89.
Inadequate sleep quality is prevalent among hemodialysis patients and is associated with feelings of fatigue,
anxiety, and depression. Issues such as insomnia and daytime sleepiness are frequently experienced by these
individuals, exacerbating their fatigue and depression levels and ultimately aecting their overall QOL. It is
crucial to address sleep disturbances, as well as eectively manage fatigue, anxiety, and depression, to enhance
the well-being and QOL of hemodialysis patients90. Moreover, the elimination of waste products from the body
during hemodialysis can also lead to hemodynamic instability, blood pressure uctuations, electrolyte imbal-
ances, and thereby, fatigue and energy loss91 (Hypothesis-1).
We also found a signicant inverse relationship between pruritus and QOL. is nding is consistent with the
ndings of a study that reported that uremic pruritus reduced sleep quantity and quality among patients receiving
hemodialysis and thereby, reduced their QOL54. Patients with severe pruritus are more likely to stay awake at
night, feel sleepy during the day, and have inadequate sleep92. A study also showed that dermatologic problems
and altered body image due to pruritus and erosion reduced QOL among patients receiving hemodialysis93.
Moreover, aesthetic problems and pruritus caused these patients occupational dysfunction and social isolation
which in turn negatively aected their disease burden, daily life, and QOL93 (Hypothesis-2).
Our ndings also demonstrated a signicant inverse relationship between TD and QOL. A study on patients
receiving hemodialysis reported that uid restriction caused these patients problems such as thirst, guilt, distress,
and anxiety, while their constant exposure to thirst caused them fatigue and reduced their QOL26. Dryness of
the mouth due to uid restriction has a direct relationship with thirst and increases the risk of weight gain and
orodental problems such as bacterial and fungal infections, candidiasis, dental caries, and periodontal diseases94.
ese problems cause diculty in speaking, chewing, and eating, and thereby, greatly aect oral health and
QOL95 (Hypothesis-3).
Another nding of the present study was the signicant positive relationship between TA with QOL. Simi-
larly, a study showed that low medication adherence had a signicant inverse correlation with physical QOL96.
e close adherence of patients receiving hemodialysis to their treatment regimen signicantly improves all
dimensions of their QOL and reduces their vulnerability and hemodialysis complications. Moreover, adherence
to dietary restrictions, uid restrictions, and medications signicantly reduces symptoms and medication side
eects and thereby, improves QOL and hope among patients43. Close TA also allows patients receiving hemodi-
alysis to have an active role in their care, improves their sense of control and empowerment, and enhances their
mental well-being97 (Hypothesis-4).
Findings also indicated that TA indirectly aects QOL through mediating the fatigue-QOL relationship.
Because of treatment-induced fatigue, patients receiving hemodialysis feel energy depletion and physical exhaus-
tion and need more energy and time to adhere to their strict treatment regimen98. Fatigue can also negatively
aect patients’ attendance at hemodialysis sessions, while timely attendance at the sessions can improve hemo-
dialysis eciency, reduce fatigue, and improve QOL99 (Hypothesis-5).
We also found the indirect eect of TA on QOL through mediating the relationship between pruritus and
QOL. Pruritus reduces sleep quality, increases fatigue, and thereby, negatively aects the dierent aspects of TA
such as attendance at hemodialysis sessions92. Poor adherence to hemodialysis sessions and medications obvi-
ously increases the need for re-hospitalization, imposes added costs on patients and healthcare systems, and
reduces patients’ physical and mental QOL100. Conversely, close TA can reduce pruritus and discomfort and
hence, improve QOL, social interactions, and self-condence, and increase patients’ ability to perform their daily
activities101. On the other hand, eective management of pruritus enhances patient satisfaction with treatment
which in turn improves their TA in a virtuous cycle and ultimately improves QOL and treatment outcomes102
(Hypothesis-6).
We also found the signicant mediating role of TA in the relationship of TD with QOL. Physiological symp-
toms such as TD and mouth dryness are one of the major barriers to adherence to uid restriction25. erefore,
improving adherence to uid restriction can reduce the overconsumption of uids and weight gain between
hemodialysis sessions and thereby, can maintain electrolyte balance and improve treatment outcomes103. Besides,
adherence to dietary regimens, such as limited salt intake, can reduce TD which is a major contributing factor
to uid overconsumption39 (Hypothesis-7).
e ndings not only support the SMT but also highlight the crucial relationship between complications
such as fatigue, pruritus, and TD, as well as TA, and QOL in hemodialysis patients. Improving TA is identied
as a key strategy to reduce the negative impact of complications on QOL. is underscores the importance of
comprehensive care approaches that focus on both symptom management and TA to enhance patient outcomes
in this population. Healthcare providers should use these study results to improve patient outcomes by focusing
on symptoms like fatigue, pruritus, and TD in hemodialysis patients. ey can tailor interventions, emphasize
TA, educate patients, monitor symptoms, and provide collaborative care to enhance QOL. By addressing these
specic complications and promoting patient involvement in their care, healthcare providers can work towards
better health outcomes for hemodialysis patients.
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Limitations
Like all studies, this study had some limitations. For example, the study is limited by its cross-sectional design,
which does not allow for causal conclusions to be reached. e sample size may be small and not representative
of the larger population of patients undergoing hemodialysis. As study data were collected through the self-report
method, fatigue might have aected participants’ desire to participate in the study, and the accuracy, and concen-
tration for answering the study instruments. We attempted to manage this limitation by providing participants
with clear explanations about the study’s aim and methods and providing them with adequate time to provide
answers to the instruments. Moreover, some participants could not personally complete the study instruments
due to problems such as arteriovenous stula in the limb or low literacy level. We did our best to manage this
limitation by involving their companions in data collection and using the interview method for data collection.
Conclusion
is study suggests that patients receiving hemodialysis can reduce their fatigue, pruritus, and TD and improve
their QOL through close TA. Healthcare providers need to improve their knowledge about inuential factors
on QOL among these patients and employ appropriate interventions to improve their TA, reduce hemodialysis-
related complications, and improve their QOL and clinical conditions. Understanding the mediating role of TA
can clarify how these complications are associated with QOL and oer valuable insights for developing targeted
interventions, education, and strategies to improve QOL in hemodialysis patients. Additionally, comprehending
the relationships of these factors with QOL allows patients to eectively communicate their experiences and seek
appropriate support, ultimately leading to improved care and outcomes. It can also aid in developing evidence-
based guidelines to manage complications and promoting adherence in hemodialysis patients. e results could
change clinical guidelines and policies, through the management of complications for hemodialysis patients. is
might include regular screening and incorporating complication management into care plans.
Recommendations
Further studies are necessary to assess the mediating role of the dierent dimensions of TA in the relationship
of dierent hemodialysis complications with QOL. Moreover, the structural equation modeling approach used
in the present study is recommended to assess the association of TA on patient outcomes among patients with
cardiovascular disease, particularly hypertension. Studies on patients receiving hemodialysis are also necessary
to assess the relationship of fatigue, pruritus, and TD with age, gender, and comorbid illnesses in order to iden-
tify patients who may be more susceptible to complications of hemodialysis. Adequate knowledge about these
complications and their contributing factors helps healthcare providers use more eective strategies for fullling
the unique needs of each patient and improving patient outcomes and QOL.
Longitudinal studies are needed to determine the relationship between fatigue, pruritus, TD, TA, and QOL.
ey can help researchers understand the underlying mechanisms and potential causal relationships between
these factors, as well as the bidirectional relationship between TA and complication severity. Further research
is required to investigate the role of social support in TA and QOL, including the inuence of family, friends,
healthcare providers, and support groups. Understanding how social support aects TA and QOL can guide the
development of interventions to enhance social support networks (Supplementary Information).
Data availability
e data that support the ndings of this study are available from the corresponding author upon reasonable
request.
Received: 6 February 2024; Accepted: 25 April 2024
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Acknowledgements
We are greatly thankful to all patients who participated in this study and shared their valuable experiences with
us. Moreover, we thank the sta of hospitals in Amol, Iran, who helped us recruit eligible participants and col-
lect relevant data. Special thanks go to the Student Research Committee of Mazandaran University of Medical
Sciences (Sari, Iran) for providing research support (Proposal Code: 17855).
Author contributions
Performance of data gathering: RF; Planning and supervision of the work: HSH; Performance of the analysis:
JM and SB, Manuscript dra: NS and All authors; and comment on the nal manuscript: EF and All authors.
Competing interests
e authors declare no competing interests.
Additional information
Supplementary Information e online version contains supplementary material available at https:// doi. org/
10. 1038/ s41598- 024- 60679-2.
Correspondence and requests for materials should be addressed to R.F.
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