Objective: Approximately 50 to 85% of patients on chronic hemodialysis (HD) have sleep complaints. Primary sleep disorders such as sleep apnea syndrome, periodic limb movement disorder, and restless legs syndrome are also common. The high prevalence of sleep disturbances in this population is likely related to a wide variety of demographic, psychologic, metabolic, and disease-related factors. Based on a review of the literature and our own research results which demonstrated that treatment was associated with body temperature elevations and daytime sleepiness, we hypothesized that HD may also contribute to the development of sleep problems, possibly by interacing with homeostatic and circadian regulatory processes. Thus, the purpose of this investigation was to describe the effects of HD, including treatment time of day, on polysomnographic measures of nocturnal sleep.
Design: This was a descriptive study.
Population, Sample, Setting, Years: The sample was obtained from the population of HD patients in the metro area. Careful control of demographic, psychologic, metabolic, and disease-related variables that might confound study results led to an extensive set of exclusion criteria. In addition, any subject taking centrally acting medications was eliminated from participation. As a control group, patients with end-stage renal disease meeting the same entrance criteria, but not yet on HD, were selected. The final sample included 8 controls and 46 chronic HD patients who received treatment on one of three shifts; 18 on Shift 1 (6 am to 10 am), 13 on Shift 2 (10 am to 2 pm), and 15 on Shift 3 (2 pm to 6 pm). The mean age of the sample was 50.3 (11.3) years; 28 were male and 26 were female. Data were collected from 1997 to 2001.
Concept or Variables Studied Together: Differences in nocturnal sleep parameters among groups of HD subjects based on treatment time of day were examined. In addition, the entire group of HD subjects was compared to controls.
Methods: All subjects underwent polysomnography in a sleep laboratory using standardized procedures.
Findings: In comparison to controls (ANCOVA - controlling for serum creatinine levels), the entire group of HD subjects had a significantly lower sleep efficiency (F=3.3, p=0.02), greater percentage of wake time after sleep onset (F=2.6, p=0.05), decreased REM sleep (F=1.8, p=0.02), and a greater brief arousal index(F=3.7, p=0.01). The HD group also had a shorter total sleep time (F=2.0, p 0.06), a finding that approached statistical significance, and a higher respiratory disturbance index and periodic limb movement index. There were no significant differences among groups of HD subjects based on treatment time of day.
Conclusions: The results of this study support the hypothesis that treatment with HD has adverse effects on nocturnal sleep and is specifically associated with disturbances of sleep maintenance. These effects occur independent of treatment time of day.
Implications: Sleep complaints in the HD population are associated with poor quality of life and reduced functional status. In addition, they have been related to disruption of family normalcy, inability to learn and perform home dialysis, and increased anxiety, depression, and days of disability. Our results underscore the importance of the development and testing of population-specific interventions, suggesting that treatment with HD itself contributes to sleep problems. Research designed to address the iatrogenic effects of HD on sleep is warranted.
Research supported by the National Institute of Nursing Research, RO1 NR04340
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