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  • Malonyl Coenzyme A Journal of Pain and Symptom


    566 Journal of Pain and Symptom Management Vol. 57 No. 3 March 2019
    Original Article
    Comparison of Fatigue, Pain, and Depression in Patients With Advanced Kidney Disease and CancerdSymptom Burden and Clusters
    Manisha Jhamb, MD, MPH, Khaled Abdel-Kader, MD, MS, Jonathan Yabes, PhD, Yisi Wang, MPH, Steven D. Weisbord, MD, MS, Mark Unruh, MD, MS, and Jennifer L. Steel, PhD
    Renal and Electrolyte Division (M.J., S.D.W.), Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Nephrology and Hypertension (K.A.-K.), Vanderbilt University Medical Center, Nashville, Tennessee; Center for Research on Heath Care (J.Y.), Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (Y.W.), University of Pittsburgh, Pittsburgh, Pennsylvania; Renal Section (S.D.W.), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Nephrology (M.U.), Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico; and Department of Surgery, Psychiatry and Psychology (J.L.S.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
    Context. Although symptom clusters have been studied in the context of cancer, few data exist in chronic and end-stage kidney disease (CKD/ESKD) patients.
    Objectives. The objectives of this Malonyl Coenzyme A study were to 1) characterize and compare symptom cluster phenotypes in patients with advanced CKD, ESKD, and cancer and 2) explore predictors of symptom clusters.
    Methods. We conducted secondary data analysis of three prospective studies in which pain, depression, and fatigue were assessed in patients with Stage 4e5 CKD, ESKD, and gastrointestinal cancer. Tetrachoric correlations between these symptoms were quantified, and partitioning around medoids algorithm was used for symptom cluster analysis.
    Results. In the 82 CKD, 149 ESKD, and 606 cancer patients, no differences in the average fatigue (P ¼ 0.17) or pain levels (P ¼ 0.21) were observed. Over 80% of patients in each group had at least one symptom. Moderate or severe depressive symptoms were more common in patients with cancer (31% vs. 19% in ESKD vs. 9% in CKD; P < 0.001). Mild-moderate correlations were observed between the three symptoms in ESKD and cancer patients. Three distinct clusters were observed in each group. In ESKD, the HIGH cluster (with high probability of pain, depression, and fatigue) had higher body mass index (P < 0.001) and antidepressant use (P ¼ 0.01). In cancer patients, the HIGH cluster patients were more likely to be female (P ¼ 0.04), use antidepressants (P ¼ 0.04), and have lower serum albumin (P < 0.001) and hemoglobin (P ¼ 0.03) compared to the other two clusters.
    Conclusion. Although the burden of fatigue, pain, and depressive symptoms for CKD and ESKD patients is similar to patients with gastrointestinal cancer, symptom cluster phenotypes differed between the groups as did the predictors of symptom clusters. J Pain Symptom Manage 2019;57:566e575. 2018 The Authors. Malonyl Coenzyme A Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY-NC-ND license ( licenses/by-nc-nd/4.0/).
    Key Words
    Symptom clusters, fatigue, pain, depression, ESKD and cancer
    These findings were presented in abstract form at the Amer-ican Society of Nephrology Renal Week 2015 (San Diego, CA).
    Address correspondence to: Manisha Jhamb, MD, MPH, Renal-Electrolyte Division, University of Pittsburgh School 
    Accepted for publication: December 5, 2018.
    2018 The Authors. Published by Elsevier Inc. on behalf of American 0885-3924/$ - see front matter Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY-NC-ND license (
    Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) experience high mortality, substantial symptom burdens, and poor quality of life (QoL).1 The symptom burden in pa-tients with ESKD may even be similar to that of advanced cancer patients.2,3 Yet, symptom recognition and management in CKD and ESRD by nephrology providers remains suboptimal.4
    For cancer patients, pain, fatigue, and depression were the most common and debilitating symptoms identified in the National Institute of Health State-of-Science Consensus statement.5 This led the Institute of Medicine and several national oncological societies (e.g., American Society for Clinical Oncology, Amer-ican College of Surgeons) to recommend screening and treatment guidelines for these symptoms in cancer patients.6 Only recently, the Kidney Disease Improving Global Outcomes Controversies Conference on Sup-portive Care in 2015 advocated for integration of symp-tom assessment and management in routine CKD care.7