Effects of cognitive behavioral therapy on insomnia of maintenance hemodialysis patients

Effectiveness of Progressive Muscle Relaxation and Deep Breathing Exercise on Pain, Disability, and Sleep Among Patients With Chronic Tension-Type Headache: A Randomized Control Trial

A randomized control trial was conducted to assess the effectiveness of progressive muscle relaxation and deep breathing exercises on pain, disability, and sleep quality among patients with chronic tension-type headache. Of the 169 randomly selected patients, 84 performed the intervention and reported less pain severity and disability and better sleep quality after 12 weeks.

Approaches to the identification and management of depression in people living with chronic kidney disease: A scoping review of 860 papers

BACKGROUND

Depression is prevalent across the spectrum of Chronic Kidney Disease and associated with poorer outcomes. There is limited evidence regarding the most effective interventions and care pathways for depression in Chronic Kidney Disease.

OBJECTIVES

To investigate how depression is identified and managed in adults with Chronic Kidney Disease.

DESIGN

Scoping review.

METHODS

Systematic search of eight databases with pre-defined inclusion criteria. Data relevant to the identification and/or management of depression in adults with Chronic Kidney Disease were extracted.

RESULTS

Of 2147 articles identified, 860 were included. Depression was most identified using self-report screening tools (n = 716 studies, 85.3%), with versions of the Beck Depression Inventory (n = 283, 33.7%) being the most common. A total of 123 studies included data on the management of depression, with nonpharmacological interventions being more frequently studied (n = 55, 45%). Cognitive Behavioural Therapy (n = 15) was the most common nonpharmacological intervention, which was found to have a significant effect on depressive symptoms compared to controls (n = 10). However, how such approaches could be implemented as part of routine care was not clear. There was limited evidence for antidepressants use in people with Chronic Kidney Disease albeit in a limited number of studies.

CONCLUSIONS

Depression is commonly identified using validated screening tools albeit differences exist in reporting practices. Evidence regarding the management of depression is mixed and requires better-quality trials of both pharmacological and nonpharmacological approaches. Understanding which clinical care pathways are used and their evidence, may help facilitate the development of kidney care specific guidelines for the identification and management of depression.

Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial

BACKGROUND

Chronic insomnia is common in patients undergoing in-center hemodialysis, yet there is limited evidence on effective treatments for this population.

OBJECTIVE

To compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), trazodone, and placebo for insomnia in patients undergoing long-term hemodialysis.

DESIGN

Randomized, multicenter, double-blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT03534284).

SETTING

26 dialysis units in Albuquerque, New Mexico, and Seattle, Washington.

PARTICIPANTS

Patients with Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months.

INTERVENTION

Participants were randomly assigned to 6 weeks of CBT-I, trazodone, or placebo.

MEASUREMENTS

The primary outcome was the ISI score at 7 and 25 weeks from randomization.

RESULTS

A total of 923 patients were prescreened, and of the 411 patients with chronic insomnia, 126 were randomly assigned to CBT-I (n = 43), trazodone (n = 42), or placebo (n = 41). The change in ISI scores from baseline to 7 weeks with CBT-I or trazodone was no different from placebo: CBT-I, -3.7 (95% CI, -5.5 to -1.9); trazodone, -4.2 (CI, -5.9 to -2.4); and placebo, -3.1 (CI, -4.9 to -1.3). There was no meaningful change in ISI scores from baseline to 25 weeks: CBT-I, -4.8 (CI, -7.0 to -2.7); trazodone, -4.0 (CI, -6.0 to -1.9); and placebo, -4.3 (CI, -6.4 to -2.2). Serious adverse events (SAEs), particularly serious cardiovascular events, were more frequent with trazodone (annualized cardiovascular SAE incidence rates: CBT-I, 0.05 [CI, 0.00 to 0.29]; trazodone, 0.64 [CI, 0.34 to 1.10]; and placebo, 0.21 [CI, 0.06 to 0.53]).

LIMITATION

Modest sample size and most participants had mild or moderate insomnia.

CONCLUSION

In patients undergoing hemodialysis with mild or moderate chronic insomnia, there was no difference in the effectiveness of 6 weeks of CBT-I or trazodone compared with placebo. The incidence of SAEs was higher with trazodone.

PRIMARY FUNDING SOURCE

National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

Cognitive behavioural group therapy for insomnia (CBGT-I) in patients undergoing haemodialysis: a randomized clinical trial

Background:

Given the many complications of drug therapy, it seems reasonable to use non-pharmacological therapies that can improve mental and physical disorders in haemodialysis patients.

Aims:

This study aims to determine the effectiveness of cognitive behavioural group therapy for insomnia (CBGT-I) in sleep quality, depression, anxiety and general psychological health of haemodialysis patients.

Method:

This randomized clinical trial was conducted on 116 haemodialysis patients who were randomly assigned to experimental (n=58) and control (n=58) groups. In the experimental group, CBGT-I was provided during nine weekly sessions. Data collection tools included Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory-II (BDIII), Beck Anxiety Inventory (BAI), General Health Questionnaire (GHQ-28), Clinical Global Improvement Scale (CGI), Client Satisfaction Questionnaire (CSQ) and Working Alliance Inventory-Short Form (WAI-S). Data were analysed by SPSS-25 and p<.05 was considered significant.

Results:

The findings demonstrated that CBGT-I compared with control group was effective in improving sleep quality (p<.001, η2=.790), depression (p<.001, η2=.616), anxiety (p<.001, η2=.682) and general psychological health (p<.001, η2=.871). Participants of CBGT-I showed notable improvements as a result of the treatment, were satisfied with treatment, and had a good therapeutic relationship.

Conclusions:

CBGT-I is effective in reducing depression and anxiety in addition to improving sleep quality and general psychological health in haemodialysis patients. Therefore, it is recommended to be used as a complementary treatment for these patients.

Insomnia and Poor Sleep in CKD: A Systematic Review and Meta-analysis

Rationale & Objective

Poor sleep quality and insomnia are pervasive among patients with advanced chronic kidney disease (CKD); however, these health issues have not been systematically evaluated.

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

Adult patients with CKD not receiving kidney replacement therapy (KRT), as well as adults receiving KRT, including hemodialysis, peritoneal dialysis, and kidney transplantation.

Selection Criteria for Studies

A systematic literature search using PubMed, Embase, and PsycNET, was conducted for articles published between January 1, 1990, and September 28, 2018.

Data Extraction

Data on the prevalences of poor sleep quality and insomnia in patients with CKD, including those receiving and not receiving KRT, were extracted.

Analytical Approach

Pooled prevalences were estimated using a random-effects meta-analysis and were stratified according to age, CKD stage, World Health Organization region, risk of bias, Pittsburgh Sleep Quality Index score, and the different criteria for insomnia that were used at diagnosis.

Results

Of 3,708 articles, 93 were selected, and significant methodological heterogeneity was present. The pooled prevalences of poor sleep quality for CKD without KRT, hemodialysis, peritoneal dialysis, and kidney transplantation were 59% (95% CI, 44%-73%), 68% (95% CI, 64%-73%), 67% (95% CI, 44%-86%), and 46% (95% CI, 34%-59%), respectively. The corresponding prevalences of insomnia were 48% (95% CI, 30%-67%), 46% (95% CI, 39%-54%), 61% (95% CI, 41%-79%), and 26% (95% CI, 9%-49%), respectively. Insomnia was significantly more prevalent among patients aged 51-60 years and those aged >60 years than among those aged <50 years. The prevalence of insomnia in the European region was the lowest of all World Health Organization regions.

Limitations

High interstudy heterogeneity.

Conclusions

Approximately half of the patients with advanced CKD had poor sleep quality or insomnia, and the prevalence was even higher among those who received KRT. Kidney transplantation may reduce the burden of poor sleep quality and insomnia.

Emerging Treatments for Insomnia, Sleep Apnea, and Restless Leg Syndrome Among Dialysis Patients

Sleep disturbances are highly prevalent in patients with predialysis chronic kidney disease, end-stage kidney disease, and after a kidney transplant. They contribute to impairment in daily function and are associated with a high burden of physical and psychiatric symptoms, decreased quality of life, and increased morbidity and mortality. Sleep disturbances also may precipitate and accelerate kidney disease progression. They often evolve across the spectrum of kidney dysfunction and may persist or re-emerge in kidney transplant recipients. Investigation into the multifaceted and dynamic relationships between sleep disturbance and chronic kidney disease requires consideration of myriad contributors including the progression of kidney disease itself, the role of treatment via dialysis and kidney transplant, psychosocial factors, and underlying sleep disorders. Despite sleep disturbance being identified as a priority to address by patients and caregivers, sleep disorders including insomnia, sleep apnea, and restless leg syndrome remain under-recognized and undertreated, and innovation in their management remains modest. In this article, we review the relationships between sleep disturbance and kidney disease, the impact of sleep disturbance and sleep disorders on symptom burden and mental health, and treatment opportunities that may address overlapping symptoms across the spectrum of kidney disease and that could improve patient-related and clinical outcomes.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations.

METHODS

The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations.

RESULTS

The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

Depression symptoms and quality of life in patients receiving renal replacement therapy in Jordan: A cross-sectional study

Patients with chronic illnesses, such as those with chronic kidney disease (CKD) that are undergoing renal replacement therapy (RRT), face significant psychological changes. This descriptive cross-sectional research was carried out to investigate the factors that influence depressive symptoms and quality of life (QoL) in patients with end-stage renal disease. Data were collected from 70 participants undergoing RRT using a self-reported questionnaire that included sociodemographic information, depressive symptoms, disease status, and QoL. The Beck Depression Inventory-II (BDI-II) screening scale was used to measure depressive symptoms and the SF-36 (Medical Outcome Survey-Short Form 36) was used to assess QoL. Participants in the study rated their depressive symptoms as 'minimum (44.3%), 'mild' (20%), 'moderate' (21.4%), and 'severe (14.3%). Furthermore, a shorter duration of dialysis and comorbid conditions were significantly associated with the development of depressive symptoms. Patients on RRT for a longer period of time had lower physical activity scores than patients on dialysis for a shorter period of time. Male participants have a higher mental QoL than female participants, suggesting that the mental aspect of renal disease is less impaired than the physical aspect. The findings of this study are expected to increase awareness of RRT therapy targets and enhance patient outcomes.

The effect of the progressive muscle relaxation combined withs lavender aromatherapy on insomnia of hemodialysis patients

disorder in hemodialysis patients, which will cause a decrease in quality of life. Aromatherapy combined with progressive muscle relaxation are expected to increase the effects of relaxation on the patient so that the patient's sleep quality can improve optimally.Objective: The study aimed to investigate the effect of the progressive muscle relaxation combined with lavender aromatherapy on insomnia among patients undergoing hemodialysis. Material and Methods: The design of this study included a quasi-experiment with a pretest-posttest control group approach. The sample selection was performed using a consecutive sampling technique and involved 50 respondents, divided into two equal control and study group. Patients in study group recommended to do progressive muscle relaxation at least four times per week for three weeks and were told to drop two – three drops lavender aromatherapy on a pillow 30 minutes before bedtime at least 4 nights per week for three weeks. The control group recommended to do muscle relaxation and daily routine care at least four times per week for three weeks. Results: The results showed that both study and control groups were equal in terms of demographics, and scores of insomnia at the baseline. There no significant difference between the mean insomnia scores of two group before intervention, while the difference was statistically significant after the intervention. The mean insomnia scores were lower in study group than in the control group.Conclusion: Progressive muscle relaxation and lavender aromatherapy were effective in decreasing insomnia scores among patients undergoing hemodialysis.

Zolpidem Versus Trazodone Initiation and the Risk of Fall-Related Fractures among Individuals Receiving Maintenance Hemodialysis

BACKGROUND AND OBJECTIVES

Zolpidem, a nonbenzodiazepine hypnotic, and trazodone, a sedating antidepressant, are the most common medications used to treat insomnia in the United States. Both drugs have side effect profiles (e.g., drowsiness, dizziness, and cognitive and motor impairment) that can heighten the risk of falls and fractures. Despite widespread zolpidem and trazodone use, little is known about the comparative safety of these medications in patients receiving hemodialysis, a vulnerable population with an exceedingly high fracture rate.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using data from the United States Renal Data System registry (2013-2016), we conducted a retrospective cohort study to investigate the association between the initiation of zolpidem versus trazodone therapy and the 30-day risk of hospitalized fall-related fractures among Medicare-enrolled patients receiving maintenance hemodialysis. We used an active comparator new-user design and estimated 30-day inverse probability of treatment-weighted hazard ratios and risk differences. We treated death as a competing event.

RESULTS

A total of 31,055 patients were included: 18,941 zolpidem initiators (61%) and 12,114 trazodone initiators (39%). During the 30-day follow-up period, 101 fall-related fractures occurred. Zolpidem versus trazodone initiation was associated with a higher risk of hospitalized fall-related fracture (weighted hazard ratio, 1.71; 95% confidence interval, 1.11 to 2.63; weighted risk difference, 0.17%; 95% confidence interval, 0.07% to 0.29%). This association was more pronounced among individuals prescribed higher zolpidem doses (hazard ratio, 1.85; 95% confidence interval, 1.10 to 3.01; and risk difference, 0.20%; 95% confidence interval, 0.04% to 0.38% for higher-dose zolpidem versus trazodone; and hazard ratio, 1.60; 95% confidence interval, 1.01 to 2.55 and risk difference, 0.14%; 95% confidence interval, 0.03% to 0.27% for lower-dose zolpidem versus trazodone). Sensitivity analyses using longer follow-up durations yielded similar results.

CONCLUSIONS

Among individuals receiving maintenance hemodialysis, zolpidem initiators had a higher risk of hospitalized fall-related fracture compared with trazodone initiators.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_12_18_CJN10070620_final.mp3.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.

Efficacy of Face-to-Face Delivered Cognitive Behavioral Therapy in Improving Health Status of Patients With Insomnia: A Meta-Analysis

Background: Face-to-face cognitive behavioral therapy (CBT) is one of the most widely used non-pharmacological treatment approaches for insomnia. The aim of this study is to assess the efficacy of face-to-face delivered CBT on health outcomes and to evaluate the effect of CBT components as subgroup variables to explain the efficacy of face-to-face delivered CBT on health outcomes in adults over 18 years old with insomnia. Methods: Relevant randomized controlled trial studies published in the past 22 years were searched through the electronic databases. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the 31 included studies. The mean difference and standard deviation of outcome variables and subgroup variables were analyzed using random effect model, and the heterogeneity among the articles was assessed with the Q-test and I ². Egger regression analysis was used to assess publication bias. Results: The meta-analysis showed a significant reduction in Insomnia Severity Index [standardized mean difference (SMD) = -2.56, 95% CI -3.81 to -1.30, p < 0.001], Pittsburgh Sleep Quality Index (SMD = -0.96, 95% CI -1.25 to -0.68, p < 0.001), sleep onset latency (SMD = -1.31, 95% CI -2.00 to -0.63, p < 0.001), wakening after sleep onset (SMD = -1.44, 95% CI -2.14 to -0.74, p < 0.001), number of awakenings (SMD = -1.18, 95% CI -2.10 to -0.26, p < 0.05), depression (SMD = -1.14, 95% CI -1.85 to -0.42, p < 0.01), and fatigue (SMD = -2.23, 95% CI -3.87 to -0.58, p < 0.01), and a significant increase in total sleep time (SMD = 0.63, 95% CI 0.28 to 0.98, p < 0.001), sleep efficiency (SMD = 1.61, 95% CI 0.92 to 2.29, p < 0.001), and physical health (SMD = 0.42, 95% CI 0.08 to 0.76, p < 0.05), in the CBT intervention group compared with the control group. There was no significant change in anxiety (SMD = -0.62, 95% CI -1.55 to 0.32, p > 0.05) and mental health (SMD = 1.09, 95% CI -0.59 to 2.77, p > 0.05) in CBT intervention group compared with control group. Group-delivered studies with larger number of intervention sessions and longer duration of single session provided a larger improvement in sleep quality. Conclusion: Face-to-face delivered CBT is effective in increasing total sleep time, sleep efficiency, and physical health, and reducing Insomnia Severity Index scores, Pittsburgh Sleep Quality Index scores, sleep onset latency, wakening after sleep onset, number of awakenings, depression, anxiety, and fatigue in patients with insomnia. Face-to-face delivered CBT is more effective when delivered through a larger number of sessions with longer duration of each session, and when delivered in groups. Face-to-face CBT is recommended to provide treatment to patients with insomnia in clinical settings. Systematic Review Registration: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200091, identifier: CRD4202020009.

Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis

BACKGROUND

Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD.

METHODS

This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy.

DISCUSSION

This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD.

TRIAL REGISTRATION

NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).

Can non-pharmacological interventions improve sleep quality for haemodialysis patients?

Poor sleep quality is a major issue for haemodialysis (HD) patients, with as many as 80% reporting problems with sleep. Poor sleep has a negative impact on HD patients' mental health, quality of life and day-to-day functioning, along with increasing morbidity and mortality risks. Non-pharmacological interventions have fewer side-effects compared to hypnotic medications and have been shown to be effective in research studies. Ruth Edley examines acupressure, massage, aerobic and non-aerobic exercise and cognitive behavioural therapy. All have been shown in small-scale studies to improve sleep quality in HD patients, although no intervention has been found to improve sleep quality to normal levels. It is recommended that further research using larger, randomised controlled trials is undertaken to increase confidence in the benefits of these interventions.

A systematic review and meta-analysis of randomized controlled trials of cognitive behavioral therapy for hemodialysis patients with depression

OBJECTIVE

The aim of this meta-analysis was to examine the efficacy of cognitive behavioral therapy (CBT) for hemodialysis patients with comorbid depression and to identify which other aspects, including anxiety and quality of life, can be improved through intervention.

METHODS

A systematic literature review was performed using multiple databases (PubMed, EMBase, PsycINFO, CENTRAL). The inclusion criteria included randomized controlled trials (RCTs) of CBT conducted in hemodialysis patients with depression. Study reporting quality was assessed with the Cochrane tool and Review Manager version 5.3 was used to obtain pooled results.

RESULTS

Eight RCTs, with a total sample size of 540 participants, met the inclusion criteria. Compared with control groups, the CBT groups had statistically significant improvements in depression (standardized mean differences [SMD] = -0.68, 95% confidence interval [CI] (-0.94 to -0.42), P < .001), anxiety (SMD = -0.99, 95%CI (-1.99 to 0.00), P = .05) and quality of life (SMD = 0.34, 95%CI (0.13 to 0.54), P < .001).

CONCLUSIONS

The results of this meta-analysis showed that CBT could have an effective role in reducing symptoms of depression and anxiety as well as improving quality of life in hemodialysis patients with comorbid depression.

Interventions for improving sleep quality in people with chronic kidney disease

BACKGROUND

Sleep disorders are commonly experienced by people with chronic kidney disease (CKD). Several approaches for improving sleep quality are used in clinical practice including relaxation techniques, exercise, acupressure, and medication.

OBJECTIVES

To assess the effectiveness and associated adverse events of interventions designed to improve sleep quality among adults and children with CKD including people with end-stage kidney disease (ESKD) treated with dialysis or kidney transplantation.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 8 October 2018 with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-randomised RCTs of any intervention in which investigators reported effects on sleep quality. Two authors independently screened titles and abstracts of identified records.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias for included studies. The primary outcomes were sleep quality, sleep onset latency, sleep duration, sleep interruption, and sleep efficiency. Risks of bias were assessed using the Cochrane tool. Evidence certainty was assessed using the GRADE approach. We calculated treatment estimates as risk ratios (RR) for dichotomous outcomes or mean difference (MD) or standardised MD (SMD) for continuous outcomes to account for heterogeneity in measures of sleep quality.

MAIN RESULTS

Sixty-seven studies involving 3427 participants met the eligibility criteria. Thirty-six studies involving 2239 participants were included in meta-analyses. Follow-up for clinical outcomes ranged between 0.3 and 52.8 weeks (median 5 weeks). Interventions included relaxation techniques, exercise, acupressure, cognitive-behavioural therapy (CBT), educational interventions, benzodiazepine treatment, dopaminergic agonists, telephone support, melatonin, reflexology, light therapy, different forms of peritoneal dialysis, music, aromatherapy, and massage. Incomplete reporting of key methodological details resulted in uncertain risk of bias in many studies.In very low certainty evidence relaxation techniques had uncertain effects on sleep quality and duration, health-related quality of life (HRQoL), depression, anxiety, and fatigue. Studies were not designed to evaluate the effects of relaxation on sleep latency or hospitalisation. Exercise had uncertain effects on sleep quality (SMD -1.10, 95% CI -2.26 to 0.05; I2 = 90%; 5 studies, 165 participants; very low certainty evidence). Exercise probably decreased depression (MD -9.05, 95% CI -13.72 to -4.39; I2 = 0%; 2 studies, 46 participants; moderate certainty evidence) and fatigue (SMD -0.68, 95% CI -1.07 to -0.29; I2 = 0%; 2 studies, 107 participants; moderate certainty evidence). Compared with no acupressure, acupressure had uncertain effects on sleep quality (Pittsburgh Sleep Quality Index (PSQI) scale 0 - 21) (MD -1.27, 95% CI -2.13 to -0.40; I2 = 89%; 6 studies, 367 participants: very low certainty evidence). Acupressure probably slightly improved sleep latency (scale 0 - 3) (MD -0.59, 95% CI -0.92 to -0.27; I2 = 0%; 3 studies, 173 participants; moderate certainty evidence) and sleep time (scale 0 - 3) (MD -0.60, 95% CI -1.12 to -0.09; I2 = 68%; 3 studies, 173 participants; moderate certainty evidence), although effects on sleep disturbance were uncertain as the evidence certainty was very low (scale 0 - 3) (MD -0.49, 95% CI -1.16 to 0.19; I2 = 97%). In moderate certainty evidence, acupressure probably decrease fatigue (MD -1.07, 95% CI -1.67 to -0.48; I2 = 0%; 2 studies, 137 participants). Acupressure had uncertain effects on depression (MD -3.65, 95% CI -7.63 to 0.33; I2 = 27%; 2 studies, 137 participants; very low certainty evidence) while studies were not designed to evaluate the effect of acupressure on HRQoL, anxiety, or hospitalisation. It was uncertain whether acupressure compared with sham acupressure improved sleep quality (PSQI scale 0 to 21) because the certainty of the evidence was very low (MD -2.25, 95% CI -6.33 to 1.82; I2 = 96%; 2 studies, 129 participants), but total sleep time may have been improved (SMD -0.34, 95% CI -0.73 to 0.04; I2 = 0%; 2 studies, 107 participants; low certainty evidence). 2 =2 =There were no studies designed to directly examine and/or correlate efficacy of any interventions aimed at improving sleep that may have been attempted for the spectrum of sleep disordered breathing. No studies reported treatment effects for children. Adverse effects of therapies were very uncertain.

AUTHORS' CONCLUSIONS

The evidence base for improving sleep quality and related outcomes for adults and children with CKD is sparse. Relaxation techniques and exercise had uncertain effects on sleep outcomes. Acupressure may improve sleep latency and duration, although these findings are based on few studies. The effects of acupressure were not confirmed in studies in which sham acupressure was used as the control. Given the very low certainly evidence, future research will very likely change the evidence base. Based on the importance of symptom management to patients, caregivers and clinicians, future studies of sleep interventions among people with CKD should be a priority.

The effect of non-pharmacological sleep interventions on depression symptoms: A meta-analysis of randomised controlled trials

Poor sleep is a significant risk factor for depression across the lifespan and sleep problems have been hypothesised to contribute to the onset and maintenance of depression symptoms. However, sleep problems are usually not a direct target of interventions for depression. A range of non-pharmacological treatments can reduce sleep problems but it is unclear whether these interventions also reduce other depression symptoms. The aim of this review was to examine whether non-pharmacological interventions for sleep problems are effective in reducing symptoms of depression. We carried out a systematic search for randomised controlled trials of non-pharmacological sleep interventions that measured depression symptoms as an outcome. Forty-nine trials (n = 5908) were included in a random effects meta-analysis. The pooled standardised mean difference for depression symptoms after treatment for sleep problems was -0.45 (95% CI: -0.55,-0.36). The size of the effect on depression symptoms was moderated by the size of the effect on subjective sleep quality. In studies of participants with mental health problems, sleep interventions had a large effect on depression symptoms (d = -0.81, 95% CI: -1.13,-0.49). The findings indicate that non-pharmacological sleep interventions are effective in reducing the severity of depression, particularly in clinical populations. This suggests that non-pharmacological sleep interventions could be offered as a treatment for depression, potentially improving access to treatment.

Sleep disturbance, negative affect and health-related quality of life in patients with maintenance hemodialysis

The study was designed to examine the relationships between sleep disturbance, negative affect and quality of life among patients with maintenance hemodialysis. A total of 118 patients in Shanghai, China, with maintenance hemodialysis (>40 years old) participated in the study. They completed three questionnaires: the Positive and Negative Affect Scale (PANAS), the Pittsburgh Sleep Quality Index (PSQI) and the European Quality of 5-Dimensions (EQ-5D-5L). Results showed that male participants' negative affect scored significantly higher than female participants'.The mean global PSQI score was 8.64 (poor sleepers score 6 or more); sleep disturbance affected 63.6% of the patients, which indicated that in general the participants' sleep quality was relatively poor.The patients with worse sleep quality and negative affect were more likely to have a lower quality of life. In addition, the effect of the sleep disturbance on quality of life was mediated by negative affect (The Z value of Sobel test was -3.18, p< .01).These findings suggest sleep disturbance and negative affect were common among patients with maintenance hemodialysis and had a negative impact on their quality of life; negative affect may mediate the relationship between sleep disturbance and quality of life.

A randomized controlled trial for effectiveness of zolpidem versus acupressure on sleep in hemodialysis patients having chronic kidney disease-associated pruritus

BACKGROUND

Pruritus adds to the complications of chronic kidney disease (CKD) patient and a well-recognized complication among the CKD patients. Majority of the patients on hemodialysis experience a generalized pruritus and patients reported being moderately to extremely disturbed by at least one of the sleep-related condition. This study aim to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-associated pruritus.

METHODS

A multicentered, open-label, parallel group, prospective randomized controlled trial among patients suffering from CKD-associated pruritus with sleep disturbance, after randomization into control, and intervention group to be held at North West General Hospital and Research Center Peshawar, Pakistan and Institute of Kidney Diseases Peshawar, Pakistan.

RESULTS

The primary outcome is to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-associated pruritus. After baseline assessment by Urdu version of 5D itch scale and Urdu version of Pittsburgh Sleep Quality Index (PSQI) and Urdu EQ-5D 3L, the intervention group will be given zolpidem 10 mg oral tablets and control group with acupressure on both foots on KI-1 acupoints for total of 6 minutes. Assessment will be done at weeks 4 and 8 from baseline by using Urdu version of 5D itch scale and Urdu version of PSQI and Urdu EQ-5D 3L, whereas safety profiling of zolpidem 10 mg tablet at week 6 from baseline and acupressure acceptability at week 6 from baseline. Analysis of covariance will be used to examine the differences in treatment effects between the intervention and control groups.

CONCLUSION

Improvement of sleep quality and quality of life among patients with CKD-associated pruritus requires great importance. This study aims to improve the quality of sleep and quality of life among patients with hemodialysis suffering from CKD-associated pruritus.

Symptom Prioritization among Adults Receiving In-Center Hemodialysis: A Mixed Methods Study

BACKGROUND AND OBJECTIVES

Individuals receiving in-center hemodialysis experience a high symptom burden that detrimentally affects their quality of life. There are few evidence-based interventions for symptom relief in this population. To stimulate innovation in symptom management, data on patient symptom prioritization and treatment preferences are needed. We undertook this study to (1) identify patient-prioritized symptoms for the development of symptom relief therapies and (2) elicit preferences for treatments among individuals receiving hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a mixed methods study that included focus groups in Carrboro, North Carolina; Tucson, Arizona; and Seattle, Washington and a nationally distributed online survey. Focus group transcripts were analyzed for patterns, and the highest priority symptoms were determined on the basis of frequency and report severity. We used focus group findings to inform survey items. Focus group and survey results were crossvalidated and synthesized for final symptom prioritization.

RESULTS

There were 32 participants across three focus groups and 87 survey respondents from 27 states in the United States. The physical symptoms of insomnia, fatigue, muscle cramping, and nausea/vomiting and the mood symptoms of anxiety and depressed mood were reported by participants in all focus groups. Among survey respondents, fatigue (94%), cramping (79%), and body aches (76%) were the most common physical symptoms, and feeling depressed (66%), worried (64%), and frustrated (63%) were the most common mood symptoms. The top-prioritized symptoms were consistent across focus group and survey participants and included the physical symptoms insomnia, fatigue, and cramping and the mood symptoms anxiety, depression, and frustration. Participants indicated that symptom frequency, duration, unpredictability, and social and financial effects factored most heavily into symptom prioritization.

CONCLUSIONS

Patients prioritized the physical symptoms of insomnia, fatigue, and cramping and the mood symptoms of anxiety, depression, and frustration as the top symptoms for which to find new therapies.

The SIESTA Trial: A Randomized Study Investigating the Efficacy, Safety, and Tolerability of Acupressure versus Sham Therapy for Improving Sleep Quality in Patients with End-Stage Kidney Disease on Hemodialysis

Objectives. To compare the effectiveness of real acupressure versus sham acupressure therapy in improving sleep quality in patients receiving hemodialysis (HD) or hemodiafiltration (HDF). Methods. A multicenter, single-blind, randomized controlled trial was conducted in two Australian dialysis units located in Princess Alexandra Hospital and Logan Hospital, respectively. Forty-two subjects with self-reported poor sleep quality were randomly assigned to real (n = 21) or sham (n = 21) acupressure therapy delivered thrice weekly for four consecutive weeks during routine dialysis sessions. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) score measured at week four adjusted for baseline PSQI measurements. Secondary outcomes were quality of life (QOL) (SF-8), adverse events, and patient acceptability (treatment acceptability questionnaire, TAQ). Results. The two groups were comparable on global PSQI scores (difference 0.19, 95% confidence interval [CI] −1.32 to 1.70) and on the subscale scores. Similar results were observed for QOL both in the mental (difference −3.88, 95% CI −8.63 to 0.87) and the physical scores (difference 2.45, 95% CI −1.69 to 6.58). There were no treatment-related adverse events and acupressure was perceived favorably by participants. Conclusion. Acupressure is a safe, well-tolerated, and highly acceptable therapy in adult hemodialysis patients in a Western healthcare setting with uncertain implications for therapeutic efficacy.

Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients

Maintenance dialysis patients experience a high burden of physical and emotional symptoms that directly affect their quality of life and health care utilization. In this review, we specifically highlight common troublesome symptoms affecting dialysis patients: insomnia, restless legs syndrome, and uremic pruritus. Epidemiology, pathophysiology, and evidence-based current treatment are reviewed with the goal of providing a guide for diagnosis and treatment. Finally, we identify multiple additional areas of further study needed to improve symptom management in dialysis patients.

Do psychological interventions reduce depression in hemodialysis patients?: A meta-analysis of randomized controlled trials following PRISMA

BACKGROUND

Depression is highly prevalent in hemodialysis patients and results in poor patient outcomes. Although psychological interventions are being developed and used for these patients, there is uncertainty regarding the effectiveness of these interventions. The purpose of this meta-analysis is to evaluate the effects of psychological interventions on depression treatment in hemodialysis patients.

METHODS

All randomized controlled trials (RCTs) relevant to the depression treatment of hemodialysis patients through psychological interventions were retrieved from the following databases: Embase, Pubmed, PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. The reference lists of identified RCTs were also screened. The Cochrane risk of bias tool was used to evaluate the quality of the studies, RevMan (5.3) was used to analyze the data, and the evidence quality of the combined results was evaluated using GRADE (3.6.1).

RESULTS

Eight RCTs were included. The combined results showed that psychological interventions significantly reduced the scores of the Beck Depression Inventory (P<0.001) and interdialysis weight gain (P<0.001). However, due to the high heterogeneity, effect size combinations of sleep quality and quality of life were not performed.

CONCLUSION

Psychological interventions may reduce the degree of depression and improve fluid intake restriction adherence. More rigorously designed research is needed.

A Novel Application of a Biopsychosocial Theory in the Understanding of Disturbed Sleep before and after Kidney Transplantation

STUDY OBJECTIVES

Sleep and fatigue difficulties appear to be highly prevalent among individuals with end-stage renal disease and individuals who have received a kidney transplant. While there is some evidence of biopsychosocial factors predicting sleep disturbance in these populations, previous studies have relied on single time point retrospective measurements.

METHODS

The study utilized a 2-week prospective measurement approach, including one night of polysomnographic measurement, nightly sleep diaries, and self-report measures of health, sleep, and mood.

RESULTS

The current study demonstrates that a number of psychological and behavioral factors, including negative mood, quality of life, napping, and caffeine consumption, are related to sleep disturbance among pre- and post-kidney transplant patients. This study also found that many of these factors have different relationships with sleep disturbance when comparing pre- and post-kidney transplant patients.

CONCLUSIONS

These results suggest that such factors may be worthwhile areas for intervention in treating the symptoms of insomnia among pre- and post-transplant recipients. A nuanced approach to understanding sleep problems is likely warranted when conceptualizing insomnia and developing a treatment plan.