Poor sleep quality and associated factors among adult chronic kidney disease patients

Background

Poor sleep quality is a common concern in chronic kidney disease (CKD) patients, which can accelerate the progression of chronic renal disease and negatively impact their health-related quality of life, potentially leading to greater morbidity and mortality rates. It can also have an effect on the immune system, cognitive function, and emotional well-being of CKD patients. Furthermore, poor sleep quality may contribute to drug noncompliance and decreased participation in the entire treatment plan. Nonetheless, no research has been undertaken in Ethiopia on the prevalence of poor sleep quality and its associated factors among CKD patients.

Objective

This study aimed to assess the prevalence of poor quality of sleep and associated factors among chronic kidney disease patients at the University of Gondar Comprehensive Specialized and Felege Hiwot Referral Hospitals in 2020.

Methods

A cross-sectional study design was implemented at the University of Gondar Comprehensive Specialized and Felege Hiwot Referral Hospitals between February and April 2020. The study participants were chosen through systematic random sampling techniques. The Pittsburgh Sleep Quality Index (PSQI), a validated assessment tool, was utilized to measure sleep quality. A PSQI total score > 5 was used as an indicator of poor sleep quality. Subsequently, the data obtained were entered into Epi Data version 3.0 and then transferred to STATA 14 for analysis. Both bivariable and multivariable binary logistic regression analyses were performed to recognize factors associated with poor sleep quality. In the multivariable logistic regression analysis, variables demonstrating a p-value of ≤0.05 were considered statistically associated to poor sleep quality.

Results

In this study, 424 CKD patients were included. Among screened CKD patients, 42.9% tested positive for poor sleep quality with a 95% CI (38 to 47%). Independent predictors of poor sleep quality among CKD patients were common mental disorder [AOR = 1.8, 95% CI (1.19-2.89)], anemia [AOR = 2.7, 95% CI (1.71-4.36)], declined eGFR between 60 and 89.9 [AOR = 1.6; 95% CI (2.28-5.54)], 30-59.9 [AOR = 2.6, 95% CI (1.53-4.43)], and ≤ 30 [AOR = 3.8, 95% CI (1.17-12.61)], age > 50 years [AOR = 1.7(1.11-2.69)] and duration of disease 2.9 [AOR = 2.9, 95% CI (1.77-4.90)].

Conclusion

In our study, almost 1 out of 2 CKD patients assessed for poor sleep quality tested positive. It was noted that poor sleep quality was more frequent among CKD patients with common mental disorders, anemia, decreased eGFR levels, individuals aged over 50 years, and those with a longer duration of the disease. Consequently, it's advised to regularly screen these CKD patients for poor sleep quality.

Association between sleep quality and cardiovascular disease in maintenance hemodialysis patients: a prospective cohort study

OBJECTIVE

This study aimed to analyze the association between sleep quality and cardiovascular disease in patients on maintenance hemodialysis (MHD).

METHODS

A total of 601 patients with MHD in the second affiliated hospital of Nanjing Medical University, were prospectively enrolled in this cohort study from January 2019 to December2019. The global Pittsburgh sleep quality index (PSQI) score > 7 indicates that a person with poor sleep quality. Patients were divided into two groups according to the PSQI score. Follow-up was conducted about 3 years with all-cause death and major adverse cardiovascular events (MACEs) as the endpoint events.

RESULTS

Of the 601 patients, 595 patients completed the PSQI assessment, with 278 patients having poor sleep quality. Patients in the PSQI > 7 group were older and had a higher proportion of cardiovascular disease or diabetes. Years of education, diastolic blood pressure, and heart rate were lower in the PSQI > 7 group. At a mean follow-up period of 3 years, 116 patients died, 64 patients were lost to follow-up, and 115 patients experienced MACEs. After adjusting for confounding factors such as age, gender, dialysis age, and previous cardiovascular disease, the risk of MACE in patients with poor sleep quality was twice that of patients with good sleep quality (HR = 2.037 (1.339, 3.097), p = 0.001). There was no significant difference in the risk of all-cause death between the two groups.

CONCLUSION

The prevalence of poor sleep quality was 46.7% in patients with MHD. Poor sleep quality was an independent risk factor for MACEs in patients with MHD.

Impact of Nocturnal Polyuria and Sleep Quality in Kidney Transplant Recipients With Nocturia

BACKGROUND

To investigate the quality of life (QOL) of patients with nocturia after kidney transplantation (KT) and the association between nocturnal polyuria and sleep quality.

METHODS

In a cross-sectional study, a patient who consented was evaluated using the following items: international prostate symptom QOL score, nocturia-quality of life score, overactive bladder symptom score, Pittsburgh sleep quality index, bladder diary, uroflowmetry, and bioimpedance analysis. Clinical and laboratory data were obtained from medical charts.

RESULTS

Forty-three patients were included in the analysis. Approximately 25% of patients urinated once at night, and 58.1% had nocturia twice. Nocturnal polyuria was observed in 86.0% of patients, and overactive bladder was observed in 23.3% of patients. According to the Pittsburgh sleep quality Index, 34.9% of patients had poor sleep quality. Multivariate analysis revealed that patients with nocturnal polyuria tended to have a high estimated glomerular filtration rate (P = .058). On the other hand, multivariate analysis for poor sleep quality revealed that high body fat percentage and low nocturia-quality of life total score were independently correlated factors (P = .008 and P = .012, respectively). Furthermore, the patients with nocturia ≥3/night were significantly older than those with nocturia ≤2/night (P = .022).

CONCLUSION

Nocturnal polyuria, poor sleep quality, and aging may decrease the QOL of patients with nocturia after KT. Further investigations, including optimal water intake and interventions, can lead to better management after KT.

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

Rationale & Objective

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

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

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

Selection Criteria for Studies

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

Data Extraction

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

Analytical Approach

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

Results

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

Limitations

High interstudy heterogeneity.

Conclusions

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

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

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

The effect of acupoint therapy on sleep quality of hemodialysis patients: A protocol for systematic review and meta-analysis

BACKGROUND

Hemodialysis patients usually have sleep disturbance at varying degrees, which seriously affects the therapeutic efficacy and quality of life. Therefore, improving the sleep quality of hemodialysis patients is the key during treatment. Acupoint therapy can improve the sleep quality of patients. However, guidelines for improving sleep quality of hemodialysis patients by acupoint therapy are scant. This study aims to evaluate the effect of acupoint therapy on sleep quality in hemodialysis patients through a meta-analysis, providing clinical evidences.

METHODS

Randomized controlled trials (RCTs) reporting the effect of acupoint therapy on sleep quality in hemodialysis patients published before November 2021 will be searched in the China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Wanfang database, the Chinese Scientific Journal Database, PubMed, Embase, The Cochrane Library, and Web of Science databases. Eligible literatures will be screened according to inclusion and exclusion criteria and assessed for quality using the Cochrane Risk of Bias Assessment Tool. Meta-analysis will be performed using Revman 5.4 software.

RESULTS

This study will evaluate the effect of acupoint therapy on sleep quality in hemodialysis patients using the Pittsburgh Sleep Quality Index (PSQI).

CONCLUSION

This study will provide a reliable evidence-based basis for conducting acupoint therapy to improve sleep quality in hemodialysis patients.

Effects of nonpharmacological intervention on sleep quality in hemodialysis patients: A protocol for systematic review and meta-analysis

BACKGROUND

Nonpharmacological intervention can improve the sleep quality of hemodialysis patients. However, there are many types of nonpharmacological interventions, which makes it difficult to determine the best one. Therefore, this study carried out network meta-analysis to evaluate the effects of nonpharmacological intervention on sleep quality of hemodialysis patients, so as to provide evidence for the selection of the optimal nonpharmacological intervention for the improvement of sleep quality of hemodialysis patients clinically.

METHODS

Randomized controlled trials on the effects of nonpharmaceutical interventions on sleep quality in hemodialysis patients were conducted by searching English databases (PubMed, Cochrane Library, EMBASE, and Web of Science) and Chinese databases (Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Wanfang, and China Biomedical Literature Database) on computer. The retrieval time was from the establishment of the database to May 2021. Literature screening, data extraction, and evaluation of the risk of bias in the included studies were conducted independently by two researchers. Data analysis was performed with STATA14.0 and GEMTC 0.14.3 software.

RESULTS

We will disseminate the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSIONS

This study will provide the best evidence-based evidence to support the effects of non-pharmacological interventions on sleep quality in hemodialysis patients.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms. This review would be disseminated in a peer-reviewed journal or conference presentations.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/4BPKT.

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 Effects of Valerian on Sleep Quality, Depression, and State Anxiety in Hemodialysis Patients: A Randomized, Double-blind, Crossover Clinical Trial

OBJECTIVES

Our study sought to determine the effects of valerian on sleep quality, depression, and state anxiety in hemodialysis (HD) patients.

METHODS

This randomized, double-blind, placebo-controlled, crossover clinical trial was conducted on 39 patients undergoing HD allocated into a valerian and placebo group. In the first phase of the study, group A (n = 19) received valerian and group B (n = 20) received a placebo one hour before sleep every night for a total of one month. Sleep quality, state anxiety, and depression were assessed in the patients at the beginning and end of the intervention using the Pittsburgh Sleep Quality Index, the Spielberger State-Trait Anxiety Inventory, and Beck Depression Inventory. In the second phase, the two groups' treatment regimen was swapped. After a one-month washout period, the same process was repeated on the crossover groups (i.e., group A received placebo and group B received valerian).

RESULTS

In the first phase, the mean sleep quality, depression, and state anxiety scores showed significant reductions in both groups, but the reduction was significantly higher in group A compared to group B (7.6 vs. 3.2, p< 0.001; 6.5 vs. 2.3, p =0.013; 14.6 vs. 7.3, p =0.003, respectively). In the second phase, the mean sleep disorder, depression, and state anxiety scores showed significant reductions in both groups, but the reduction was significantly lower in group A compared to group B (1.4 vs. 4.6, p< 0.001; 1.2 vs. 3.8, p =0.002; 1.5 vs. 6.2, p< 0.001, respectively).

CONCLUSIONS

Valerian significantly improved sleep quality, the symptoms of state anxiety, and depression in HD patients.

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.

Patient experiences of sleep in dialysis: systematic review of qualitative studies

RATIONALE AND OBJECTIVE

Sleep problems affect more than half of patients receiving dialysis and are associated with increased risk of mortality, cardiovascular events, depression and impaired functioning and quality of life. Symptoms such as fatigue and exhaustion may be attributed to sleep problems or sleep disorders, as well as the burden of kidney disease and treatment. This study aims to describe the patient perspectives on the reasons, impact and management of sleep problems in dialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies that report patient experience and perspectives on sleep in dialysis.

SETTING AND POPULATION

Patients receiving dialysis.

SEARCH STRATEGY AND SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, reference lists and PhD dissertations were searched from inception to August 2019.

DATA EXTRACTION

All text from the results/conclusion of the primary studies.

ANALYTICAL APPROACH

Thematic synthesis.

RESULTS

We included 48 studies involving 1156 participants from 16 countries. We identified six themes: dominating demands of treatment (with subthemes of: demanding and relentless schedule, regret for wasted time); scheduling and control (managing sleep routines, napping and nocturnal sleep disruption, meditative aids); disruptions due to dialysis (unsettled sleep, hypervigilance and worry); symptoms depriving sleep (difficulty falling asleep, constant waking); overwhelmed and without choice (futility of sleep, uncontrollable exhaustion, restlessness is irrepressible); and as a coping mechanism (avoiding anxiety, alleviating symptoms, combating boredom).

LIMITATIONS

Most studies were conducted in high-income, English-speaking countries.

CONCLUSION

The treatment and symptom burden of dialysis disrupts and deprives patients of sleep, which leads to overwhelming and uncontrollable exhaustion. Better management of symptoms and effective strategies to manage sleep routines may improve sleep quality for better overall health in patients receiving dialysis.

Patient and caregiver perspectives on sleep in dialysis

Sleep disturbances are common among patients receiving dialysis and are associated with an increased risk of mortality and morbidity, and impaired quality of life. Despite being highly prioritised by patients, sleep problems remain under-diagnosed and inadequately managed. The aim of the present study was to describe the perspectives of patients receiving dialysis and their caregivers on sleep. We extracted qualitative data on sleep from 26 focus groups, two international Delphi surveys, and two consensus workshops involving 644 patients and caregivers from 86 countries as part of the Standardised Outcomes in Nephrology-Haemodialysis and -Peritoneal Dialysis (SONG-HD/SONG-PD) initiatives. The responses were from patients aged ≥18 years receiving haemodialysis or peritoneal dialysis, and their caregivers. We analysed the data using thematic analysis with five themes identified: constraining daily living (with subthemes of: battling intrusive tiredness, exacerbating debilitating conditions, broken and incapacitated); roadblocks in relationships (unable to meet family needs, antipathy due to misunderstanding, wreaking emotional havoc); burden on caregivers (stress on support persons, remaining alert to help); losing enjoyment (limiting social contact, disempowerment in life); and undermining mental resilience (aggravating low mood, diminishing coping skills, reducing functional ability). Sleep disturbances are exhausting for patients on dialysis and pervade all aspects of their lives including the ability to do daily tasks, and maintaining relationships, mental and emotional well-being. Better assessment and management of sleep problems in dialysis is needed, which may lead to improvements in overall health and quality of life.

Sleep Disorders and Restless Legs Syndrome in Hemodialysis Patients in Greece: A Cross-Sectional Study

INTRODUCTION

Sleep disorders, including insomnia and extreme sleep times, adversely affect the risk of developing illnesses and contribute to increased mortality rates. The aim of the study was to investigate sleep disorders experienced by hemodialysis patients in order to draw useful conclusions and to propose solutions to address this serious problem.

MATERIAL AND METHOD

This is a cross-sectional study, and the study sample consisted of 120 patients undergoing hemodialysis from February to April 2017 at a general hospital in Greece. The main tools of the survey were the Athens Insomnia Scale, the Berlin Questionnaire, and the RLS (Restless Legs Syndrome) Questionnaire.

RESULTS

Most of the patients were males (68.3%), aged 68.1 ± 14.1 years. Half of the responders suffered from insomnia. About two thirds were at low risk for sleep apnea. Most of the responders suffered from restless legs syndrome (62.5%). Insomnia was significantly associated with higher BMI (RR: 0.180; 95% CI [0.032, 1.003]), analgesics receiving (RR: 0.125; 95% CI [0.031, 0.513]), hypnotics receiving (RR: 0.072; 95% CI [0.010, 0.533]), and restless legs syndrome (RR: 2.281; 95% CI [1.179, 4.413]) after adjusting for sociodemographic variables.Sleep apnea was significantly linked to analgesics (RR: 0.309; 95% CI [0.093, 1.027]; p = 0.045). RLS was significantly tied to hypnotics (RR: 0.077; 95% CI [0.008, 0.745]; p = 0.027) and insulin (RR: 0.019; 95% CI [0.001, 0.542]; p = 0.020).

CONCLUSIONS

Sleep disorders are common symptoms among hemodialysis patients. The restless legs syndrome occurs at a lower frequency among hemodialysis patients but is a major problem for them.

Sleep Quality in Iranian Hemodialysis Patients: A Systematic Review and Meta-analysis

Background:

Hemodialysis is a major therapeutic method for many chronic kidney disease patients that causes complications. One of these complications tends to be sleep disorders. This study was performed through systematic review and meta-analysis to determine the prevalence of low sleep quality in hemodialysis patients in Iran.

Materials and Methods:

Journal papers written in English and Persian searched from January 2000 to July 2018 were selected. The search keywords included (Prevalence OR Epidemiology) AND (hemorenodialysis OR hemodialysate OR 'intermittent chronic haemodialysis' OR 'intermittent chronic hemodialysis' OR 'intermittent haemodialysis' OR 'intermittent hemodialysis' OR 'kidney dialysis' OR 'renal dialysis') AND ('sleep problem' OR 'sleep disturbance' OR 'sleep disorder' OR 'sleep quality' OR 'chronobiology disorders' OR dyssomnia). To determine the pooled prevalence, the stochastic DerSimonian-Laird model was used, computing the effect size with its 95 per cent confidence interval. The main international electronic databases were Embase, PubMed/MEDLINE, ISI/Web of Science (WOS), Scopus, Psych INFO, and Iranian databases such as MagIran, SID and Irandoc. The data were analysed using the Stata (version 13.0).

Results:

After searching through the databases and other resources, 21 articles (7 in Persian and 14 in English language) were included. The overall prevalence of low sleep quality in dialysis patients was 75.30 per cent (95 per cent confidence interval, 70.08–82.50). The heterogeneity study showed moderate heterogeneity among studies (I² = 50.30 per cent, p < 0.05).

Conclusions:

The results of this study showed that the prevalence of low sleep quality in hemodialysis patients has become a common problem. Thus, patients' sleep quality need to be evaluated periodically.

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.

Effect of extended hours dialysis on sleep quality in a randomized trial

AIM

Poor sleep quality is common in haemodialysis patients and associated with worse outcomes. In this pre-specified analysis, we examined the impact of extended hours haemodialysis on sleep quality.

METHODS

The ACTIVE Dialysis trial randomized 200 participants to extended (≥24 h/week) or standard (target 12-15 h) hours haemodialysis over 12 months. Sleep quality was measured in the Kidney Disease Quality of Life Short Form 1.3 (KDQOL-SF) by overall sleep quality score (0-10, 10 = 'very good') and the sleep subscale (0-100, 100 = 'best possible sleep') every 3 months via blinded telephone interview. The average intervention effect was calculated by mixed linear regression adjusted by time point and baseline score. Factors predicting sleep quality were assessed by multivariate regression analysis.

RESULTS

Overall sleep quality score and sleep subscale at baseline were similar in both groups (5.9 [95%CI 5.4-6.4] vs. 6.3 [5.9-6.8]; 65.0 [60.9-69.1] vs. 63.2 [59.1-67.3]; extended and standard hours, respectively). Extended hours haemodialysis led to a non-significant improvement in overall sleep quality score (average intervention effect 0.44 (-0.01 to 0.89), P = 0.053) and sleep subscale (average intervention effect 3.58 (-0.02 to 7.18), P = 0.051). Poor sleep quality was associated with being female and with current smoking. Sleep quality was positively associated with EuroQol-5D (EQ5D) and the SF-36 Physical Component and Mental Component Summary Scores but not with hospitalizations.

CONCLUSION

Sleep quality was not significantly improved by extended hours dialysis in this study. Sleep quality is positively correlated with quality of life in haemodialysis patients and is poorer in women and current smokers.

Change of sleep quality from pre- to 3 years post-solid organ transplantation: The Swiss Transplant Cohort Study

BACKGROUND

Poor sleep quality (SQ) is common after solid organ transplantation; however, very little is known about its natural history. We assessed the changes in SQ from pre- to 3 years post-transplant in adult heart, kidney, liver and lung recipients included in the prospective nation-wide Swiss Transplant Cohort Study. We explored associations with selected variables in patients suffering persistent poor SQ compared to those with good or variable SQ.

METHODS

Adult single organ transplant recipients enrolled in the Swiss Transplant Cohort Study with pre-transplant and at least 3 post-transplant SQ assessment data were included. SQ was self-reported pre-transplant (at listing), then at 6, 12, 24 and 36 months post-transplant. A single SQ item was used to identify poor (0-5) and good sleepers (6-10). Between organ groups, SQ was compared via logistic regression analysis with generalized estimating equations. Within the group reporting persistently poor SQ, we used logistic regression or Kaplan-Meier analysis as appropriate to check for differences in global quality of life and survival.

RESULTS

In a sample of 1173 transplant patients (age: 52.1±13.2 years; 65% males; 66% kidney, 17% liver, 10% lung, 7% heart) transplanted between 2008 and 2012, pre- transplant poor SQ was highest in liver (50%) and heart (49%) recipients. Overall, poor SQ decreased significantly from pre-transplant (38%) to 24 months post-transplant (26%) and remained stable at 3 years (29%). Patients reporting persistently poor SQ had significantly more depressive symptomatology and lower global quality of life.

CONCLUSION

Because self-reported poor SQ is related to poorer global quality of life, these results emphasize the need for further studies to find suitable treatment options for poor SQ in transplant recipients.

A single question regarding mobility in the World Health Organization quality of life questionnaire predicts 3-year mortality in patients receiving chronic hemodialysis

Low quality of life, depression and poor quality of sleep are associated with increased mortality in hemodialysis patients. It is not clear which factor has the highest predictive power and what the core element is to explain the predictability. We thus conducted a prospective cohort study that included 151 hemodialysis adults. Three traits of interest were assessed by World Health Organization Quality of Life questionnaire, an abbreviated version (WHOQOL-BREF), Taiwanese Depression Questionnaire, and Athens Insomnia Scale, respectively. They were followed for more than 3 years and the all-cause mortality was 30.5%. The prevalence of quality of life at the lowest tertile, depression and poor quality of sleep was 19.9%, 43.0% and 74.2%, respectively. Discriminant analysis showed the standardized coefficient of each factor as 0.813, −0.289 and 0.066, indicating the highest discriminating power by quality of life to predict mortality. Question 15 “how well are you able to get around?” in the physical health domain of WHOQOL-BREF independently associated a hazard ratio of mortality 0.623 (95% confidence interval 0.423-0.918). Subjective perception of overall quality of life was more related to psycho-social-environmental factors. In conclusion, mobility is an independent and powerful predictor to long term mortality in patients on chronic hemodialysis.

Development of a multidimensional assessment tool for uraemic pruritus: Uraemic Pruritus in Dialysis Patients (UP-Dial)

BACKGROUND

Dialysis patients with uraemic pruritus (UP) have significantly impaired quality of life. To assess the therapeutic effect of UP treatments, a well-validated comprehensive and multidimensional instrument needed to be established.

OBJECTIVES

To develop and validate a multidimensional scale assessing UP in patients on dialysis: the Uraemic Pruritus in Dialysis Patients (UP-Dial).

METHODS

The development and validation of the UP-Dial instrument were conducted in four phases: (i) item generation, (ii) development of a pilot questionnaire, (iii) refinement of the questionnaire with patient recruitment and (iv) psychometric validation. Participants completed the UP-Dial, the visual analogue scale (VAS) of UP, the Dermatology Life Quality Index (DLQI), the Kidney Disease Quality of Life-36 (KDQOL-36), the Pittsburgh Sleep Quality Index (PSQI) and the Beck Depression Inventory (BDI) between 15 May 2012 and 30 November 2015.

RESULTS

The 27-item pilot UP-Dial was generated, with 168 participants completing the pilot scale. After factor analysis was performed, the final 14-item UP-Dial encompassed three domains: signs and symptoms, psychosocial, and sleep. Face and content validity were satisfied through the item generation process and expert review. Psychometric analysis demonstrated that the UP-Dial had good convergent and discriminant validity. The UP-Dial was significantly correlated [Spearman rank coefficient, 95% confidence interval (CI)] with the VAS-UP (0·76, 0·69-0·83), DLQI (0·78, 0·71-0·85), KDQOL-36 (-0·86, -0·91 to -0·81), PSQI (0·85, 0·80-0·89) and BDI (0·70, 0·61-0·79). The UP-Dial revealed excellent internal consistency (Cronbach's α 0·90, 95% CI 0·87-0·92) and reproducibility (intraclass correlation 0·95, 95% CI 0·90-0·98).

CONCLUSIONS

The UP-Dial is valid and reliable for assessing UP among patients on dialysis. Future research should focus on the cross-cultural adaptation and translation of the scale to other languages.

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.

The effect of renal transplantation on quality of sleep in former dialysis patients

Data on sleep quality in renal transplanted (RTX) patients are scarce, and longitudinal studies are lacking. The purpose of this study was to assess the prevalence of sleep complaints in RTX patients and identify variables associated with improvement in sleep quality. In a longitudinal study, 301 dialysis patients were followed for up to 5.5 years, during which time 142 were transplanted. Out of the transplanted patients, a total of 110 were eligible for inclusion. Sleep quality and depression were assessed with the validated questionnaires Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI), and data were collected during dialysis and after RTX. Based on PSQI scores, 59% were characterized as poor sleepers after RTX compared to 75% when in dialysis (P = 0.016). A total of 46% experienced a clinical relevant improvement in overall sleep quality, while 21% experienced a clinical relevant deterioration. In multivariable analyses, clinical meaningful change in sleep quality was not associated with either depressive symptoms assessed with BDI or other clinical variables. Sleep quality improved after RTX in nearly half of the patients, but poor sleep quality was prevalent in RTX patients. Therefore, sleep quality should routinely be assessed in RTX patients.

Sleep Characteristics in Early Stages of Chronic Kidney Disease in the HypnoLaus Cohort

STUDY OBJECTIVES

To evaluate the association between early stages of chronic kidney disease (CKD) and sleep disordered breathing (SDB), restless legs syndrome (RLS), and subjective and objective sleep quality (SQ).

METHODS

Cross-sectional analysis of a general population-based cohort (HypnoLaus). 1,760 adults (862 men, 898 women; age 59.3 (± 11.4) y) underwent complete polysomnography at home.

RESULTS

8.2% of participants had mild CKD (stage 1-2, estimated glomerular filtration rate [eGFR] ≥ 60 mL/min/1.73 m(2) with albuminuria) and 7.8% moderate CKD (stage 3, eGFR 30-60 mL/min/1.73 m(2)). 37.3% of our sample had moderate-to-severe SDB (apnea-hypopnea index [AHI] ≥ 15/h) and 15.3% had severe SDB (AHI ≥ 30/h). SDB prevalence was positively associated with CKD stages and negatively with eGFR. In multivariate analysis, age, male sex, and body mass index were independently associated with SDB (all P < 0.001), but kidney function was not. The prevalence of RLS was 17.5%, without difference between CKD stages. Periodic leg movements index (PLMI) was independently associated with CKD stages. Subjective and objective SQ decreased and the use of sleep medication was more frequent with declining kidney function. Older age, female sex, and the severity of SDB were the strongest predictors of poor SQ in multivariate regression analysis but CKD stage was also independently associated with reduced objective SQ.

CONCLUSIONS

Patients with early stages of CKD have impaired SQ, use more hypnotic drugs, and have an increased prevalence of SDB and PLM. After controlling for confounders, objective SQ and PLMI were still independently associated with declining kidney function.

Change in quality of life and one-year mortality risk in maintenance dialysis patients

BACKGROUND

Quality of life (QOL) is an important metric of high-quality dialysis care. QOL is commonly measured by the Short Form 36 Questionnaire (SF-36), which provides two summary scores: a mental component score (MCS) and a physical component score (PCS). Poor QOL is associated with mortality in dialysis patients. Small studies show that changes in QOL also predicts mortality. We investigated whether changes in QOL over time are associated with mortality in a large cohort of maintenance hemodialysis patients.

METHODS

This retrospective study was conducted in 1017 outpatient dialysis facilities. Over 10,000 hemodialysis patients completed two SF-36 surveys. We compared 1-year morality rates in those whose MCS or PCS increased or decreased ±5 vs. those whose did not.

RESULTS

For those who completed two surveys, mean score for PCS was unchanged, whereas MCS increased slightly (48.6 vs. 48.9, p = 0.05). Individual patients, however, showed marked variation. On the second survey, more than half of patients demonstrated a ± 5 point change in the PCS and/or MCS. After multivariate adjustment, a ≥ 5 decrease in MCS was associated with an increase in mortality (HR = 1.33, 95 % CI 1.18, 1.50).

CONCLUSIONS

Clinicians should be aware that many patients experience a significant change in both the MCS and PCS on dialysis. A MCS decrease of ≥5 was associated with increased mortality. More study is needed to determine whether this is a causal relationship. Physicians should evaluate root causes and seek to mitigate declines in QOL whenever possible.

The relationship between serum asymmetric dimethylarginine levels and subjective sleep quality in normotensive patients with type 2 diabetes mellitus

BACKGROUND/AIMS

Poor sleep quality (SQ) is associated with increased cardiovascular mortality and morbidity. Additionally, asymmetric dimethylarginine (ADMA) is an independent predictor of cardiovascular mortality and morbidity. However, no sufficient data regarding the relationship between ADMA levels and SQ have been reported. The goal of the current study was to evaluate the association between SQ and ADMA levels in normotensive patients with type 2 diabetes mellitus.

METHODS

The study participants consisted of 78 normotensive type 2 diabetics. The SQ of all participants was assessed using the Pittsburgh Sleep Quality Index (PSQI). Patients with a global PSQI score > 5 were defined as "poor sleepers." Factors associated with poor SQ were analyzed using a multiple regression model. Serum ADMA levels were measured using high performance liquid chromatography.

RESULTS

The median ADMA levels of the poor sleepers were increased compared with patients defined as good sleepers (5.5 [4.2 to 6.6] vs. 4.4 [2.9 to 5.4], p < 0.01, respectively). However, the L-arginine/ADMA ratio was decreased in poor sleepers (p < 0.01). Global PSQI scores were positively correlated with ADMA levels (p < 0.01) and negatively correlated with the L-arginine/ADMA ratio (p = 0.02). ADMA levels were correlated with sleep latency (p < 0.01) and sleep efficiency (p = 0.01). Logistic regression analysis showed that ADMA levels (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.16 to 2.44; p = 0.01) and body mass index (OR, 1.15; 95% CI, 1.01 to 1.31; p = 0.04) were associated with poor SQ independently of glomerular filtration rate, sex, age, duration of diabetes, hemoglobin A1c, total cholesterol, and systolic blood pressure.

CONCLUSIONS

Self-reported SQ was independently associated with ADMA levels in normotensive patients with diabetes mellitus.

Sleep quality among Iranian hemodialysis patients: a multicenter study

Background:

Sleep disorders are prevalent complication in patients with end-stage renal disease undergoing hemodialysis (HD). The factors affecting sleep quality (SQ) of patients on HD have not been completely recognized yet. In addition, some studies have shown that poor SQ increases the risk of mortality in patients on HD.

Objectives:

This study aimed to identify the prevalence of poor SQ and its associated risk factors in Iranian patients on HD.

Patients and Methods:

This cross-sectional and multicenter study was conducted on 6878 patients on HD from 132 dialysis centers in Iran. Sleep domain of disease specific core of KDCS-SF questionnaire and generic core of this questionnaire (SF-36) were used to assess patients’ SQ and quality of life (QoL), respectively. A poor SQ was defined as a score of ≤ 61.2. Logistic and linear regression analyses were applied to assess predictors of SQ and their associations.

Results:

The mean age of patients was 54.4 ± 17.1 years and 39.7% of patients were > 60 years old. The majority of our patients had poor SQ (60.6%). Patients with diabetes mellitus were significantly more likely to have poor quality of sleep (63.4%). In logistic regression analysis, there were significant correlation between good SQ and younger age, shorter dialysis vintage, less muscle cramp, high QoL, high cognitive function score, and high sexual function. In addition, linear regression showed a significant association among SQ, QoL, and hospital stay as an outcome.

Conclusions:

With improving some factors and QoL of patients on HD, we can promote SQ in these patients that it might lead to reduction in length of hospital stay.