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Sleep disorders in chronic kidney disease

Abstract

Sleep disorders are highly prevalent in chronic kidney disease (CKD) but are often under-recognized. Restless legs syndrome, which is common in CKD owing to issues with dopamine metabolism and is exacerbated by iron deficiency and uraemia, can lead to poor sleep quality and increased daytime fatigue. Insomnia is also prevalent in CKD, particularly in patients requiring dialysis, with increased sleep latency and sleep fragmentation being reported. The cause of insomnia in CKD is multifactorial — poor sleep habits and frequent napping during dialysis, uraemia, medications and mood disorders have all been suggested as potential contributing factors. Sleep apnoea and CKD are also now recognized as having a bi-directional relationship. Sleep apnoea is a risk factor for accelerated progression of CKD, and fluid overload, which is associated with kidney failure, can lead to both obstructive and central sleep apnoea. The presence of obstructive sleep apnoea in CKD can exacerbate the already heightened cardiovascular morbidity and mortality in these patients, as well as leading to daytime fatigue and reduced quality of life. Increased awareness, timely diagnosis and appropriate therapeutic interventions are essential to reduce the negative impact of sleep disorders in patients with kidney disease.

Key points

  • Sleep disorders, such as sleep apnoea, restless legs syndrome and insomnia, are very common in patients with chronic kidney disease (CKD), and their presence can have a substantial impact on symptom burden (including poor sleep quality, daytime fatigue and sleepiness), morbidity and mortality.

  • Various treatment options for restless legs syndrome in CKD, including cool dialysate, iron supplementation and gabapentin, can be effective in improving sleep quality and reducing daytime fatigue.

  • Evidence to support the use of sedatives or sleeping medications in CKD is lacking, but cognitive behavioural therapy for insomnia can be effective to improve sleep quality and daytime functioning.

  • Sleep apnoea and kidney disease have a bi-directional relationship; obstructive sleep apnoea is associated with an accelerated decline in estimated glomerular filtration rate, whereas hypervolaemia in kidney failure can lead to obstructive and central sleep apnoea.

  • Intensification of kidney replacement therapy or fluid removal by ultrafiltration attenuates the severity of sleep apnoea in patients with kidney failure.

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Fig. 1: Potential causes of insomnia in patients with CKD or kidney failure.
Fig. 2: Negative effects of obstructive sleep apnoea on kidney function.
Fig. 3: Pathophysiological mechanisms promoting sleep apnoea in patients with kidney failure.

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Glossary

Apnoea

The absence of any breathing or tidal volume for at least 10 s. If apnoea occurs when the airway is closed it is termed obstructive apnoea, whereas if it occurs with a patent airway it is termed central apnoea.

Polysomnography

An overnight sleep study in which various parameters are measured, including brain activity to determine wake and sleep stages, airflow, respiratory effort, oxygen saturations and leg movements.

Hypopnoea

A decrease in the tidal volume of 30% for at least 10 s that is accompanied by at least a 3% decrease in oxygen saturation or terminated by an arousal from sleep.

Nocturnal rostral fluid shift

Redistribution of fluid that has accumulated in the intravascular and interstitial spaces of the legs during the day under the influence of gravity, to the head, neck and thorax at night after lying down.

Pulmonary irritant receptors

Nerve receptors located between airway epithelial cells that, when activated, send signals via the vagus nerve that lead to increased respiratory rate.

Ventilatory instability

Excessive fluctuations in respiratory drive leading to periodic breathing (that is, cycles of hyperventilation alternating with central apnoea).

Cardiothoracic ratio

The ratio of the maximal horizontal cardiac diameter to maximal horizontal thoracic diameter; measured on a chest X-ray.

Continuous positive airway pressure

A positive airway pressure device that delivers a constant pressure during inspiration and expiration.

Adaptive servo-ventilation

A positive airway pressure device that uses a sophisticated algorithm to vary the inspiratory and expiratory pressures delivered based on its ability to detect the underlying type of sleep apnoea (OSA or CSA) at any one time.

Transcutaneous CO2

A non-invasive measurement of CO2 that reflects partial pressure of CO2 in the blood.

Respiratory drive

The output from the respiratory centre in the brain to the respiratory muscles (intercostals and diaphragm) and the upper airway dilator muscles.

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Lyons, O.D. Sleep disorders in chronic kidney disease. Nat Rev Nephrol (2024). https://doi.org/10.1038/s41581-024-00848-8

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