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Saudi J Kidney Dis Transpl 2013;24(3):514-518

© 2013 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Quality of Life and Sleep in Hemodialysis Patients

Mahnaz Edalat-Nejad, Mehdi Qlich-Khani

Department of Internal Medicine, Arak Medical Sciences University, Arak, Iran

ABSTRACT. The purpose of this study was to determine the quality of life and sleep of chronic
hemodialysis (HD) patients. Quality of sleep was measured using the Pittsburgh Sleep Quality
Index (PSQI) and quality of life (QoL) was measured using the Medical Outcomes Study 36-item
Short Form (SF-36) in 115 HD patients. One hundred (87%) patients were “poor sleepers” (global
PSQI ≥5). The SF-36 mental component summary and physical component summary (PCS)
scores were higher than 50 only in 43% and 32% of the subjects, respectively. No significant
differences were found in QoL and sleep according to the patient’s gender, presence of diabetes
and time on HD. Correlation between total SF-36 score and global PSQI was statistically
significant (r = -0.227, P <0.05). Poor sleep is common in dialysis patients and is associated with
lower QoL, especially with mental health component of life quality.

Introduction
Although there have been improvements in
end-stage renal disease (ESRD) treatment, pa-
tients continue to have significant problems
with their quality of life (QoL). ESRD and
hemodialysis (HD) have been associated with
reduced QoL compared with the general popu-
lation,1 and measures of QoL in ESRD have
been associated with increased frequency of
hospitalization and mortality rates.2-5
Also, sleep complaints are common in HD
patients, and include delayed sleep onset,
frequent awakening, restlessness and daytime
Correspondence to:
Dr. Mahnaz Edalat-Nejad,
Assistant Professor of Nephrology,
Arak Medical Sciences University,
Arak, Iran
E-mail: mahedalat@arakmu.ac.ir
sleepiness.6-12
We aimed from our study to determine the
prevalence of “poor sleep” in HD patients and
to examine the association between quality of
sleep and QoL.
Patients and Methods
This cross-sectional study was performed in
the HD unit of the medical center of Vali-Asr,
Arak, Iran. It was approved by the Arak Medical
Sciences University Research Ethics Review
Committee (No. 88-76-4) and informed con-
sents were obtained from all participants. All
patients received daytime dialysis, and the total
hours per week varied from 8 h to 13.5 h. The
inclusion criteria were as follows: Patients
should have been receiving maintenance HD
>3 months; age >18 years and provided in-
formed consent.
The personal information form (PIF) was de-
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Quality of life and sleep in HD patients
veloped by the researchers and included ques-
tions about the patients’ age, gender, educa-
tional level, occupation and duration of HD
treatment.
Sleep quality was measured using the
Pittsburgh Sleep Quality Index (PSQI).13 This
19-question questionnaire measures the sleep
quality of the previous month. From the an-
swers, seven components (each scored from 0
to 3) were calculated: Subjective sleep quality,
sleep latency, sleep duration, sleep efficiency,
sleep disturbance, use of sleep medications and
daytime dysfunction. From the sum of the
scores of the seven components, the global
PSQI score was calculated (0–21). A patient
with a global PSQI score 5 was considered as a
bad sleeper and a patient with a value of <5
was considered as a good sleeper. The patients
completed the questionnaire by themselves or
with the assistance of research nurses at the
time when the HD was performed.
The SF-36, one of the most commonly used
health status questionnaires, was developed as
a measure of function and well-being in the
Medical Outcomes Study. It comprised 36
items evaluating eight dimensions of health:
Physical functioning, role limitations due to
physical problems, physical pain, general
health perceptions, vitality, social functioning,
role limitations due to emotional problems and
mental health. Each dimension is scored on a 0
to 100 scale, with lower scores corresponding
with more significant dysfunction.
The SF-36 is divided into two domains: Phy-
sical health (PCS) and mental health (MCS).
The PCS and MCS scores are standardized to
a mean of 50, with scores above and below 50
indicating above and below average functio-
ning, respectively. Global SF, PCS and MCS
scores can all vary between 0 and 100. A high
score indicates a better QoL. We screened the
patients’ QoL in all eight dimensions of health
and global SF, PCS and MCS.
After obtaining the informed consents and
excluding patients with the major barriers for
filling QOL and sleep evaluator questionnaires
(such as dementia or psychotic disorder, as
diagnosed by researcher) and ruling out the
presence of malignancy, active infection, un-
515
controlled heart failure and acute medical or
surgical condition that required hospitalization
or operation within the prior month, we en-
rolled 115 patients for assessment of QoL and
sleep. We gathered medical and demographic
data by reviewing of patients medical records
and measured QoL and sleep scores from pa-
tients’ answers to questionnaires of the PSQI
and the Medical Outcomes Study 36-item Short
Form (SF-36).
Statistical Analysis
The Statistical Package for Social Sciences
(SPSS) version 15.0 was used for data analysis
in the study. Pearson correlation analysis was
used to determine relationships between QoL
and sleep quality, QoL and age, QoL and dura-
tion of HD, sleep quality and age, and sleep
quality and duration of HD. The t-test and
analysis of variance were used in the evalua-
tion of QoL and sleep quality according to de-
mographic characteristics. P-value <0.05 was
considered significant.
Results
Of the 155 patients available to enter the
study, 40 did not meet inclusion criteria or did
not complete the PSQI and the SF-36 ques-
tionnaires. One hundred and fifteen patients
were included in the analysis. The age range of
the patients was 19–87 years, with a mean age
of 63 ± 15 years. Sixty-five (55.7%) patients
were male and five had failed renal allografts.
The causes of renal disease were: vascular/
hypertension (43), diabetic nephropathy (34),
glomerulonephritis (eight), polycystic kidney
disease (seven), urological problem (four) and
unknown (19). The majority of patients atten-
ded HD for 4 h three times weekly.
The majority of patients were illiterate (52.2%),
and only 7.8% had high school or graduate
study. In this study, less than 30% reported the
perception that their income was sufficient.
The mean (SD) global and component PSQI
scores for the study population are shown in
Table 1. The global PSQI score ranged from 0 to
21, and 100 (87%) patients were “poor sleepers”
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516 Edalat-Nejad M, Qlich-Khani M

Table 1. Quality of sleep in the study population according to the Pittsburgh Sleep Quality Index (PSQI).
95% confidence interval
PSQI components Mean ± SD Range
for mean
Subjective sleep quality 1.27 ± 0.84 0.98–1.57 0–3
Sleep latency 1.42 ± 0.75 1.16–1.69 0–3
Sleep duration 1.12 ± 1.19 0.70–1.54 0–3
Sleep efficiency 0.76 ± 1.23 0.32–1.19 0–3
Sleep disturbance 1.67 ± 0.60 1.46–1.88 0–3
Use of sleep medications 0.91 ± 1.21 0.48–1.34 0–3
Daytime dysfunction 1.48 ± 0.80 1.20–1.77 0–3
Global PSQI 8.64 ± 4.17 7.16–10.12 0–21

(global PSQI ≥5). For patients who recorded in our study (P <0.05). However, there was no
the cause of sleep disturbance, 42 described correlation between QoL and quality sleep
severe restless legs and 28 described trouble scores and time on dialysis. Furthermore, we
breathing. No significant differences were did not find differences of PSQI and SF-36
found between PSQI scores according to pa- scores and between males and females and
tients’ gender, age and time on HD. between diabetics and non-diabetics.
The mean (±SD) scores for the SF-36 MCS, There was a negative relationship between
PCS and HRQoL domains are shown in Table the quality of sleep and the MCS scores (r = -
2. The MCS ranged from 19.1 to 68.7 (44.0 ± 0.222; P <0.01), and the global SF-36 (r = -
15.9), while the PCS ranged from 12.8 to 62.0 0.227; P >0.05) show that as the quality of
(41.0 ± 13.1). The total SF-36 score ranged sleep worsened, the QoL decreased. Unlike the
from 14 to 91 (44.7 ± 14.2). Only 45 patients MCS scores, there was no correlation between
(39%) had a total SF-36 score more than 50. the PCS and the global PSQI (r = -0.159; P =
Prevalence of PCS and MCS scores higher 0.090). In addition, we assessed the correlation
than 50 based on self–reported items were between the PCS components and the global
32% and 43%, respectively. PSQI, and noticed a correlation between phy-
The effects of kidney disease on the QoL sical functioning (r = 0.196; P <0.05) and
were assessed and their results are shown in body pain (r = -0.192; P <0.05) in a positive
Table 3. The main adverse effect of renal and a negative way, respectively.
failure and HD is reflected on occupation and
income. Discussion
As shown by the analysis of data, there was a
significant relationship between age and QoL In the present cross-sectional study, quality
Table 2. Assessment of the quality-of-life survey results.
95% confidence
Variable Mean ± SD Range
interval for mean
Physical function 57.4 ± 29.4 74.0–68.0 0–100
Role-physical 36.4 ± 45.1 20.4–52.4 0–100
Body pain 43.1 ± 30.4 32.30–53.9 0–100
General health 36.6 ± 19.4 29.7–43.5 0–100
Vitality 32.1 ± 23.3 23.9–40.4 0–100
Social functioning 61.6 ± 23.0 53.5–69.8 0–100
Role emotional 41.4 ± 41.7 26.6–56.20 0–100
Mental health 48.6 ± 19.3 41.70–55.39 0–100
Reported health 2.61 ± 1.27 2.15–3.06 1–5
Physical health 41.0 ± 13.1 36.4–45.6 0–100
Mental health 44.0 ± 15.9 38.4–49.7 0–100
Total SF36 Score 44.7 ± 14.15 39.7 - 49.7 0 - 100
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Quality of life and sleep in HD patients
Table 3. Kidney disease quality-of-life survey results.
Mean ± SD
Effects of kidney disease 54.9 ± 29.9
Burden of kidney disease 38.9 ± 24.7
Sexual function 52.3 ± 35.6
Work status 22.7 ± 28.2
Dialysis staff encouragement 53.0 ± 31.1
Satisfaction with care 59.1 ± 32.4
Social support 73.2 ± 26.7
of sleep and QoL were measured using vali-
dated questionnaires. The PSQI and SF-36
evaluated quality of sleep and QoL during the
preceding 4-week period.
The prevalence of poor sleep in the present
study was 87%, comparable with the 70–89%
prevalence of sleep–wake complaints in dia-
lysis patients reported in previous studies.14-19
Also, the prevalence of low QoL based on
self-reported total SF-36 score measurement
was 60%, which is much better than most
previous reports.20,21 Prevalence of PCS and
MCS scores higher than 50 based on self–
reported items were 32% and 43%, respec-
tively. These findings suggest that our patients
had better perception of mental health com-
pared with physical health. There was a strong
association between quality of sleep and men-
tal QoL, especially for subjective sleep quality
and sleep efficiency. However, we did not find
a significant correlation between quality of
sleep and physical QoL. In the present study,
only mental QoL was associated with sleep
efficiency, subjective sleep quality and use of
sleep medications. Our findings were compa-
tible with those of Sathuik et al21; however, the
majority of studies have shown a strong asso-
ciation between quality of sleep and PCS of
SF-36 scores, seperately18,20,22 or in conjunc-
tion with components of mental health.14,15
The best evidence that ESRD can directly
influence quality of sleep, which in turn results
in reduced QoL, comes from studies of
obstructive sleep apnea (OSA) in dialysis pa-
tients; OSA is common in dialysis patients.9-11
In the present study, 28 (24%) patients des-
cribed trouble breathing and 42 (36%) des-
cribed severe restless legs.
517
95% confidence
Range
interval for mean
44.3–65.5 0–100
30.12–47.61 0–100
39.7–64.9 0–100
12.7–32.7 0–100
42.0–64.1 0–100
47.6–70.6 0–100
63.8–82.7 0–100
In our study, quality of sleep and QoL were
not associated with time on HD in the biva-
riate analysis. These findings are consistent
with other studies.20
No statistically significant differences in pa-
tients’ sleep quality scores were found accor-
ding to their age. However, there were diffe-
rences in patients’ mental health component of
QoL based on their age. These results were
similar to the results from previous studies.16,20
Furthermore, we noted no statistically signi-
ficant differences in patients’ QoL and sleep
quality scores between diabetic and non-dia-
betic patients. These results were different
from the findings of Nazmiye et al.16 They
showed a significant association between the
sleep quality and presence of diabetes mellitus.
Sorensen et al22 showed a correlation between
diabetes and low PSC scores, but not MSC
scores. We assumed that this difference comes
from excluding diabetics with severe comor-
bidity such as cardiovascular problems and
neuropathy from our study population.
Some studies have reported a negative corre-
lation between QoL and female gender,19-21 but
we did not detect any statistical difference in
QoL or sleep quality according to gender. In
this study, more than half of the patients were
female.
There were several limitations in our study.
First of all, because of the cross-sectional de-
sign, it is not possible to establish a cause and
effect relationship in the examined associa-
tions. Second, in the absence of polysomno-
graphic data, it is not possible to ascertain the
exact causes of insomnia and sleep disturbance.
Also, subjective reports of sleep quality do not
have a single criterion standard.
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518
In conclusion, the results of this study sug-
gest that “poor sleep” and low QoL are com-
mon in dialysis patients.
Acknowledgment
The authors would like to thank the staff and
patients of the Vali-Asr HD center.
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