Sleep-related breathing disorders impair quality of life in haemodialysis recipients

Sleep apnoea syndrome prevalence in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis

Background

Several studies have examined the frequency of sleep apnoea (SA) in patients with chronic kidney disease (CKD), reporting different prevalence rates. Our systematic review and meta-analysis aimed to define the clinical penetrance of SA in CKD and end-stage kidney disease (ESKD) patients.

Methods

Ovid-MEDLINE and PubMed databases were explored up to 5 June 2023 to identify studies providing SA prevalence in CKD and ESKD patients assessed by different diagnostic methods, either sleep questionnaires or respiration monitoring equipment [such as polysomnography (PSG), type III portable monitors or other diagnostic tools]. Single-study data were pooled using the random-effects model. The Chi2 and Cochrane-I2 tests were used to assess the presence of heterogeneity, which was explored performing sensitivity and/or subgroup analyses.

Results

A cumulative analysis from 32 single-study data revealed a prevalence of SA of 57% [95% confidence interval (CI) 42%-71%] in the CKD population, whereas a prevalence of 49% (95% CI 47%-52%) was found pooling data from 91 studies in ESKD individuals. The prevalence of SA using instrumental sleep monitoring devices, including classical PSG and type III portable sleep monitors, was 62% (95% CI 52%-72%) and 56% (95% CI 42%-69%) in CKD and ESKD populations, respectively. Sleep questionnaires revealed a prevalence of 33% (95% CI 16%-49%) and 39% (95% CI 30%-49%).

Conclusions

SA is commonly seen in both non-dialysis CKD and ESKD patients. Sleep-related questionnaires underestimated the presence of SA in this population. This emphasizes the need to use objective diagnostic tools to identify such a syndrome in kidney disease.

Impact of the 3% Oxygen Desaturation Index via Overnight Pulse Oximetry on Cardiovascular Events and Death in Patients Undergoing Hemodialysis: A Retrospective Cohort Study

It is unclear whether the severity of sleep-disordered breathing (SDB) affects the risk of cardiovascular events and mortality in patients undergoing hemodialysis (HD). We determined the severity of SDB with the 3% oxygen desaturation index (ODI) via overnight pulse oximetry. This study was a retrospective cohort, observational study of 134 patients on maintenance HD at a single center. They were divided into four groups according to SDB severity (normal, mild, moderate, and severe), and were followed. The baseline characteristics of all patients were as follows: the median age was 67 (interquartile range, 59-75) years, 64.2% were men, 37.3% were diabetic, and the median duration of HD was 69 (29-132) months. During follow-up, major adverse cardiovascular events (MACEs) occurred in 71 patients and deaths in 60 (including 32 cardiovascular deaths). Severe SDB was an independent risk factor for MACEs (hazard ratio [HR] = 4.66, 95% confidence interval [CI] = 1.87-11.61, p = 0.001) and all-cause death (HR = 5.74, 95% CI = 1.92-16.70, p = 0.001). Severe SDB had a statistically significant impact on the risk of MACEs and mortality in patients undergoing HD. The severity of the 3% ODI via overnight pulse oximetry may be a useful marker as a risk factor for cardiovascular outcomes and mortality in these patients.

Effects of 12 months of continuous positive airway pressure therapy on cognitive function, sleep, mood, and health-related quality of life in a peritoneal dialysis patient with obstructive sleep apnea

This report describes the case of a hypertensive 51-year-old male with a 3-year history of peritoneal dialysis. We followed the patient through his diagnosis of severe obstructive sleep apnea (OSA) and treatment with continuous positive airway pressure (CPAP). Therapeutic use of CPAP led to the improvement of not only sleep-related problems, but also cognitive function and quality of life. To our knowledge, this is the first paper describing the benefits of long-term CPAP treatment in an OSA patient undergoing dialysis. This case report emphasizes the need for the proactive diagnosis and treatment of OSA in end-stage renal disease patients to improve patient-centered healthcare.

A systematic review of sleep disorders in patients with chronic kidney disease undergoing hemodialysis

The purpose of this study was to conduct a systematic review of the available evidence on sleep disorders in patients with end stage renal disease (ESRD) undergoing hemodialysis (HD). [Subjects and Methods] Two independent reviewers performed a computer-assisted search of the MEDLINE, SciELO, LILACS, and BIREME Virtual Health Library medical databases from their inception to November 2015. [Results] One thousand one hundred twenty-six articles were found that met the inclusion criteria. Articles were excluded if they were not in English, the patients did not undergo HD, or the studies were not cross-sectional or clinical trials. After reading the full text, a further 300 studies were excluded because they did not use polysomnography. The remaining 18 studies with ESRD patients undergoing HD comprised 8 clinical trials and 10 cross-sectional studies. This systematic review followed the criteria outlined by the PRISMA declaration. [Conclusion] In this systematic review, a high prevalence of sleep disorders was observed in ESRD, including sleep-disordered breathing. This knowledge may enable health professionals to devise new strategies for the diagnosis and treatment of these patients, in order to reduce morbidity and mortality and improve their quality of life.

Association between serum bicarbonate and pH with depression, cognition and sleep quality in hemodialysis patients

Metabolic acidosis is a common feature in chronic renal failure patients, worsening progressively as renal function declines. There are conflicting data in hemodialysis (HD) patients with regard to acidosis, alkalosis and mortality. In HD patients, cognitive impairment, depression, sleep disorders and impaired quality of life are very common. Besides, these conditions are related with increased morbidity and mortality. However, no previous study investigated the relationship between pH, venous bicarbonate and anion gap with depression, sleep problems and cognitive function in HD patients. In this study we investigated these relationships. In total, 65 HD patients were included. The demographic parameters and laboratory parameters including bicarbonate, pH and anion gap was measured for all patients. Depressive symptoms, sleep quality and cognitive function, were measured by Beck depression inventory, The Pittsburgh Sleep Quality Index and by Mini Mental State Examination, respectively. We found that, sleep quality but not cognitive function or depression was independently related with venous pH and bicarbonate. Anion gap has no independent relationship with sleep quality, cognitive function and depression. In conclusion, metabolic acidosis and bicarbonate levels were independently related with sleep quality in HD patients. However, there was no association between metabolic acidosis and bicarbonate levels with cognitive function and depression.

Uremic versus idiopathic restless legs syndrome: impact on aspects related to quality of life

Restless legs syndrome (RLS) affects both the general population and patients with chronic renal failure. Even though it has been suggested that all forms of RLS share a common pathophysiology, not much evidence exists on how RLS of different etiology could affect aspects related to quality of life (QoL). The aim of this study was to investigate whether patients with uremic RLS (uRLS) experience lower QoL, mental health, and sleep quality, compared with their idiopathic RLS (iRLS) counterparts. Fifteen iRLS patients, 26 uRLS patients, and 15 age-matched healthy individuals participated in the study. The RLS diagnosis and severity, the depression levels, the perception of sleep, and perceived health-related QoL levels were assessed through validated questionnaires. Sleep status was not different between the two RLS groups. In contrast, the uRLS patients scored higher in RLS symptoms severity, depression, while they scored lower in QoL levels compared with iRLS patients. QoL levels were significantly lower in both RLS groups compared with healthy individuals. In conclusion, the uRLS patients experienced lower QoL levels and more severe RLS symptoms, compared with the idiopathic group, possibly leading to the observed higher depression symptoms score.

Fatigue in hemodialysis patients: a review of current knowledge

CONTEXT

End-stage renal disease is a common chronic illness increasing in incidence and prevalence. Although kidney function is partially replaced through dialysis, patients endure many symptoms of the disease such as fatigue. Many factors have been studied regarding their relationship with fatigue in this population.

OBJECTIVES

To provide a state of the science review regarding fatigue in hemodialysis patients by examining the experience of fatigue for patients on hemodialysis and correlates of fatigue in patients on hemodialysis.

METHODS

PubMed, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Sociological Abstracts were searched using the key terms "fatigue," "dialysis," and "hemodialysis." Articles written after 1980 and those with explicit findings related to fatigue were included in this review. Articles that discussed fatigue in peritoneal dialysis patients or renal transplant patients were not included.

RESULTS

There is little knowledge regarding the experience of fatigue for patients on hemodialysis and there has been little success identifying demographic, psychosocial, or physiological factors that are consistently related to fatigue.

CONCLUSION

Further work in this area of inquiry would be of benefit and may shed light on the domains of life that are affected by fatigue for hemodialysis patients. It also may help deepen our knowledge regarding correlates that could identify hemodialysis patients who are at increased risk for fatigue.

Association of sleep-disordered breathing with cognitive dysfunction in CKD stages 4-5

BACKGROUND

Sleep-disordered breathing and cognitive impairment are common in patients with chronic kidney disease (CKD). Sleep-disordered breathing is known to be a risk factor for cognitive dysfunction in the general population, but this association has not been studied in patients with CKD.

STUDY DESIGN

Cross-sectional study.

SETTINGS & PARTICIPANTS

A cohort of 169 patients with CKD stages 4-5.

PREDICTORS

Sleep-disordered breathing; covariates included demographics, diabetes, cardiovascular disease, depression, and dialysis modality.

OUTCOMES

Cognitive impairment, generally defined as a score 1.5 standard deviations or more from the age- and education level-adjusted normative cognitive test score.

MEASUREMENTS

Standardized health interview, neurocognitive assessment, sleep-related questionnaires, and polysomnography.

RESULTS

Sleep-disordered breathing (apnea-hypopnea index >15) was diagnosed in 83 (49.1%) individuals. This group had a significantly higher prevalence of nocturnal hypoxemia (65.8% vs 26.8%; P < 0.001) and excessive daytime sleepiness (38.6% vs 20.7%; P = 0.01). In addition, this group had significantly lower scores in tests measuring verbal memory, working memory, attention, and psychomotor speed. Sleep-disordered breathing was associated with higher risk of immediate verbal memory impairment after adjustment for known confounders (adjusted OR, 2.67; 95% CI, 1.17-6.08). However, in a subgroup analysis of older adults (aged >60 years), there were no significant differences in cognitive testing between the groups with and without sleep-disordered breathing.

LIMITATIONS

Cross-sectional design, limited sample size.

CONCLUSIONS

Sleep-disordered breathing is associated with cognitive impairments, especially impaired verbal memory, in patients with advanced CKD. However, the impact appeared limited in older adults. Early evaluation and management of sleep-disordered breathing in patients with CKD may provide an opportunity to improve cognitive function.

Association of insomnia symptoms with kidney disease quality of life reported by patients on maintenance dialysis

Results of many studies indicate that sleep disorders can reduce quality of life (QoL) in patients with chronic kidney disease. This study aimed to investigate therelation of insomnia symptoms to QoL among haemodialysis (HD) and peritoneal dialysis patients. A sample of 144 patients was recruited from three General Hospitals in the broader area of Athens, consisting of 84 patients undergoing in-centre HD and 60 patients in continuous ambulatory peritoneal dialysis. Measurements were conducted with the following instruments: The World Health Organization Quality of Life (WHOQOL) instrument, the General Health Questionnaire, the State-Trait Anxiety In ν entory and the Center for Epidemiologic Studies Depression Scale. The results indicated that insomnia symptoms had negative association with all the domains of WHOQOL questionnaire (physical health, psychological well-being, social relationships and environment). Insomnia symptoms were also related positively to depression as well as state and trait anxiety. The findings provide evidence that the presence of insomnia symptoms relates significantly to the negative evaluation of mental health and QoL in patients with chronic kidney disease.

Sleep-disordered breathing and excessive daytime sleepiness in chronic kidney disease and hemodialysis

BACKGROUND AND OBJECTIVES

Sleep-disordered breathing (SDB) and excessive daytime sleepiness (EDS) are highly prevalent among hemodialysis (HD) patients. It is unclear to what extent SDB is associated with advanced chronic kidney disease (CKD; stages 4 to 5). This paper describes and compares the prevalence, severity, and patterns of SDB and EDS among patients with advanced CKD, HD-dependent patients, and community individuals without known renal disease.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Eighty-nine CKD and 75 HD patients were compared with 224 participants from the Sleep-Strategies Concentrating on Risk Evaluation Sleep-SCORE study of sleep and cardiovascular risk. Participants had in-home unattended polysomnography for quantifying SDB. EDS was defined by a score ≥10 on the Epworth Sleepiness Scale.

RESULTS

The sample had a median age 58.1 years, was predominantly male (57.4%) and white (62.5%), and had a median body mass index of 28.1 kg/m(2). Controls and Sleep-SCORE Study CKD patients had significantly higher median total sleep time and sleep efficiency compared with HD patients. The adjusted odds of severe SDB were higher for CKD and HD groups compared with the controls. Nocturnal hypoxemia was significantly elevated in the HD group compared with the CKD group. There were similar proportions of participants with EDS between the controls (33%), the CKD patients (29.3%), and the HD patients (40.6%).

CONCLUSIONS

Severe SDB (predominantly obstructive) and EDS are common among advanced CKD and HD patients. EDS correlated modestly with severe SDB and its obstructive and mixed patterns in the HD group.

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

BACKGROUND

Many patients with end-stage renal disease who are undergoing chronic hemodialysis suffer from sleep disturbance. This paper was designed to study the severity and prevalence of sleep disorders and the factors affecting the syndromes in this unique patient group.

METHODS

We conducted this study by the use of questionnaires. Included in this study were a total of 245 patients at our center who had end-stage renal disease (ESRD) and who received hemodialysis thrice weekly for more than three months. Their demographic data and biochemical and hematologic parameters were analyzed. All patients were asked to complete two questionnaires (in a Chinese version) of the Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory second edition (BDI-II), either by themselves or with assistance from the medical staff.

RESULTS

One hundred and sixty-four patients completed both questionnaires with a response rate of 70.4%. Their mean age was 57.9 +/- 11.8 (ranging from 23.1 to 83.7) years old. They had been receiving hemodialysis for an average of 49.1 +/- 50.9 months before the study. The male to female ratio was 77:87. Seventy six (46.3%) patients had diabetes mellitus. The prevalence of sleep disturbance was 74.4% (122/164), defined as PSQI scores >5. The poor sleepers had higher BDI scores and a higher ratio of females comparing to the good sleepers. By a multivariate analysis, the BDI scores and female sex were the independent predictors of the patients being poor sleepers. In analyzing the poor sleepers, the BDI scores, durations of hemodialysis and hemoglobin levels were the independent factors for predicting the global PSQI scores.

CONCLUSION

The questionnaire showed a high prevalence of insomnia in the dialytic population. The study also attributes a predictive role in sleep quality to gender, depression, dialytic duration, and hemoglobin levels. The data indicate that in the management of insomnia in this patient group, anemia and depression, both of which are potentially correctable, should be assessed.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: Sleepiness, Sleeplessness, and Pain in End-Stage Renal Disease: Distressing Symptoms for Patients

Symptoms are increasingly recognized as problematic for patients with end-stage renal disease (ESRD) treated with dialysis. Sleep disorders are common in ESRD patients treated with dialysis and are associated with patients' perceptions of quality of life, assessed by diverse measures, as well as depressive affect. Sleep disorders appear to be equally prevalent in peritoneal dialysis (PD) and hemodialysis (HD) patients. Treatment for sleep disorders in dialysis patients depends on establishing the diagnosis, often in a sleep laboratory, using polysomnography. Reversing coexistent medical and psychological disorders is important. The sleep apnea syndrome (SAS) can be treated with continuous positive airway pressure in dialysis patients, but conventional hemodialytic techniques have little effect on its severity. In contrast, nocturnal HD and transplantation appear to have important beneficial effects on sleep disordered breathing in ESRD patients. Although pain has been appreciated as a problem for ESRD patients for more than 20 years, few studies exist on this subject. Pain appears to be an underappreciated problem for ESRD patients. More research must be performed on the problem of pain in patients with chronic kidney disease (CKD).

Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors

Fatigue is a debilitating symptom or side effect experienced by many patients on long-term dialysis therapy. Fatigue has a considerable effect on patient health-related quality of life and is viewed as being more important than survival by some patients. Renal providers face many challenges when attempting to reduce fatigue in dialysis patients. The lack of a reliable, valid, and sensitive fatigue scale complicates the accurate identification of this symptom. Symptoms of daytime sleepiness and depression overlap with fatigue, making it difficult to target specific therapies. Moreover, many chronic health conditions common in the long-term dialysis population may lead to the development of fatigue and contribute to the day-to-day and diurnal variation in fatigue in patients. Key to improving the assessment and treatment of fatigue is improving our understanding of potential mediators, as well as potential therapies. Cytokines have emerged as an important mediator of fatigue and have been studied extensively in patients with cancer-related fatigue. In addition, although erythropoietin-stimulating agents have been shown to mitigate fatigue, the recent controversy regarding erythropoietin-stimulating agent dosing in patients with chronic kidney disease suggests that erythropoietin-stimulating agent therapy may not serve as the sole therapy to improve fatigue in this population. In conclusion, fatigue is an important and often underrecognized symptom in the dialysis population. Possible interventions for minimizing fatigue in patients on long-term dialysis therapy should aim at improving health care provider awareness, developing improved methods of measurement, understanding the pathogenesis better, and managing known contributing factors.

Sleep apnea in hemodialysis patients: risk factors and effect on survival

Sleep disorders are common in patients with end-stage renal disease (ESRD). Using a simple questionnaire, we estimate the probability of sleep apnea in ESRD patients, determine the factors associated with a higher probability of sleep apnea, and determine the association between the probability of sleep apnea and cardiovascular and all-cause mortality.

STUDY DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

prevalent hemodialysis patients (n=270) in 7 urban outpatient hemodialysis units.

PREDICTOR

Probability of sleep apnea as quantified by the Flemons questionnaire.

OUTCOMES AND MEASUREMENTS

Clinical, demographic, and dialysis-related characteristics were obtained at baseline. Total and cardiovascular mortality was ascertained after a median follow-up of 34 months. The probability of sleep apnea was low in 79 (29%) patients, moderate in 116 (43%) patients, and high in 75 (28%) patients. Male gender (odds ratio [OR] 5.13, p<0.001), obesity (BMI >30, OR 7.58, p<0.01), and interdialytic weight gain (OR 1.72/kg change, p<0.004) were independently associated with a high probability of sleep apnea. A high probability of sleep apnea at baseline did not predict total (hazard ratio [HR] 0.81, p=NS) or cardiovascular mortality (HR 0.9, p=NS). The Flemons questionnaire is validated in the general population, but has not been tested specifically in hemodialysis patients. The study may not be adequately powered to detect a difference in mortality. A high proportion of hemodialysis patients are likely to have sleep apnea; a simple bedside questionnaire can be used for screening to identify these patients. Excessive interdialytic weight gain is a potentially modifiable factor that increases the likelihood of sleep apnea. Despite the presence of a strong association between sleep apnea and mortality in the general population, a similar association could not be demonstrated in ESRD patients with a high prevalence of this condition.

Sleep apnea and dialysis therapies: things that go bump in the night?

Sleep apnea has been linked to excessive daytime sleepiness, depressed mood, hypertension, and cardiovascular disease in the general population. The prevalence of severe sleep apnea in the conventional thrice-weekly hemodialysis population has been estimated to be more than 50%. Sleep apnea leads to repetitive episodes of hypoxemia, hypercapnia, sleep disruption, and activation of the sympathetic nervous system. The hypoxemia, arousals, and intrathoracic pressure changes associated with sleep apnea lead to sympathetic activation, endothelial dysfunction, oxidative stress, and inflammation. Because sleep apnea has been shown to be widespread in the conventional dialysis population, it may be that sleep apnea contributes substantially to the sleepiness, poor quality of life, and cardiovascular disease found in this population. The causal links between conventional dialysis and sleep apnea remain speculative, but there are likely multiple factors related to volume status and azotemia that contribute to the high rate of severe sleep apnea in dialysis patients. Both nocturnal automated peritoneal dialysis and nocturnal hemodialysis have been associated with reduced severity of sleep apnea. Nocturnal dialysis modalities may provide tools to increase our understanding of the uremic sleep apnea and may also provide therapeutic alternatives for end-stage renal disease patients with severe sleep apnea. In conclusion, sleep apnea is an important, but overlooked, public health problem for the dialysis population. The impact of sleep apnea treatment in this high-risk population may include reduced sleepiness, better mood and blood pressure, and lowered risk of cardiovascular disease.

Sleep Apnea in Patients on Conventional Thrice-Weekly Hemodialysis: Comparison with Matched Controls from the Sleep Heart Health Study

Sleep-disordered breathing (SDB) has been noted commonly in hemodialysis (HD) patients, but it is not known whether this is related directly to the treatment of kidney failure with HD or to the higher prevalence of obesity and older age. Forty-six HD patients were compared with 137 participants from the Sleep Heart Health Study (SHHS) who were matched for age, gender, body mass index (BMI), and race. Home unattended polysomnography was performed and scored using similar protocols. The study sample was 62.7 +/- 10.1 yr, was predominantly male (72%) and white (63%), and had an average BMI of 28 +/- 5.3 kg/m(2). The HD sample had a higher systolic BP (137 versus 121 mmHg; P < 0.01) and a higher prevalence of diabetes (33 versus 9%; P < 0.01) and cardiovascular disease (33 versus 13%; P < 0.01) compared with the SHHS sample. The HD group had significantly less sleep time (320 versus 379 min; P < 0.0001) but similar sleep efficiency. HD patients had a higher frequency of arousals per hour (25.1 versus 17.1; P < 0.0001) and apnea-hypopneas per hour (27.2 versus 15.2; P < 0.0001) and greater percentage of the total sleep time below an oxygen saturation of 90% (7.2 versus 1.8; P < 0.0001). HD patients were more likely to have severe SDB (>30 respiratory events per hour) compared with the SHHS sample (odds ratio 4.07; 95% confidence interval 1.83 to 9.07). There was a strong association of HD with severe SDB and nocturnal hypoxemia independent of age, BMI, and the higher prevalence of chronic disease. The potential mechanisms for the higher likelihood of SDB in the HD population must be identified to provide specific prevention and therapy.

Diagnosis and management of insomnia in dialysis patients

Sleep-related complaints affect 50-80% of patients on dialysis. Sleep disorders impair quality of life significantly. Increasing evidence suggests that sleep disruption has a profound impact both on an individual and on a societal level. The etiology of sleep disorders is often multifactorial: biologic, social, and psychological factors play a role. This is especially true for insomnia, which is the most common sleep disorder in different populations, including patients on dialysis. Biochemical and metabolic changes, lifestyle factors, depression, anxiety, and other underlying sleep disorders can all have an effect on the development and persistence of sleep disruption, leading to chronic insomnia. Insomnia is defined as difficulty initiating or maintaining sleep, or having nonrestorative sleep. It is also associated with daytime consequences, such as sleepiness and fatigue, and impaired daytime functioning. In most cases, the diagnosis of insomnia is based on the patient's history, but in some patients objective assessment of sleep pattern may be necessary. Optimally the treatment of insomnia involves the combination of both pharmacologic and nonpharmacologic approaches. In some cases acute insomnia resolves spontaneously, but if left untreated, it may lead to chronic sleep problems. The treatment of chronic insomnia is often challenging. There are only a few studies specifically addressing the management of this sleep disorder in patients with chronic renal disease. Considering the polypharmacy and altered metabolism in this patient population, treatment trials are clearly needed. This article reviews the diagnosis of sleep disorders with a focus on insomnia in patients on dialysis.

Sleep Behavior Disorders in a Large Cohort of Chinese (Taiwanese) Patients Maintained by Long-Term Hemodialysis

BACKGROUND

Disorders of sleep behavior and sleep-related breathing disorders are common in hemodialysis patients. Most such evidence is based on studies involving small numbers of patients.

METHODS

We undertook a large multicenter analysis of sleep behavior in more than 700 Taiwanese patients on maintenance hemodialysis therapy for 6 months to 20-plus years by using self-administered questionnaires: the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Berlin Questionnaire for risk for sleep apnea, validated for the general population. Patients also completed a questionnaire to assess symptoms related to restless legs and periodic limb movements (PLMs). Sleep behavior was analyzed in relation to demographic and dialysis-related parameters provided by the participating dialysis centers.

RESULTS

Sleep disturbance was very common in this cohort, with problems of insomnia (66.6%) exceeding those related to daytime sleepiness (17.8%). Sleep disturbances were associated with restless legs syndrome (RLS)/PLM and a high risk for sleep apnea, determined by using the Berlin Questionnaire. Older age increased the odds of daytime sleepiness, but not insomnia. Lower dialysis dose (single-pool Kt/V) increased the likelihood of daytime sleepiness and was associated with greater rates for RLS/PLM and risk for sleep apnea. Use of antihypertensive medications (a probable surrogate for more severe hypertension) was associated strongly with high risk for sleep apnea. Smoking was associated with RLS/PLM and risk for sleep apnea, whereas consumption of stimulant beverages (coffee and tea) had contrary effects on RLS/PLM and risk for sleep apnea and were not implicated in measures of insomnia or daytime sleepiness. A greater likelihood of insomnia for greater hemoglobin levels and greater likelihood of daytime sleepiness for patients administered vitamin D analogues were not explained by the available data.

CONCLUSION

Sleep disorders and sleep-related breathing disorders are common in hemodialysis patients. Greater attention in the care of dialysis patients needs to be directed to the diagnosis and management of sleep disorders.

Which instrument is more suitable to assess health-related quality of life: Nottingham Health Profile or Short-Form-36?

BACKGROUND

Recent publications in rehabilitation research describe a new category of outcome measures, so-called patient-reported outcomes (PROs). This is an umbrella term for different degrees of subjective symptom intensity, treatment satisfaction and, particularly, health-related quality of life (HrQoL). Given the countless new developments in the field of HrQoL, it has become difficult to select the most appropriate or the best instrument for outcome-oriented studies. We evaluated and compared the two most frequently used questionnaires to assess HrQoL, namely the Nottingham Health Profile (NHP) and the MOS Short-Form-36 Health Survey (SF-36) with regard to their applicability in gerontology.

METHODS

A sample of active "elderly gymnasts" (mean age, 68 years) was compared with a "young" control group (mean age, 36 years). Both groups were asked to fill out the two questionnaires and enter on a visual analogue scale (VAS) their assessment of the suitability of each instrument for application in a scientific study.

RESULTS

While the control group generally favoured the SF-36 and rated this questionnaire significantly better than the NHP, the two survey instruments were given nearly the same rating by the elderly gymnasts. Younger experimental subjects particularly objected to the wording of the items (all of these were found to be negatively oriented) and the dichotomous response format of the NHP (it allows only yes-no answers in contrast to the SF-36 which offers several graded choices) while elderly patients considered this limited range of responses to be an advantage of the NHP.

CONCLUSIONS

The decision in favour of or against a survey instrument should always be made individually for each situation, based on the test criteria and the characteristics of the study population. In elderly patients with stronger symptoms, one may well decide in favour of the NHP despite its disadvantages (limited response format, floor effects, less frequent use of the questionnaire).

Sleep apnea, coronary artery disease, and antioxidant status in hemodialysis patients

BACKGROUND

It recently was suggested that sleep apnea syndrome (SAS) is associated with the cardiovascular complications and outcomes seen in patients with end-stage renal disease (ESRD). This study investigates the association of SAS with coronary artery disease and antioxidant status in patients with ESRD.

METHODS

Twenty-six hemodialysis patients underwent overnight polysomnography to evaluate sleep parameters. We performed multirow spiral computed tomography to derive coronary artery calcification (CAC) scores as an indicator of the severity of coronary artery disease and measured predialysis serum total antioxidant status (TAS) as a marker of antioxidant defenses.

RESULTS

Nine of 26 patients had normal to mild SAS with an apnea-hypopnea index (AHI) less than 15, 9 patients had moderate SAS with an AHI of 15 to 30, and the remaining 8 patients had severe SAS with an AHI greater than 30. AHI and oxygen desaturation index (ODI) were strongly interrelated (r = 0.754; P < 0.001). CAC severity was associated with SAS severity: median CAC scores increased (P = 0.009) with increasing AHI category. However, values for TAS were not significantly different among the 3 AHI categories. CAC score also correlated positively (r = 0.564; P = 0.003) with ODI, and TAS correlated negatively (r = -0.539; P = 0.005) with ODI.

CONCLUSION

These results suggest that frequent oxygen desaturation triggered by SAS is associated with severe coronary artery disease and decreased antioxidant status in patients with ESRD. However, conclusions from this study should be drawn with caution because of its methodological limitations (cross-sectional design, heterogeneity of study population, and small number of patients).

Quality of Sleep and Quality of Life in Renal Transplantation Patients

INTRODUCTION

Sleep and sleep-related disorders are common among end-stage renal disease patients. In the general population and hemodialysis patients, insomnia impairs health-related quality of life (HRQOL). The aims of this study were to examine the prevalence of sleep problems among renal transplantation patients and the relationship between the quality of sleep and the HRQOL.

METHODS

Pittsburgh Sleep Quality Index (PSQI) for measuring quality of sleep, WHOQOL-BREF for quality of life, and Beck Depression Inventory (BDI) were applied to 100 renal transplant patients.

RESULTS

Thirty (30%) subjects were "poor sleepers" (global PSQI > 5). Poor sleepers were younger (mean age: 31 vs 37); less educated (mean years of education: 7.80 vs 9.55), and more depressed (mean BDI scores 13.63 vs 7.18). There were significant inverse correlations between global PSQI and physical health (r = -0.31; P < .001) and psychological state (r = -.20; P = .04) with a significant correlation with BDI scores (r = .36; P < .001). The BDI score (P < .001) was the only significant factor of physical health, psychological state, and social functioning. BDI score (P < .001) and education (P < .022) were significant predictors of environmental conditions.

CONCLUSION

Sleep problems are not as common among transplant as dialysis patients, but still higher than the general population. Poor sleep seems to be a part of depressive symptomatology. Severity of depression and lower education were more negatively effective factors on the quality of life of these patients than the quality of sleep.

Analgesic prescription patterns among hemodialysis patients in the DOPPS: Potential for underprescription

BACKGROUND

Dialysis patients require special consideration regarding analgesics, given their altered pharmacokinetic and pharmacodynamic profiles and increased potential for adverse reactions.

METHODS

Analgesic prescription patterns were investigated using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), with 3749 patients in 142 United States facilities studied between May 1996 and September 2001.

RESULTS

The proportion of patients prescribed any analgesic decreased from 30.2% to 24.3%; narcotic prescriptions decreased from 18.0% to 14.9%. The most commonly prescribed narcotics were propoxyphene/acetaminophen combinations (47.2%). Combinations containing acetaminophen were prescribed concurrently for 84.1% of patients on narcotics. About one half of prescriptions for narcotics, acetaminophen, and cyclooxygenase-2 (COX-2) agents were for 12 months or more; one half of prescriptions for nonsteroidal anti-inflammatory drugs (NSAIDs) were for 8 months or more. The proportion of patients prescribed analgesics varied by facility (mean +/- SD = 27.9%+/- 18.9% for all analgesics, range 0% to 89.3%). Analgesic prescription was more likely among the elderly, women, and patients with cardiovascular disease (other than coronary artery disease or congestive heart failure), lung and psychiatric disease, cancer (other than skin), and recurrent cellulitis. Patients prescribed laxatives were almost twice as likely to be on a narcotic (odds ratio = 1.95, P < 0.0001). Analgesic prescription did not correlate with loss of residual renal function or hospitalization for a gastrointestinal disorder. Three-quarters of patients reporting moderate to very severe pain were not prescribed analgesics. Furthermore, 74% of patients with pain that interfered with work had no analgesic prescription.

CONCLUSION

Dialysis patients and providers may benefit from both refinement of existing guidelines and a renewed understanding regarding appropriate prescription of analgesics.

Sleep disorders and illness intrusiveness in patients on chronic dialysis

BACKGROUND

The prevalence of sleep problems (insomnia, restless legs syndrome, periodic limb movements in sleep and sleep apnoea) has been shown to be high in patients with end-stage renal disease (ESRD) and might contribute to impaired quality of life in this population.

METHODS

In a cross-sectional study using self-administered questionnaires, we examined the prevalence of sleep disorders and assessed their effect on different aspects of health-related quality of life in a sample of Hungarian patients on maintenance dialysis.

RESULTS

Our data confirm that sleep problems are frequent in patients with ESRD; 65% of the patients reported symptoms of at least one specific sleep disorder; insomnia was the most common sleep complaint with 49%, the prevalence of sleep apnoea was 32% and the prevalence of restless legs syndrome was 15%. Co-morbidity, assessed by the End-Stage Renal Disease Severity Index, was shown to be an independent predictor of sleep disorders. Patients with sleep disorders reported higher illness intrusiveness and worse self-perceived health than those without sleep problems. The presence of sleep disorders was an independent predictor of illness intrusiveness, an important determinant of health-related quality of life.

CONCLUSION

Sleep disorders are important determinants of illness intrusiveness and health-related quality of life in patients with ESRD. Sleep problems may be treated successfully; therefore, more attention should be paid to assessing these problems in this patient population.

ESRD patient quality of life: symptoms, spiritual beliefs, psychosocial factors, and ethnicity

BACKGROUND

Recent research suggests that patients' perceptions may be more important than objective clinical assessments in determining quality of life (QOL) for patients with end-stage renal disease (ESRD).

METHODS

We interviewed 165 hemodialysis patients from 3 sites using a QOL questionnaire that included the Satisfaction With Life Scale (SWLS) and the McGill QOL (MQOL) scale, which includes a single-item global measure of QOL (Single-Item QOL Scale [SIS]). The MQOL scale asks patients to report their most troublesome symptoms. We also initiated the use of a Support Network Scale and a Spiritual Beliefs Scale.

RESULTS

Mean patient age was 60.9 years, 52% were men, 63% were white, and 33% were African American. Patients had a mean treatment time for ESRD of 44 months, mean hemoglobin level of 11.8 g/dL (118 g/L), mean albumin level of 3.7 g/dL (37 g/L), and mean Kt/V of 1.6. Forty-five percent of patients reported symptoms. Pain was the most common symptom (21% of patients). There was an inverse relationship between reported number of symptoms and SWLS (P < 0.01), MQOL scale score (P < 0.001), and SIS (P < 0.001). The Spiritual Beliefs Scale correlated with the MQOL scale score, SWLS (both P < 0.01), and SIS (P < 0.05). The Support Network Scale score correlated with the MQOL Existential (P = 0.01) and MQOL Support (P < 0.01) subscales. No clinical parameter correlated with any measure of QOL, spiritual beliefs, or social support.

CONCLUSION

Symptoms, especially pain, along with psychosocial and spiritual factors, are important determinants of QOL of patients with ESRD. Additional studies, particularly a longitudinal trial, are needed to determine the reproducibility and utility of these QOL measures in assessing patient long-term outcome and their association with other QOL indices in larger and more diverse patient populations.

Nocturnal sleep, daytime sleepiness, and quality of life in stable patients on hemodialysis

BACKGROUND

Although considerable progress has been made in the treatment of chronic kidney disease, compromised quality of life continues to be a significant problem for patients receiving hemodialysis (HD). However, in spite of the high prevalence of sleep complaints and disorders in this population, the relationship between these problems and quality of life remains to be well characterized. Thus, we studied a sample of stable HD patients to explore relationships between quality of life and both subjective and objective measures of nocturnal sleep and daytime sleepiness

METHODS

The sample included forty-six HD patients, 24 men and 22 women, with a mean age of 51.6 (10.8) years. Subjects underwent one night of polysomnography followed the next morning by a Multiple Sleep Latency Test (MSLT), an objective measure of daytime sleepiness. Subjects also completed: 1) a brief nocturnal sleep questionnaire; 2) the Epworth Sleepiness Scale; and, 3) the Quality of Life Index (QLI, Dialysis Version) which provides an overall QLI score and four subscale scores for Health & Functioning (H&F), Social & Economic (S&E), Psychological & Spiritual (P&S), and Family (F). (The range of scores is 0 to 30 with higher scores indicating better quality of life.)

RESULTS

The mean (standard deviation; SD) of the overall QLI was 22.8 (4.0). The mean (SD) of the four subscales were as follows: H&F - 21.1 (4.7); S&E - 22.0 (4.8); P&S - 24.5 (4.4); and, F - 26.8 (3.5). H&F (rs = -0.326, p = 0.013) and F (rs = -0.248, p = 0.048) subscale scores were negatively correlated with periodic limb movement index but not other polysomnographic measures. The H&F subscale score were positively correlated with nocturnal sleep latency (rs = 0.248, p = 0.048) while the H&F (rs = 0.278, p = 0.030) and total QLI (rs = 0.263, p = 0.038) scores were positively associated with MSLT scores. Both of these latter findings indicate that higher life quality is associated with lower sleepiness levels. ESS scores were unrelated to overall QLI scores or the subscale scores. Subjective reports of difficulty falling asleep and waking up too early were significantly correlated with all four subscale scores and overall QLI. Feeling rested in the morning was positively associated with S&E, P&S, and Total QLI scores.

CONCLUSION

Selected measures of both poor nocturnal sleep and increased daytime sleepiness are associated with decreased quality of life in HD patients, underscoring the importance of recognizing and treating these patients' sleep problems.