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| Year : 2010 | Volume
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| Issue : 2 | Page : 300-305 |
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| Sleep disorders in hemodialysis patients |
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Alaa A Sabry1, Hamdy Abo-Zenah2, Ehab Wafa1, Khaled Mahmoud1, Khaled El-Dahshan1, Ahmed Hassan1, Tarek Medhat Abbas1, Abd El-Baset M Saleh3, Kamal Okasha4
1 Mansoura Urology and Nephrology Center, Mansoura University, Egypt
2 Menuifiya University Faculty of Medicine, Tanta University, Egypt
3 Thoracic Medicine Department (Sleep-Disordered Breathing Unit), Mansoura University, Egypt
4 Department of Internal medicine, Division of nephrology, Tanta University, Egypt
Click here for correspondence address and email
| Date of Web Publication | 9-Mar-2010 |
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 Abstract | | |
The prevalence of sleep disorders is higher in patients with kidney failure than the general population. We studied the prevalence of sleep disorders in 88 (mean age; 41.59 ± 16.3 years) chronic hemodialysis (HD) patients at the Urology and Nephrology Center, Mansoura University, Egypt over 4-month period. The investigated sleep disorders included insomnia, restless leg syndrome (RLS), obstructive sleep apnea syndrome (OSAS), excessive daytime sleepiness (EDS), narcolepsy and sleep walking, and we used a questionnaire in accordance with those of the International Restless Legs Syndrome Study Group, the Berlin questionnaire, Italian version of Epworth Sleepiness Scale, International Classification of Sleep Disorders, and the specific questions of Hatoum's sleep questionnaire. The prevalence of sleep disorders was 79.5% in our patients, and the most common sleep abnormality was insomnia (65.9%), followed by RLS (42%), OSAS (31.8%), snoring (27.3%), EDS (27.3%), narcolepsy (15.9%), and sleep walking (3.4%). Insomnia correlated with anemia (r=0.31, P= 0.003), anxiety (r=0.279, P= 0.042), depression (r=0.298, P= 0.24) and RLS (r=0.327, P= 0.002). Also, RLS correlated with hypoalbuminemia (r=0.41, P= < 0.0001), anemia (r=0.301 and P= 0.046), hyperphosphatemia (r=0.343 and P= 0.001). EDS correlated with OSAS (r=0.5, P= < 0.0001), snoring (r=0.341, P= 0.001), and social worry (r=0.27, P= 0.011). Sleep disorders are quite common in the HD patients, especially those who are anemic and hypoalbuminemic. Assessment of sleep quality, preferably with polysomnography, is necessary to confirm our results. Interventional studies for management of sleep disorders in HD patients are warranted.
How to cite this article:
Sabry AA, Abo-Zenah H, Wafa E, Mahmoud K, El-Dahshan K, Hassan A, Abbas TM, Saleh ABM, Okasha K. Sleep disorders in hemodialysis patients. Saudi J Kidney Dis Transpl 2010;21:300-5 |
How to cite this URL:
Sabry AA, Abo-Zenah H, Wafa E, Mahmoud K, El-Dahshan K, Hassan A, Abbas TM, Saleh ABM, Okasha K. Sleep disorders in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Nov 28];21:300-5. Available from: https://www.sjkdt.org/text.asp?2010/21/2/300/60199 |
| Introduction | |  |
Sleep disorders affect the majority of chronic kidney disease (CKD) patients. [1] Some investigators hypothesized that end-stage renal disease (ESRD) directly influences the quality of sleep. [2] Interestingly, 80% of hemodialysis or peritoneal dialysis patients suffer from sleep abnormalities, [3] and the prevalence is higher than that in the general population. The most frequently reported complaints are insomnia, restless leg syndrome (RLS), sleep-disordered breathing and excessive daytime sleepiness (EDS). [5]
The causal link between conventional dialysis and sleep dissatisfaction remains speculative, [6] while psychological causes such as anxiety and depression, [7],[8] and physical disturbances such as hypertension, muscle cramps, and electrolytes or body fluids imbalances may significantly contribute to the sleep disorders. [5] In addition, primary sleep disorders such as restless legs syndrome (RLS) and sleep-disordered breathing (SDB) are potential contributors. [9]
Recently, Parker et al proposed different etiologies for sleep problems in CKD and chronic HD patients. Functional and psychological factors may play a more prominent role in the former group, while intrinsic sleep disruption may play a more significant role in the latter. [10] Furthermore; there is race influence on the self-reported sleep quality. [11]
We aimed in this study to evaluate the selfreported sleep quality in our hemodialysis population in order to estimate the prevalence of sleep disorders and determine the factors affecting them in this patient population.
| Patients and Methods | | |
We studied 88 chronic HD patients in a crosssectional design, who attended the 3 hemodialysis units of the Urology and Nephrology Center, Mansoura University, Egypt, over 4 months period. The patients were randomly selected for the study, and randomization was done manually, without the use of a computer algorithm, to allocate every other patient on the patients' list. The inclusion criteria included adult patients > 18 years, who consented to participate in the study and were maintained on conventional hemodialysis (CHD) three times per week for at least 6 months. The patients were relatively young (mean age: 41.59 ± 16.3 years) with a male predominance (68.2%).
With the use of a questionnaire-based survey, we examined the prevalence of symptoms that reflect sleep disorders such as insomnia, RLS, OSAS, EDS, narcolepsy, and sleepwalking in our study patients. In order to determine the prevalence of sleep disturbances and the possible effect of demographic or clinical data on sleep patterns, our questionnaire consisted of two parts. The first part was completed by the nephrologists at the dialysis unit and included: demographic data, some information about patient's lifestyle such as smoking, general medical history and pharmacological therapy. The questions concerned with sleep description were guided by the pulmonologist at the Sleep-Disordered Breathing Unit in our university hospital. The following questionnaires were used to design our questionnaire:
- The score for insomnia was done according to the Ohayon method. [12] Those with insomnia but no daytime dysfunction were labeled as having level I, while insomnia and day-time dysfunction was labeled as level 2.
- The International Restless Legs Syndrome Study Group (IRLSSG) to evaluate RLS. [13]
- The Berlin Questionnaire to evaluate OSAS. [14]
- The Italian version of Epworth Sleepiness Scale (ESS) to evaluate EDS as suggested by Vignatelli et al in 2003. A score of > 9 was considered as the minimal criterion for the diagnosis of EDS. [15]
- The International Classification of Sleep Disorders (ICSD) to evaluate narcolepsy. [16]
- Hatoum's sleep questionnaire to evaluate sleep-walking. [17]
The study was approved by the Local Medical Research and Ethics Committee. Informed consent was obtained from all the participants after being informed in detail of the purpose and methods of the study. The study was conducted according to the Good Clinical Practice (GCP) guidelines.
| Statistical Analysis | | |
Analysis was performed using the Statistical Package for Social Science (SPSS) version 10. Data are expressed as mean ± standard deviation (SD) unless stated otherwise. ANOVA single factor, Student's t and Chi-squared tests were used as deemed appropriate. The relation of investigated sleep disorders with the other baseline characteristics was assessed by using spearman's correlation. Odds ratios were taken as approximation of relative risk and expressed with 95% CI for increased urinary albumin excretion in the study population. P value :5 0.05 was considered statistically significant.
| Results | | |
The mean duration of dialysis in our study patients was 54.48 months. Seventeen percent of our patients were smokers. A significant proportion of our cohort suffered from some psychiatric disorders such as anxiety (43.2%), depression (27.2%) and social worry (30.7%). [Table 1] shows the dialysis-associated parameters for our patients. They were adequately dialyzed (Kt/V > 1.2), but hypoalbuminemic and anemic.
The prevalence of sleep disorders was 79.5% in our patients. The most common sleep abnormality was insomnia (65.9%), followed by RLS (42%), OSAS (31.8%), snoring (27.3%), EDS (27.3%), narcolepsy (15.9%), and sleep walking (3.4%).
There was comparable parameters in patients without insomnia and those with level 1 and level 2 of insomnia except for sodium plasma levels (P= 0.022). However, RLS patients with low-risk (< 9) and high-risk (> 9) on Epworth questionnaire were not different regarding their electrolytes level as well as their markers of hemodialysis adequacy.
Insomnia correlated with the presence of anemia (r=0.31 and P= 0.003), anxiety (r=0.279 and P= 0.042), depression (r=0.298 and P= 0.24), and RLS (r=0.327 and P= 0.002). Also, RLS correlated with the presence of hypoalbuminemia (r=0.41 and P= < 0.0001), anemia (r= 0.301 and P= 0.046), and hyperphosphatemia (r=0.343 and P= 0.001). EDS correlated with OSAS (r=0.5 and P= < 0.0001), snoring (r= 0.341 and P= 0.001), and social worry (r=0.27 and P= 0.011). We found no significant correlation between sleep disorders and gender, cause of renal failure (diabetics vs non diabetics), and smoking habits.
As shown in [Table 2], the risk factors for insomnia among our study population were inadequate dialysis, anemia, hypoalbuminemia and RLS. In addition, the risk factors for RLS included anemia, hypoalbuminemia, and hyperphosphatemia [Table 3].
| Discussion | | |
The results of our study show increased pre-valence of sleep disorders in the HD population. The sleep disorders are usually observed in the old age groups, [18],[19] while our patients' mean age was relatively young, which supports more the notion that uremia and its complications are more likely the cause of sleep disorders observed in HD patients than aging.
The prevalence of sleep disorders observed in our patients was nearly similar to that reported elsewhere [20] with lesser, [21],[22] or higher [23] prevalence of insomnia. Varied prevalence was also observed regarding RLS [24],[25] and sleep apnea. [26]
The country to country variability has been recently noted, [27] and could be explained at least in part by the suggested racial influence on self-reported sleep quality. [11]
Interestingly, we found no difference between diabetic and non-diabetic HD patients regarding the associated psychiatric disorders and the investigated sleep disorders, except more prevalent snoring among diabetics. Unruh and co-workers noted that sleep-disordered breathing (SDB) was more common in HD patients with DM. [28]
Anemia was indicative of the most frequently reported sleep abnormalities, insomnia and RLS. Such observation was reported by many inves tigators. [2],[21],[23]
Hypoalbuminemia was recently reported to be associated with lower sleep and even life quality. [29] in our study, we found that hypoalbuminemia increased the odds ratio for insomnia and RLS.
Lower dialysis dose and hyperphosphatemia were highly correlated with sleep disorders in our study. Underdialysis was considered by Chen and colleagues [30] as a factor that increased the likelihood of sleep disruption in hemodialysis patients, while Perl and associates [31] regarded the sleep abnormality as a marker of inadequate dialysis. Also, previous studies showed that higher serum phosphate was associated with a lower sleep quality in maintenance dialysis patients. [32]
RLS increased the odds for sleep disorders in our study patients. Such observation is in agreement with that in other populations. [22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33]
We did not detect any significant correlation between the noticed sleep disruption and age as many other did, [2],[20],[34] possibly because of the relatively young age of our study population. Also, female gender was not a contributing factor for the sleep abnormalities seen in this study as in others. [23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] However, this study and many others [22],[23],[29] found a correlation of psychological factors such as depression, anxiety, and social worry with the sleep quality impairment in chronic HD patients.
We have not noticed any association between cigarette smoking and sleep disorders as many other have observed. [20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35] A simple explanation would be the small percentage (17%) of our study population who were smokers.
Finally, appropriate management of sleep disorders could improve cognitive functions [36] and quality of life. [27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37] Although sleep disorders are not improved by conventional modes of dialysis [38] nocturnal hemodialysis (NHD) has been suggested as a treatment option as it normalizes the higher heart rates and impaired vagal and augmented sympathetic hear rate modulation during sleep with better removal of uremic toxins. [39] Also it increases the pharyngeal cross-sectional area. [40] Furthermore, cool dialysate (35 degrees centigrade) during chronic HD was observed to improve nocturnal sleep. [41]
We conclude that Sleep disorders are quite common in the HD patients, especially those who are anemic and hypoalbuminemic. Assessment of sleep quality, preferably with polysomnography, is necessary to confirm our results. Interventional studies for management of sleep disorders in HD patients are warranted.
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Correspondence Address:
Alaa A Sabry
Assistant Professor of Nephrology, Mansoura Urology and Nephrology Center, Mansoura University
Egypt
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 20228517 
[Table 1], [Table 2], [Table 3] |
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