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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 3  |  Page : 630-636
Who is sleeping more efficient? Patients on peritoneal dialysis or hemodialysis

1 Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
2 Social Determinants of Health Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Submission06-Jun-2017
Date of Acceptance26-Jul-2017
Date of Web Publication28-Jun-2018


Sleep disorder, a common complaint among patients with the end-stage renal disease can affect most aspects of life. Therefore, we aimed to compare sleep quality of patients with peritoneal dialysis (PD) and hemodialysis (HD). This cross-sectional study was conducted on patients on dialysis who were referred to three major centers of Shiraz. The Pittsburgh Sleep Quality Index (PSQI) was used to compare sleep quality between patients on PD and HD. We also assessed some baseline characteristics to find out if they were independent predictors of sleep quality. Spearman correlation coefficients, one and two sample t-test, Chi-square, or Fisher's exact test were used to analyze the data. P <0.05 was considered statistically significant. The Statistical Package for Social Sciences version 18.0 for Windows was used for data analyzing. A total of 144 patients including 63 (43.8%) men and 81 (56.2%) women with the mean age of 54.4 ± 11.8 years completed the questionnaire survey. The total PSQI score showed that 77 (54.6%) of all patients had sleep disturbances without statistical difference between genders (P >0.05). On the other hand, the prevalence of sleep disturbance in HD patients (70.1%) was significantly higher than PD patients (35.9%), (P <0.001). HD patients had a higher rate of poor sleep quality than PD patients. Further studies are necessary to investigate the causes of poor quality of sleep in these patients and also to investigate methods to improve sleep quality in this population.

How to cite this article:
Malekmakan L, Tadayon T, Azadian F, Sayadi M. Who is sleeping more efficient? Patients on peritoneal dialysis or hemodialysis. Saudi J Kidney Dis Transpl 2018;29:630-6

How to cite this URL:
Malekmakan L, Tadayon T, Azadian F, Sayadi M. Who is sleeping more efficient? Patients on peritoneal dialysis or hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2022 Dec 2];29:630-6. Available from: https://www.sjkdt.org/text.asp?2018/29/3/630/235182

   Introduction Top

Chronic kidney disease (CKD) a rapidly growing health problem and its last stage end-stage renal disease (ESRD) resulting in prema-ture mortality and poor quality of life.[1]

Sleep as an index of quality of life[2] will be disturbed in most of the patients undergoing dialysis. Although dialysis has some advantages in sleep induction such as limitation of mobility, interleukin-1 production, increase in body temperature, and osmotic imbalances of the brain that result in decreased alertness,[3] several disadvantages are attributed to dialysis. The previous study reported that sleep disturbance might be the result of successive confronting with these advantage processes during the waking phase.[4] In addition, another paper concluded both hemodialysis (HD) and peritoneal dialysis (PD) affected melatonin rhythm.[3] Chiu Y-L and his colleagues also mentioned inflammation as one of the pathogeneses factors in inducing sleep disorder in dialysis patients.[5] The presence and severity of sleep disorders may be related to the efficacy or type of dialysis, the presence of comorbidities, or the level of systemic inflammation.[5],[6],[7]

Sleep disorders influence quality of life and may cause increase in morbidity and decrease in survival rate. Thus, early diagnosis and effort to improve sleep quality in these patients is essential.[5],[8],[9] Evaluations of the sleep quality in HD and PD groups showed that sleep quality was poor in both HD and PD patients.[8],[9],[10],[11] In this study, we, however, hypothesized that the type of dialysis may affect the quality of sleep among ESRD patients. The aim of the present study is to evaluate and compare the sleep quality between PD and HD patients in our dialysis centers.

   Materials and Methods Top

This cross-sectional analytical study designed to evaluate the quality of sleep among ESRD population on dialysis who were referred to three major Shiraz hospitals. From 200 patients, who were on maintenance dialysis, 150 patients were selected by convenient sampling methods. Six patients did not agree to joint to our study, but the rest of them (144 cases: 79 HD and 65 PD patients) agreed to complete a self-administered questionnaire assessing the quality of sleep. Patients completed the questionnaire during or before dialysis sessions. A trained research assistant provided help if necessary. The exclusion criteria were those that cannot complete a Pittsburgh Sleep Quality Index (PSQI) due to cognitive impairment, dementia, and active psychosis, patients on dialysis <2 months, patients under the age of 15 years and above age 80 years, non-Persian and patients who refuse to complete PSQI.

Ethical consideration

The study has been approved by the Ethics Committee of Shiraz University of Medical Sciences. Informed consent was obtained from all patients.

Measurement tool

Quality of sleep was measured using PSQI which consists of 18 items. Answering to these items generate seven component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, the use of sleeping medications, and daytime dysfunction. Items were scored from 0 to 3 (severe difficulty). The sum of the scores for the seven components gives a global score from 0 to 21. Poor sleep quality was defined by a score >5.[11] This questioner had a validated version in Persian.[2]

   Statistical Analysis Top

The statistical analysis of the data was performed using Statistical Package for Social Sciences (SPSS) version 18.0 for Windows (SPSS Inc., Chicago, IL, USA). The results related to the continuous variables were presented as mean ± standard deviation and those related to the qualitative or categorical data were shown as percentage and frequency. Statistical analyses were performed by Chi-square analysis, t-test, and Spearman correlation coefficients. P <0.05 was considered being statistically significant.

   Results Top

A total of 144 patients consisting of 63 (43.8%) men and 81 (56.2%) women with mean age of 54.4 ± 11.8 years (range 24–80 years) completed the questionnaire survey. Demographic data are presented in [Table 1]. Seventy-nine patients (54.9%) were under HD, and 56 patients (45.1%) were under PD. There was no significant difference in age, sex, dialysis duration, and cause of dialysis in both groups (P >0.05).
Table 1: Demographic data among studied groups.

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During one month, 49% of patients did not fall into sleep after 30 min from lying down, and 55.1% of patients woke up one time in the middle of the night or early morning. In this study, 36.7% of patients woke up one time due to breathing problems and 57.2% patients have nightmares and 63.2% of patients had pain during the night. In general, 66.7% of patients had problems for doing daily works. Furthermore, 27.1% of patients evaluated their sleep quality as very good while 40.1% of patients considered it almost good and 10.2% reported it bad.

[Table 2] describes PSQI score in patients with sleep problems and those without. The total PSQI score was 9.5 ± 1.7 in all patients which no statistically difference was seen between this score and gender (P = 0.905). In addition, other values (subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction) showed that no statistically difference was seen between men and women (P >0.05). The total PSQI score was significantly higher in patients with sleep difficulty than the patients who had no sleep difficulty (9.3 ± 3.2 vs. 4.4 ± 0.5, P <0.001). The positive and significant correlation was seen between total PSQI score and sleep quality (r = 0.55, P<0.001), sleep latency (r =0.37, P = 0.001), sleep duration (r = 0.642, P <0.001), sleep efficiency (r = 0.552, P <0.001), sleep disturbances (r = 0.448, P <0.001), use of sleeping medications (r = 0.394, P <0.001), and day-time dysfunction (r = 0.452, P<0.001).
Table 2: Comparison of PSQI score in dialysis patients and good sleepers.

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[Table 3] shows the comparison of PSQI score in HD and PD patients. Total PSQI score in patients with ESRD indicated that HD patients have more sleep disturbances than PD patients (10.4 ± 3.1 vs. 8.1 ± 2.3, P = 0.001). Although disturbances in different values of sleep quality was much higher in HD patients than PD patients, only in values such as subjective sleep quality (P <0.001), sleep latency (P = 0.001), sleep duration (P = 0.007), and sleep disturbances (P = 0.001) the differences were statistically significant.
Table 3: Comparison of PSQI score among studied groups.

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As shown in [Table 4], the prevalence of all PSQI values was significantly more in HD patients except sleep efficiency and daytime dysfunction. In general, the prevalence of sleep disturbance was 54.6% which was in HD patients higher than PD patients (54, 70.1% vs. 23, 35.9%, P <0.001).
Table 4: Prevalence of sleep disturbance among studied groups.

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Some laboratory tests measured in this study shown in [Table 5]. Although we found significant association between total PSQI and C-reactive protein (CRP), (r = 0.327, P = 0.002) also between total PSQI and hemoglobin (Hb), (r = -334, P = 0.001), our results showed that there were no significant association between other laboratory tests and PSQI (r <0.05, P >0.05) and also there was no significant difference in biochemical variables of both groups (P >0.05).
Table 5: Laboratory tests among studied groups.

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   Discussion Top

Sleep disturbance is one of the disastrous and common complaints in patients who referred to clinics. It can affect all people but its prevalence increases in patients with somatic disorders. It is common in CKD patients especially patients who are on dialysis. Its prevalence in normal population reported 20%–30% while in patients on dialysis, it was reported as high as 90%.[2],[3],[13] This complaint can impair other aspects of health such as immune system[5] and results in increase in morbidity and mortality. As a result in the present study, we assessed this problem in dialyzed patients, and we compared the sleep quality in two types of dialysis (HD and PD) to see if there was any difference.

In this study, the prevalence of poor sleep quality was about 55% which is less than other reports from Iran that reported 86.6% and 87.8%.[8],[14] In other countries, the frequencies of poor sleep quality in ESRD patients measured by PSQI index was reported from 40% to 90%.[13],[15] This variation between different populations can be due to the role of some factors such as prior sleep habit, previous hypnotic drug consumption, other underlying disease, daily activity, and environmental factors which affecting the sleep quality. In addition, the different scoring system and studied samples that only few of studies included both HD and PD patients may be responsible for the difference in results of different studies.[16],[17],[18]

In spite of some previous studies, we found no correlation between age and gender with sleep quality.[13],[19] Zeitlhofer et al reported increase in the prevalence of poor sleep quality by increase in age even in normal population.[2] In addition, Foley et al mentioned female gender complained more about sleep quality.[20] However, this result has not been confirmed in many studies.[10],[21] Hence, the effect of age and gender on sleep quality remains controversial among dialysis patients.

Similar to other previous reports, we found direct association between the level of CRP and sleep quality.[5],[8] Chiu also mentioned elevation of inflammation in normal population with sleep disturbance. On the other hand, patients with ESRD almost always have a baseline inflammation, and they have a higher rate of poor sleep quality.[3],[5] These associations can indirectly imply the role of inflammation in sleep disturbance pathogenesis.

In our study, serum albumin level was in normal range without any association with sleep quality while in the previous study conducted on HD and PD patients, the mean value of albumin was lesser than our study and it had a negative correlation with sleep quality.[15] Also, like Baraz et al[22] that mentioned the relation between low level of hemoglobin and poor sleep quality that we found reverse association between level of Hb and PSQI score while other previous studies found no relation.[15] However, this situation is controversial among different studies.[10],[21]

Based on our results HD patients had poorer sleep quality with higher prevalence than PD patients. Travel from home to HD center, more hospitalizations for HD than PD patients, and also dialysis procedure performed by the patients themselves in PD may be possible reasons for higher rate of poor sleep quality in HD patients. In addition, each aspect of PSQI scoring system were significantly higher in HD patients except the sleep efficiency and daytime dysfunction. Similar to our results Masoumi and his colleague found poorer sleep in patients on HD.[8] Koch et al compared the sleep quality in daytime HD, nocturnal HD, and automated PD patients. They found that sleep parameters were impaired in three groups, though the daytime HD group had the worst sleep quality. Also, they reported that mela-tonin rhythm remained intact only in nocturnal HD patients.[3] On the other hand, Turkmen et al and Roumelioti et al found similar sleep quality scores between the HD and PD patients.[9],[11] Holley et al also reported no association between type of dialysis and prevalence of sleep quality[10] while Eryavuz et al reported a similar rate of sleep disturbance in both types of dialysis.[15] In contrast to our results in a cohort study performed in the USA, results showed that HD patients had a better sleep quality and overall quality of life.[6]

As described different studies revealed different results; therefore, we recommend a cohort study with the control of normal population and higher number of dialysis patients. One limitation of this study is not using the polysomnography for assessing the quality of sleep which it can be used in future study for better evaluation.

In conclusion, poor sleep quality is observed at a high rate in both HD and PD patients. It can result in disastrous complications and finally increase morbidity and mortality in these patients. As a result, further studies are necessary to investigate the causes of sleep disturbance and to find methods to improve sleep quality in this population. All clinicians must try to diagnose and treat patients with sleep problem at the beginning of the complaints itself.

   Acknowledgment Top

The vice-chancellor of research and technology of Shiraz University of Medical Sciences funded this study by the research project number 7062.

Conflict of interest: None declared.

   References Top

Khajehdehi P, Malekmakan L, Pakfetrat M, Roozbeh J, Sayadi M. Prevalence of chronic kidney disease and its contributing risk factors in Southern Iran: A cross-sectional adult population-based study. Iran J Kidney Dis 2014;8:109-15.  Back to cited text no. 1
Zeitlhofer J, Schmeiser-Rieder A, Tribl G, et al. Sleep and quality of life in the Austrian population. Acta Neurol Scand 2000;102:249-57.  Back to cited text no. 2
Koch BC, Nagtegaal JE, Hagen EC, Wee PM, Kerkhof GA. Different melatonin rhythms and sleep-wake rhythms in patients on peritoneal dialysis, daytime hemodialysis and nocturnal hemodialysis. Sleep Med 2010;11:242-6.  Back to cited text no. 3
Casey KR. Sleep disorders in chronic kidney disease. Sleep Med 2010;11:231-2.  Back to cited text no. 4
Chiu YL, Chuang YF, Fang KC, et al. Higher systemic inflammation is associated with poorer sleep quality in stable haemodialysis patients. Nephrol Dial Transplant 2009;24: 247-51.  Back to cited text no. 5
Wu AW, Fink NE, Marsh-Manzi JV, et al. Changes in quality of life during hemodialysis and peritoneal dialysis treatment: Generic and disease specific measures. J Am Soc Nephrol 2004;15:743-53.  Back to cited text no. 6
Tosun N, Kalender N, Cinar FI, et al. Relationship between dialysis adequacy and sleep quality in haemodialysis patients. J Clin Nurs 2015;24:2936-44.  Back to cited text no. 7
Masoumi M, Naini AE, Aghaghazvini R, Amra B, Gholamrezaei A. Sleep quality in patients on maintenance hemodialysis and peritoneal dialysis. Int J Prev Med 2013;4:165-72.  Back to cited text no. 8
Turkmen K, Yazici R, Solak Y, et al. Health-related quality of life, sleep quality, and depression in peritoneal dialysis and hemodialysis patients. Hemodial Int 2012;16:198-206.  Back to cited text no. 9
Holley JL, Nespor S, Rault R. A comparison of reported sleep disorders in patients on chronic hemodialysis and continuous peritoneal dialysis. Am J Kidney Dis 1992;19:156-61.  Back to cited text no. 10
Roumelioti ME, Argyropoulos C, Pankratz VS, et al. Objective and subjective sleep disorders in automated peritoneal dialysis. Can J Kidney Health Dis 2016;3:6.  Back to cited text no. 11
Hasanzadeh M, Alavi KN, Ghalehbandi M, Gharaei B. Sleep quality in Iranian drivers recognized as responsible for severe road accidents. J Behav Sci 2006;6:97-107.  Back to cited text no. 12
Li J, Guo Q, Ye X, et al. Prevalence and risk factors of sleep disturbance in continuous ambulatory peritoneal dialysis patients in Guangzhou, Southern China. Int Urol Nephrol 2012;44:929-36.  Back to cited text no. 13
Dashti-Khavidaki S, Chamani N, Khalili H, et al. Comparing effects of clonazepam and zolpidem on sleep quality of patients on maintenance hemodialysis. Iran J Kidney Dis 2011;5:404-9.  Back to cited text no. 14
Eryavuz N, Yuksel S, Acarturk G, et al. Comparison of sleep quality between hemo-dialysis and peritoneal dialysis patients. Int Urol Nephrol 2008;40:785-91.  Back to cited text no. 15
Moore M, Meltzer LJ. The sleepy adolescent: Causes and consequences of sleepiness in teens. Paediatr Respir Rev 2008;9:114-20.  Back to cited text no. 16
Tembo AC, Parker V. Factors that impact on sleep in intensive care patients. Intensive Crit Care Nurs 2009;25:314-22.  Back to cited text no. 17
Bihari S, Doug McEvoy R, Matheson E, et al. Factors affecting sleep quality of patients in Intensive Care Unit. J Clin Sleep Med 2012; 8:301-7.  Back to cited text no. 18
Guney I, Atalay H, Solak Y, et al. Predictors of sleep quality in hemodialysis patients. Int J Artif Organs 2010;33:154-60.  Back to cited text no. 19
Foley DJ, Monjan AA, Brown SL, et al. Sleep complaints among elderly persons: An epide-miologic study of three communities. Sleep 1995;18:425-32.  Back to cited text no. 20
Stepanski E, Faber M, Zorick F, Basner R, Roth T. Sleep disorders in patients on continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 1995;6:192-7.  Back to cited text no. 21
Baraz SH, Mohammadi I, Borumand B. Correlation of quality of sleep or quality of life and some of blood factors in hemodialysis patients. Shahrekord Univ Med Sci J 2008; 9:67-74.  Back to cited text no. 22

Correspondence Address:
Dr. Taraneh Tadayon
Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.235182

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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