Insomnia and Poor Sleep in CKD: A Systematic Review and Meta-analysis

Abstract

Rationale & objective: Poor sleep quality and insomnia are pervasive among patients with advanced chronic kidney disease (CKD); however, these health issues have not been systematically evaluated.

Study design: Systematic review and meta-analysis.

Setting & study populations: Adult patients with CKD not receiving kidney replacement therapy (KRT), as well as adults receiving KRT, including hemodialysis, peritoneal dialysis, and kidney transplantation.

Selection criteria for studies: A systematic literature search using PubMed, Embase, and PsycNET, was conducted for articles published between January 1, 1990, and September 28, 2018.

Data extraction: Data on the prevalences of poor sleep quality and insomnia in patients with CKD, including those receiving and not receiving KRT, were extracted.

Analytical approach: Pooled prevalences were estimated using a random-effects meta-analysis and were stratified according to age, CKD stage, World Health Organization region, risk of bias, Pittsburgh Sleep Quality Index score, and the different criteria for insomnia that were used at diagnosis.

Results: Of 3,708 articles, 93 were selected, and significant methodological heterogeneity was present. The pooled prevalences of poor sleep quality for CKD without KRT, hemodialysis, peritoneal dialysis, and kidney transplantation were 59% (95% CI, 44%-73%), 68% (95% CI, 64%-73%), 67% (95% CI, 44%-86%), and 46% (95% CI, 34%-59%), respectively. The corresponding prevalences of insomnia were 48% (95% CI, 30%-67%), 46% (95% CI, 39%-54%), 61% (95% CI, 41%-79%), and 26% (95% CI, 9%-49%), respectively. Insomnia was significantly more prevalent among patients aged 51-60 years and those aged >60 years than among those aged <50 years. The prevalence of insomnia in the European region was the lowest of all World Health Organization regions.

Limitations: High interstudy heterogeneity.

Conclusions: Approximately half of the patients with advanced CKD had poor sleep quality or insomnia, and the prevalence was even higher among those who received KRT. Kidney transplantation may reduce the burden of poor sleep quality and insomnia.

Keywords: Chronic kidney disease; hemodialysis; insomnia; kidney transplantation; peritoneal dialysis; poor sleep quality.

Figure 1

Flowchart of the selection process of the included studies. Abbreviations: APA, American Psychiatric Association; CKD, chronic kidney disease; KRT, kidney replacement therapy; PSQI, Pittsburgh Sleep Quality Index.

Figure 2

Geographic distribution showing the pooled prevalences of (A) poor sleep. quality and (B) insomnia across WHO regions. The numbers in the orange circles indicate the number of studies from respective countries. The size of the orange circles is proportional to the number of studies. Abbreviation: WHO, World Health Organization.

Figure 3

Summary pooled prevalence of poor sleep quality and insomnia according to the whole spectrum of CKD. Abbreviations: CI, confidence interval; CKD, chronic kidney disease; IV, inverse variance; KRT, kidney replacement therapy.

Figure 4

Random-effects meta-regression plots showing the relationships between age and the prevalences of (A) poor sleep quality and (B) insomnia, according to different CKD spectrums and types of kidney replacement therapy. Abbreviations: CKD, chronic kidney disease; KRT, kidney replacement therapy.