Sleep quality is an important and determining factor in the quality of life in dialysis patients. Although many chronic dialysis patients complain of poor sleep, we know little about its related factors. Therefore, this study was designed to study sleep quality and its predictors among dialysis patients.
Materials and Methods:
This was a cross-sectional study carried out during August-December 2009 in Shariati Dialysis Center, Fasa University of Medical Sciences. Data were gathered on 61 patients receiving a hemodialysis treatment. Quality of sleep was measured using the Pittsburgh Sleep Quality Index (PSQI) in dialysis patients in association with the main clinical and biochemical variables. Logistic and multiple linear regressions were used to assess predictors of sleep quality.
Forty-five subjects (73.8%) reported poor sleep quality defined as a global PSQI score > 5. As the age (p = 0.036) and duration of dialyses (p = 0.022) increased, sleep quality decreased. Significant differences were found between sex and sleep quality (p = 0.044). Sleep quality problems had a significant association with MCV (p = 0.025).
Poor sleep quality is a very common problem in dialysis patients. Assessment and management of sleep quality should be an important component of care giving to these patients. Large prospective longitudinal studies are needed to confirm the high prevalence of impaired quality of sleep and its related factors while controlling confounding variables.
Hemodialysis; sleep quality; Pittsburgh sleep quality index (PSQI) questionnaire; MCV; CBC
Studies examining sleep in the hemodialysis (HD) population have largely lacked an adequate comparison group. It therefore remains uncertain if poor sleep quality among the HD population reflects the age, chronic health conditions, or the effects of conventional hemodialysis.
Cross-sectional matched-group study
Setting & Participants
Forty-six in-center hemodialysis patients were compared with 137 community subjects participating in the Sleep Heart Health Study matched for age, sex, body mass index (BMI), and race.
HD patients compared to community dwelling non-HD subjects.
Outcomes and Measurements
Home unattended polysomnography (PSG) was performed and scored using similar protocols. Sleep habits and sleepiness were assessed using the Sleep Habits Questionnaire and the Epworth Sleepiness Scale.
The average age of the study samples was 63 years, 72% were white, and the average BMI was 28±5 kg/m2. HD patients were significantly more likely than the community participants to have short sleep (odds ratio [OR] 3.27; 95% confidence interval [CI] 1.16–9.25) and decreased sleep efficiency (OR 5.5; CI 1.5–19.6). The HD patients reported more difficulty getting back to sleep (OR 2.25; CI 1.11–4.60) and waking up too early (OR 2.39; CI 1.01–5.66). There was no association between PSG sleep time and self-reported sleep time (r=0.09; p=0.6) or between the Epworth Sleepiness Scale and the severity of sleep apnea (r=0.10; p=0.5) in the HD population.
The study was limited to participants older than 45 years.
Kidney failure treated with thrice-weekly HD is significantly associated with poor subjective and objective sleep quality.
Hemodialysis; sleep; polysomnography; self-report; questionnaire
Disturbed sleep is common in end-stage renal disease (ESRD). Exogenous melatonin has somniferous properties in normal subjects and can improve sleep quality (SQ) in several clinical conditions. Recent studies have shown that melatonin may play a role in improving sleep in patients undergoing dialysis. The goal of the present study was to assess the effect of exogenous melatonin administration on SQ improvement in daytime hemodialysis patients. Lipid profile and the required dose of erythropoietin (EPO) are also reported as secondary outcomes. In a 6-week randomized, double-blind cross-over clinical trial, 3 mg melatonin or placebo was administered to 68 patients at bedtime. A 72-h washout preceded the switch from melatonin to placebo, or vice versa. SQ was assessed by the Pittsburgh sleep quality index (PSQI). Sixty-eight patients completed the study protocol and were included in the final analysis. Melatonin treatment significantly improved the global PSQI scores (P < 0.001), particularly subjective SQ (P < 0.001), sleep efficiency (P = 0.005) and sleep duration (P < 0.001). No differences in sleep latency and daytime sleepiness were observed. Melatonin also increased the high-density lipoprotein (HDL) cholesterol (P = 0.003). The need for EPO prescription decreased after melatonin treatment (P < 0.001). We conclude that melatonin can improve sleep in ESRD. The modest increase in HDL cholesterol and decrease in the EPO requirement are other benefits associated with this treatment
End-stage renal disease; hemodialysis; melatonin; pittsburgh sleep quality index; sleep
It has been suggested that oxidative stress and inflammation are associated with the pathophysiology of sleep disorders in end-stage renal disease (ESRD) patients. We examined the relationship of the sleep variables reflecting sleep breathing disorder and limb movements during sleep with the clinical variables reflecting the metabolic abnormalities in ESRD patients receiving hemodialysis.
Nocturnal polysomnography was conducted in 30 ESRD patients (21 men, 9 women), who were receiving hemodialysis. Blood was sampled before hemodialysis for each patient in order to measure uric acid (UA), C-reactive protein (CRP), and interleukin-6 (IL-6).
UA was correlated positively with the total sleep time (TST)(r=0.407) and negatively with the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI)(r=-0.377, -405).
CRP was positively correlated with the limb movement index (LMI)(r=0.401). Our study showed that increased UA was related to decreased respiratory disturbance during sleep in ESRD patients receiving hemodialysis.
End-stage renal disease; Nocturnal sleep; Uric acid; C-reactive protein; Sleep breathing disorder
To evaluate if anger expression affects sleep quality in patients with coronary heart disease (CHD). Research has indicated that poor sleep quality independently predicts adverse outcomes in patients with CHD. Risk factors for poor sleep quality include older age, socioeconomic factors, medical comorbidities, lack of exercise, and depression.
We sought to examine the association of anger expression with sleep quality in 1020 outpatients with CHD from the Heart and Soul Study. We assessed anger-in, anger-out, and anger temperament, using the Spielberger State-Trait Anger Expression Inventory 2, and measured sleep quality, using items from the Cardiovascular Health Study and Pittsburgh Sleep Quality Index. We used multivariate analysis of variance to examine the association between anger expression and sleep quality, adjusting for potential confounding variables.
Each standard deviation (SD) increase in anger-in was associated with an 80% greater odds of poor sleep quality (odds ratio (OR) = 1.8, 95% Confidence Interval (CI) = 1.6–2.1; p < .0001). This association remained strong after adjusting for demographics, comorbidities, lifestyle factors, medications, cardiac function, depressive symptoms, anger-out, and anger temperament (adjusted OR = 1.4, 95% CI = 1.5–1.7; p = .001). In the same model, each SD increase in anger-out was associated with a 21% decreased odds of poor sleep quality (OR = 0.79, 95% CI = 0.64–0.98; p = .03). Anger temperament was not independently associated with sleep quality.
Anger suppression is associated with poor sleep quality in patients with CHD. Whether modifying anger expression can improve sleep quality or reduce cardiovascular morbidity and mortality deserves further study.
anger expression; sleep quality; coronary heart disease
Both the incidence and the prevalence of end-stage renal disease (ESRD) in elderly patients are increasing worldwide. Elderly ESRD patients have been found to be more prone to depression than the general population. There are many studies that have addressed the relationship between sleep quality (SQ), depression, and health related quality of life (HRQoL) in ESRD patients, but previous studies have not confirmed the association in elderly hemodialysis (HD) patients. Therefore, the aim of the present study was to demonstrate this relationship in elderly HD patients.
Patients and methods
Sixty-three elderly HD patients (32 females and 31 males aged between 65 and 89 years) were included in this cross-sectional study. A modified Post-Sleep Inventory (PSI), the Medical Outcomes Study 36-item short form health survey, and the Beck Depression Inventory (BDI) were applied.
The prevalence of poor sleepers (those with a PSI total sleep score [PSI-4 score] of 4 or higher) was 71% (45/63), and the prevalence of depression was 25% (16/63). Of the 45 poor sleepers, 15 had depression, defined as a BDI score of 17 or higher. Poor sleepers had a significantly higher rate of diabetes mellitus (P = 0.03), significantly higher total BDI scores, and lower Physical Component Scale scores (ie, lower HRQoL) than good sleepers. The PSI-4 score correlated negatively with Physical Component Scale (r = −0.500, P < 0.001) and Mental Component Scale scores (r = −0.527, P < 0.001) and it correlated positively with the BDI score (r = 0.606, P < 0.001). In multivariate analysis, independent variables of PSI-4 score were BDI score (beta value [β] = 0.350, P < 0.001), Mental Component Scale score (β = −0.291, P < 0.001), and age (β = 0.114, P = 0.035).
Poor SQ is a very common issue and is associated with both depression and lower HRQoL in elderly HD patients.
health-related quality of life; end-stage renal disease; poor sleep quality; Post-Sleep Inventory; Beck Depression Inventory
Self-reported physical health and functioning and direct measures of physical performance are decreased in hemodialysis patients and are associated with mortality and hospitalization.
We determined baseline cross-sectional associations of physical performance, health, and functioning with demographics, clinical characteristics, nutritional indexes, laboratory benchmarks, and measures of body composition in participants in the Frequent Hemodialysis Network (FHN) trial.
Setting & Participants
375 persons enrolled in the FHN with data for physical performance, health, and functioning.
Explanatory variables were categorized into fixed factors of age, race, comorbid conditions (diabetes mellitus, heart failure, and peripheral arterial disease) and potentially modifiable factors of dialysis dose, phosphorus level, hemoglobin level, equilibrated normalized protein catabolic rate (enPCR), body composition, body mass index, phase angle, and ratio of intracellular water volume to body weight (calculated from bioelectrical impedance).
Scores on tests of physical performance, health, and functioning.
Physical performance measured using the Short Physical Performance Battery, self-reported physical health and functioning using the 36-Item Short Form Health Survey (SF-36). Body composition (body mass index and bioimpedance analysis) and laboratory data were obtained from affiliated dialysis providers.
Relative to population norms, scores for all 3 physicality metrics were low. Poorer scores on all 3 metrics were associated with diabetes mellitus and peripheral arterial disease. Poorer scores on the SF-36 Physical Functioning subscale and Short Physical Performance Battery also were associated with age, lower ratio of intracellular water volume to body weight, and lower enPCR. Black race was associated with poorer scores on the Short Physical Performance Battery.
This was a cross-sectional study of individuals agreeing to participate in the FHN study and may not be generalizable to the general dialysis population.
Hemodialysis patients show markedly impaired physical performance, health, and functioning relative to population norms. Although some factors associated with these impairments are not modifiable, others may change with improvement in nutritional status or body composition.
Cardiovascular disease; congestive heart failure; diabetes; inflammation; intracellular water; muscle mass; phase angle; peripheral arterial disease
The aim of this study was to expand the research on psychiatric complications of end-stage renal disease (ESRD), as well as to examine the prevalence of a broad range of psychopathology in diabetic and non-diabetic hemodialysis (HD) patients.
One hundred nineteen HD patients were invited to enter the cross-sectional study. To assess quality of life, quality of sleep, mental status and depression and anxiety symptoms, the 36-item Short Form, Pittsburgh Sleep Quality Index (PSQI), Mini-Mental State Examination and Hospital Anxiety and Depression Scale, respectively, were used.
The mean age of all patients was 56.9±16.1 years; 54 (45.4%) were female. In the diabetic patients group, 84.8% of the patients had low MCS scores, and 89.2% patients had low PCS scores; 73.9% were poor sleepers; 63.0% had cognitive decline; 62.0% patients were depressive symptoms; and 28.3%had symptoms of anxiety. When comparing the diabetic and non-diabetic patients, the diabetic patients had lower role-emotional, sleep duration, and sleep efficiency scores.
Incorporating a standard assessment and, eventually, treatment of psychopathologic symptoms into the care provided to diabetic and hemodialysis patients might improve quality of life and sleep, depressive symptoms and, reduce mortality risk.
Anxiety; depression; hemodialysis patients; diabetes mellitus; quality of sleep; quality of life
Patients with ESRD requiring renal replacement have impaired quality of life (HRQoL), and there is general consensus that HRQoL improves with successful transplant and evidence of improvement with frequent hemodialysis. This study reports changes in HRQoL associated with changes in treatment modality to daily hemodialysis (DHD) and transplant among patients requiring renal replacement.
This cohort study had assessments at baseline and 6-months following modality change. Subjects were non-diabetic individuals receiving conventional hemodialysis who a) remained on conventional hemodialysis (n=13), b) changed to daily hemodialysis (DHD) (n=10), or c) received a living donor transplant (n=20). Thirty-four healthy controls were assessed once for comparison. HRQoL was measured using the Kidney Disease Quality of Life Instrument. The Physical Functioning and Physical Composite Scale Scores were primary outcomes.
Transplantation resulted in significant improvements in six of eight generic scales and the physical composite scale (PCS). Those changing to DHD had significant improvements in Physical Function and PCS scales. Those remaining on dialysis remained lower than controls on all scales except for Vitality; the transplant group remained lower than controls only on the Vitality and General Health scales. Transplant resulted in significant improvements in 4 of the 7 disease-specific scales (symptoms, effects and burden of kidney disease, work). DHD resulted in improvements in the effects of kidney disease.
Modality change to transplant results in significant improvement in HRQoL, achieving levels similar to controls. Change to daily hemodialysis improves only select HRQoL domains, and remains low in disease-specific domains.
Quality of Life; Dialysis; Transplant; Daily Dialysis
Comparisons of subjective and objective sleep measures have shown discrepancies between reported sleep and polysomnography (PSG) in non-drug dependent individuals with and without insomnia. Sleep may affect behavioral and physiologic aspects of drug abuse and dependence; patients in methadone maintenance therapy (MMT) for opioid dependence frequently report sleep problems. Whether subjective sleep reflects objective sleep in MMT patients is unknown. We undertook these analyses to establish the correlations among subjective and objective sleep measures in MMT patients.
We compared one week of daily sleep diaries, one night of home PSG, a questionnaire completed the morning after PSG, and the Pittsburgh Sleep Quality Inventory (PSQI) as well as demographics and drug use measures in 62 MMT patients with disturbed sleep (PSQI score > 5).
Subjective and objective sleep durations were similar in this sample; average sleep times for the diary, morning questionnaire, and PSG were 340, 323, and 332 minutes, respectively. Average diary sleep time, subjective ratings of feeling rested, and PSG sleep efficiency were correlated significantly with PSQI score. Age was inversely correlated with PSG sleep time. Participants whose urine toxicology showed benzodiazapine use reported significantly longer sleep times on the morning questionnaire.
Objective sleep measures confirm subjective measures in MMT patients with disturbed sleep. The high prevalence of sleep complaints in this population likely reflects pathology rather than sleep misperception. Both objective and subjective measures are useful in research and clinical settings for assessing sleep in opioid-dependent patients.
methadone; opioid dependence; sleep; polysomnography; PSQI; sleep diaries
An increase in left ventricular mass (LVM) is associated with mortality and cardiovascular morbidity in patients with end-stage renal disease.
Methods and Results
The Frequent Hemodialysis Network (FHN) Daily Trial randomized 245 patients to 12 months of 6 times per week daily in-center hemodialysis or conventional hemodialysis; the FHN Nocturnal Trial randomized 87 patients to 12 months of 6 times per week nocturnal hemodialysis or conventional hemodialysis. The main cardiac secondary outcome was change in LVM. In each trial, we examined whether several pre-defined baseline demographic or clinical factors, as well as change in volume removal, blood pressure or solute clearance influenced the effect of frequent hemodialysis on LVM. In the Daily Trial, frequent hemodialysis resulted in a significant reduction in LVM (13.1(95% CI 5.0 to 21.3) g, p=0.002), LVM index (6.9 (2.4 to 11.3) g/m2, p=0.003) and percent change in geometric mean of LVM (7.0 (1.0 to 12.6)%, p =0.02). Similar trends were noted in the Nocturnal Trial but did not reach statistical significance. In the Daily Trial, a more pronounced effect of frequent hemodialysis on LVM was evident among patients with left ventricular hypertrophy at baseline. Changes in LVM were associated with changes in blood pressure (conventional hemodialysis: R=0.28, P=0.01, daily hemodialysis: R=0.54, P<0.001) and were not significantly associated with changes in other parameters.
Frequent in-center hemodialysis reduces LVM. The benefit of frequent hemodialysis on LVM may be mediated by salutary effects on blood pressure.
Left Ventricular Mass; Frequent Hemodialysis; Daily Hemodialysis; Nocturnal Hemodialysis; Blood Pressure
End-stage renal disease patients experience significant impairments in health-related quality of life (HRQOL). Testing various strategies to improve patient HRQOL in multicenter clinical trials, such as the Frequent Hemodialysis Network (FHN) trials is vitally important. Aims: Theaim of this paper is to describe the design and conduct of HRQOL and patient-reported outcomes (PRO) assessment in the FHN trials.
In the FHN trials, HRQOL was examined as a multidimensional concept, and the SF-36 RAND Physical Health Composite score was one of the co-primary outcomes. The instruments completed to assess HRQOL included the Medical Outcomes Study Short Form SF-36, Health Utilities Index 3, Sleep Problems Index, Beck Depression Inventory and feeling thermometer. These instruments have been shown to have high reliability, validity and responsiveness to change in the end-stage renal disease population. Additional items evaluating PRO including sexual function, time to recovery after dialysis and patients’ self-perceived burden to caregiver were also assessed. All questionnaires were administered by trained interviewers using computer-assisted telephone interviewing to ensure blinding and minimizing selection bias. Interim analysis reveals that these instruments can be used to collect a comprehensive set of HRQOL measures with minimal patient burden.
Accurate measurement of HRQOL and PRO can help us test whether hemodialysis interventions improve the health and well-being of this compromised patient population. We have shown that a comprehensive set of HRQOL measures can be centrally collected through telephone interviews in a blinded fashion, in a way that is well tolerated with minimum respondent burden.
Health-related quality of life; Frequent Hemodialysis Network; End-stage renal disease
“Does the type of dialysis treatment make a difference to the quality of life (QoL) and mental health of renal patients in Athens?” The study investigated the differences in 84 in-center hemodialysis (HD) and 60 continuous ambulatory peritoneal dialysis (CAPD/PD) patients.
Patient-reported assessments included: WHOQOL-BREF inventory of World Health Organization, General Health Questionnaire (GHQ-28) of Goldberg, State-Trait Anxiety Inventory, Center for Epidemiologic Studies Depression Scale (CES-D) and Multidimensional Health Locus of Control (MHLC).
Results indicated that HD patients reported lower QoL in the environment and social relationships domains. More symptoms were also reported in the GHQ-28 subscales of anxiety/insomnia and severe depression. This measurement includes sleep problems and suicidal thoughts.
The findings confirm the differences between the two treatment modalities, indicating that HD patients have poorer QoL in several aspects of their environment and their social relationships. Both groups reported elevated depression. However, HD patients reported more suicidal thoughts and sleep problems compared to PD patients.
Quality of life; Hemodialysis; Peritoneal dialysis; Renal disease
OBJECTIVE: To determine whether there is a difference in the allocation of types of dialysis to male and female patients with end-stage renal disease (ESRD). DESIGN: Descriptive study. SETTING: Canada. PATIENTS: All patients registered with the Canadian Organ Replacement Register (CORR) whose treatment began between 1981 and 1991. Data were obtained for 19,732 patients, of whom 18,010 had sufficiently complete data and were being treated with either peritoneal dialysis or hemodialysis 3 months after the diagnosis of ESRD. OUTCOME MEASURES: Proportions of patients receiving peritoneal dialysis and hemodialysis according to sex. RESULTS: Significantly more male (58.1%) than female (50.8%) patients were receiving hemodialysis 3 months after diagnosis (p < 0.00001). Multivariate analysis to control for the possible confounding effects of age, province of treatment, diagnosis, concurrent illness and year of diagnosis did not explain the difference. CONCLUSIONS: In Canada from 1981 to 1991 male patients were more likely than female patients to receive hemodialysis for the treatment of ESRD. Additional research is needed to explain this finding.
To examine the independent and interactive effects of race and socioeconomic status (SES) on objective indices and self-reports of sleep.
The sleep of 187 adults (41% Black; mean age = 59.5 ± 7.2 years) was examined. Nine nights of actigraphy and two nights of inhome polysomnography (PSG) were used to assess average sleep duration, continuity, and architecture; self-report was used to assess sleep quality. Psychosocial factors, health behaviors, and environmental factors were also measured.
Blacks had shorter sleep duration and lower sleep efficiency, as measured by actigraphy and PSG, and they spent less time proportionately in Stage 3 to 4 sleep, compared with others (p < .01). Lower SES was associated with longer actigraphy-measured latency, more wake after sleep onset as measured by PSG, and poorer sleep quality on the Pittsburgh Sleep Quality Index (p < .05).
Blacks and perhaps individuals in lower SES groups may be at risk for sleep disturbances and associated health consequences.
race; socioeconomic status; sleep; polysomnography; actigraphy
Poor sleep quality is one of the factors that adversely affects patient quality of life after kidney transplantation, and sleep disorders represent a significant cardiovascular risk factor. The objective of this study was to investigate the prevalence of changes in sleep quality and their outcomes in kidney transplant recipients and analyze the variables affecting sleep quality in the first years after renal transplantation.
Kidney transplant recipients were evaluated at two time points after a successful transplantation: between three and six months (Phase 1) and between 12 and 15 months (Phase 2). The following tools were used for assessment: the Pittsburgh Sleep Quality Index; the quality of life questionnaire Short-Form-36; the Hospital Anxiety and Depression scale; the Karnofsky scale; and assessments of social and demographic data. The prevalence of poor sleep was 36.7% in Phase 1 and 38.3% in Phase 2 of the study.
There were no significant differences between patients with and without changes in sleep quality between the two phases. We found no changes in sleep patterns throughout the study. Both the physical and mental health scores worsened from Phase 1 to Phase 2.
Sleep quality in kidney transplant recipients did not change during the first year after a successful renal transplantation.
Quality of Life; Sleep; Renal Transplantation
Children with arthritis experience frequent pain, but the predictors of daily pain variations are largely unidentified. The goal of this study was to examine sleep quality as a predictor of pain in children with arthritis and to determine whether mood moderates this relationship.
In this prospective, longitudinal study children with polyarticular arthritis (n = 51, ages 8–16 years) tracked daily symptoms including sleep quality over 2 months. Self-reported daily pain intensity, as indicated on a visual analog scale, was used as the primary outcome measure in multilevel models.
Poorer sleep quality was associated with higher next-day pain ratings (p < .01). Mood moderated this relationship such that as positive mood increased, the relationship between poor sleep quality and high pain weakened (p < .01). Daily pain did not predict nightly sleep quality (p > .05).
Sleep quality is an important predictor of pain in children with arthritis. These findings add to the growing body of literature on the utility of daily diaries for analyzing patterns of pain, sleep, and mood in children with chronic painful conditions.
juvenile arthritis; sleep quality; disease-related pain; positive mood; daily pain diaries
Although hemodialysis has a therapeutic effect on end stage renal disease (ESRD), these patients encounter many physical, psychological, and social stressful factors that lead to a decrease in their quality of life (QOL). One of the factors that are effective on increasing the QOL is the self-care ability. Review of literature demonstrated a few studies done on different aspects of QOL in ESRD patients under hemodialysis and their relationships with self-care ability in Iran. So, in this research besides determining the quality of life and its dimensions and self-care ability of hemodialysis patients, we evaluated their relationships with each other.
For this purpose, all hemodialysis patients who had inclusion criteria and were hospitalized in hemodialysis wards of Bonab, Maragheh, and Miandoab hospitals were selected and data were collected by interview using a questionnaire that included three parts, demographic factors, quality of life, and self-care ability.
The results indicated that quality of life in 34%, and self-care ability in 78.3% of hemodialysis patients were desirable, and there was a direct and significant relationship between these two variables (p < 0.001, r = 0.4), as self-care ability explained 29% of variance of QOL. In quality of life subsectors, social dimension in 98.3% of patients was desirable, while physical dimension (80%) and psychological dimension (63.5%) in most patients were undesirable. Physical dimension was the most impressible dimension of quality of life in self-care ability whereas self-care ability explained 27% of total variance of physical dimension of QOL.
Nearly two thirds of mentioned patients had no desirable QOL and regarding the positive relationship between QOL and self-care ability, it is suggested that health care planner and managers prepare the condition that through educating and reinforcing self-care ability in these patients improve the QOL in hemodialysis patients.
Hemodialysis; quality of life; self-care
Complaints of unrefreshing sleep are a prominent component of chronic fatigue syndrome (CFS); yet, polysomnographic studies have not consistently documented sleep abnormalities in CFS patients. We conducted this study to determine whether alterations in objective sleep characteristics are associated with subjective measures of poor sleep quality in persons with CFS.
We examined the relationship between perceived sleep quality and polysomnographic measures of nighttime and daytime sleep in 35 people with CFS and 40 non-fatigued control subjects, identified from the general population of Wichita, Kansas and defined by empiric criteria. Perceived sleep quality and daytime sleepiness were assessed using clinical sleep questionnaires. Objective sleep characteristics were assessed by nocturnal polysomnography and daytime multiple sleep latency testing.
Participants with CFS reported unrefreshing sleep and problems sleeping during the preceding month significantly more often than did non-fatigued controls. Participants with CFS also rated their quality of sleep during the overnight sleep study as significantly worse than did control subjects. Control subjects reported significantly longer sleep onset latency than latency to fall asleep as measured by PSG and MSLT. There were no significant differences in sleep pathology or architecture between subjects with CFS and control subjects.
People with CFS reported sleep problems significantly more often than control subjects. Yet, when measured these parameters and sleep architecture did not differ between the two subject groups. A unique finding requiring further study is that control, but not CFS subjects, significantly over reported sleep latency suggesting CFS subjects may have an increased appreciation of sleep behaviour that may contribute to their perception of sleep problems.
Background. Cardiac disease is a significant cause of morbidity and mortality in children with end-stage renal disease (ESRD). This study aimed to report the frequency of cardiac disease diagnostic methods used in US pediatric maintenance hemodialysis patients.
Methods. A cross-sectional analysis of all US pediatric (ages 0.7–18 years, n = 656) maintenance hemodialysis patients was performed using data from the Centers for Medicare and Medicaid Services ESRD Clinical Performance Measures Project. Clinical and laboratory information was collected in 2001. Results were analysed by age, sex, race, Hispanic ethnicity, dialysis duration, body mass index (BMI), primary ESRD cause and laboratory data.
Results. Ninety-two percent of the patients had a cardiovascular risk factor (63% hypertension, 38% anemia, 11% BMI > 94th percentile, 63% serum phosphorus > 5.5 mg/dL and 55% calcium–phosphorus product ≥ 55 mg2/dL2). A diagnosis of cardiac disease was reported in 24% (n = 155) of all patients: left ventricular hypertrophy/enlargement 17%, congestive heart failure/pulmonary edema 8%, cardiomyopathy 2% and decreased left ventricular function 2%. Thirty-one percent of patients were not tested. Of those tested, the diagnostic methods used were chest X-rays in 60%, echocardiograms in 35% and electrocardiograms in 33%; left ventricular hypertrophy/enlargement was diagnosed using echocardiogram (72%), chest X-ray (20%) and electrocardiogram (15%).
Conclusions. Although 92% of patients had cardiovascular risk factors, an echocardiography was performed in only one-third of the patients. Our study raises the question of why echocardiography, considered the gold standard for cardiac disease diagnosis, has been infrequently used in pediatric maintenance dialysis patients, a high-risk patient population.
cardiac disease; end-stage renal disease; hypertension; maintenance hemodialysis; pediatric
Patients with end-stage renal disease (ESRD) can display the features of endogenous hypercortisolism but are difficult to evaluate for Cushing's syndrome. We evaluated the circadian rhythm of plasma compared with salivary cortisol in subjects with ESRD.
Plasma and salivary cortisol and plasma ACTH samples were drawn frequently over 24 h in an inpatient research unit in stable ESRD subjects on daytime chronic hemodialysis (n=16) vs controls (n=8).
Plasma cortisol was measured every 2 h from 0800 to 0600 h the following day. Salivary cortisol was measured every 2 h, except between 2400 and 0400 h (sleep time). Plasma ACTH measured in a subset of samples and C-reactive protein (CRP) was measured as a marker of a subclinical inflammatory state in all subjects.
ESRD subjects had a discernable circadian rhythm in plasma and salivary cortisol, but with a significantly higher nadir (1800–2400 h) compared with the controls (P=0.016–<0.001). After excluding four ESRD subjects without a normal circadian rhythm, the ESRD subjects still had higher nadir plasma and salivary cortisol and plasma ACTH compared with controls. There was no difference in the correlation of salivary and plasma cortisol in control vs ESRD subjects. ESRD subjects had higher CRP levels compared with controls.
ESRD subjects had increased late-night plasma and salivary cortisol and plasma ACTH levels. Late-night salivary cortisol is a reliable index of plasma cortisol in ESRD patients.
cortisol; circadian rhythm; ACTH; C-reactive protein; end-stage renal disease
The etiology of sleep problems in PD is not well understood, as they may arise from the pathology of the disease or from other disease related-factors such as motor dysfunction, dopaminergic medication, and mood disturbances. The aim of this study was to investigate factors associated with sleep including disease-related variables such as motor symptom severity, dose of medication and mood and disease subtypes. Thirty-five non-demented patients with PD were included. Sleep was measured using 24-hour wrist actigraphy over a seven-day period, during which time participants kept a sleep diary. Subjective sleep and arousal questionnaires included the Parkinson’s Disease Sleep Scale and Epworth Sleepiness Scale. Motor symptom severity and dopaminergic medication were significantly related to measures of sleep quality. Gender differences in sleep were found, with men having worse sleep quality and more excessive daytime sleepiness than women. We also found that actigraphy may serve as a useful tool for identifying individuals with possible REM behavior disorder, a sleep disorder that has important implications in early detection of PD.
The population of patients with ESRD in the United States is progressively increasing, with hemodialysis (HD) as the major mode of renal replacement therapy. The National Kidney Foundation's Dialysis Outcomes and Quality Initiative and the Fistula First Initiative recommend increasing the use of arteriovenous fistulae (AVF) in both incident and prevalent hemodialysis patients. One measure proposed is the use of pre-operative vascular mapping to assess the upper extremities for the presence of suitable vessels prior to the surgical creation of an AVF among both pre-dialysis CKD and ESRD patients on HD. This article aims to review the literature on vascular mapping, including the various techniques; their advantages and disadvantages; and whether they help to maximize the AVF creation rate as well as increase the use of AVF in the HD population.
Venous mapping; Hemodialysis
Cognitive impairment is common but often undiagnosed in patients with end-stage renal disease, in part reflecting limited validated and easily administered tools to assess cognitive function in dialysis patients. Accordingly, we assessed the utility of the Kidney Disease Quality of Life Cognitive Function (KDQOL-CF) scale in comparison to an extensive neuropsychological battery, building on a prior assessment of this potential cognitive screen.
Setting & Participants
Maintenance hemodialysis patients at 6 Boston area dialysis units were administered an extensive neurocognitive battery and the KDQOL-CF at the beginning of a hemodialysis session.
KDQOL-CF score, depression symptom burden, and demographic and clinical characteristics.
Neurocognitive performance classified into executive function and memory domains, determined using principal components analysis.
Univariate and multivariable linear regression models adjusting for age, sex, race, and end-stage renal disease cause were used to evaluate the association between KDQOL-CF score and cognitive performance, and test metrics were determined for a KDQOL-CF cutoff score of 60 or less from a maximum score of 100.
For 168 prevalent hemodialysis patients, KDQOL-CF score was 76 ± 19 and 40 (24%) had scores of 60 or less, consistent with self-identified worse cognitive performance. There was no significant correlation between KDQOL-CF score and either memory (P = 0.2 and P = 0.3) or executive function (P = 0.1 and P = 0.4) in univariate and multivariable models, respectively. There was a strong correlation between higher KDQOL-CF score and fewer depression symptoms (P <0.001). Sensitivity of the KDQOL-CF was poor (range, 0.28–0.36), with modest specificity (range, 0.77–0.81) for identifying worse executive function and memory.
Cross-sectional study, modest population size, and abbreviated gold-standard cognitive battery.
The KDQOL-CF is a poor determinant of neurocognitive performance in hemodialysis patients, with limited sensitivity. To assess cognitive impairment in hemodialysis patients, better screening tests are essential.
Dialysis; dementia; cognitive impairment; screening; depression; quality of life
Cardiovascular morbidity and mortality are common in end stage renal disease (ESRD) patients. There is scarce data on carotid and bulb intima-media thickness (IMT-C and IMT-B) as an early marker of atherosclerosis and related factors in children on hemodialysis (HD) and peritoneal dialysis (PD). Since we did not have enough information about our patients, this study was carried on all ESRD children (hemodialysis and peritoneal dialysis) in a referral center. Data was collected from 16 ESRD children under 18 years with seven patients on PD and nine on HD. Lab tests and biochemical parameters including serum von Willebrand factor (vWF), homocystein, apo lipoprotein A, apo lipoprotein B and quantitative CRP were measured in fasting patients just before initiating dialysis. IMT-C and IMT-B were measured by gray scale ultrasound using 7.5 MHZ probe. The mean of age was 12.76±4.5 years. The mean duration of dialysis in HD and PD patients were not significantly different; 11.88±3.25 months and 10.14±2.4 months respectively. Mean of systolic blood pressure in HD group was significantly higher than PD group, 135.55±25.54 mmHg versus 121.42±12.14 mmHg, P<0.05. Significant differences among all following parameters in ESRD patients, with normal laboratory values, were clarified: cholesterol, triglycerides, apo A, apo B, quantitative CRP, VWF, homocystein and IMT-C. However, we could not demonstrate any difference between IMT-B in case and control group. After adjusting for age, partial correlation showed significant correlation between IMT-C and following factors: N-PTH and serum alkaline phosphatase. Longitudinal studies with large size samples are needed to clarify the contributing factors with intima-media thickness in ESRD children.
Carotid intima-media thickness; children; end stage renal disease