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Wipper B, Cooke MP, Winkelman JW. Prevalence of Current Restless Legs Syndrome Symptoms Among Patients Treated with Buprenorphine/Naloxone for Opioid Use Disorder. Nat Sci Sleep 2023; 15:851-859. [PMID: 37886689 PMCID: PMC10599248 DOI: 10.2147/nss.s427403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/10/2023] [Indexed: 10/28/2023] Open
Abstract
Objective The purpose of this study was to determine the prevalence of Restless Legs Syndrome (RLS) in patients with Opioid Use Disorder (OUD) taking buprenorphine/naloxone maintenance therapy, and to assess symptom frequency, severity, and sleep disruption due to RLS. Methods Surveys inquired about demographic information, amount of time on maintenance treatment, previous drug use, current prescribed medications and alcohol use, and RLS symptoms. Participants were determined to have definite, probable, possible, or no RLS symptoms based on pre-established criteria from the Cambridge-Hopkins Questionnaire. Results The sample (n=129) was 33.3% female, 81.5% white, and the mean age was 40.6 years (SD=11.9). The median duration of buprenorphine/naloxone use was 3 years. 13.2% of participants had definite/probable RLS symptoms; these symptoms tended to be of moderate severity, occur at least 5-15 times a month, and disrupt sleep to a moderate degree. Of the 17 participants with definite/probable RLS symptoms, just four were taking a medication commonly used to alleviate RLS. An additional 7.0% had possible RLS symptoms. Conclusion Relatively high rates of current RLS symptoms were observed; the prevalence of clinically significant RLS was notably higher than that seen in the general population or in previously assessed clinical populations. RLS is common in those acutely withdrawing from opioids, and our data demonstrate that these symptoms are present in a sizable portion of patients on OUD maintenance therapy. Most patients with definite/probable current RLS symptoms did not report taking prescribed medications that have established efficacy for RLS.
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Affiliation(s)
- Benjamin Wipper
- Sleep Disorders Clinical Research Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Michelle Pearl Cooke
- Substance Use Disorder Services, Lemuel Shattuck Hospital, Jamaica Plain, MA, USA
| | - John W Winkelman
- Sleep Disorders Clinical Research Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Hamed SA, Abdulhamid SK, El-Hadad AF, Fawzy M, Abd-Elhamed MA. Restless leg syndrome in patients with chronic kidney disease: a hospital-based study from Upper Egypt. Int J Neurosci 2023; 133:257-268. [PMID: 33789073 DOI: 10.1080/00207454.2021.1910256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Chronic kidney disease (CKD) is a common cause of restless leg syndrome (RLS). RLS is under-recognized, misdiagnosed and undertreated disorder in our locality. In this study, we aimed to determine the prevalence of RLS due to CKD and its predictors. METHODS This cross-sectional study included 520 patients [male = 200; female = 320; age: 48.45 ± 3.63yrs; uremia duration: 6.44 ± 1.65yrs; CKD5D = 400; CKD3D = 120). RLS diagnosis was done by clinical interviewing according to International RLS Study Group criteria. All underwent detailed biochemical testing and iron and ferritin levels' measurements. Insomnia, depression and anxiety severities were assessed using insomnia sleep index (ISI), Beck Depression Inventory (BDI-II) and State-Trait Anxiety Inventory for Adults (STAI-AD) scales. RESULTS RLS was found in 22.31% [ESKD = 26%, CKD3D = 10%]. Insomnia, depression and anxiety were found in 76.15%, 91.15% and 44.23%, respectively. Insomnia was correlated with depression (r = 0.488, p = 0.001) and anxiety (r = 0.360, p = 0.006) but not RLS. Multiple linear regression analysis showed that ESKD (OR = 3.8, 95%CI = 2.5-8.5, p = 0.001), inadequate dialysis (OR = 4.6, 95%CI = 3.5-8.6, p = 0.001), hyperparathyroidism (OR = 5.1, 95%CI 3.2-13.7, p = 0.0001) and peripheral neuropathy (OR = 5.6, 95%CI = 3.8-12.8, p = 0.0001) were independently associated with RLS. CONCLUSION The prevalence of RLS with CKD is 22.31%. It is 2.6 times more frequent and severe with ESKD compared to CKD3D. It seems that RLS may occur early with CKD and becomes worse with progressive kidney impairment. Also, insomnia, depression and anxiety are common with CKD, however, their severities were not correlated with RLS. Predictors for RLS were ESKD, inadequacy of dialysis, hyperparathyroidism and peripheral neuropathy.
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Affiliation(s)
- Sherifa Ahmed Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt
| | | | | | - Mohamed Fawzy
- Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt
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Fulda S, Allen RP, Earley CJ, Högl B, Garcia-Borreguero D, Inoue Y, Ondo W, Walters AS, Williams AM, Winkelman JW. We need to do better: A systematic review and meta-analysis of diagnostic test accuracy of restless legs syndrome screening instruments. Sleep Med Rev 2021; 58:101461. [PMID: 33838561 DOI: 10.1016/j.smrv.2021.101461] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
This systematic review and meta-analysis evaluated the diagnostic accuracy of screening instruments for restless legs syndrome (RLS) and reports sensitivity, specificity, positive (PPV) and negative predictive values (NPV). Searches for primary studies were conducted in electronic databases. Of the 1541 citations identified, 52 were included in the meta-analysis. The methodological quality of each study was evaluated using QUADAS-2. Only 14 studies assessed the reference standard in all participants or in all screen-positives and a selection of screen-negatives. Bivariate meta-analysis of these 14 studies estimated median sensitivity to be 0.88 (0.72-0.96) and specificity 0.90 (0.84-0.93); based on a population prevalence of 5%, the calculated PPV was 0.31 (0.27-0.34). For all 52 studies, with either full or partial verification of RLS status, we constructed best-case scenario sensitivities and specificities at pre-defined levels of prevalence: across all samples, when prevalence is 5%, the median best-case scenario PPV is 0.48 with significant between-study heterogeneity. No RLS screening instruments can currently be recommended for use without an expert clinical interview in epidemiological studies. For conditions with statistically low prevalence such as RLS, the specificity, not the sensitivity, of a screening instrument determines true prevalence. Therefore, future instruments should maximize specificity. We provide guidelines on RLS ascertainment in epidemiological studies that requires a two-step process with clinical interview following a screening test, and given the poor reporting quality of many RLS epidemiological studies, we include an RLS reporting checklist.
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Affiliation(s)
- Stephany Fulda
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Via Tesserete 46, 6903, Lugano, Switzerland.
| | - Richard P Allen
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Birgit Högl
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | | | - Yuichi Inoue
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan; Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - William Ondo
- Methodist Neuroscience Institute, Dept. of Neurology, Houston, TX, USA; Weill Cornell Medical School, New York, NY, USA
| | - Arthur S Walters
- Sleep Division, Dept of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Guay A, Houle M, O'Shaughnessy J, Descarreaux M. Current Evidence on Diagnostic Criteria, Relevant Outcome Measures, and Efficacy of Nonpharmacologic Therapy in the Management of Restless Legs Syndrome (RLS): A Scoping Review. J Manipulative Physiol Ther 2020; 43:930-941. [PMID: 32900545 DOI: 10.1016/j.jmpt.2020.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 04/13/2020] [Accepted: 05/13/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this scoping review is to outline the current evidence regarding the management of restless legs syndrome (RLS) with nonpharmacologic approaches. To categorize the efficacy of conservative approaches in reducing symptoms of RLS, we have identified and summarized the current data regarding diagnostic criteria and relevant outcome measures, to inform future research and to guide clinical practice. METHODS A scoping review was conducted using the National Center for Biotechnology Information; EBSCO; the Manual, Alternative and Natural Therapy Index System; the Cumulative Index to Nursing & Allied Health Literature; and Scopus. All literature related to RLS was extracted, screened, and reviewed based on titles and abstract contents. The authors then extracted data from the 24 admissible studies, that is, the ones about manual therapy, exercises, and alternative treatments for RLS. The Physiotherapy Evidence Database scale was used to rate the methodological quality of the included randomized controlled trials by 2 independent readers. RESULTS In the 24 articles fulfilling the selection criteria, there was a consistent trend in the findings showing positive results in lowering RLS symptom severity. Most clinical studies based their diagnosis on the International Restless Legs Syndrome Study Group diagnostic criteria; the International Restless Legs Syndrome Study Group rating scale was the most often used outcome measure. The efficacy of exercise, yoga, massage, acupuncture, traction straight leg raise, cryotherapy, pneumatic compression devices, whole-body vibration, transcranial and transcutaneous stimulation, and near-infrared lights showed different effects on RLS symptom severity, and the level of evidence was evaluated. CONCLUSION Our results showed clinically significant effects for exercises, acupuncture, pneumatic compression devices, and near-infrared light. Short-lasting effects were identified with whole-body cryotherapy, repetitive transcranial stimulation, and transcutaneous stimulation. More studies are necessary to investigate efficacy of yoga, massage, traction straight leg raise, and whole-body vibration. No adverse effects were identified for moderate-intensity exercise, yoga, massage, and pneumatic compression devices.
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Affiliation(s)
- Alexe Guay
- Département des Sciences de l'Activité Physique, University of Quebec at Trois-Rivieres, Trois-Rivières, Québec, Canada
| | - Mariève Houle
- Département des Sciences de l'Activité Physique, University of Quebec at Trois-Rivieres, Trois-Rivières, Québec, Canada
| | - Julie O'Shaughnessy
- Département de Chiropratique, University of Quebec at Trois-Rivieres, Trois-Rivières, Québec, Canada
| | - Martin Descarreaux
- Département des Sciences de l'Activité Physique, University of Quebec at Trois-Rivieres, Trois-Rivières, Québec, Canada.
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Guney I, Biyik Z, Gencer V, Akgül YSS. Restless legs syndrome and arterial stiffness in pre-dialysis chronic kidney disease. Sleep Biol Rhythms 2020. [DOI: 10.1007/s41105-020-00268-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Restless Leg Syndrome in Peripheral Artery Disease: Prevalence among Patients with Claudication and Benefits from Low-Intensity Exercise. J Clin Med 2019; 8:jcm8091403. [PMID: 31500156 PMCID: PMC6780675 DOI: 10.3390/jcm8091403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/1970] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/24/2022] Open
Abstract
Restless leg syndrome (RLS) disrupts sleep, affecting the quality of life of patients with various chronic diseases. We assessed the prevalence of RLS in peripheral artery disease (PAD) patients and the effects of a pain-free exercise program. A total of 286 patients with claudication were enrolled in a home-based low-intensity exercise program prescribed at the hospital. RLS was determined through standardized questions. Hemodynamics, degree of calf deoxygenation, and mobility were assessed using the ankle-brachial-index, a treadmill test assisted by near-infrared spectroscopy and the 6-min walk test, respectively. During hospital visits, persistence of RLS, adherence to exercise, hemodynamics, and mobility were assessed. At the enrollment, 101 patients (35%) presented RLS, with higher prevalence among females (p = 0.032). Compared to RLS-free patients, they showed similar hemodynamics but more severe calf deoxygenation (p < 0.001) and lower mobility (p = 0.040). Eighty-seven RLS patients (83%) reported the disappearance of symptoms after 39 (36−70) days of exercise. This subgroup, compared to nonresponders, showed higher adherence (p < 0.001), hemodynamic (p = 0.041), and mobility improvements (p = 0.003). RLS symptoms were frequent in PAD but were reduced by a pain-free walking exercise aimed at inducing peripheral aerobic adaptations. The concomitant recovery of sleep and mobility may represent a synergistic action against the cardiovascular risk in PAD.
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Calviño J, Cigarrán S, Gonzalez-Tabares L, Guijarro M, Millán B, Cobelo C, Cillero S, Sobrido MJ. Restless Legs Syndrome: An Unresolved Uremic Disorder after Renal Transplantation. Nephron Clin Pract 2018; 139:23-29. [DOI: 10.1159/000486401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/17/2017] [Indexed: 11/19/2022] Open
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DeFerio JJ, Govindarajulu U, Brar A, Cukor D, Lee KG, Salifu MO. Association of restless legs syndrome and mortality in end-stage renal disease: an analysis of the United States Renal Data System (USRDS). BMC Nephrol 2017; 18:258. [PMID: 28764654 PMCID: PMC5540277 DOI: 10.1186/s12882-017-0660-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 07/10/2017] [Indexed: 11/24/2022] Open
Abstract
Background Objective of the study is to assess prevalence and survival among end stage renal disease patients with restless legs syndrome (RLS) within a national database (USRDS). Methods A case-control, retrospective analysis was performed. Differences in characteristics between the groups, RLS and those with no sleep disorder (NSD), were determined using χ2 tests. Cox proportional hazard regression was used to assess survival between those with RLS and propensity score matched controls. Results Cases of restless legs syndrome were defined as patients that had received an ICD-9 code of 333.94 at any point during their treatment (n = 372). RLS group demonstrated a significantly higher proportion of patients with major depressive disorder, dysthymic disorder, anxiety, depression, minor depressive disorder, and psychological disorder. The difference between the survival was not statistically significant in those without sleep disorder as compared to those with RLS (HR =1.16±0.14, p = 0.3). Conclusions True prevalence of RLS in dialysis patients can only be estimated if knowledge gap for care providers in diagnosis of RLS is addressed. RLS patients also have increased incidence of certain psychological disorders which needs to be addressed. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0660-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph J DeFerio
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Usha Govindarajulu
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Amarpali Brar
- Division of Nephrology, Department of Medicine, SUNY Downstate Medical Center, 450 Clarkson Ave, Box 52, Brooklyn, NY, 11203, USA
| | - Daniel Cukor
- Department of Psychiatry and Behavioral Science, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Kathleen G Lee
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Moro O Salifu
- Division of Nephrology, Department of Medicine, SUNY Downstate Medical Center, 450 Clarkson Ave, Box 52, Brooklyn, NY, 11203, USA.
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Szentkirályi A, Völzke H, Hoffmann W, Dörr M, Hense HW, Berger K. Ankle-brachial index and peripheral artery disease are not related to restless legs syndrome. Sleep Med 2017; 35:74-79. [PMID: 28619186 DOI: 10.1016/j.sleep.2017.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Our aim was to investigate the relationship between impaired peripheral arterial circulation as measured by ankle-brachial index (ABI) and restless legs syndrome (RLS) in the general population. METHODS Data are derived from three independent, German population-based, prospective studies: the control sample of BiDirect (N = 966), the second follow-up of SHIP (N = 2333), and a subsample of SHIP-Trend (N = 1269). RLS was assessed with questions based on the RLS minimal criteria. ABI was measured with an automated method in BiDirect and with Doppler ultrasound in both SHIP studies. An ABI score below 0.9 was indicative of peripheral arterial disease (PAD). Co-morbidities, medications and behavioural factors were self-reported. Additional measurements included body mass index and haemoglobin from blood serum. For BiDirect, a follow-up with identical methodology was performed after a median of 2.5 years. RESULTS In cross-sectional analyses, decreased ABI was not significantly associated with RLS as outcome in multivariable logistic regression models adjusted for several potential confounders (BiDirect: odds ratio (OR) = 1.07 for a -0.1 change in ABI, 95% confidence interval (CI): 0.81-1.42, p = 0.62; SHIP-2: OR = 0.99, CI: 0.85-1.16, p = 0.94; SHIP-Trend: OR = 0.99, CI: 0.87-1.13, p = 0.88). Similar non-significant results were achieved using PAD (instead of ABI) as an independent variable. In BiDirect, baseline ABI was not a significant predictor of incident RLS in longitudinal analysis (OR = 0.77, CI: 0.53-1.12, p = 0.17). CONCLUSION Results from three independent studies suggest that reduced ABI is not a risk factor for RLS in the general population.
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Affiliation(s)
- A Szentkirályi
- Institute of Epidemiology and Social Medicine, Westfälische Wilhelms-Universität Münster, Germany.
| | - H Völzke
- Institute for Community Medicine, University Medicine Greifswald, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, Germany
| | - W Hoffmann
- Institute for Community Medicine, University Medicine Greifswald, Germany; German Centre for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - M Dörr
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, Germany; Department of Internal Medicine B, University Medicine Greifswald, Germany
| | - H W Hense
- Institute of Epidemiology and Social Medicine, Westfälische Wilhelms-Universität Münster, Germany
| | - K Berger
- Institute of Epidemiology and Social Medicine, Westfälische Wilhelms-Universität Münster, Germany; German Centre for Diabetes Research, Partner Site Münster, Germany
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Cabrera VJ, Hansson J, Kliger AS, Finkelstein FO. Symptom Management of the Patient with CKD: The Role of Dialysis. Clin J Am Soc Nephrol 2017; 12:687-693. [PMID: 28148557 PMCID: PMC5383375 DOI: 10.2215/cjn.01650216] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Valerie Jorge Cabrera
- Department of Medicine, Section of Nephrology, Yale University, New Haven, Connecticut; and
| | - Joni Hansson
- Department of Medicine, Section of Nephrology, Yale University, New Haven, Connecticut; and
| | - Alan S. Kliger
- Yale New Haven Health System–Performance Management, New Haven, Connecticut
| | - Fredric O. Finkelstein
- Department of Medicine, Section of Nephrology, Yale University, New Haven, Connecticut; and
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Lin Z, Zhao C, Luo Q, Xia X, Yu X, Huang F. Prevalence of restless legs syndrome in chronic kidney disease: a systematic review and meta-analysis of observational studies. Ren Fail 2016; 38:1335-1346. [PMID: 27765002 DOI: 10.1080/0886022x.2016.1227564] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Nowadays prevalence of restless legs syndrome (RLS) in chronic kidney disease (CKD) patients was reported in many studies, while the results varied. The aim of our study was to investigate the prevalence of RLS in this population, considering different data collecting measures and diagnostic criteria. METHODS MEDLINE, Embase, PsycINFO, and Scopus databases were searched for relevant studies. We limited the analyses to studies using clinical interview or questionnaire for diagnosis. Univariate meta-regression analysis was preformed to assess the effects of the disease-related covariates on prevalence estimates. Comprehensive Meta-Analysis 2.0 was used to perform the meta-analysis. RESULTS Fifty-one studies were included in the analysis. Prevalence of RLS was varied by renal function and diagnostic methods. Overall prevalence in CKD populations was 24.2% (95%CI, 20.1-28.7). Pooled prevalence of RLS was higher in patients diagnosed by questionnaire than by clinical interview [26.2% (95%CI, 17.9-36.5) vs. 23.6% (95%CI, 19.6-28.1)]. When grouped by CKD setting, the prevalence was 28.4% (95%CI, 24.6-32.6) in dialysis patients, followed by early stages patients [9.9% (95%CI, 5.4-17.5)], and kidney transplant recipients [6.7% (95%CI, 5.6-7.8)]. CONCLUSIONS Our meta-analysis suggested that more than one-quarter of CKD sufferers, especially those who were on dialysis, were plagued by RLS. Higher sensitivity of diagnostic criteria in interview may be valuable for timely treatment.
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Affiliation(s)
- Zhenchuan Lin
- a Department of Nephrology , The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health , Guangzhou , China
| | - Chen Zhao
- a Department of Nephrology , The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health , Guangzhou , China
| | - Qimei Luo
- a Department of Nephrology , The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health , Guangzhou , China
| | - Xi Xia
- a Department of Nephrology , The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health , Guangzhou , China
| | - Xueqing Yu
- a Department of Nephrology , The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health , Guangzhou , China
| | - Fengxian Huang
- a Department of Nephrology , The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health , Guangzhou , China
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