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A Comprehensive Assessment of Pain Among Haemodialysis Patients: A Cross-sectional Study
* Corresponding author: Dr. Nalini M, Department of Mental Health Nursing, Nitte Usha Institute of Nursing Sciences, NITTE (Deemed to be University), Deralakatte, Mangaluru, Karnataka, India. nalini@nitte.edu.in
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Received: ,
Accepted: ,
How to cite this article: George S, Nalini M, Sarosh Kumar KK, Dsilva F, Shenoy P, Pillai SG. A Comprehensive Assessment of Pain Among Hemodialysis Patients: A Cross-sectional Study. J Health Allied Sci NU. doi: 10.25259/JHASNU_33_2025
Abstract
Objectives
Pain is a prevalent and significant concern among haemodialysis (HD) patients, with most experiencing moderate to severe intensity. It has multiple detrimental effects on patients' quality of life and overall well-being. Therefore, regular and systematic pain assessment is crucial for early detection and effective management. The study aimed to assess the prevalence, severity, and location of pain among patients undergoing maintenance HD using the McGill Pain questionnaire (MPQ), and to determine the association between pain and selected socio-demographic and clinical variables.
Material and Methods
The cross-sectional study was conducted in the dialysis unit of a tertiary care centre in northern Kerala. HD patients (n=110) aged ≥18 years were enrolled. Patients with cognitive impairments like dementia, delirium, or critical illnesses were excluded from the study. The structured questionnaire for socio-demographic and clinical variables and the Short-Form MPQ (SF-MPQ) for pain assessment were used.
Results
The majority of participants (92%) reported experiencing varying degrees of pain. Many (39%) experienced pain following dialysis treatment, whereas many (44%) reported pain during the procedure. Chronic pain was reported by 9%. A higher percentage (70%) reported pain at the fistula site during cannulation, and 60% experienced pain in the lower extremities. The total pain rating index (PRI) was calculated as 4.8, while the mean Present Pain Intensity (PPI) was moderate (3.9 ± 1.88). Sensory subscale analysis revealed that 64.5% of respondents described pain as cramping and 48.2% identified it as aching. In the affective subscale, 59% of participants reported their pain as tiring and exhausting. Half of the participants reported that pain significantly interfered with their daily functioning. A significant association was observed between pain and variables such as age, gender, and duration of being on HD.
Conclusion
A high prevalence of pain was observed among HD patients, significantly impacting their functional ability. Pain assessment aids in identifying complications, such as musculoskeletal and neurological problems and allows for tailored interventions. The care team needs to assess pain symptoms consistently and manage them effectively. Proactive pain management helps to improve quality of life, enhance daily functioning, reduce complications, and promote overall well-being.
Keywords
Chronic kidney disease
Haemodialysis patients
Intensity
Pain
Prevalence
INTRODUCTION
Chronic kidney disease (CKD) is a progressive illness affecting over 850 million people worldwide. In its advanced stage, End-Stage Renal Disease, the Glomerular Filtration Rate drops below 15 mL/min. The kidneys fail to function adequately to meet the body's requirements, making renal replacement therapy, such as dialysis or a kidney transplant, necessary. Over 1,75,000 patients in India receive haemodialysis (HD) to sustain life, showing a prevalence of 129 per million population.[1,2] Patients receiving HD frequently report high symptom burden, like pain, that interferes with daily activities, decreases their functional capacity, and lowers the quality of life. The focus of care often involves achieving target laboratory values, managing comorbid illness, and reducing mortality. The symptom assessment is not a routine part of dialysis care. As a result, symptoms are often undiagnosed, and when they are recognised, treatment is rarely initiated.[3]
Pain is among the frequently reported symptoms experienced by patients on HD. It causes functional limitations and negatively affects the coping process. It is triggered by painful procedures such as venipuncture, creating an arterio-venous fistula, complications like cramps, headache, and other painful conditions, including musculoskeletal and neuropathic syndromes. Pain associated with dialysis can arise during or after the procedure, varying in both location and intensity. It may manifest as muscle soreness, headaches, joint pain, neuropathic discomfort, or pain at the needle insertion site.[4]
A meta-analysis of 116 studies among 40,678 patients reported an average prevalence of pain of 60% (95% CI: 56%–64%). The high prevalence of pain exhibited by the dialysis group, estimated as 63% (95% CI: 57%–68%). Musculoskeletal pain emerged as the most frequent pain symptom, affecting 42% (28–56%) of CKD patients receiving conservative management and 45% (36–55%) of those undergoing dialysis.[5]
A systematic review of 25 studies involving a total of 98,162 adult and elderly patients indicates that pain is a frequent complaint among HD patients, presenting as either acute or chronic pain. The most frequently reported sites are the head, back, bones, chest, and upper & lower limbs. Pain also affects daily activities, the ability to walk, mood, relationships with other people, sleep, and work. Moderate to severe pain appears to be more prevalent in this population. Understanding pain characteristics among HD patients is essential, as proper symptom management can significantly enhance their quality of life. A thorough patient assessment facilitates the implementation of appropriate pain management strategies.[6]
Early identification and management of pain can reduce suffering and improve quality of life. Poorly managed pain has both physical and psychological consequences. Despite being a common problem, only a few studies in the literature have examined the occurrence of pain among HD patients in Kerala. In the present study, the researchers aimed to identify the prevalence, severity, and location of pain among HD patients. The results provide a more comprehensive understanding of pain among this specific population from northern Kerala.
MATERIAL AND METHODS
Design and setting
The cross-sectional research design was used to determine the pain experienced by patients receiving HD. The present study was conducted in the HD unit of Government Medical College Kannur, a multi-speciality hospital in Northern Kerala. The study objectives were to assess the prevalence of pain, determine the severity and location of pain among patients undergoing maintenance HD, and find the association between pain and selected socio-demographic and clinical variables. This study adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.[7,8]
Sample
The sample size was estimated using the formula:
Assuming a prevalence of 89.9% (p=0.899), a margin of error of 5% (d=0.05), and a 90% confidence level (Z=1.645), the required sample size was calculated as 98 participants. To ensure adequate representation, the final sample size was rounded up to 110 participants.[4] Patients undergoing HD for CKD, aged over 18 years, willing to participate in the study, and able to read and write Malayalam were included. The Malayalam version of the tool was administered, as it was the most widely spoken and understood language among the target population. Patients with cognitive impairments (dementia, delirium) and those who were hemodynamically unstable were excluded from the study. The consecutive sampling technique was used, where every subject who met the sampling criteria was enrolled in the study until the required sample size was reached.
Tools
Socio-demographic and clinical data were collected using a structured questionnaire prepared by the researchers. It included age, sex, BMI, duration of being diagnosed with CKD, duration of being on HD, dialysis access, frequency of dialysis per week, functional interference, and comorbid illness.
Pain was measured using the McGill pain questionnaire (MPQ), developed in 1975 by Melzack and Torgerson at McGill University. It is a validated, self-administered tool for assessing pain, with a short-form version (SF-MPQ) introduced in 1987. The MPQ has demonstrated high reliability, with a test-retest correlation coefficient of r = 0.96.[9] In this study, the Malayalam version of the questionnaire was utilised. The SF-MPQ consists of 11 sensory and 4 affective components, each rated on a four-point intensity scale (0 = none, 1 = mild, 2 = moderate, and 3 = severe). Three pain scores, the pain rating index (PRI), are derived by summing the ratings of the sensory (1-11 items), affective (12- 15 items), and total (15 items) descriptors, which range from 0 to 45. Additionally, it includes a single item measuring current pain intensity and a visual analogue scale (VAS) to evaluate average pain levels as present pain intensity scores (PPI). Higher scores indicate greater pain severity.
Data collection
Data was collected from the participants during the dialysis sessions without disrupting the treatment plan. The principal investigator introduced herself to the study participants, outlined the purpose of the study, and provided a participant information sheet. Among the 114 subjects who met the sampling criteria, 110 participants consented to participate. Four participants declined, citing fatigue and unwillingness to engage. After clarifying the doubts and ensuring confidentiality, the investigator obtained informed consent and administered the instruments. Socio-demographic and clinical data were collected using the structured questionnaire. MPQ was used to assess pain. The time taken for data collection was 15-20 minutes.
Ethical considerations
Ethical approval was obtained from the institutional ethics committee. Detailed information regarding the study was given, and the participants signed informed consent. Confidentiality was upheld throughout the study. The investigator followed the principles outlined in the Declaration of Helsinki.
Statistical analysis
The normality of the data distribution was assessed using the Kolmogorov-Smirnov test. Depending on the normality of the distribution, continuous variables were summarised using either the mean and standard deviation (SD) or the median and interquartile range (IQR). The categorical variables were summarised as frequencies and percentages. Spearman's rank correlation coefficient was employed to find the correlation between sensory and affective subscales, and the Chi-square or Fisher’s exact test was utilised to find the association between categorical variables. All statistical analyses were conducted using SPSS software, version 24.
RESULTS
The socio-demographic and clinical characteristics of the study participants have been presented in Table 1. A significant proportion of participants (42%) were aged over 60 years, with a mean and SD of 52±9.42 years. The majority of the sample was male (61.8%).
| N=110 | ||||
|---|---|---|---|---|
| Sr No | Variable | Percentage (%) | χ2 Value | p-value |
| 1 | Age (in years) | |||
| 18-44 | 18 | |||
| 45-60 | 40 | 13.118 | 0.004* | |
| >60 | 42 | |||
| 2 | Sex | |||
| Male | 61.8 | 11.116 | <0.001* | |
| Female | 38.2 | |||
| 3 | BMI | |||
| <18 kg/m2 | 6.4 | |||
| 18-24 kg/m2 | 80 | 7.576 | 0.813 | |
| >24 kg/m2 | 13.6 | |||
| 4 | Duration of being diagnosed with CKD | |||
| <1year | 16.4 | |||
| 1-5years | 44.5 | 5.937 | 0.430 | |
| >5years | ||||
| 5 | Duration of being on haemodialysis | |||
| <1year | 25.5 | |||
| 1-5years | 40.9 | 16.455 | 0.012* | |
| >5years | 33.6 | |||
| 6 | Frequency of undergoing haemodialysis (week) | |||
| Twice | ||||
| Thrice | 30.9 | 2.028 | 0.320 | |
Body mass index (BMI) data indicated that 80% of participants fell within the normal range (18–24 kg/m2). Regarding the duration of CKD diagnosis, 44.5% of the participants had been diagnosed within the past 1–5 years. Similarly, 40.9% of the participants had been undergoing HD for 1–5 years, and 76% of patients were receiving HD treatment three times per week.
Pain location and functional interference
Most (92%) of the patients who participated in the study reported experiencing varying degrees of pain, which differed in location, intensity, and duration. Most of the participants (44%) experienced pain during the procedure, while 39% of participants reported pain following dialysis treatment, and 9% of respondents indicated that they were in constant pain throughout the day. Most subjects (70%) reported pain at the fistula site during cannulation. However, by location, lower extremity pain was experienced by 60% of participants, and upper extremity pain by 12.7%. Headache was the second most common pain (40.9%), followed by back and shoulder pain (39.2%). Half (50%) of participants reported experiencing a high level of functional interference due to pain, while 34% indicated low functional interference, and the remaining 16% reported no interference. A majority of the participants (74.6%) used paracetamol for pain management.
Pain intensity and pain rating index
The mean PPI was moderate, with a mean and standard deviation of 3.9 ± 1.88. The total PRI was summarised using the median and IQR, with the median measured at 4.0 and an IQR of 3.0. The sensory subscale of the PRI had a median of 2.0 and an IQR of 2.0, while the affective subscale also exhibited a median of 2.0 and an IQR of 2.0.
The sensory and affective subscales of pain perception
The distribution of patients based on the number of words chosen in the sensory and affective subscales of pain description is shown in Table 2. In the sensory subscale, 71 (64.5%) respondents identified pain as cramping, among which 4.5% reported severe cramps, followed by 53 (48.2%) who described it as aching. In the affective subscale, 65 respondents (59%) reported pain as tiring and exhausting, while 44.5% described it as sickening, and 37.3% characterised it as fearful. Furthermore, 37.3% of participants described their pain as discomforting, 6.4% as distressing, and most of the subjects (56.4%) reported experiencing mild pain.
| N=110 | |||||
|---|---|---|---|---|---|
| Descriptors of pain | Severe | Moderate | Mild | Total | No pain |
| Sensory subscale | |||||
| Throbbing | 0 | 3(2.7) | 10(9) | 17(15.5) | 93(84.6) |
| Shooting | 0 | 1(0.9) | 3(2.7) | 4(3.6) | 106(96.4) |
| Stabbing | 0 | 0 | 0 | 0 | 110 |
| Sharp | 1(0.9) | 4(3.6) | 3(2.7) | 8(7.3) | 102(92.7) |
| Cramping | 5(4.5) | 12(10.9) | 51(46.4) | 71(64.5) | 39(35.5) |
| Gnawing | 0 | 6(5.5) | 17(15.5) | 23(20.9) | 87(79.1) |
| Hot-burning | 0 | 5(4.5) | 17(15.5) | 21(19.1) | 89(80.9) |
| Aching | 3(2.7) | 12(10.9) | 38(34.5) | 53(48.2) | 57(51.8) |
| Heavy | 0 | 2(1.8) | 10(9.1) | 12(10.9) | 98(89.1) |
| Tender | 0 | 6(5.5) | 23(20.9) | 29(26.4) | 81(73.6) |
| Splitting | 0 | 0 | 0 | 0 | 110 |
| Affective subscale | |||||
| Tiring/exhausting | 18(16.4) | 23(20.9) | 24(21.8) | 65(59.1) | 45(40.9) |
| Sickening | 14(11.8) | 18(12.7) | 17(24.5) | 49(44.5) | 61(55.5) |
| Fearful | 3(2.7) | 6(5.5) | 32(29.1) | 41(37.3) | 69(62.7) |
| Punishing cruel | 0 | 0 | 0 | 0 | 110 |
Data is presented as numbers and percentages. N: Number of patients.
A significant moderate positive correlation was observed between the sensory and affective subscales, with Spearman’s rho (ρ) = 0.409, which was statistically significant at p < 0.001.
Association between pain perception and selected variables
The hypothesis, stating that there will be a significant association between pain perception and selected socio-demographic and clinical variables, was formulated and tested at a 0.05 level of significance. The calculated Chi-square value for variables age, gender, and duration of being on HD was greater than the critical value at p<0.05 [Table 1]. Hence, it is inferred that there is a significant association between pain perception and the variables, age, gender, and duration of being on HD.
DISCUSSION
The present study aimed to investigate the frequency of pain and evaluate its intensity among patients undergoing routine maintenance HD. A substantial portion of the participants (42%) were above the age of 60 years, with males making up the majority of the sample (61.8%) and females 38.2%. The study found that most participants (92%) experienced pain, varying in location, severity, and duration. Among the subjects, 44% experienced discomfort during the procedure, and post-dialysis pain was reported by 39% of patients. Only 9% endured continuous pain throughout the day. The fistula area during cannulation was the most common pain site, affecting 70% of participants. Lower limb pain was reported by 60% of patients, followed by headaches (40.9%). Back and shoulder pain (39.2%), and 12.7% reported pain in their upper extremities. A minority (5%) suffered from generalised body pain. The mean level of pain perceived by the patients was 3.9±1.88. The findings of the present study emphasise the increased prevalence of pain among patients undergoing HD.
The findings regarding pain are consistent with other research studies that have evaluated pain experience among patients with CKD undergoing HD. A cross-sectional study was conducted to assess the prevalence of musculoskeletal manifestations among 89 patients undergoing HD, with an average age of 67.5 ± 12 years. More than half (56.2%) identified pain as the most frequently reported symptom, affecting 44.9% of participants.[10] In a comparable prospective cohort study involving 205 Canadian HD patients, 50% (103 patients) reported experiencing pain.[11] Another investigation aimed at evaluating pain prevalence through the use of a brief pain inventory found that 89.23% of patients experienced some form of pain. This study further identified specific pain locations, with 18.46% of participants reporting headaches, 55.38% reporting pain in the trunk, 35.38% experiencing pain in the upper limbs, and 60.00% in the lower limbs.[4] Moreover, a cross-sectional study conducted in Palestine, among 261 HD patients, reported a mean patient age of 51 years, with males comprising 63.6% of the cohort. Among these patients, 47.1% reported chronic pain. Significant statistical associations (r = 0.409) were found between pain severity and factors like gender (p = 0.011), social status (p = 0.003), education level (p = 0.01), and the number of chronic illnesses (p = 0.004).[12] Whereas, in the present study, age, gender, and duration of being on HD were significantly associated with pain (p<0.05).
“Cramping" was the most frequently reported term in the sensory subscale (n=71), while "tiring" and "exhausting" (n=65) were the most common in the affective subscale. A moderate positive correlation was found between sensory and affective subscales (ρ=0.409). The cross-sectional study to assess pain among HD patients reported that patients frequently used the words "tiring" (n=47), "sickening" (n=42), "fearful" (n=41), and "wretched" (n=38) to describe their pain.[13]
Limitations: Relying on participants’ memory for pain reporting may impact the accuracy and external validity of the results. Without a control group of non-HD patients, it is challenging to determine if the pain is specific to HD.
CONCLUSION
The findings of the study provide valuable insights into pain perceptions. The participants characterised pain as discomforting (37.3%), distressing (6.4%), and mild (56.4%), with a mean PPI score in the moderate range. Pain is a highly subjective experience, with individuals being the sole reliable source for its description. It exacerbates chronic conditions, increases the likelihood of comorbidities such as depression and anxiety, and significantly diminishes overall quality of life and functional ability. The consistent and comprehensive evaluation of pain is essential for its effective management. A multidisciplinary approach, combining pharmacological and non-pharmacological interventions, improves patient outcomes. This study emphasises the importance of a thorough assessment of pain perception. Future research should involve longitudinal and multicentre studies to gain a deeper understanding of the multifactorial nature of pain. Replicating this study with a larger sample size would enhance the generalisability and robustness of the findings.
Ethical approval
The research/study approved by the Institutional Review Board at Central Ethics Committee, NITTE (Deemed to be University), number NU/CEC/2021/194, dated 23rd October 2021.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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