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Sleep disorders in end-stage renal disease

Authors
Patrick J Hanly, MD, FRCPC, MRCPI, DABSM
Andreas Pierratos, MD, FRCPC
Istvan Mucsi, MD, PhD
Marta Novak, MD, PhD
Section Editor
Gary C Curhan, MD, ScD
Deputy Editor
Alice M Sheridan, MD

INTRODUCTION

Sleep disorders are common in patients with end-stage renal disease (ESRD). A systematic review of 17 studies in patients with ESRD indicated that "sleep disturbance" was one of their most common symptoms, with a mean prevalence of 44 percent [1]. Sleep disorders tend to be under-recognized by renal healthcare providers [2].

This topic reviews sleep disorders among ESRD patients, including insomnia, excessive sleepiness, sleep apnea, restless legs syndrome (RLS), and periodic limb movement (PLM) disorder. Sleep disorders in the general population are discussed elsewhere. (See "Classification of sleep disorders" and "Overview of insomnia" and "Approach to the patient with excessive daytime sleepiness".)

INSOMNIA

The reported prevalence of insomnia among ESRD patients treated with conventional hemodialysis or chronic ambulatory peritoneal dialysis (CAPD) ranges from 19 to 71 percent [3-14]. Insomnia is a significant source of stress [5,15] and has been associated with increased mortality among ESRD patients [14,16]. The mechanism by which insomnia increases mortality among such patients is not clear, but may be via an increase in systemic inflammation, which has been associated with both ESRD and poor cardiovascular outcomes among ESRD patients [17,18].

Pathogenesis — Contributors to insomnia include restless leg syndrome (RLS); periodic limb movement (PLM); sleep apnea [19-21]; metabolic factors, including uremia, anemia, hypercalcemia [22,23], bone pain, and pruritus; anxiety and depression [24,25]; circadian rhythm disorders, such as delayed-sleep phase syndrome [4,26]; the use of medications that prevent sleep; and poor sleep hygiene, including frequent napping during daytime dialysis.

Elevated plasma levels of orexin (a neuropeptide that promotes wakefulness) [27] and systemic inflammation [17,18] may also contribute to poor sleep among ESRD patients. The diurnal rhythm of melatonin is disturbed in patients with ESRD, and it is also related to the degree of kidney dysfunction in patients with chronic kidney disease (CKD) [28]. Some studies have suggested that the timing of the dialysis shift alters the severity of insomnia such that insomnia is worse among patients who are dialyzed in the morning [6,29], but this has not been shown in all studies [30].

                       

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