Sleep quality in renal transplant patients: a never investigated problem

Cultural adaptation and validation of the Filipino version of Kidney Disease Quality of Life--Short Form (KDQOL-SF version 1.3)

AIM

Chronic kidney disease is the 10th leading cause of death among Filipinos. Those with chronic kidney disease are exposed to stressors which effect their daily lives. Therefore, assessment of health-related quality of life is important in these patients. The objective of the present study was to translate the Kidney Disease Quality of Life--Short Form version 1.3 (KDQOL-SF ver. 1.3) into Filipino and measure its validity and reliability.

METHODS

Translation and cultural adaptation began with two translations into Filipino, with reconciliation of the forward translators. Pretesting with 10 renal patients, review by experts (nephrologist, translator and dialysis nurse) and back-translation was also done. The final questionnaire was administered to 80 patients with chronic renal disease undergoing haemodialysis for at least 3 months, who could understand Filipino, and were without life-threatening or terminal conditions at the time of the test. A convenience sample of 30 patients from the group had a repeat test 10-14 days after to determine test-retest reliability. Test-retest reliability was assessed by intraclass correlation coefficient and internal consistency reliability was measured by determining the Cronbach's alpha value. Validity was measured using Pearson's correlation between the overall health rating scale and the items from the questionnaire.

RESULTS

All of the items showed good test-retest reliability (intraclass correlation coefficient >0.40), ranging from 0.58 (social interaction) to 0.98 (role--emotional). Internal consistency reliability values were acceptable, with Cronbach's alpha ranging from 0.60 (cognitive function) to 0.80 (physical functioning and role--physical). Regarding construct validity, overall health rating in kidney disease-targeted scales was significantly correlated with symptoms/problems, effects of kidney disease and burden of kidney disease. All items in the SF 36 scales had significant correlation with overall health rating (P < 0.05) except for role--emotional.

CONCLUSION

The Filipino version of the Kidney Disease Quality of Life--Short Form can be used to evaluate the health-related quality of life of Filipinos with chronic renal disease on haemodialysis.

Sleep quality in patients with chronic renal failure: A 3-year longitudinal study

BACKGROUND

Despite the high prevalence of sleep disorders in patients with kidney disease, no relationship has been demonstrated between sleep quality and the degree of renal function in cross-sectional studies. A prospective trial was, therefore, started in patients with chronic renal failure (CRF) to evaluate whether a link exists between the modifications of these parameters observed during a three-year follow-up period.

METHODS

Sleep quality was determined by the Pittsburgh Sleep Quality Index (PSQI) at baseline and after two and three years (Time 0, 2 and 3, respectively) in 78 patients with various degrees of CRF in association with the main clinical and biochemical variables.

RESULTS

The baseline PSQI averaged 6.2+/-3.8 (range: 0-21, with higher values indicating worse sleep quality) and was significantly increased at both Time 2 and 3 (8.8+/-3.7 and 10.2+/-3.5, respectively, P<0.0001 vs baseline), whereas creatinine clearance progressively decreased (45+/-24 vs 41+/-26 and 32+/-20ml/min, at time 0, 2 and 3, respectively, P<0.0001), although an independent association with PSQI could not be demonstrated after adjustment for confounding factors (P=0.90, mixed linear model).

CONCLUSIONS

Our data suggest that the progression of renal disease is accompanied by a progressive worsening of sleep quality; age is strongly related to both phenomena. PSQI represents an easy tool to use to detect sleep disorders and to more effectively evaluate renal patients; the prevention of sleep disorders by early and appropriate treatments could beneficially influence the course of the disease.

Evaluation of effect of renal transplantation in treatment of restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a common cause of sleep disturbance frequently experienced by hemodialysis patients. It is a neurological movement disorder. Patients with RLS suffer an irresistible urge to move the legs during inactivity with relief by motion and various activities.

MATERIALS AND METHODS

We investigated the clinical course of RLS in 30 (12 female and 18 male) hemodialysis patients with mean dialysis duration of 16.8 +/- 14.13 months who underwent kidney transplantation. Patients were given a standardized questionnaire evaluating details of RLS at baseline and twice after kidney transplantation. They were diagnosed to have RLS by International RLS Study Group criteria. Biochemical (serum calcium, phosphate, Na, and K and blood urea and creatinine) and hematological indices (serum iron, hemoglobin) were measured at each time.

RESULTS

RLS in hemodialysis patients was significantly reduced by renal transplantation (43.3%; P<.0001). There was a significant association between RLS and lower serum iron (P<.01) and phosphorus (P<.02) after renal transplantation: We did not observe any association between hemoglobin levels, age, sex, dialysis duration, and time after transplantation with RLS.

CONCLUSION

Kidney transplantation showed a strong, positive influence on RLS symptoms in hemodialysis patients. Correction of serum phosphate and serum iron (by mechanisms different than its effect on hemoglobin) can affect RLS in kidney transplant patients.

Does etiology of end-stage renal disease affect sleep quality in kidney transplant recipients?

BACKGROUND

That hypertension (HTN) as a leading cause of end-stage renal disease (ESRD) is linked to sleep disorders in the general population can be the basis of a hypothesis that HTN may be a contributing factor to the poor quality of sleep in some kidney transplant recipients. This study was designed to investigate the correlation between ESRD secondary to HTN and sleep quality among kidney transplant recipients.

METHODS

In this case control study, 201 kidney transplant recipients were divided into group I (ESRD) secondary to HTN, (n=82) and group II (ESRD secondary to other causes, n=119). The groups were matched for medical comorbidities, demographic and clinical data, and symptoms of anxiety and depression. Sleep quality assessed by means of the Pittsburgh Sleep Quality Index (PSQI) was compared between the study groups.

RESULTS

The mean (SD) of the total PSQI score was significantly high in group I compared with group II (7.42 +/- 2.36 vs 6.60 +/- 3.07, P=.042). Similar results were observed for the sleep duration scores in the groups (1.22 +/- 1.12 vs 0.86 +/- 1.12, P=.026). In group I, all the other PSQI components were higher than those in group II, difference that were statistically significant.

CONCLUSION

Sleep quality and duration was poorer among our kidney transplant recipients with ESRD secondary to HTN compared with the controls. Further studies, however, are required to investigate whether HTN is responsible for the reported poor quality of sleep in some kidney transplant recipients.

Sleep quality and its correlates in renal transplant patients

BACKGROUND

The aim of this study was to evaluate correlated morbidity measures with poor sleep quality among kidney transplanted patients.

METHODS

In a cross-sectional study of 125 Iranian kidney transplant patients in 2006, we employed self-administered questionnaires to evaluate the quality of sleep (PSQI), quality of life (SF-36), anxiety and depression, sexual activity, marital relationship, and medical comorbidity. Patients with PSQI score of >5 were considered to be "poor sleepers." Students t-test was used to compare the morbidity measures between the two groups: "poor sleeper" versus "good sleepers."

RESULTS

Seventy-eight (62%) patients were poor sleepers. This group showed a higher total medical comorbidity score (P=.009), more bodily pain, poorer general mental health, and less physical function on SF- 36 (P=.02), less sexual function, and more severe anxiety (P=.02). There was no significant difference between poor sleepers and good sleepers in the mean of other subscores of the SF-36, marital status, and depressive symptoms.

CONCLUSIONS

A poor quality of sleep is common after kidney transplantation. This problem is associated with higher medical comorbidity and poorer emotional state. Therefore, more attention should be paid to evaluation of sleep quality in this patient population.

Virally mediated cervical cancer in the iatrogenically immunocompromised: applications for psychoneuroimmunology

Oncogenic or high-risk (HR) human papillomavirus (HPV) infection is implicated in the pathogenesis of a number of cancers, including cervical cancer. HPV infected individuals who are immunocompromised secondary to acquired (e.g., human immunodeficiency virus [HIV]) or iatrogenic (e.g., systemic lupus erythematosus [SLE] patients and organ and hematopoeitic stem cell transplant recipients undergoing immunosuppressive therapy) immune deficiency are particularly at risk for HPV-initiated cervical neoplasia and cancer. Psychoneuroimmunologic (PNI) research has demonstrated that psychosocial factors such as stress, pessimism, and sleep quality may play a role in the promotion of HPV-mediated cervical neoplasia in HIV-positive women. However, no research to our knowledge has examined PNI mechanisms of HPV-mediated cervical neoplasia and cancer in women who are undergoing iatrogenic immunosuppressive therapy for the treatment of autoimmune disease or the prevention of graft-rejection. This article reviews the PNI mechanisms that may underlie the promotion of HPV-mediated cervical neoplasia and applies this model to HPV-infected women who are iatrogenically immunosuppressed, an understudied population at-risk for cervical cancer. Female transplant recipients, one such group, may provide a unique paradigm in which to explore further PNI mechanisms of HPV-mediated cervical neoplasia.

Anxiety and Depression Are Correlated With Higher Morbidity After Kidney Transplantation

BACKGROUND

Psychiatric comorbidities have been reported to be associated with low quality of life, but less attention has been paid to their impact on other morbidity measures. The aim of this study was to investigate the correlation of anxiety and depression with marital relation, sexual function, and sleep quality in kidney transplant recipients.

METHODS

In a cross-sectional study between 2005 and 2006, 88 kidney transplant recipients were divided into four groups according to their scores of anxiety and depression using Hospital Anxiety Depression Scale (HADS): group I(anx) (anxiety score <11; n=64); group II(anx) (anxiety score >or= 11; n=24); group I(dep) (depression score <11; n=68); and group II(dep) (depression score >or= 11; n=20). Morbidity measures including quality of life (Short Form-36), marital adjustment (Revised Dyadic Adjustment Scale), sexual relationship (Relationship and Sexuality Scale), and quality of sleep (Pittsburgh Sleep Quality Index) were separately compared between groups of anxious versus nonanxious and depressed versus nondepressed.

RESULTS

Group I(anx), compared with group II(anx), displayed a better state of mental health (48.80 +/- 7.14 vs. 44.45 +/- 7.80; P=.01), general health (49.36 +/- 12.77 vs. 42.91 +/- 16.67; P=.05), marital adjustment (55.13 +/- 8.01 vs. 48.35 +/- 16.62; P=.04), and lower sleep disturbance (1.36 +/- 0.62 vs. 1.66 +/- 0.63; P=.05). Group I(dep), compared with group II(dep), showed lower fatigue score (39.79 +/- 8.30 vs. 46.84 +/- 8.85; P=.002) and better sexual relationships (15.28 +/- 5.50 vs. 19.00 +/- 5.92; P=.03).

CONCLUSIONS

Screening for anxiety and depression in kidney transplant recipients is essential. Appropriate treatment of these prevalent psychiatric comorbidities may improve various aspects of patient well-being, including quality of life, sleep, marital relations, and sexual relationship.

Sleeping disorders in patients with end-stage renal disease and chronic kidney disease

About 85% of patients on maintenance hemodialysis have sleep disorders that depend on comorbidities, age, morning dialytic shift, and blood pressure. They are ameliorated by erythropoietin, by transplantation, and by daily and nocturnal dialysis. Some data exist on sleep disorders in CKD patients, and show that lack of a refreshing sleep is present even at early stages of the disease and may affect 82.2% of patients without any relationship to comorbidities.

Reviews: Diagnosis and Management of Sleep Apnea Syndrome and Restless Legs Syndrome in Dialysis Patients

Sleep complaints are very common in patients with end-stage renal disease (ESRD) and contribute to their impaired quality of life. Both obstructive and central sleep apnea syndromes are reported more often in patients on dialysis than in the general population. Impaired daytime functioning, sleepiness, and fatigue, as well as cognitive problems, are well known in patients with sleep apnea. Increasing evidence supports the pathophysiological role of sleep apnea in cardiovascular disorders, which are the leading cause of death in ESRD patients. Uremic factors may be involved in the pathogenesis of sleep apnea in this patient population and optimal dialysis may reduce disease severity. Furthermore, treatment with continuous positive airway pressure may improve quality of life and may help to manage hypertension in these patients. Secondary restless legs syndrome is highly prevalent in patients on maintenance dialysis. The pathophysiology of the disorder may also involve uremia-related factors, iron deficiency, and anemia, but genetic and lifestyle factors might also play a role. The treatment of restless legs syndrome involves various pharmacologic approaches and might be challenging in severe cases. In this article we review the diagnosis and treatment of sleep apnea and restless legs syndrome, with a focus on dialysis patients. We also briefly review current data regarding sleep problems after transplantation, since these studies may indirectly shed light on the possible pathophysiological role of uremia or dialysis in the etiology of sleep disorders. Considering the importance of sleep disorders, more awareness among professionals involved in the care of patients on dialysis is necessary. Appropriate management of sleep disorders could improve the quality of life and possibly even impact upon survival of renal patients.

Chronic Insomnia in Kidney Transplant Recipients

BACKGROUND

Recent studies confirmed that sleep disorders have a significant impact on various aspects of health in patients at different stages of chronic kidney disease. At the same time, there is an almost complete lack of information on the prevalence and correlates of insomnia in kidney transplant recipients.

METHODS

In a cross-sectional study, the Athens Insomnia Scale was used to assess the prevalence of insomnia in a large sample of kidney transplant recipients compared with wait-listed dialysis patients and also a matched group obtained from a nationally representative sample of the Hungarian population.

RESULTS

The prevalence of insomnia was 15% in wait-listed patients, whereas it was only 8% in transplant recipients (P < 0.001), which, in turn, was not different from the prevalence of this sleep problem in the sample of the general population (8%). Prevalences of insomnia in the transplant group were 5%, 7%, and 14% for the groups with glomerular filtration rates (GFRs) greater than 60 mL/min (> 1.00 mL/s), 30 to 60 mL/min (0.50 to 1.00 mL/s), and less than 30 mL/min (< 0.5 mL/s), respectively (P < 0.01). However, estimated GFR was no longer associated significantly with insomnia in the transplant population after statistical adjustment for several covariates. In a multivariate model, insomnia was significantly and independently associated with treatment modality (transplantation versus wait listing), as well as the presence of depression, restless legs syndrome, and high risk for obstructive sleep apnea syndrome, and with self-reported comorbidity.

CONCLUSION

The prevalence of insomnia was substantially less in the transplant group than in wait-listed dialysis patients and similar to that observed in the general population. Because this condition potentially is treatable, attention should be directed to the appropriate diagnosis and management of insomnia in the kidney transplant recipient population.