Prevalence,severity and multidimensional factors associated with pain among hemodialysis patients: A cross-sectional study in a resource-limited healthcare system

Abstract

Objectives

This study aimed to determine the prevalence, severity and multidimensional factors associated with pain among hemodialysis (HD) patients in a resource-limited healthcare system.

Methods

A multicenter cross-sectional study was conducted across eight hospitals in the West Bank of Palestine, enrolling 361 adult patients on maintenance HD. Pain intensity was measured using the Visual Analog Scale (VAS), pain interference with the Brief Pain Inventory (BPI) and health-related quality of life with the EuroQol 5-Dimension 5-Level (EQ-5D-5L).

Results

Pain was reported by 281 patients, corresponding to a prevalence of 77.8%, with more than half (53.8%) experiencing moderate to severe intensity. Gender (OR = 2.29, 95% CI: 1.17-4.50), comorbid chronic diseases (OR = 3.62, 95% CI: 1.59-8.23), and HD vintage (OR = 1.12, 95% CI: 1.04-1.20) were independently associated with presence of pain. Pain severity was higher among females (B = 0.86, p = 0.006) and those with longer HD vintage (B = 0.05, p = 0.047), while smoking was linked to lower scores (B = -0.59, p = 0.006). Pain interference was higher in females (B = 1.23, p < 0.001) and patients with chronic diseases (B = 1.46, p = 0.001). Lower EQ-5D utility values were associated with age (β = -0.19, p = 0.003) and regular exercise (B = -0.14, p = 0.011). Self-assessed health scores declined with age (B = -0.23, p < 0.001) and chronic diseases (B = -4.69, p = 0.041). Pain control effectiveness was negatively associated with employment status (B = -2.53, p = 0.001).

Conclusion

Pain is highly prevalent and undertreated among HD patients. The findings underscore the need for multidisciplinary, culturally sensitive strategies integrating pharmacologic, non-pharmacologic, psychosocial and spiritual care to better manage pain and enhance patient quality of life.

Keywords

chronic kidney disease health and social care services health professional education hemodialysis pain prevalence pain management quality of life

Introduction

Chronic kidney disease (CKD) is a progressive condition that often culminates in end-stage renal disease (ESRD), with hemodialysis (HD) serving as the most common life-sustaining therapy.^1–4 While HD prolongs survival, it does not alleviate the heavy symptom burden carried by these patients. Among the most pervasive and distressing symptoms is pain, reported by the majority of patients undergoing HD.^5–7

Pain is increasingly recognized as one of the most prevalent and debilitating symptoms among patients undergoing HD, with international studies reporting rates between 60% and 80%.^6–9 Its etiology is multifactorial, encompassing musculoskeletal disorders related to immobility and mineral bone disease, neuropathic changes secondary to uremic toxins and metabolic derangements and complications associated with vascular access such as stenosis, thrombosis, or repeated cannulation.¹⁰ Beyond biological mechanisms, pain is frequently intensified by treatment-related fatigue, sleep disturbances and psychological distress.^11,12 These factors compound the burden of pain and lead to functional impairment, anxiety and depression. Together, they severely compromise health-related quality of life of the affected patients.^11–13 It is noteworthy to mention also that pain in HD patients has broader clinical and socioeconomic consequences. Procedural factors such as repeated vascular access cannulation and intradialytic muscle cramps contribute to persistent discomfort.¹⁴ Neurological complications, including restless legs syndrome and peripheral neuropathy,¹⁵ further exacerbate the burden. Importantly, uncontrolled pain may reduce adherence to dialysis sessions, increase hospitalization rates and impose substantial economic costs on healthcare systems and families.^16,17 These multidimensional impacts underscore the need for comprehensive pain management strategies that extend beyond symptom relief to safeguard treatment adherence and long-term outcomes. Several studies have identified patient-level factors associated with greater pain burden, including female gender, higher body mass index (BMI), longer disease duration and the presence of multiple comorbidities.^5,7,18,19 Despite its high prevalence and impact, pain in dialysis populations remains underrecognized and undertreated. This is partly due to limited therapeutic options in the context of renal impairment, where the use of opioids and nonsteroidal anti-inflammatory drugs is restricted.^20,21 Understanding factors associated with pain in this vulnerable group is therefore essential to improving both clinical outcomes and patient-centered care, notably in resource-limited settings.

In Palestine, HD services have been steadily expanding in recent years, reflecting both improved patient survival and the rising incidence of diabetes and hypertension as leading causes of CKD progression.^22,23 This growing reliance on dialysis has placed increasing demands on healthcare infrastructure and resources,^24,25 underscoring the importance of addressing not only survival but also the quality of life of patients. According to the Palestinian Ministry of Health, approximately 1,778 patients are currently receiving maintenance HD in the West Bank,²⁶ reflecting the growing burden of end-stage kidney disease in the country. Within this context, pain management emerges as a critical yet often overlooked component of care,⁵ with implications that extend beyond symptom relief to encompass functional capacity, psychological well-being and overall treatment outcomes.

Despite the global recognition of pain as a major determinant of quality of life in patients with CKD,^5,27,28 evidence from low-resource and culturally specific settings remains limited. In Palestine, existing studies have documented the high prevalence of pain among HD patients,^22,23 yet little is known about how this symptom is managed, the relative use of pharmacologic versus non-pharmacologic strategies, or the extent to which psychosocial and spiritual factors shape pain perception and coping. Moreover, the effectiveness and safety of commonly used analgesics in this population have not been systematically evaluated and non-pharmacologic interventions such as physiotherapy, counseling, or relaxation techniques remain underexplored. These gaps hinder the development of comprehensive, culturally appropriate pain management protocols and leave patients vulnerable to undertreatment of a highly prevalent and disabling symptom. This study was situated within a resource-limited healthcare system that faces unique challenges. The West Bank is characterized by constrained medical infrastructure, shortages of specialized staff and limited access to advanced pain management modalities. These difficulties are compounded by the broader context of political instability, recurrent conflict and economic hardship, which restrict patient mobility, disrupt supply chains and impose financial burdens on both hospitals and families.^29–31 Within this environment, dialysis units often operate under considerable strain, prioritizing life-sustaining treatment while symptom management, including pain control, remains underemphasized. Conducting research in such a setting underscores the urgent need for evidence-based, culturally sensitive and cost-effective strategies to improve patient outcomes. The present study aimed to¹: determine the prevalence and severity of pain among patients with CKD undergoing maintenance HD in Palestine²; characterize the pharmacologic and non-pharmacologic strategies employed for pain management³; identify demographic, clinical, psychosocial and spiritual factors associated with pain; and⁴ evaluate the impact of pain on health-related quality of life, including utility values, self-assessed health scores and perceived effectiveness of pain control.

Methods

Study design and settings

This study employed a multicenter cross-sectional design to evaluate pain prevalence, severity and management among patients with CKD undergoing maintenance HD in Palestine. The study was conducted in strict adherence to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist, ensuring methodological rigor and transparent reporting (Supplemental Table S1). Data collection took place between June and August 2025 across eight major dialysis centers distributed in the principal cities of the West Bank, including Nablus, Ramallah, Bethlehem, Jenin, Qalqilya, Tulkarm, Salfit and Tubas. These centers represent the backbone of renal replacement therapy in the region and provide services to a diverse patient population drawn from urban, rural and refugee camp settings.

Patients and sample size

Eligible patients were adults (≥18 years) with a confirmed diagnosis of CKD receiving maintenance HD at one of the participating centers. Only patients able to provide informed consent and complete the study questionnaire were included. Exclusion criteria comprised acute renal failure, cognitive impairment, communication difficulties, severe psychiatric illness, active or prior malignancy and refusal to participate.

According to the statistic of the Palestinian Ministry of Health, 1,778 patients were receiving maintenance HD in the West Bank of Palestine. The target sample size was determined using Daniel’s formula and verified with the Raosoft online calculator (www.raosoft.com), assuming a 95% confidence level, a 5% margin of error and a 50% response distribution. The minimum required sample was 317 patients; however, to account for potential non-response, the recruitment target was increased. Ultimately, 361 patients were enrolled, ensuring adequate statistical power and representativeness.

Recruitment was conducted in collaboration with dialysis staff across all active centers. Given the logistical and contextual constraints of conducting research in the West Bank, including limited resources, movement restrictions and the instability of a conflict-affected environment, a convenience sampling strategy was employed. To mitigate potential bias, data collection was distributed across multiple centers, shifts and days, thereby capturing a broad spectrum of patient experiences. This approach enhanced geographic and demographic diversity, though the non-probability design may limit generalizability to the entire CKD population in Palestine.

Data collection tool

Data were collected using a comprehensive, structured, interviewer-administered questionnaire designed to capture the multidimensional experience of pain among patients undergoing maintenance HD. The instrument consisted of 40 items organized into six domains: sociodemographic and lifestyle characteristics, clinical and dialysis-related information, pain assessment, health-related quality of life, pain management strategies and contextual psychosocial factors. To ensure measurement reliability and comparability with international research, we incorporated previously validated Arabic versions of the Visual Analog Scale (VAS),^32,33 the Brief Pain Inventory (BPI),³⁴ and the EuroQol 5-Dimension 5-Level (EQ-5D-5L) into the questionnaire.³⁵ These instruments have demonstrated robust reliability and validity in Arabic-speaking Middle Eastern populations, including studies conducted in neighboring Jordan and Syria.^32–40

The sociodemographic and lifestyle section gathered information on age, gender, weight, height, place of residence, marital and employment status, educational attainment, smoking history and physical activity.

Clinical and dialysis-related data encompassed the presence of comorbid chronic diseases such as hypertension, diabetes and cardiovascular disease, in addition to HD vintage, dialysis frequency and average session length.

Pain was assessed using the VAS to measure intensity on a 0-10 scale, complemented by the BPI to evaluate interference across functional domains.^32–34 Patients were also asked to describe the nature of their pain, whether acute, chronic, throbbing, burning, pressure-like, or fatigue-related/aching and to report its duration, aggravating factors and impact on sleep and daily activities.

To ensure clarity and reproducibility, all scales and variables were explicitly defined and analyzed according to validated standards. Pain intensity (severity) was measured using the VAS, a 0-10 continuum where 0 indicates “no pain” and 10 “worst imaginable pain.” For interpretation, scores were categorized as mild,^1–3 moderate,^4–6 severe^7–9 and very intense.¹⁰ Pain interference with daily functioning (general activity, mood, walking ability, work, relationships, sleep and enjoyment of life) was further assessed using the BPI, which evaluates the extent to which pain disrupts seven functional domains. Each domain is scored on a 0-10 scale, with higher scores indicating greater interference. For descriptive purposes, patients were asked to characterize their pain as acute or chronic. In this study, acute pain was defined as pain of recent onset lasting less than 3 months, while chronic pain was defined as pain persisting for 3 months or longer, consistent with international standards.

Health-related quality of life was evaluated using the EQ-5D-5L instrument, which captures five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression), each rated on five levels (no problems, slight problems, moderate problems, severe problems, extreme problems). Utility values were calculated from EQ-5D-5L responses using the Middle Eastern Arab value set, where disutility weights for each dimension/level were summed and subtracted from 1 to generate the index score (range <0 to 1). Overall health status was self-rated using the EQ-VAS (0 = worst imaginable health, 100 = best imaginable health). Perceived effectiveness of treatment was measured on a 0-10 scale, with higher scores reflecting greater patient-reported benefit. For pain management, pharmacologic strategies were classified into three levels: level 1 (non-opioid analgesics such as paracetamol/acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)), level 2 (weak opioids such as tramadol or codeine, often combined with non-opioids) and level 3 (strong opioids such as morphine or fentanyl, reserved for severe pain). Non-pharmacologic interventions, including physiotherapy, relaxation techniques, exercise and counseling, were documented separately to capture multimodal approaches. This structured organization of variables allowed for consistent categorization in the tables and facilitated multivariable analyses linking sociodemographic, clinical, psychosocial and treatment factors with pain prevalence, severity, interference and quality-of-life outcomes.

Finally, contextual variables were included to capture the broader environment in which patients experienced and managed pain. These encompassed satisfaction with household income, perceived social support from family and community and levels of religious or spiritual commitment. By integrating these domains, the questionnaire provided a holistic view of pain prevalence, severity, management and its impact on quality of life, while also accounting for the cultural and socioeconomic realities of patients living in a resource-limited healthcare system. The study questionnaire is provided in Supplemental Table S2.

The questionnaire was administered to patients in person by final-year medical students (AA, MA, FS, TS) who had been trained during their medical education to conduct structured interviews and collect medical histories. For this study, they received additional tailored training from the supervisors (RS, HH), both of whom have extensive experience in conducting quality-of-life research and caring for patients with CKD. This training was designed to ensure accurate data collection and clear communication with participants of varying educational backgrounds. The questionnaire was in hard-copy paper format and completed during face-to-face interviews in the dialysis centers. Patients were approached privately with the help of dialysis staff in the centers, where the researchers explained the study design, objectives and procedures in simple, non-technical language before obtaining written informed consent. All interviews were conducted privately to safeguard confidentiality and minimize reporting bias. Each questionnaire item was read aloud and explained to participants, with clarifications provided for medical terms (e.g., differentiating between NSAIDs and opioids, or identifying medications by their trade names). Patients were encouraged to ask questions whenever an item was unclear and the interviewers provided culturally and linguistically appropriate explanations to facilitate understanding. To ensure accuracy, clinical variables such as comorbidities, dialysis vintage, frequency and duration of sessions and prescribed medications were cross-checked against medical records, including physician and nursing notes. Permission to access patient records was formally granted by the participating centers.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics, version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were first generated to summarize patient characteristics as categorical variables were expressed as frequencies (n) and percentages (%), while continuous variables were reported as means with standard deviations (SD).

Group comparisons for categorical variables were performed using chi-square or Fisher’s exact tests, and continuous variables were analyzed using t-tests or analysis of variance (ANOVA). Pearson’s correlation coefficients assessed associations between continuous variables and the score-based outcomes.

To ensure consistency and retain all potentially independent factors, regression analyses were conducted including all variables regardless of bivariate significance. Multivariate logistic regression was applied to identify independent factors associated with presence of pain, with odds ratios (OR) and 95% confidence intervals (95% CI) reported. Multiple linear regression was used for continuous outcomes (pain severity, pain interference, EQ-5D utility, EQ-VAS, and effectiveness of pain control), with unstandardized coefficients (B), standard errors (SE), standardized beta coefficients (β), t-statistics, and p-values presented to quantify effect sizes. Model assumptions were rigorously checked. Multicollinearity was assessed using tolerance values (>0.20) and variance inflation factors (VIF < 5). Normality of residuals and homoscedasticity were visually inspected to confirm model adequacy. All statistical tests were two-tailed, and statistical significance was set at p ≤ 0.05.

Ethical considerations

This study was conducted in strict accordance with both international and local ethical principles, including the Declaration of Helsinki and relevant national regulations governing research involving human participants. Formal approval was obtained from the Institutional Review Board (IRB) of An-Najah National University (Approval #: Pharm. Dec. 2024/58). In addition, authorization was granted by the Palestinian Ministry of Health to conduct the study within governmental dialysis centers. Prior to enrollment, all participants received detailed information about the study objectives and procedures and each provided written informed consent. Confidentiality and anonymity were safeguarded throughout data collection and analysis and participation was entirely voluntary, with the right to withdraw at any stage without consequence.

Results

Characteristics of the patients

A total of 361 patients with ESRD undergoing maintenance HD were enrolled, surpassing the minimum required sample size of 317. Of the 400 patients initially approached, 370 met the eligibility criteria and 361 (97.6%) provided written informed consent. The recruitment and inclusion process is illustrated in Figure 1.

Figure 1.

Flow diagram of participant selection.

The mean age of patients was 57.7 ± 14.7 years, with males constituting 57.9% (n = 209) of the cohort. The mean BMI was 28.3 ± 7.7 kg/m². More than half of the patients resided in villages (57.3%), while 36.6% lived in urban areas and 6.1% in refugee camps. The majority were married (84.5%) and unemployed (87.8%). Educational attainment was predominantly at the school level (80.1%), with only 19.9% holding a university degree. Comorbidities were highly prevalent, with 85.3% of patients reporting at least one chronic condition. Hypertension was the most common (80.3%), followed by diabetes mellitus (54.3%) and cardiovascular disease (13.3%). The mean HD vintage (duration of ESRD) was 5.7 ± 5.1 years. Patients typically received three HD sessions per week, each lasting an average of 3.6 hours. A detailed summary of sociodemographic and clinical characteristics is presented in Table 1.

Table 1.

Sociodemographic and health characteristics of the patients (n = 361).

Variable	Subcategory	Mean ± SD or n (%)
Age (years), mean ± SD		57.7 ± 14.7
Gender	Male, n (%)	209 (57.9)
Gender	Female, n (%)	152 (42.1)
BMI (kg/m²), mean ± SD		28.3 ± 7.7
Place of residence	City, n (%)	132 (36.6)
	Village, n (%)	207 (57.3)
	Refugee camp, n (%)	22 (6.1)
Marital status	Currently unmarried, n (%)	56 (15.5)
Marital status	Currently married, n (%)	305 (84.5)
Employment status	No, n (%)	317 (87.8)
Employment status	Yes, n (%)	44 (12.2)
Self-rated satisfaction with household income	Unsatisfied, n (%)	307 (85.0)
Self-rated satisfaction with household income	Satisfied, n (%)	54 (15.0)
Self-rated satisfaction with support from family, friends and community	Unsatisfied, n (%)	82 (22.7)
	Satisfied, n (%)	279 (77.3)
Self-rated satisfaction with religious/spiritual commitment	Unsatisfied, n (%)	53 (14.7)
Self-rated satisfaction with religious/spiritual commitment	Satisfied, n (%)	308 (85.3)
Educational level	School, n (%)	289 (80.1)
Educational level	University, n (%)	72 (19.9)
Smoking status	Current smoker, n (%)	77 (21.3)
	Former smoker, n (%)	70 (19.4)
	Never smoked, n (%)	214 (59.3)
Pack-years, mean ± SD		15.3 ± 28.1
Regular exercise	No, n (%)	318 (88.1)
Regular exercise	Yes, n (%)	43 (11.9)
Chronic diseases	No, n (%)	53 (14.7)
	Yes, n (%)	308 (85.3)
	Hypertension, n (%)	290 (80.3)
	Diabetes mellitus, n (%)	196 (54.3)
	Cardiovascular disease, n (%)	48 (13.3)
	Gout, n (%)	3 (0.8)
	Others, n (%)	6 (1.7)
HD vintage (years), mean ± SD		5.7 ± 5.1
Number of HD sessions/week, mean ± SD		2.9 ± 0.3
Duration of HD session (h), mean ± SD		3.6 ± 0.5

BMI: body mass index, HD: hemodialysis, SD: standard deviation, h: hours.

Prevalence, characteristics, intensity, interference and management of pain

In the study cohort, pain was reported by 281 patients (77.8%), while 80 patients (22.2%) did not report pain (Table 2). Of those with pain, 83 patients (23.0%) experienced mild pain, 118 (32.7%) reported moderate pain, 76 (21.1%) described severe pain, and 4 (1.1%) reported very intense pain. The overall mean pain severity score was 4.2 ± 2.8. Fatigue-related or aching pain was the most frequently reported descriptor (n = 144, 40.0%), followed by pressure-like pain (n = 70, 19.5%) and chronic pain (n = 100, 27.8%). Acute and throbbing pain were less commonly endorsed.

Table 2.

Prevalence, description and management of pain.

Variable	Subcategory	n (%)
Pain/discomfort	No, n (%)	80 (22.2)
Pain/discomfort	Yes, n (%)	281 (77.8)
Severity of pain	No, n (%)	80 (22.2)
	Mild, n (%)	83 (23.0)
	Moderate, n (%)	118 (32.7)
	Severe, n (%)	76 (21.1)
	Very intense, n (%)	4 (1.1)
Pain description	No, n (%)	80 (22.2)
	Fatigue-related/aching, n (%)	144 (40)
	Chronic, n (%)	100 (27.8)
	Pressure, n (%)	70 (19.5)
	Acute, n (%)	51 (14.1)
	Throbbing, n (%)	12 (3.5)
	Burning, n (%)	6 (1.7)
Pain relief method	No treatment, n (%)	81 (22.4)
	Analgesics, n (%)	258 (71.5)
	Physiotherapy, n (%)	22 (6.1)

Pain intensity was further assessed across four temporal dimensions: current pain score (1.4 ± 2.5), average pain over the past 24 hours (2.0 ± 2.8), lowest pain level (1.4 ± 2.2), and highest pain level (2.6 ± 3.5) (Supplemental Table S3). These ratings contributed to the overall perception of pain severity (4.8 ± 3.2). Pain interference was evaluated across seven functional domains, with the highest impact reported on general activity (4.8 ± 3.6), mood (4.6 ± 3.7), and enjoyment of life (4.6 ± 3.6). Sleep quality, walking ability, social relationships, and work/daily activities were also notably affected, with scores ranging from 3.9 to 4.5. The composite pain interference score averaged 3.5 ± 2.8. Health-related quality of life was captured using the EQ-5D utility value (0.6 ± 0.3) and a self-assessed health score on a 0-100 scale (60.6 ± 15.1). Perceived effectiveness of pain control was relatively high (7.9 ± 3.7).

Analgesics constituted the predominant management strategy, reported by 258 patients (71.5%). When classified according to the World Health Organization’s analgesic ladder, all patients who used analgesics reported paracetamol/acetaminophen (100.0%), while smaller proportions reported flurbiprofen (5.8%), tramadol (1.6%), or meperidine (0.4%). Pregabalin, an adjuvant agent outside the ladder, was reported by 0.8% of patients (Supplemental Table S4). Physiotherapy was rarely utilized (n = 22, 6.1%), and a notable proportion of patients (n = 81, 22.4%) reported not employing any form of pain management.

Associations between sociodemographic, clinical and dialysis-related variables with pain

In the bivariate analyses, several factors were significantly associated with the presence of pain. These included higher BMI (p = 0.049), presence of other chronic comorbidities (p < 0.001), absence of regular exercise (p = 0.032), longer HD vintage (p = 0.005), lower satisfaction with social support from family, friends and community (p = 0.008) and reduced religious or spiritual commitment (p < 0.001). The full set of bivariate associations is presented in Supplemental Table S5.

In the multivariate logistic regression model, several variables remained independently associated with presence of pain (Table 3). Gender was significantly associated with higher odds of pain (OR = 2.29, 95% CI: 1.17-4.50), with females showing greater likelihood. The presence of comorbid chronic diseases markedly increased the likelihood of pain (OR = 3.62, 95% CI: 1.59-8.23), and HD vintage was also a significant associated factor (OR = 1.12 per year, 95% CI: 1.04-1.20), with longer dialysis exposure linked to higher odds. Other variables did not retain statistical significance after adjustment, although lower spiritual commitment showed a borderline association (OR = 0.51, 95% CI: 0.25-1.05, p = 0.068). The model demonstrated acceptable fit (Hosmer-Lemeshow χ² = 9.05, p = 0.338), explained approximately 20% of the variance in pain (Nagelkerke R² = 0.203), and correctly classified 77.6% of cases, with high sensitivity but limited specificity.

Table 3.

Factors associated with prevalence of pain.

Variable	B	SE	Wald	p	OR	95% CI for OR
Variable	B	SE	Wald	p	OR	Lower	Upper
Gender (female vs. male)	0.83	0.34	5.84	0.016	2.29	1.17	4.50
Age (per year increase)	0.00	0.01	0.00	0.967	1.00	0.98	1.02
BMI (per unit increase)	0.02	0.03	0.72	0.396	1.02	0.97	1.07
Place of residence (village vs. city)	0.12	0.61	0.04	0.847	1.13	0.34	3.75
Place of residence (camp vs. city)	0.21	0.61	0.12	0.728	1.23	0.38	4.04
Marital status (married vs. unmarried)	0.12	0.45	0.07	0.785	1.13	0.47	2.73
Employment status (no vs. yes)	0.18	0.45	0.15	0.696	1.19	0.49	2.90
Self-rated satisfaction with household income (satisfied vs. unsatisfied)	-0.32	0.45	0.52	0.473	0.73	0.30	1.74
Self-rated satisfaction with support from family, friends, and community (satisfied vs. unsatisfied)	-0.55	0.32	2.90	0.089	0.58	0.30	1.09
Self-rated satisfaction with religious/spiritual commitment (satisfied vs. unsatisfied)	-0.68	0.37	3.33	0.068	0.51	0.24	1.05
Educational level (university vs. school)	0.29	0.34	0.70	0.403	1.33	0.68	2.61
Smoking status (former vs. current)	0.05	0.45	0.01	0.912	1.05	0.44	2.53
Smoking status (never vs. current)	0.45	0.48	0.87	0.351	1.56	0.61	3.99
Pack-years (per unit increase)	0.00	0.01	0.22	0.638	1.00	0.99	1.02
Regular exercise (yes vs. no)	-0.52	0.42	1.49	0.222	0.60	0.26	1.37
Chronic diseases (yes vs. no)	1.29	0.39	11.15	0.001	3.62	1.70	7.71
HD vintage (per year increase)	0.11	0.04	9.40	0.002	1.12	1.04	1.20
Number of dialysis sessions per week (per unit increase)	-0.19	0.48	0.16	0.689	0.83	0.32	2.12
Duration of dialysis session (per hour increase)	0.34	0.30	1.31	0.252	1.40	0.79	2.50

BMI: body mass index, HD: hemodialysis, SE standard error, t t-statistics, statistically significant p-values are in boldface.

Associations Between Sociodemographic, Clinical and Dialysis-Related Variables with Pain Severity, Interference, Quality of Life and Effectiveness of Pain Control

Bivariate analysis of patient characteristics demonstrated several significant associations with pain severity, pain interference and health-related quality of life. These associations are shown in Supplemental Table S6. Female patients reported higher pain severity compared with males (2.1 ± 2.6 vs. 1.5 ± 2.4, p = 0.033), greater pain interference (4.1 ± 2.8 vs. 3.2 ± 2.8, p = 0.003), and lower utility values (0.5 ± 0.3 vs. 0.6 ± 0.3, p = 0.029). Advancing age was correlated with increased pain interference (r = 0.16, p = 0.003) and poorer health outcomes, reflected in lower utility values (r = -0.25, p < 0.001) and self-assessed health scores (r = -0.28, p < 0.001). Higher BMI was modestly associated with reduced utility values (r = -0.11, p = 0.033). Marital status also influenced outcomes, with married individuals reporting better self-assessed health scores than unmarried patients (64.5 ± 17.2 vs. 59.9 ± 14.6, p = 0.037).

Employment status emerged as a strong determinant of well-being, as employed patients exhibited higher utility values (0.7 ± 0.2 vs. 0.6 ± 0.3, p < 0.001) and superior self-assessed health scores (68.2 ± 11.4 vs. 59.5 ± 15.3, p < 0.001) compared with unemployed patients. Religious or spiritual commitment showed an inverse association, with lower commitment linked to less pain interference (2.5 ± 2.6 vs. 3.7 ± 2.8, p = 0.003), higher utility values (0.7 ± 0.3 vs. 0.6 ± 0.3, p = 0.015), and better self-assessed health scores (65.6 ± 17.9 vs. 59.8 ± 14.4, p = 0.010). Educational attainment was similarly influential, as patients with university education reported lower pain severity (1.2 ± 2.1 vs. 1.9 ± 2.6, p = 0.025), reduced pain interference (3.8 ± 2.9 vs. 4.9 ± 2.7, p = 0.017), higher utility values (p = 0.002), and markedly better self-assessed health scores (57.9 ± 13.1 vs. 41.8 ± 19.6, p < 0.001).

Lifestyle and clinical factors further shaped outcomes. Regular exercise was consistently associated with favorable results, including lower pain severity (0.9 ± 1.7 vs. 1.9 ± 2.6, p = 0.017), reduced pain interference (2.7 ± 2.1 vs. 3.7 ± 2.9, p = 0.028), higher utility values (0.8 ± 0.2 vs. 0.6 ± 0.3, p < 0.001), and improved self-assessed health scores (70.6 ± 10.8 vs. 59.3 ± 15.1, p < 0.001). Conversely, the presence of chronic diseases was linked to greater pain interference (3.8 ± 2.8 vs. 2.3 ± 2.6, p < 0.001), lower utility values (0.6 ± 0.3 vs. 0.7 ± 0.3, p = 0.009), and poorer self-assessed health scores (59.6 ± 14.6 vs. 66.2 ± 16.7, p = 0.009). Finally, longer HD vintage correlated with increased pain interference (r = 0.12, p = 0.019), suggesting that cumulative treatment exposure contributes to worsening functional limitations.

Multiple linear regression analyses identified several independent associated factors across pain severity, pain interference, health-related quality of life, self-assessed health, and pain control effectiveness. The factors that were independent associated are presented in Table 4, while the full set of variables included in the regression models is detailed in Supplemental Table S7. For pain severity, gender (B = 0.86, SE = 0.31, β = 0.17, p = 0.006), smoking status (B = -0.59, SE = 0.21, β = -0.19, p = 0.006), and HD vintage (B = 0.05, SE = 0.03, β = 0.11, p = 0.047) were independently associated with higher scores, with females and patients with longer dialysis exposure reporting greater severity, while smokers reported lower scores. Pain interference was associated with gender (B = 1.23, SE = 0.34, β = 0.22, p < 0.001), lower satisfaction with religious/spiritual commitment (B = 0.85, SE = 0.43, β = 0.11, p = 0.048), smoking status (B = -0.51, SE = 0.24, β = -0.15, p = 0.032), presence of chronic diseases (B = 1.46, SE = 0.43, β = 0.18, p = 0.001), and HD vintage (B = 0.10, SE = 0.03, β = 0.18, p = 0.001). In terms of health-related quality of life, lower EQ-5D utility values were independently associated with gender (B = -0.09, SE = 0.04, β = -0.14, p = 0.023), age (β = -0.19, p = 0.003), unemployment (B = -0.11, SE = 0.05, β = -0.11, p = 0.045), regular exercise (B = -0.14, SE = 0.05, β = -0.14, p = 0.011), chronic diseases (B = -0.10, SE = 0.05, β = -0.11, p = 0.034), and HD vintage (B = -0.01, SE = 0.00, β = -0.11, p = 0.036), while smoking status was associated with higher utility values (B = 0.06, SE = 0.03, β = 0.14, p = 0.037). For self-assessed health scores, age (B = -0.23, SE = 0.07, β = -0.23, p < 0.001), regular exercise (B = -6.80, SE = 2.51, β = -0.15, p = 0.007), and chronic diseases (B = -4.69, SE = 2.28, β = -0.11, p = 0.041) were associated with lower ratings, while smoking status was significantly associated with higher scores (B = 2.48, SE = 1.26, β = 0.13, p = 0.049). Finally, pain control effectiveness was negatively associated with marital status (B = -1.84, SE = 0.75, β = -0.18, p = 0.016) and employment status (B = -2.53, SE = 0.78, β = -0.23, p = 0.001), suggesting that social and occupational factors may influence perceived responsiveness to pain management strategies.

Table 4.

Factors independently associated with pain severity, interference, quality of life and effectiveness of pain control.

Domain/variable	Unstandardized coefficients		Standardized coefficients	t	p	Collinearity statistics
Domain/variable	B	SE	Beta	t	p	Tolerance	VIF
Pain severity score
Gender	0.86	0.31	0.17	2.78	0.006	0.68	1.46
Smoking status	-0.59	0.21	-0.19	-2.75	0.006	0.53	1.89
HD vintage	0.05	0.03	0.11	2.00	0.047	0.86	1.17
Pain interference score
Gender	1.23	0.34	0.22	3.61	< 0.001	0.68	1.46
Self-rated satisfaction with religious/spiritual commitment	0.85	0.43	0.11	1.98	0.048	0.84	1.20
Smoking status	-0.51	0.24	-0.15	-2.15	0.032	0.53	1.89
Chronic diseases	1.46	0.43	0.18	3.41	0.001	0.85	1.18
HD vintage	0.10	0.03	0.18	3.40	0.001	0.86	1.17
Utility value of health state
Gender	-0.09	0.04	-0.14	-2.29	0.023	0.68	1.46
Age	0.00	0.00	-0.19	-3.01	0.003	0.59	1.69
Employment status	-0.11	0.05	-0.11	-2.01	0.045	0.80	1.25
Smoking status	0.06	0.03	0.14	2.09	0.037	0.53	1.89
Regular exercise	-0.14	0.05	-0.14	-2.55	0.011	0.84	1.19
Chronic diseases	-0.10	0.05	-0.11	-2.13	0.034	0.85	1.18
HD vintage	-0.01	0.00	-0.11	-2.10	0.036	0.86	1.17
Self-assessed health score (0-100)
Age	-0.23	0.07	-0.23	-3.55	< 0.001	0.59	1.69
Smoking status	2.48	1.26	0.13	1.98	0.049	0.53	1.89
Regular exercise	-6.80	2.51	-0.15	-2.70	0.007	0.84	1.19
Chronic diseases	-4.69	2.28	-0.11	-2.05	0.041	0.85	1.18
Pain control effectiveness (0-10)
Marital status	-1.84	0.75	-0.18	-2.44	0.016	0.64	1.57
Employment status	-2.53	0.78	-0.23	-3.24	0.001	0.75	1.33

BMI: body mass index, B: the unstandardized coefficient represents the raw change in the dependent variable for a one-unit change in the variable, holding other variables constant, β: standardized coefficient represents the change in the dependent variable for a one-standard-deviation change in the variable and allows comparison of the relative strength of variable measured on different scales, HD: hemodialysis, SE: standard error, t: t-statistics, VIF: variance inflation factor, statistically significant p-values are in boldface.

Discussion

Pain is increasingly recognized as one of the most burdensome symptoms among patients undergoing HD, profoundly impairing quality of life and functional capacity.^7,41 In this study, pain was reported by 77.8% of Palestinian HD patients, with more than half experiencing moderate to severe intensity and analgesics being the predominant management strategy. The findings of this study reveal a higher burden of pain compared to an earlier study,²³ suggesting worsening symptom profiles over time. Importantly, this study adds novel insights by identifying comorbid chronic diseases, longer HD vintage, and female gender as independent factors associated with pain, while also highlighting gender-specific disparities and the underutilization of non-pharmacologic interventions. Lower spiritual satisfaction showed a borderline association, warranting further exploration in future studies.

Pain in HD populations consistently emerges as a high-frequency, high-impact symptom across settings and the pattern observed here, greater burden than previously reported in Palestine, aligns with global meta-analytic estimates while signaling a concerning intensification locally.^6,7,23 The predominance of musculoskeletal and dialysis-related descriptors (e.g., fatigue/aching, pressure-like) is consistent with pathophysiology linked to immobility, mineral bone disease and vascular access factors, underscoring the need to embed routine musculoskeletal screening and access-site evaluation into dialysis care pathways.¹⁸ The management pattern, heavy reliance on analgesics alongside limited uptake of non-pharmacologic strategies, mirrors international experience in CKD but carries heightened clinical risk in ESRD given constrained opioid choices and NSAIDs hazards, reinforcing calls for renal-appropriate analgesic protocols, dose-adjustment guidance and stewardship to reduce iatrogenic harm.^20,21 Regionally and globally, structured exercise, physiotherapy, and psychological therapies show benefit and safety in CKD. Yet, in our cohort, regular exercise was paradoxically associated with poorer quality-of-life measures, suggesting that physically active patients may be more attuned to musculoskeletal discomfort. This underlines both the need to explore contextual factors influencing exercise outcomes and the opportunity to integrate low-cost physiotherapy, relaxation training, and brief pain-focused counseling within dialysis units.^42,43 Taken together, these findings argue for a shift from ad hoc analgesic use to standardized, multidisciplinary pain care, prioritizing early identification of musculoskeletal sources, non-pharmacologic first-line options and culture-sensitive supports, likely to reduce interference with daily life and improve quality of life in a resource-limited context where marginal gains have outsized impact.^9,22

The identification of comorbid chronic diseases, longer HD vintage, and female gender as independent factors associated with presence of pain highlights the multidimensional drivers of symptom burden in CKD. The strong association with comorbidities reflects the intertwined pathophysiology of renal, cardiovascular, and metabolic disorders, where hypertension, diabetes, and vascular complications amplify musculoskeletal and neuropathic pain pathways.^44,45 The cumulative effect of longer disease duration underscores the progressive nature of CKD, with repeated vascular access procedures, mineral bone disease, and uremic neuropathy contributing to escalating pain over time.⁴⁶ Although lower spiritual satisfaction did not retain statistical significance, its borderline association suggests a potential psychosocial dimension, particularly in the Palestinian context where spirituality is a central coping mechanism.^47,48 Taken together, these associated factors indicate that pain in HD patients is not merely a biological symptom but a biopsychosocial phenomenon, requiring early, integrated interventions that address comorbidity management, vascular access care, and psychosocial support. For clinicians and policymakers, these findings emphasize the need to prioritize high-risk groups, patients with multiple comorbidities, prolonged HD exposure, and women, when designing pain management protocols in resource-limited settings.

Our findings on the high prevalence of pain and its interference with daily functioning among HD patients are consistent with reports from other Arab countries, where pain has been described as a frequent and under-recognized complication of dialysis care.^23,49,50 Similar to these regional studies, we observed that female gender, comorbid chronic diseases, and longer dialysis vintage were important factors associated with pain burden and impaired quality of life. In addition, smoking status emerged as a notable factor, being associated with lower pain severity and interference but paradoxically linked to higher EQ-5D utility and self-assessed health scores. In line with these observations, the recent Moroccan study demonstrated that sociodemographic and clinical factors such as gender, comorbidities, and dialysis duration were significantly associated with both pain severity and pain interference, reinforcing the cumulative impact of biological and social variables on patient outcomes.⁵⁰ Taken together, these findings emphasize that pain and pain control are central to the lived experience of hemodialysis patients across the Arab region, and that improving health-related quality of life requires systematic assessment and management of pain intensity and interference.

This study is novel in that it provides the first comprehensive, multicenter assessment of pain prevalence, severity, associated factors, and management strategies among HD patients in Palestine, a resource-limited healthcare system where such evidence has been lacking. Unlike previous studies that have largely focused on biological or clinical correlates, our work incorporates psychosocial and spiritual dimensions into a unified framework, offering a more holistic understanding of pain in dialysis patients. Importantly, the study highlights the limited use of non-pharmacologic interventions and the unexpected negative associations of regular exercise with quality-of-life measures, underscoring the need for culturally tailored, multidisciplinary pain management approaches. These results can inform government and policymakers by emphasizing the importance of integrating pain assessment and management into routine dialysis care, allocating resources for psychosocial and spiritual support, and developing national guidelines that balance pharmacologic and non-pharmacologic strategies. Furthermore, the findings provide a foundation for future research to explore longitudinal trajectories of pain, evaluate multimodal interventions, and examine how addressing pain can improve adherence, reduce hospitalizations, and enhance quality of life in patients with end-stage renal disease. The findings of this study are particularly informative for nephrologists, dialysis staff, pain specialists, and policymakers in resource-limited healthcare systems, as they underscore the urgent need for integrated, multidisciplinary pain management strategies tailored to the cultural and clinical realities of ESRD care in Palestine.

Strengths of the study

This study offers several notable strengths that enhance the credibility and relevance of its findings. First, the large sample size of 361 patients, exceeding the calculated requirement, provided robust statistical power and minimized the risk of type II error. The exceptionally high response rate further reduced selection bias and strengthened the representativeness of the cohort. Second, recruitment from eight major hospitals across diverse geographic regions of the West Bank provided broad coverage of urban, rural, and refugee populations. While this enhances the diversity of the sample, the findings cannot be fully generalized to the national CKD population. Third, the use of validated and internationally recognized instruments, the VAS, BPI, and EQ-5D-5L, enhanced measurement reliability and facilitated meaningful comparison with global research. Fourth, the study applied rigorous statistical methods, including multivariable regression models with checks for collinearity and confounding, which strengthened internal validity and allowed for nuanced identification of independent factors associated with pain and quality of life. Finally, the inclusion of psychosocial and spiritual dimensions alongside clinical and demographic variables represents a unique strength, offering a holistic perspective that is often overlooked in nephrology research. Although spirituality showed only borderline associations, its consideration enriches scientific understanding and provides actionable insights for clinicians, policymakers, and healthcare planners in resource-limited settings.

Limitations of the study

Some limitations should be acknowledged, though they do not diminish the overall value of this study. First, the cross-sectional design restricts causal inference, as temporal relationships between pain and associated factors cannot be definitively established. However, this design is widely used in nephrology research and remains appropriate for generating robust prevalence estimates and identifying associated factors that can inform future longitudinal studies. Second, convenience sampling was employed due to logistical challenges in a resource-limited and conflict-affected setting. While this may introduce some selection bias, the exceptionally high response rate and recruitment across eight major hospitals representing diverse geographic and social contexts substantially mitigate concerns about representativeness. Third, a pilot study of the composite questionnaire was not conducted. However, the embedded instruments, including the VAS, BPI, and EQ-5D-5L, were previously validated Arabic versions that have demonstrated acceptable reliability in Arabic-speaking Middle Eastern populations, including studies from neighboring countries. In addition, the final questionnaire was reviewed by the research team, which comprised experienced researchers, practicing physicians, and four final-year medical students, to ensure content relevance, clarity, and appropriateness for the target population. Fourth, reliance on self-reported measures for pain, quality of life, and behavioral factors such as exercise and smoking introduces potential recall or reporting bias. Yet, patient-reported outcomes are considered the gold standard for capturing subjective experiences such as pain, and the use of validated tools enhances confidence in the findings. Fifth, this study did not attempt to localize pain to specific anatomical sites (e.g., generalized pain, head pain, low back pain, joint pain, or leg pain). As a result, while we were able to capture the prevalence, severity, associated factors, and impact of pain on quality of life, we could not differentiate between site-specific pain syndromes that may have distinct etiologies and management strategies. Sixth, adequacy of dialysis and constrained access to dialysis services were not systematically assessed. Underdialysis could contribute to pain prevalence and severity, and may act as a potential confounder. Finally, residual confounding from unmeasured variables cannot be excluded, but the application of multivariable regression models adjusting for key sociodemographic, clinical, and psychosocial factors strengthens the validity of the associations observed.

Future research should incorporate instruments that allow for precise pain localization to provide a more granular understanding of symptom burden in hemodialysis patients. In addition, studies evaluating changes in pain intensity before, during, and after dialysis sessions are needed to capture its dynamic nature and guide more targeted interventions. Finally, future investigations should include measures of dialysis adequacy (e.g., Kt/V, missed sessions, treatment interruptions) to disentangle the independent contribution of pain from the effects of inadequate dialysis, thereby clarifying the complex interplay between treatment quality and symptom experience.

Conclusion

Pain is highly prevalent among Palestinian patients undergoing HD, with more than three-quarters affected and over half experiencing moderate to severe intensity, underscoring its role as a major determinant of quality of life. This study demonstrates that pain is not only common but also shaped by comorbid chronic diseases, longer dialysis vintage, and gender, while advancing in age further compromises health-related quality of life. Lower spiritual satisfaction showed only borderline associations but remains an important psychosocial dimension warranting further exploration. The findings reveal critical gaps in management, with heavy reliance on pharmacologic approaches and minimal use of non-pharmacologic strategies, highlighting the risk of undertreatment in a population already vulnerable to medication-related complications. These results emphasize that pain assessment and management must be integrated as a routine component of dialysis care, rather than treated as a secondary concern. Dialysis teams should adopt multidisciplinary approaches that combine safe pharmacologic regimens with non-pharmacologic interventions such as physiotherapy, counseling, and spiritual support. Embedding systematic pain screening into dialysis sessions, training staff in culturally sensitive communication, and expanding access to supportive therapies can improve adherence, reduce hospitalizations, and enhance overall patient well-being. In resource-limited healthcare systems, prioritizing pain management within HD care pathways is essential to safeguard both survival and quality of life.

Supplemental material

Supplemental material - Prevalence, severity and multidimensional factors associated with pain among hemodialysis patients: A cross-sectional study in a resource-limited healthcare system

Supplemental material for Prevalence, severity and multidimensional factors associated with pain among hemodialysis patients: A cross-sectional study in a resource-limited healthcare system by Abdallah Alqurnah, Mohammad Alsharouf, Faruq Salah, Taha Salhab, Hatim Hijaz and Ramzi Shawahna in Sage Open Medicine.

Footnotes

Acknowledgements

The authors would like to thank the patients who participated in this study. An-Najah National University (www.najah.edu) and An-Najah National University Hospital () are acknowledged for making this study possible.

ORCID iD

Ramzi Shawahna

Ethical considerations

Consent to participate

Written informed consent was obtained from all patients.

Author contributions

Ramzi Shawahna and Hatim Hijaz were responsible for the study conception and design. Abdallah Alqurnah, Mohammad Alsharouf, Faruq Salah and Taha Salhab were responsible for the data collection. Ramzi Shawahna, Abdallah Alqurnah, Mohammad Alsharouf, Faruq Salah and Taha Salhab were responsible for statistical analysis and data interpretation. Ramzi Shawahna and Hatim Hijaz were responsible for supervision and mentorship. All authors contributed with intellectual content during manuscript drafting or revision and approved the final manuscript to be submitted.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Data Availability Statement

All data analyzed in this study were included in the manuscript. The datasets used in the analysis or entered into statistical software can be obtained from the corresponding author upon making a reasonable request.*

Generative AI disclosure

In line with the journal’s policy on transparency, the authors wish to declare that during the preparation of the manuscript, the authors used Grammarly (Superhuman Platform Inc., San Francisco, California), Copilot (Microsoft Inc., Redmond, Washington), and ChatGPT (OpenAI, San Francisco, California) solely to edit the language and improve grammar, spelling, punctuation, readability, and style of the manuscript. After using these tools/services, the authors reviewed and edited the content as needed and take full responsibility for the scientific content, accuracy, and integrity of the manuscript. Artificial intelligence tools/services were not used for generative editorial work, autonomous content creation, data analysis, statistical interpretation, or the generation of scientific content.

Supplemental material

Supplemental material for this article is available online.

References

Bai

Tang

, et al. Machine learning to predict end stage kidney disease in chronic kidney disease. Sci Rep 2022; 12(1): 8377. https://doi.org/10.1038/s41598-022-12316-z

Raynaud

Aubert

Reese

, et al. Trajectories of glomerular filtration rate and progression to end stage kidney disease after kidney transplantation. Kidney Int 2021; 99(1): 186–197. https://doi.org/10.1016/j.kint.2020.07.025

Htay

Bello

Levin

, et al. Hemodialysis Use and Practice Patterns: An International Survey Study. Am J Kidney Dis 2021; 77(3): 326–35e1. https://doi.org/10.1053/j.ajkd.2020.05.030

Lee

Flythe

Allon

. Dialysis Care around the World: A Global Perspectives Series. Kidney360 2021; 2(4): 604–607. https://doi.org/10.34067/KID.0001082021

Dos Santos

Mendonca

Hernandes

, et al. Pain in Patients With Chronic Kidney Disease Undergoing Hemodialysis: A Systematic Review. Pain Manag Nurs 2021; 22(5): 605–615. https://doi.org/10.1016/j.pmn.2021.05.009

Lambourg

Colvin

Guthrie

, et al. The prevalence of pain among patients with chronic kidney disease using systematic review and meta-analysis. Kidney Int 2021; 100(3): 636–649. https://doi.org/10.1016/j.kint.2021.03.041

Davison

Rathwell

Ghosh

, et al. The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2021; 8: 2054358121993995. https://doi.org/10.1177/2054358121993995

dos Santos

Mendonça

Noll

, et al. Pain in Hemodialysis Patients: Prevalence, Intensity, Location, and Functional Interference in Daily Activities. Healthcare 2021; 9(10): 1375. https://doi.org/10.3390/healthcare9101375

Aljawadi

Babaeer

Alghamdi

, et al. Quality of life tools among patients on dialysis: A systematic review. Saudi Pharm J 2024; 32(3): 101958. https://doi.org/10.1016/j.jsps.2024.101958

10.

Prajjwal

Marsool

MDM

Yadav

, et al. Neurological, cardiac, musculoskeletal, and renal manifestations of scleroderma along with insights into its genetics, pathophysiology, diagnostic, and therapeutic updates. Health Science Reports 2024; 7(4): e2072. https://doi.org/10.1002/hsr2.2072

11.

Gerogianni

. Factors Affecting Pain in Hemodialysis and Non-pharmacological Management. Cureus 2023; 15(2): e35448. https://doi.org/10.7759/cureus.35448

12.

Zhao

Zhang

Sun

, et al. Analysis of factors influencing the trajectory of fatigue in maintenance haemodialysis patients: a longitudinal study. Int Urol Nephrol 2024; 56(12): 3825–3833. https://doi.org/10.1007/s11255-024-04129-y

13.

Malhotra

Desai

Ficociello

, et al. Associated Pruritus With the Sleep Disturbance, Depression, Pain, Anxiety, Low Energy/Fatigue Symptom Cluster: A Retrospective Cohort Study. Kidney Medicine 2025; 8: 101162. https://doi.org/10.1016/j.xkme.2025.101162

14.

Fielding

Bramley

Stalker

, et al. Patients' experiences of cannulation of arteriovenous access for haemodialysis: A qualitative systematic review. J Vasc Access 2023; 24(5): 1121–1133. https://doi.org/10.1177/11297298211067630

15.

Matar

El-Nahas

Aladwan

, et al. Restless Leg Syndrome in Hemodialysis Patients: A Narrative Review. Neurologist 2022; 27(4): 194–202. https://doi.org/10.1097/NRL.0000000000000436

16.

MSN

Chan

DNS

Cheng

, et al. Association between Financial Hardship and Symptom Burden in Patients Receiving Maintenance Dialysis: A Systematic Review. International journal of environmental research and public health 2021; 18(18): 9541. https://doi.org/10.3390/ijerph18189541

17.

Sulkowski

Matyja

. The Impact of Dialysis Duration on Multidimensional Health Outcomes: A Cross-Sectional Study. Journal of clinical medicine 2025; 14(2): 376. https://doi.org/10.3390/jcm14020376

18.

Caravaca

Gonzales

Bayo

MÁ

, et al. Musculoskeletal pain in patients with chronic kidney disease. Nefrología (English Edition) 2016; 36(4): 433–440. https://doi.org/10.1016/j.nefro.2016.03.024

19.

Jadoul

Aoun

Masimango Imani

. The major global burden of chronic kidney disease. The Lancet Global Health 2024; 12(3): e342–e343. https://doi.org/10.1016/S2214-109X(24)00050-0

20.

Tang

Shah

. Nonsteroidal anti-inflammatory drugs in end-stage kidney disease: dangerous or underutilized? Expert Opin Pharmacother 2021; 22(6): 769–777. https://doi.org/10.1080/14656566.2020.1856369

21.

Tobin

Lockwood

Kimmel

, et al. Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol 2022; 18(2): 113–128. https://doi.org/10.1038/s41581-021-00484-6

22.

Naseef

Haj Ali

Arafat

, et al. Quality of Life of Palestinian Patients on Hemodialysis: Cross-Sectional Observational Study. ScientificWorldJournal 2023; 2023: 4898202, ScientificWorldJournal. 2023. https://doi.org/10.1155/2023/4898202

23.

Marzouq

Samoudi

Samara

, et al. Exploring factors associated with pain in hemodialysis patients: a multicenter cross-sectional study from Palestine. BMC nephrology 2021; 22(1): 96. https://doi.org/10.1186/s12882-021-02305-1

24.

Himmelfarb

Vanholder

Mehrotra

, et al. The current and future landscape of dialysis. Nat Rev Nephrol 2020; 16(10): 573–585. https://doi.org/10.1038/s41581-020-0315-4

25.

Okpechi

Bello

Luyckx

, et al. Building optimal and sustainable kidney care in low resource settings: The role of healthcare systems. Nephrology (Carlton) 2021; 26(12): 948–960. https://doi.org/10.1111/nep.13935

26.

Health Mo . Annual Health Report Palestinian. Ministry of Health, 2024.

27.

Bdair

Tamimi

Shratih

, et al. Assessing pain levels and quality of life in peritoneal dialysis patients: a cross-sectional study. BMC nephrology 2025; 26(1): 155. https://doi.org/10.1186/s12882-025-04083-6

28.

Elendu

Enyong

, et al. Comprehensive review of current management guidelines of chronic kidney disease. Medicine (Baltimore) 2023; 102(23): e33984. https://doi.org/10.1097/MD.0000000000033984

29.

Asi

Tanous

Wispelwey

, et al. Are there 'two sides' to attacks on healthcare? Evidence from Palestine. Eur J Public Health 2021; 31(5): 927–928. https://doi.org/10.1093/eurpub/ckab167

30.

Barhoush

Amon

. Medical apartheid in Palestine. Glob Public Health 2023; 18(1): 2201612. https://doi.org/10.1080/17441692.2023.2201612

31.

El Jabari

Nawajah

Takruri

, et al. Barriers to Elderly Health Care in the Occupied Palestinian Territories. International Journal of Social Determinants of Health and Health Services 2024; 54(2): 143–150. https://doi.org/10.1177/27551938231217413

32.

Alghadir

Anwer

Iqbal

. The psychometric properties of an Arabic numeric pain rating scale for measuring osteoarthritis knee pain. Disabil Rehabil 2016; 38(24): 2392–2397. https://doi.org/10.3109/09638288.2015.1129441

33.

Alhalal

Jackson

. Evaluation of the Arabic version of the Chronic Pain Grade scale: Psychometric properties. Res Nurs Health 2021; 44(2): 403–412. https://doi.org/10.1002/nur.22116

34.

Ballout

Noureddine

Huijer

, et al. Psychometric evaluation of the arabic brief pain inventory in a sample of Lebanese cancer patients. J Pain Symptom Manage 2011; 42(1): 147–154. https://doi.org/10.1016/j.jpainsymman.2010.09.019

35.

Aburuz

Bulatova

Twalbeh

, et al. The validity and reliability of the Arabic version of the EQ-5D: a study from Jordan. Ann Saudi Med 2009; 29(4): 304–308. https://doi.org/10.4103/0256-4947.55313

36.

Shawky

El-Sharkawi

Sarhan

, et al. Validation of the arabic version of the EuroQol-5-dimension 5-level (EQ-5D-5 L) in patients with spinal degenerative diseases. BMC public health 2024; 24(1): 1119. https://doi.org/10.1186/s12889-024-18367-3

37.

Al Sayah

Roudijk

El Sadig

, et al. A Value Set for EQ-5D-5L in the United Arab Emirates. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research 2025; 28(4): 611–621. https://doi.org/10.1016/j.jval.2025.01.003

38.

Al-Jedai

Almudaiheem

Al-Salamah

, et al. Valuation of EQ-5D-5L in the Kingdom of Saudi Arabia: A National Representative Study. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research 2024; 27(5): 552–561. https://doi.org/10.1016/j.jval.2024.01.017

39.

Al Rabayah

Roudijk

Purba

, et al. Valuation of the EQ-5D-3L in Jordan. The European journal of health economics : HEPAC : health economics in prevention and care 2025; 26(3): 487–501. https://doi.org/10.1007/s10198-024-01712-z

40.

Antoun

Alkhayer

Aljabal

, et al. The validity and reliability of the Arabic version of the EQ-5D in atrial fibrillation patients in a conflict country: a study from Syria. BMC cardiovascular disorders 2024; 24(1): 541. https://doi.org/10.1186/s12872-024-04203-4

41.

Lin

, et al. The incidence of pain and its association with quality of life in patients with peritoneal dialysis. Ren Fail 2022; 44(1): 724–730. https://doi.org/10.1080/0886022X.2022.2068444

42.

Deligiannis

D'Alessandro

Cupisti

. Exercise training in dialysis patients: impact on cardiovascular and skeletal muscle health. Clin Kidney J 2021; 14(Suppl 2): ii25–ii33. https://doi.org/10.1093/ckj/sfaa273

43.

Williams

ACC

Fisher

Hearn

, et al. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020; 8(8): Cd007407. https://doi.org/10.1002/14651858.CD007407.pub4

44.

Kalantar-Zadeh

Fouque

. Nutritional Management of Chronic Kidney Disease. N Engl J Med 2017; 377(18): 1765–1776. https://doi.org/10.1056/NEJMra1700312

45.

Krishnan

Kiernan

. Uremic neuropathy: clinical features and new pathophysiological insights. Muscle Nerve 2007; 35(3): 273–290. https://doi.org/10.1002/mus.20713

46.

Yamada

Nakano

. Role of Chronic Kidney Disease (CKD)-Mineral and Bone Disorder (MBD) in the Pathogenesis of Cardiovascular Disease in CKD. J Atheroscler Thromb 2023; 30(8): 835–850. https://doi.org/10.5551/jat.RV22006

47.

Best

Butow

Olver

. Do patients want doctors to talk about spirituality? A systematic literature review. Patient education and counseling 2015; 98(11): 1320–1328. https://doi.org/10.1016/j.pec.2015.04.017

48.

Koenig

. Religion, spirituality, and health: the research and clinical implications. ISRN psychiatry 2012; 2012: 278730. https://doi.org/10.5402/2012/278730

49.

Mizher

Hammoudi

Hamed

, 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. https://doi.org/10.1038/s41598-023-32648-8

50.

Bouchachi

Al Wachami

Iderdar

, et al. Bio-sociological and clinical factors of chronic pain and pain interference in patients undergoing hemodialysis: a cross-sectional study. BMC nephrology 2025; 26(1): 83. https://doi.org/10.1186/s12882-025-03987-7

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