Sleep Disturbance in Chronic Hemodialysis Patients: The Impact of Depression and Anemia

Association of Sleep Problems With Dialysis Shifts in Patients Undergoing Hemodialysis in Tbilisi, Georgia

Introduction According to a 2023 poll by the International Society of Nephrology, 850 million individuals worldwide suffer from chronic kidney disease (CKD) and hemodialysis (HD) is the primary treatment for 69% of the patients with CKD. While HD effectively regulates fluid balance and electrolyte levels, patients often face challenges such as weakness, exhaustion, and cognitive changes, which impact their quality of life. Sleep-related issues, including poor quality, excessive morning sleepiness, insomnia, and restless leg syndrome (RLS), are particularly common among HD patients. These disturbances stem from various factors, including psychological discomfort and biochemical imbalances. Dialysis shifts, despite their importance, remain poorly studied regarding their impact on sleep and biochemical parameters. Our study aims to address these gaps, exploring how different dialysis shifts affect sleep quality and biochemical parameters. Our hypothesis suggests that the particular dialysis shift that hemodialysis patients undergo has an impact on the quality of sleep, with various groups exhibiting varying degrees of sleep disturbance. Simultaneously, we believe that the time of dialysis shifts could influence biochemical parameter variations, which in turn could affect the quality of sleep in hemodialysis patients. Methodology This cross-sectional study focuses on assessing sleep problems and analyzing biochemical variables among hemodialysis (HD) patients in Georgia. A total of 150 participants were selected from morning, afternoon, and evening dialysis shifts, with strict inclusion criteria and exclusion criteria. Assessment procedures involved questionnaires on sleep quality, restless leg syndrome (RLS), daytime sleepiness, and severity of insomnia. Biochemical variables were obtained from the hospital records. Statistical analyses were performed using Graph Pad Prism software (GraphPad, San Diego, USA), including ANOVA and Chi-square tests for association between biochemical variables and dialysis shifts, as well as logistic regression for assessing the influence of biochemical variables on insomnia and poor sleep quality. The significance level was set at 95%. Results Results showed that patients in the afternoon shift undergo longer sessions of hemodialysis compared to other shifts. Notably, a larger proportion of morning shift patients reported poor sleep quality, while a smaller fraction of evening shift patients experienced insomnia. There were no significant associations between dialysis shift and excessive morning sleepiness or restless leg syndrome. Potassium emerged as the sole biochemical variable exhibiting an association with all three dialysis shifts. Biochemical parameters showed no discernible impact on insomnia or poor sleep quality. Conclusion Our findings suggest an association between poor sleep quality and insomnia with dialysis shifts. Hemodialysis does influence potassium levels. However, biochemical variables like sodium, potassium, calcium, phosphorus, vitamin D3, parathyroid gland hormone (PTH), and hemoglobin do not seem to affect poor sleep quality and insomnia. Further research is needed to explore potential sleep issues with nocturnal shifts and to assess if creatinine and chloride have any influence on poor sleep quality. It is important to acknowledge dialysis shift as a contributor to sleep problems, emphasizing the need for targeted interventions to enhance the quality of life for these patients.

Sleep quality and associated factors among patients with chronic kidney disease in Nigeria: a cross-sectional study

OBJECTIVE

Poor sleep quality adversely affects the overall well-being and outcomes of patients with chronic kidney disease (CKD). However, it has not been well studied in Africans with CKD. We determined the prevalence of poor sleep quality and associated factors among patients with CKD.

DESIGN

This was a cross-sectional study that involved patients with CKD .

SETTINGS

The study was carried out in the outpatient clinic of nine hospitals in Nigeria.

METHODS

Sleep quality, depressive and anxiety symptoms and quality of life (QoL) were assessed among 307 patients with CKD using Pittsburgh Sleep Quality Index Questionnaire, Hospital Anxiety Depression Scale Questionnaire and 12-item Short Form Health Survey Quality of Life Questionnaire, respectively. The prevalence of poor sleep quality and associated factors were determined. A p<0.05 was considered as statistically significant.

RESULTS

The mean age of the study participants was 51.40±15.17 years. The male:female ratio was 1.5:1 One hundred and twenty-one (39.4%) of the patients were on maintenance haemodialysis (MHD). The prevalence of poor sleep quality, anxiety symptoms and depressive symptoms among the patients was 50.2%, 37.8% and 17.6%, respectively. The prevalence of poor sleep quality in the CKD stages 3, 4, 5 and 5D was 38.1%, 42.6%, 52.2% and 58.7%, respectively. The prevalence of poor sleep quality was significantly higher in MHD patients compared with predialysis CKD (59.5% vs 43.6%; p=0.008). Factors associated with poor sleep quality were CKD stage (p=0.035), anaemia (p=0.003), pruritus (p=0.045), anxiety symptoms (p≤0.001), depressive symptoms (p≤0.001) and reduced QoL (p≤0.001). On multivariate analysis, factors associated with poor sleep were anxiety (AOR 2.19; 95% CI 1.27 to 3.79; p=0.005), anaemia (AOR 5.49; 95% CI 1.43 to 21.00;p=0.013) and reduced physical component of QoL (AOR 4.11; 95% CI 1.61 to 10.47; p=0.003).

CONCLUSION

Poor sleep quality is common among patients with CKD especially in the advanced stage. The significant factors associated with poor sleep quality were QoL, anaemia and anxiety symptoms. These factors should be adequately managed to improve the overall outcomes of patients with CKD.

The impact of perceived social support on sleep quality in a sample of patients undergoing hemodialysis in Somalia

Objective

The main objective of the present study is to examine the relationship between perceived social support and the quality of sleep and to determine the predictors of sleep quality in a sample of patients undergoing hemodialysis (HD) in Somalia.

Methods

A sample of 200 patients with end-stage renal disease (ESRD) who were undergoing hemodialysis treatment approximately two to three times a week were included. All participants were administered a sociodemographic data form, the Multidimensional Scale of Perceived Social Support (MSPSS), the Insomnia Severity Index (ISI), and the Pittsburgh Sleep Quality Index (PSQI). Patients undergoing HD for less than 3 months prior to the study date were excluded.

Results

Of the patients undergoing hemodialysis, 200 patients aged between 18 and 68 years (mean = 52.29; SD = 14.13) gave consent and participated in the study. Sixty-three subjects (31.5%) reported poor sleep quality, defined as having a total PSQI score > 5. Forty-one subjects (20.5%) reported clinically significant (moderate-to-severe) insomnia. The majority of our patients undergoing HD reported remarkably high family support, but low friends and significant other support. Poor sleep quality significantly correlated with perceived friends' support and perceived total social support. While perceived family support significantly correlated with both family income and the duration of chronic kidney disease (CKD), perceived friends' support significantly correlated with age and family income. Hierarchical regression analyses showed that perceived family support and friends' support were significant predictors of poor sleep quality. Perceived friends' support was a significant predictor of insomnia severity. Perceived family support was a significant predictor of subjective sleep quality and sleep duration. Perceived friends' support was a significant predictor of subjective sleep quality, sleep duration, sleep latency, sleep disturbance, and daytime dysfunction. Family income was a significant predictor of sleep duration. Age and gender were significant predictors of sleep efficiency. The duration of CKD and duration of HD were significant predictors of sleep disturbance.

Conclusion

This present study has highlighted the value of family as a principal support system in Somalian culture. Understanding the impact of perceived social support on the quality of sleep in patients undergoing HD will help healthcare providers and social services to focus on and improve the social support systems of the patients as an integral part of their treatment.

Prevalence and risk factors of poor sleep quality in continuous ambulatory peritoneal dialysis patients in Nanchang, Southeast China

This study aimed to explore the prevalence and risk factors of poor sleep quality in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) at the peritoneal dialysis center of the First Affiliated Hospital of Nanchang University. This cross-sectional study was conducted from March 2019 to December 2019. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate the sleep quality of patients undergoing CAPD. A PSQI score of ≥5 was defined as poor sleep quality, whereas a PSQI of <5 was defined as good sleep quality. Logistic regression analysis was used to analyze risk factors for poor sleep quality. In total, 456 patients undergoing CAPD were investigated. The average PSQI score was 5.0 ± 2.9. Among the participants, 46.3% had poor sleep quality, and 45.6% were female patients. The average age was 49.4 ± 13.3 years. Compared with good sleepers, poor sleepers included a higher proportion of females and calcium–phosphorus (Ca × P) product, longer dialysis durations, lower total endogenous creatinine clearance rates, less residual renal function, and lower albumin levels. Multivariate logistic regression analysis showed that a long dialysis duration, low albumin level, and high Ca × P product were independent risk factors for poor sleep quality in patients undergoing CAPD. Odds ratios (95% confidence interval) for these risk factors were 1.01 (1.00–1.02), 0.95 (0.91–1.00), and 1.02 (1.00–1.03), respectively. Interventions aimed at improving albumin and Ca × P product levels may improve quality of life for CAPD patients.

Prevalence of anaemia in adults with chronic kidney disease in a representative sample of the United States population: analysis of the 1999-2018 National Health and Nutrition Examination Survey

Background

Population-based estimates of anaemia prevalence in patients with chronic kidney disease (CKD) vary, and data on the prevalence of severe anaemia of CKD are limited. This study examined the prevalence of anaemia and anaemia eligible for erythropoiesis-stimulating agent (ESA) treatment in patients with CKD in the USA.

Methods

National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 were used to determine the prevalence of diagnosed anaemia (haemoglobin <12 g/dL in women; <13 g/dL in men) and anaemia eligible for ESA treatment (haemoglobin <10 g/dL) in survey participants aged ≥18 years with stage 3-5 non-dialysis-dependent CKD (estimated glomerular filtration rate <60 mL/min/1.73 m²). The study objectives were to (i) obtain a more recent estimate of anaemia prevalence in patients with non-dialysis-dependent CKD and (ii) examine the characteristics of individuals with CKD and haemoglobin <10 g/dL.

Results

Of 51 163 eligible NHANES participants, 2926 (5.7%) with stage 3-5 CKD were included. In all participants, the weighted prevalences of anaemia and haemoglobin <10 g/dL were 25.3% and 1.9%, respectively. Mean haemoglobin levels decreased numerically between 1999 and 2012 and remained stable thereafter. The prevalence of anaemia and haemoglobin <10 g/dL increased with advancing CKD stage. The odds of haemoglobin <10 g/dL were significantly higher in stage ≥3B versus 3A and in non-Hispanic Blacks versus other races.

Conclusions

In our analysis, approximately 25% of individuals with stage 3-5 CKD in the USA had anaemia and approximately 2% had anaemia eligible for ESA treatment.

Prevalence and related factors of poor sleep quality in patients with pre-dialysis chronic kidney disease

BACKGROUND

Sleep disturbances in patients with chronic kidney disease (CKD) are related to decreased quality of life and increased health-related risks. There is insufficient data about actual prevalence and related factors of poor sleepers in this group. In this study, we aimed to investigate prevalence and related risk factors of self-reported poor sleep quality in patients with pre-dialysis CKD.

METHODS

In this cross-sectional study, 259 pre-dialysis CKD patients (median age 56 years; range, 19-85) were included. Demographical, clinical and laboratory correlates were recorded. Body mass index (BMI) was calculated. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease (MDRD) formula. Sleep quality was assessed by Pittsburgh Sleep Quality Index (PSQI), a self-rated questionnaire. Depression was evaluated using the Beck Depression Inventory (BDI).

RESULTS

Median eGFR was 27.6 ml/min/1.73 m² (range, 9-56). Of the 259 patients, 110 (42.5%) were poor sleepers with global PSQI score >5. The univariate correlation analysis revealed that global PSQI score was positively correlated with age, BMI, waist circumferences (WC), hip circumferences (HC), serum phosphorus and triglyceride levels, systolic blood pressure (BP), pulse pressure and BDI score, and negatively correlated with male gender and hemoglobin level. Logistic regression analysis, showed that HC, systolic BP, and BDI scores were independently associated with poor sleep quality (p = 0.001, p = 0.020 and p < 0.001, respectively).

CONCLUSION

Prevalence of poor sleep quality in our pre-dialysis CKD patients was 42.5%. Systolic BP, depression and HC, all of these are potentially correctable factors, were associated with poor sleep quality independently.

Patient and Care Partner Burden in CKD With and Without Anemia: A US-Based Survey

Rationale & Objective

Chronic kidney disease (CKD) has a far-reaching impact on both patients and care partners, which can be further compounded by frequent complications such as anemia. This study assessed the burden experienced by patients with CKD and the care partners of patients with CKD, with and without anemia.

Study Design

Online survey.

Setting & Participants

Adult patients with CKD and the care partners of adult patients with CKD living in the United States were recruited through the American Association of Kidney Patients and a third-party online panel (January 9, 2020-March 12, 2020).

Outcomes

Patient and care partner characteristics, care received or provided; health-related quality of life, and work productivity.

Analytical Approach

Descriptive statistics were reported separately based on the presence or absence of anemia.

Results

In total, 410 patients (anemia: n=190, no anemia: n=220) and 258 care partners (anemia: n=110, no anemia: n=148) completed the survey. Most patients reported receiving paid or unpaid care because of their health condition (anemia: 58.9%, no anemia: 50.9%), with an overall average of 14.2 and 11.3 h/wk among the anemia and no anemia patients, respectively. The care partners also reported providing numerous hours of care (anemia: 33.6 h/wk, no anemia: 38.0 h/wk), especially care partners living with their care recipient (anemia: 52.6 h/wk, no anemia: 42.8 h/wk). Among the patients, those with anemia reported a numerically lower average health-related quality of life (Functional Assessment of Cancer Therapy-Anemia score, anemia: 110.1; no anemia: 121.6). Most care partners reported a severe or very severe burden (Burden Scale for Family Caregivers-Short Version score≥15, anemia: 69.1%; no anemia: 58.8%). The work productivity impairment was substantial among employed patients (anemia: 44.9%, no anemia: 35.4%) and employed care partners (anemia: 47.9%, no anemia: 40.7%).

Limitations

The survey results may have been subject to selection and recall biases; moreover, the observational nature of the study does not allow for causal inferences.

Conclusions

Patients with CKD and the care partners of patients with CKD experience a considerable burden, especially when anemia is present.

Subjective Assessment of Sleep Quality and Excessive Daytime Sleepiness in Conventional Hemodialysis Population: A Single-Center Experience

Introduction

Sleep disturbances are common in patients with end-stage kidney disease on hemodialysis (hemodialysis population: HDP). Higher rates of primary sleep disorders, demographic characteristics, metabolic abnormalities, and the efficacy of treatment place HDP at higher risk. The pattern observed is delayed onset of sleep, frequent awakening episodes, insomnia, sleep apnoea, excessive daytime sleepiness, restless leg syndrome, abnormal limb movements, pain in limbs, confusion, and nightmares. Two commonly used subjective assessment scores are the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality and the Epworth Sleepiness Scale (ESS) to assess excessive daytime sleepiness.

Objective

Subjective assessment of sleep using PSQI and ESS scores in HDP and correlation with clinical and demographic characteristics.

Patients and Methods

A cross-sectional descriptive study of 148 patients with ESKD undergoing in-center hemodialysis. From June 2021 to October 2021 in Madurai medical college, Madurai, India. Subjective assessment with PSQI and ESS scores was done to identify sleep quality and daytime sleepiness, respectively.

Results

The median PSQI score was 6 (IQ:4–10), and as much as 68.24% scored >5 on the PSQI (poor sleepers). The median ESS score of the study participants was 4 (Iq range 3–7), and 19.59% had a total ESS score of more than 10 (excessive daytime sleepiness). The mean age of the participants was 44±14.5. Age more than 60, lower body mass index, unemployment, higher dialysis vintage of more than 2 years, lower hemoglobin, high calcium-phosphorus product are statistically significant for both PSQI and ESS scores.

Conclusion

The prevalence of poor sleep quality and excessive daytime sleepiness is high in HDP. Subjective assessment scores (PSQI and ESS) on the bedside are valuable tools in identifying sleep quality and EDS where objective assessment methods are not feasible and will help in the short time identification and management of sleep disturbances.

Association Between Sleep Disorders and Cognitive Impairment in Middle Age and Older Adult Hemodialysis Patients: A Cross-Sectional Study

Objective: The aims of the current study were to (1) explore the features of overall poor sleep and specific sleep disorders in Chinese middle age and older adult hemodialysis patients; (2) examine the association between sleep disorders and cognitive impairment (CI) in middle age and older patients undergoing hemodialysis in China.

Methods: Data of patients undergoing maintenance hemodialysis were collected from the prospective cohort study of CI in Chinese patients undergoing hemodialysis (Registered in Clinical Trials.gov, ID: NCT03251573). We included 613 patients (mean age = 63.7; SD = 7.8) in this study. We assessed sleep conditions using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and cognitive function by the Chinese Beijing version of the Montreal Cognitive Assessment (MoCA-BJ) scale. Then the association between sleep disorders and CI was evaluated using multivariate logistic regression analysis.

Results: The prevalence of sleep disorders in this group of 613 hemodialysis patients was 77.0%. Patients with CI were more inclined to have sleep disorders in specific aspects of sleep latency, habitual sleep efficiency, sleep disturbances, and daytime dysfunction (p < 0.05). In multivariate logistic regression analyses, every 1-point increase in global PSQI score was associated with a 1.2-fold increased risk of CI (adjusted OR = 1.201; 95%CI = 1.123–1.284, p < 0.001). For each specific PSQI, every 1-point increase in sleep disturbances score was associated with a 2.6-fold increased risk of CI (adjusted OR = 2.624; 95%CI = 1.891–3.640, p < 0.001), and every 1-point increase in daytime dysfunction score was associated with a 3.7-fold increased risk of CI (adjusted OR = 3.709; 95%CI = 2.653–5.184, p < 0.001), whereas every 1-point increase in sleep duration score was associated with a decreased risk of CI (adjusted OR = 0.600; 95%CI = 0.434–0.830, p = 0.002).

Conclusion: Poor sleep quality especially sleep disturbances, daytime dysfunction, and long sleep duration are associated with CI in middle age and older adult hemodialysis patients. Thus, the early detection of sleep disorders may help identify patients with cognitive impairment among hemodialysis individuals.

Clinical Trial Registration: [Clinical Trials.gov], identifier [NCT03251573]

Prevalence of Depression and Sleep Disorders in Patients on Dialysis: A Cross-Sectional Study in Qatar

Patients with end-stage renal disease treated with dialysis have poor quality of life (QOL). Improving QOL in these patients with multiple comorbidities is a large challenge. We performed a cross-sectional study to evaluate the prevalence and associated factors of depression and sleep disorders in this population. Our primary aim was to evaluate QOL measures in dialysis patients in Qatar through a series of validated questionnaires mainly concerning depression and sleep disorders. Our secondary aim was to study the associations of age, sex, and comorbid conditions with the QOL measures. We hypothesized that end-stage renal disease (ESRD) patients on dialysis would have disturbed QOL due to both ESRD and dialysis and comorbidities. This prospective cross-sectional study included adult ESRD patients receiving either hemodialysis (HD) or peritoneal dialysis (PD) in the main tertiary dialysis unit in Qatar. We administered two surveys to evaluate depression (the Center for Epidemiologic Studies Depression Scale, http://www.bmedreport.com/archives/7139) and sleep disorders (the Pittsburgh Sleep Quality Index, https://www.sleep.pitt.edu/instruments/). We also reviewed patient demographics, comorbidities, and laboratory test results to evaluate any associated factors. We randomly studied 253 patients (62% on HD and 38% on PD). Overall, 48% of patients had depression, while 83.8% had sleep disorders. The PD had more poor sleepers than the HD group (89.1% versus (vs.) 75%, p=0.003). Most of our dialysis patients had poor sleep, but it was more significant in the elderly group 109 (90%) than in the young group 103 (78%) (p=0.009). Patients with diabetes mellitus (DM) had significantly more prevalence of poor sleep (131 (88.5%)) than those without DM (81 (77.1%), p=0.01). More female patients had depression than male patients (52% vs. 25%, p < 0.0001; odds ratio: 3.27 (95% confidence interval: 1.9-5.6), p < 0.0001). This is the first study in Qatar to evaluate depression and sleep disorders in patients on dialysis therapy.

[Self-reported sleep and wake disorders in patients with ostheoarthrosis and end-stage renal disease]

OBJECTIVE

This study aimed to assess subjective sleep and wake disorders (SWD) in patients with osteoarthritis and comorbid end-stage renal disease (ESRD) receiving hemodialysis (ESRD-HD) compared to patients with osteoarthritis and without chronic kidney disease (CKD) as well as to clarify of the association of subjective sleep characteristics with the levels of anxiety and depression and pain, general health score and laboratory parameters in these cohorts.

MATERIAL AND METHODS

This pilot case-control study included the patients with stage III hip osteoarthritis with ESRD-HD (n=19) and without CKD (n=19) aged 18-85 years. The patients received the consultations of orthopedic surgeon and internal medicine specialist with anthropometry and clinical and biochemical blood tests. Subjective SWD were assessed with Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Insomnia Severity Index (ISI), diagnostic criteria for restless legs syndrome (RLS) and Berlin questionnaire. Anxiety and depression were assessed with Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI). Subjective general health and osteoarthritis-related pain were assessed with visual analog scales (VAS).

RESULTS

Compared to the patients with osteoarthritis and without CKD, the patients with osteoarthritis and ESRD-HD had a lower VAS score for general health (50.00 (40.00-75.00) points and 80.00 (70.00-80.00) points, p=0.014), a higher PSQI (12.0 (8.5-14.5) points and 8.0 (6.0-11.0) points, p=0.046), a higher incidence of RLS (59% and 16.8%, p=0.017) and a lower level of anxiety according to HADS (0.0 (0.0-3.0) points and 3.0 (2.0-5.5) points, p=0.025). The correlation and regression analysis showed the association of PSQI score with VAS score for general health (b= -1.7 points, p=0.002 with adjustment for age, sex and ESRD-HD), as well as the association of SWD with laboratory markers (PSQI score with creatinine level, FSS with eosinophil count, RLS with creatinine, urea and potassium levels).

CONCLUSION

The results of our study demonstrated the high incidence of SWD in patients with osteoarthritis. These SWD have complex pathogenesis and require specific approach in patients with osteoarthritis and ESRD-HD.

Pittsburgh Sleep Quality Index score predicts all-cause mortality in Chinese dialysis patients

BACKGROUND

The relationship between Pittsburgh Sleep Quality Index (PSQI) score and survival of dialysis patients has not been well studied. The aim of this study was to explore the association between PSQI score and all-cause mortality in dialysis patients.

METHODS

Fifty-one hemodialysis and 58 peritoneal dialysis patients were enrolled in this study. PSQI score > 5 and ≤ 5 indicated "poor sleepers" and "good sleepers", respectively. The primary outcome was all-cause mortality. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were performed.

RESULTS

The median PSQI score was 7.0 (4.0-10.0). Sixty-seven (61.5%) patients had poor sleep quality (SQ). Compared with good sleepers, poor sleepers had significantly lower levels of hemoglobin [74.0 (61.0, 85.0) vs. 78.0 (68.0, 97.0), P = 0.03] and serum bicarbonate (18.0 ± 4.5 vs. 20.0 ± 3.7, P = 0.022). The follow-up time was 69.1 ± 29.9 months. By multivariate Cox proportional hazards analysis, PSQI total score was the independent risk factor of all-cause mortality [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.05-1.36, P = 0.007]. Restricted cubic spline (RCS) analysis showed that 7 was the cutoff value at which the effect of PSQI score on mortality changed. Patients with a PSQI score > 7 had a 2.96-fold increased risk of all-cause mortality (HR 2.96, 95% CI 1.15-7.61, P = 0.025).

CONCLUSIONS

PSQI score can be used as a predictor of all-cause mortality in dialysis patients, and those with PSQI > 7 were associated with increased odds of mortality.

The Effect of Acupressure on Daytime Sleepiness and Sleep Quality in Hemodialysis Patients

This study was carried out to evaluate the effect of acupressure applied to hemodialysis patients on the level of daytime sleepiness and sleep quality. The data were collected using the Descriptive Information Form, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. In the study, a total of 12 sessions of acupressure were applied to the Shenmen (HT7), Sanyingjao (Sp6), and Yungquan (KI1) points in the experimental group for 4 weeks. No intervention was applied to the control group. After the acupressure, it was determined that the sleep quality of the experimental group was better than that of the control group and that daytime sleepiness was less compared with the control group. After the acupressure, it was determined that the sleep latency of the experimental group was statistically significantly less and their total sleep duration was higher compared with the control group (P < .05). Although there was a decrease in the sleep quality of the experimental group 1 month after the cessation of the acupressure, it was determined that the sleep quality of the experimental group was better than that of the control group (P < .05). It was concluded that acupressure was an effective nursing intervention in increasing sleep quality and decreasing daytime sleepiness of hemodialysis patients.

Daily physical activity in patients on chronic haemodialysis and its relation with fatigue and depressive symptoms

OBJECTIVE

Fatigue and depressed mood are considered main impediments to physical activity in haemodialysis (HD) patients. A better understanding of their interrelationships is crucial to develop effective therapies. Moreover, measurement of daily physical activity (DPA) in HD patients is tricky, as it is usually assessed by subjective self-report questionnaires. Therefore, we aimed to objectively measure sponteanous DPA with motion sensors and to explore its relation with fatigue and depressive symptoms.

METHODS

DPA was assessed for seven consecutive days in 37 HD patients based on their daily step count measured with the SenseWear™ Armband. The Fatigue Severity Scale (FSS) and Beck Depression Inventory-II (BDI-II) were administered to evaluate fatigue and depressed mood.

RESULTS

Median DPA was 2424 steps/day, (IQR:892-4545). In 81% of subjects, DPA felt within a sedentary lifestyle classification, as they made < 5.000 steps/day. DPA did not correlate with fatigue (r_s = 0.04, p = 0.832), and did not significantly differ between patients categorized as clinically fatigued (n = 23, FSS ≥ 4) or not (n = 14, FSS < 4) (p = 0.654, d = 0.20). Although low-depressed subjects (n = 19, BDI-II ≤ 13) made on average 1.7 times more steps/day than high-depressed subjects (n = 18, BDI-II > 13) (p = 0.111, d = 0.60), depressive mood did also not correlate significantly with DPA (r_s = - 0.23, p = 0.175).

CONCLUSION

Objective assessment of DPA with motion sensors is feasible in HD patients and allows identifying a sedentary lifestyle. Our results suggest that spontanous DPA is determined by age rather than by fatigue or mood.

The effects of omega-3 on the sleep quality of patients with uremic pruritus undergoing hemodialysis: a randomized crossover study

OBJECTIVES

Information on sleep quality and its effective factors in the patients undergoing hemodialysis are important factors in future planning for improving sleep quality and ultimately the quality of life in these patients. The present study investigated the effect of omega-3 on the sleep quality of hemodialysis patients.

METHODS

The 52 hemodialysis patients were randomized into two groups and underwent two different treatment modes (A and B). The first group was given omega-3 and cetirizine and the second group only received cetirizine for six weeks. After one week wash out, the study was followed by crossover treatment in both groups for six weeks. Sleep quality and pruritus severity were evaluated in patients before the intervention and at the end of each treatment period using the Pittsburgh Sleep Quality Index and the Yosipovitch Itch Questionnaire. The collected data was analyzed using repeated measures ANOVA and the Pearson correlation coefficient.

RESULTS

The results of the study showed that majority of the patients (94.2%) had poor sleep quality (sleep score > 5 based on the questionnaire) and 5.8% of the patients had favorable sleep quality (sleep score < 5). Repeated measures ANOVA showed that sleep quality scores were different in two groups in phases 0, I and II (p <0.001).

CONCLUSIONS

Sleep quality improved in both modes but more improvement was observed in mode A. Therefore, omega-3 fatty acids can be used as a suitable method for improving sleep quality in hemodialysis patients.

The effects of depression and age on sleep disturbances in patients with non-dialysis stage 3-5 chronic kidney disease: a single-center study

PURPOSE

Sleep disturbances have a negative impact on the prognosis of chronic kidney disease (CKD). However, information on the prevalence and predictors is limited. This study aimed to evaluate the prevalence and explore clinical factors affecting the quality of sleep in patients with non-dialysis CKD.

METHODS

Participants included 152 adult non-dialysis patients with stage 3-5 CKD. Demographic and clinical data were collected. Sleep quality and depression were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI), respectively. Sleep disturbances were defined as a PSQI score ≥ 5. Logistic regression was conducted to explore the independent factors of sleep disturbances. Clinical parameters were correlated with BDI scores using linear regression models.

RESULTS

The total prevalence of patients with sleep disturbances was 66.4%. Older age, higher BDI scores, lower estimated glomerular filtration rate (eGFR) changes per month (△eGFR/m) before the study, and lower serum magnesium levels were found in patients with sleep disturbances. BDI scores (odds ratio [OR] 1.224, 95% confidence interval [CI] 1.091-1.373, p = 0.001) and age (OR 1.041, 95% CI 1.013-1.069, p = 0.003) were independent predictors of sleep disturbances. Serum uric acid levels (β - 0.629, 95% CI - 1.244 to - 0.013, p = 0.046), △eGFR/m before the study (β - 0.454, 95% CI - 0.885 to - 0.024, p = 0.039), and daily protein intake (β - 0.052, 95% CI - 0.102 to - 0.002, p = 0.043) were negatively associated with BDI scores.

CONCLUSION

A high overall prevalence of sleep disturbances was found in patients with non-dialysis stage 3-5 CKD. Depression, as a manageable predictor, should be managed, especially in elderly patients.

Economic Burden and Health-Related Quality of Life Associated with Current Treatments for Anaemia in Patients with CKD not on Dialysis: A Systematic Review

BACKGROUND

The cost and health-related quality of life (HRQoL) burden associated with treatments for anaemia of chronic kidney disease (CKD) is not well characterized among non-dialysis-dependent (NDD) patients.

OBJECTIVE

Our objective was to review the literature on costs and HRQoL associated with current treatments for anaemia of CKD among NDD patients.

METHODS

The Cochrane Library, MEDLINE, Embase, NHS EED, and NHS HTA databases were searched for original studies published in English between 1 January 2000 and 17 March 2017. The following inclusion criteria were applied: adult population; primary focus was anaemia of CKD; patients received iron supplementation, red blood cell transfusion, or erythropoiesis-stimulating agents (ESAs); and reported results on HRQoL and/or costs. Studies that included NDD patients, did not compare different treatments, and had relevant designs were retained. HRQoL and cost outcomes were summarized in a narrative synthesis.

RESULTS

In total, 16 studies met the inclusion criteria: six randomized controlled trials, four prospective single-arm trials, three retrospective studies, one prospective observational study, one simulation study, and one cross-sectional survey. All included ESAs. Treatment of anaemia (compared with no treatment) was associated with HRQoL improvements in five of six studies and lower costs in four of four studies. Treatment aiming for higher haemoglobin targets (compared with lower targets) resulted in modest HRQoL improvements, higher healthcare resource utilization (HRU), and higher costs.

CONCLUSIONS

In NDD patients, untreated anaemia of CKD leads to higher costs, higher HRU, and lower HRQoL compared with initiating anaemia treatment. Relative to aiming for lower haemoglobin targets with ESAs, higher targets conferred modest HRQoL improvements and were associated with higher HRU.

Effect of bioelectrical impedance analysis-guided dry weight adjustment, in comparison to standard clinical-guided, on the sleep quality of chronic haemodialysis patients (BEDTIME study): a randomised controlled trial

BACKGROUND

Sleep disturbance is common among chronic haemodialysis patients, which leads to poor quality of life, in addition to increased instances of morbidity and mortality. Hypervolemia has been linked to sleep problems observed in chronic haemodialysis patients, which suggests that optimising one's fluid status could improve the sleep quality of this patient group. In our study, we subjectively examined and objectively measured sleep parameters, using actigraphy recordings, the Pittsburgh Sleep Quality Index (PSQI) questionnaire, and Epworth Sleepiness Scale (ESS), in order to compare bioelectrical impedance analysis (BIA)-guided and standard clinical-guided dry weight adjustment.

METHODS

We randomly selected 19 chronic haemodialysis patients with subclinical hypervolemia, defined as a clinically euvolemic status, despite the ratio of extracellular water to total body water being more than 0.4 in BIA. Furthermore, these patients, who were poor sleepers (PSQI > 5), were assigned to either a BIA-guided dry weight group (BIA group) or a standard clinical-guided one (clinical group). The primary outcome was changes in sleep actigraphy parameters between the groups at 1, 3, and 6 months. Changes observed in the PSQI and ESS score between the two groups over the same period of time were the secondary endpoints.

RESULTS

The mean age of the participants was 63.53 ± 11.12 years, and 42% of them were male. All sleep parameters measured by means of actigraphy were not significantly different between the two groups. Interestingly, at 3 and 6 months, the subjective sleep quality significantly improved in the BIA group, as reflected by a greater decline in the PSQI score, in comparison with the clinical group (3 months: mean difference - 1.82 [- 3.13 to - 0.51], P = 0.006; 6 months: mean difference - 3.16 [- 4.49 to - 1.83], P <  0.001). However, sleepiness assessed by the ESS was not significantly different between the groups throughout the study.

CONCLUSIONS

Optimisation of the fluid status by employing BIA did not improves sleep actigraphy parameter, however, it significantly ameliorates the subjective sleep quality of chronic haemodialysis patients. This observation should be further explored in larger samples and longer clinical trials.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov ( NCT02825589 ) on July 7, 2016.

Differential effects of age on quality of sleep and depression in patients receiving maintenance haemodialysis

BACKGROUND

Poor quality of sleep and depression are common and highly associated with each other in patients on haemodialysis. We aimed to investigate whether they share common risk factors and how age may influence their development.

METHODS

Cross-sectional observation study on 120 haemodialysis patients with quality of sleep and depression assessed by Pittsburgh Sleep Quality Index (PSQI) and Taiwanese Depression Questionnaire (TDQ), respectively.

RESULTS

The prevalence of poor quality of sleep and depression was 92.5% and 43.3%, respectively. PSQI scores were associated with age, gender, education and monthly income while TDQ scores were associated with low serum creatinine and albumin levels. Elderly patients at ages older than 65 had the highest average PSQI score (12.26 ± 4.35) than the young group at age 20-44 (8.25 ± 4.39) (P = 0.028) but the average TDQ scores were similar across three age groups. The proportion of those who had high PSQI scores was significantly higher in the elderly group (54.4%, P = 0.017) and the 44-65-years group (51.9%, P = 0.028) than the young group (16.7%). The proportion of those who reported normal quality of sleep was much lower in the elderly group (0.0%) than the other two groups (25.0%, P < 0.001 and 11.7%, P < 0.01). The proportions of those who had different ranges of TDQ scores did not show such a pattern of strong age dependence.

CONCLUSIONS

Poor quality of sleep in haemodialysis patients is associated with socio-economic factors while depression is more related to biochemistry indicators. A majority of older patients suffer very poor quality of sleep while depression appears equally severe and common across different age groups.

Biopsychosocial experiences and coping strategies of elderly ESRD patients: a qualitative study to inform the development of more holistic and person-centred health services in Singapore

Background

As the incidence and prevalence rates of end stage renal disease (ESRD) rise globally, a disproportionate increase has been observed in the elderly population. Singapore has the fifth highest incidence of treated ESRD worldwide, with the upward trend of ESRD being most apparent among those aged 70 years and older. Although it is well-documented that ESRD patients suffer an impaired quality of life compared to the general population, there is limited research focusing on the unique experiences and needs of elderly ESRD patients in Asian populations. To address the knowledge gap, this study seeks to explore the impact of ESRD and dialysis on the quality of life of elderly (≥70 years old) ESRD patients in Singapore and examine the coping strategies utilised by these patients.

Methods

This qualitative study involved semi-structured, in-depth interviews with 7 peritoneal dialysis patients, 5 haemodialysis patients, 4 patients on non-dialysis supportive care and 7 caregivers in Singapore. Interviews were conducted in English, Chinese, and Malay and fully transcribed. QSR NVivo 11 software was used for analysis.

Results

Participants reported that ESRD and dialysis had an impact on three highly interconnected areas of their quality of life: (a) biological/physical (general symptoms, neuromuscular problems, skin problems and poor sleep quality); (b) psychological (depressive symptoms, anxiety and fears, stress and negative self-perceptions); and (c) social (increased dependence on family and loss of social life). There were four key strategies that participants used to cope with these biopsychosocial challenges: (a) family support (financial, practical and emotional support); (b) religious/spiritual support (experiencing gratitude/contentment, the power of prayer and belonging to a faith community); (c) avoidance (cognitive avoidance and distraction techniques); and (d) acceptance (positive thinking and problem solving).

Conclusions

This study has provided insights into the biopsychosocial impact of ESRD and dialysis, as well as cultural and religious factors that shape the experiences and coping mechanisms of elderly ESRD patients and caregivers in Singapore, which can be used to further the development and implementation of more holistic and person-centred services to help each patient achieve a better quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7433-6) contains supplementary material, which is available to authorized users.

Factors associated with anemia among female adult vegetarians in Malaysia

BACKGROUND/OBJECTIVES

A large number of studies on anemia have focused mostly on pregnant women or children. The vegetarian population, which is another potential risk group for anemia, remains largely unexplored. Therefore, this cross-sectional study examined the associations of the sociodemographic, lifestyle, nutritional, and psychological factors with the anemia status among female adult vegetarians.

SUBJECTS/METHODS

A total of 177 female vegetarians were recruited from a Buddhist and Hindu organization in Selangor, Malaysia. The participants completed a self-administered questionnaire, which analyzed their sociodemographic characteristics, physical activity level, sleep quality, depression, anxiety, and stress. The body weight, height, waist circumference, and body fat percentage of the participants were also measured. A 3-day dietary recall was conducted to assess their dietary intake. Blood samples (3 ml) were withdrawn by a nurse from each participant to determine the hemoglobin (Hb) level.

RESULTS

The findings revealed 28.2% of the participants to be anemic. The age group (AOR = 2.46, 95% CI = 1.19-5.05), marital status (AOR = 2.69, 95% CI = 1.27-5.71), and percentage of energy from protein (AOR = 5.52, 95% CI = 1.41-21.65) were the significant predictors of anemia.

CONCLUSIONS

Anemia is a public health problem among female vegetarians in this study. Health promotion programs that target female adult vegetarians should be conducted to manage and prevent anemia, particularly among those who are married, aged 50 and below, and with an inadequate protein intake.

Association between abnormal thalamic metabolites and sleep disturbance in patients with end-stage renal disease

Sleep disturbances are common in end-stage renal disease (ESRD) patients. However, the underlying neuropathological mechanisms are largely unclear. Previous studies have revealed the important role of the thalamus in the potential mechanisms of sleep disorders. We hypothesized that the sleep disturbances in ESRD patients may correspond to metabolic changes of thalamus and the uremic factors may have a vital contribution on these changes. We performed multi-voxel ¹H-MRS of bilateral thalami in 27 ESRD patients who currently receiving hemodialysis treatment and 21 age-matched healthy volunteers. ESRD patients underwent Pittsburgh Sleep Quality Index (PSQI) scale and restless legs syndrome (RLS) rating scale assessment. Laboratory blood tests including serum creatinine, serum urea, cystatin-C, serum parathyroid hormone (PTH), calcium and phosphorus levels, hemoglobin and hematocrit were performed in all ESRD patients close to the time of the MR examination. We found correlations among elevated PTH, higher PSQI score and RLS rating score in ESRD patients. ESRD patients displayed decreased N-acetylaspartate and creatine ratio (NAA/Cr) of thalami compared with controls. There were significantly negative correlation between NAA/Cr and serum PTH level or PSQI score. The metabolic changes of thalami played an important role in the neuropathological mechanisms of lower sleep quality in ESRD patients. Secondary hyperparathyroidism as one of the main uremia-related factors was closely related to abnormal metabolites of the thalamus in patients with ESRD, revealing the crosstalk procedure between renal impairment and brain function.

Exploring sleep disorders in patients with chronic kidney disease

Kidney disorders have been associated with a variety of sleep-related disorders. Therefore, researchers are placing greater emphasis on finding the role of chronic kidney disease (CKD) in the development of obstructive sleep apnea and restless legs syndrome. Unfortunately, the presence of other sleep-related disorders with CKDs and non-CKDs has not been investigated with the same clinical rigor. Recent studies have revealed that myriad of sleep disorders are associated with CKDs. Furthermore, there are a few non-CKD-related disorders that are associated with sleep disorders. In this narrative review, we provide a balanced view of the spectrum of sleep disorders (as identified in International Classification of Sleep disorders-3) related to different types of renal disorders prominently including but not exclusively limited to CKD.

Predictors of Sleep Quality in Hemodialysis Patients

Purpose

Poor sleep quality (SQ) is common in hemodialysis (HD) patients. Factors associated with poor SQ are not well understood. The objectives of the present study were to determine the prevalence of poor SQ in HD patients in our region and to examine the association between SQ and health-related quality of life (HRQoL), depression, and certain clinical and laboratory parameters.

Methods

A total of 233 HD patients at 5 centers in the city center of Konya, Turkey were included in this study. Their demographic data and biochemical parameters were analyzed. All patients were instructed to complete Turkish versions of three questionnaires, namely, a modified post-sleep inventory (PSI), Beck Depression Inventory (BDI) and a Short Form of Medical Outcomes Study (SF-36).

Results

The mean age of the patients was 52.8±15.3 years and the male to female ratio was 1.33:1. The prevalence of poor sleepers, defined as those having a total sleep score (PSI-4 score) ≥ 4, was 60.9%. Compared with good sleepers, poor sleepers had higher BDI scores and as well as lower PCS and MCS domains of HRQoL. In addition, poor sleepers were older and more likely to be unemployed. There was a significant inverse correlation of PSI-4 score with PCS and MCS, and significant positive correlation of PSI-4 score with BDI and age (p<0.001). The significant independent predictors of PSI-4 score were BDI score, MCS score and employment status.

Conclusions

Depression, MCS score and employment status were the most important predictors of sleep quality in HD patients.

A comparison of quality of sleep between patients with chronic kidney disease not on hemodialysis and end-stage renal disease on hemodialysis in a developing country

Few studies have compared quality of sleep between pre-dialysis chronic kidney disease (pre-dialysis CKD) patients and end-stage renal disease patients on dialysis (ESRD) and have found inconsistent results. Objective of this study is to compare quality of sleep between patients with pre-dialysis CKD and ESRD in a developing country. This study was conducted in an out-patient department and hemodialysis unit of a tertiary care facility. Patients included had either pre-dialysis CKD or ESRD. Assessment of quality of sleep was done using Pittsburgh sleep quality index (PSQI). A total of 152 patients were included in the study. Out of these patients, 79 (52%) had ESRD and 73 (48%) had pre-dialysis CKD. Median PSQI score was 6 (IQR 3-8.8). Poor sleep quality (PSQI ≥5) was present in 100 (65.8%) patients. Only hemoglobin (β = -0.39, p < .01), depression (β = 0.56, p < .01) and history of cardiovascular disease (β = 0.22, p < .01) were associated with PSQI global score in a multiple linear regression analysis. There was no significant association between ESRD vs. pre-dialysis CKD and PSQI global scores and no significant co-relation between eGFR and global PSQI score (r = -0.34, p value .80) in pre-dialysis CKD patients. Poor sleep quality is common in patients with CKD including hemodialysis patients in a developing country, which is independent of kidney function in non-dialysis patients. There is no difference in quality of sleep between pre-dialysis CKD and ESRD patients.

What to eat for a better sleep in haemodialysis patients: Potential role of B vitamins intake and appetite

Objective:

Sleeping disorders are common among Haemodialysis-HD patients. In addition to well-known factors, food consumption impact on sleep quality needs being discovered. Aim was to examine the nutrition-related factors that may influence sleep quality in HD patients.

Methods:

One hundred and three patients in three HD centres participated. Data were collected with Pittsburgh Sleep Quality Index-PSQI and Questionnaire Form about socio-demographic characteristics and appetite. Biochemical findings were obtained; food consumption for three consecutive days was recorded. Independent Samples t/Mann Whitney U tests for mean comparison; Logistic Regression Analysis for determining variables affecting sleep quality, were used.

Results:

Mean age was 59.19±14.57 years. 51.5% were women. 37.9% had good (PSQI<5) and 62.1% had poor (PSQI≥5) sleep quality. Appetite had significant impact on sleep quality; poor sleeping risk was 4.194 fold higher in patients with bad appetite than those with good appetite (p=0.038). Biochemical findings of poor and good sleepers were similar, except for potassium and creatinine. Vitamins B₁, B₆ and folate intake of good and poor sleepers were significantly different. Patients with good sleep quality consumed significantly higher amounts of above B vitamins (p=0.030, p=0.036, p=0.034, respectively).

Conclusions:

Favourable effect of appetite and certain nutrients intake on sleep quality in HD patients was shown. Improving nutritional status of HD patients has potential to increase their sleep quality.

Association between Serum Vitamin D Levels and Sleep Disturbance in Hemodialysis Patients

Sleep disturbance is a frequent and serious complication of hemodialysis (HD). Low serum vitamin D levels have been associated with sleep quality in non-HD subjects. Our aim was to examine the possible association between serum vitamin D levels and the presence of sleep disturbance in HD patients. We recruited 141 HD patients at the HD center of the First Affiliated Hospital of Jiaxing University during 2014–2015. Serum levels of 25-hydroxyvitamin D (25(OH)D) were determined by the competitive protein-binding assay. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Demographic, clinical and laboratory data were recorded. Meanwhile, 117 healthy control subjects were also recruited and underwent measurement of 25(OH)D. Eighty-eight patients (62.4%) had sleep disturbance (PSQI scores ≥ 5). Patients with sleep disturbance showed lower levels of 25(OH)D as compared to those without sleep disturbance (85.6 ± 37.4 vs. 39.1 ± 29.1 nmol/L, p < 0.001). In multivariate analyses, serum levels of 25(OH)D (≤48.0 nmol/L) were independently associated with sleep disturbance in HD patients (OR 9.897, 95% CI 3.356–29.187, p < 0.001) after adjustment for possible variables. Our study demonstrates that low serum levels of vitamin D are independently associated with sleep disturbance in HD patients, but the finding needs to be confirmed in future experimental and clinical studies.

Sleep quality and risk factors of atherosclerosis in predialysis chronic kidney disease

INTRODUCTION

Chronic kidney disease (CKD) patients have more frequent sleep disorders and cardiovascular disease than normals. Since arterial stiffness as a risk factor of atherosclerosis can be evaluated with pulse wave velocity (PWV), we aimed to investigate the prevalance of sleep quality (SQ) and the relationship between SQ and risk factors of atherosclerosis and whether there is a relationship between SQ and PWV (the indicator of arterial stiffness) in predialysis CKD patients.

METHODS

This cross-sectional study was carried out in CKD patients followed at the Nephrology Department in Konya, Turkey, between November 2014 and March 2015. A total of 484 CKD patients were screened. Of the 484 patients, 285 patients were excluded. The remaining 199 CKD patients without cardiovascular disease at stage 3, 4, and 5 (predialysis) were included in the final study. The SQ of the patients was evaluated by the Pittsburgh Sleep Quality Index (PSQI). PWV was measured by using a single-cuff arteriography device (Mobil-O-Graph PWA, a model pulse wave analysis device; IEM).

RESULTS

A total of 199 predialysis CKD patients were included in the study, 73 of whom (36.7 %) were 'poor sleepers' (global PSQI &gt;5). Patients with poor SQ were older than those with good SQ (p = 0.077). SQ was worse in female patients compered to male patients (p = 0.001). SQ was worse in obese patients. As laboratory parameters, serum phosphorus, LDL cholesterol, and triglycerides levels correlated positively with SQ (respectively; r = 0.245, p&amp;0.001; r = 0.142, p = 0.049; r = 0.142, p = 0.048). The indicator of arterial stiffness, PWV, was higher in patients with poor SQ (p = 0.033). Hyperphosphatemia and female gender are determined as risk factors for poor SQ in multivariate analysis (p = 0.049, ExpB = 1.477; p = 0.009, ExpB = 0,429, respectively).

CONCLUSIONS

Our study showed for the first time that there is a relationship between SQ and risk factors of atherosclerosis in predialysis CKD 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.

The Efficacy of a Nurse-Led Disease Management Program in Improving the Quality of Life for Patients with Chronic Kidney Disease: A Meta-Analysis

BACKGROUND

The impacts of nurse-led disease management programs on the quality of life for patients with chronic kidney disease have not been extensively studied. Furthermore, results of the existing related studies are inconsistent. The focus of the proposed meta-analysis is to evaluate the efficacy of nurse-led disease management programs in improving the quality of life for patients with chronic kidney disease.

METHODS

Literature survey was performed to identify the eligible studies from PubMed, Current Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials with predefined terms. The outcome measured was quality of life. This meta-analysis was conducted in line with recommendations from the preferred reporting items for systematic reviews and meta-analyses.

RESULTS

Eight studies comprising a total of 1520 patients were included in this meta-analysis, with 766 patients assigned to the nurse-led disease management program. Nurse-led disease management improved the quality of life in terms of symptoms, sleep, staff encouragement, pain, general health perception, energy/fatigue, overall health and mental component summary when evaluated 6 weeks after the beginning of intervention. When evaluated 12 weeks later, the quality of life in terms of symptoms, sleep, staff encouragement, energy/fatigue, and physical component summary was improved. Stratified by the modalities of dialysis, similar results of pooled analyses were observed for patients with peritoneal dialysis or hemodialysis, compared with the overall analyses. The results of sensitivity analyses were the same as the primary analyses. The symmetric funnel plot suggested that the possibility of potential publication bias was relatively low.

CONCLUSION

Nurse-led disease management program seems effective to improve some parameters of quality of life for patients with chronic kidney disease. However, the seemingly promising results should be cautiously interpreted and generalized and still need to be confirmed through well-designed large-scale prospective randomized controlled trials.

Effects of cognitive behavioral therapy on insomnia of maintenance hemodialysis patients

The objective of the study was to evaluate the effects of cognitive behavioral therapy [sleep-related behavior modification and progressive muscle relaxation on insomnia of maintenance hemodialysis (MHD) patients] on improving insomnia of MHD patients. 103 MHD patients complicated with insomnia were randomly assigned to treatment (n = 52) and control (n = 51) groups. The control group was treated with conventional hemodialysis, and the treatment group was additionally treated with cognitive behavioral therapy for 3 months (sleep-related behavior modification and progressive muscle relaxation). All cases were assessed by Symptom Checklist 90 (SCL-90) and Pittsburgh Sleep Quality Index (PSQI) before and 2, 4, 6, 8, 10, and 12 weeks after treatment. Fifty-one patients in the treatment group and 47 patients in the control group completed the experiments. After treatment, the total mean scores were (1.94 ± 0.50/2.29 ± 0.31); scores of somatization, depression, anxiety, hostility, and additional items were (1.87 ± 0.58/2.56 ± 0.26), (2.25 ± 0.80/2.79 ± 0.50), (1.79 ± 0.26/2.37 ± 0.34), (1.71 ± 0.46/2.25 ± 0.43), and (1.91 ± 0.67/2.26 ± 0.59) in SCL-90, respectively. The total scores for PSQI were (12.63 ± 2.27/16.40 ± 2.16); scores of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, hypnotics, and daytime dysfunction which were (1.98 ± 0.76/2.57 ± 0.58), (1.75 ± 0.59/2.60 ± 0.50), (2.10 ± 0.50/2.62 ± 0.53), (2.06 ± 0.47/2.57 ± 0.54), (2.04 ± 0.69/2.45 ± 0.72), (1.02 ± 0.79/1.51 ± 0.98), and (1.69 ± 0.55/2.09 ± 0.58), respectively, were significantly lower in the treatment group compared with the control group. However, there were no significant differences in the scores of factors of obsessive-compulsive (2.26 ± 0.62/2.32 ± 0.38), interpersonal sensitivity (2.23 ± 0.64/2.43 ± 0.47), phobic anxiety (1.98 ± 0.62/2.01 ± 0.67), paranoid ideation (1.55 ± 0.43/1.69 ± 0.39), and psychoticism (1.57 ± 0.46/1.66 ± 0.49). The conclusion is that sleep-related behavior modification in combination with progressive muscle relaxation effectively improved the mental state and sleep quality of MHD patients with insomnia.

Prevalence of sleep disorders among ESRD patients

Sleep disorders are common among the patients undergoing dialysis in end stage renal disease (ESRD). Although variable, their prevalence has been reported to be higher when compared to the general population. The most frequently reported complaints are insomnia, restless leg syndrome (RLS), sleep-disordered breathing and excessive daytime sleepiness (EDS). The aim of this study was to assess the prevalence of sleep disorders in end stage renal disease patients on regular hemodialysis (group I with 30 patients) and CKD patients (group II with 30 patients) in comparison to 30 normal population (control group). In addition to laboratory investigations which included creatinine clearance using Cockroft and Gault formula, hemoglobin level (Hb), blood urea, serum creatinine, serum albumin, serum calcium and phosphorus and lipid profile, all subjects underwent one night of laboratory-based polysomnography (PSG) consisting of a standard montage of electroencephalography (EEG) (C3/A1 and O2/C3 or O1/C4), monopolar left and right electrooculography (EOG) referenced to the opposite mastoid, surface mentalis electromyography (EMG), respiratory airflow (measured by thermistor) and effort (piezoelectric sensors), electrocardiography (ECG), anterior tibialis EMG and pulse oximetry. For hemodialysis subjects, this study was performed on a night immediately following hemodialysis treatment. The results showed that patients on hemodialysis have sleep disorders, and that sleep disorders are common in group I and II than control group. The percentage of sleep disorders in hemodialysis patients were as follows: insomnia (69%), followed by obstructive sleep apnea syndrome OSAS (24%), RLS and periodic limb movement PLM (18%), nightmares (13%), EDS (12%), sleepwalking (2%), possible rapid eye movement behavior disorders RED (2%), possible narcolepsy (1.4%). While the percentage of sleep disorders in CKD patients were as follows: insomnia (54%), followed by RLS (19%), PLM (12%), OSAS (16%), nightmares (15%), EDS (15%), sleepwalking (4%), possible RBD (3%), possible narcolepsy (1%). There was inverse correlation between sleep disorders and Hb, albumin and creatinine clearance; also there was positive correlation between sleep disorder and phosphorus. We concluded that the sleep disorders are common in CKD patients either on conservative management or on regular hemodialysis. Treatment of anemia, hyperphosphatemia and hypoalbuminemia may improve sleep disorders among those patients.

Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.

Influence of dialysis modality and membrane flux on insomnia severity in haemodialysis patients

AIM

Insomnia is an important problem in dialysis patients. A greater prevalence of insomnia in chronic kidney disease compared with non-renal patients suggests a role for uraemic toxins in contributing to insomnia. The aim of this study was to examine if dialysis modality and membrane permeability is associated with the frequency and severity of insomnia in haemodialysis patients.

METHODS

In our cross-sectional study, we evaluated 122 patients who were divided into three groups: on-line haemodiafiltration, high flux haemodialysis and low flux haemodialysis. The frequency and severity of insomnia was evaluated with the Insomnia Severity Index.

RESULTS

Insomnia was present in 47.5% of all patients. The majority of patients who reported insomnia were receiving low flux haemodialysis (80%), followed by patients on high flux haemodialysis (43.6%) and haemodiafiltration (20.9%). Patients using low flux membranes, had a significantly higher Insomnia Severity Index (11.9 ± 6.6) compared with patients receiving high flux haemodialysis (6.8 ± 6.3) and haemodiafiltration (5.2 ± 7.0). The insomnia severity index did not differ between patients receiving high flux haemodialysis compared with on-line haemodiafiltration.

CONCLUSION

This study indicates that different haemodialysis modalities are associated with insomnia and suggests a potential benefit of using high flux membranes.

Association of sleep disturbances with cognitive impairment and depression in maintenance hemodialysis patients

BACKGROUND

There are few data on the relationship of sleep with measures of cognitive function and symptoms of depression in dialysis patients.

METHODS

We evaluated the relationship of sleep with cognitive function and symptoms of depression in 168 hemodialysis patients, using multivariable linear and logistic regression. Sleep disturbances were assessed using the sleep subscale battery of the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Health Experience Questionnaire. The cognitive battery assessed a broad range of functioning including global ability, verbal intelligence, supraspan learning, auditory retention, visual retention, attention/mental processing speed, visual construction/fluid reasoning and motor speed. Depressive symptoms were assessed using the Center for Epidemiological Studies of Depression (CESD) Scale, with depression indicated by a CESD score >16.

RESULTS

Mean (SD) age of participants was 62 (17) years, 49% were women, 30% were African American and 33% had diabetes. There was no significant relationship between sleep score and performance on any neurocognitive test (p>0.13, for all multivariable analyses). The prevalence of depression increased from 16% in the highest quartile (best) of sleep score, to 31% in the lowest quartile (worst) of sleep score. In multivariable analyses, each 1 SD increase in sleep score was associated with a 2.18 (95% confidence interval, 1.07-3.29, p<0.001) lower CESD score. Results were consistent when considering individual components of both the CESD and sleep score.

CONCLUSIONS

Disturbances in sleep are associated with symptoms of depression but not measures of cognitive function. Dialysis patients with disturbances in sleep should be screened for depression.

A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome

BACKGROUND

Uraemic restless legs syndrome (RLS) affects a significant proportion of patients receiving haemodialysis (HD) therapy. Exercise training has been shown to improve RLS symptoms in uraemic RLS patients; however, the mechanism of exercise-induced changes in RLS severity is still unknown. The aim of the current randomized controlled exercise trial was to investigate whether the reduction of RLS severity, often seen after training, is due to expected systemic exercise adaptations or it is mainly due to the relief that leg movements confer during exercise training on a cycle ergometer. This is the first randomized controlled exercise study in uraemic RLS patients.

METHODS

Twenty-four RLS HD patients were randomly assigned to two groups: the progressive exercise training group (n = 12) and the control exercise with no resistance group (n = 12). The exercise session in both groups included intradialytic cycling for 45 min at 50 rpm. However, only in the progressive exercise training group was resistance applied, at 60-65% of maximum exercise capacity, which was reassessed every 4 weeks to account for the patients' improvement. The severity of RLS symptoms was evaluated using the IRLSSG severity scale, functional capacity by a battery of tests, while sleep quality, depression levels and daily sleepiness status were assessed via validated questionnaires, before and after the intervention period.

RESULTS

All patients completed the exercise programme with no adverse effects. RLS symptom severity declined by 58% (P = 0.003) in the progressive exercise training group, while a no statistically significant decline was observed in the control group (17% change, P = 0.124). Exercise training was also effective in terms of improving functional capacity (P = 0.04), sleep quality (P = 0.038) and depression score (P = 0.000) in HD patients, while no significant changes were observed in the control group. After 6 months of the intervention, RLS severity (P = 0.017), depression score (P = 0.002) and daily sleepiness status (P = 0.05) appeared to be significantly better in the progressive exercise group compared with the control group.

CONCLUSION

A 6-month intradialytic progressive exercise training programme appears to be a safe and effective approach in reducing RLS symptom severity in HD patients. It seems that exercise-induced adaptations to the whole body are mostly responsible for the reduction in RLS severity score, since the exercise with no applied resistance protocol failed to improve the RLS severity status of the patients.

Health-related qualıty of lıfe, sleep qualıty, and depressıon in peritoneal dialysis and hemodıalysıs patıents

Health-related quality of life (HRQoL) and sleep quality (SQ) were impaired in patients with end-stage renal disease (ESRD). The impairment of both HRQoL and SQ and being in a depressive mood were found to be associated with increased morbidity and mortality in dialysis patients. We aimed to investigate the association between SQ, HRQoL, and depression, and to define independent predictors of SQ and depression in peritoneal dialysis (PD) and hemodialysis (HD) patients. Ninety HD patients (41 females, 49 males with mean age 50 ± 15.7 years) and 64 PD patients (27 females, 37 males with mean age 52.4 ± 15.3 years) receiving renal replacement therapy for at least 3 months were screened for the assessment of SQ, HRQoL, and depression in this cross-sectional study. A modified postsleep inventory, Short Form of Medical Outcomes Study (SF-36) and Beck depression inventory (BDI) were applied to all patients for evaluating SQ, HRQoL, and depression, respectively. HD and PD patients had similar total SQ scores. Physical and mental component scale of HRQoL were found to be significantly higher in HD patients (p < 0.001). PD patients were found to be much more in depressive mood when compared with HD patients (p < 0.001). Independent predictors of depression in patients were mental component scale of HRQoL, gender (being female), and dialysis modality (being PD patient). Physical component scale was also found to be an independent predictor of SQ. This study showed that despite similar SQ scores between two groups, HD patients had better HRQoL and less depression than PD patients.

The effect of social support and coping style on depression in patients with continuous ambulatory peritoneal dialysis in southern China

PURPOSE

To explore the effect of social support and coping style on depression in patients on CAPD in Southern China.

METHODS

The patients undergoing CAPD therapy for more than 3 months were recruited from Jan 1 to May 31, 2009. The Beck Depression Inventory-II (BDI-II), Social Support Rating Scale, Medical Coping Modes Questionnaire, and Medical Outcomes Study Short Form (SF-36) were used to evaluate depression, social support, coping style, and quality of life (QoL), respectively.

RESULTS

Of the 191 recruited patients, 65 patients (34.0 %) suffered from depression, with a BDI-II score of 23.8 ± 8.4. The average score of QoL (44.9 ± 13.9 vs. 64.7 ± 14.2, p < 0.001), social support (37.9 ± 7.2 vs. 42.1 ± 7.3, p < 0.001), and "confrontation" coping style (17.2 ± 3.9 vs. 18.8 ± 3.8, p = 0.006) in depressed patients was significantly lower than those in non-depressed patients, respectively. While the depressed patients had significantly higher score of "acceptance-resignation" coping style (12.9 ± 2.5 vs. 10.4 ± 3.5, p < 0.001) compared with those of non-depressed patients. Univariate analysis showed that the BDI-II score was negatively associated with social support (r = -0.284, p < 0.001) and "confrontation" (r = -0.180, p = 0.013), but positively associated with "acceptance-resignation" (r = 0.482, p < 0.001). Logistic regression analysis revealed that age (OR = 0.971, p = 0.038), female sex (OR = 2.211, p = 0.039), diabetes mellitus (OR = 3.046, p = 0.015), long PD duration (OR = 1.021, p = 0.020), fatigue (OR = 2.500, p = 0.032), high Pittsburgh Sleep Quality Index (PSQI) score (OR = 1.143, p = 0.001), low social support (OR = 0.945, p = 0.046), and high "acceptance-resignation" (OR = 1.096, p = 0.020) were independently associated with depression.

CONCLUSION

There was a high prevalence of depression in CAPD patients. Age, female sex, diabetes mellitus, long PD duration, fatigue, sleep disturbance, low social support, and high "acceptance-resignation" coping style were independently associated with depression.

Sleep quality, depression, and quality of life in elderly hemodialysis patients

OBJECTIVE

Both the incidence and the prevalence of end-stage renal disease (ESRD) in elderly patients are increasing worldwide. Elderly ESRD patients have been found to be more prone to depression than the general population. There are many studies that have addressed the relationship between sleep quality (SQ), depression, and health related quality of life (HRQoL) in ESRD patients, but previous studies have not confirmed the association in elderly hemodialysis (HD) patients. Therefore, the aim of the present study was to demonstrate this relationship in elderly HD patients.

PATIENTS AND METHODS

Sixty-three elderly HD patients (32 females and 31 males aged between 65 and 89 years) were included in this cross-sectional study. A modified Post-Sleep Inventory (PSI), the Medical Outcomes Study 36-item short form health survey, and the Beck Depression Inventory (BDI) were applied.

RESULTS

The prevalence of poor sleepers (those with a PSI total sleep score [PSI-4 score] of 4 or higher) was 71% (45/63), and the prevalence of depression was 25% (16/63). Of the 45 poor sleepers, 15 had depression, defined as a BDI score of 17 or higher. Poor sleepers had a significantly higher rate of diabetes mellitus (P = 0.03), significantly higher total BDI scores, and lower Physical Component Scale scores (ie, lower HRQoL) than good sleepers. The PSI-4 score correlated negatively with Physical Component Scale (r = -0.500, P < 0.001) and Mental Component Scale scores (r = -0.527, P < 0.001) and it correlated positively with the BDI score (r = 0.606, P < 0.001). In multivariate analysis, independent variables of PSI-4 score were BDI score (beta value [β] = 0.350, P < 0.001), Mental Component Scale score (β = -0.291, P < 0.001), and age (β = 0.114, P = 0.035).

CONCLUSION

Poor SQ is a very common issue and is associated with both depression and lower HRQoL in elderly HD patients.