Why do patients sleep on dialysis?

Effects of Melatonin on Salivary Levels of Cortisol and Sleep Quality of Hemodialysis Patients: A Randomized Clinical Trial

Objective: The aim of this study was to investigate the effects of exogenous melatonin on the quality of sleep in patients undergoing dialysis and to investigate its mechanism for the regulation of total circadian rhythm and salivary levels of cortisol in hemodialysis patients admitted to Pange Azar hospital in Gorgan in winter of 2017.

Method: This was a double-blind randomized clinical trial. Samples were transferred to the laboratory by maintaining the cold chain. Then, the patients were divided into two groups. In a double-blind trial, one group received three mg melatonin and another group received placebo for two weeks at 10 PM. At the end of two weeks, sampling was performed to investigate the salivary level of cortisol under the same conditions. The research instrument was Pittsburgh questionnaire. Data were analyzed before and after intervention using SPSS 16 software.

Results: Salivary levels of cortisol decreased significantly after the intervention in the melatonin group (melatonin: 1.40 ± 1.82 and placebo: 4.94 ± 4.43; P = 0.008). Salivary levels of cortisol in the morning after intervention were also lower in the melatonin group, but were not statistically significant (melatonin 3.99 ± 3.45 and placebo: 5.35 ± 4.9; P = 0.93). Also, the difference in salivary levels of cortisol at night and before and after intervention significantly decreased in melatonin group. PSQI difference (interventional dimension) and PSQI (before intervention) were significantly decreased in melatonin group (P = 0.0001). The rate of change in the subscales of sleep latency, sleep efficiency, and sleep disorders in the melatonin group than in the placebo group was significantly higher.

Conclusion: Melatonin can be used as a safe and cost-effective treatment to improve sleep quality and can also reduce salivary cortisol increased in hemodialysis patients at night.

Possible benefits of exogenous melatonin for individuals on dialysis: a narrative review on potential mechanisms and clinical implications

Prevention of oxidative stress and inflammation in chronic kidney disease patients (CKD) on dialysis may reduce dialysis-associated complications. Administration of powerful antioxidants may improve the consequences of peritoneal dialysis (PD) and hemodialysis (HD). This narrative review aimed to show the potential therapeutic effects of melatonin (MLT) on the consequences of CKD patients receiving HD or PD. The results of preclinical and clinical studies have proven that CKD and dialysis are accompanied by reduced endogenous MLT levels and related complications such as sleep disorders. Enhanced oxidative stress, inflammation, cellular damages, and renal fibrosis, along with dysregulation of the renin-angiotensin system (RAS), have been observed in CKD and patients on dialysis. Results of studies have revealed that the restoration of MLT via the exogenous source may regulate oxidative stress, inflammation, and RAS functions, inhibit fibrosis, and improve complications in patients with long-term dialysis patients. In summary, treatment of patients with CKD and dialysis with exogenous MLT is suggested as a practical approach in reducing the outcomes and improving the quality of life in patients via antioxidant, anti-inflammatory, and anti-fibrotic signaling pathways. Therefore, this hormone can be considered in clinical practice to manage dialysis-related complications.

Exploring sleep disorders in patients with chronic kidney disease

Kidney disorders have been associated with a variety of sleep-related disorders. Therefore, researchers are placing greater emphasis on finding the role of chronic kidney disease (CKD) in the development of obstructive sleep apnea and restless legs syndrome. Unfortunately, the presence of other sleep-related disorders with CKDs and non-CKDs has not been investigated with the same clinical rigor. Recent studies have revealed that myriad of sleep disorders are associated with CKDs. Furthermore, there are a few non-CKD-related disorders that are associated with sleep disorders. In this narrative review, we provide a balanced view of the spectrum of sleep disorders (as identified in International Classification of Sleep disorders-3) related to different types of renal disorders prominently including but not exclusively limited to CKD.

Sleep Parameters in Short Daily versus Conventional Dialysis: An Actigraphic Study

Previous studies have observed worse sleep quality in patients undergoing conventional dialysis as compared to daily dialysis. Our aim was to compare the sleep parameters of patients undergoing daily or conventional dialysis using an objective measure (actigraphy). This cross-sectional study was performed in three dialysis centers, including a convenience sample (nonprobability sampling) of 73 patients (36 patients on daily hemodialysis and 37 patients on conventional hemodialysis). The following parameters were evaluated: nocturnal total sleep time (NTST), expressed in minutes; wake time after sleep onset (WASO), expressed in minutes; number of nighttime awakenings; daytime total sleep time (DTST), expressed in minutes; number of daytime naps; and nighttime percentage of sleep (% sleep). The Mini-Mental State Examination and the Beck Depression Inventory were also administered. The mean age was 53.4  ±  17.0 years. After adjustment of confounding factors using multiple linear regression analysis, no difference in actigraphy parameters was detected between the groups: NTST (p = 0.468), WASO (p = 0.88), % sleep (p = 0.754), awakenings (p = 0.648), naps (p = 0.414), and DTST (p = 0.805). Different from previous studies employing qualitative analysis, the present assessment did not observe an influence of hemodialysis modality on objective sleep parameters in chronic renal patients.

A review of the neuro- and systemic inflammatory responses in post concussion symptoms: Introduction of the "post-inflammatory brain syndrome" PIBS

Post-concussion syndrome is an aggregate of symptoms that commonly present together after head injury. These symptoms, depending on definition, include headaches, dizziness, neuropsychiatric symptoms, and cognitive impairment. However, these symptoms are common, occurring frequently in non-head injured controls, leading some to question the existence of post-concussion syndrome as a unique syndrome. Therefore, some have attempted to explain post-concussion symptoms as post-traumatic stress disorder, as they share many similar symptoms and post-traumatic stress disorder does not require head injury. This explanation falls short as patients with post-concussion syndrome do not necessarily experience many key symptoms of post-traumatic stress disorder. Therefore, other explanations must be sought to explain the prevalence of post-concussion like symptoms in non-head injury patients. Many of the situations in which post-concussion syndrome like symptoms may be experienced such as infection and post-surgery are associated with systemic inflammatory responses, and even neuroinflammation. Post-concussion syndrome itself has a significant neuroinflammatory component. In this review we examine the evidence of neuroinflammation in post-concussion syndrome and the potential role systemic inflammation plays in post-concussion syndrome like symptoms. We conclude that given the overlap between these conditions and the role of inflammation in their etiologies, a new term, post-inflammatory brain syndromes (PIBS), is necessary to describe the common outcomes of many different inflammatory insults. The concept of post-concussion syndrome is in its evolution therefore, the new term post-inflammatory brain syndromes provides a better understanding of etiology of its wide-array of symptoms and the wide array of conditions they can be seen in.

Racial differences in restless legs symptoms and serum ferritin in an incident dialysis patient cohort

PURPOSE

Restless legs syndrome (RLS), a debilitating sleep disorder that is frequently reported by CKD patients on dialysis, may be more common in whites than in non-whites. Iron deficiency is associated with RLS, and serum ferritin is higher among African Americans compared to Caucasians in the general population. No prior studies have compared restless legs symptoms and serum ferritin levels of African-American and those of the Caucasian patients on dialysis.

METHODS

In a multicenter observational study that included in-person interviews and medical chart review, we studied 210 patients who had recently started renal dialysis. Predictors of restless legs symptoms were examined in a multivariable logistic regression model.

RESULTS

African Americans had a reduced risk of restless legs complaint compared to Caucasian patients (OR, 0.44 [95% CI 0.21-0.93]; P=0.03). African-American patients were also less likely than Caucasian patients to have low serum ferritin values (<100 ng/ml), and among patients with serum ferritin≥100 ng/ml, the average serum ferritin of African-American patients was higher than that of Caucasian patients.

CONCLUSIONS

Further study of racial and iron status relationships could advance the understanding of RLS pathophysiology, and RLS is an important patient outcome to monitor, as revised anemia and iron protocols are implemented in the clinical setting.

Depression, insomnia and sleep apnea in patients on maintenance hemodialysis

Depression and sleep disorders are more frequent in patients on maintenance hemodialysis (HD) than the general population, and are associated with reduced quality of life and increased mortality risk. The purpose of this study was to assess the prevalence of depression, sleep apnea, insomnia in patients on HD as well as depression in their primary caregiver and to correlate these with the demographic profile. A cross-sectional study was conducted among 69 patients on maintenance HD for more than 3 months. There was high p revalence of depression (47.8%), insomnia (60.9%), increased risk of sleep apnea (24.6%) and depression in caregiver (31.9%). Depression was significantly more in patients with low monthly income (P=0.03), those on dialysis for more than 1 year (P=0.001) and the unemployed (P=0.009). High-risk patients for sleep apnea tended to be males with low monthly income (P=0.02). Insomnia was significantly higher in patients who were on dialysis for more than 1 year (P=0.003).

Fatigue in patients receiving maintenance dialysis: a review of definitions, measures, and contributing factors

Fatigue is a debilitating symptom or side effect experienced by many patients on long-term dialysis therapy. Fatigue has a considerable effect on patient health-related quality of life and is viewed as being more important than survival by some patients. Renal providers face many challenges when attempting to reduce fatigue in dialysis patients. The lack of a reliable, valid, and sensitive fatigue scale complicates the accurate identification of this symptom. Symptoms of daytime sleepiness and depression overlap with fatigue, making it difficult to target specific therapies. Moreover, many chronic health conditions common in the long-term dialysis population may lead to the development of fatigue and contribute to the day-to-day and diurnal variation in fatigue in patients. Key to improving the assessment and treatment of fatigue is improving our understanding of potential mediators, as well as potential therapies. Cytokines have emerged as an important mediator of fatigue and have been studied extensively in patients with cancer-related fatigue. In addition, although erythropoietin-stimulating agents have been shown to mitigate fatigue, the recent controversy regarding erythropoietin-stimulating agent dosing in patients with chronic kidney disease suggests that erythropoietin-stimulating agent therapy may not serve as the sole therapy to improve fatigue in this population. In conclusion, fatigue is an important and often underrecognized symptom in the dialysis population. Possible interventions for minimizing fatigue in patients on long-term dialysis therapy should aim at improving health care provider awareness, developing improved methods of measurement, understanding the pathogenesis better, and managing known contributing factors.

Patient-reported sleep difficulty and cognitive function during the first year of dialysis

BACKGROUND

Research in the general population indicates that sleep fragmentation is detrimental for cognitive function, but little attention has been given to this issue in dialysis patients. We hypothesized that patients with self-reported persistent sleep difficulty would have an increased risk of scoring lower on a cognitive function measure at follow-up compared to their score at baseline.

METHODS

Sleep difficulty and cognitive function were reported by a large national patient cohort near the start of dialysis and at a 9- to 12-month follow-up. Logistic regression was used to investigate the risk of scoring lower on a cognitive function measure at follow-up as a function of self-reported sleep difficulty, controlling for patients' sociodemographic, clinical and treatment characteristics, including depressed mood.

RESULTS

At follow-up, cognitive function scores were lower among 35.8% of the cohort. Patients with self-reported persistent sleep difficulty had the lowest average cognitive function score. Men with reported persistent sleep difficulty, regardless of presence of depressed mood, had a significantly increased risk of a lower cognitive function score at follow-up. Women with reported persistent sleep difficulty as well as depressed mood had significantly increased risk of a lower cognitive function score.

CONCLUSION

The potential impact of sleep difficulty and depressed mood on the cognitive function of dialysis patients emphasizes the importance of evaluating and treating these risks and highlights the value of continued research to improve our understanding and management of these issues.

Association of sleep difficulty with Kidney Disease Quality of Life cognitive function score reported by patients who recently started dialysis

Sleep disorders are associated with impaired cognition in the general population, but little attention has been given to the potential association between sleep and cognitive function in the dialysis population. This study investigated reported sleep difficulty and cognitive function scores in a national cohort of patients who initiated maintenance hemodialysis and peritoneal dialysis. The cognitive function scale of the Kidney Disease Quality of Life instrument (KDQOL-CF), which measures aspects of cognitive ability that are important for daily functioning (perceived reaction time, ability to concentrate, and tendency to become confused), was used. The study population included 2286 patients who responded to a questionnaire at baseline in the US Renal Data System Dialysis Morbidity and Mortality Study Wave 2. Reported sleep difficulty was associated in a univariate manner with lower KDQOL-CF score. In a multivariable regression analysis that controlled for age, gender, race, education, diabetic ESRD, cardiovascular comorbidity, smoking, hemoglobin, serum albumin, prescribed sleep medications, dialysis modality, pre-ESRD care, bodily pain, and depressed mood, the association of sleep difficulty with KDQOL-CF score remained significant (P < 0.0001); the association also was significant in a multivariable analysis that was restricted to hemodialysis patients and included adjustment for Kt/V (P = 0.001). Depressed mood and sleep medication prescription predicted a lower KDQOL-CF score, and higher educational level and less bodily pain predicted a higher KDQOL-CF score. Increased understanding of links among sleep difficulty, management of sleep difficulty, and cognitive function could benefit multiple dimensions of dialysis patients' quality of life and daily functioning.