Saudi Journal of Kidney Diseases and Transplantation

: 2020  |  Volume : 31  |  Issue : 2  |  Page : 454--459

A prospective study on prevalence and causes of insomnia among end-stage renal failure patients on hemodialysis in selected dialysis centers in Qassim, Saudi Arabia

Rand Suliman Alkhuwaiter, Raneem Ahmad Alsudais, Amal Ahmed Ismail 
 Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, Qassim, Saudi Arabia

Correspondence Address:
Amal Ahmed Ismail
Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, P. O. Box 5888, Unaizah 51911, Qassim
Saudi Arabia


Studies directed toward improving the life quality of hemodialysis (HD) patients revealed different etiologies for insomnia. We aimed to assess the prevalence of insomnia and determine associated etiologies in the AL Qassim region. This interview-based questionnaire study was conducted in HD centers for assessment of insomnia and its related causes using a validated screening questionnaire, developed by the JPS health network. Accordingly, patients were classified as insomnia, insomnia for further evaluation and management and no insomnia. Of 111 patients, there were 55 males and 56 females. The prevalence of primary insomnia was 28.82%, compared to 44% for secondary insomnia. Significant correlations linked insomnia with apnea, night itching, and not using phosphate binder usage. Primary and secondary insomnia is frequent among dialysis patients and require an application of diagnostic tools and severity scales. The assessment of causes and treatment of the complaints of apnea, usage of phosphate binders, and itching should be considered to decrease complications and improve quality of life.

How to cite this article:
Alkhuwaiter RS, Alsudais RA, Ismail AA. A prospective study on prevalence and causes of insomnia among end-stage renal failure patients on hemodialysis in selected dialysis centers in Qassim, Saudi Arabia.Saudi J Kidney Dis Transpl 2020;31:454-459

How to cite this URL:
Alkhuwaiter RS, Alsudais RA, Ismail AA. A prospective study on prevalence and causes of insomnia among end-stage renal failure patients on hemodialysis in selected dialysis centers in Qassim, Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Aug 4 ];31:454-459
Available from:

Full Text


Renal failure is a debilitating disease having a major impact on patients’ quality of life. Not only because of suffering from different symptoms daily but also because of structural changes of the body due to edema, presence of arteriovenous fistula or a central venous catheter, let alone having to spend time and money on dialysis process.[1]

Over the last 10-15 years, there has been an increasing interest in studying sleep disorders in patients on maintenance dialysis.[2] A 30%- 80% prevalence of sleep disorders has been reported among patients of hemodialysis with insomnia as the most frequent disorder.[3]

End-stage renal failure is a frequent problem in Saudi Arabia.[4] The number of patients attending hemodialysis (HD) sessions is growing with an estimated annual increase of approximately 8.6%.[5],[6] According to the International Classification of Sleep Disorders - Third Edition (ICSD-3) criteria, insomnia was defined as persistent difficulty with sleep initiation, duration, consolidation or quality that occurs despite the opportunity and circumstances for sleep, which results in some type of disability during the day.[7] that means it is characterized by one or more of the following symptoms: difficulty of initiating sleep (“sleep onset insomnia”), difficulty in maintaining continuous sleep (“sleep maintenance insomnia:), early awakening or poor sleep quality (“non- restorative sleep”).[8]

Secondary insomnia occurs as a result of co- morbidly in association with a medical, psychiatric, or psychological process. It can occur in association with different types of disorders like in pain of rheumatoid arthritis.[9] It is associated with daytime sleep impairment. Accurate estimates of prevalence and incidence are not available due to the limitations of the assessment of the stressors in current epidemiological research.[10],[11],[12]

Many studies described the prevalence of insomnia in renal failure patients noted that it is greater in dialysis patients and reported to range from 45% to 59%.[13],[14],[15],[16] Uremic patients has greater daytime consequences compared to the general population.[17],[18] Elderly patients, those with longer dialysis duration, frequent dialysis shifts and those with high levels of parathyroid hormone (PTH) or diabetes mellitus (DM) are expected to have a higher incidence of insomnia, while the studies found no significant associations between dialysis type, biochemical parameters, and insomnia.[19]


A quantitative descriptive cross-sectional study was designed and ethically approved by the regional research ethics committee of the Qassim region. The study was conducted during the period between January and March 2018. All patients attending the selected dialysis centers in four of the major cities in the Qassim region (Buraydah, Unaizah, Albukairya, and Alrass) were included. After applying the exclusion criteria, i.e., patients, who were <18 years, unstable patients, and patients who refused to be interviewed, only 111 could be included in the study. Participants were informed about the purpose of the study first, and they signed a written approval to conduct the interview. We interviewed patients in HD centers to answer a validated insomnia-screening questionnaire. It is a screening tool to find out insomnia symptoms necessary for diagnosis through a Likert type questionnaire questions which were designed by the JPS health network to help clinicians to screen patients for insom- nia.[20] The selected assessment tool composed of questions covering different valuable items diagnosing insomnia, psychiatric disorders, circadian rhythm disorder, movement disorders, parasomnias, and sleep apnea. In addition, additional questions were related to insomnia causes were added, and it was translated forward into Arabic and backward into English and double-checked. Data were analyzed using the IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA). The internal consistency of the questionnaire was assessed by Cronbach’s alpha and was acceptable (0.716). Statistical frequencies, cross-tabulations, and correlations were done between insomnia and suggested causes. Assessment of insomnia questionnaire responses was applied, and accordingly, patients were classified into four groups; those without insomnia, likely insomnia, insomnia for further diagnosis and management (secondary insomnia), insomnia (primary insomnia).


Of the 111 interviewed patients, there were 55 males and 56 females with a median age of 56.77 years. DM was reported by half of the patients [Table 1]. Sixty-nine (62.2%) of HD patients stated that they are having a good sleep [Figure 1]. The prevalence of primary insomnia found to be 32 (28.82%), while the prevalence of secondary insomnia among participants was 49 (44%) [Figure 2].{Figure 1}{Figure 2}{Table 1}

About13.5% are always complaining of a medical condition preventing them from sleeping. Fifty-five percent of the patients are complaining of itching at night [Figure 3], and 56% of them are not taking phosphate binders. More than half (55%) are complaining of bone pain, moreover 65% are taking caffeine at bedtime and 50% have a morning shift of dialysis. Furthermore, we found that 27% are always suffering from restless leg syndrome and parasomnia was described by 6.3% and 15.3 complained of snoring always.{Figure 3}

Complaint of apnea showed a significant correlation with insomnia (P 0.001). The result showed positive significant correlation with night itching P 0.005) and not using phosphate chelator (P 0.007).


ESRD patients are suffering from different medical conditions as a complication of their disease. This is why secondary insomnia management can improve HD patient’s quality of life, but cases first need to be identified. In our study, we choose to use questionnaire for assessing not only primary insomnia but also screen cases of secondary insomnia who needs further management.

Definition of insomnia based on questionnaire questions was based on identifying (difficulty falling asleep, difficulty staying asleep, or non-refreshing sleep in a patient who has the opportunity to acquire a normal night’s sleep of 7-8 h. However, the insomnia is only clinically relevant if the patient presents with insomnia in combination with daytime dysfunction or distress such as fatigue, poor concentration, and irritability.[21] During the short duration of the study, 111 interviews were held with equal numbers of male and female with a median age 60 what gives a 50% probability of insomnia in our population to be directly caused by aging,[22] we noticed that primary insomnia was more in the age group 20-40. Primary insomnia increases the risk of getting depression among HD patients and carrying a worse prognosis for patients. Females were more primarily insomniacs, while males were the dominant group in secondary insomnia in comparison with previous studies reported that females have more insomnia than males.[17] We found that 50% of the patients had DM which is one of the risk factors of insomnia among HD patients.[22] Results of this study showed higher prevalence of secondary insomnia, but less of primary than similar other studies which were ranging between 45 and 70.[16],[17],[21] However, the difference in studies tools make it difficult to compare results let alone the different sample size among studies. Duration of dialysis relation to insomnia showed insignificant results in our study compared with Sabbatini study[17] that discussed the effect of dialysis duration on the occurrence of insomnia among patients.

The relationship between insomnia and restless leg syndrome was insignificant, and this can be due to a low number of RLS cases among participating patients in comparison with other studies in which restless syndrome was frequent.[17] Night itching was a significant problem in relation to insomnia and may be due to high levels of blood urea or as a result of a disturbance in phosphorus concentration level in the blood of patients, which is not effectively controlled in those not on phosphate chelators. This was supported by the significant statistical correlations, and this can be associated with abnormally very high levels of parathyroid hormone which affects the melatonin level secretion resulting in insomnia, circadian rhythm changes and daytime impairment hence there is a need to assess patients biochemical markers and follow serum parathyroid and phosphorus which was a limitation in our study.

Insomnia in our participant patients was not related to caffeine intake, and this can be due to genetic polymorphism and different responses to caffeine effects on sleeping.[23] Sleep apnea although not frequent in our patients but strongly associated with insomnia similar with results by Roumelioti and his research group.[24]

The diagnosis of insomnia requires to be confirmed by polysomnography, actigraphy and sleeping diary for follow up.[1]


Primary and secondary insomnia is frequent in HD patients and further studies with a larger population and longer follow up duration with sleep diaries and confirmation of diagnosis on the screened cases by polysomnography, acti- graphy accompanied by serum level of parathyroid hormone and renal function parameters. Identification of cases of insomnia to start management will have a positive impact not only on the patient quality of life but also on the prognosis of their disease progression and minimize complications.


We express our gratitude to all patients who participated in this study and for the deanship of Unaizah College of Pharmacy and to everyone who helped us in this work.

Conflict of interest: None declared.


1Ginieri-Coccossis M, Theofilou P, Synodinou C, Tomaras V, Soldatos C. Quality of life, mental health and health beliefs in haemodia- lysis and peritoneal dialysis patients: Investigating differences in early and later years of current treatment. BMC Nephrol 2008;9:14
2Holley J, Nespor S, Rault R. A comparison of reported sleep disorders in patients on chronic hemodialysis and continuous peritoneal dialysis. Am J Kidney Dis 1992;19:156-61
3Parker KP. Sleep disturbances in dialysis patients. Sleep Med Rev 2003;7:131-43
4Ibrahim MA, Kordy MN. End-stage renal disease (ESRD) in Saudi Arabia. Asia Pac J Public Health 1992;6:140-5
5Shaheen FA, Al-Khader AA. Epidemiology and causes of end stage renal disease (ESRD). Saudi J Kidney Dis Transpl 2005;16:277-81
6Jondeby MS, De-Los Santos GG, Al-Ghamdi AM, et al. Caring for hemodialysis patients in Saudi Arabia. Past, present and future. Saudi Med J 2001;22:199-204
7International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014
8Roth T. Sleep Medicine Clinics: Insomnia. Vol. 1. Philadelphia: W.B. Saunders Company; 2006
9National Institutes of Health State-of-the- Science Conference Statement: Manifestations and Management of Chronic Insomnia in Adults; August, 2005. [Last accessed on 21 December 2017]
10Morin CM, LeBlanc M, Daley M, Gregoire JP, Merette C. Epidemiology of insomnia: Prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med 2006;7:123-30
11Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. Recommendations for a standard research assessment of insomnia. Sleep 2006;29:1155-73
12Ohayon MM. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111
13Meyer TJ. Evaluation and management of insomnia. Hosp Pract (1995) 1998;33:75-8, 83-6
14Terzano MG, Parrino L, Cirignotta F, et al. Studio Morfeo: Insomnia in primary care, a survey conducted on the Italian population. Sleep Med 2004;5:67-75
15Leger D, Guilleminault C, Dreyfus JP, Delahaye C, Paillard M. Prevalence of insomnia in a survey of 12,778 adults in France. J Sleep Res 2000;9:35-42
16Iliescu E, Yeates K, Holland D. Quality of sleep in patients with chronic kidney disease. Nephrol Dial Transplant 2004;19:95-9
17Sabbatini M. Insomnia in maintenance hemodialysis patients. Nephrol Dial Transplant 2002;17:852-6
18Merlino G, Piani A, Dolso P, et al. Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy. Nephrol Dial Transplant 2006;21:184-90
19Merlino G, Gigli GL, Valente M. Sleep disturbances in dialysis patients. J Nephrol 2008;21 Suppl 13:S66-70
20Clinical Practice Guideline Adult Insomnia: Assessment of Diagnosis; 2007
21Al-Jahdali HH, Khogeer HA, Al-Qadhi WA, et al. Insomnia in chronic renal patients on dialysis in Saudi Arabia. J Circadian Rhythms 2010;8:7
22Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: Results of the 2003 National Sleep Foundation Sleep in America Survey. J Psychosom Res 2004;56:497-502
23Yang A, Palmer AA, de Wit H. Genetics of caffeine consumption and responses to caffeine. Psychopharmacology (Berl) 2010; 211:245-57
24Roumelioti ME, Buysse DJ, Sanders MH, Strollo P, Newman AB, Unruh ML. Sleep- disordered breathing and excessive daytime sleepiness in chronic kidney disease and hemodialysis. Clin J Am Soc Nephrol 2011; 6:986-94.