The RenalTracker Team
October 20, 2021

Having good restful sleep contributes to a healthy lifestyle. It is estimated that over 50 million Americans suffer chronically from sleep disorders, affecting their routine and impacting their health adversely. This article will talk about common sleep disorders and people with Chronic Kidney Disease (CKD).

Among the people who suffer from sleep problems are chronic kidney disease (CKD) patients. As kidney function declines, sleep problems become more prevalent. Sleep disorders are under-recognized in patients at all CKD stages. The prevalence of sleep disturbances among patients is as high as 80.3%. A review conducted among patients with End-Stage Renal Studies (ESRD) revealed that sleep disturbance was common, with a mean prevalence of 44%. 

woman having sleeping issues

Sleep Issues and Chronic Kidney Disease

Sleep disorders and poor quality of sleep are very common with people with CKD. Poor sleep is linked to sleepiness, impaired daytime functioning, fatigue, increased morbidity, and mortality. Factors such as metabolic changes, inflammation, CKD complications and symptoms, comorbid conditions, medications, and dialysis may interrupt sleep and lead to insomnia. The long-term effects of sleep deprivation and sleep disorders have been linked to various health issues such as hypertension, diabetes, obesity, depression, stroke, and heart attack. All these health conditions are linked to diminishing Glomerular Filtration Rate (GFR).

It has been suggested that sleep deprivation due to periodic limb movements during sleep (PLMS) may trigger a renin-angiotensin-aldosterone system hyperactivation or renin-angiotensin-system (RAS) that lead to increased blood pressure. It can increase the risk of CKD progression as a result. In addition, high rates of insomnia and excessive daytime sleepiness (EDS) may also contribute to the risk of cardiovascular disease. 

woman having insomnia

Sleep-related problems are largely undertreated, even though they are very essential for patients with CKD. A study revealed that patients with various degrees of kidney failure had progressively worse sleep quality over a 3-year follow-up. 

These sleep problems can be connected to underlying uremia, (a condition when waste products related to declined kidney function build up in the blood). Patients need to undergo clinical assessment, polysomnography, and other standardized assessments for diagnosis. 

On the other hand, poor sleep quality has been associated with the development of CKD. A study in the Journal of Clinical Sleep Medicine by Bo et al analyzed the development of kidney disease in almost 200,000 patients. CKD was defined using the modification of diet in renal disease (MDRD) study equation.

Sleep disturbances in CKD patients include insomnia, sleep apnea, excessive daytime sleepiness (EDS), and restless legs syndrome (RLS). Let's go through common sleep disorders of CKD patients:

Insomnia

Insomnia is a common sleep disorder defined as trouble falling asleep, staying asleep, or getting enough restful sleep. Over time, lack of sleep can lead to health issues including diabetes, hypertension, and weight gain -factors that can exacerbate kidney function. 

This sleep disorder is common in patients with ESRD who are treated with the conversion from conventional hemodialysis (CHD) or continuous ambulatory peritoneal dialysis (CAPD). Factors including sleep disruption related to sleep apnea, RLS, and PLM disorder, bone pain, and pruritus can trigger insomnia.  

man having problems managing Insomnia

Sleep Apnea is a serious sleep disorder that happens when a person's breathing is interrupted during sleep, while pruritus is characterized by itchy skin and is often caused by dry skin. Additionally, insomnia is also triggered by medications and frequent napping during daytime dialysis. This is why it is a common sleep disorder of CKD patients.

The diagnosis of insomnia is based on clinical assessments, detailed history of sleeping habits, and data from a sleep diary. Among the chronic complaints include the challenge in starting or maintaining sleep, unrefreshing sleep despite enough opportunity for sleep, and interruption of daily routine. 

Managing Insomnia

There are therapeutic options you can do to manage insomnia. These include correcting underlying medical conditions such as ESRD and medications to improve sleep-related symptoms. A few studies have been conducted evaluating the impact of renal function replacement on insomnia. Patients who were started on CAPD have improved sleep-related symptoms component of the Pittsburgh Symptom Score. 

Meanwhile, further studies are still needed to assess the safety and efficacy in patients with ESRD. 

Sleep Apnea

Untreated sleep apnea causes breathing to stop during sleep, causing loud snores and daytime tiredness. Your heart rate tends to drop the longer your body stops breathing. This is when your involuntary reflexes startle you to waking up at the end of the period of not breathing. The heart rate accelerates fast and the blood pressure spikes.

man having trouble managing Sleep Apnea

Studies suggested that CKD patients were more likely to develop sleep apnea than people with normal kidney function. Sleep apnea can also happen even before the patients begin dialysis and after transplant.  

Over 50% of ESRD patients have sleep apnea, which is significantly higher than the general population. It is also the same among patients in pre-dialysis, peritoneal dialysis, or hemodialysis. This is a common sleep disorder of CKD patients in different stages.

Sleep apnea may worsen CKD symptoms like daytime fatigue, sleepiness, and diminished neurocognitive function. It may also aggravate the cardiovascular complications of ESRD. In the general population, the risk factors of sleep apnea include advancing age, male gender, and unwanted weight gain. However, these factors are different in ESRD patients. Even in the absence of obesity, ESRD patients develop sleep apnea. 

Managing Sleep Apnea

You have to go through a physical exam and a sleep study to determine if you have sleep apnea. Among the treatment options for sleep apnea are lifestyle changes such as weight management, avoidance of alcohol consumption before sleep time, and the use of continuous positive airway pressure therapy to keep the upper airway open during sleep. Changing the mode of renal replacement therapy may improve sleep apnea. 

Sleep Apnea written on clip board

Meanwhile, nocturnal hemodialysis (NHD) has been shown to improve sleep apnea. NHD allows patients to undergo hemodialysis at home during sleep. Patients receiving CAPD with nocturnal cycler-assisted peritoneal dialysis also showed similar results. The improvement was linked to more effective fluid removal and its results on the upper airway during sleep. Although there are case reports indicating sleep apnea correction after successful kidney transplantation, results from these cases are mixed. Some patients report that their sleep apnea improved, while others indicated that the sleep apnea only resolved in a minority of patients after kidney transplant. 

Excessive Sleepiness

Excessive sleepiness is significantly linked with an increased risk of sleep apnea. It can be clinically quantified as falling asleep involuntarily in passive or active circumstances, the inability to stay awake or alert during the major waking episodes of the day, leading to unintended lapses into sleeplessness.

man with excessive sleepiness

This sleeping disorder appears to be equally common in ESRD patients treated with CAPD compared to those receiving CHD. Since excessive sleepiness happens in passive situations i.e. reading, watching TV, and active circumstances such as driving, the effects of excessive daytime sleepiness can include diminished productivity to increase vehicular accidents. This is why it's important to include excessive sleepiness to our list of common sleep disorders of CKD patients.

Managing excessive sleepiness

Despite its high prevalence, excessive daytime sleepiness often goes unrecognized in the primary care setting. Treating excessive sleepiness involves determining and treating the underlying medical conditions. Furthermore, regular and timely follow-up is essential to evaluate the effectiveness of and compliance with the treatment. Meanwhile, you can improve sleep duration and practice proper sleep hygiene to relieve excessive daytime sleepiness symptoms.

Restless Legs Syndrome (RLS)

Restless Legs Syndrome diagnosis text

Restless Legs Syndrome (RLS), also called Willis-Ekbom Disease, causes an unpleasant or uncomfortable sensation in the legs. Patients who suffer RLS typically have the urge to move the legs, typically in the early part of the night or evening, and get worse during periods of passivity and temporarily relieved by movement. 20 to 57% of CKD patients reported RLS. Because RLS symptoms occur at night, sleep can become difficult. The sensations in the leg often return once you stop moving your legs or walking.

Although RLS is classified as a sleep disorder, it is, however, best characterized as a neurological disorder. The symptoms are produced within the brain itself. Studies have linked RLS to insufficient response to dopamine in the brain and central nervous system that may be attributed to uremia, anemia, and/or neuropathy.

Managing RLS

RLS impacts the quality of life among people with CKD. Symptoms may manifest before patients get to stage 6 and are often minimized after a kidney transplant. Among the factors of RLS in dialysis patients include years on dialysis, body weight, underdialysis, female gender, vitamin, and iron deficiency. RLS can be treated by prescription medication, although not all patients need medication.

person holding calf in pain

Ruling out potential causes of RLS is a way to treat this condition. There may be factors that are out of your control such as genetics or pregnancy but triggers such as daily habits, medications, and health conditions can be addressed. Your doctor may perform a physical and neurological exam to diagnose RLS. They may also order blood tests to rule out possible causes for the RLS symptoms. 

Tips for getting quality sleep and staying asleep

Check-in with your nephrologist to address issues if you are having trouble sleeping or if your sleep quality is compromised. Meanwhile, here are ways you can do to alleviate sleeplessness:

Observe sleep hygiene

Sleep hygiene refers to good sleeping habits. Your behaviors during the day can affect the quality of your sleep. Keeping a consistent sleep schedule reinforces your body’s sleep cycle, making it easier for you to fall asleep and wake up daily. A consistent sleep schedule may also help manage daytime sleepiness. 

Minimize nap times

Longer naps can interrupt your sleep schedule. Try limiting the number of naps and the amount of time you sleep during the daytime.

woman sleeping

Cut back on stimulants such as caffeine and alcohol

Besides affecting your kidney condition, caffeine and alcohol can disrupt your sleep. Steering clear from stimulants, at least 8 hours before intended sleep time, can get you back to normal sleeping patterns. Consider minimizing caffeine intake and taking it before noon to reduce sleep interruption. Slow down on alcohol or try not to drink them before bedtime since it can disrupt your sleep.


The Bottom Line

Sleep disorder of Chronic Kidney Disease patients are often unrecognized and untreated. This is because in most cases, the sleep disorder issues have been attributed to the kidney disease itself or comorbid conditions. Hence, you must check in with your nephrologist and report if you have sleep problems. This way, you can work together to address your sleep issues and so you can receive effective treatment.