End-Stage Renal DiseaseSleep Disturbance in Patients with Advanced Chronic Kidney Disease or End-Stage Renal Disease
Creators: name: Kennedy, Claire
Publisher: name: Royal College of Surgeons in Ireland
Year: 2020
Subjects: subject: 119999 Medical and Health Sciences not elsewhere classified
subject: FOS: Other medical sciences
subject: FOS: Other medical sciences

description: Patients with advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD) have a large burden of symptoms, with sleep disturbance, restless legs syndrome and fatigue among the most prevalent (1). These sleep-related symptoms are considered an absolutepriority for both treatment and research by patients and their caregivers (2). Despite this, clinicians consistently underestimate and overlook these symptoms in clinical encounters (3). The impact of RRT modality choiceon such symptoms is not well defined and is poorly communicated to patients choosing between modalities. In fact, communication regarding the impact of modality choice is so poor that patients consistently reportfeeling excluded entirely from ‘shared decision-making’ (4). It is critical that physicans consider the impact of RRT modality on all aspects of patient care, including sleep, engage patients in this major decision, andcommunicate in outcomes that patients understand and value (such as symptoms and quality of life).Disturbed sleep has a major negative impact on health-related quality of life, mood, and neurocognitive function. There is a growing body of evidence suggesting that sleep disturbance in general, and some of the specific sleep disorders in particular, are independent cardiovascular riskfactors (5). The American Heart Association called for promotion of healthy sleep along with other risk factor modifications in their 2019 scientific statement (6). Patients with advanced CKD or ESRD are already at high cardiovascular risk, and any modifiable element to this risk should be aggressively managed. The impact of initiating a particular RRT modality or changing RRTmodality on sleep-related symptoms is not well understood, particularly in the case of the nocturnal therapies, where alarms and anxiety maycounteract any positve effects of improved uraemia and extracellular fluid volume control. My published, peer-reviewed, systematic review aimed toassess the impact of a change in RRT modality on sleep quality in patients with ESRD (7). Sixteen heterogeneous studies, with a combinedtotal of 670 patients and 191 controls, were included. Meta-analysis of the sixteen studies favoured increased intensity RRT (either intensivehemodialysis (HD), automated peritoneal dialysis (APD) or transplant) over conventional RRT (conventional HD or continuous ambulatory peritoneal dialysis (CAPD)) in terms of overall sleep quality, with statisticalsignificance. Restless legs syndrome (RLS) and sleep apnoea also improved in the majority of patients following a switch to increased intensity RRT. This cohort study assessed sleep quality in sixty patients (unselected forsleep disturbance) with advanced CKD or ESRD. There was a high prevalence of self-reported poor sleep quality (54%), RLS, (44%) and excessive daytime sleepiness (22%). Polysomnography (PSG) andactigraphy studies identified marked sleep fragmentation and distorted sleep architecture, with longer time than usual spent in the lighter stages of sleep, and shorter time than usual spent in the deeper, restorativestages of sleep. Sleep apnoea and abnormal periodic limb movements (PLMs) were also highly prevalent (44% and 47% respectively). Markedbenefits in terms of sleep quality, health related quality of life (HRQoL) and sleep apnoea were demonstrated post-transplant in the subgroup thatwere transplanted. Many parameters of subjective and objective sleep quality improved after either initiating dialysis from chronic kidney disease(CKD) or optimisation dialysis in those already on some form of dialysis.There was a high prevalence (44%, n=14) of sleep apnoea in the 32 patients that underwent baseline PSG, with older age as an independent risk factor. Screening tools (such as the Epworth Sleepiness Scale) andactigraphy did not accurately predict the diagnosis or obviate the need for PSG for the diagnosis. 70% of patients with an abnormal apnoeahypopnoeaindex (AHI) had subjective and / or objective improvementwith initiation of continuous positive airways pressure (CPAP) or optimisation of RRT. As there is emerging evidence that sleep apnoea is an independent cardiovascular risk factor in ESRD, the concept of treatingsleep apnoea and potentially improving the cardiovascular risk profile is an appealing one (8).RLS and abnormal PLMs were also prevalent (45% and 47% respectively). Increased age was, again, an independent risk factor. Actigraphy did not predict an abnormal PLM index but was useful inselected cases. 73% of patients with an abnormal PLM index had subjective and / or objective improvement with pharmacologic therapy oroptimisation of RRT. As there is emerging evidence that PLMs are associated with nocturnal hypertension and increased cardiovascular riskin ESRD, the concept of treating them and modifying this risk is, again,appealing (9).With regard to screening for sleep disturbance, the individual questionnaires performed poorly in terms of predicting their specific outcome of interest in this study cohort. However, the Pittsburgh Sleep Quality Index (PSQI) proved useful in identifying those patients who hadsleep disturbance in general (rather than a specific problem). Paired actigraphy and PSG analyses showed good agreement for sleep efficiency and time spent awake after sleep onset. The PSQI and wristactigraphy may, therefore, help to triage patients for PSG assessment in jurisdictions with limited PSG access. There were no safety issues with the 55 unattended home PSG studies and seventy actigraphy studies,including those performed during nocturnal dialysis (PD or HD). To conclude, sleep disorders are highly prevalent, easily and safely studied with unattended home PSG and eminently modifiable in stable outpatients with advanced CKD or ESRD. Given that the sleep disordershave such a negative impact on clinical outcomes in these patients, identification and management of sleep disorders should be a priority in Nephrology clinics. With ongoing dissemination of these research findings, we hope to highlight the prevalence of sleep disorders in thispopulation, guide appropriate investigations, facilitate discussions regarding modality choice, encourage patients and doctors to intensify dialysis, and ultimately contribute to improved management of sleep disorders and patient outcomes in patients with advanced CKD or ESRD.