Journal of Nephrology

, Volume 31, Issue 1, pp 61–70 | Cite as

The impact of change of renal replacement therapy modality on sleep quality in patients with end-stage renal disease: a systematic review and meta-analysis

  • C. Kennedy
  • S. A. Ryan
  • T. Kane
  • R. W. Costello
  • P. J. Conlon



Sleep disorders are common and multi-factorial in patients with advanced chronic kidney disease and end-stage renal disease (ESRD). Sleep disorders and disturbance have a negative impact on wellbeing and quality of life.


To assess the impact of a change in renal replacement therapy (RRT) modality on sleep quality and sleep disturbance in patients with ESRD.

Data sources

Multiple electronic databases were searched without publication type/period restrictions. The reference lists of all included articles were manually searched for additional citations. Non-published data was identified by hand searching key conference abstracts.

Study eligibility criteria

Participants of interest were adult patients with ESRD requiring RRT [conventional haemodialysis (HD), short daily HD, nocturnal HD, continuous ambulatory peritoneal dialysis (CAPD), continuous cycler-assisted peritoneal dialysis (CCPD) or transplantation]. The exposure or intervention of interest was switch of RRT modality.

Study appraisal

Two reviewers independently assessed all studies for inclusion and extracted relevant data.


Sixteen studies with a combined total of 670 patients and 191 controls were included for review and described in detail. Looking specifically at restless leg syndrome, symptoms resolved in over 60% of affected patients with a switch to increased intensity RRT (either intensive HD, CCPD or transplant). Meta-analysis of the nine studies that looked specifically at sleep apnoea parameters again favoured intensive RRT over standard/conventional RRT (conventional HD or CAPD) with statistical significance [Risk ratio 0.66 (95% CI 0.51–0.84)]. Meta-analysis of all studies favoured a switch to increased intensity RRT in terms of overall sleep quality, with statistical significance [Risk ratio 0.58 (95% CI 0.40–8.83)].


Restriction to the English language may have introduced selection bias. Funnel plot analysis suggested there was also an element of publication bias. Studies were heterogeneous in terms of patient selection, means of sleep quality assessment and modality switch.

Conclusions and implications of key findings

Sleep disturbance, sleep apnoea and restless legs syndrome all tend to improve when a switch is made to intensive dialysis or transplant. This is important information for patients struggling with disturbed sleep and marked fatigue. This hypothesis-generating review highlights the need for more high quality prospective research in the area.


Sleep disorders Renal replacement therapy Transplant Dialysis modality Sleep apnoea Restless leg syndrome 



Funding was provided by Royal College of Surgeons in Ireland (STAR MD).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

40620_2017_409_MOESM1_ESM.docx (56 kb)
Supplementary material 1 (DOCX 56 KB)


  1. 1.
    Yngman-Uhlin P, Johansson A, Fernström A, Börjeson S, Edéll-Gustafsson U (2011) Fragmented sleep: an unrevealed problem in peritoneal dialysis patients. Scand J Urol Nephrol 45(3):206–215CrossRefPubMedGoogle Scholar
  2. 2.
    Unruh ML, Sanders M, Redline S, Piraino BM, Umans JG, Chami H, Budhiraja R, Punjabi NM, Buysse D, Newman AB (2008) Subjective and objective sleep quality in patients on conventional thrice-weekly hemodialysis: comparison with matched controls from the sleep heart health study. Am J Kidney Dis 52(2):305–313CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Elias RM, Chan C, Bradley TD (2016) Altered sleep structure in patients with end-stage renal disease. Sleep Med 20:67–71CrossRefPubMedGoogle Scholar
  4. 4.
    Hallett M, Burden S, Stewart D, Mahony J, Farrell P (1995) Sleep apnea in end-stage renal disease patients on hemodialysis and continuous ambulatory peritoneal dialysis. ASAIO J 41(3):M435-M441CrossRefGoogle Scholar
  5. 5.
    Beecroft JM, Hoffstein V, Pierratos A, Chan CT, McFarlane PA, Hanly PJ (2007) Pharyngeal narrowing in end-stage renal disease: implications for obstructive sleep apnoea. Eur Respir J 30(5):965–971CrossRefPubMedGoogle Scholar
  6. 6.
    Beecroft J, Duffin J, Pierratos A, Chan CT, McFarlane P, Hanly PJ (2006) Enhanced chemo-responsiveness in patients with sleep apnoea and end-stage renal disease. Eur Respir J 28(1):151–158CrossRefPubMedGoogle Scholar
  7. 7.
    Lee J, Nicholl D, Ahmed SB, Loewen AH, Hemmelgarn BR, Beecroft JM, Turin TC, Hanly PJ (2013) The prevalence of restless legs syndrome across the full spectrum of kidney disease. J Clin Sleep Med 19(5):455–459Google Scholar
  8. 8.
    Araujo SM, de Bruin V, Nepomuceno LA, Maximo ML, Daher Ede F, Correia Ferrer DP, de Bruin PF (2010) Restless legs syndrome in end-stage renal disease: clinical characteristics and associated comorbidities. Sleep Med 11(8):785–790CrossRefPubMedGoogle Scholar
  9. 9.
    Kavanagh D, Siddiqui S, Geddes CC (2004) Restless legs syndrome in patients on dialysis. Am J Kidney Dis Off J Natl Kidney Found 43(5):763–771CrossRefGoogle Scholar
  10. 10.
    Maung SC, El Sara A, Chapman C, Cohen D, Cukor D (2016) Sleep disorders and chronic kidney disease. World J Nephrol 5(3):224–232CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Jhamb M, Liang K, Yabes J, Steel JL, Dew MA, Shah N, Unruh M (2013) Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue? Am J Nephrol 38(6):489–495CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Brekke FB, Waldum B, Amro A, Østhus TB, Dammen T, Gudmundsdottir H, Os I (2014) Self-perceived quality of sleep and mortality in Norwegian dialysis patients. Hemodial Int 18(1):87–94CrossRefPubMedGoogle Scholar
  13. 13.
    Kang EW, Abdel-Kader K, Yabes J, Glover K, Unruh M (2012) Association of sleep-disordered breathing with cognitive dysfunction in CKD stages 4–5. Am J Kidney Dis 60(6):949–958CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Pierratos A, Hanly PJ (2011) Sleep disorders over the full range of chronic kidney disease. Blood Purif 31(1–3):146–150CrossRefPubMedGoogle Scholar
  15. 15.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8(5):336–341CrossRefPubMedGoogle Scholar
  16. 16.
    Higgins JP, Altman D, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods Group; Cochrane Statistical Methods Group (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Tang SC, Lam B, Lai AS, Pang CB, Tso WK, Khong PL, Ip MS, Lai KN (2009) Improvement in sleep apnea during nocturnal peritoneal dialysis is associated with reduced airway congestion and better uremic clearance. Clin J Am Soc Nephrol 4(2):410–418CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Tang SC, Lam B, Ku PP, Leung WS, Chu CM, Ho YW, Ip MS, Lai KN (2006) Alleviation of sleep apnea in patients with chronic renal failure by nocturnal cycler–assisted peritoneal dialysis compared with conventional continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 17(9):2607–2616CrossRefPubMedGoogle Scholar
  19. 19.
    Chan CT, Hanly P, Gabor J, Picton P, Pierratos A, Floras JS (2004) Impact of nocturnal hemodialysis on the variability of heart rate and duration of hypoxemia during sleep. Kidney Int 65(2):661–665CrossRefPubMedGoogle Scholar
  20. 20.
    Hanly PJ, Pierratos A (2001) Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal hemodialysis. N Engl J Med 344(2):102–107CrossRefPubMedGoogle Scholar
  21. 21.
    Unruh ML, Larive B, Eggers PW, Garg AX, Gassman JJ, Finkelstein FO, Kimmel PL, Chertow GM, FHN Trial Group (2016) The effect of frequent hemodialysis on self-reported sleep quality: frequent hemodialysis network trials. Nephrol Dial Transplant 31(6):984–991CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Auckley DH S-NW, Brown LK (1999) Reversal of sleep apnea hypopnea syndrome in end-stage renal disease after kidney transplantation. Am J Kidney Dis 34(4):739–744CrossRefPubMedGoogle Scholar
  23. 23.
    Albanese M, Placidi F, Romigi A, Liguori C, Marchi A, Mercuri NB, Marciani MG, Izzi F (2015) Refractory restless legs syndrome remitting after dual kidney transplantation. Parkinsonism Relat Disord 21(1):81–83CrossRefPubMedGoogle Scholar
  24. 24.
    Beecroft JM, Zaltzman J, Prasad R, Meliton G, Hanly PJ (2007) Impact of kidney transplantation on sleep apnoea in patients with end-stage renal disease. Nephrol Dial Transplant 22(10):3028–3033CrossRefPubMedGoogle Scholar
  25. 25.
    Beecroft JM, Hoffstein V, Pierratos A, Chan CT, McFarlane P, Hanly PJ (2008) Nocturnal haemodialysis increases pharyngeal size in patients with sleep apnoea and end-stage renal disease. Nephrol Dial Transplant 23(2):673–679CrossRefPubMedGoogle Scholar
  26. 26.
    Hanly PJ, Gabor J, Chan C, Pierratos A (2003) Daytime sleepiness in patients with CRF: impact of nocturnal hemodialysis. Am J Kidney Dis 41(2):403–410CrossRefPubMedGoogle Scholar
  27. 27.
    Beecroft JM, Duffin J, Pierratos A, Chan CT, McFarlane P, Hanly PJ (2009) Decreased chemosensitivity and improvement of sleep apnea by nocturnal hemodialysis. Sleep Med 10(1):47–54CrossRefPubMedGoogle Scholar
  28. 28.
    Jaber BL, Schiller B, Burkart JM, Daoui R, Kraus MA, Lee Y, Miller BW, Teitelbaum I, Williams AW, Finkelstein FO, FREEDOM Study Group (2011) Impact of short daily hemodialysis on restless legs symptoms and sleep disturbances. Clin J Am Soc Nephrol 6(5):1049–1056CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Russcher M, Nagtegaal J, Nurmohamed SA, Koch BC, van der Westerlaken MM, van Someren EJ, Bakker SJ, Ter Wee PM, Gaillard CA (2015) The effects of kidney transplantation on sleep, melatonin, circadian rhythm and quality of life in kidney transplant recipients and living donors. Nephron 129(1):6–15CrossRefPubMedGoogle Scholar
  30. 30.
    Winkelmann J, Stautner A, Samtleben W, Trenkwalder C (2002) Long-term course of restless legs syndrome in dialysis patients after kidney transplantation. Mov Disord 17(5):1072–1076CrossRefPubMedGoogle Scholar
  31. 31.
    Mallamaci F, Leonardis D, Tripepi R, Parlongo G, Catalano C, Tripepi G, Castronovo V, Ferini-Strambi L, Zoccali C (2009) Sleep disordered breathing in renal transplant patients. Am J Transplant 9(6):1373–1381CrossRefPubMedGoogle Scholar
  32. 32.
    Lee JJ, Kim G, Kim JA, Kim SJ, Kang JG, Kim GH, Jung HH (2011) Improvement of sleep-related breathing disorder in patients with end-stage renal disease after kidney transplantation. Clin Transplant 25(1):126–130CrossRefPubMedGoogle Scholar
  33. 33.
    Rodrigues CJ, Marson O, Togeiro SM, Tufik S, Ribeiro AB, Tavares A (2010) Sleep-disordered breathing changes after kidney transplantation: a polysomnographic study. Nephrol Dial Transplant 25(6):2011–2015CrossRefPubMedGoogle Scholar
  34. 34.
    Azar SA, Hatefi R, Talebi M (2007) Evaluation of effect of renal transplantation in treatment of restless legs syndrome. Transplant Proc 39(4):1132–1133CrossRefPubMedGoogle Scholar
  35. 35.
    Mehrotra R (2009) Long-term outcomes in automated peritoneal dialysis: similar or better than in continuous ambulatory peritoneal dialysis? Perit Dial Int 29(Suppl 2):S111–S114PubMedGoogle Scholar
  36. 36.
    Dahlerus C, Quinn M, Messersmith E, Lachance L, Subramanian L, Perry E et al (2016) Patient perspectives on the choice of dialysis modality: results from the empowering patients on choices for renal replacement therapy (EPOCH-RRT) study. Am J Kidney Dis 68(6):901–910Google Scholar

Copyright information

© Italian Society of Nephrology 2017

Authors and Affiliations

  • C. Kennedy
    • 1
    • 2
  • S. A. Ryan
    • 3
  • T. Kane
    • 4
  • R. W. Costello
    • 1
    • 4
  • P. J. Conlon
    • 1
    • 2
  1. 1.Royal College of Surgeons in IrelandDublinIreland
  2. 2.Department of NephrologyBeaumont HospitalDublin 9Ireland
  3. 3.Department of NeurologyBeaumont HospitalDublin 9Ireland
  4. 4.Department of Respiratory and Sleep MedicineBeaumont HospitalDublin 9Ireland

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