Sleep disorders in chronic kidney disease

Sleep disorders are highly prevalent in chronic kidney disease (CKD) but are often under-recognized. Restless legs syndrome, which is common in CKD owing to issues with dopamine metabolism and is exacerbated by iron deficiency and uraemia, can lead to poor sleep quality and increased daytime fatigue. Insomnia is also prevalent in CKD, particularly in patients requiring dialysis, with increased sleep latency and sleep fragmentation being reported. The cause of insomnia in CKD is multifactorial - poor sleep habits and frequent napping during dialysis, uraemia, medications and mood disorders have all been suggested as potential contributing factors. Sleep apnoea and CKD are also now recognized as having a bi-directional relationship. Sleep apnoea is a risk factor for accelerated progression of CKD, and fluid overload, which is associated with kidney failure, can lead to both obstructive and central sleep apnoea. The presence of obstructive sleep apnoea in CKD can exacerbate the already heightened cardiovascular morbidity and mortality in these patients, as well as leading to daytime fatigue and reduced quality of life. Increased awareness, timely diagnosis and appropriate therapeutic interventions are essential to reduce the negative impact of sleep disorders in patients with kidney disease.

Evaluation of Gabapentin and Pregabalin Use in Hospitalized Patients With Decreased Kidney Function

Background: Gabapentin and pregabalin are well-tolerated medications primarily cleared by the kidney. Patients receiving higher gabapentinoid doses with decreased kidney function may be at an increased risk of adverse effects (AEs), but limited evidence exists evaluating gabapentinoid dosing and AEs in this population. Objective: To determine whether patients with decreased creatinine clearance (CrCl) experienced increased frequency of AEs related to gabapentinoid dose at hospital admission. Methods: Single-center retrospective cohort study in adults with a gabapentinoid prescription and serum creatinine measurement documented on hospital admission. The primary outcome was the appropriateness of gabapentinoid prescription based on CrCl (stratified by CrCl ≥60 mL/min, <60 mL/min, 15-29 mL/min, and <15 mL/min) at admission. Secondary outcomes included the incidence of AEs related to gabapentinoids and concomitant opioid and psychiatric prescriptions. Results: A total of 286 patients were included in this study (gabapentin n = 234, pregabalin n = 52). Patients with a CrCl <60 mL/min and doses above the manufacturer's recommendation were prescribed gabapentin (34%) and pregabalin (22.7%). For patients with a CrCl of 15 to 29 mL/min and <15 mL/min groups, inappropriately high doses were prescribed for gabapentin (48.8%) and pregabalin (45%). A significant increase in recorded falls (P = 0.029) was identified in patients with a CrCl <60 mL/min. Concomitant opioid and psychiatric medications contributed to a higher prevalence of AEs regardless of CrCl. Conclusions: Patients with a CrCl <60 mL/min were frequently prescribed inappropriately high doses of gabapentinoids. The relationship between gabapentinoid dosing, kidney function, and the incidence of gabapentinoid-related AEs at hospital admission requires larger, multicentre studies.

Advancements in Restless Leg Syndrome Management: A Review of Physiotherapeutic Modalities and Their Efficacy

The goal of this review is to compile information on the use of physiotherapeutic treatments for the treatment of restless leg syndrome (RLS) and to classify the effectiveness of conservative methods in relieving the discomfort due to RLS. English literature found on PubMed, Google Scholar, and Scopus was used in the present review. According to the titles and matters of the abstracts, each literature item connected to RLS was retrieved, analyzed, and reviewed. The 24 papers that were considered admissible were those that included manual approaches, exercises, and alternative RLS management, which were then analyzed for data by the authors. A consistent trend in the data demonstrated benefits in lessening RLS symptom severity across the 24 papers that met the selection criteria. Patients were chosen based on clinical diagnostic standards, and the effectiveness of stretching, exercise therapy, yoga, vibration therapy, reflexology and massage, muscular relaxation techniques, and electrical stimulation was determined. Our findings indicated that each type of therapy significantly affected the manifestations of the illness. Stretching, fitness training, and reflexology were very beneficial, with no side effects and shorter intervention periods.

Worldwide estimation of restless legs syndrome: a systematic review and meta-analysis of prevalence in the general adult population

This systematic review, meta-analysis and meta-regression assessed the prevalence of restless legs syndrome (RLS) in the general adult population. Studies identified in Scopus, PubMed, Web of Science, and PsycInfo between January 2000 and February 2022 were included if they used a case-control or cross-sectional design and reported data regarding the prevalence of RLS. The protocol was pre-registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022300709). A total of 97 studies including 483,079 participants from 33 different countries met the eligibility criteria. The Newcastle Ottawa Scale was used to evaluate the methodological quality, and the fill-and-trim method was used to correct probable publication bias, while the jack-knife method was performed to assess small study effect. The corrected overall pooled prevalence of RLS was 3% (95% confidence interval [CI] 1.4%-3.8%). The pooled prevalence of RLS syndrome was affected by methodological quality (no data from non-respondents in the included studies), gender (higher among women), study design (lower prevalence in case-control versus cohort and cross-sectional studies). The figures for corrected pooled prevalence among men, women, alcohol consumers and smokers were 2.8% (95% CI 2%-3.7%); 4.7% (95% CI 3.2%-6.3%); 1.4% (95% CI 0%-4.2%); and 2.7% (95% CI 0%-5.3%), respectively. The prevalence among male and female participants was lower in community-based versus non-community-based studies. Moreover, the prevalence was higher in developed versus developing countries and among elders versus adults. In conclusion, RLS is a common disorder in the general adult population, with a higher prevalence in women; however, prevalence data are affected by study design and quality.

Restless Leg Syndrome in Hemodialysis Patients: A Narrative Review

BACKGROUND

Restless legs syndrome (RLS) is a clinical entity characterized by sensory-motor manifestations commonly observed in end-stage renal illness. Evidence suggests that RLS is a multifactorial phenomenon that can be influenced by many critical factors, including genetic predisposition, dietary patterns, and deficiency in some vitamins. Iron metabolism disorders and metabolic derangements have been generally accepted as predisposing elements in RLS. Furthermore, both pharmacological and neuroimaging studies demonstrated dopamine deficiency and dopamine receptors decrease in basal ganglia during RLS.

REVIEW SUMMARY

A literature search was done in three databases (PubMed, Google Scholar, and Cochrane) to identify the pertinent articles discussing the epidemiology, pathogenesis, and management of RLS in hemodialysis patients. RLS can affect the morbidity and mortality of patients treated with dialysis. It also has significant impacts on the quality of life since it can lead to insomnia, increased fatigue, mental health troubles, and other movement problems. Appropriate measures should be considered in this particular population so to prevent and treat RLS. Many drugs and other nonpharmacological methods have been investigated to attenuate the disease's severity. No treatment, however, could offer long-term effects.

CONCLUSION

Further efforts are still required to improve the understanding of RLS pathogenic trends to find more specific and efficient therapies. A wide range of treatment options is available. However, it can be individualized according to the patients' several factors.

Cannabinoids for Symptom Management in Patients with Kidney Failure

People with kidney failure can experience a range of symptoms that lead to suffering and poor quality of life. Available therapies are limited, and evidence for new treatment options is sparse, often resulting in incomplete relief of symptoms. There is growing interest in the potential for cannabinoids, including cannabidiol and tetrahydrocannabinol, to treat symptoms across a wide range of chronic diseases. As legal prohibitions are withdrawn or minimized in many jurisdictions, patients are increasingly able to access these agents. Cannabinoid receptors, CB1 and CB2, are widely expressed in the body, including within the nervous and immune systems, and exogenous cannabinoids can have anxiolytic, anti-emetic, analgesic and anti-inflammatory effects. Considering their known physiological actions and successful studies in other patient populations, cannabinoids may be viewed as potential therapies for a variety of common symptoms affecting those with kidney failure, including pruritus, nausea, insomnia, chronic neuropathic pain, anorexia, and restless legs syndrome. In this review, we summarize the pharmacology and pharmacokinetics of cannabinoids, along with what is known about the use of cannabinoids for symptom relief in those with kidney disease, and the evidence available concerning their role in management of common symptoms. Presently, while these agents show varying efficacy with a reasonable safety profile in other patient populations, evidence-based prescribing of cannabinoids for people with symptomatic kidney failure is not possible. Given the symptom burden experienced by individuals with kidney failure, there is an urgent need to understand the tolerability and safety of these agents in this population, which must ultimately be followed by robust, randomized controlled trials to determine if they are effective for symptom relief.

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.

Pharmacological and Nonpharmacological Treatments for Restless Legs Syndrome in End Stage Kidney Disease: A Systematic Review and Component Network Meta-Analysis

BACKGROUND

Restless legs syndrome (RLS) is common among patients with end stage kidney disease (ESKD) and is associated with poor outcomes. Several recently published studies had focused on pharmacological and nonpharmacological treatments of RLS, but an updated meta-analysis has not been conducted.

METHODS

The study population was adult ESKD patients on dialysis with RLS. Randomized controlled trials were selected. The primary outcome was reduction in RLS severity. The secondary outcomes were improvement in sleep quality and treatment-related adverse events. Frequentist standard network meta-analysis and additive component network meta-analysis was performed. The evidence certainty was assessed using Confidence in NMA (CINeMA) framework.

RESULTS

A total of 24 RCTs with 1,252 participants were enrolled and 14 interventions were compared. Cool dialysate produced the largest RLS severity score reduction (MD: 16.82, 95% CI: 10.635-23.02) and high level of confidence. Other potential non-pharmacologic interventions including intradialytic stretching exercise (MD: 12.00, 95% CI: 7.04-16.97) and aromatherapy massage (MD: 10.91, 95% CI: 6.96-14.85) but all with limited confidence of evidence. Among the pharmacological interventions, gabapentin was the most effective (MD: 8.95, 95% CI: 1.95-15.85), which also improved sleep quality (SMD: 2.00, 95% CI: 0.47-3.53). No statically significant adverse events were detected.

CONCLUSIONS

The NMA supports that cool dialysate is appropriate to apply to treat patients with ESKD and RLS. Gabapentin is most effective pharmacologic intervention which also might improve sleep quality. Further parallel RCTs with sufficient sample sizes are required to evaluate these potential interventions and long-term effects.

A network meta-analysis of the effectiveness and safety of drugs for restless legs syndrome in dialysis patients

OBJECTIVE

To evaluate the efficacy and safety of nine pharmacological interventions for restless legs syndrome (RLS) in dialysis patients.

METHODS

An electronic database was used to retrieve eligible trials from PubMed, Cochrane, Embase, and Web of Science. Stata 14.2 software was used to perform network meta-analysis. The primary measure was the RLS score, and the secondary measure was used to evaluate the side effects of the drug. The surface under the cumulative ranking curve method was used to rank the merits of intervention measures. A comparison of the two interventions is shown on a league table.

RESULTS

Finally, nine randomized controlled trials (RCTs) with a total of 377 participants were included. From the results of the network meta-analysis, all treatments ranked higher than placebo in terms of improving clinical symptoms, but only vitamin C (standardized mean difference [SMD] = -1.47 95% confidence interval [CI] -2.89, -0.05) showed significant differences compared with placebo. In terms of safety, there were no serious adverse reactions to any of the treatments compared to placebo.

CONCLUSION

Currently, existing evidence suggests that vitamin C may be the most ideal drug to improve the symptoms of RLS in dialysis patients.

Effect of Aerobic Exercise on Dialysis-Related Symptoms in Individuals Undergoing Maintenance Hemodialysis: A Systematic Review and Meta-Analysis of Clinical Trials

BACKGROUND

Hemodialysis is associated with a high symptom burden that impairs health-related quality of life and functional status. Effective symptom management is a priority for individuals receiving hemodialysis. Aerobic exercise may be an effective, nonpharmacologic treatment for specific hemodialysis-related symptoms. This systematic review investigated the effect of aerobic exercise on hemodialysis-related symptoms in adults with kidney failure undergoing maintenance hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched MEDLINE, PubMed, Cochrane CENTRAL, CINAHL, PsycINFO, SPORTDiscus, EMBASE, PEDro, and Scopus databases from 1960 or inception until April 15, 2020 for randomized controlled trials investigating the effect of aerobic exercise on hemodialysis-related symptoms, identified as prespecified primary or secondary outcomes, as compared with controls in adults on maintenance hemodialysis. We identified restless legs syndrome as the primary outcome.

RESULTS

Of 3048 studies identified, 15 randomized controlled trials met the eligibility criteria. These studies investigated the effect of aerobic exercise on restless legs syndrome (two studies), sleep disturbance (four studies), anxiety (four studies), depression (nine studies), muscle cramping (one study), and fatigue (one study). Exercise interventions were intradialytic in ten studies and outside of hemodialysis in five studies. Heterogenous interventions and outcomes and moderate to high risk of bias precluded meta-analysis for most symptoms. Aerobic exercise demonstrated improvement in symptoms of restless legs syndrome, muscle cramping, and fatigue, as compared with nonexercise controls. Meta-analysis of depressive symptoms in studies using the Beck Depression Inventory demonstrated a greater reduction in Beck Depression Inventory score with exercise as compared with control (mean difference -7.57; 95% confidence interval, -8.25 to -6.89).

CONCLUSIONS

Our review suggests that in adults on maintenance hemodialysis, aerobic exercise improves several hemodialysis-related symptoms, including restless legs syndrome, symptoms of depression, muscle cramping, and fatigue. However, the use of validated outcome measures with demonstrated reliability and responsiveness in more diverse hemodialysis populations is required to fully characterize the effect of this intervention.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

PROSPERO #CRD42017056658.