Reviews: Diagnosis and Management of Sleep Apnea Syndrome and Restless Legs Syndrome in Dialysis Patients

Prevalence of obstructive sleep apnea in whole spectrum chronic kidney disease patients: A systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep disorder among chronic kidney disease (CKD) patients, associated with considerable morbidity. Various studies from around the globe have reported different prevalence rates.

OBJECTIVE

This systematic review and meta-analysis aimed to determine the prevalence of OSA and quantify the relationship between OSA and mortality risk in patients with CKD.

METHODS

Four databases were systematically searched, and additional references to relevant articles were manually searched. The prevalence of OSA and the mortality risk based on random-effects models were assessed using percentages and hazard ratio (HR) with a 95 % confidence interval (95 % CI). In addition, the heterogeneity between studies was assessed using I2 statistics.

RESULTS

A total of 44 literature (47 studies with 223,967 participants) met the eligibility criteria for the meta-analysis. The results showed that the prevalence of OSA in CKD patients was reported to be 39.3 % (95 % CI, 32.3-46.7). Among study participants in different age groups, the highest prevalence of OSA was found in CKD respondents aged 60 years or older, at 47.1 % (95 % CI 34.4-60.3). Of the eight literature (10 cohorts) that provided survival data, the pooled estimates indicated a 26.5 % (HR: 1.265; 95 % CI 1.021-1.568) higher mortality risk in subjects with OSA than CKD patients without OSA.

CONCLUSIONS

This systematic review and meta-analysis found that more than 1/3 of CKD patients have comorbid OSA, which increases the risk of early death in CKD patients. These results should help policymakers to provide adequate healthcare for this population.

PROSPERO REGISTRATION ID

CRD42023465497.

Management Challenges of Sleep-Disordered Breathing in a Child With Chronic Kidney Disease: A Case Report of a Child on Peritoneal Dialysis

Chronic kidney disease in children is a challenging condition that requires careful management. When combined with sleep-disordered breathing, it can pose even greater difficulties. This case report highlights the management challenges of a child with chronic kidney disease and sleep-disordered breathing. Through careful analysis and effective intervention, we were able to address the challenges and improve the child's quality of life. Understanding the complex interaction between these two conditions is crucial for healthcare professionals to provide effective care for children with chronic kidney disease and sleep-disordered breathing.

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.

Restless leg syndrome in patients with chronic kidney disease: a hospital-based study from Upper Egypt

OBJECTIVES

Chronic kidney disease (CKD) is a common cause of restless leg syndrome (RLS). RLS is under-recognized, misdiagnosed and undertreated disorder in our locality. In this study, we aimed to determine the prevalence of RLS due to CKD and its predictors.

METHODS

This cross-sectional study included 520 patients [male = 200; female = 320; age: 48.45 ± 3.63yrs; uremia duration: 6.44 ± 1.65yrs; CKD5D = 400; CKD3D = 120). RLS diagnosis was done by clinical interviewing according to International RLS Study Group criteria. All underwent detailed biochemical testing and iron and ferritin levels' measurements. Insomnia, depression and anxiety severities were assessed using insomnia sleep index (ISI), Beck Depression Inventory (BDI-II) and State-Trait Anxiety Inventory for Adults (STAI-AD) scales.

RESULTS

RLS was found in 22.31% [ESKD = 26%, CKD3D = 10%]. Insomnia, depression and anxiety were found in 76.15%, 91.15% and 44.23%, respectively. Insomnia was correlated with depression (r = 0.488, p = 0.001) and anxiety (r = 0.360, p = 0.006) but not RLS. Multiple linear regression analysis showed that ESKD (OR = 3.8, 95%CI = 2.5-8.5, p = 0.001), inadequate dialysis (OR = 4.6, 95%CI = 3.5-8.6, p = 0.001), hyperparathyroidism (OR = 5.1, 95%CI 3.2-13.7, p = 0.0001) and peripheral neuropathy (OR = 5.6, 95%CI = 3.8-12.8, p = 0.0001) were independently associated with RLS.

CONCLUSION

The prevalence of RLS with CKD is 22.31%. It is 2.6 times more frequent and severe with ESKD compared to CKD3D. It seems that RLS may occur early with CKD and becomes worse with progressive kidney impairment. Also, insomnia, depression and anxiety are common with CKD, however, their severities were not correlated with RLS. Predictors for RLS were ESKD, inadequacy of dialysis, hyperparathyroidism and peripheral neuropathy.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

Epidemiology of haemodialysis outcomes

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement.

Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis.

Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age).

Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties.

Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial.

Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.

Effects of nonpharmacological intervention on sleep quality in hemodialysis patients: A protocol for systematic review and meta-analysis

BACKGROUND

Nonpharmacological intervention can improve the sleep quality of hemodialysis patients. However, there are many types of nonpharmacological interventions, which makes it difficult to determine the best one. Therefore, this study carried out network meta-analysis to evaluate the effects of nonpharmacological intervention on sleep quality of hemodialysis patients, so as to provide evidence for the selection of the optimal nonpharmacological intervention for the improvement of sleep quality of hemodialysis patients clinically.

METHODS

Randomized controlled trials on the effects of nonpharmaceutical interventions on sleep quality in hemodialysis patients were conducted by searching English databases (PubMed, Cochrane Library, EMBASE, and Web of Science) and Chinese databases (Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Wanfang, and China Biomedical Literature Database) on computer. The retrieval time was from the establishment of the database to May 2021. Literature screening, data extraction, and evaluation of the risk of bias in the included studies were conducted independently by two researchers. Data analysis was performed with STATA14.0 and GEMTC 0.14.3 software.

RESULTS

We will disseminate the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSIONS

This study will provide the best evidence-based evidence to support the effects of non-pharmacological interventions on sleep quality in hemodialysis patients.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms. This review would be disseminated in a peer-reviewed journal or conference presentations.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/4BPKT.

Impact of Medium Cut-Off Dialyzers on Patient-Reported Outcomes: COREXH Registry

INTRODUCTION

A new generation of hemodialysis (HD) membranes called medium cut-off (MCO) membranes possesses enhanced capacities for middle molecule clearance, which have been associated with adverse outcomes in this population. These improvements could potentially positively impact patient-reported outcomes (PROs).

OBJECTIVE

The objective of this study was to evaluate the impact of MCO membranes on PROs in a cohort of HD patients in Colombia.

METHODS

This was a prospective, multicenter, observational cohort study of 992 patients from 12 renal clinics in Colombia who were switched from high-flux HD to MCO therapy and observed for 12 months. Changes in Kidney Disease Quality of Life 36-Item Short Form Survey (KDQoL-SF36) domains, Dialysis Symptom Index (DSI), and restless legs syndrome (RLS) 12 months after switching to MCO membranes were compared with time on high-flux membranes. Repeated measures of ANOVA were used to evaluate changes in KDQoL-SF36 scores; severity scoring was used to assess DSI changes over time; Cochran's Q test was used to evaluate changes in frequency of diagnostic criteria of RLS.

RESULTS

During 12 months of follow-up, 3 of 5 KDQoL-SF36 domains improved compared with baseline: symptoms (p < 0.0001), effects of kidney disease (p < 0.0001), and burden of kidney disease (p < 0.001). The proportion of patients diagnosed with RLS significantly decreased from 22.1% at baseline to 10% at 12 months (p < 0.0001). No significant differences in the number of symptoms (DSI, p = 0.1) were observed, although their severity decreased (p = 0.009).

CONCLUSIONS

In conventional HD patients, the expanded clearance of large middle molecules with MCO-HD membranes was associated with higher health-related quality of life scores and a decrease in the prevalence of RLS.

Neurologic conditions and disorders of uremic syndrome of chronic kidney disease: presentations, causes, and treatment strategies

Introduction: Uremic syndrome of chronic kidney disease (CKD) is a term used to describe clinical, metabolic, and hormonal abnormalities associated with progressive kidney failure. It is a rapidly growing public health problem worldwide. Nervous system complications occur in every patient with uremic syndrome of CKD. Areas covered: This review summarized central and peripheral nervous system complications of uremic syndrome of CKD and their pathogenic mechanisms. They include cognitive deterioration, encephalopathy, seizures, asterixis, myoclonus, restless leg syndrome, central pontine myelinolysis, stroke, extrapyramidal movement disorders, neuropathies, and myopathy. Their pathogenic mechanisms are complex and multiple. They include (1) accumulation of uremic toxins resulting in neurotoxicity, blood-brain barrier injury, neuroinflammation, oxidative stress, apoptosis, brain neurotransmitters imbalance, ischemic/microvascular changes, and brain metabolism dysfunction (e.g. dopamine deficiency), (2) metabolic derangement (as acidosis, hypocalcemia, hyperphosphatemia, hypomagnesemia, and hyperkalemia); (3) secondary hyperparathyroidism, (4) erythropoietin and iron deficiency anemia, (5) thiamin, vitamin D, and other nutritional deficiencies, (6) hyperhomocysteinemia, and (7) coagulation problems. Expert commentary: Nervous system complications of uremia contribute to the patients' morbidity and mortality. Optimizing renal replacement therapy, correction of associated metabolic and medical conditions, and improved understanding of possible pathogenic mechanisms of these complications is a major target for their prevention and treatment.

Sleep disorders in dialysis patients

Poor sleep and sleep-related breathing disorders are common in patients with end-stage renal disease (ESRD) but are often unrecognized and undertreated. Sleep disorders are known negative prognostic factors for morbidity and mortality. The most frequent sleep disorders seen in patients with ESRD are conditioned insomnia, excessive daytime sleepiness, obstructive or central sleep apnea (SA), as well as restless legs syndrome (RLS) and periodic limb movement disorder (PLMD). Several uremic and nonuremic factors are thought to participate in the pathogenesis of sleep disorders in patients with ESRD. The therapy of sleeping disorders includes nonpharmacological and pharmacological measures that can improve the functionality and quality of life in patients with ESRD.

Restless leg syndrome in chronic hemodialysis patients in Mashhad hemodialysis centers

Introduction: Restless leg syndrome (RLS) is a sensory motor disorder. Patients with this syndrome have serious and uncontrollable desire to move their legs, which is mostly due to an uncomfortable feeling intensified when they are motionless. It may be a genetic disorder or secondary to iron deficiency, neurodegenerations, pregnancy, some drugs and severe kidney diseases.

Objectives: This study was designed to find out the prevalence and its risk factors of RLS in hemodialysis patients.

Patients and Methods: This multicenter cross-sectional study was done on 260 hemodialysis patients. The prevalence of RLS was measured using International Restless Legs Syndrome Study Group (IRLSSG)’s RLS Questionnaire (RLSQ). Potential risk factors for RLS including underlying cause of chronic renal failure, duration on dialysis, biochemical tests, dialysis adequacy, and erythropoietin and also venofer dosage in recent month and demographic data were also evaluated.

Results: The prevalence of RLS was 55% including 59.4% males and 40.6% females. Their mean age of RLS patients and their dialysis duration were significantly higher than other group (P<0.05). Their body mass index (BMI) and serum calcium were significantly higher (P<0.05). However erythropoietin dosage and serum hemoglobin level were lower in RLS patients (P<0.05). Significant predictors of RLS were history of diabetes mellitus (DM), hypertension (HTN), smoking (P<0.05). There was not significant relation between RLS and dialysis adequacy, serum intact parathyroid hormone (iPTH), urea, ferritin and venofer dosage (P>0.05).

Conclusion: According to the results, RLS is a common disorder in hemodialysis patients which can affect strongly on their life. So particular attention and sooner diagnosis of RLS in high risk patients for better management is necessary.

The Burden of Cognitive Impairment in Patients With End-Stage Renal Disease and Impact on Dialysis Modality Choice

Introduction

Kidney disease is associated with significant cognitive dysfunction. Subjective reports of cognitive ability have not been studied extensively in chronic kidney disease. We investigated the association between objective and subjective cognitive functions in predialysis patients and their association with self-care dialysis modality choice.

Methods

Cross-sectional data from the Barriers to Successful Implementation of Care in Home Haemodialysis study were used for the study of cognition in 220 predialysis patients. The data were used to ascertain the demographics, clinical, laboratory, and neuropsychometric variables. The latter includes Trail Making Tests (TMT) parts A and B, Modified Mini Mental State Examination, and metacognition questionnaire for subjective assessment of one's cognitive ability. The outcome variable was fully assisted and self-care dialysis modality choice.

Results

Within the study cohort, 90 patients chose fully assisted hemodialysis and 114 patients chose self-care dialysis. The median Modified Mini Mental State Examination, TMT part A, and TMT part B scores were greater for the assisted versus the self-care group. Metamemory was not significantly different between groups, but the metaconcentration score was significantly worse in the group choosing assisted dialysis. Higher (i.e., better) metaconcentration scores were significantly associated with the self-care modality choice in the univariate and hierarchical regression analyses. Adjusted and unadjusted analyses showed a significant association between perceived concentration and TMT part B scores (P < 0.01). With every 1.6-minute increase in TMT part B score, there was a 1-unit reduction in metaconcentration score, and the latter was associated with 20% lower odds of choosing self-care dialysis over a fully assisted dialysis modality.

Discussion

Patients' self-perception of cognitive ability is a significant predictor of self-care dialysis modality choice. Subjective report of "metaconcentration" is also strongly associated with poorer outcome on the TMT part B.

Sleep disorders in pediatric chronic kidney disease patients

The prevalence of sleep disorders during childhood has been estimated to range from 25 to 43 %. The aim of this review is to determine the prevalence of sleep disorders and possible associations with chronic kidney disease (CKD)-related factors and health-related quality of life (HRQOL) in children with CKD. An electronic systematic literature search for sleep disorders in children with CKD in Pubmed, Embase and the Cochrane Library Databases identified seven relevant articles for review, all of which reported an increased prevalence of sleep disorders in children with CKD. Five studies included children with CKD undergoing dialysis, and two studies included only non-dialysis patients. In all studies the presence of sleep disturbances was assessed by questionnaires; only one study compared the results of a validated questionnaire with laboratory-based polysomnography. The prevalence of any sleep disorder ranged from 77 to 85 % in dialysis patients, to 32-50 % in transplanted patients and 40-50 % in non-dialysis patients. The most commonly studied disorder was restless legs syndrome, which presented at a prevalence of 10-35 %. Three studies showed significant associations between presence of sleep disorders and HRQOL. We found consistent evidence of an increased prevalence of sleep disturbances in children with CKD, and these seemed to play a critical role in HRQOL.

Restless Legs Syndrome in Patients With Chronic Kidney Disease

Symptoms of restless legs syndrome (RLS) are common in patients with chronic kidney disease (CKD) on dialysis; symptoms of RLS are estimated to affect up to 25% of patients on dialysis when the international RLS diagnostic criteria are applied. RLS is a neurologic disorder with a circadian rhythmicity characterized by an overwhelming urge to move the legs during rest, which can be relieved temporarily by movement. RLS has been associated with an increase in sleep disturbance, higher cardiovascular morbidity, decreased quality of life, and an increased risk of death in patients with CKD. Although the exact pathophysiology of RLS is unknown, it is thought to involve an imbalance in iron metabolism and dopamine neurotransmission in the brain. The symptoms of moderate to severe RLS can be treated with several pharmacologic agents; however, data specific to patients on dialysis with RLS are lacking. The purpose of this article is to examine the relationship between, and complications of, RLS and CKD both in dialysis and nondialysis patients, and discuss the treatment options for patients on dialysis with RLS.

Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.

Effect of Positive Airway Pressure Therapy on Body Mass Index in Obese Patients With Obstructive Sleep Apnea Syndrome: A Prospective Study

Because obesity is a common cause of obstructive sleep apnea syndrome (OSAS), weight loss can be an effective treatment. OSAS also may cause weight gain in some patients. Effective treatment of sleep apnea may facilitate weight loss in obese patients. We hypothesize that positive airway pressure (PAP) therapy is associated with weight loss in obese patients with OSAS. This was a single-center observational prospective cohort study. Forty-five patients were diagnosed with OSAS after polysomnographic analysis in sleep laboratory and underwent continuous positive airway pressure titration. Patients were followed for 3 months in terms of change in body mass index (BMI) and compliance with PAP therapy. Of the 45 patients recruited, 3 patients were eliminated because of miss recruitment. Nine patients had incomplete data, and the rest (n = 33) were included for analysis. The mean age was 54.9 ± 16.9 years (mean ± SD), 93.9% were male, and 90.9% were whites. Mean apnea-hypopnea index was 36.3 ± 28.17 events per hour. Mean BMI before treatment was 34.7 ± 3.9 kg/m. Fifteen patients (45.5%) were compliant with therapy of OSAS with PAP. There was no difference in age, gender, neck circumference, BMI, and apnea-hypopnea index of patients compliant to therapy when compared with those who were not. There was a significant decrease in BMI in patients compliant with PAP therapy compared with noncompliant patients (-1.2 ± 0.7 vs. 0.3 ± 0.9 kg/m, P ≤ 0.001). PAP therapy may cause significant loss of weight within 3 months in obese patients with OSAS. Further study is needed to elucidate the physiological basis of this change.

Aerobic exercise improves signs of restless leg syndrome in end stage renal disease patients suffering chronic hemodialysis

Background. Restless leg syndrome (RLS) is one of the prevalent complaints of patients with end stage renal diseases suffering chronic hemodialysis. Although there are some known pharmacological managements for this syndrome, the adverse effect of drugs causes a limitation for using them. In this randomized clinical trial we aimed to find a nonpharmacological way to improve signs of restless leg syndrome and patients' quality of life. Material and Methods. Twenty-six patients were included in the study and divided into 2 groups of control and exercise. The exercise group used aerobic exercise during their hemodialysis for 16 weeks. The quality of life and severity of restless leg syndrome were assessed at the first week of study and final week. Data were analyzed using SPSS software. Results. The difference of means of RLS signs at the first week of study and final week was −5.5 ± 4.96 in exercise group and −0.53 ± 2.3 in control group. There was not any statistical difference between control group and exercise group in quality of life at the first week of study and final week. Conclusions. We suggest using aerobic exercise for improving signs of restless leg syndrome, but no evidence was found for its efficacy on patient's quality of life.

Research priorities in geriatric palliative care: nonpain symptoms

Research addressing the burden, assessment, and management of nonpain symptoms associated with advanced illness in older adults is limited. While nonpain symptoms such as fatigue, sleep, dyspnea, anxiety, depression, cognitive impairment, nausea, and anorexia-cachexia are commonly noted by patients and clinicians, research quantifying their effects on quality of life, function, and other outcomes are lacking and there is scant evidence regarding management. Most available studies have focused on relatively narrow conditions (e.g., chemotherapy-induced nausea) and there are almost no data relevant to patients with multiple morbidities or multiple concurrent symptoms. Assessment and treatment of nonpain symptoms in older adults with serious illness and multiple comorbidities is compromised by the lack of data relevant to their care. Recommended research priorities address the documented high prevalence of distressing symptoms in older adults with serious illness, the unique needs of this population due to coexistence of multiple chronic conditions along with physiologic changes related to aging, the lack of evidence for effective pharmacologic and nonpharmacologic interventions, and the need for validated measures that are relevant across multiple care settings.

Restless legs syndrome in children with chronic kidney disease

BACKGROUND

Restless legs syndrome (RLS) is considerably more common among adults with chronic kidney disease (CKD) than in the general population and is associated with increased morbidity and mortality. There is limited information on RLS in children with CKD. Failure to account for conditions that might mimic RLS can lead to overdiagnosis of this syndrome.

METHODS

In a prospective, cross-sectional study, RLS prevalence was compared between pediatric CKD patients and healthy children. RLS was assessed via a questionnaire that included exclusion of mimics. Sleep characteristics and health-related quality of life (HRQoL) were also assessed.

RESULTS

Restless legs syndrome was more prevalent in CKD patients (n = 124) than in 85 normal children (15.3 vs. 5.9 %; p = 0.04). There was no significant association between RLS and CKD stage, CKD etiology, CKD duration, and dialysis or transplant status. Children with RLS were more likely to rate their sleep quality as fairly bad or very bad (41.2 vs. 8.8 %; p = 0.003) and report using sleep medications (42.1 vs. 14.7 %; p = 0.01). RLS was associated with lower HRQoL by parent report (p = 0.03). Only five of the 19 patients (26.3 %) with CKD and RLS had discussed RLS symptoms with a healthcare provider, and only one of these patients had been diagnosed with RLS prior to this study.

CONCLUSIONS

The prevalence of RLS is increased in children with CKD and appears to be underdiagnosed. Systematic screening for RLS and sleep problems would therefore appear to be warranted in children with CKD.

Screening for depression: only one piece of the puzzle

In this issue of NDT, van den Beukel et al. from the Netherlands suggest that a 5-item survey questionnaire might be used to replace the Beck Depression Index to screen patients with chronic kidney disease (CKD) for depression. The nephrology community is at a tipping point in terms of the assessment of outcomes, especially among patients on dialysis. Indeed, the entire healthcare community has begun to shift its focus to patient-reported outcomes (PROs), including quality of life, patient satisfaction and the psychosocial determinants of health. Beyond depression, there are a myriad of aspects of psychological distress that include anxiety, worrying, fear of progression of kidney disease and the fear of the future in general, death and dying, hopelessness, questions around the meaning of life and the experience of recurrent psychological and physical trauma through the CKD trajectory. We encourage the community and its researchers to embrace and research PROs, with the aim to create a holistic, patient-centered model of care for patients at all stages of CKD, including those on chronic dialysis and after transplantation, keeping the whole person-and their families-in mind.

Cognitive-behavioral therapy for sleep disturbance decreases inflammatory cytokines and oxidative stress in hemodialysis patients

Sleep disturbance is common in dialysis patients and is associated with the development of enhanced inflammatory responses. Cognitive-behavioral therapy is effective for sleep disturbance and reduces inflammation experienced by peritoneal dialysis patients; however, this has not been studied in hemodialysis patients. To determine whether alleviation of sleep disturbance in hemodialysis patients also leads to less inflammation, we conducted a randomized controlled interventional study of 72 sleep-disturbed hemodialysis patients. Within this patient cohort, 37 received tri-weekly cognitive-behavioral therapy lasting 6 weeks and the remaining 35, who received sleep hygiene education, served as controls. The adjusted post-trial primary outcome scores of the Pittsburgh Sleep Quality Index, the Fatigue Severity Scale, the Beck Depression Inventory, and the Beck Anxiety Inventory were all significantly improved from baseline by therapy compared with the control group. The post-trial secondary outcomes of high-sensitive C-reactive protein, IL-18, and oxidized low-density lipoprotein levels significantly declined with cognitive-behavioral therapy in comparison with the control group. Thus, our results suggest that cognitive-behavioral therapy is effective for correcting disorganized sleep patterns, and for reducing inflammation and oxidative stress in hemodialysis patients.

Neurological complications of chronic kidney disease

Chronic kidney disease (CKD) is a critical and rapidly growing global health problem. Neurological complications occur in almost all patients with severe CKD, potentially affecting all levels of the nervous system, from the CNS through to the PNS. Cognitive impairment, manifesting typically as a vascular dementia, develops in a considerable proportion of patients on dialysis, and improves with renal transplantation. Patients on dialysis are generally weaker, less active and have reduced exercise capacity compared with healthy individuals. Peripheral neuropathy manifests in almost all such patients, leading to weakness and disability. Better dialysis strategies and dietary modification could improve outcomes of transplantation if implemented before surgery. For patients with autonomic neuropathy, specific treatments, including sildenafil for impotence and midodrine for intradialytic hypotension, are effective and well tolerated. Exercise training programs and carnitine supplementation might be beneficial for neuromuscular complications, and restless legs syndrome in CKD responds to dopaminergic agonists and levodopa treatment. The present Review dissects the pathophysiology of neurological complications related to CKD and highlights the spectrum of therapies currently available.

Sleep-related problems in common medical conditions

Common medical problems are often associated with abnormalities of sleep. Patients with chronic medical disorders often have fewer hours of sleep and less restorative sleep compared to healthy individuals, and this poor sleep may worsen the subjective symptoms of the disorder. Individuals with lung disease often have disturbed sleep related to oxygen desaturations, coughing, or dyspnea. Both obstructive lung disease and restrictive lung diseases are associated with poor quality sleep. Awakenings from sleep are common in untreated or undertreated asthma, and cause sleep disruption. Gastroesophageal reflux is a major cause of disrupted sleep due to awakenings from heartburn, dyspepsia, acid brash, coughing, or choking. Patients with chronic renal disease commonly have sleep complaints often due to insomnia, insufficient sleep, sleep apnea, or restless legs syndrome. Complaints related to sleep are very common in patients with fibromyalgia and other causes of chronic pain. Sleep disruption increases the sensation of pain and decreases quality of life. Patients with infectious diseases, including acute viral illnesses, HIV-related disease, and Lyme disease, may have significant problems with insomnia and hypersomnolence. Women with menopause have from insomnia, sleep-disordered breathing, restless legs syndrome, or fibromyalgia. Patients with cancer or receiving cancer therapy are often bothered by insomnia or other sleep disturbances that affect quality of life and daytime energy. The objective of this article is to review frequently encountered medical conditions and examine their impact on sleep, and to review frequent sleep-related problems associated with these common medical conditions.

[The role of family physicians in the recognition and screening of obstructive sleep apnea]

Obstructive sleep apnea is the most frequent sleep disorder. The prevalence of sleep apnea in the general population is 2-4% and the main characteristic of the disease is the intermittent cessation or substantial reduction of airflow during sleep, caused by complete, or near complete upper airway obstruction. Decreased airflow is followed by oxygen desaturation and intermittent arousals. The clinical presentation of the disorder is complex. Loud snoring with breathing pauses and daytime sleepiness should raise the suspicion of sleep apnea, but we have to consider this disease if the patient has therapy resistant hypertension, heart failure, arrhythmias, stroke, depression or memory problems. Family physicians have an important role in recognizing sleep apnea. High risk patients can easily be identified by the main symptoms and using the Berlin sleep apnea questionnaire. These patients should be referred to a sleep laboratory for polysomnographic assessment and, if necessary, for further treatment.

Association of initial hemodialysis vascular access with patient-reported health status and quality of life

BACKGROUND

Although the arteriovenous fistula (AVF) is the recommended form of vascular access for patients with ESRD, its impact on patient perception of health status, quality of life (QOL), or satisfaction is unknown.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

This study compared patient-reported health status and QOL scores and vascular access type among a national random sample of 1563 patients at dialysis initiation and day 60 of ESRD during 1996 to 1997. Patients were stratified into five categories: AVF at first dialysis and day 60 of ESRD, arteriovenous graft (AVG) at first dialysis and day 60, central venous catheter (CVC) at first dialysis and AVF at day 60, CVC at first dialysis and AVG at day 60, and CVC at first dialysis and day 60.

RESULTS

Ten percent (n = 154) of patients had an AVF, 21% (n = 326) had an AVG, and 69% (n = 1083) had a CVC at dialysis initiation; those who were most likely to use an AVF were white and male. After statistical adjustment, patients with persistent AVF use reported greater physical activity and energy, better emotional and social well-being, fewer symptoms, less effect of dialysis and burden of kidney disease, and better sleep compared with patients with persistent CVC use, whereas measures such as cognitive and sexual function did not differ by access type.

CONCLUSIONS

Compared with persistent CVC use, early persistent AVF use is associated with the perception of improved health status and QOL among patients with ESRD. Future longitudinal studies may help to clarify further the association between QOL and vascular access.