Prevalence of sleep disorders among ESRD patients

Association between Chronic Kidney Disease-Mineral and Bone Disorder Biomarkers and Symptom Burden in Older Patients with Advanced Chronic Kidney Disease: Results from the EQUAL Study

Key Points

Background

Patients with advanced CKD develop numerous symptoms, with a multifactorial origin. Evidence linking mineral disorders (CKD-Mineral and Bone Disorder) and uremic symptoms is scant and mostly limited to dialysis patients. Here, we aim to assess the association between CKD-Mineral and Bone Disorder and symptom burden in nondialysis patients with CKD.

Methods

We used data from the European Quality study, which includes patients aged ≥65 years with eGFR ≤20 ml/min per 1.73 m2 from six European countries, followed up to 5 years. We used generalized linear mixed-effect models to determine the association between repeated measurements of parathyroid hormone (PTH), phosphate, and calcium with the overall symptom number (0–33), the overall symptom severity (0–165), and the presence of 33 CKD-related symptoms. We also analyzed subgroups by sex, age, and diabetes mellitus and assessed effect mediation and joint effects between mineral biomarkers.

Results

The 1396 patients included in the study had a mean of 13±6 symptoms at baseline, with a median overall severity score of 32 (interquartile range, 19–50). The association between PTH levels and symptom burden appeared U-shaped with a lower symptom burden found for mild-to-moderately increased PTH levels. Phosphate and calcium were not independently associated with overall symptom burden. The highest symptom burden was found in patients with a combination of both severe hyperparathyroidism and severe hyperphosphatemia (+2.44 symptoms [0.50–4.38], P = 0.01). The association of both hypocalcemia and hyperphosphatemia with symptom burden seemed to differ by sex and age.

Conclusions

In older patients with advanced CKD not on dialysis, mild-to-moderately increased PTH was associated with a lower symptom burden, although the effect size was relatively small (less than one symptom). Neither phosphate nor calcium were associated with the overall symptom burden, except for the combination of severe hyperphosphatemia and severe hyperparathyroidism which was associated with an increased number of symptoms.

Associations between sleep problems and cardiometabolic risk in maintenance hemodialysis patients: A multicenter study

The incidence of cardiovascular disease is increasing around the world, and it is one of the main causes of death in chronic kidney diseases patients. It is urgent to early identify the factors of cardiometabolic risk. Sleep problems have been recognized as a risk factor for cardiometabolic risk in both healthy people and chronic patients. However, the relationship between sleep problems and cardiometabolic risk has not been clearly explored in hemodialysis patients. This study aimed to investigate the relationship between sleep problems and cardiometabolic risk in 3025 hemodialysis patients by a multicenter study. After adjusting for confounders, binary logistic regression models showed that hemodialysis patients reported sleep duration greater than 7 h were more likely to be with hypertension, hyperglycemia, hypertriglyceridemia, and hypercholesterolemia. Patients reported sleep duration less than 7 h were more likely to be with hypertriglyceridemia and hypercholesterolemia, but the risks of hyperglycemia and Low HDL-cholesterol were decreased. Poor sleep quality was negatively correlated to low HDL cholesterol and hypertriglyceridemia. Moreover, gender-based differences were explained.

Hemodialysis-induced chronodisruption and chronotype distribution in patients with chronic kidney disease

Changes in circadian rhythms have been observed in patients with chronic kidney disease (CKD), and evidence suggests that these changes can have a negative impact on health. This study aimed to investigate the existence of hemodialysis-induced chronodisruption, the chronotype distribution, and their association with sleep quality and quality of life (QoL). This was a cross-sectional study that enrolled 165 patients (mean age: 51.1 ± 12.5 y, 60.6% male) undergoing hemodialysis from three local units. The following instruments were used: the Morning-Eveningness Questionnaire (MEQ); a modified version of the Munich Chronotype Questionnaire (MCQT) to estimate hemodialysis-induced chronodisruption (HIC); the Kidney Disease QoL Short Form (KDQOL-SF); the Epworth Sleepiness Scale (ESS); the Pittsburgh Sleep Quality Index (PSQI) and the 10-Cognitive Screener (10-CS). HIC was present in 40.6% of CKD patients. Morning chronotype was prevalent in CKD patients (69%) compared to evening-type (17.1%) and significantly different from a paired sample from the general population (p < 0.001). HIC and chronotype were associated with different domains of QoL but not with sleep quality. This study suggests that there is a HIC and that morning chronotype is associated with CKD patients undergoing hemodialysis, with implications for QoL.

The Interplay of Anxiety, Depression, Sleep Quality, and Socioeconomic Factors in Somali Hemodialysis Patients

OBJECTIVE

This study aimed to assess anxiety, depression, and sleep quality in kidney failure patients receiving hemodialysis (HD) in Somalia and examine the relationship between anxiety, depression, and sleep quality.

METHODS

We conducted a study with 200 kidney failure patients on HD treatment for over 3 months. Participants completed sociodemographic questionnaires, the Patient Health Questionnaire-9 (PHQ-9), the Hospital Anxiety and Depression Scale (HADS), the Insomnia Severity Index (ISI), and the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Among the 200 participants (mean age = 52.3; SD = 14.13), 58.5% were men, 64% had CKD for 1-5 years, and 52.6% received HD for 1-5 years. Depressive symptoms were found in 61.5% (PHQ-9) and 37.5% (HADS depression subscale) of HD patients. Poor sleep quality (PSQI) was observed in 31.5% and significantly correlated with PHQ-9 (rs = 0.633), HADS anxiety (rs = 0.491), and HADS depression (rs = 0.529). The ISI score correlated significantly with PHQ-9 (rs = 0.611), HADS anxiety (rs = 0.494), and HADS depression (rs = 0.586). All PSQI components correlated with depression and anxiety, except sleep medication use. Hierarchical regression analysis revealed that HADS anxiety (β = 0.342) and HADS depression (β = 0.372) predicted ISI scores. HADS anxiety (β = 0.307) and HADS depression (β = 0.419) predicted PSQI scores.

CONCLUSIONS

Higher anxiety and depression levels negatively correlated with various dimensions of sleep quality in kidney failure patients. Early identification and appropriate management of these psychological disturbances are crucial for enhancing patients' overall quality of life.

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.

The Effects of Inhalational Lavender Essential Oil Aromatherapy on Sleep Quality in Hemodialysis Patients: A Before-and-After-Intervention Trial

One of the most essential physical prerequisites for human survival is sleep. Patients undergoing hemodialysis often experience a lack of sleep, and it is one of the decisive variables in dialysis patients' quality of life. The objective of this study was to assess the effects of inhaling lavender essential oil on sleep quality in hemodialysis patients. A total of 30 patients were enrolled in the before-and-after intervention trial, which took place in a tertiary care hospital's dialysis unit. The study participants were selected using the purposive sampling technique and they received lavender oil inhalation therapy. The sleep quality was measured using the Pittsburgh Sleep Quality Index. The mean age of the participants was 55.11 (SD = 8.45) years. The mean posttherapy Pittsburgh Global Sleep Quality Index score was 8.8 ± 1.89 compared with the pretherapy score of 14.73 ± 1.53. Patients undergoing hemodialysis experienced a substantial improvement in sleep quality ( P < .05). Aromatherapy using lavender oil is effective in enhancing sleep quality in hemodialysis patients.

Demographic and clinical risk factors for diagnosis of sleep disorders in ESRD patients

BACKGROUND

Sleep disturbances in patients with end-stage renal disease (ESRD) are common and more prevalent than in the general population. This study aims to assess the demographic and clinical risk factors for the diagnosis of sleep disorders in ESRD patients.

METHODS

This study is a retrospective analysis of the United States Renal Data System (USRDS) to evaluate risk factors for the diagnosis of sleep disorders, including hypersomnolence, insomnia, restless leg syndrome (RLS), or obstructive or central sleep apnea (OSA/CSA). All ESRD subjects enrolled in the USRDS between 2004-2015 were eligible for inclusion. The risk factors analyzed were age, race, sex, ethnicity, access type, dialysis modality, and the Charlson Comorbidity Index (CCI). All statistical analysis was performed using SAS 9.4, and statistical significance was assessed using an alpha level of 0.05. Descriptive statistics on all variables overall and by each sleep diagnosis were determined.

RESULTS

Increasing age, black race, other race, and Hispanic ethnicity were associated with decreased risk of each sleep diagnosis while CCI was associated with increased risk. Females were at increased risk of RLS and insomnia while males were at increased risk of OSA/CSA. Catheter and graft access decreased risk of RLS but increased risk of insomnia compared to AVF access. Catheter access increased risk of OSA/CSA compared to graft access. Hemodialysis increased risk of OSA/CSA compared to peritoneal dialysis.

CONCLUSIONS

Some ESRD patients are at an increased risk for diagnosis of sleep disorders based on age, race, sex, comorbid health conditions, and dialysis modality.

Efficacy and safety of Tongdutiaoshen acupuncture on insomnia in maintenance hemodialysis patients: A randomized clinical trial protocol

Background

Patients undergoing maintenance hemodialysis (MHD) experience insomnia frequently. Poor sleep quality impairs the quality of life and adversely affects long-term outcomes. Currently, the treatment of insomnia in patients undergoing MHD is mainly based on medication, although it has severe side effects and poor compliance in patients. Therefore, developing complementary and alternative therapies with higher efficacies is important. This study explores the clinical efficacy and safety of Tongdutiaoshen acupuncture in treating insomnia in patients with MHD.

Methods

This randomized controlled trial (RCT) will be performed at Beijing Luhe Hospital, affiliated with Capital Medical University in China. We will strictly adhere to the Standards for Reporting Interventions in Clinical Trials of Acupuncture (2010). A total of 110 MHD patients with insomnia will be randomly allocated in a 1:1 ratio to the drug control (DC) or Tongdutiaoshen acupuncture (TA) group. Patients in the control group will be administered estazolam tablets (1 mg/day) for four weeks, followed by a 4-week follow-up period. Based on the background therapy provided for the DC group, the TA group will be administered the interventional cohort three times a week for four weeks in a row, followed by a 4-week follow-up period. The primary endpoints will include the Pittsburgh Sleep Quality Index (PSQI), Hamilton Anxiety Scale (HAM-A), TCM Insomnia Syndrome Score, and clinical response rate, which will be evaluated on days 0, 14, 28, and 56. Secondary endpoints will include sleep data monitoring and related laboratory indices, which will be evaluated on days 0, 28, and 56, respectively.

Discussion

This study is designed based on a rigorous methodology to evaluate the efficacy and safety of Tongdutiaoshen acupuncture for insomnia in patients undergoing hemodialysis. The findings of this trial will be published in peer-reviewed journals as reliable evidence.

Trial registration

Chinese Clinical Trial Registry ChiCTR2200061967. Registered on July 07, 2022.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

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

Periodic limb movements among dialysis and non-dialysis chronic kidney disease patients: a comparative study

Background

Periodic leg movement disorder is defined as periodic episodes of repetitive limb movements during sleep that mainly occurs in the lower limb, including the hips, knees, and toes, and sometimes affects the upper limb. It may be accompanied by frequent nocturnal arousals, and if so, this sleep disturbance may cause excessive daytime sleepiness. Chronic kidney disease patients are at risk of periodic leg movements and common causes are iron deficiency, anemia, raised serum calcium, and central and peripheral nervous system disorders. This study aimed to screen the prevalence of periodic limb movements among chronic kidney disease patients using full-night attended polysomnography, compare dialysis with non-dialysis CKD patients, and correlate PLM prevalence with the HGB level and degree of renal impairment.

Results

This cross-sectional study was carried out on one hundred chronic kidney disease patients during the period between May 2017 and March 2020. The patients were subdivided into two groups: group I included patients on regular hemodialysis (n = 50), and group II included patients not on dialysis. All patients were screened for periodic limb movement using full-night attended polysomnography. Our study revealed a high prevalence of periodic limb movements in both groups of chronic kidney disease patients (60% in dialysis and 66% in non-dialysis patients) with mean PLM indices insignificantly higher in group I than group II (29.90 ± 19.19/h vs. 17.54 ± 13.56/h, P-value = 0.748). Moreover, there was a significant positive correlation between periodic leg movements and serum urea level (r-value = 0.38 and 0.33 and P-value = 0.04 and 0.030 in group I and group II consequently). Also, we reported a significant negative correlation between periodic leg movements and hemoglobin level (r = −0.251 and −0.291 and P-value = 0.037 and 0.010 in group I and group II consequently).

Conclusion

Periodic leg movement disorder is highly prevalent among CKD patients either on dialysis or not, and good management of renal dysfunction and anemia in those patients can help in the management of PLM.

Risk factors and prediction model of sleep disturbance in patients with maintenance hemodialysis: A single center study

Objectives

This study aimed to explore the risk factors and develop a prediction model of sleep disturbance in maintenance hemodialysis (MHD) patients.

Methods

In this study, 193 MHD patients were enrolled and sleep quality was assessed by Pittsburgh Sleep Quality Index. Binary logistic regression analysis was used to explore the risk factors for sleep disturbance in MHD patients, including demographic, clinical and laboratory parameters, and that a prediction model was developed on the basis of risk factors by two-way stepwise regression. The final prediction model is displayed by nomogram and verified internally by bootstrap resampling procedure.

Results

The prevalence of sleep disturbance and severe sleep disturbance in MHD patients was 63.73 and 26.42%, respectively. Independent risk factors for sleep disturbance in MHD patients included higher 0.1^*age (OR = 1.476, 95% CI: 1.103–1.975, P = 0.009), lower albumin (OR = 0.863, 95% CI: 0.771–0.965, P = 0.010), and lower 10^*calcium levels (OR = 0.747, 95% CI: 0.615–0.907, P = 0.003). In addition, higher 0.1^*age, lower albumin levels, and anxiety were independently associated with severe sleep disturbance in MHD patients. A risk prediction model of sleep disturbance in MHD patients showed that the concordance index after calibration is 0.736, and the calibration curve is approximately distributed along the reference line.

Conclusions

Older age, lower albumin and calcium levels are higher risk factors of sleep disturbance in MHD, and the prediction model for the assessment of sleep disturbance in MHD patients has excellent discrimination and calibration.

Comparison of the Effect of Reflexology and Swedish Massage on Restless Legs Syndrome and Sleep Quality in Patients Undergoing Hemodialysis: a Randomized Clinical Trial

Background

Patients undergoing hemodialysis experience painful complications such as restless leg syndrome and poor sleep quality, which negatively affect their quality of life.

Purpose

This study aimed to compare the effect of reflexology and Swedish massage on restless leg syndrome and sleep quality in patients undergoing hemodialysis.

Method

This is a randomized clinical trial conducted on 90 patients undergoing hemodialysis. The two intervention groups received either foot reflexology (n = 30) or Swedish massage (n = 30) for four weeks. In the sham group (n = 30), a simple touch of the knee down was performed with the same conditions as the intervention groups. Each sample completed the International Restless Leg Syndrome and Pittsburgh Sleep Quality Index Questionnaires before, immediately after, and one month after the intervention.

Result

The results showed that immediately after the intervention, restless leg syndrome and sleep quality were significantly better in the foot reflexology massage group than the Swedish massage and sham groups (PRLS < 0.001, PPSQI < 0.001); also, changes in restless leg syndrome and sleep quality, respectively, before and one-month follow-up after the intervention were not significant in all three groups (PRLS = 0.47, PPSQI = 0.95), (PRLS = 0.91, PPSQI = 0.87).

Conclusion

Reflexology and Swedish massage, as complementary methods, can improve the restless leg syndrome and sleep quality of patients undergoing hemodialysis. However, foot reflexology massage had been more effective.

Daily behavioral and sleep patterns are associated with aging-induced male-specific disorders in individuals with reduced renal function

BACKGROUND

The development of aging-induced male-specific disorders is accelerated by impaired renal function. Although aging-induced male-specific disorders are clinically serious complications in individuals with reduced renal function, their practical management strategies remain obscure. The purpose of this cross-sectional study was to investigate the association between daily behavioral and sleep patterns and aging-induced male-specific disorders in individuals with reduced renal function.

METHODS

Eighty men with glomerular filtration rate stage 2-4 (age, 67 ± 9 years), sedentary behavior and physical activity were assessed using a triaxial accelerometer. The mean sleep time was calculated from the sleep time during the accelerometer measurement. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Aging-induced male-specific disorders were assessed using the Aging Males' Symptoms Questionnaire (AMS).

RESULTS

A lower moderate to vigorous-intensity physical activity (MVPA) time and a higher PSQI score were independently associated with a higher AMS score. Moreover, when the participants were divided into four groups according to the median MVPA values and the PSQI score (more or less than 6 points), the AMS score was the highest in those with a lower MVPA time and a higher PSQI score. In the mediation analysis, the PSQI score did not mediate a correlation between the MVPA time and AMS score. MVPA time also did not mediate a correlation between the PSQI and AMS scores.

CONCLUSIONS

Collectively, these findings suggest that increasing MVPA time and improving sleep quality may contribute to attenuating aging-induced male-specific disorders in individuals with reduced renal function.

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 Association of Sleep Quality and Vitamin D Levels in Hemodialysis Patients

Background

To date, hemodialysis (HD) is the most common therapy for chronic kidney disease (CKD) patients. However, it causes different complications such as sleep disorders. Sleep regulation is connected to vitamin D; hence, its deficiency might influence the quality and duration of sleep. This study is aimed at evaluating the correlation of sleep quality and vitamin D levels in 80 HD patients.

Methods

This cross-sectional study was performed on 80 hemodialysis patients admitted to 29 Bahman hospitals in Tabriz, Iran. Before beginning of dialysis, serum 25 (OH) D levels were assessed among patients and the sleep patterns and sleep quality of patients were accurately calculated by the Pittsburgh sleep quality index (PSQI) standard questionnaire.

Results

Our results showed that 22 HD patients (27.5%) had severe sleep disorders. In addition, it was found that serum levels of vitamin D had significant correlation with sleep quality (r = −0.341, p = 0.002) in general, even after adjusting confounding factors such as calcium (Ca), phosphate (P), and parathyroid hormone (PTH) level. In poor sleepers (PSQI ≤ 5), a negative correlation was observed between the levels of vitamin D and PSQI score (r = −0.397, p = 0.004). PSQI scores in the normal range of PTH (r = −0.377, p = 0.006) and in >600 pg/ml of PTH (r = −0.675, p = 0.011) had a correlation with vitamin D levels. The level of vitamin D was the single independent predictor of sleep efficiency (β coefficient = −0.386, p = 0.001).

Conclusion

The present project reported that the positive effect of vitamin D is associated with sleep disorder in HD patients. In future studies, normal levels of Ca and P should be considered along with normal vitamin D levels among the included patients.

Is kidney a new organ target in patients with obstructive sleep apnea? Research priorities in a rapidly evolving field

The bidirectional relationship between sleep disordered breathing and chronic kidney disease (CKD) has recently gained a lot of interest. Several lines of evidence suggest the high prevalence of coexistent obstructive sleep apnea (OSA) in patients with CKD and end-stage renal disease (ESRD). In addition, OSA seems to result in loss of kidney function in some patients, especially in those with cardio-metabolic comorbidities. Treatment of CKD/ESRD and OSA can alter the natural history of each other; still better phenotyping with selection of appropriate treatment approaches is urgently needed. The aim of this narrative review is to provide an update of recent studies on epidemiological associations, pathophysiological interactions, and management of patients with OSA and CKD or ESRD.

Efficacy of auricular acupressure in maintenance haemodialysis patients: A systematic review and meta-analysis

OBJECTIVES

To systematically evaluate the efficacy of auricular acupressure on sleep disorders, depression, pruritus, xerostomia and daily net weight gain (%) in maintenance haemodialysis patients.

BACKGROUND

Auricular acupressure has been used for various complications in maintenance haemodialysis patients, such as sleep disorders, depression, pruritus and xerostomia, but the efficacy has not yet been unified.

DESIGN

Systematic review and meta-analysis.

METHODS

Randomised controlled trials comparing auricular acupressure intervention with non-AA intervention in maintenance haemodialysis patients were included. We searched English databases (PubMed, Cochrane Library, Embase, Web of Science) and Chinese databases (CNKI, WanFang, CBM and VIP database) from the inception to 27 November 2020. The risk of bias was assessed by the Cochrane risk of bias tool. The RevMan 5.3 software was used to perform the meta-analysis. A descriptive analysis was conducted if the data were high of heterogeneity or could not be meta-analysed. The PRISMA statement was used to report systematic review and meta-analysis.

RESULTS

A total of 12 RCTs with 805 MHD patients were included. Meta-analysis showed that auricular acupressure had a significant difference for improving sleep disorders (MD = -1.97 points, 95% CI: -2.62 to -1.32, p < .0001), pruritus (MD = -1.55 points, 95% CI: -2.01 to -1.08, p < .0001), and daily net weight gain (%) (MD = -0.29, 95% CI: -0.37 to -0.21, p < .0001). The efficacy of depression and xerostomia were analysed descriptively due to insufficient data.

CONCLUSIONS

The meta-analysis results indicated that auricular acupressure had a positive efficacy in maintenance haemodialysis patients to improve sleep disorders, pruritus and daily net weight gain (%). But the results should be treated conservatively on account of the low quality of included studies. Future researchers need to conduct more high-quality, large sample, multi-centre randomised controlled studies to provide a solid basis to demonstrate of the efficacy of auricular acupressure in maintenance haemodialysis patients.

RELEVANCE TO CLINICAL PRACTICE

Auricular acupressure has the advantages of low cost, non-invasive and easy to be accepted by patients. This review suggested that auricular acupressure could be considered a non-pharmacological intervention for maintenance haemodialysis patients. Medical staff could teach maintenance haemodialysis patients auricular acupressure to help them self-manage some complications at home.

Relationship between salt intake and sleep disordered breathing in dialysis patients

BACKGROUND

The prevalence of sleep disordered breathing is high in patients with end-stage renal disease. Salt intake is related to the severity of obstructive sleep apnea in patients with resistant hypertension and hyperaldosteronism. We investigated the relationship between salt intake and sleep disordered breathing in patients on maintenance hemodialysis.

PATIENTS AND METHODS

We studied 128 dialysis outpatients (mean age 63 ± 11 years) who were followed at Kokura Daiichi Hospital. We estimated each patient's salt intake using an InBody S10 body composition analyzer and measured the 3% oxygen desaturation index (ODI) during sleep using a Pulsewatch: PMP-200 GplusX.

RESULTS

The average estimated salt intake was 8.0 ± 2.6 g/day, and the median value of that was 7.5 g/day. Blood pressure (BP) before and after dialysis were 140 ± 18/78 ± 11 and 127 ± 13/72 ± 8 mmHg, respectively. The geometric average number of 3% ODI was 7.1, and sleep disordered breathing was detected in 30% of all subjects. The patients with ≥ 7.5 g/day salt intake were younger and more frequently male and had higher body mass index (BMI) and BP before dialysis compared to those with salt intakes < 7.5 g/day. Patients with ≥ 7.5 g/day salt intake had a significantly higher geometric average number of 3% ODI; however, this relationship became weaker after adjusting for BMI. The same relationship was obtained for the prevalence of sleep disordered breathing.

CONCLUSION

The prevalence of sleep disordered breathing in patients on maintenance hemodialysis was high, and the sleep disordered breathing was associated with salt intake and BMI.

Sleep apnea is associated with residual kidney function and mortality in patients with peritoneal dialysis: Prospective cohort study

INTRODUCTION

Fluid overload and sleep apnea (SA) are known risk factors for mortality in dialysis patients. Although incidence and severity of SA were shown higher in peritoneal dialysis (PD) patients than in hemodialysis patients, data regarding the association of SA with body fluid status and mortality are limited. Therefore, the association of SA with body fluid status and mortality were investigated in a prospective cohort with patients undergoing PD.

METHODS

The present study included 103 prevalent PD patients who were followed up for median 70 months. At baseline, the subjects underwent in-home polysomnography, bioelectrical impedance analysis, and urea kinetics. Excessive daytime sleepiness and sleep quality were assessed using sleep questionnaires. SA was defined as apnea/hypopnea index higher than 15 events per hour.

RESULTS

Sleep apnea was diagnosed in 57 (55.3%) patients (SA group); the subjects had significantly higher extracellular water (10.3 ± 1.4 vs. 9.2 ± 1.8, p = 0.001) and lower residual kidney function (RKF) (3.3 ± 3.3 vs. 5.9 ± 7.2, p = 0.02) compared with subjects in the non-SA group. SA was significantly associated with RKF [odds ratio, 0.84; 95% confidence interval (CI), 0.73-0.97] in multivariable logistic regression analysis. In multivariable Cox regression models, SA was a significant predictor of mortality in PD patients (adjusted hazard ratio, 5.74; 95% CI, 1.09-30.31) after adjusting for well-known risk factors.

CONCLUSIONS

Sleep apnea was very common in PD patients and significantly associated with lower RKF. SA was also a novel risk predictor of mortality in PD patients.

Dietary Factors and Sleep Quality Among Hemodialysis Patients in Malaysia

OBJECTIVES

Poor sleep quality is a commonly seen problem in hemodialysis patients. This study investigated the associations between dietary factors and sleep quality among hemodialysis patients.

DESIGN AND METHODS

This is a cross-sectional study conducted among 184 eligible hemodialysis patients at four dialysis units in Malaysia. Three days dietary recall were used in the analysis of dietary intake and behavior. Sleep quality was assessed through Pittsburgh Sleep Quality Index.

RESULTS

More than half of the patients were poor sleepers. Among the sleep components, sleep latency affected patients the most, with the use of sleep medications was relatively low. A majority of the patients had inadequate dietary intake of energy (88%) and protein (75%). Dietary protein, potassium adjusted for body weight, and sodium intake were significantly increased in poor sleepers. Lower percentage of energy from carbohydrates; higher percentage of energy from fats; higher intakes of dietary protein, fat, phosphorus, and sodium were correlated with poorer sleep quality and its components. Skipping dinner on non-dialysis days and having supper on dialysis days were associated with poor sleep quality.

CONCLUSION

Poor sleep is prevalent among hemodialysis patients. Sleep quality of hemodialysis patients was highly associated with certain dietary factors. Periodical assessment of sleep quality and dietary intake is necessary to identify poor sleepers with inappropriate dietary intake to allow effective clinical and nutritional interventions to improve the sleep quality and nutritional status of these 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.

Cyst Reduction by Melatonin in a Novel Drosophila Model of Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) causes progressive cystic degeneration of the renal tubules, the nephrons, eventually severely compromising kidney function. ADPKD is incurable, with half of the patients eventually needing renal replacement. Treatments for ADPKD patients are limited and new effective therapeutics are needed. Melatonin, a central metabolic regulator conserved across all life kingdoms, exhibits oncostatic and oncoprotective activity and no detected toxicity. Here, we used the Bicaudal C (BicC) Drosophila model of polycystic kidney disease to test the cyst-reducing potential of melatonin. Significant cyst reduction was found in the renal (Malpighian) tubules upon melatonin administration and suggest mechanistic sophistication. Similar to vertebrate PKD, the BicC fly PKD model responds to the antiproliferative drugs rapamycin and mimics of the second mitochondria-derived activator of caspases (Smac). Melatonin appears to be a new cyst-reducing molecule with attractive properties as a potential candidate for PKD treatment.

Poor Sleep Quality, Depression and Social Support Are Determinants of Serum Phosphate Level among Hemodialysis Patients in Malaysia

Despite optimal control of serum phosphate level being imperative to avoid undesirable health outcomes, hyperphosphataemia is a highly prevalent mineral abnormality among the dialysis population. This study aimed to determine factors associated with hyperphosphatemia among hemodialysis patients in Malaysia. Multiple linear regression analysis was used to ascertain the possible factors that influence serum phosphate levels. A total of 217 hemodialysis patients were recruited. Hyperphosphatemia was prevalent. Only approximately 25% of the patients were aware that optimal control of hyperphosphatemia requires the combined effort of phosphate binder medication therapy, dietary restriction, and dialysis prescription. The presence of diabetes mellitus may affect serum phosphate levels, complicating dietary phosphorus management. Patients who were less depressive portrayed higher serum phosphate levels, implying intentional non-compliance. Better compliance on phosphate binder, longer sleep duration, and higher social support was associated with a lower level of serum phosphate. Despite sleep disturbance being one of the most prevalent and intense symptom burdens identified by hemodialysis patients, relatively few studies have addressed this issue. It is time to formulate sleep therapeutic interventions besides the encouragement of strong social support, hoping which many clinical outcomes including hyperphosphatemia can be better controlled among hemodialysis patients.

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.

A Guide to Management of Sleepiness in ESKD

Daytime sleepiness, also known as hypersomnolence, is common among patients receiving maintenance dialysis and following successful kidney transplantation. Sleepiness may be secondary to medical comorbid conditions, medication side effect, insufficient sleep syndrome, and sleep-disordered breathing or the result of a primary central disorder of hypersomnolence, such as narcolepsy. Unrecognized and untreated sleep disorders are associated with substantial morbidity and mortality among patients with end-stage kidney disease. Effective management of hypersomnolence can improve quality of life in patients with kidney disease. This review focuses on the principal causes of sleepiness in patients with end-stage kidney disease. Awareness of these disorders by treating nephrologists is crucial. This review provides a systematic approach to guide providers through the recognition, early diagnosis, and treatment of hypersomnolence, which is commonly encountered in this patient population. Areas of future research are also suggested.

Trastornos del sueño en el paciente con enfermedad renal crónica avanzada

Objetivo: Conocer las alteraciones y/o trastornos del sueño en los pacientes con Enfermedad Renal Crónica Avanzada. Método: Se realizó una búsqueda en las bases de datos Google Académico, Scielo, Science Direct, PubMed y Scopus. Se incluyeron artículos científicos en español e inglés y texto completo disponible. Se analizaron aquellos artículos que trataban sobre alteraciones del sueño en los pacientes en prediálisis, y en tratamiento renal sustitutivo: Hemodiálisis, Diálisis Peritoneal y Trasplante Renal. Resultados: Se han incluido 30 artículos publicados entre los años 2013 y 2018. Los pacientes con Enfermedad Renal Crónica Avanzada presentan una alta prevalencia de alteraciones del sueño, llegando a alcanzar una prevalencia de casi el 90% en pacientes en hemodiálisis y diálisis peritoneal, y 62% en pacientes con trasplante renal; y entre el 44% y el 77% en la etapa prediálisis. Las alteraciones del sueño más frecuentes encontradas, fueron: insomnio, síndrome de piernas inquietas, apnea del sueño y somnolencia diurna excesiva. Como principales medidas y tratamientos utilizados para las alteraciones del sueño en estos pacientes se han encontrado terapias tanto farmacológicas, como no farmacológicas y la combinación de ambas. Conclusiones: Las alteraciones del sueño tienen una alta prevalencia en los pacientes con Enfermedad Renal Crónica Avanzada, tanto en prediálisis como en tratamiento renal sustitutivo; siendo las más frecuentes el insomnio, el síndrome de piernas inquietas, la apnea obstructiva del sueño y la somnolencia diurna excesiva. Entre los factores de riesgo más influyentes destacan: ansiedad y depresión, Diabetes Mellitus, hipertensión arterial, problemas respiratorios y tiempo en diálisis.

Risk of obstructive sleep apnea among senegalese dialysis patients

Obstructive sleep apnea syndrome (OSAS) is a common condition in patients undergoing chronic dialysis and is associated with increased cardiovascular morbidity and mortality. This study aimed to determine the prevalence and risk factors of OSAS in Senegalese dialysis patients. In a cross-sectional study including 128 patients (75 men and 53 women) dialyzed since ≥6 months in four dialysis units. Data were collected during the dialysis session in the units. OSAS was assessed with the Berlin Questionnaire. Factors associated with OSAS risk were identified by multivariate logistic regression. The mean age of patients was 46.8 ± 16.9 ¥16-85 years). OSAS was found in 53 patients (overall prevalence of 41.4%) with predominance among individuals aged ≥50 years (52.6%). Hypertension and diabetes were more frequent in patients with OSAS, while the prevalence of obesity and sedentary was not different. The majority of patients were not aware of their disease before the survey, and none was treated. After multivariate regression analysis, age >50 years [odds ratio (OR) = 1.09, P = 0.02], neck circumference >45 cm (OR= 1.25, P= 0.03), and daytime hypersomnia (OR = 1.18, P= 0.02) were significantly associated with OSAS. This study showed that OSAS is frequent among Senegalese dialysis patients but is usually under-diagnosed. Older age, excessive daytime sleepiness, and neck circumference are the main associated factors.

The health-related quality of life among patients on maintenance haemodialysis: Evaluation using the "EQ-5D"

PURPOSE

We conducted a cross-sectional investigation of health-related quality of life (HRQOL) among maintenance haemodialysis (MHD) patients, and determined important predictive factors of HRQOL in these patients.

METHODS

Psychological factors were evaluated with the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI) and the General Self-Efficacy Scale (GSES). HRQOL was evaluated with the EQ-5D. Laboratory data (albumin, haemoglobin and C-reactive protein) were collected for medical evaluation. We also collected participants' demographic data, including gender, age, et al. This study was in compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

RESULTS

The mean EQ-5D score was 0.86 ± 0.12, mean HADS-anxiety score was 5.27 ± 3.41, mean HADS-depression score was 5.29 ± 3.58, mean PSQI score was 7.00 ± 4.23 and mean GSES score was 6.86 ± 2.03. Participants' mean haemoglobin was 108.18 ± 16.45 g/L, mean albumin was 41.80 ± 4.61 g/L and mean C-reactive protein was 8.88 ± 18.50 mg/L. HRQOL was negatively correlated with HADS-anxiety (r = -0.390, p < 0.001), HADS-depression (r = -0.385, p < 0.001), PSQI (r = -0.285, p < 0.001) and C-reactive protein (r = -0.198, p = 0.034). HRQOL was positively correlated with GSES (r = 0.205, p = 0.007). Age (p < 0.001), anxiety (p < 0.001), depression (p = 0.002), and postdialysis unemployment (p < 0.001) were independent risk factors for HRQOL.

CONCLUSION

Different health interventions should be implemented to improve patients' HRQOL.

RELEVANCE TO CLINICAL PRACTICE

The results will provide evidence for establishing healthcare interventions to maintain or improve HRQOL among this patient population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Risk factors of sleep-disordered breathing in haemodialysis patients

Background

Sleep-disordered breathing (SDB) is common in patients with kidney disease; but often underdiagnosed as it is infrequently assessed in clinical practice. The objective of this study was to assess the risk factors of SDB in haemodialysis patients, and to identify useful assessment tools to detect SDB in this population.

Methods

We used nocturnal oximetry, Epworth Sleepiness Scale (ESS) and STOPBANG questionnaire to screen for SDB in haemodialysis patients. Presence of SDB was defined by Oxygen desaturation index (ODI≥5/h), and further confirmed by apnoea-hypopnea index (AHI) from an in-laboratory polysomnography. Blood samples were collected prior to commencing a haemodialysis treatment.

Results

SDB was detected in 70% of participants (N = 107, mean age 67 years). STOPBANG revealed that 89% of participants were at risk of SDB; however, only 17% reported daytime sleepiness on the ESS. Of the participants who underwent polysomnography (n = 36), obstructive sleep apnoea was identified in 86%, and median AHI was 34.5/h. Oximetry and AHI results were positively correlated (r = 0.62, P = 0.0001), as were oximetry and STOPBANG (r = 0.48; P<0.0001), but not ESS (r = 0.19; P = 0.08). Multivariate analysis showed that neck circumference (OR: 1.20; 95% CI: 1.07–1.34; P = 0.02) and haemoglobin (OR: 0.93; 95% CI: 0.88–0.97; P = 0.003) were independently associated with the presence of SDB.

Conclusion

Dialysis patients with a large neck circumference and anaemia are at risk of SDB; using nocturnal oximetry is practical and reliable to screen for SDB and should be considered in routine management of dialysis patients, particularly for those who demonstrate risk factors.

Interventions for improving sleep quality in people with chronic kidney disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Subjective Sleep Quality and Excessive Daytime Sleepiness in Hemodialysis Patients Waitlisted for Renal Transplant

OBJECTIVE

Sleep disturbances are common in hemodialysis (HD) patients, impeding their daily activities and reducing their overall quality of life. The aim of this study was to investigate sleep quality and excessive daytime sleepiness (EDS) in HD patients waitlisted for renal transplant.

METHODS

The study included 137 patients (84 men and 53 women) undergoing HD three times per week; the mean age was 49.74±12.49 years. I used the Pittsburgh Sleep Quality Index (PSQI) to identify poor sleepers and the Epworth Sleepiness Scale (ESS) to identify those with EDS.

RESULTS

PSQI scores classified 87 of the 137 patients (63.5%) as poor sleepers, and ESS scores indicated that 47 patients (34.3%) had EDS. Among the 87 poor sleepers, 46% presented with EDS. Among the patients with EDS, 85% were also poor sleepers. Multivariate analysis revealed a positive correlation between the PSQI and ESS scores (P=0.002).

CONCLUSIONS

Poor sleep quality and EDS are quite common among patients receiving HD, but these sleep disturbances often go undiagnosed or untreated. Better awareness and treatment of SDs could improve quality of life for HD patients waitlisted for renal transplant.

A Review of Cannabis in Chronic Kidney Disease Symptom Management

PURPOSE OF REVIEW

Physical and psychological symptom burden in patients with advanced chronic kidney disease (CKD) is significantly debilitating; yet, it is often inadequately treated. Legalization of cannabis in Canada may attract increasing interest from patients for its medical use in refractory symptom management, but its indications and long-term adverse health impacts are poorly established, creating a challenge for clinicians to support its use. In this review, we summarize key clinical studies and the level of evidence for nonsynthetic cannabinoids in the treatment of common symptoms encountered in advanced stages of CKD, including chronic pain, nausea and vomiting, anorexia, pruritus, and insomnia.

SOURCES OF INFORMATION

Medline and Embase.

METHODS

A search was conducted in MEDLINE and EMBASE (inception to March 1, 2018) on cannabis and CKD symptoms of interest, complemented with a manual review of bibliographies. Studies that examined synthetic cannabinoids that are manufactured to mimic the effects of ∆9-tetrahydrocannabinol such as dronabinol, levonantradol, nabilone, and ajulemic acid were excluded. We focused on studies with higher level of evidence where available, and quality of studies was graded based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (1a to 5).

FINDINGS

Based on studies conducted in patients without renal impairment, those treated with nonsynthetic cannabinoids were 43% to 300% more likely to report a ≥30% reduction in chronic neuropathic pain compared with placebo. However, there is currently insufficient evidence to recommend nonsynthetic cannabinoids for other medical indications, although preliminary investigation into topical endocannabinoids for uremia-induced pruritus in end-stage renal disease is promising. Finally, any benefits of cannabis may be offset by potential harms in the form of cognitive impairment, increased risk of mortality post-myocardial infarction, orthostatic hypotension, respiratory irritation, and malignancies (with smoked cannabis).

LIMITATIONS

Nonsynthetic cannabinoid preparations were highly variable between studies, sample sizes were small, and study durations were short. Due to an absence of studies conducted in CKD, recommendations were primarily extrapolated from the general population.

IMPLICATIONS

Until further studies are conducted, the role of nonsynthetic cannabinoids for symptom management in patients with CKD should be limited to the treatment of chronic neuropathic pain. Clinicians need to be cognizant that nonsynthetic cannabinoid preparations, particularly smoked cannabis, can pose significant health risks and these must be cautiously weighed against the limited substantiated therapeutic benefits of cannabis in patients with CKD.

EFFECT OF EDUCATIONAL INTERVENTION ON THE QUALITY OF LIFE OF HYPERPHOSPHATHEMIC CHRONIC RENAL PATIENTS ON HEMODIALYSIS

ABSTRACT Objective: to evaluate the health-related quality of life of hyperphosphatemic chronic renal patients on hemodialysis before and after a nursing educational intervention. Method: a quasi-experimental before-and-after study, conduted with 63 hyperphosphatemic chronic renal patients from a renal unit of the state of Rio Grande do Sul (Brazil). A sociodemographic and clinical characterization form was used, pruritus intensity record, Kidney Disease Quality of Life - Short Form and Nursing Educational Intervention. This included individual guidance, clarification of doubts and a printed manual. Laboratory data and pruritus evaluated before, 30 and 60 days after intervention, and quality of life, before and after two months. Analysis from descriptive and analytical measures. Results: after the intervention, there was a statistical difference between the mean scores of the following dimensions: Physical function, Emotional function, Energy/Fatigue, List of problems/symptoms and Cognitive function. Significant correlation was found in the following dimensions: Physical functioning, Physical function, Pain, General health, Emotional wellbeing, List of problems/symptoms, Effects of kidney disease, Kidney disease overload, Sleep and stimulation by the dialysis team. With the intervention there was a reduction in phosphorus, creatinine, calcium and parathyroid hormone levels. Itching also decreased. Regarding the evaluation of their health, 31.7% considered it “good” and 58.8% “regular” before the intervention; afterwards, 50.8% and 36.5% rated it as “good” and “fair” respectively. Conclusion: nursing educational intervention improves health-related quality of life and health perception of hyperphosphatemic chronic renal patients on hemodialysis.

Auricular acupressure for insomnia in hemodialysis patients: study protocol for a randomized controlled trial

Background

Patients on maintenance hemodialysis (MHD) frequently complain of insomnia. Poor sleep quality impairs their quality of life and adversely affects long-term outcome. Previously we applied auricular acupressure therapy (AAT) for MHD patients with insomnia and yielded favorable results. AAT probably improves sleep quality by stimulating the vagus nerve and inhibiting sympathetic overactivity. However, the efficacy of AAT for insomnia in this population is still lacking. The proposed randomized controlled trial (RCT) will evaluate the efficacy and safety of AAT for improvement of sleep quality in MHD patients with insomnia.

Methods/design

The proposed study is a multi-center, double-blind (participants and assessors), parallel-group RCT. A total of 112 participants with insomnia will be recruited from six hemodialysis centers in Guangzhou, China, and randomly allocated in a 1:1 ratio to receive auricular acupressure on either active points (AA group) or control points (points irrelevant to insomnia management, SAA group). The treatment will last for 8 weeks prior to a follow-up period of 12 weeks. Evaluation by blinded assessors at baseline, at 8 weeks (end of treatment) as well as at 4-week, 8-week and 12-week follow-ups (after intervention) will include Pittsburgh Sleep Quality Index (PSQI) scores and average weekly dose of hypnotics. The primary endpoint is clinical response rate (percentage of participants who reach a reduction of PSQI global score ≥ 3 in each group) at 8 weeks from baseline. Secondary endpoints include the changes in PSQI scores over time from baseline, as well as the changes in weekly dose of hypnotics.

Discussion

This paper describes the rationale and design of a double-blind RCT that aims to determine the efficacy and safety of AAT for insomnia of hemodialysis patients. If successful, this project will provide evidence of the efficacy and safety of AAT for insomnia of hemodialysis patients.

Trial registration

ClinicalTrials.gov, Identifier: NCT03015766. Registered on 22 December 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2546-2) contains supplementary material, which is available to authorized users.

Effects of inspiratory muscle training on pulmonary functions and muscle strength in sedentary hemodialysis patients

[Purpose] This study was conducted to evaluate the effect of Inspiratory Muscle Trainer (IMT) on respiratory muscle strength and pulmonary functions. [Subjects and Methods] Fifteen sedentary unemployed patients were recruited from both genders who received regular hemodialysis sessions from at least three months. Those patients received Threshold IMT program for 12 weeks. Pulmonary functions and respiratory muscle strength in form of (PImax) and (PEmax) were measured by electronic spirometry and digital pressure vacuum meter respectively. Additionally oxygen saturation was measured by Finger pulse oximeter. All measurements were performed before and at the end of the treatment program after 12 weeks. [Results] The results of this study revealed significant improvement in FVC%, FEV1%, PEF%, PImax and PEmax after three months of treatment by using inspiratory muscle trainer while no significant difference was recorded regarding to FEV1/FVC% ratio and SpO₂. [Conclusion] Inspiratory muscle trainer is an effective therapeutic technique to improve respiratory muscle strength and pulmonary functions in patients undergoing hemodialysis.

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.

Exploring sleep disorders in patients with chronic kidney disease

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

Chronic respiratory disease: an unrecognized risk factor in dialysis

Background

Few studies have analysed the impact of chronic respiratory disease (CRD) on outcomes in dialysis. We therefore sought to describe patients with CRD and end-stage renal disease and their outcomes after dialysis start, compared with patients without CRD, focusing especially on causes of death, access to renal transplantation and causes of hospital admissions.

Methods

The study included 52 797 adults aged 18 years and older who began dialysis from 2008 to 2013 and are recorded in the French national REIN registry. Survival, specific mortality and access to the waiting list and to renal transplantation were analysed, with adjustment for various comorbidities and consideration of competitive risks. The numbers of hospitalizations and hospital days, together with their causes, were analysed through an indirect link between the REIN database and the national French hospital discharge database.

Results

The frequency of CRD at dialysis start was 12% and was associated with various other comorbidities, including obesity and tobacco use. After adjustment for those comorbidities, CRD remained associated with a higher risk of death [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.16-1.25]. Patients with CRD were 30% less likely to undergo transplantation (HR 0.67, 95% CI 0.6-0.7) than patients without CRD. Their risk of dying from a respiratory disease was 8.8 times higher; their risk of dying from infection was also higher. Patients with CRD had a higher rate of admissions and more hospital days, for all causes and for every cause, except cancer.

Conclusions

CRD was associated with higher risks of death and hospital admissions and with lower likelihoods of being wait-listed for and undergoing renal transplantation. Increasing clinical awareness by patients and doctors and encouragement of spirometry use should promote more accurate clinical diagnosis and better preventive care for CRD.

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.

Physical Activity and Sleep Patterns in Hemodialysis Patients in a Suburban Environment

Background/Aims: Hemodialysis (HD) patients are less active than their healthy counterparts. They are often plagued with sleep disorders that affect the quality of their sleep. Our aim was to objectively quantify activity and sleep quality among HD patients in a suburban HD population. Methods: Activity and sleep parameters were measured using a commercially available activity tracker in 29 HD patients from Baton Rouge, LA, USA. Patients in the feedback group received their activity and sleep data at each dialysis treatment. In addition, questionnaires were administered at the beginning and end of the study period. Patients were stratified based on activity levels and sleep quality. Results: Patients walked an average of 5,281 steps/day and slept 370.5 min/night. Informing patients about their daily number of steps taken, did not increase activity. Only 3% of the population followed were active, defined as walking more than 10,000 steps per day. Patients walked significantly less on dialysis days compared to the other days of the week. Many of the patients experienced poor sleep quality, with patients in the first shift experiencing the greatest disturbance to their sleep/wake cycle. Conclusion: Patients in a suburban environment walked much less than those in a previously studied urban population. They rarely met the recommended goal of 10,000 steps/day, even on non-dialysis days. Interventions to increase physical activity may target any day of the week, particularly HD days. Prospective, long-term studies are needed to evaluate the use of activity trackers in dialysis patients and their impact on physical activity.

Sleep disorders in children with chronic kidney disease

Background and Objectives

This case-control study assessed the prevalence of sleep disorders among Egyptian children with chronic kidney disease (CKD), either maintained or not maintained on hemodialysis (HD), and compared them with healthy age and sex-matched children.

Patients and methods

The total study population included 95 children, 54 of whom were CKD patients, 22 maintained on HD and 32 not maintained on HD; 41 healthy children of matched age and sex composed the control group.

Subjective impairment of sleep quality was assessed using the Arabic version of the Children's Sleep Habits Questionnaire (CSHQ). Daytime sleepiness and restless leg syndrome (RLS) were assessed using a pediatric modification of the Epworth sleepiness scale (ESS) and RLS Questionnaire, respectively.

Results

Sleep disturbances were detected in 75.9% of the studied children with CKD: 81.8% in children with CKD undergoing dialysis, and 71.8% in children with CKD not on dialysis. Excessive daytime sleepiness (EDS) and RLS symptoms were reported in 22% and 20.4% of the studied children with CKD, respectively.

Conclusions

Sleep disturbances are very common among children with CKD. Sleep disturbances in patients with CKD include restless legs syndrome (RLS), excessive daytime sleepiness (EDS), sleep-disordered breathing (SDB), behavioral insomnias, and parasomnias.