Association of Sleep-Related Problems With CKD in the United States, 2005-2008

doi:10.1053/j.ajkd.2011.05.024

American Journal of Kidney Diseases

Volume 58, Issue 4, October 2011, Pages 554-564

https://doi.org/10.1053/j.ajkd.2011.05.024 Get rights and content

Background

Sleep-related problems, which have been associated with poor health outcomes, have not been investigated thoroughly in people with chronic kidney disease (CKD). We examined the prevalence of a variety of sleep-related problems in persons with and without CKD.

Study Design

National cross-sectional survey (National Health and Nutrition Examination Survey 2005-2008).

Setting & Participants

Community-based survey of 9,110 noninstitutionalized US civilian residents 20 years or older.

Predictor

CKD, defined as estimated glomerular filtration rate (eGFR) of 15-59 mL/min/1.73 m² (stages 3 and 4) or eGFR ≥60 mL/min/1.73 m² and albumin-creatinine ratio ≥30 mg/g (stages 1 and 2).

Outcome

Sleep quality, defined using self-report in a multi-item sleep questionnaire including items from previously validated instruments.

Measurements

Albuminuria and eGFR assessed from urine and blood samples; sleep, demographics, and comorbid conditions assessed using a standardized questionnaire.

Results

Inadequate sleep (≤6 hours per night) differed by CKD severity (37.4%, 43.0%, and 30.9% for no CKD, CKD stages 1 and 2, and CKD stages 3 and 4, respectively; P = 0.003). Frequent sleeping pill use (8.4%, 9.9%, and 16.6%), leg symptoms (39.2%, 48.0%, and 50.9%), and nocturia (20.9%, 35.2%, and 43.6%; P < 0.001 for all) also differed by CKD severity. After adjustment for age, sex, race/ethnicity, obesity, diabetes, and cardiovascular disease, the prevalence of these sleep-related problems remained higher in people with CKD stages 1 and 2 relative to no CKD. Most other measures of sleep quality, disorder, and functional outcomes did not differ by CKD.

Limitations

Inability to establish causality and possible unmeasured confounding.

Conclusion

Providers should be aware of early sleep-related CKD manifestations, including inadequate sleep, leg symptoms, and nocturia, and of the high rate of reported sleep medication use in this population.

Section snippets

Study Design

The NHANES is conducted by the National Center for Health Statistics of the US Centers for Disease Control and Prevention and consists of a standardized in-home interview followed by physical examination and blood and urine collection at a mobile examination center. NHANES is a representative sample of noninstitutionalized US civilian residents.²⁶ This analysis was limited to 9,110 NHANES 2005-2008 participants who met the inclusion criteria: 20 years or older, respondent to the sleep

Characteristics of Study Population by CKD

As listed in Table 2, patients with CKD stages 3 and 4 were older and more likely to be women, have insurance, and be nonsmokers than those without CKD. Patients with CKD stages 1 and 2 were more likely to be non-Hispanic black than those without CKD and with CKD stages 3 and 4. Education and income levels and body mass index were higher in patients without CKD than those with CKD regardless of severity. Diabetes, hypertension, and CVD were more frequent with greater CKD severity. Depressive

Discussion

The prevalence of sleep-related problems in the US population generally was high. Many of the sleep symptoms examined, including prolonged sleep-onset latency/trouble falling asleep, frequent waking at night or too early, sleep-disordered breathing, snoring, diagnosed sleep disorders, and functional outcomes of sleep, did not differ by CKD severity. However, prevalence estimates for inadequate sleep, frequent daytime sleepiness, reported use of sleeping pills, leg symptoms, and nocturia were

Acknowledgements

The Centers for Disease Control and Prevention (CDC) CKD Surveillance Team consists of members from teams associated with the University of California, San Francisco (Neil Powe, Laura Plantinga, Kirsten Bibbins-Domingo, Josef Coresh, Alan Go, Chi-yuan Hsu, Lesley Inker, Deidra Crews), University of Michigan (Rajiv Saran, Elizabeth Hedgeman, Brenda Gillespie, William Herman, Freidrich Port, Bruce Robinson, Vahakn Shahinian, Jerry Yee, Eric Young), and the CDC (Desmond Williams, Nilka Ríos

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Cited by (57)

Nocturia and Chronic Kidney Disease: Systematic Review and Nominal Group Technique Consensus on Primary Care Assessment and Treatment
2022, European Urology Focus
Citation Excerpt :
Thus, nine papers met the inclusion criteria [15–23]. Of the nine studies, eight were observational [15,17–23], using either a cross-sectional, case-control, or cohort design, and one was a pilot study [16]. Four studies were from Japan [15,20–22], three were from the USA [16,17,19], and two were from Taiwan [18,23].
Reduced renal function impairs salt and water homeostasis, which can drive nocturnal or 24-h polyuria. Nocturia can arise early in chronic kidney disease (CKD). Evidence-based recommendations can facilitate management outside nephrology clinics.
To conduct a systematic review (SR) of nocturia in CKD and achieve expert consensus for management in primary care and in specialist clinics outside nephrology.
Four databases were searched from January 2000 to April 2020. A total of 4011 titles and abstracts were screened, and 108 studies underwent full-text screening. Seven studies met the inclusion criteria and two were identified through other sources. Consensus was achieved among an expert panel with public involvement using the nominal group technique (NGT).
Several plausible mechanisms contribute to nocturnal or 24-h polyuria in CKD, but there is little evidence on interventions to improve nocturia. NGT assessment recommendations for nocturia (at least two voids per night) in patients with CKD or at risk of CKD being assessed in a non-nephrology setting are: history (thirst, fluid intake), medication review (diuretics, lithium, calcium channel antagonists, nonsteroidal anti-inflammatory medications), examination (oedematous state, blood pressure), urinalysis (haematuria and albumin/creatinine ratio), blood tests (blood urea, serum creatinine and electrolytes, estimated glomerular filtration rate), and a bladder diary. Renal ultrasound should follow local CKD guidelines. Treatment options include optimising blood pressure control, dietary adjustment to reduce salt intake, fluid advice, and a medication review. Referral to specialist nephrology services should follow local guidelines.
CKD should be considered when evaluating patients with nocturia. The aim of assessment is to identify mechanisms and instigate therapy, but the latter may be more applicable to reducing wider morbidity associated with CKD than nocturia itself.
People with kidney disease can suffer severe sleep disturbance because of a need to pass urine overnight. We looked at published research and found some useful information about the underlying mechanisms. A group of experts was able to develop practical approaches for assessing and treating this condition.
A Narrative Review of Management Strategies for Common Symptoms in Advanced CKD
2021, Kidney International Reports
Patients with advanced chronic kidney disease (CKD) experience multiple bothersome symptoms, undermining their quality of life (QOL). With growing attention to the importance of symptom management in advanced CKD, the evidence regarding symptoms is increasing. In this review, we briefly summarize the current evidence of effective pharmacologic and nonpharmacologic interventions to improve symptoms and QOL in patients with advanced CKD, including those on dialysis. We focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment, and anxiety and depression. We noted that research in symptom science focused on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the major gaps in the current literature include the evidence regarding mechanistic pathways to inform the development of effective symptom management for CKD populations, the evidence to confirm effective pharmacologic interventions in other populations for CKD populations, and research on how to incorporate effective symptom management approaches into clinical care. Although improving mortality remains as an important area in the kidney community, there is an urgent need to focus on improving symptom management to improve QOL in advanced CKD.
Pediatric and adolescent patients with CKD and ESRD
2020, Psychosocial Aspects of Chronic Kidney Disease: Exploring the Impact of CKD, Dialysis, and Transplantation on Patients
While children and adolescents with chronic kidney disease (CKD) exhibit some of the same psychosocial issues seen in adults with CKD, there are unique pediatric aspects observed due to progressive physical, neurological, psychological, and developmental changes. The approach to psychosocial health in children must be holistic, involving caregivers, family, educators, and healthcare professionals. The concern for optimal mental health in children with CKD transcends childhood, as improved healthcare allows the majority of children with childhood onset CKD to live into adulthood. The goal is for both a healthy physical and mental transition to adulthood.
Sleep Disorders in Chronic Kidney Disease
2019, Chronic Renal Disease
Sleep is an essential function of life. Sleep clearly serves a crucial role in the promotion of health and performance. Poor sleep quality and sleep disorders have been a recurrent finding in patients with chronic kidney disease (CKD). Sleep disorders such as obstructive sleep apnea (OSA) can contribute to hypertension, diabetes (type 2 diabetes mellitus [T2DM]), cardiovascular disease (CVD), and worsen obesity, all of which are implicated in the etiology of CKD. CKD itself may lead to OSA. Mechanisms specific to OSA could hasten decline in renal function in and of themselves. OSA, in spite of its high prevalence, remains underdiagnosed and undertreated in CKD patients. Optimal sleep duration and quality play a significant role in improving control of T2DM. Insufficient sleep has been shown to increase the risk of obesity. Restless legs syndrome (RLS) and insomnia worsen health-related quality of life in CKD patients. RLS and depression are associated with increased mortality in CKD patients. There is emerging evidence linking insomnia and RLS to an increased risk of CVD, which is an important cause of mortality in CKD patients, and insomnia is increasingly recognized as having a causal link to dementia and white matter disease. Addressing sleep disorders could help to prevent not only the development but also the progression of CKD.
Association of Sleep Duration, Symptoms, and Disorders With Mortality in Adults With Chronic Kidney Disease
2017, Kidney International Reports
In general populations, short and long sleep duration, poor sleep quality, and sleep disorders have been associated with increased risk of death. We evaluated these associations in individuals with CKD.
This was a prospective cohort study of 1452 NHANES 2005 to 2008 participants with CKD. CKD was defined by estimated glomerular filtration rate <60 ml/min per 1.73 m² or urine albumin-to-creatinine ratio ≥30 mg/g. Sleep duration, sleep symptoms (difficulty falling asleep, difficulty staying asleep, daytime sleepiness, and nonrestorative sleep), and sleep disorders (restless legs syndrome and sleep apnea) were self-reported. Vital status was determined using NHANES mortality linkage through December 31, 2011.
In this cohort, the mean age was 61 years, 58% were women, and 75% non-Hispanic white. During 4.4 years of median follow-up, we observed 234 deaths, of which 75 were due to cardiovascular causes. In multivariable analyses, compared with individuals who reported 7 to 8 hours of sleep, HR (95% CI) for all-cause mortality for sleep duration <7 hours and >8 hours were 1.50 (1.08–2.10) and 1.36 (0.89–2.08), respectively. The corresponding HR (95% CI) for cardiovascular mortality were 1.56 (0.72–3.37) and 1.56 (0.66–3.65). Nonrestorative sleep and restless legs syndrome were associated with increased risk for all-cause mortality (HR, 1.63 [95% CI, 1.13–2.35], and HR, 1.69 [95% CI, 1.04–275], respectively).
In adults with CKD, short sleep duration, nonrestorative sleep, and restless legs syndrome are associated with increased risk of death. These findings underscore the importance of promoting adequate sleep in patients with CKD, and the need for future studies evaluating the impact of sleep interventions in this population.
Sleep duration and the associated cardiometabolic risk scores in adults
2017, Sleep Health
Citation Excerpt :
The Sleep Disorders Questionnaire was administered to participants aged ≥16 y, who reported their typical sleep duration for the past month.26 Although this questionnaire has not been validated in its entirety, it contains items from two previously validated sleep questionnaires.27 Our study used the question that collected data on participants' sleep duration: “How much sleep do you usually get on weekdays or workdays?”
To identify the sleep duration associated with the lowest cardiometabolic risk score in adults and to determine if the association varies by subgroups (eg, sex, age groups, ethnicity, and smoking status).
Cross-sectional data from the 2005–2012 National Health and Nutrition Examination Survey.
Non-institutionalized civil sample from the United States.
Age ≥20 y (N = 8827) with sleep and cardiometabolic health data.
N/A.
Sleep duration from the Sleep Disorders Questionnaire was categorized as ≤3, 4, 5, 6, 7, 8, 9, and ≥10 h per night. HDL cholesterol (HDL) and waist circumference (WC) were stratified by sex first, while fasting insulin, fasting plasma glucose (Glu), triglycerides (TG), body max index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were standardized without stratifications. The standardized scores were summed for each participant using the following formula: −zHDL + zInsulin + zGlu + zTG + (zBMI + zWC)/2 + (zSBP + zDBP)/2.
Seven hours of sleep was associated with the lowest cardiometabolic risk score (−0.30 (95% CI: −0.43, −0.18)), which remained similar after adjusting for age, sex, ethnicity, education, family income, alcohol intake and smoking status. However, 8 hours of sleep was associated with the lowest score in non-Hispanic Blacks.
This study supports recent sleep duration recommendations in adults, and provides evidence that in general 7 hours of sleep per night is associated with optimal cardiometabolic health of adults. Longitudinal studies using objective measures of sleep would help further clarify this association.

View all citing articles on Scopus

: Originally published online August 5, 2011.

: Because the Editor-in-Chief and Deputy Editor recused themselves from consideration of this manuscript, the peer-review and decision-making processes were handled entirely by a Co-Editor (James S. Kaufman, MD, Boston University) who served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website.

^⁎: A list of the members of the CDC CKD Surveillance Team appears in the Acknowledgements.

View full text

Original InvestigationPathogenesis and Treatment of Kidney DiseaseAssociation of Sleep-Related Problems With CKD in the United States, 2005-2008

Background

Study Design

Setting & Participants

Predictor

Outcome

Measurements

Results

Limitations

Conclusion

Section snippets

Study Design

Characteristics of Study Population by CKD

Discussion

Acknowledgements

Am J Kidney Dis

Sleep Med

Am J Kidney Dis

Am J Kidney Dis

Chest

J Ren Nutr

Am J Kidney Dis

Sleep Med

Sleep Med

Am J Kidney Dis

Sleep disorders and end-stage renal disease

Curr Opin Pulm Med

Sleep disorders in dialysis patients

Int J Artif Organs

Sleep disruption in patients with sleep apnea and end-stage renal disease

J Clin Sleep Med

Clinical presentation of obstructive sleep apnea in patients with end-stage renal disease

J Clin Sleep Med

Impact of obstructive sleep apnea in hemodialysis patients

Semin Dial

Sleep disturbances and sleep apnea in patients on chronic peritoneal dialysis

J Nephrol

Sleep apnea in hemodialysis patients: risk factors and effect on survival

Hemodial Int

Sleep apnea in patients on conventional thrice-weekly hemodialysis: comparison with matched controls from the Sleep Heart Health Study

J Am Soc Nephrol

Sleep quality and its correlates in the first year of dialysis

Clin J Am Soc Nephrol

Significance of self-reported sleep quality (SQ) in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD Study

Clin Nephrol

Sleep disturbances in children and adolescents with non-dialysis-dependent chronic kidney disease

Arch Pediatr Adolesc Med

Restless legs syndrome in pediatric patients with chronic kidney disease

Pediatr Nephrol

Original Investigation
Pathogenesis and Treatment of Kidney Disease
Association of Sleep-Related Problems With CKD in the United States, 2005-2008