Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
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Thirsty Interdialytic Weight Gain and Thirst-Interventions
in Hemodialysis Patients: A Literature Review
PATRIEK MISTIAEN
Noncompliance is a common problem in hemodialysis (HD) patients (Christensen, Benotsch, & Smith,
1997).
Patients are asked to comply with medical advice that may disturb their normal routine. In addition to the
dialysis sessions two to three times a week for many years, patients have to take many medications
and adhere to diet and strict fluid intake restrictions. Noncompliance is found in all aspects (Leggat et al.,
1998), but adhering to the fluid restriction is the most difficult aspect for most patients (Baldree, Murphy, &
Powers,, 1982; Goverde & Grypdonck, 1998).
Noncompliance with fluid restriction may cause a large interdialytic weight gain (IWG) and may lead
to chronic fluid overload, resulting in a much greater risk for cardiovascular comorbidity and mortality
(Abuleo, 1998; Leggat et al., 1998). Depending on the definition, excessive weight gain occurs in 10"/i)
{Leggat et al., 1998) to 9m) {Lin & Uang, 1997) of all dialysis patients.
One obvious reason for drinking too much and excessive IWG might be that these patients suffer
from thirst as demonstrated by quotes from the literature, such as ".,.many hemodialysis patients complain
of compulsive thirst, which causes an exaggerated ingestion of fluids and this in turn may lead to chronic
fluid overload..." {Graziani et al., 1993) or "....They explain that they do not comply because of intolerable
thirst and even those who do comply usually also complain of thirst. TTiey com- plain bitterly of thirst
although they are often overhydrated." (De Nour & Czaczkes, 1980).
However, thirst is a difficult area to research due to its subjective nature.
Moreover, many physiological, psychological, and social variables influence the thirst sensation. In
addition, the drinking reaction to thirst is influenced by many of these factors. Like pain, thirst is a
subjective feeling that exists when a person says it exists, and can not be measured other than by asking
people. However, in contrast to pain, which is generally considered as a burden, thirst is seen as a
normal signal without the negative connotation of burden.
Goal: To summarize the findings in the literature concerning thirst, interdialytic weight gain and thrist
interventions in hemodialysis patients.
Objectives: 1. Identify why thirst is a difficult concept to measure and study.
2. Describe the relationship between thirst and interdialytic weight gain in hemodialysis patients.
3. Discuss the three interventions presented to treat thirst in the hemodialysis population.
One of the tasks of nephrology nurses is counseling patients and helping them cope with their
regimens, especially the fluid restriction.
It would be very helpful for nurses to know how many HD patients suffer from thirst and how to prevent
or treat thirst. Therefore, a literature search was performed to review the body of knowledge on thirst in
HD patients and to address the following questions; (a) What is the prevalence of thirst (how many HD
patients have thirst)? (b) To what extent is thirst related to IWG? and (c) What interventions are applied to
minimize thirst?
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
METHODS
A search was made using several electronic literature databases (MEDUNE, CINAHL, EMBASE,
PSYCHFIRST, SCI) with the keywords "thirst and hemodialysis." In addition, a free-text search with
"thirst" and a retrograde search were made via references from the articles that were already identified. All
searches were done in the second half of December 1999. The literature search was hmited to articles
published in journals between 1980 and 1999 in the English, Dutch, German, or French language.
Furthermore, articles had to describe empirical research on HD patients and thirst had to be explicitly
measured.
The search with the keywords "thirst and hemodialysis" in MEDLINE, EMBASE, and SCI resulted in the
identification of 18, 9, and 25 studies, respectively. No articles were found in the databases CINAHL
and PSYCHFIRST The overlap between MEDUNE and EMBASE was three references, between
MEDLINE and SCI seven references, and between EMBASE and SCI five references.
Three references appeared in all 3 databases. This initial search resulted in a total of 40 articles. After
reading the articles, 22 were excluded for the following reasons: the study was a review (n = 1); thirst was
not measured as a variable (n — 13); the article was a conference abstract [n = 2); the article was not
research [n = 2); the article did not concem HD patients [n
— 4), Additional searches produced five complementary articles. A total of 23 studies were eligible for
analysis.
The studies were published in 19 different journals and originated from 12 different countries. In some
studies, thirst was the main focus, and in others, it was measured together with several other variables.
Sample characteristics are shown in Table 1.
Sample sizes varied from 5 to 247 patients (mean = 39.6; median = 22).
There was a large variety between samples with regard to patient characteristics (such as age, time on
HD, comorbidity, etc.) and the sampling method. Also, many studies lacked important information on
factors that may influence the thirst-feeling.
Therefore, all comparisons between studies have to be interpreted with caution. Nine studies gave
information about the prevalence of thirst.
Prevalence is defined as how many patients have a certain condition (thirst) at a certain moment in
time (Bowling, 1997). Six studies gave information about the relationship between thirst and IWG, and 15
articles reported about some kind of intervention.
RESULTS
WHAT IS THE PREVALENCE OF
thirst? Thirst was measured in many different ways with regard to both the format of the questions and
the answer options. For example, in one study patients were asked, "Are you thirsty?" in another, the
question was "How thirsty are you?" and in yet another, "To what extent are you bothered by excessive
thirst?' Answer categories varied from a dichotomous yes/no answer over 5-point answer categories to
continuous visual analogue scales (VAS). For the sake of comparison, in the two studies (Heidbreder et al.,
1990; Wirth & Folstein, 1982) in which VAS scores were used with only anchors at the extremes,
frequencies were calculated from the figures given by the authors, and the VAS scale was divided into four
categories. However, much more problematic to compare numbers of the different studies was the
great diversity in time-frames, varying from thirst right now to thirst in the previous 2 months; four studies
did not mention a time frame. Moreover, comparison of the studies was difficult because the samples
differed a lot in patient characteristics that can influence thirst symptoms. Only baseline measurements
from the intervention studies were included. An overview is presented in Table 2.
When taking the limitations into consideration, the prevalence of thirst varied fi-om 6% (Eevin &
Goldstein, 199(i) to 95'yo (Dominic, Ramachandran, Somiah, Mani, & Dominic, 1996). However, these
extremes were found in small and selective study populations. The most representative studies were those
of Giovannetd et al. (1994) and Virga et al.
(1998). The sample in Giovannetti's study was relatively large (n = 247) and comprised of compliant
(according to the authors) patients from five different centers, with no diabetic patients. In the sample in
Virga's study, all patients were from one center {n— 73), and there was very little nonresponse. Both
studies reported comparable percentages of patients with low thirst scores (14"/o not abnormally thirsty and
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
15 % never thirsty, respectively) and similar percentages of patients with high thirst scores (44"/ii with
thirst almost always present and disturbing sleeping and working and 49"/i) with thirst occurring every
day, respectively). Giovannetd's study concerned thirst in the last interdialytic period and Virga's about the
occurrence of thirst at home, (thus, not in the intradialytic period). In three studies (Bjorvell & Hylander,
1989; Hang & Clyne, 1997; Virga et al,, 1998) in which the prevalence of several symptoms
was investigated, thirst was the most common symptom. In the study of Hays, Kallich, Mapes, Coons, and
Carter (1994), thirst ranked in seventh place out of 35 symptoms, and it ranked in third place among
symptoms that caused severe distress to the patients.
[TABLE 1]
[TABLE 2]
To what extent is thirst related
to interdialytic weight gain? In the study by Giovannetti et al. (1994), exaggerated thirst was reported by 86"/o
of the patients, while IWG greater than 4"/i) of body weight was found in 34"/i) of patients. Patients with the most severe thirst
had a mean IWG of 4.1"/(j, or 2.6 kg, in contrast to 3.1"/o or 1.9 kg in patients with the lowest thirst scores. An analogous picture is
presented by Yamamoto et al. (1986), in which the patients with the most severe thirst had a mean IWG of 5.3 kg, and the patients
with no thirst or mild thirst gained 1.4 kg.
MartinezA/ea, Garcia, Gaya, Rivera, and Oliver (1992) studied the influence of a hypertonic saline-infusion on thirst in two
groups of HD patients (IWG greater than .5%:, IWG less than 3%] and one group of healthy controls. The study was done before
the dialysis session. No differences were found at baseline, but during and after the infusion, thirst scores were higher in patients
with a higher IWG. This group also needed more fluid to quench their thirst afterwards.
Wirth and Folstein (1982) studied the relationship between thirst (in the previous 2 months) and the mean IWG over
the previous ten dialysis sessions. They found a significant correlation coefficient of 0.78 in patients without kidneys
and 0.46 (but no longer significant) in patients with kidneys. Heidbreder et al. (1990) also found a positive correlation
coefficient of 0.86 between thirst, measured on a VAS at the beginning of a dialysis session, and the preceding IWG.
Moreover, patients with IWG less than 3 kg appeared to have a lower thirst score than patients with IWG of greater
than 3 kg. In contrast, Oldenburg, MacDonald, and Perkins (1988) reported a negative correlation between thirst and
drinking, and no relationship between thirst and IWG.
What interventions are applied
to minimize thirst? In the selected studies, thirst was measured as a dependent variable, but not always as the
main outcome variable. Some studies focused on hypertension, but measured thirst as a possible sideeffect.
Broadly speaking, three types of interventions could be distinguished: dialysis-technical, pharmaceutical, and
dietetic.
Dialysis-technical interventions.
The dialysis-technical interventions can be divided into two groups: frequency of dialysis and varying
the amount of dialysate sodium, which was sometimes combined with varying the ultrafiltradon rate.
The effect of daily dialysis compared to three times a week has been studied in home dialysis
patients (Kooistra, Vos, Koomans, & Vos, 1998). It was concluded that quality of life and hemodynamic
control improved with daily dialysis and that patients were less thirsty. Second, many studies have been
carried out with dialysate sodium concentration (NaJ, with both high and low sodium levels, as wel! as
many different ways of sodium profiling during dialysis.
Profiling is a method used during a dialysis session to decrease a level of a concentration of dialysate
constituents (e.g., sodium) or to decrease the ultrafiitration (UF) rate. There are three types of profiling (see
Figure 1): a linear decrease, an exponential decrease, and a stepwise decrease.
Some studies were aimed at lowering side-effects and symptoms during dialysis, such as cramps and
hypotension, and others focused more on lowering symptoms between dialysis sessions, such as
hypertension or thirst In the current review, only effects on thirst and IWG are discussed (see Table
3), Three studies (Barre, Brunelle, & Gascon-Barre, 1988; Cybulsky, Matni, & Hollomby, 1985; Daugirdas,
Al Kudsi, Ing, & Norusis, 1985) compared dialyzing at a constant high sodium level versus dialyzing with a
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
constant lower concentration. All found a greater IWG in the high sodium group, but were inconclusive
with regard to thirst.
Profiling sodium versus dialyzing at a constant sodium level was compared in four studies; two
(Daugirdas et al., 1985; Sang, Kovithavongs, Ulan, & Kjellstrand, 19!)7) found a greater IWG and more
thirst in the group with sodium profiling, while the other two (Parsons, Yuill, Llapitan, & Harris,
1997; Sadowski, Allred, &Jabs, 1993) found no differences between the groups.
Two studies investigated the effect of profiling the UF rate versus a constant UF rate; Ebel et al. (1997)
found no effect on thirst or IWG, and Parsons et al. (1997) reported that the patients in the control group
were more thirsty.
Finally, four studies combined sodium profiling with profiling the UF rate: Ebel et al. (1997) and Levin
and Goldstein (1996) found more thirst in the profiled group while the other two studies (Dominic et al.,
1996; Parsons et al., 1997) found the opposite. Only one study (Ebel et al., 1997) found that the IWG was
greater in the profiled group, while the other three found no difference between the groups.
[FIGURE 1]
Pharmaceutical interventions.
The pharmaceufical interventions are based on the main dipsogenic (= thirst inducing) role of
angiotensine- II, which is well known from physiological research (Fitzsimons, 1998).
Angiotensine-II is a circulating hormone that interacts on the limbic structures of the brain and causes
a thirst sensation. Angiotensine-II is mainly formed through interaction of angiotensine and renin into
angiotensine- I, which in turn reacts with angiotensine converting enzyme (ACE) and forms angiotensineII.
Experiments have been done with ACE-iniiibitors that inhibit the conversion of angiotensine-1
into angiotensine-II. An overview of the results of the ACE inhibitor experiments in HD patients is
presented in Table 4. It is important to note that the studies investigating ACEinhibitors in diaiysis patients
focused in the first instance on hypertension and not on thirst.
Studies have been done with enaiaprii (Oldenburg, MacDonaid, & Shelley, 1988), captoprii (Giovannetti
et ai., 1994; Yamamoto et ai., 1986), ciiazapril {Kuriyama, Tomonari, & Sai^ai, 1996) and
iisinoprii (Giovannetti et al., 1994). Three studies (Kuriyama et al, 1996; Oidenburg et al., 1988;
Yamamoto et al., 1986) found a decrease in thirst and IWG after administration of an ACE-inhibitor, and a
fourth study (Giovannetti et al., 1994) found no effect on thirst for either lisinoprii or captopril.
Finally, one more study should be mentioned (Rosansky, Johnson, & McConnell, l!)93) in which
transcutaneous administration of clonidine, a central alpha-2 agonist antihypertensive agent, was
investigated. No difference in thirsl was found between this method of administration and the conventional
oral method.
[TABLE 3]
[TABLE 4]
Dietetic intervention. One dietetic intervention was identified. A low-protein diet te.sted by Giovannetti et al.
(1994) was found to decrease thirst.
Discussion and Conclusions From this review it is concluded that thirst is a common and severe symptom in
dialysis patients. There is also a positive relationship between thirst and excessive IWG, meaning patients with high
thirst scores show also high IWG.
However, only a small number of relevant studies were found between 19H0 and 1999. Moreover, most studies were
difficult to ctmipare because of methodological differences, which included small, nonrepresentative samples. It was
also found that many different scales and time frames were used to measure thirst. There is also a language problem in
the interpretation of the results. Thirst is a natural phenomenon that urges people to drink - so, is it a problem area
when some patients say they "have" thirst, or is there oniy a problem when people are "troubled" with thirst? Are
the numbers of thirsty patients in the different studies comparable when so many different wordings of questions were
used? Is l^'Vo of patients having the burden of thirst more problematic than 2()"/(i of patients having thirst? It is
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
important to have uniform measurements of thirst, however, regardless of the way thirst is measured, all patients with
thirst have a problem, because all HD patients are not allowed to respond in a natural way to the thirst signal.
Scajcely any data were available in the time period searched on the course of thirst during the day or over the inter
and intradiaiytic periods, and no data at all was found on the course of thirst over the entire illnessperiod.
Although there is a relationship between thirst and IWG, no conclusions can be drawn on a causal relationship that
finds thirst leading to drinking, leading to large IWG. This relationship is not necessarily as linear as often thought.
For example, patients with high IWGs who do not complain of thirst may drink a lot to prevent thirst, or drink
whenever they feel slightly thirsty. It may also be that a patient feels very thirsty but has the willpower to refrain from
drinking.
Patients may be very thirsty, but still have low IWGs because they participate in sports and lose fluid by sweating.
It is difficult to compare the dialysis- technical interventions, because of the many different levels of
sodium concentrations, the various methods of profiling, and various combinations with UF profiling. Positive,
negative, and no effects on thirst have been rept)rted making conclusions difficult to draw. With regard to
the pbarmaceutical interventions with ACE-inhibitors, it was found that they have a general tendency to decrease thirst
and IWG, or at least that they cause no increase. However, no firm conclusions can be drawn because of the small
sample sizes and the lack of double-blind studies. Since only one study rept)rted on a dietetic intervention for thirst, no
conclusion can be drawn. It is amazing that the search produced no studies on the effect of low-sodium diets, since
many articles indicate that sodium intake is a major cause of thirst.
It was also surprising to find that no studies have been published on the effect of symptomatic interventions such as
ice cubes, chewing gum, distraction, etc., since these remedies are frequently discussed by patients and can be found
on internet bulletinboards.
Recently Welch and Davis (2000) reported that patients use many different strategies and., surprisingly they do not
use the strategy they consider the most effective most often.
Based on the results of this review, it is recommended that complementary literature reviews should be performed to
investigate thirst interventions in other patient categories, such as terminal patients, preoperative and postoperative
patients, or diabetics, for whom thirst is also a major problem, although thirst may be from another origin in those
patients. In this way, more potential therapeutic and symptomatic thirst intei-ventions could be identified, and
subsequently tested in HD patients.
There is also a need for more empirical research on the prevalence of thirst in HD patients and on the course of thirst
across the time-fi-ame ofa day and a week. More qualitative research is also needed to investigate how patients
experience thirst and how they cope with it.
Finally, this literature review gives an overview of studies on HD patients in which thirst was measured.
However, the practical applicability of this review is limited in view of the problem of noncompliance, which was
the starting point in the introduction.
Noncompliance is a very complex concept, with many influencing and causal factors, and there are many ways in
which to intervene.
Thirst, as a possible cause of chronic fluid-overload and excessive IWG, is just one of many possible targets
for interventions.
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review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
TABLES
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
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Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
Mistiaen, P. Thirst, interdialytic weight gain, and thirst interventions in hemodialysis patients: a literature
review. Nephrology Nursing Journal: 2001, 28(6), 601-604, 610-615
FIGURES
This is a NIVEL certified Post Print, more info at http://www.nivel.eu