Association of sleep difficulty with Kidney Disease Quality of Life cognitive function score reported by patients who recently started dialysis

Cognitive Impairment and Brain Atrophy in Patients with Chronic Kidney Disease

In Japan, the aging of the population is rapidly accelerating, with an increase in patients with chronic kidney disease (CKD) and those undergoing dialysis. As a result, the number of individuals with cognitive impairment (CI) is rising, and addressing this issue has become an urgent problem. A notable feature of dementia in CKD patients is the high frequency of vascular dementia, making its prevention through the management of classical risk factors such as hypertension, diabetes mellitus, dyslipidemia, smoking, etc., associated with atherosclerosis and arteriosclerosis. Other effective measures, including the use of renin-angiotensin system inhibitors, addressing anemia, exercise therapy, and lifestyle improvements, have been reported. The incidence and progression of CI may also be influenced by the type of kidney replacement therapy, with reports suggesting that long-duration dialysis, low-temperature hemodialysis, peritoneal dialysis, and kidney transplantation can have a preferable effect on the preservation of cognitive function. In conclusion, patients with CKD are at a higher risk of developing CI, with brain atrophy being a contributing factor. Despite the identification of various preventive measures, the evidence substantiating their efficacy remains limited across all studies. Future expectations lie in large-scale randomized controlled trials.

Subjective cognitive complaints in end-stage renal disease: a systematic review and meta-analysis

Cognitive impairment is common in patients with end-stage renal disease (ESRD) and is associated with compromised quality of life and functional capacity, as well as worse clinical outcomes. Most previous research and reviews in this area were focused on objective cognitive impairment, whereas patients' subjective cognitive complaints (SCCs) have been less well-understood. This systematic review aimed to provide a broad overview of what is known about SCCs in adult ESRD patients. Electronic databases were searched from inception to January 2022, which identified 221 relevant studies. SCCs appear to be highly prevalent in dialysis patients and less so in those who received kidney transplantation. A random-effects meta-analysis also shows that haemodialysis patients reported significantly more SCCs than peritoneal dialysis patients (standardised mean difference -0.20, 95% confidence interval -0.38 to -0.03). Synthesis of longitudinal studies suggests that SCCs remain stable on maintenance dialysis treatment but may reduce upon receipt of kidney transplant. Furthermore, SCCs in ESRD patients have been consistently associated with hospitalisation, depression, anxiety, fatigue, and poorer quality of life. There is limited data supporting a strong relation between objective and subjective cognition but preliminary evidence suggests that this association may be domain-specific. Methodological limitations and future research directions are discussed.

Effect of exercise interventions for sleep quality in patients with chronic kidney disease: a systematic review and meta-analysis

INTRODUCTION

Sleep disorder is a common and unpleasant symptom in patients with chronic kidney disease (CKD), bringing a heavy burden on the patients and families. As a non-pharmacological therapy, exercise interventions are widely recommended for CKD patients. However, whether exercise can improve overall sleep quality in such a population remains ambiguous. The systematic review and meta-analysis aimed to evaluate the effect of exercise interventions on sleep quality in CKD patients.

METHODS

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from inception to April 22, 2022. A randomized controlled trial (RCT) added an exercise intervention to conventional treatment/usual care to assess the effect on sleep quality in CKD patients. Two authors independently selected literature, extracted data, assessed the risk of bias using the Cochrane risk of bias tool 2, and assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation. The outcome was analyzed using a random-effect model using the Hartung-Knapp-Sidik-Jonkman method as a standardized mean difference (SMD). Additional statistical analysis includes the Egger regression test, subgroup analysis, sensitivity analysis, and meta-regression.

RESULTS

Nineteen articles (20 RCTs) enrolling 989 patients with CKD were included. The pooled SMD suggested favorably associated exercise interventions (SMD - 0.16; 95% CI - 0.62 to 0.31; very low evidence) with substantial heterogeneity (I² = 87%). Subgroup analyses demonstrated that SMD for sleep quality favored moderate intensity and aerobic exercise, no matter the time, but not statistically significant. Meta-regression showed that the effect size of exercise interventions on sleep quality was not associated with the total sample size, the proportion of males, duration of intervention, mean age, and exercise volume but was associated with baseline sleep scores. In addition, there may be an exercise threshold for the effect of exercise on sleep in CKD patients (i.e., 80 min/week).

CONCLUSION

This systematic review and meta-analysis suggest that exercise interventions may be associated with improved sleep quality in patients with CKD. However, high heterogeneity and a small effect size limit this result. More studies and standardized reporting of exercise intervention characteristics should be conducted in the future to strengthen the most convincing evidence in this field.

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]

Health-Related Quality of Life in Home Dialysis Patients Compared to In-Center Hemodialysis Patients: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

Dialysis patients judge health-related quality of life (HRQoL) as an essential outcome. Remarkably, little is known about HRQoL differences between home dialysis and in-center hemodialysis (HD) patients worldwide.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & STUDY POPULATIONS

Search strategies were performed on the Cochrane Library, Pubmed, and EMBASE databases between 2007 and 2019. Home dialysis was defined as both peritoneal dialysis and home HD.

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials and observational studies that compared HRQoL in home dialysis patients versus in-center HD patients.

DATA EXTRACTION

The data extracted by 2 authors included HRQoL scores of different questionnaires, dialysis modality, and subcontinent.

ANALYTICAL APPROACH

Data were pooled using a random-effects model and results were expressed as standardized mean difference (SMD) with 95% CIs. Heterogeneity was explored using subgroup analyses.

RESULTS

Forty-six articles reporting on 41 study populations were identified. Most studies were cross-sectional in design (90%), conducted on peritoneal dialysis patients (95%), and used the 12-item or 36-item Short-Form Health Survey questionnaires (83%). More than half the studies showed moderate or high risk of bias. Pooled analysis of 4,158 home dialysis patients and 7,854 in-center HD patients showed marginally better physical HRQoL scores in home dialysis patients compared with in-center HD patients (SMD, 0.14; 95% CI, 0.04 to 0.24), although heterogeneity was high (I 2>80%). In a subgroup analysis, Western European home dialysis patients had higher physical HRQoL scores (SMD, 0.39; 95% CI, 0.17 to 0.61), while home dialysis patients from Latin America had lower physical scores (SMD, -0.20; 95% CI, -0.28 to -0.12). Mental HRQoL showed no difference in all analyses.

LIMITATIONS

No randomized controlled trials were found and high heterogeneity among studies existed.

CONCLUSIONS

Although pooled data showed marginally better physical HRQoL for home dialysis patients, the quality of design of the included studies was poor. Large prospective studies with adequate adjustments for confounders are necessary to establish whether home dialysis results in better HRQoL.

TRIAL REGISTRATION

PROSPERO 95985.

Symptom Management of the Patient with CKD: The Role of Dialysis

As kidney disease progresses, patients often experience a variety of symptoms. A challenge for the nephrologist is to help determine if these symptoms are related to advancing CKD or the effect of various comorbidities and/or medications prescribed. The clinician also must decide the timing of dialysis initiation. The initiation of dialysis can have a variable effect on quality of life measures and the alleviation of uremic signs and symptoms, such as anorexia, fatigue, cognitive impairment, depressive symptoms, pruritus, and sleep disturbances. Thus, the initiation of dialysis should be a shared decision-making process among the patient, the family and the nephrology team; information should be provided, in an ongoing dialogue, to patients and their families concerning the benefits, risks, and effect of dialysis therapies on their lives.

Prognostic Value of the Delivery Dialysis Dose on Twice-Weekly Hemodialysis Patients

BACKGROUND

Few studies have evaluated the prognostic value of dialysis dose in twice-weekly hemodialysis (HD). A single-pool Kt/V (spKt/V) over 1.70 may benefit patients receiving twice-weekly maintenance HD.

METHODS

This is a multicenter randomized controlled trial performed on 163 patients from 17 dialysis centers in Shanghai who were allocated to high- (n = 98) and standard-dose groups (n = 65) and followed through 96 weeks of study period. Therapeutic approaches were given to increase spKt/V to over 1.70 in the high-dose group. Data were collected every 12-24 weeks. The primary outcomes were all-cause mortality and major adverse cardio-cerebrovascular events (MACEs) occurrence, and secondary outcomes included residual kidney function (RKF) and health-related quality of life (HR-QOL).

RESULTS

The spKt/V in high-dose and standard-dose groups were 1.80 ± 0.23 and 1.55 ± 0.19, respectively, after an 8-week intervention (p < 0.001). At the end of the study, SF-36 physical function and total score in high-dose group were 82 (69-90) and 74 (47-84), respectively, both of which were higher than those in the standard-dose group. Decline in urine volume was observed in both groups with no significant difference (p = 0.431). No difference was found in overall survival between the 2 groups (p = 0.580). The 1-year MACE-free survival for high-dose group was 84.49%, better than 76.72% for standard-dose group (p = 0.029).

CONCLUSIONS

Higher spKt/V is also associated with MACE-free survival and better HR-QOL, especially in physical function aspect for twice-weekly dialysis patients. Increasing spKt/V over 1.70 in twice-weekly HD population does not cause loss of RKF.

Predialysis volume overload and patient-reported sleep duration and quality in patients receiving hemodialysis

INTRODUCTION

Previous studies of patients with end-stage renal disease have examined the role of fluid shifts on apnea-hypopnea episodes, but the association between volume overload and patient-reported sleep quality or duration has not been well-established.

METHODS

We studied the association between predialysis bioimpedance spectroscopy-derived volume estimates and self-reported sleep quality and duration in 638 patients in the United States Renal Data System ACTIVE/ADIPOSE study receiving hemodialysis from 2009 to 2011. We used questionnaires to assess self-reported sleep duration and quality. We used relative hydration status (fluid overload/extracellular water; FO/ECW) as the primary predictor and examined associations with hours of sleep duration using linear regression. We used multivariable ordinal logistic regression to determine the association between categories of relative hydration status (normal hydration [FO/ECW < 6.8%], mild overhydration [FO/ECW 6.8%-15%], and hyperhydration [FO/ECW > 15%]) and four levels of difficulty with falling asleep, waking, and returning to sleep.

FINDINGS

Higher relative hydration status was associated with fewer hours of sleep (-0.31 hours per 10%, 95% confidence interval (CI) -0.49 to -0.13). Compared to the normal hydration group, there was a statistically significant association between higher relative hydration status category and more frequent nighttime waking (OR: mild overhydration 1.92 [95% CI 1.23-2.99], hyperhydration 1.87 [95% CI 1.16-2.99]), a trend toward more difficulty returning to sleep (OR: mild overhydration 1.46 [95% CI 0.94-2.27], hyperhydration 1.52 [95% CI 0.95-2.43]), and no association between relative hydration category and difficulty falling asleep.

DISCUSSION

Hydration status was associated with self-reported sleep duration in patients on dialysis. Future studies should prospectively examine the effects of optimizing fluid status on sleep duration and quality.

Objective and subjective sleep disorders in automated peritoneal dialysis

Background

Automated peritoneal dialysis (APD) is one of the fastest growing dialysis modalities. It is unknown whether sleep and mood are disturbed while performing repeated overnight exchanges.

Objectives

In this report, we aim to describe and compare the prevalence of sleep-disordered breathing (SDB), periodic limb movements (PLMS), poor sleep quality (SQ), and depression among APD patients compared with stages 3b–5 (estimated glomerular filtration rate ≤44 ml/min/1.73 m2) chronic kidney disease (CKD) and hemodialysis (HD) patients.

Design

This is a cross-sectional, descriptive study.

Setting

Study participants were recruited from outpatient nephrology clinics, local dialysis centers, and the Thomas E. Starzl Transplant Institute in Western Pennsylvania between April 2004 and July 2009.

Patients

There were 186 participants in this study including 22 APD patients, 89 CKD patients, and 75 HD patients.

Measurements

In-home polysomnography was performed and two questionnaires were completed, the Pittsburgh Sleep Quality Index (PSQI) and the Patient Health Questionnaire-9 (PHQ-9).

Methods

SDB and PLMS were quantified by in-home unattended polysomnography; poor SQ was defined by a score >5 on the PSQI, and the presence of moderate to severe depression was defined by a score >5 on the PHQ-9.

Results

The APD patients had a median age of 37.5 years, were predominantly female (72.7 %), and had a median body mass index (BMI) of 23.8 kg/m2. In univariate analyses, APD patients had significantly lower apnea-hypopnea index compared to HD patients by 12.2 points (likelihood ratio test p = 0.008) and revealed the least percent of TST with nocturnal hypoxemia compared to CKD patients by 2.7 points, respectively (likelihood ratio test p = 0.01). The APD group had also significantly greater stages 3 to 4 sleep compared to the CKD patients by 8.6 points (likelihood ratio test p = 0.009). In multivariate analyses and after adjustment for age, gender, race, and BMI, both APD and HD patients had higher average PSQI scores than CKD patients by 2.54 and 2.22 points, respectively (likelihood ratio test p = 0.005). No other comparisons of sleep parameters among groups reached statistical significance.

Limitations

The limitations of this study are the small sample size of the APD population and the demographic and clinical differences among the three study groups.

Conclusions

Despite differences in univariate analyses, after multivariate adjustment, APD patients had similar sleep parameters and sleep architecture and as poor SQ and symptoms of depression as HD patients. Future studies with larger APD cohorts are needed.

How Can We Improve the Quality of Life of Dialysis Patients?

As medical advances are made in the care of persons with chronic illnesses including those with end-stage renal disease (ESRD), patients are not only experiencing increasing life expectancy but also bearing the burden of illness and treatment for a longer duration of time. With this in mind, it is increasingly important for health care providers to pay close attention to their individual patient's perceptions of their health, fitness, life satisfaction, and well-being. This assessment of Health-Related Quality of Life (HRQOL) also includes an evaluation of the patient's level of satisfaction with treatment, outcome, and health status, also taking into account their perspective on future prospects. In addition to improving patient-provider communication by helping in the identification and prioritization of problems, it is important to note that high HRQOL has been shown to be associated with better medical outcomes, including reduction in hospitalizations and death. In this review, we outline several validated tools that are used to quantitatively measure HRQOL in the ESRD population and incorporate these instruments in a review of specific, evidence-based measures by which we can measurably improve health-related quality of life in dialysis patients.

Importance of hypertension and social isolation in causing sleep disruption in dementia

This study aimed to determine the effects of diabetes mellitus (DM), hypertension (HT), heart disease, social isolation, and sociodemographic factors on sleep in the elderly patients with dementia. Samples included 1210 noninstitutionalized, Malaysian elderly patients with dementia. The multiple logistic regression analysis was applied to estimate the risk of sleep disturbances among respondents. Approximately 41% of the patients experienced sleep problems. The results showed that age (odds ratio [OR] = 1.02), social isolation (OR = 1.33), and HT (OR = 1.53) significantly increased sleep disruption in respondents (P <.05). Furthermore, education (OR =.63) and non-Malay ethnicity (OR = 0.63) significantly decreased sleep problems (P <.05). It was found that DM, heart disease, sex differences, and marital status were not significant predictors of sleep disturbances (P >.05). It was concluded that age, social isolation, and HT increased sleep disruption but education and ethnic non-Malay reduced the risk of sleep problems. Moreover, HT was the most important variable to increase sleep disturbances in the elderly patients with dementia.

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.

Prevalence of sleep disturbances in children and adolescents with chronic kidney disease

Although sleep disorders are common in adults with chronic kidney disease, little is known about the prevalence of sleep problems in children and adolescents with chronic kidney disease and their relationship to health-related quality of life measurements. We performed a clinic-based survey of sleep habits and common symptoms of sleep disturbances in 159 school-aged patients with chronic kidney disease. Three patient groups of chronic kidney disease were assessed: group 1, those not on dialysis and not transplanted; group 2, those on dialysis; and group 3, those with a functioning renal allograft. Four symptom domains for sleep disorders were assessed: excessive daytime sleepiness; sleep disordered breathing; restless legs syndrome symptoms; and insufficient sleep. Patients and the parent-proxy also completed the Pediatric Quality of Life Inventory Version 4.0 Generic Core Scales questionnaire. Ninety-three (93) patients (58.5%) had symptoms of a sleep disturbance. The presence of a sleep disturbance correlated with a decrease in health-related quality of life scores that was independent of the chronic kidney disease study group or estimated glomerular filtration rate. We conclude that sleep disturbances are common throughout the spectrum of chronic kidney disease in children and adolescents and are associated with diminished health-related quality of life scores.

Factors associated with irritable bowel syndrome symptoms in hemodialysis patients

AIM: To investigate clinical characteristics associated with the presence of irritable bowel syndrome (IBS) symptoms in hemodialysis (HD) patients.

METHODS: This was a cross-sectional study. A questionnaire based on the Bowel Disease Questionnaire that records gastrointestinal symptoms was given to 294 patients in 4 dialysis centers. A total of 196 (67%) subjects returned the survey. A multivariable logistic regression model was used to identify factors significantly associated with IBS symptoms.

RESULTS: Symptoms compatible with IBS were present in 27 (13.8%) subjects and independently associated with low post-dialysis serum potassium [OR = 0.258, 95% CI (0.075-0.891), P = 0.032], paracetamol use [OR = 3.159, 95% CI (1.214-8.220), P = 0.018], and Kidney Disease Quality of Life (KDQOL) cognitive function score [OR = 0.977, 95% CI (0.956-0.999), P = 0.042]. Univariate regressions were also performed and the reported significance is for multivariate analysis. No association was detected for age, gender, depressed mood, smoking (present or past), body mass index, albumin level, Kt/V, sodium pre- or post-dialysis level, change in potassium level during HD, proton pump inhibitor or H2 blocker use, aspirin use, residual diuresis, hepatitis B or C infection, diabetes mellitus, marital status and education level.

CONCLUSION: This study examined potential risk factors for symptoms compatible with IBS in HD patients and identified an association with paracetamol use, post-dialysis potassium level and KDQOL-cognitive function score.

Neurocognitive profile of an adult sample with chronic kidney disease

Chronic kidney disease (CKD) is a common and debilitating illness that impacts neurocognitive function. However, the majority of previous studies varied in methodologic design and rigor, thus minimizing definitive conclusions. The present study was designed to determine the impact of CKD on neurocognitive function through specific examination of CKD factors and therapeutic interventions. We evaluated 120 CKD outpatients and 41 healthy donors (controls) in terms of neurocognitive function, anxiety, and depressive symptomatology, and somnolence. Information regarding medical and treatment history was recorded. Twenty-three percent of CKD patients presented with cognitive impairment. Stage 5 patients had lower scores (p < .05) compared with controls and patients in stage 3 and 4 on measures of global cognitive function. No differences in global cognitive function were found between stage 3 and 4 patients and controls. A greater proportion of patients undergoing hemodialysis relative to those treated with peritoneal dialysis showed impairment on measures of memory functions. Results suggest that stage 5 CKD patients may present with impaired cognitive functions. Anemia appeared to be a key variable that may explain the memory impairment in this sample. Future longitudinal investigations of CKD are warranted to determine the trajectory of cognitive impairment.

Health-related quality of life in CKD Patients: correlates and evolution over time

BACKGROUND AND OBJECTIVES

Very few large-scale studies have investigated the determinants of health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients not on dialysis or the evolution of HRQOL over time.

DESIGN AND SETTING

A prospective evaluation was undertaken of HRQOL in a cohort of 1186 CKD patients cared for in nephrology clinics in North America. Baseline and follow-up HRQOL were evaluated using the validated Kidney Disease Quality Of Life instrument.

RESULTS

Baseline measures of HRQOL were reduced in CKD patients in proportion to the severity grade of CKD. Physical functioning score declined progressively with more advanced stages of CKD and so did the score for role-physical. Female gender and the presence of diabetes and a history of cardiovascular co-morbidities were also associated with reduced HRQOL (physical composite score: male: 41.0 +/- 10.2; female: 37.7 +/- 10.8; P < 0.0001; diabetic: 37.3 +/- 10.6; nondiabetic: 41.6 +/- 10.2; P < 0.0001; history of congestive heart failure, yes: 35.4 +/- 9.7; no: 40.3 +/- 10.6; P < 0.0001; history of myocardial infarction, yes: 36.1 +/- 10.0; no: 40.2 +/- 10.6; P < 0.0001). Anemia and beta blocker usage were also associated with lower HRQOL scores. HRQOL measures declined over time in this population. The main correlates of change over time were age, albumin level and co-existent co-morbidities.

CONCLUSIONS

These observations highlight the profound impact CKD has on HRQOL and suggest potential areas that can be targeted for therapeutic intervention.

Comparison of sleep/wake behavior in CKD stages 4 to 5 and hemodialysis populations using wrist actigraphy

BACKGROUND

Patients with kidney failure have more sleep symptoms than the general population, but the contribution to sleep symptoms of kidney failure versus its treatment with thrice-weekly hemodialysis has been unclear. We assessed the influence of hemodialysis on sleep/wake behavior by using wrist actigraphy and self-reported sleep quality compared with patients with chronic kidney disease (CKD) stages 4 to 5.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

Thirty-six patients with CKD stages 4 to 5 and 51 hemodialysis (HD) patients wore wrist actigraphs and completed sleep diaries for 2 weeks.

PREDICTORS

Thrice-weekly HD versus CKD stages 4 to 5, unstable total sleep times (TSTs), early HD shift.

OUTCOMES

Self-reported sleep quality and objective measures of sleep/wake behavior.

MEASUREMENTS

Diaries, sleep questionnaires, and wrist actigraphy were performed.

RESULTS

The group with CKD stages 4 to 5 had an average age of 51 years, 69% were men, 19% were African American, and average body mass index was 28.9 kg/m2. The HD group had an average age of 54 years, 60.8% were men, 49% were African American, and average body mass index was 27.5 kg/m2. Average TST was 66.8 minutes shorter and sleep efficiency was 5.2% lower in the HD group compared with the population with CKD stages 4 to 5. In the HD population, 28 individuals had a mean change in TST greater than 60 minutes between HD and non-HD nights, and this unstable sleep pattern was associated with daytime sleepiness. The early-HD group had TST 62 minutes (95% confidence interval, approximately 22 to 102) shorter than those with later HD shifts. No significant differences in sleep efficiency or fragmentation index were found between the early- and late-HD groups.

LIMITATIONS

Study included those older than 18 years.

CONCLUSIONS

Both patients with CKD stages 4 to 5 and HD patients have short and fragmented sleep. An early-morning HD shift was associated with shorter TST and greater variation in nightly TST. Additional trials of the possible beneficial effect of behavioral sleep interventions, more frequent HD, and later HD shifts on sleep patterns are needed.

Subjective and objective sleep quality in patients on conventional thrice-weekly hemodialysis: comparison with matched controls from the sleep heart health study

BACKGROUND

Studies examining sleep in the hemodialysis (HD) population have largely lacked an adequate comparison group. It therefore is uncertain whether poor sleep quality in the HD population reflects age, chronic health conditions, or effects of conventional HD therapy.

STUDY DESIGN

Cross-sectional matched-group study.

SETTING & PARTICIPANTS

Forty-six in-center HD patients were compared with 137 community participants participating in the Sleep Heart Health Study matched for age, sex, body mass index, and race.

PREDICTOR

HD patients compared with community-dwelling non-HD participants.

OUTCOMES & MEASUREMENTS

Home unattended polysomnography was performed and scored by using similar protocols. Sleep habits and sleepiness were assessed by using the Sleep Habits Questionnaire and Epworth Sleepiness Scale.

RESULTS

Average age of study samples was 63 years, 72% were white, and average body mass index was 28 +/- 5 kg/m(2). HD patients were significantly more likely than community participants to have short sleep (odds ratio, 3.27; 95% confidence interval, 1.16 to 9.25) and decreased sleep efficiency (odds ratio, 5.5; 95% confidence interval, 1.5 to 19.6). HD patients reported more difficulty getting back to sleep (odds ratio, 2.25; 95% confidence interval, 1.11 to 4.60) and waking up too early (odds ratio, 2.39; 95% confidence interval, 1.01 to 5.66). There was no association between polysomnography sleep time and self-reported sleep time (r = 0.09; P = 0.6) or between the Epworth Sleepiness Scale and severity of sleep apnea (r = 0.10; P = 0.5) in the HD population.

LIMITATIONS

The study was limited to participants older than 45 years.

CONCLUSIONS

Kidney failure treated with thrice-weekly HD is significantly associated with poor subjective and objective sleep quality.

Patient-reported sleep difficulty and cognitive function during the first year of dialysis

BACKGROUND

Research in the general population indicates that sleep fragmentation is detrimental for cognitive function, but little attention has been given to this issue in dialysis patients. We hypothesized that patients with self-reported persistent sleep difficulty would have an increased risk of scoring lower on a cognitive function measure at follow-up compared to their score at baseline.

METHODS

Sleep difficulty and cognitive function were reported by a large national patient cohort near the start of dialysis and at a 9- to 12-month follow-up. Logistic regression was used to investigate the risk of scoring lower on a cognitive function measure at follow-up as a function of self-reported sleep difficulty, controlling for patients' sociodemographic, clinical and treatment characteristics, including depressed mood.

RESULTS

At follow-up, cognitive function scores were lower among 35.8% of the cohort. Patients with self-reported persistent sleep difficulty had the lowest average cognitive function score. Men with reported persistent sleep difficulty, regardless of presence of depressed mood, had a significantly increased risk of a lower cognitive function score at follow-up. Women with reported persistent sleep difficulty as well as depressed mood had significantly increased risk of a lower cognitive function score.

CONCLUSION

The potential impact of sleep difficulty and depressed mood on the cognitive function of dialysis patients emphasizes the importance of evaluating and treating these risks and highlights the value of continued research to improve our understanding and management of these issues.