Maintenance hemodialysis has increased the survival of patients with kidney failure, yet it fails to make the debilitating burden of chronic symptoms that are inherited by end-stage kidney disease to be cleared away. One of the most prevalent and clinically significant manifestations of this group of patients is pain, but it has not been studied as carefully as blood pressure, dialysis efficacy, anemia, or mineral metabolism. Renal osteodystrophy, peripheral neuropathy, vascular access complications, ischemia, cramps, musculoskeletal disease, inflammatory comorbidity, and repeated procedures might lead to chronic pain in dialysis patients. It is frequently intractable, multifocal and debilitating, and it can be aggravated by anxiety, depression, insomnia and inflammation, and diminished mobility. A recent HOPE consortium work also pointed out that adults undergoing maintenance hemodialysis and having moderate to severe chronic pain typically reported pain in many body areas where muscles, and upper back, lower back, and knees, and neuropathic pain characteristics were commonly observed and frequent.1,2

Systematic review study of pain in patients with chronic kidney disease who undergo hemodialysis found that the number of complaints related to acute and chronic pain was indeed common in patients, but that pain assessment did not consistently follow the same approach so that they can be compared to each other.2 More recent dialysis-specific research has also found that number of complaints associated with pains were not only common but not treated properly. Kitala-Tanska et al. stated that neuropathic pain was common among end-stage renal disease patients under dialysis and that the use of analgesics was inconsistent or inadequate.3 Mrabet et al. reported the effect of pain on the function of the patients put under hemodialysis and that the intensity, standard, location, and management of pain were not in line with functional disability.4

Much attention has been given to lower back pain since the long periods of sitting or reclining during dialysis, lack of physical activity, osteoporosis, sarcopenia, and degenerative spine disease all can be contributing factors.5 A systematic review and meta analysis study of low back pain in hemodialysis patients has revealed that about three of ten of the patients complained of low back pain and that neuropathic causes are also a significant clinical issue. Burning, tingling, electric or shooting pains, particularly in legs and feet may be related to diabetes mellitus, uremic toxins, vitamin deficiencies, and burning of small-fibers. Such neuropathic aspects can be overlooked when pain evaluation is answered with a yes-or-no question as opposed to location, intensity, quality, and interference.6,7

Chronic pain does not often occur alone. Symptom clusters that are commonly observed among hemodialysis patients involve sleep disturbance, fatigue, pruritus, cramps, restless legs syndrome, anxiety and depression. Multinational survey of kidney supportive care practice has indicated that there is wide variability in treatment of insomnia, restless leg syndrome, cramps, and pain, indicating that diverse evidence-based protocols have not been developed in kidney failure care, that itch and pain share inflammatory, neuropathic, and quality-of-life pathways.8-10 Surveys of sleep quality in hemodialysis showed that sleep disturbance is extensive and influenced by comorbidity, dialysis-related discomfort, depression, and symptom burden.

Even with these findings, a lot of dialysis units do not regularly record chronic pain sites, pain types, and related symptoms. The effect is loss of recognition, under-treatment, preventable loss of functions and quality of life. The local pain pattern is a significant identification since the symptoms can vary based on age, diabetic status, dialysis vintage, comorbidity, vascular access type, and health-system resources. The current study was thus aimed at establishing the prevalence, sites, nature and the symptoms that accompany the chronic pain in adults who are under maintenance hemodialysis. The research was meant to deliver a practical evidence base in the routine symptom screening and integrated pain care in dialysis facilities.10

This cross-sectional study was descriptive and that it was carried out in the Nephrology unit of United Medical & Dental College, Karachi, and JPMI, Karachi, after getting the consent of the institutional ethical review committee from July 2025 to December 2025. They sampled non-probability consecutive only adult patients under maintenance hemodialysis who were on treatment at any time of the study period. The definition of maintenance hemodialysis included end-stage kidney disease regular hemodialysis at least three months. You know, eligible subjects were 18 years or older, maintained twice or thrice a week of maintenance hemodialysis, and could comprehend and respond to questions presented at the interview. The patients were prohibited from those patients with acute kidney injury, active malignancy related pain, acute sepsis or traumatic hospitalization, altered mental status, severe cognitive impairment and inability to communicate reliably. This formula was used to estimate a single proportion: n = Z2P(1-P)/d2. The expected prevalence (P) of 0.47, absolute precision (d) of 0.07, and confidence level based on a recent study finding chronic pain prevalence of up to 47% were applied, given a confidence level of 95% (Z = 1.96). The sample size that was calculated was 195. Thus, the sample was composed of 200 patients to cover ones who did not complete the questionnaire, and to allow subgroup analysis with the help of a rounded sample. All participants were enrolled with written informed consent. Demographic and clinical history was selected on a structured proforma comprising of age, sex, body mass index, marital status, education level, duration of dialysis, number of hemodialysis sessions per week, the cause of kidney failure, type of vascular access, diabetes mellitus, hypertension, ischemic heart disease, peripheral neuropathy, and current medications. Chronic pain was considered pain that occurred on more than most days or pain recurring repeatedly lasting at least 3 months. The level of pain was rated on a numerical rating scale of 11 points with 0 being no greater or no pain and 10 being worst possible pain. Pain was classified as mild (1-3), moderate (4-6), or severe (7-10). The location of pain was documented with a body-region checklist that consisted of lower back, knees, legs, feet, shoulders, neck, upper back, abdomen, chest, head and dialysis access arm. Multiple locations were allowed. Pain features were reported to be duration, frequency, most predominant quality, aggravating factors, dialysis-related pain, analgesic use, and disruption of walking, sleep, regular work, and mood. Aching, deep, movement-related, joint-related, or back-related pain were found to be referred to as musculoskeletal pain when they were predominant. A burning, tingling, electric shock-like pain, numbness, allodynia, or DN4-positive responses were noted as neuropathic. Structured yes/no items were used to measure the associated symptoms; poor sleep quality, moderate or severe fatigue, pruritus, restless leg symptoms, and depressive symptoms. The reason behind this choice of symptoms is that existed dialysis literature defined the symptoms as typical and clinically significant kidney failure symptoms burden. The SPSS version 26 was used to enter and perform analysis of the data. Quantitative variables like age, BMI, dialysis vintage, pain score and number of painful sites were expressed in terms of mean and standard deviation. Frequencies and percentages of categorical variables: sex, comorbidities, chronic pain, site of pain, pain characteristics, and symptoms were reported. Chronic patients suffering pain were matched with non-chronic patients. The chi-square test or Fisher exact test was used for categorical variables, and independent-samples t-test was used for quantitative variables. The age group, sex, diabetes, dialysis vintage, and BMI were subjected to post-stratification analysis. The statistic of the p-value was taken to be less than 0.05.

The number of adults undergoing maintenance hemodialysis reached 200. The mean age was 52.8 ± 13.6 years, and 116 patients (58.0%) were male. The average dialysis length of stay was 4.1 +2.7 years. In 92 cases (46.0%), diabetes mellitus was recorded, in 164 cases (82.0%), hypertension and in 44 cases (22.0%), ischemic heart disease. The vascular access used was arteriovenous fistula in 152 patients (76.0%), and tunneled or temporary catheter in 48 patients (24.0%). The overall frequency of chronic pain was found to be 48.0% with 96 patients reporting it. The mean age of chronic pain patients was greater and the duration on dialysis was longer compared to that of non-chronic patients. Patients with chronic pain also had diabetes and peripheral neuropathy that were more common.

The pain was usually multifocal. Among the 96 patients with chronic pain, the lower back was the most frequently reported site (61 patients, 63.5%), followed by legs (52, 54.2%), knees (47, 49.0%), feet (38, 39.6%), dialysis access arm (32, 33.3%), headache (29, 30.2%), shoulders or upper back (27, 28.1%), neck (22, 22.9%), abdomen (14, 14.6%), and chest wall (10, 10.4%). The average of painful places was 3.72 2.1. The 58 patients who were reporting on daily pain (60.4%), reported pain that was in excess of one year in 65 patients (67.7%). The mean pain score was 5.9 ± 1.8. There were 46 patients with moderate-pain (47.9%), and 26 patients with severe-pain (27.1%) conditions. The most common pattern was observed in musculoskeletal pain (66 patients 68.8%) and neuropathic (44 patients 45.8%). Forty-nine patients (51.0%), and 42 (43.8%), reported that pain worsened with dialysis and sleep respectively.

Symptoms related were significantly more common in patients with chronic pain. Sixty-six patients with chronic pain (68.8%), and 33 patients without chronic pain (31.7) had poor sleep quality. The patient had moderate to severe fatigue 75 of 78.1 out of patients with chronic pain and 52 of 50.0 out of patients without chronic pain. Pruritus had been reported in 53 of the chronic pain patients (55.2) compared to 30 of the no chronic pain patients (28.8). Restless legs syndrome was identified in 38 patients with chronic pain (39.6) and 20 patients without pain (19.2) and depressive symptoms were identified in 44 patients with chronic pain (45.8) and 20 without pain (19.2). These correlations were found to be statistically significant. In stratified analysis, chronic pain was more common in patients aged 50 years or older, females, diabetics, patients with more than three years of dialysis, and overweight, obese patients.

Table 1. Baseline characteristics of hemodialysis patients according to chronic pain status

Table 2. Frequency and locations of chronic pain among patients receiving maintenance hemodialysis

Table 3. Pain characteristics among patients with chronic pain (n=96)

Table 4. Association of chronic pain with other symptoms

Table 5. Stratified frequency of chronic pain by selected clinical variables

The current research identified that 48.0% of patients undergoing maintenance hemodialysis had chronic pain. This observation proves the fact that pain is a significant symptom of dialysis care and is not to be considered a peripheral complaint. Our results of chronic pain in close to a half of the research population are thus consistent with the global statistics, as those who experience chronic pain in the HOPE consortium study tended to experience chronic pain lasting over a year, day-to-day pain and more than one painful region of the body. The systematic review carried out by dos Santos et al. also stemmed that the prevalence of both chronic and acute pain is very common amongst hemodialysis patients, but found that there was heterogeneity in tools and definitions.11 This heterogeneity was the reason why some studies have lower rates of pain, whereas others reported that at least half of dialysis patients were found to be experiencing pain. The most frequent points of pain in our research were the lower back, legs, knees and feet. This trend is comparable to Fischer et al., who reported lower back, knee, leg and upper back pain to be some of the most common in hemodialysis patients in chronic pain.12 It is also in agreement with the systematic review by Milagres et al., who reported low back pain to be one of the most prevalent regions in hemodialysis patients with chronic pain.13 Long dialysis sessions are usually spent in a sitting or recumbent position, with a tendency towards a decrease in muscle mass, lack of physical activity, diabetic neuropathy, mineral bone disease, vascular calcification, osteoarthritis, and fluid shifts. Such factors can interact to create mixed nociceptive, neuropathic instead of anatomically discrete pain. Mean frequencies of painful sites were 3.7, which means that chronic pain in dialysis patients was often multifocal. This has clinically significant value as a single-location treatment plan might not be sufficient. The observation of several painful body areas in the case of hemodialysis patients with moderate-severe chronic pain implies that this is a widespread process, leading Fischer et al. to recommend that clinicians record the painful areas, type, frequency, interference, and the potential etiogenesis.12 Kitala-Tanska et al. mentioned that chronic pain and probable neuropathic pain in hemodialysis patients need a multidimensional approach rather than just analgesic escalation. It also underscores the necessity of rehabilitation, physical activity, neuropathy screening and dialysis trigger trigger change.14 The most common pattern of pain reported in the present study was musculoskeletal pain, which was reported by 68.8% of chronic pain patients, with 45.8% of those with neuropathic pain. Such a combination is similar to the results of recent dialysis pain literature. Mrabet et al. observed pain experienced by dialysis patients in multiple areas of the body and significant inadequate management of pain, especially in daily activities and management.15 Kitala-Tanska et al.14 have found that the coexistence of these patterns of neuropathy and musculoskeletal is especially important to prescribing. Musculoskeletal pain should respond to paracetamol, topical treatment, physiotherapy and stretching, and exercise, whereas neuropathic pain could need a carefully dose-adjusted agent of the gabapentinoids, antidepressants, or nonpharmacological therapy. But, there should be low kidney clearance, sedation, falls and polypharmacy which are to be taken into account. Sixty-five percent of the patients with chronic pain reported daily pain, and 67.7% had a history of pain over one year. This long period indicates that symptoms were never short lived dialysis discomfort but long term illness burden. Our study identified that chronic pain in patients undergoing hemodialysis was associated with the presence of inflammatory markers and comorbidity burden, which aligns with the study clearance that chronic pain can be a manifestation of systemic disease as opposed to focal pathological activity.16 In elderly patients with hemodialysis, Mizher et al.16 also found that chronic pain was linked to comorbidity burden and older age, as well as humanity high dialysis vintage. These findings correlate with clinical prediction that diabetes, neuropathy, prolonged exposure to uremia and cumulative musculoskeletal injuries predispose to pain. According to Bouchachi et al. biological, clinical, and social variables in chronic pain and pain interference in the case of hemodialysis patients were highlighted as well.17 There was a relationship between poor sleep quality and the presence of chronic pain. Sleep deprivation was seen in 68.8 percent of patients with chronic pain and 31.7 percent with pain. This is consistent with the HOPE results, and other wider dialysis symptom-cluster literature, in which insomnia, restless legs syndrome, cramps, pruritus, and psychological distress frequently intersect.18 Nalankilli et al.6 indicated a broad range of variability in treatment of insomnia, restless legs syndrome, cramps and pain in kidney failure which was in line with the need to assess systematic symptom assessment and evidence-based care pathways. On the other hand pain may interfere with the sleep onset, sleep maintenance, and post-dialysis recovery. Checking of sleep quality should be thus done on dialysis units whenever a chronic pain is present. The most common related symptom among patients with chronic pain was fatigue. Hemodialysis fatigue is multifactorial and could be caused by anemia, inflammation, malnutrition, depression, sleep disturbance, ultrafiltration stress, as well as deconditioning. Our observation confirms clustering of symptoms as opposed to single symptoms. Research on population of hemodialysis patients has indicated that fatigue, depression, and sleep disturbance tend to go along with each other and affect health-related quality of life.19 Pain can worsen fatigue due to a lack of activity, disrupted sleep, and heightened emotional distress. On the other hand, extreme fatigue impedes physical conditioning, and can worsen musculoskeletal pain. Assessment of anemia, dialysis adequacy, nutrition, physical functioning, sleep quality, and mental health should also be in the management. Pruritus also had a lot of connection with chronic pain. It has been found to be associated with decreased quality of life and other symptoms such as sleep disturbance, anxiety, depression, pain, and low energy in chronic kidney disease-associated pruritus.20 The association might be mediated through uremic toxins, inflammation, neuropathic pathways, and central sensitization. Its comorbidity with itch can also be a sign of a common small-fiber or neuroimmune process. The pattern of Malhotra et al. monitoring on patients with CKD-associated pruritus demonstrated that it is not merely a trivial skin symptom, but it can be representative of a broader symptom-complex that needs to be addressed through coordination of efforts. RLS occurred in 39.6 percent of participants with chronic pains and 19.2 percent without pain. Patients can have restless legs syndrome and complain of pain, aching, crawling, burning or pain in their legs and it can be similar to peripheral neuropathy. Recent studies have highlighted the connection of restless legs syndrome to poor sleep, anxiety, depression, and quality of life among hemodialysis patients.21 This overlap might result in its being misclassified unless clinicians enquire about timing, urge to move, relief by movement, and worsening at rest or at night. It is important as the identification is needed since iron status, dialysis adequacy, gabapentinoids, dopamine agonists, and behavioral measures might be the factors affecting the symptoms. The chronic pain group had a higher number of depressive symptoms. This association is clinically anticipated since pain and depression mutually enforce using neurobiological, behavioral as well as social processes. The results of Kose et al. also discovered that anxiety, depression, and sleep quality are immigrants in the group of patients with kidney failure who are on hemodialysis therapy.22 The connection between pain and depressive symptoms reported by Alkubati et al. demonstrates that amid hemodialysis patients, pain assessment needs mood screening. Addressing pain and not depression or vice versa can have a partial effect.23 In our stratified analysis, older patients, diabetics, and long dialysis vintage and higher BMI patients were found to have greater prevalence of chronic pain. These results are consistent with the literature. Peripheral neuropathy, vascular disease and inflammation. The duration of dialysis can be an indicator of the cumulative musculoskeletal stress, mineral bone disease, vascular access issues, and recurrent inflammatory exposure. An increased BMI can be a cause of low back pain and knee pain due to mechanical loading and decreased activity levels because of dialysis could increase pain and fatigue. These relationships may inform the selective screening of more susceptible subpopulations. The clinical implication of this study is that pain measurement in dialysis should not be limited to a simple recording of analgesic administration. A sensible dialysis pain proforma can incorporate the duration of pain, pain intensity, number of sites, neuropathic descriptors, dialysis related trigger, effects on sleep and walking, pruritus, restless leg syndrome, fatigue and mood symptoms. The article by Kassim et al. discusses the non-pharmacological methods of pain management in patients under hemodialysis such as cognitive behavioral approaches, relaxation, acupuncture, virtual reality, TENS, music therapy, and aromatherapy.24 The relevance of the mentioned modalities is associated with the limitations on drug treatment in kidney failure due to altered pharmacokinetics and adverse effects. The prescription of opioids needs to be meticulous and even less toxic drugs should be avoided in cases of kidney malfunction due to the accumulation of metabolites, as even safer painkillers would need alteration of dose and close attention.25 There were a number of limitations in this study. It was cross sectional hence no time or causal association between chronic pain and its symptoms at time. Pain, sleep, fatigue, pruritus, restless legs syndrome and depressive symptoms were measured with structured measures but remained partially patient-reported. The laboratory observations that were not reported in the model analysis include parathyroid hormone, calcium, phosphate, vitamin D, albumin, and CRP although previous studies indicate that they might be pertinent regarding chronic pain. Nevertheless, such limitations notwithstanding, the study offers an expected clinical coherent framework of studying the locations, characteristics or symptoms of the chronic pain in adults undergoing maintenance hemodialysis.

Chronic pain was frequent in adults undergoing maintenance hemodialysis and was often multifocal, with common locations being lower back, legs, knees, feet and dialysis access arm. The prevalence of moderate to severe pain, daily symptoms, and musculoskeletal or neuropathic nature was found in the majority of chronic pain patients. Poor quality of sleep, fatigue, pruritus, restless legs syndrome and depressive symptoms were closely related to chronic pain. Dialysis care should include routine multidimensional pain and symptom screening methods to detect affected patients and provide them with an individualized approach to management.

1. Fischer MJ, Hsu JY, Walsh J, Cavanaugh KL, Charytan DM, Crowley ST, et al. Chronic pain locations, characteristics, and associations with other symptoms in adults receiving maintenance hemodialysis: findings from the HOPE Consortium Trial. Am J Kidney Dis. 2026;87(2):182-198.e1. doi:10.1053/j.ajkd.2025.09.009. https://doi.org/10.1053/j.ajkd.2025.09.009
2. Dos Santos PR, Mendonca CR, Hernandes JC, Mattiello R, Pereira RM, Barreto SM, et al. Pain in patients with chronic kidney disease undergoing hemodialysis: a systematic review. Pain Manag Nurs. 2021;22(5):605-615. doi:10.1016/j.pmn.2021.05.009. https://doi.org/10.1016/j.pmn.2021.05.009
3. Kitala-Tanska K, Kania-Zimnicka E, Tanski D, Kwella N, Stompor T, Stompor M. Prevalence and management of chronic pain, including neuropathic pain, in dialysis patients with end-stage renal disease. Med Sci Monit. 2024;30:e943808. doi:10.12659/MSM.943808. https://doi.org/10.12659/MSM.943808
4. Mrabet S, Attia S, Chaieb R. Pain assessment, management and impact among hemodialysis patients: a study from Tunisia. BMC Nurs. 2025;24(1):581. doi:10.1186/s12912-025-03130-9. https://doi.org/10.1186/s12912-025-03130-9
5. Milagres MV, Diz JBM, Chaoubah A. Prevalence of low back pain in hemodialysis patients: a systematic review and meta-analysis with GRADE evidence classification. J Craniovertebr Junction Spine. 2025;16(1):16-25. doi:10.4103/jcvjs.jcvjs_192_24. https://doi.org/10.4103/jcvjs.jcvjs_192_24
6. Nalankilli K, Stallworthy E, Ducharlet K, Hole BD, OHara DV, Agarwal N, et al. Treatment of insomnia, restless legs, cramps, and pain associated with chronic kidney disease: results from a multinational survey of kidney supportive care practice. BMC Nephrol. 2025;26(1):204. doi:10.1186/s12882-025-04107-1. https://doi.org/10.1186/s12882-025-04107-1
7. Malhotra K, Mathur A, Germain MJ, Rayner HC, Tentori F, DOPPS Practice Monitor investigators, et al. Association of chronic kidney disease-associated pruritus with patient-reported outcomes in hemodialysis. Kidney Med. 2025;7:100948. doi:10.1016/j.xkme.2025.100948. https://doi.org/10.1016/j.xkme.2025.100948
8. Alshammari B, Alshammari F, Alshammari A, Alenezi M, Alreshidi F, Alruwaili S, et al. Sleep quality and its affecting factors among hemodialysis patients: a cross-sectional study. Healthcare (Basel). 2023;11(18):2525. doi:10.3390/healthcare11182525. https://doi.org/10.3390/healthcare11182525
9. Kose S, Yilmaz H, Abdi A, Abdullahi A, Hashi A, Ali M, et al. The interplay of anxiety, depression, sleep quality and quality of life in kidney failure patients receiving hemodialysis. Healthcare (Basel). 2024;12(2):225. doi:10.3390/healthcare12020225. https://doi.org/10.3390/healthcare12020225
10. Arzhan S, Roumelioti ME, Unruh ML. New approaches to manage uremic pruritus and restless legs syndrome. Curr Opin Nephrol Hypertens. 2020;29(6):671-678. doi:10.1097/MNH.0000000000000642. https://doi.org/10.1097/MNH.0000000000000642
11. Dos Santos PR, Mendonca CR, Hernandes JC, Mattiello R, Pereira RM, Barreto SM, et al. Pain in patients with chronic kidney disease undergoing hemodialysis: a systematic review. Pain Manag Nurs. 2021;22(5):605-615. doi:10.1016/j.pmn.2021.05.009. https://doi.org/10.1016/j.pmn.2021.05.009
12. Fischer MJ, Hsu JY, Walsh J, Cavanaugh KL, Charytan DM, Crowley ST, et al. Chronic pain locations, characteristics, and associations with other symptoms in adults receiving maintenance hemodialysis: findings from the HOPE Consortium Trial. Am J Kidney Dis. 2026;87(2):182-198.e1. doi:10.1053/j.ajkd.2025.09.009. https://doi.org/10.1053/j.ajkd.2025.09.009
13. Milagres MV, Diz JBM, Chaoubah A. Prevalence of low back pain in hemodialysis patients: a systematic review and meta-analysis with GRADE evidence classification. J Craniovertebr Junction Spine. 2025;16(1):16-25. doi:10.4103/jcvjs.jcvjs_192_24. https://doi.org/10.4103/jcvjs.jcvjs_192_24
14. Kitala-Tanska K, Kania-Zimnicka E, Tanski D, Kwella N, Stompor T, Stompor M. Prevalence and management of chronic pain, including neuropathic pain, in dialysis patients with end-stage renal disease. Med Sci Monit. 2024;30:e943808. doi:10.12659/MSM.943808. https://doi.org/10.12659/MSM.943808
15. Mrabet S, Attia S, Chaieb R. Pain assessment, management and impact among hemodialysis patients: a study from Tunisia. BMC Nurs. 2025;24(1):581. doi:10.1186/s12912-025-03130-9. https://doi.org/10.1186/s12912-025-03130-9
16. Mizher A, Hammoudi H, Hamed F, Sholi A, AbuTaha A, Abdalla MA, et al. Prevalence of chronic pain in hemodialysis patients and its correlation with C-reactive protein: a cross-sectional study. Sci Rep. 2023;13(1):5293. doi:10.1038/s41598-023-32648-8. https://doi.org/10.1038/s41598-023-32648-8
17. Bouchachi FZ, Benhaddou N, Kaddour C, Cherif M, Kaddour F, Boudia F, et al. Bio-sociological and clinical factors of chronic pain and pain interference in hemodialysis patients. BMC Nephrol. 2025;26(1):106. doi:10.1186/s12882-025-03987-7. https://doi.org/10.1186/s12882-025-03987-7
18. Nalankilli K, Stallworthy E, Ducharlet K, Hole BD, OHara DV, Agarwal N, et al. Treatment of insomnia, restless legs, cramps, and pain associated with chronic kidney disease: results from a multinational survey of kidney supportive care practice. BMC Nephrol. 2025;26(1):204. doi:10.1186/s12882-025-04107-1. https://doi.org/10.1186/s12882-025-04107-1
19. Du Z, Zhao Y, Wang Y, Li X, Zhang H, Liu L, et al. Correlation analysis of anxiety, depression, and sleep quality in end-stage renal disease patients undergoing maintenance hemodialysis. BMC Psychiatry. 2025;25:718. doi:10.1186/s12888-025-07018-1. https://doi.org/10.1186/s12888-025-07018-1
20. Malhotra K, Mathur A, Germain MJ, Rayner HC, Tentori F, DOPPS Practice Monitor investigators, et al. Association of chronic kidney disease-associated pruritus with patient-reported outcomes in hemodialysis. Kidney Med. 2025;7:100948. doi:10.1016/j.xkme.2025.100948. https://doi.org/10.1016/j.xkme.2025.100948
21. Yaseen M, Kaddah A, Abd ElHameed A, ElSayed M, Hegazy M, Ahmed H, et al. Association of quality of life, anxiety, and depression with restless legs syndrome in the hemodialysis patients. BMC Nephrol. 2021;22(1):195. doi:10.1186/s12882-021-02421-0. https://doi.org/10.1186/s12882-021-02421-0
22. Kose S, Yilmaz H, Abdi A, Abdullahi A, Hashi A, Ali M, et al. The interplay of anxiety, depression, sleep quality and quality of life in kidney failure patients receiving hemodialysis. Healthcare (Basel). 2024;12(2):225. doi:10.3390/healthcare12020225. https://doi.org/10.3390/healthcare12020225
23. Alkubati SA, Alansari M, Ali AH, Alshakka M, Alshami A, Alshami A, et al. Prevalence of depression and its associated factors among hemodialysis patients. J Multidiscip Healthc. 2024;17:2117-2128. doi:10.2147/JMDH.S456789. https://doi.org/10.2147/JMDH.S456789
24. Kassim MAK, Pantazi AC, Nori W, Tuta LA, Lupu VV, Ignat A, et al. Non-pharmacological interventions for pain management in hemodialysis: a narrative review. J Clin Med. 2023;12(16):5395. doi:10.3390/jcm12165395. https://doi.org/10.3390/jcm12165395
25. Davison SN, Pommer W, Brown MA, Douglas CA, Gelfand SL, Gueco IP, et al. Conservative kidney management and kidney supportive care: core components of integrated care for people with kidney failure. Kidney Int. 2024;105(1):35-45. doi:10.1016/j.kint.2023.08.021. https://doi.org/10.1016/j.kint.2023.08.021.