Restless Legs Syndrome in Patients With Chronic Kidney Disease

Association between Chronic kidney disease and restless leg syndrome (RLS): a systematic review and meta-analysis

Restless leg syndrome (RLS) is characterized by unpleasant nocturnal sensations in the lower limbs, and it has emerged as the fourth leading cause of insomnia and is often an underdiagnosed medical condition among sleep disorders. The symptoms of RLS are more common in chronic kidney disease patients than in the general population. Therefore, we performed the first meta-analysis to estimate the risk of RLS among chronic kidney disease patients. We conducted a comprehensive search in Embase, Ovid-MEDLINE, PubMed, Scopus, Web of Science, and CINAHL databases. Data were analyzed with the random-effects model using Comprehensive Meta-Analysis (CMA) software to find the odds ratio (OR). The heterogeneity was checked with the I2 test and Cochran's Q-statistic, and we performed the moderator analysis to find potential sources of heterogeneity. The study quality was assessed using the Newcastle-Ottawa Scale. Of 1175 studies, we found nine studies, with a total of 18,983 participants. The pooled OR of RLS among chronic kidney disease was 5.64 (95%CI 2.70-11.78). Regarding moderator analysis results, it was observed that higher body mass index and abnormal laboratory results would increase the risk of RLS; however, the statistical test was not significant in the current study. The findings reveal a substantial sixfold increase in the likelihood of RLS when compared to the general population. Therefore, health professionals should encourage patients to adhere to the treatment and practice a healthy lifestyle to manage their condition and reduce the risk of RLS. Moreover, future research can develop an intervention to reduce RLS symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-024-00513-4.

Prevalence of restless legs syndrome in maintenance hemodialysis patients: A systematic review and meta-analysis

BACKGROUND

Restless legs syndrome is associated with quality of life and risk of death in maintenance hemodialysis patients. Although relevant meta-analyses have been conducted, epidemiological studies of restless legs syndrome have increased in recent years.

OBJECTIVE

Our aim was to systematically assess the prevalence of restless legs syndrome in maintenance hemodialysis patients and to evaluate the effect of different geographic regions, genders, study designs, and years of publication on the prevalence of restless legs syndrome.

METHODS

PubMed, Web of Science, EMBASE, The Cochrane Library, China Knowledge Resource Integrated Database, Wanfang Database, Weipu, and Chinese Biomedical Database were searched before March 16, 2023 for the published literature. Two investigators independently performed literature screening, data extraction for eligible studies, and risk of bias assessment. A random-effects model using the stata 15.0 software was used to assess the pooled prevalence of restless legs syndrome.

RESULTS

Fifty-seven articles were included in this meta-analysis, and the pooled prevalence of restless legs syndrome in 12,573 maintenance hemodialysis patients was 24.0 % (95 % CI: 21.0%-26.0 %). Maintenance hemodialysis patients from the Americas region and females had severe symptoms of restless legs syndrome, and the prevalence of restless legs syndrome increased from year to year. The prevalence of restless legs syndrome was higher in maintenance hemodialysis patients in cross-sectional studies and cohort studies compared to case-control studies.

CONCLUSIONS

Maintenance hemodialysis patients have a significantly higher prevalence of restless legs syndrome. These findings may provide some reference value for hospital nursing staff to focus on the management and treatment of restless legs syndrome in maintenance hemodialysis patients.

Alexithymia, Suicidal Ideation, and Self-Esteem As Psychological Factors Affecting Chronic Kidney Disease Patients Under Haemodialysis: A Contextual Review

Chronic kidney disease is a universal topic gravitating towards various aspects of widespread illness, impacting the overall well-being of human beings. Patients with longstanding renal complaints under dialysis encounter challenges correlated with physical, intuitive, and socio-economic conditions to a greater extent in their daily existence. These portions may include changes in the appearance of a person, restricted physique movements, curbed diet, duration of surgical protocols, travelling time during the period of prevention, financial load, role reversal in the family followed by ruining their livelihood, deprived social rank, difficulty in relational, cordial relationships, and so on. Excluding these details, the sick may be profoundly influenced by sorrow, health anxiety, despair, itching, the impoverished essence of vitality, dysfunction in sexual intimacy, impaired cognition, disturbances in disposition, sleeping fluctuations, frequent panic attacks, delirium, brain-afflicted degeneration disabilities, etcetera. Our analysis focuses on exploring a few unidentified intrinsic factors that distinguish these views over combined elements due to the existing disorder.

The Relationship between Serum Selenium Levels and Restless Leg Syndrome in Chronic Kidney Disease Patients

Background and Objectives: Chronic kidney disease (CKD) is a global public health issue with rising incidence linked to substantial morbidity and mortality. Selenium, an antioxidant trace element, has been linked to low serum levels in end-stage renal disease. Restless Leg Syndrome (RLS), a sleep disorder, is prevalent in CKD patients and significantly impacts their quality of life. The objective of this study was to examine the correlation between serum selenium levels and the prevalence of restless leg syndrome in individuals with chronic kidney disease. Materials and Methods: Forty-six CKD patients undergoing serum selenium level assessments between 1 January 2020 and 28 February 2022, at the Hitit University Faculty of Medicine Department of Nephrology Outpatient Clinic or Hemodialysis Unit, were included. Patients over 18 years of age with no history of hematological or oncological diseases or acute or chronic inflammatory conditions were included in the study groups. Patients taking selenium supplements were excluded. Demographic data, comorbidities, and laboratory values were collected, and RLS presence and severity were evaluated. Statistical analyses include descriptive statistics, correlation analysis, the Mann-Whitney U test, Student's t test, and Chi-square test. Results: Among the 46 patients, 16 (34.78%) had RLS symptoms. The patient group included 34.78% predialysis, 34.78% peritoneal dialysis, and 30.44% hemodialysis patients, with a median age of 47.98 years. There was no difference in age, gender, and Charlson comorbidity between patients with or without RLS (p = 0.881, p = 0.702, p = 0.650). RLS prevalence varied across CKD subgroups, with hemodialysis patients having a higher prevalence (p = 0.036). Clinical parameters such as blood urea nitrogen, creatinine, calcium, phosphorus, platelet counts, and parathyroid hormone levels exhibited significant differences between patients with and without RLS (p < 0.05). Serum selenium levels were not significantly different between patients with and without RLS (p = 0.327). Conclusions: With an increased comorbidity burden, CKD poses a significant healthcare challenge. When accompanied by RLS, this burden can be debilitating. The difference in CKD stages between groups has shed light on a critical determinant of RLS in this population, emphasizing the role of the chronic kidney disease stage. In our study, serum selenium levels were not associated with the presence and severity of RLS. However, prospective studies with larger numbers of participants are needed to draw a definitive conclusion.

Renal and Electrolyte Disorders and the Nervous System

OBJECTIVE

Neurologic complications are a major contributor to death and disability in patients with renal disease. Oxidative stress, endothelial dysfunction, accelerated arteriosclerosis, and uremic inflammatory milieu affect both the central and peripheral nervous systems. This article reviews the unique contributions of renal impairment to neurologic disorders and their common clinical manifestations as the prevalence of renal disease increases in a globally aging population.

LATEST DEVELOPMENT

Advances in the understanding of the pathophysiologic interplay between the kidneys and brain, also referred to as the kidney-brain axis, have led to more widespread recognition of associated changes in neurovascular dynamics, central nervous system acidification, and uremia-associated endothelial dysfunction and inflammation in the central and peripheral nervous systems. Acute kidney injury increases mortality in acute brain injury to nearly 5 times that seen in matched controls. Renal impairment and its associated increased risks of intracerebral hemorrhage and accelerated cognitive decline are developing fields. Dialysis-associated neurovascular injury is increasingly recognized in both continuous and intermittent forms of renal replacement therapy, and treatment strategies for its prevention are evolving.

ESSENTIAL POINTS

This article summarizes the effects of renal impairment on the central and peripheral nervous systems with special considerations in acute kidney injury, patients requiring dialysis, and conditions that affect both the renal and nervous systems.

Restless Legs Syndrome in Chronic Kidney Disease- a Systematic Review

Objectives

The objective of this review is to provide updated information on the epidemiology, correlating factors and treatment of chronic kidney disease associated restless legs syndrome (CKD-A-RLS) in both adult and pediatric population.

Materials and Methods

We have reviewed the Medline search and Google Scholar search up to May 2022, using key words restless legs syndrome, chronic kidney disease and hemodialysis and kidney transplant. The reviewed articles were studied for epidemiology, correlating factors, as well as pharmacologic and non-pharmacologic treatment options.

Results

Our search revealed 175 articles, 111 were clinical trials or cross- sectional studies and 64 were review articles. All 111 articles were retrieved and studied in detail. Of these, 105 focused on adults and 6 on children. A majority of studies on dialysis patients reported a prevalence between 15-30%, which is notably higher than prevalence of RLS in general population (5-10%). The correlation between presence of CKD-A-RLS with age, gender, abnormalities of hemogram, iron, ferritin, serum lipids, electrolytes and parathyroid hormones were also reviewed. The results were inconsistent and controversial. Limited studies have reported on the treatment of CKD-A-RLS. Non-pharmacological treatment focused on the effect(s) of exercise, acupuncture, massage with different oils and infra-red light whereas, pharmacologic treatment options include the effects of dopaminergic drugs, Alpha2-Delta ligands (gabapentin and pregabalin), vitamins E and C, and intravenous iron infusion.

Conclusion

This updated review showed that RLS is two to three times more common in patients with CKD compared to the general population. More patients with CKD-A-RLS demonstrated increased mortality, increased incidence of cardiovascular accident, depression, insomnia and impaired quality of life than those with CKD without RLS. Dopaminergic drugs such as levodopa, ropinirole, pramipexole and rotigotine as well as calcium channel blockers (gabapentin and pregabalin) are helpful for treatment of RLS. High quality studies with these agents are currently underway and hopefully confirm the efficacy and practicality of using these drugs in CKD-A-RLS. Some studies have shown that aerobic exercise and massage with lavender oil can improve symptoms of CKD-A- RLS suggesting that these measures can be useful as adjunct therapy.

Respiratory complications and sleep disorders in children with chronic kidney disease: A correlation often underestimated

Chronic Kidney Disease (CKD) is characterized by a progressive and irreversible loss of kidney function which gradually leads to end-stage kidney disease (ESKD). Virtually all the organs are damaged by the toxicity of uremic compounds. The lungs may be affected and the impaired pulmonary function may be the direct result of fluid retention and metabolic, endocrine and cardiovascular alterations, as well as systemic activation of the inflammation. An increased prevalence in sleep disorders (SD) is also reported in patients with CKD, leading to a further negative impact on overall health and quality of life. While these complex relationships are well documented in the adult population, these aspects remain relatively little investigated in children. The aim of this review is to provide a brief overview of the pathophysiology between lung and kidney and to summarize how CKD may affect respiratory function and sleep in children.

"Unvoluntary" Movement Disorders: Distinguishing between Tics, Akathisia, Restless Legs, and Stereotypies

Tics, stereotypies, akathisia, and restless legs fall at different places on the spectrum of discrete, unwanted and potentially disabling motor routines. Unlike tremor, chorea, myoclonus, or dystonia, this subgroup of abnormal movements is characterized by the subject's variable ability to inhibit or release undesired motor patterns on demand. Though it may be sometimes clinically challenging, it is crucial to distinguish these "unvoluntary" motor behaviors because secondary causes and management approaches differ substantially. To this end, physicians must consider the degree of repetitiveness of the movements, the existence of volitional control, and the association with sensory symptoms, or cognitive-ideational antecedent. This review aims to summarize the current existing knowledge on phenomenology, diagnosis, and treatment of tics, stereotypies, akathisia, and restless leg syndrome.

Movement Disorders in Chronic Kidney Disease Patients on Hemodialysis in Mosul City

BACKGROUND: Movement disorders are not rare in patients with chronic kidney disease (CKD) on hemodialysis (HD). The prevalence and the exact mechanism of these disorders are unknown. Iron deficiency and dopamine dysregulation are implicated from one perspective, whereas chronic inflammation and calcium dysmetabolism may be involved from another perspective. AIM: We studied the prevalence, delay in the diagnosis and the role of iron deficiency, inflammation, and bone abnormalities on some movement disorders in patients with CKD on HD. METHODS: A cross-sectional study examined the prevalence, among patients with CKD on HD in Mosul city, of restless leg syndrome (RLS), periodic limb movement syndrome (PLMS), Parkinsonism, asterixis, and myoclonus. Delay in diagnosis of these disorders was also studied. Validated questionnaires and specified neurological examination were applied to define patients with these disorders. Using IBM® SPSS® v. 23 statistical software, we compared between the different groups of patients by different parameters (case–control design). RESULTS: Among 281 enrolled CKD patients on HD in Mosul city, the prevalence of RLS, PLMS, Parkinsonism, asterixis, and myoclonus was 28.72%, 17.02%, 2.84%, 20.92%, and 24.11% respectively. Average delay in diagnoses was 2.6 (±3.09) years, 3.02 (±3.13) years, 1 (±0.78) year, 1.23 (±1.51) years, and 2.28 (±2.34) years, respectively. Median duration of dialysis in patients with PLMS and Parkinsonism tended to be higher than in those without PLMS or Parkinsonism. Neither inflammation, ferritin level nor bone dysmetabolism discriminated patients with CKD on HD with and without these movement disorders. CONCLUSIONS: Movement disorders are prevalent in patients with CKD on HD. In Mosul city, there would be still delay in diagnosis and treatment of these movement disorders. The longer the duration on HD, the more frequent the PLMS and Parkinsonism cases.

Prevalence of sleep disorders in children with chronic kidney disease: a meta-analysis

BACKGROUND

The reported prevalence of sleep disorders in children with chronic kidney disease (CKD) varies greatly. A quantitative meta-analysis to estimate the prevalence of sleep disorders among pediatric CKD patients may provide further information.

OBJECTIVES

The objective of this study is to estimate the prevalence of sleep disorders in children with CKD. The study protocol was registered on PROSPERO (registration number CRD42021268378).

DATA SOURCES

Two authors independently searched the PubMed, MEDLINE, EMBASE, and Cochrane review databases up to June 2021.

STUDY ELIGIBILITY CRITERIA

Eligible studies include data of prevalence of sleep disorders in children with CKD.

STUDY APPRAISAL AND SYNTHESIS METHODS

The prevalence of restless legs syndrome, sleep-disordered breathing, pediatric obstructive sleep apnea (i.e., apnea-hypopnea index &gt; 1 event/h in polysomnography), excessive daytime sleepiness, and insomnia/insufficient sleep was estimated using a random-effects model. Subgroup analyses were conducted to compare the prevalence of sleep disorders between children on dialysis and not on dialysis. This meta-analysis included 12 studies with 595 children (mean age: 12.9 years; gender ratio: 55.6% boys; mean sample size: 49.6 patients).

RESULTS

The prevalence of restless legs syndrome in children with CKD was 21% (95% confidence interval [CI], 14-30%). The prevalence of sleep-disordered breathing, pediatric obstructive sleep apnea, excessive daytime sleepiness, and insomnia/insufficient sleep was 22% (95% CI, 12-36%), 34% (95% CI, 19-53%), 27% (95% CI, 17-41%), and 14% (95% CI, 7-27%), respectively. Subgroup analysis revealed the pooled prevalence of excessive daytime sleepiness was significantly higher in children on dialysis than in children not on dialysis (43.3% vs. 11.2%; P = 0.018). Children on dialysis also had a high prevalence of other sleeping disorders, although the differences did not reach statistical significance. Children with CKD exhibited a 3.9-fold (95% CI, 1.37 to 10.93) increased risk of restless legs syndrome and a 9.6-fold (95% CI, 3.57 to 25.76) increased risk of excessive daytime sleepiness compared with controls.

LIMITATIONS

The selected papers are of small sample size, lack of a control group, and exhibit substantial heterogeneity.

CONCLUSIONS

Sleep disorders are common in children with CKD. Our results indicate that while the prevalence rates of various sleep disorders were higher in children on dialysis than in children not on dialysis, the prevalence of excessive daytime sleepiness was statistically significant in children on dialysis. A higher resolution version of the Graphical abstract is available as Supplementary information.

The prevalence and potential aetiological factors associated with restless legs syndrome in patients with chronic kidney disease: a cross-sectional study

BACKGROUND

There is limited understanding of aetiological factors of and treatment options for restless leg syndrome (RLS) in patients with chronic kidney disease (CKD). This study aimed to estimate the prevalence of RLS in CKD patients and identify factors that may contribute to RLS.

METHODS

A questionnaire-based cross-sectional study of patients with CKD stage 4 (CKD 4), pre-dialysis stage 5 (CKD-5ND) and haemodialysis-dependent stage 5 (CKD-5D) was conducted. Eligible patients were enrolled from the local dialysis units and renal clinics. The International RLS Study Group rating scale was used to establish the diagnosis of RLS and quantify its severity.

RESULTS

212 patients with CKD 4 (n = 92), CKD-5ND (n = 14) and CKD-5D (n = 106) were included. The overall prevalence of RLS was 32.1%. Women had a significantly higher odds of having RLS despite adjustment for age, diabetes, cardiovascular disease and whether patients were on dialysis (odds ratio 2.8 [95% confidence intervals 1.5-5.2]). In pre-dialysis groups, patients with RLS had significantly higher serum ferritin (323.9 [SD 338.1] vs 177.5 [SD 178.5] µg/L, p = 0.020) compared to non-RLS patients. In dialysis patients (CKD-5D), those with RLS had significantly higher total white cell (8.0 [SD 3.5] vs 6.8 [SD 1.9] × 10⁹/L, p = 0.026) and neutrophil (6.4 [SD 3.9] vs 4.6 [SD1.7] × 10⁹/L, p = 0.002) counts compared to patients without RLS.

CONCLUSION

RLS remains a significant problem in patients with CKD and may be related to underlying inflammation. Targeting this pathway may be useful. Prevalence of RLS, diagnosed using validated measures, is higher than previous reports.

TRIAL REGISTRATION

N/A (the current study is not a trial).

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.

Clinical Efficacy and Safety of Massage for the Treatment of Restless Leg Syndrome in Hemodialysis Patients: A Meta-Analysis of 5 Randomized Controlled Trials

AIM

We conducted this meta-analysis to evaluate the clinical efficacy and safety of massage for the treatment of hemodialysis patients with restless leg syndrome (RLS).

METHODS

A comprehensive literature search was performed using the PubMed database, EMBASE database (via OVID), and the Cochrane Library in order to identify eligible randomized controlled trials (RCTs) published before August 31, 2021. After extracted essential data and assessed risk of bias of each eligible study, we calculated the pooled estimate of RLS score and safety after treatment. Statistical analysis was performed by using Review Manager 5.3.

RESULTS

Five studies involving 369 hemodialysis patients with RLS were analyzed. The RLS score after treatment [mean difference (MD), -12.01; 95% confidence interval (CI), -14.91 to -9.11] and mean difference of RLS score at the beginning and end of treatment [mean difference (MD), -11.94; 95% confidence interval (CI), -15.45 to -8.43] in a massage group was significantly better than that in route care group. Subgroup analysis suggested that massage with lavender oil also significantly reduced the RLS score after treatment (MD, -14.22; 95% CI, -17.81 to -10.63) and mean difference of RLS score at the beginning and end of treatment (MD, -14.87; 95% CI, -18.29 to -11.45) compared with route care. Meanwhile, massage regime significantly relieved RLS severity compared with route care but did not increase adverse events.

CONCLUSION

Massage may be a preferred treatment modality for hemodialysis patients with RLS because it effectively reduces RLS symptoms, relieves RLS severity, and does not increase the risk of adverse events. However, future study with a larger sample size is warranted due to the fact that only limited number of eligible studies with small sample size are enrolled.

Relation of Serum Hepcidin Levels and Restless Legs Syndrome in Patients Undergoing Peritoneal Dialysis

Introduction: Restless legs syndrome is a common and severe complication in patients undergoing peritoneal dialysis (PD), which seriously affects the life quality and prognosis of patients undergoing PD. Unfortunately, there are still no effective prevention and treatment measures. Serum hepcidin was demonstrated to be related to primary restless legs syndrome (RLS), whereas there are no studies on the relationship between serum hepcidin and RLS in patients undergoing PD. We aimed to evaluate the role and function of serum hepcidin in patients undergoing PD with RLS.

Methods: A total of 51 patients undergoing PD with RLS and 102 age-and gender-matched patients undergoing PD without RLS were included. We collected the clinical data including serum hepcidin of those patients undergoing PD. We scored the severity of RLS according to the International restless leg Syndrome Research Group rating scale (IRLS). We compared the clinical characteristics of the two groups and evaluated the determinant factors of RLS by Logistic regression analysis. In addition, we evaluated the diagnostic value of serum hepcidin in patients undergoing PD with RLS by receiver operating characteristic (ROC) curve. We also analyzed the influencing factors of IRLS by multivariate linear regression analysis.

Results: The duration of PD, serum hepcidin, and calcium were found to be significantly higher in patients undergoing PD with RLS than those patients undergoing PD without RLS (P < 0.001, P < 0.001, and P = 0.002, respectively). The level of hemoglobin, albumin, and RKF were significantly lower in patients undergoing PD with RLS (P = 0.002, P = 0.042, and P < 0.001, respectively). The duration of PD [odds ratio (OR) 1.038, 95% CI: 1.017, 1.060, P < 0.001], hemoglobulin level (OR 0.969, 95% CI: 0.944, 0.995, P = 0.019), calcium level (OR 9.224, 95% CI: 1.261, 67.450, P = 0.029), albumin level (OR 0.835, 95% CI: 0.757, 0.921, P < 0.001), hepcidin level (OR 1.023, 95% CI: 1.009, 1.038, P = 0.001), and RKF (OR 0.65, 95% CI: 0.495, 0.856, P = 0.002) are independent determinant factors of RLS in patients undergoing PD. Multivariate linear regression analysis revealed that, in addition to albumin, they were also independently associated with the severity of RLS.

Conclusion: A significant relation was detected between serum hepcidin level and RLS in patients undergoing PD.

Restless legs syndrome and hypertension in men and women: a propensity score-matched analysis

OBJECTIVE

To evaluate the association between restless legs syndrome (RLS) and hypertension in men and women based on a community-based cohort of middle-aged and elderly participants.

METHODS

This cross-sectional observational study enrolled 4080 participants from the Sleep Heart Health study (SHHS). RLS was defined by positive responses on a self-administered questionnaire assessing the four diagnostic criteria, with symptoms occurring at least five times per month and associated with at least moderate distress. Hypertension was defined as SBP ≥140 mmHg, DBP ≥90 mmHg, or current use of antihypertensive medication. Propensity score-matched (PSM) inverse probability treatment weighting (IPTW) analyses and multivariable logistic regression were used to examine the relationship between RLS and hypertension.

RESULTS

RLS was present in 6.8% of women (n = 152) and 3.2% of men (n = 59). In the primary cohort analysis, the odds ratio (OR) for hypertension was 1.60 [95% confidence interval (CI) 1.19-2.16, p < 0.001] for participants with RLS compared to those without RLS. In the PSM analyses, the OR for hypertension was 1.66 (95% CI 1.09-2.54, p = 0.019) for participants with RLS compared to those without RLS. In sex subgroup analyses, the association between RLS and hypertension persisted in women. In the PSM cohort, the ORs for hypertension were 1.67 (95% CI 1.01-2.81, p = 0.048) and 1.85 (95% CI 0.75-4.75, p = 0.191) in women and men, respectively. Similar results were found in IPTW cohort.

CONCLUSIONS

This study revealed a positive association between RLS and hypertension in a community-based population; in sex subgroup analyses, the association persisted in women.

Cerebral blood flow alterations in hemodialysis patients with and without restless legs syndrome: an arterial spin labeling study

Hemodialysis with restless legs syndrome (HD-RLS) is associated with alterations in neuronal function, the blood-brain barrier and iron deposition, thus affecting cerebral metabolism and perfusion. This study utilized three-dimensional arterial spin labeling (ASL) to identify HD-RLS-related perfusion patterns and potential relationships with disease severity. Twenty-six HD-RLS patients, 30 hemodialysis patients without restless legs syndrome (HD-nRLS) and 30 age-, sex-, and education-matched healthy controls were included in this study. One-way analysis of covariance and post hoc analyses were used to assess differences in cerebral blood flow (CBF) values, demographics and clinical data among the three groups. Pearson's correlation analysis was conducted between altered CBF values in the HD-RLS group and clinical data. Compared with HD-nRLS patients, HD-RLS patients showed increased CBF in the right primary motor cortex (false discovery rate [FDR]-corrected P < 0.05). Compared with the normal controls, both HD subgroups (i.e., those with and without RLS) exhibited consistent CBF changes, including increased CBF in the left medial superior frontal gyrus and bilateral thalamus and decreased CBF in the left insular cortices (FDR-corrected P < 0.05). This abnormal hyperperfusion in the sensorimotor cortex and basal ganglia provides evidence for a sensory processing disorder in RLS that may be involved in the pathogenesis of RLS in HD patients.

Circadian rhythms of mineral metabolism in chronic kidney disease-mineral bone disorder

PURPOSE OF REVIEW

The circadian rhythms have a systemic impact on all aspects of physiology. Kidney diseases are associated with extremely high-cardiovascular mortality, related to chronic kidney disease-mineral bone disorder (CKD-MBD), involving bone, parathyroids and vascular calcification. Disruption of circadian rhythms may cause serious health problems, contributing to development of cardiovascular diseases, metabolic syndrome, cancer, organ fibrosis, osteopenia and aging. Evidence of disturbed circadian rhythms in CKD-MBD parameters and organs involved is emerging and will be discussed in this review.

RECENT FINDINGS

Kidney injury induces unstable behavioral circadian rhythm. Potentially, uremic toxins may affect the master-pacemaker of circadian rhythm in hypothalamus. In CKD disturbances in the circadian rhythms of CKD-MBD plasma-parameters, activin A, fibroblast growth factor 23, parathyroid hormone, phosphate have been demonstrated. A molecular circadian clock is also expressed in peripheral tissues, involved in CKD-MBD; vasculature, parathyroids and bone. Expression of the core circadian clock genes in the different tissues is disrupted in CKD-MBD.

SUMMARY

Disturbed circadian rhythms is a novel feature of CKD-MBD. There is a need to establish which specific input determines the phase of the local molecular clock and to characterize its regulation and deregulation in tissues involved in CKD-MBD. Finally, it is important to establish what are the implications for treatment including the potential applications for chronotherapy.

Patterns of Gray Matter Volume Alterations in Hemodialysis Patients With and Without Restless Legs Syndrome: Evidence From a Voxel-Based Morphometry Study

PURPOSE

The purpose of this study was to investigate the differences of gray matter volume (GMV) alteration patterns between hemodialysis with restless legs syndrome (HD-RLS) and hemodialysis without restless legs syndrome (HD-nRLS) patients using voxel-based morphometry.

METHODS

Twenty-three HD-RLS patients, 27 HD-nRLS patients, and 27 age-, sex-, and education-matched healthy controls were included in this study. One-way analysis of covariance and post hoc analyses were used to assess differences in GMV, demographics, and clinical data among the 3 groups. Pearson correlation analysis was conducted between altered GMV in the HD-RLS group and clinical data.

RESULTS

Compared with HD-nRLS patients, HD-RLS patients showed decreased GMV in the left primary motor cortex (false discovery rate corrected, P < 0.05). Compared with the healthy controls, both HD subgroups (ie, those with and without RLS) exhibited consistent GMV changes, including decreased GMV in the bilateral anterior cingulate and paracingulate gyrus and left middle temporal gyrus (false discovery rate corrected, P < 0.05). The GMV values in the left precentral gyrus were negatively correlated with the RLS rating scores (r = 0.2138, P = 0.0263).

CONCLUSIONS

This abnormal decreased GMV in the sensorimotor cortex provides evidence for a sensory processing disorder in RLS that may be involved in the pathogenesis of RLS in HD patients.

Prescribing in renal supportive care

Renal supportive care incorporates the principles of palliative care into the management of patients with advanced kidney disease. Its focus is on improving the quality of life for patients with a high burden of symptoms Common problems include pain, restless legs syndrome and uraemic pruritus. Symptom management must involve patient participation, education and non-pharmacological strategies to address both physical and psychosocial problems, and to prioritise patient-centred goals The patients are medically complex and polypharmacy is common. When prescribing, it is important to consider the altered pharmacokinetics, potential drug interactions and the clearance of drugs by dialysis

Acupuncture for restless legs syndrome: A systematic review and meta-analysis protocol

BACKGROUND

Restless legs syndrome (RLS) is a neurological disorder that causes an irresistible urge to move the legs. An increasing number of studies have been published in recent years to support the effectiveness of acupuncture for RLS. We will conduct a comprehensive systematic review and meta-analysis to evaluate the evidence of randomized controlled trials for acupuncture treatment of RLS.

METHODS

The following electronic databases will be searched: PubMed, Embase, Web of Science, Cochrane Library, the China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and China Science and Technology Journal Database. The range of publication time will be from the inception of the database to September 2019. Two reviewers will independently conduct article selection, data collection, and risk of bias evaluation. Any disagreement will be resolved by discussion with the third reviewer. Review Manager Software 5.3 will be used for meta-analysis. The Cochrane risk of bias tool will be used to assess the risk of bias.

RESULTS

This study will provide a high-quality evidence to assess the effectiveness and safety of acupuncture for RLS.

CONCLUSIONS

This systematic review will explore whether acupuncture is an effective and safe intervention for RLS.

REGISTRATION

PROSPERO CRD42019148948.

Restless Legs Syndrome in Chronic Kidney Disease: Is Iron or Inflammatory Status To Blame?

STUDY OBJECTIVES

Restless legs syndrome (RLS) is increased in pediatric chronic kidney disease (CKD). In adults without CKD, central nervous system iron deficiency is involved in RLS pathogenesis and a low serum ferritin levels is consequently an indication for initiation of iron therapy. However, children with CKD are at risk for iron deficiency and inflammation, which raises serum ferritin. We examined the role of iron deficiency and inflammation in RLS in pediatric CKD.

METHODS

This cross-sectional study examined RLS prevalence in three groups of pediatric patients with CKD: nontransplant, nondialysis CKD (estimated GFR < 60 mL/min/1.73 m²) (n = 27); renal transplant recipients (n = 65); and dialysis (n = 32). RLS was diagnosed using a validated questionnaire. Serum ferritin < 100 ng/mL or transferrin saturation < 20% defined iron deficiency. Serum high sensitivity C-reactive protein ≥ 1 mg/L defined inflammation.

RESULTS

Among 124 patients, RLS prevalence was 15.3%; this did not differ across groups. There was no significant difference in RLS prevalence between those with and without iron deficiency, defined by either reduced ferritin or transferrin. Median ferritin levels in patients with RLS tended to be higher than in those without RLS (51.2 versus 40.1 ng/mL; P = .08). Inflammation (elevated CRP) also did not differ significantly by RLS status (57.9% [with RLS] versus 41.2% [without RLS], P = .18).

CONCLUSIONS

Neither ferritin nor inflammation differentiated pediatric patients with CKD with and without RLS. This study suggests that the factors mediating the pathogenesis and, potentially, treatment, of RLS in pediatric CKD may be different from non-CKD populations.

Mineral absorption is an enriched pathway in a brain region of restless legs syndrome patients with reduced MEIS1 expression

Restless legs syndrome is a common complex disorder with different genetic and environmental risk factors. Here we used human cell lines to conduct an RNA-Seq study and observed how the gene showing the most significant association with RLS, MEIS1, acts as a regulator of the expression of many other genes. Some of the genes affected by its expression level are linked to pathways previously reported to be associated with RLS. We found that in cells where MEIS1 expression was either increased or prevented, mineral absorption is the principal dysregulated pathway. The mineral absorption pathway genes, HMOX1 and VDR are involved in iron metabolism and response to vitamin D, respectively. This shows a strong functional link to the known RLS pathways. We observed the same enrichment of the mineral absorption pathway in postmortem brain tissues of RLS patients showing a reduced expression of MEIS1. The expression of genes encoding metallothioneins (MTs) was observed to be dysregulated across the RNA-Seq datasets generated from both human cells and tissues. MTs are highly relevant to RLS as they bind intracellular metals, protect against oxidative stress and interact with ferritins which manage iron level in the central nervous system. Overall, our study suggests that in a subset of RLS patients, the contribution of MEIS1 appears to be associated to its downstream regulation of genes that are more directly involved in pathways that are relevant to RLS. While MTs have been implicated in the pathogenesis of neurodegenerative diseases such as Parkinson’s diseases, this is a first report to propose that they have a role in RLS.

Effects of glycerin oil and lavender oil massages on hemodialysis patients' restless legs syndrome

OBJECTIVES

To determine the effects of glycerin oil and lavender oil massages on hemodialysis patients' restless legs syndrome (RLS).

METHODS

Ninety hemodialysis patients with RLS were randomly allocated into two intervention groups and one control group, each consisting of 35 participants. The control group received routine care, and the intervention groups received effleurage massage with lavender and glycerin oil in addition to routine care for one month. RLS intensity was measured among the three groups using the Restless Legs Syndrome Rating Scale.

RESULTS

At the beginning of the study, the results showed no significant difference among the three groups' scores. At the end of the study, the mean RLS scores were significantly lower in the intervention groups compared to the control group (F = 63.4, p ≤ 0.001). This difference was not significant between the two intervention groups; nonetheless, the differences between the control and lavender oil groups, as well as the control and glycerin oil groups, were significant (p < 0.05).

CONCLUSION

The findings showed the effectiveness of the oils through the effleurage massage for reducing RLS in a sample of hemodialysis patients.

Comparative efficacy and acceptability of treatments for restless legs syndrome in end-stage renal disease: a systematic review and network meta-analysis

Background

Restless legs syndrome (RLS) is common in end-stage renal disease (ESRD) patients and impairs health and quality of life significantly. However, the optimal treatment of RLS in ESRD patients is uncertain and less studied compared with idiopathic RLS patients.

Methods

We conducted a systematic review and network meta-analysis to compare the efficacy and acceptability of treatments for RLS in ESRD patients. Randomized controlled trials (RCTs) by February 2019 in the PubMed, Cochrane Library, Embase and ClinicalTrials.gov were reviewed. RLS severity reduction was treated as treatment efficacy, and adverse events were treated as acceptable. Both outcomes were appraised using a random effects model expressed as standardized mean differences and odds ratios with 95% confidence intervals (CIs), respectively, and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to obtain a hierarchy of interventions.

Results

A total of 12 RCTs were included, comprising 9 interventions and 498 participants. All the interventions significantly improved RLS severity without critical side effects compared with placebo. Gabapentin achieved the greatest decrease of RLS severity [standardized mean difference (SMD) = 1.95, 95% CI 0.81–3.09 (SUCRA: 79.3%)], despite its frequent adverse events [SMD = 0.18, 95% CI 0.02–1.50 (19.9%)]. The combination therapy of exercise plus dopamine agonist had better efficacy [SMD = 1.60, 95% CI 0.08–3.12 (59.8%)] and acceptability [SMD = 1.41, 95% CI 0.01–142.53 (63.9%)] compared with that of vitamin C plus vitamin E [SMD = 1.50, 95% CI 0.47–2.54 (56.6%); SMD = 0.32, 95% CI 0.04–2.86 (32.5%)].

Conclusions

This network meta-analysis supports that gabapentin is the most effective treatment for RLS in ESRD patients. Exercise plus dopamine agonist is a favorable combination therapy concerning side effects. Future large RCTs with long-term treatment outcomes are necessary.

Restless legs syndrome in end stage renal disease patients undergoing hemodialysis

BACKGROUND

The prevalence of Restless legs syndrome (RLS) in End Stage Renal Disease (ESRD) patients is higher than that in the general population. However, the associations of RLS within the ESRD population are inconsistent and RLS is usually neglected in dialysis centers, although it impairs the life quality among ESRD patients. We aim to investigate the prevalence of RLS in patients with ESRD undergoing maintenance hemodialysis and evaluate the risk factors of developing RLS and the effect of RLS on quality of life among ESRD patients.

METHODS

ESRD patients undergoing maintenance hemodialysis in Shanghai General Hospital dialysis unit from July 2016 to October 2016 were enrolled in the study. RLS was diagnosed according to the criteria of the International Restless Legs Syndrome Study Group (IRLSSG). IRLSSG Severity Scale was used to evaluate the severity of RLS. Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality, and Hospital Anxiety and Depression Scale (HADS) was used to estimate anxiety and depression. Serologic and historic variables were analyzed to determine predictors of RLS in the ESRD population.

RESULTS

A total of 137 ESRD patients were enrolled. The prevalence of RLS among the ESRD patients was 20.44%. The risk of RLS was increased significantly in females (OR = 2.729, p = 0.032) and daily alcohol drinkers (OR = 4.716, p = 0.022). RLS increased the risks of sleep disorders (25/28, 89.3% vs 73/109, 67.0%, p = 0.02) and sedative hypnotics intake (7/28, 25.0% vs 10/109, 9.2%, p = 0.047) and impaired the sleep quality (7/109 vs 11/28, p = 0.001) according to PSQI sum scores.

CONCLUSION

A high RLS prevalence among the ESRD patients undergoing hemodialysis was confirmed. ESRD patients who are women and drinking alcohol have a higher risk of RLS. The sleep quality was significantly impaired and sleeping medication use was more common among the ESRD patients with RLS.

Discovery of restless legs syndrome plasmatic biomarkers by proteomic analysis

OBJECTIVES

Restless legs syndrome (RLS) can lead to severe clinical consequences, thus negatively impacts on patients' overall health and quality of life. Nevertheless, the pathophysiology of RLS is still unclear, resulting in underestimate, incorrect, or ignored diagnosis and in limited management and treatment. The aim of this study was to compare the plasma proteome of RLS patients and healthy controls, in the search of diagnostic biomarkers related to the disease severity.

MATERIALS AND METHODS

Two-dimensional gel electrophoresis coupled with liquid chromatography-mass spectrometry was employed to analyze plasma samples of 34 patients with primary RLS, divided into two subgroups according to the disease severity: MMS group (mild-moderate symptoms) and HS group (severe and very severe symptoms), and 17 age- and sex-matched control subjects. Sleep quality, daytime sleepiness, and the level of depression were also evaluated.

RESULTS

We identified eight upregulated spots, corresponding to five unique proteins, in both RLS group vs. controls (alpha-1B-glycoprotein, alpha-1-acid glycoprotein 1, haptoglobin, complement C4-A, and immunoglobulin kappa constant); five increased spots, consistent with three unique proteins, only in HS-RLS (kininogen-1, immunoglobulin heavy constant alpha 1, and immunoglobulin lambda constant 2); one downregulated spot in both patient's groups (complement C3) and another one only in HS-RLS (alpha-1-antitrypsin).

CONCLUSIONS

The significantly different plasma proteins detected in RLS were mainly associated with inflammation, immune response, and cardiovascular disorders. Particularly, the gradual increasing in immunoglobulins could be indicative of the disease severity and evolution. Accordingly, these proteins may represent a valid set of useful biomarkers for RLS diagnosis, progression and treatment.

The association between the prevalence of restless leg syndrome, fatigue, and sleep quality in patients undergoing hemodialysis

OBJECTIVE

To determine the prevalence of restless legs syndrome (RLS) in patients with chronic renal failure (CRF) and to compare CRF patients with or without RLS in terms fatigue and sleep quality.

METHODS

A cross-sectional study was conducted on 220 patients (18-75 years) who were undergoing dialysis 3 times weekly in Çorum Province, Corum, Turkey, between January 2014 and January 2016. The diagnosis of RLS was based on the diagnostic form proposed by the international RLS study group. Sleep quality was evaluated using the Pittsburgh sleep quality index (PSQI), and severity of fatigue was determined by using fatigue severity scale (FSS).

RESULTS

Of all the participants, 16.8% (n= 37) (Group 1) were found to have RLS, while 183 patients had no RLS (Group 2). The mean ages were similar between groups. With respect to laboratory analyses, a p-value of less than 0.05 was considered in Group 1 than in Group 2. Restless legs syndrome was mild (7.1%), moderate (46.4%) and severe (39.3%) in patients with RLS. Factors associated with the severity of RLS included weight, duration of dialysis, anuria, iron, total iron binding capacity, calcium and transferrin saturation. The PSQI and FSS scores were significantly worse in Group 1 (p less than 0.001).

CONCLUSION

Restless legs syndrome is a common condition in patients undergoing hemodialysis; the results of our study confirm the adverse effects of RLS in terms of many aspects of sleep quality and fatigue.

Fatigue is associated with high prevalence and severity of physical and emotional symptoms in patients on chronic hemodialysis

PURPOSE

The symptom burden of fatigued hemodialysis patients is poorly known. We aimed to investigate possible differences in the prevalence and severity of symptoms between fatigued and not fatigued patients on chronic hemodialysis.

METHODS

All prevalent patients on chronic hemodialysis referring to the Hemodialysis Service between January 2016 and June 2017 were considered eligible. The Dialysis Symptom Index (DSI) questionnaire was performed during the dialysis treatment. Patients underwent assessment of fatigue using the Italian version of the vitality scale of the SF-36 (SF-36VS).

RESULTS

We studied 137 patients: 107 (78.1%) were fatigued and 30 (31.9%) were non-fatigued. The median [95% CI] number of symptoms was 15 [14-16] for patients who reported fatigue and 9 [8-19] for the non-fatigued (P < 0.0001). In fatigued patients, with respect to non-fatigued ones, the prevalence of dry skin, itching, muscle soreness, bone or joint pain, restless legs, shortness of breath, feeling sad, feeling anxious, difficulty concentrating, and difficulty becoming sex aroused was significantly higher. Restless legs, feeling sad, difficulty concentrating, and difficulty becoming sex aroused were symptoms independently associated with fatigue. The severity of dry skin, trouble staying asleep, and bone/joint pain was higher in fatigued patients.

CONCLUSION

Fatigued hemodialysis patients report suffering from physical and emotional symptoms more frequently than non-fatigued patients. This finding suggests the need to accurately and routinely define the symptom burden of chronic hemodialysis patients and may help to investigate eventually common underlying pathogenic mechanisms of symptoms in these patients.

Iron therapy in heart failure patients without anaemia: possible implications for chronic kidney disease patients

Iron deficiency anaemia is a global health problem that manifests as fatigue and poor physical endurance. Anaemia can be caused by dietary iron deficiency, blood loss or a combination of poor iron absorption and ineffective iron mobilization in patients with chronic disease. Nephrologists caring for patients with impaired renal function understand that iron treatment is necessary to provide adequate iron for erythropoiesis during the treatment of overt anaemia. However, a less well-understood health problem is iron deficiency, which creates symptoms that overlap with those of anaemia and often occurs in concert with chronic disease. Recently, several randomized controlled clinical trials have been conducted to investigate the effects of treatment with intravenous iron in heart failure patients with iron deficiency who may or may not also have anaemia. Given that heart and kidney disease are often comorbid, these clinical trials may have implications for the way nephrologists view their patients with iron deficiency. In this article, we review several clinical studies of intravenous iron therapy for patients with iron deficiency and heart failure and discuss possible implications for the treatment of patients with kidney disease.

Motor hyperactivity of the iron-deficient rat - an animal model of restless legs syndrome

Background

Abnormal striatal dopamine transmission has been hypothesized to cause restless legs syndrome. Dopaminergic drugs are commonly used to treat restless legs syndrome. However, they cause adverse effects with long‐term use. An animal model would allow the systematic testing of potential therapeutic drugs. A high prevalence of restless legs syndrome has been reported in iron‐deficient anemic patients. We hypothesized that the iron‐deficient animal would exhibit signs similar to those in restless legs syndrome patients.

Methods

After baseline polysomnographic recordings, iron‐deficient rats received pramipexole injection. Then, iron‐deficient rats were fed a standard rodent diet, and polysomnographic recording were performed for 2 days each week for 4 weeks.

Results

Iron‐deficient rats have low hematocrit levels and show signs of restless legs syndrome: sleep fragmentation and periodic leg movements in wake and in slow‐wave sleep. Iron‐deficient rats had a positive response to pramipexole treatment. After the iron‐deficient rats were fed the standard rodent diet, hematocrit returned to normal levels, and sleep quality improved, with increased average duration of wake and slow‐wave sleep episodes. Periodic leg movements decreased during both waking and sleep. Hematocrit levels positively correlated with the average duration of episodes in wake and in slow‐wave sleep and negatively correlated with periodic leg movements in wake and in sleep. Western blot analysis showed that striatal dopamine transporter levels were higher in iron‐deficient rats.

Conclusions

The iron‐deficient rat is a useful animal model of iron‐deficient anemic restless legs syndrome. © 2017 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society

Association of Sleep Duration, Symptoms, and Disorders with Mortality in Adults with Chronic Kidney Disease

INTRODUCTION

In general populations, short and long sleep duration, poor sleep quality and sleep disorders have been associated with increased risk of death. We evaluated these associations in individuals with chronic kidney disease (CKD).

METHODS

Prospective cohort study of 1,452 National Health and Nutrition Examination Survey (NHANES) 2005-2008 participants with CKD. CKD was defined by estimated glomerular filtration rate <60 ml/min/1.73m² or urine albumin-to-creatinine ratio ≥30 mg/g. Sleep duration, sleep symptoms (difficulty falling asleep, difficulty staying asleep, daytime sleepiness and non-restorative sleep), and sleep disorders (restless legs syndrome and sleep apnea) were self-reported. Vital status was determined using NHANES mortality linkage through December 2011.

RESULTS

Mean age was 61 years, 58% were women, and 75% non-Hispanic white. During 4.4 years of median follow-up, we observed 234 deaths of which 75 were due to cardiovascular causes. In multivariable analyses, compared with individuals who reported 7-8 hours of sleep, HR (95% CI) for all-cause mortality for sleep duration <7 hours and >8 hours were 1.50 (1.08-2.10) and 1.36 (0.89-2.08), respectively. The corresponding HR (95%CI) for cardiovascular mortality were 1.56 (0.72-3.37) and 1.56 (0.66-3.65). Non-restorative sleep and restless legs syndrome were associated with increased risk for all-cause mortality (1.63 [1.13-2.35], and 1.69 [1.04-275], respectively).

CONCLUSION

In adults with CKD, short sleep duration, nonrestorative sleep and restless legs syndrome are associated with increased risk of death. These findings underscore the importance of promoting adequate sleep in patients with CKD, and the need for future studies evaluating the impact of sleep interventions in this population.

Symptom Management of the Patient with CKD: The Role of Dialysis

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.

Effect of Mineral and Bone Metabolism on Restless Legs Syndrome in Hemodialysis Patients

STUDY OBJECTIVES

Restless legs syndrome (RLS) is a highly prevalent sleep disease among patients on hemodialysis. The physiopathology is still unclear, and may be multifactorial. Because of the association between iron metabolism and chronic kidney disease-mineral and bone disorders (CKD-MBD), we hypothesized that both factors would be associated with RLS.

METHODS

We have evaluated hemodialysis patients, in a face-to-face interview for the diagnosis and severity of RLS, as measured by the International Restless Legs Syndrome Study Group. Clinical, demographic, and biochemical characteristics were measured.

RESULTS

Out of 101 adult patients included, RLS was found in 29 (28.7%). Adjusted multinomial regression analysis revealed that age older than 35 years, transferrin saturation less than 47%, serum ferritin level less than 700 ng/mL, hemoglobin level less than 9.8 g/dL, serum phosphate level higher than 5.2 mg/dL, FGF-23 higher than 2,000 RU/mL, and C-reactive protein less than 1.24 mg/dL were independently associated with RLS. RLS was classified as mild, moderate, severe, and very severe in 3.4%, 41.7%, 44.8%, and 10.1% of patients, respectively. Scores of severity correlated significantly with erythropoietin dose/kg/w (p = 0.046), phosphate (p = 0.003), and inversely with serum albumin (p = 0.003) and calcium (p = 0.008). Phosphate and 25(OH)-vitamin D correlated with transferrin saturation. Patients with severe/very severe symptoms were mostly women, presented with lower serum iron, ionic calcium, and serum albumin levels and higher levels of serum phosphate, and higher percentage of 25(OH)-vitamin D deficiency and levels of FGF-23 higher than 2,000 RU/mL than did those with mild/moderate symptoms.

CONCLUSIONS

CKD-MBD factors besides iron metabolism are associated with RLS in patients on hemodialysis, providing new insights into the understanding of RLS in this population.

Supportive Care: Integration of Patient-Centered Kidney Care to Manage Symptoms and Geriatric Syndromes

Dialysis care is often associated with poor outcomes including low quality of life (QOL). To improve patient-reported outcomes, incorporation of the patient's needs and perspective into the medical care they receive is essential. This article provides a framework to help clinicians integrate symptom assessment and other measures such as QOL and frailty scores into a clinical approach to the contemporary supportive care of patients with advanced CKD. This approach involves (1) defining our understanding of kidney supportive care, patient-centered dialysis, and palliative dialysis; (2) understanding and recognizing common symptoms associated with advanced CKD; (3) discussing the concepts of physical function, frailty, and QOL and their role in CKD; and (4) identifying the structural and process barriers that may arise when patient-centered dialysis is being introduced into clinical practice.

Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients

Maintenance dialysis patients experience a high burden of physical and emotional symptoms that directly affect their quality of life and health care utilization. In this review, we specifically highlight common troublesome symptoms affecting dialysis patients: insomnia, restless legs syndrome, and uremic pruritus. Epidemiology, pathophysiology, and evidence-based current treatment are reviewed with the goal of providing a guide for diagnosis and treatment. Finally, we identify multiple additional areas of further study needed to improve symptom management in dialysis patients.