Table 2.

Knowledge gaps, barriers, and potential solutions by symptom

Symptom	Knowledge Gaps	Barriers	Potential Solutionsa
Insomniab	Limited understanding of pathophysiology (i.e., sleep-wake cycle disruption with dialysis schedule, napping during dialysis, restless leg syndrome, extracellular hypervolemia, sleep apnea, uremic toxins)	Challenges in implementing CBT in dialysis settings	CBT adapted for dialysis settings
	Unknown if pathophysiology of insomnia differs by dialysis modality	Insomnia medications identified as high-risk by payers	Pharmacological treatments (e.g., sleep aids)
	Limited knowledge of effect of insomnia on patient-reported and clinical outcomes	Low adherence to CPAP machines	Improvement in CPAP technology
	Lack of PK/PD modeling studies of insomnia drugs among patients with ESKD		Stimulation to help patients stay awake during dialysis
Muscle crampsc	Limited understanding of pathophysiology (i.e., electrolyte imbalance, muscle fatigue, fluid shifts, hypotension, neurologic).	Limited data to drive treatment selection	Intradialytic exercise
	No single, universally accepted definition of cramping	Patient reservations about reporting cramps to clinic personnel (personal pride, fear of being labeled as “difficult”)	Spicy substances (e.g., pickle juice, mustard)
	Limited knowledge of effect of cramping on patient-reported and clinical outcomes	Lack of objective approaches to dry-weight estimation	Ultrafiltration rate reduction
			Pharmacologic treatments (e.g., gabapentin, quinine)
			Technological advances in dry-weight estimation
Fatigued	Limited understanding of pathophysiology (i.e., role of sleep disorders, mental health, anemia, ultrafiltration, uremia, comorbid medical conditions, treatment shift, modality)	Payer-driven dialysis scheduling, limited flexibility	Pharmacologic treatments (e.g., ESAs, psychostimulants)
	Lack of standardized approach to medical work-up of fatigue	Fatigue often multifactorial and may be without clear, modifiable root cause in some individuals	Physical exercise
	Limited evidence on medication use for fatigue among patients with ESKD	Unclear ownership of medical work-up of fatigue (cost and provider barriers to acceptability)	CBT
		Lack of objective approaches to dry-weight estimation	Standardized approach to medical work-up

CBT, cognitive–behavioral therapy; CPAP, continuous positive airway pressure; PK/PD, pharmacokinetic/pharmacodynamic; ESAs, erythropoiesis-stimulating agents.

^aThe overarching recommendations of payment reform, dialysis care delivery system modifications, and standardized symptom data collection as avenues by which to improve symptom management were common to all three symptoms and are excluded from the table.

^bInsomnia small group (n=12) included patients (n=2), care partner (n=1), nephrologists (n=3), researcher content expert (n=2), clinical pharmacist (n=1), payer representative (n=1), industry representative (n=1), and dialysis organization representative (n=1).

^cMuscle cramps small group (n=9) included patients (n=2), nephrologists (n=5), clinical pharmacist (n=1), and dialysis organization representative (n=1).

^dFatigue group (n=23) included insomnia (n=12) and muscle cramps (n=9) participants and government representatives (n=2).