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Saudi J Kidney Dis Transpl 2012;23(2):251-261

© 2012 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Prevalence of Sleep Apnea and Excessive Day Time Sleepiness in Patients

with End-Stage Renal Disease on Dialysis
Hamdan Al-Jahdali

Department of Medicine, Sleep Disorders Centre, King Saud University for Health Science, King
Abdulaziz Medical City, Riyadh, Saudi Arabia

ABSTRACT. Sleep apnea (SA) and excessive daytime sleepiness (EDS) are common sleep
disorders among patients with end-stage renal disease (ESRD). This cross-sectional study, carried
out in two dialysis centers in Saudi Arabia, assessed the prevalence of sleep apnea and sleepiness in
Saudi patients with ESRD who are on maintenance dialysis with either peritoneal or hemodialysis.
We used questionnaires to assess the prevalence of SA and EDS. The association between sleep
apnea, EDS, and other sleep disorders, the underlying causes of renal failure, and other demo-
graphic data were also examined. Among 227 enrolled patients, the mean patient age was 55.7 years
± 17.2 years; 53.7% were male, and 46.3% were female. The overall prevalence of SA as defined by
the Berlin questionnaire (BQ) was 37% in males and 34% in females, which was not a statistically
significant difference (P = 0.459). Sleep apnea was significantly associated with age, neck size,
afternoon and evening hemodialysis shift, obesity, diabetes, and hypertension (P-values, 0.001,
0.029, < 0.0001, < 0.0001, < 0.008, 0.002, and < 0.001, respectively). Sleep apnea was also
significantly associated with other sleep disorders such as restless leg syndrome, insomnia, habitual
snoring, and EDS (P-values, < 0.001, < 0.001, < 0.001, and < 0.001, respectively). The prevalence
of EDS was 44%, and EDS was significantly more prevalent in patients undergoing peritoneal
dialysis (P < 0.001); it was also associated with older age, diabetes mellitus, and other sleep
disorders. SA and EDS are common in dialysis patients and are significantly associated with other
sleep disorders.

Correspondence to: Introduction

Dr. Hamdan H. Al-Jahdali, The prevalence of sleep disorders in chronic

Associate Professor, renal failure patients who are on dialysis is
Head of Pulmonary Division, quite high; approximately 80% of such patients
Medical Director of Sleep Disorders Centre, have sleep complaints. Unfortunately, little
King Saud University for Health Sciences attention has been paid to the impact of these
King Abdulaziz Medical City, disorders on patients with end-stage renal
Riyadh, Saudi Arabia disease (ESRD) who are on dialysis.1-5 The pre-
E-mail: Jahdali@yahoo.com valence of sleep apnea (SA) in ESRD and dia-
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252
lysis patients has been reported in (13–70%),6
which is much higher than the general popu-
lation (2–4%).7--10 This large variation in the
prevalence of SA in dialysis patients is probably
due to different populations being studied, the
method of diagnosis [whether it is based on
questionnaires or polysomnography (PSG)] and
the definition used to diagnose SA. Excessive
daytime sleepiness (EDS), a major consequence
of SA, is caused by sleep fragmentation that is
triggered by repetitive episodes of partial or
complete upper airway obstruction. Sleep frag-
mentation may also contribute to impaired cog-
nition and altered moods as well as subject the
patient to increased risk of work- or driving-
related accidents.11,12 Ques-tionnaires based on
symptoms are not sensitive or specific enough
to identify patients with SA and may under-
estimate the true prevalence of SA. Nevertheless,
sleep questionnaires are easy to administer, and
subjective descriptions may still provide vital
information for the diagnosis and management
of sleep disturbances in dialysis patients. The
Berlin questionnaire (BQ) has been validated as
a good screening tool to identify patients at high
risk for developing SA based on snoring beha-
vior, daytime sleepiness or fatigue, and the
presence of obesity or hypertension.13 Patients
may report insomnia or EDS. Insomnia is
usually defined as difficulties initiating or main-
taining sleep.14 EDS is a physiological drive,
defined as difficulty in maintaining an alert and
awake state.14 Both problems may impair qua-
lity of life in patients with ESRD and those on
dialysis. In addition, insomnia and sleepiness
are manifestations of other sleep disorders that
include obstructive sleep apnea, restless leg
syndrome (RLS) or periodic leg movement dis-
order (PLMD). Insomnia is reported in 50% of
patients on hemodialysis, whereas subjective
EDS have been reported in 52–67% of hemo-
dialysis patients.1,2 RLS has been reported in
12–62% of dialysis patients, and PLMD was
reported in approximately 14% of these pa-
tients.15-20 Any condition causing disturbed sleep
due to respiratory events (apneas) or body
movements (periodic leg movements) can cause
frequent awakenings or brief arousals and may
Al-Jahdali H
also increase daytime sleepiness, even if total
sleep time is normal. Since its development in
1991, the Epworth sleepiness scale (ESS) has
been commonly used in both clinical and
research settings as a cost-effective method for
assessing subjective day-time sleepiness.21 It is
an eight-item questionnaire that is designed to
quantify a patient’s sleep propensity by estima-
ting the chance of dozing. Subjects rate each of
the questions on a 0–3 scale, and the results are
summed to produce a final score from 0 to 24.
ESS scores less than 10 are considered normal,
and scores greater than 10 suggest problems
with excessive sleepiness.21 The prevalence of
“poor sleep” as estimated by Pittsburgh Sleep
Quality Index (PSQI), (global score >5) has
been reported to be 71% in dialysis patients.22
The association of poor sleep quality with
biochemical parameters is controversial;22,23
however, sleep quality is usually affected by the
presence of other sleep disorders. The detection
and management of sleep disorders in hemo-
dialysis patients is often challenging. This study
is designed to determine the sleep quality, the
prevalence of SA (using BQ), and the preva-
lence of EDS in our patients with ESRD on
maintenance dialysis and to delineate the asso-
ciated clinical and biomedical parameters that
may be linked to these sleep disorders. As we
examine the prevalence of sleep apnea in our
population, we will also summarize the preva-
lence of sleep apnea in most of the published
studies.
Methods
This study was conducted as an observational
cross-sectional study at King Abdulaziz Medical
City – King Fahad National Guard Hospital
(KAMC-KFNGH) – Riyadh and King Faisal
Specialist Hospital and Research Centre
(KFHRC) – Jeddah during the period from May
2007 to September 2007. This study was
approved by the research and ethics committee
at KAMC-KFNGH-Riyadh. All stable patients
undergoing regular dialysis at both centers were
enrolled in this study. We excluded confused or
demented patients and those patients who refused
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Prevalence of sleep apnea in patients on dialysis 253

Table 1. Demographic characteristics.

Demographic No. %
Age (years) Mean ± SD 55.7 ± 17.2
Gender
Male 122 53.7
Female 105 46.3
Marital status
Married 25 11.0
Single/divorced/widowed 202 89
Educational level
Illiterate 100 44.1
High school or less 103 45.4
More than high school 24 10.6
Occupation
Employed 34 15.0
Unemployed 193 85
BMI categories
Under weight (BMI: below 19.5) 27 11.9
Normal (BMI: 18.5–24.9) 72 31.7
Over weight ( BMI: 25.0–29.9) 72 31.7
Obese (BMI: 30.0 and above) 56 24.7
Habits
Nonsmoker 162 71.4
Smoker 13 5.7
Extrasmoker 52 22.9
Coffee intake 172 75.8
Methods of dialysis
Peritoneal 39 17.2
Hemodialysis 188 82.8
Duration/12 40.4 ± 37.8
Kt/V (126) 1.5 ± 0.27
Shift time
Morning 89 47.3
Afternoon 65 34.6
Evening 34 18.1
PMH
DM 119 52.4
HBP 190 83.7
Others 33 14.5
Medication
Erythropoietin and iron 219 96.5
Vitamins 208 91.6
Antihypertensive agents 191 84.1
Antiosteoporosis 134 59.0
Diabetic agents 120 52.9
Antidepression 20 8.8
Others 36 15.9

to participate. The data collection was carried tionnaires and are used routinely at our sleep
out by a professional personal interviewer, using disorders center. All questionnaires were trans-
a structured questionnaire. These questionnaires lated from English to Arabic and back translated
were adapted from standard international ques- from Arabic to English language by a profes-
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254
sional medical translator. Moreover, these ques-
tionnaires were also reviewed by two sleep
specialists for accuracy and the clarity of the
Arabic translation. Finally, these questionnaires
were pretested on 30 patients and then modified
for any ambiguity or vagueness.
Data collected included common demographic
characteristics such as age, gender, education
level, marital status, employment, and personal
habits. Data regarding past medical history,
medication, underlying cause of chronic renal
failure, duration of the dialysis and the dialysis
shift were also collected.
The ESS was used to measure daytime sleepi-
ness, with a score of more than 10 indicating
increased sleepiness.21 BQ was used to assess
the risk of SA. The BQ was developed in 1996,
and its validity and accuracy in primary care
settings has been previously shown.13 The de-
tails of the questionnaire have been published
previously.13 However, in brief, the question-
naire is divided into three sections. Section 1
addresses snoring and witnessed apnea. Those
patients who snore are asked to rate their sno-
ring with regard to loudness, frequency, and
whether their snoring bothers other people.
Section 2 addresses daytime fatigue and sleepi-
ness. Section 3 addresses personal history of
hypertension, as well as height, weight, and
gender. Then, the body mass index (BMI) is
calculated.
Three categories in BQ are defined based on
the information collected. In category 1, a posi-
tive response is defined as frequent symptoms
(>3 times per week) in the questions about
snoring and witnessed apneas. In category 2, a
positive response is defined as frequent symp-
toms in two or more questions about fatigue,
sleepiness, and/or drowsy driving. In category
3, a positive response is defined as a self-report
of hypertension and/or a BMI >30 kg/m2. Based
on the data collected, patients are stratified into
high risk for SA and low risk for SA according
to their responses. Individuals who have posi-
tive scores in at least two of the three categories
are scored as high risk for SA. Individuals who
do not meet the above criteria are scored as low
risk for SA. The high-risk pretest probability for
Al-Jahdali H
SA has been previously found to predict a respi-
ratory disturbance risk expressed as a respi-
ratory disturbance index (RDI) of >5 with a
sensitivity of 86% and a specificity of 77%.13
The Pittsburgh Sleep Quality Index (PSQI) was
also used to assess sleep quality. In this ques-
tionnaire, the details of which have been pub-
lished previously, a score of 5 or more indicates
poor sleep quality.24 We also used the ICSD-2
definition for insomnia: difficulty in falling
asleep or waking up too early, frequent awake-
ning with difficulty falling asleep again, and
secondary daytime impairment related to night-
time sleep difficulties.25 The diagnosis of RLS
is clinical, and its definition has been clarified
and standardized by internationally recognized
diagnostic criteria, published by the International
Restless Legs Syndrome Study Group (IRLSSG)
which we used in our study.26 Data were sum-
marized as either mean and standard deviation
or number and percent, as appropriate. To assess
the possible influence of demographic and other
variables on the prevalence of SA and EDS, we
used the unpaired t-test and the Mann–Whitney
U-test for nonparametric data, as appropriate. A
multivariate logistic regression analysis was
used to assess the risk of EDS (defined by an
ESS score >10) and the risk of SA (defined by
the BQ as high risk or low risk categories)
while controlling for other sleep disorders, such
as RLS and an elevated PSQI score (greater
than 5, indicating poor sleep quality). A P-value
of less than 0.05 was considered statistically
significant. Data management and analyses
were carried out using the Statistical Package
for Social Sciences (SPSS), version 13.
Results
A total of 227 patients were recruited for the
study with mean age of 55.7 ± 17.2 years. There
were 122 males (53.7%) and 105 females
(46.3%). The mean duration on dialysis was 40.4
± 37.8 months. Diabetes mellitus was the most
common cause of renal failure (52%). A majo-
rity of patients (80%) had less than a high school
education, and 50.7% were employed. Among
these patients, nonsmokers were a majority as
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Prevalence of sleep apnea in patients on dialysis 255

Table 2. Association between OSAS and other characteristics (patient characteristics, shift and type of dialysis,
lifestyle habits, and underlying medical problems).
Characteristics High risk for OSA Low risk for OSA P-value OR (95% CI )
Number (%) 161 (70.9%) 66 (29.1)
Age (year) mean ±SD 58.07 ± 15.89 50.09 ± 19.1 0.001
Neck size (centimeters)
Male 40.05 ± 3.35 38.27 ± 5.45 0.029
Female 37.62 ± 4.37 34.68 ± 3.62 0.002
Gender
Male 84 (37.1) 38 (16.7)
Female 77( 33.9) 28 (12.3) 0.459 0.80 (0.43–1.49)
Time of hemodialysis
Morning 77 (33.9) 12 (5.3) 1 -
Afternoon 35 (15.4) 30 (13.2) 0.000 0.18 (0.08–0.42)
Evening 13 (5.7) 21 (9.3) 0.000 0.10 (0.03–0.26)
Dialysis duration (months)
<12 60 (26.4) 17 (7.5) 1 -
12-48 55 (24.2) 31 (13.7) 0.051 0.50 (0.24–1.06)
49-84 27 (11.9) 12 (5.3) 0.301 0.64 (0.25–1.66)
> 84 19 (8.4) 6 (2.6) 0.842 0.90 (0.28–2.98)
Dialysis type
Hemodialysis (188) 125 (55.1) 63 (27.8) 0.001 0.17 (0.04–0.59)
Peritoneal dialysis (39) 36 (15.9) 3 (1.3)
BMI
Normal 20-25 63 (27.8) 36 (15.9) 1 -
Overweight ≥25-30 51 (22.5) 21 (9.3) 0.324 1.39 (0.69–2.81)
Obese >30 47 (20.7) 9 (4%) 0.008 2.98 (1.23–7.40)
Comorbidities
DM 95 (41.9) 24 (10.6) 0.002 2.52 (1.34–4.76)
Hypertension 145 (63.9) 45 (19.9) 0.000 4.23 (1.92–9.37)
KT/V
Hemo <1.2 13 (5.7) 5 (2.2) 0.504 0.69 (0.20–2.24)
1.2+ 99 (43.6) 55 (24.2)
Peritoneal <1.7 7 (3.1) 0 1.000 0.00 (0.00–62.10)
1.7+ 21 (9.3) 1 (0.44.)
Habit
Smoking 34 (15) 18 (7.9) 0.316 0.71 (0.35–1.46)
Coffee intake (daily and regular) 121 (53.3) 51 (22.5) 0.735 0.89 (0.43–1.84)

well (77%). Daily and regular coffee intake was
reported in 75.8%. The most common medica-
tions used were erythropoietin and iron supple-
ments (96.5%), vitamins (91.6%), antihyperten-
sive medications (84%), and antidepressants
(8.8%). Other patient characteristics are shown
in Table 1. The overall prevalence of SA as
defined by the BQ was 37% in males and 34%
in females, which was not a statistically signi-
ficant difference (P = 0.459). Age was a signi-
ficant risk factor for SA (P = 0.001), with older
patients at higher risk than young. Risk of SA
was significantly higher in peritoneal dialysis
patients than in hemodialysis patients (P =
0.001) and also more in the morning shift pa-
tients compared to afternoon or evening shift (P
< 0.001). Obesity was also significantly asso-
ciated with increased the risk for SA (P = 0.028).
There were also significant associations of higher
risk for SA with DM (P = 0.002) and hypertension
(P = 0.001). Smoking and coffee intake were not
associated with a significantly increased risk for
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256
Table 3. Association between risk of OSA and other sleep disorders.
Characteristics High risk for OSAS Low risk for OSA
PSQI
<5 1 2
>5 160
EDS
≥10 94
<10 67
Insomnia 114
RLS 98
Habitual snoring
Yes 103
No 58
obstructive sleep apnea (P = 0.31 and P = 0.735,
respectively). There was no significant associa-
tion between higher risk for SA and dialysis
efficacy as measured by KT/V, as shown in
Table 2, or between higher risk and other bio-
chemical parameters, such as hemoglobin, urea,
creatinine, calcium, and phosphorus (data not
shown). Patients who were at higher risk for SA
had significantly greater symptoms of insomnia,
RLS, habitual snoring, and excessive daytime
sleepiness (all P-values <0.001), as shown in
Table 3. EDS, as measured by an ESS score
greater than 10, was also associated with a
higher risk of SA, snoring, and RLS, as shown
in Table 4. Almost all of the patients, 224 (99%),
had poor sleep quality. The reported prevalence
of SA in previous studies, including our study,
is summarized in Table 5.
Discussion
Sleep disorders are common in dialysis pa-
tients.2,5-7,27-29 SA is common and causes signi-
ficant comorbidities in patients with end-stage
renal disease who are on dialysis; the reported
prevalence ranges from 20% to 90% (Table 5).
The major reasons for this variation in preva-
lence are the method of the diagnosis selected
(questionnaire or overnight polysomnography)
and the definition used to diagnose SA. The re-
ported prevalences for SA are much higher than
those for the general population (2–4%).30 How-
ever in our study, the prevalence of SA as
defined by the BQ was 37% in males and 34%
in females, which is not a statistically significant
Al-Jahdali H
P-value OR (CI)
0.203 5.00 (0.35–141.9)
64
6 0.000 14.03 (5.42–38.43)
60
24 0.000 4.24 (2.22–8.15)
16 0.000 4.86 (2.44–9.78)
6
60 0.000 17.76 (6.84–48.82)
difference. If we compare the prevalence of SA
in dialysis patients to the prevalence of SA in
the general Saudi population, it is not signifi-
cantly different. Using the same BQ, the preva-
lence of SA was 39% in females and 33.3% in
males.31,32 We believe that this is a major strength
of our study: we used the same questionnaires
in both the normal population and the dialysis
patients, and we found no significant diffe-
rences in prevalence. Similar to other reported
studies, there was a significant association bet-
ween higher risk for SA and older age, neck
size, dialysis shift, hypertension, DM, and obe-
sity.12,33-37 However, some other reported studies
did not find any such associations.28,38-41
In our study, the BMI was 26.7 ± 6.4, which is
a much higher than the BMI in the studies that
reported a lower prevalence of SA2,6,35 but
similar to other studies with a moderate to high
prevalence of SA.9,34,42 Previous studies have
reported almost equal prevalence of sleep apnea
in patients undergoing both hemodialysis and
peritoneal dialysis.43,44 In our study we sleep
disorders was significantly less common in
patients undergoing hemodialysis.
Excessive daytime sleepiness was significantly
associated with a higher risk of SA. Although
such an association has been reported before,4,28
others have questioned it.4 Furthermore, SA is
not the only cause of EDS in dialysis patients; it
may be caused by associated medical problems,
insomnia or RLS,6,9,12 which were significantly
associated with SA in our study as well. Hui et
al35 reported no association between EDS and
age, SA, RLS, and habitual snoring. However,
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Prevalence of sleep apnea in patients on dialysis 257

Table 4. Association between EDS (ESS ≥10) and other characteristics (patient characteristics, shift and
type of dialysis, lifestyle habits, and underlying medical problems).
Characteristics ESS: <10 ESS: ≥10 P-value OR (95% CI)
Number (%) 127 (55.9) 100 (44.1)
Age (years) Mean ± SD 52.48 ± 17.1 59.87 ± 16.62 0.001
Gender
Male 73 (32.2) 49 (21.6)
Female 54 (23.8) 51 (22.5) 0.203 1.41 (0.80–2.47)
Time of hemodialysis
Morning 35 (15.4) 54 (23.8) 1.000 -
Afternoon 55 (24.2) 10 (4.4) 0.000 0.18 (0.08–0.42)
Evening 28 (12.3) 6 (2.6) 0.000 7.20 (2.50–21.74)
Dialysis duration (months)
< 12 39 (17.2) 38 (16.7) 1 -
12-48 56 (24.7) 30 (13.2) 0.061 1.82 (0.92–3.59)
49-84 23 (10.1) 16 (2.6) 0.396 1.40 (0.60–3.29)
> 84 9 (4) 16 (2.6) 0.202 0.55 (0.19–1.52)
Dialysis type
Hemodialysis (188) 118 (52) 70 (31) 0.000 5.62 (2.38–13.60)
Peritoneal dialysis (39) 9 (4) 30 (13.2)
BMI
Normal (20–25) 58 (26) 41 (18) 1 -
Overweight (≥ 25-30) 43 (19) 29 (12.8) 0.881 1.05 (0.54–2.31)
Obese (>30) 26 (11.5) 30 (13.2) 0.144 0.61 (0.30–1.25)
Co-morbidities
DM 5 (2.2) 64 (28.2) 0.002 0.02 (0.01–0.07)
Hypertension 105 (46.3) 85 (37.5) 0.638 0.84 (0.39–1.82)
KT/V
Hemo <1.2 10 (4.4) 8 (3.5) 0.502 1.40 (0.47–4.13)
1.2+ 98 (43.2) 56 (24.7)
Peritoneal <1.7 2 (0.88) 5 (2.2) 0.612 0.56 (0.05–6.04)
1.7+ 4 (2.2) 18 (7.9)
Other sleep disorders
PSQI
<5 3 0 0.254 0.00 (0.00–2.84)
>5 124 100
Risk for OSAS
High 67 94 0.000 0.07 (0.03–0.18)
Low 60 6
Insomnia 60 78 0.000 0.25 (0.13–0.47)
RLS 43 71 0.000 0.21 (0.11–0.38)
Habitual snoring
Yes 53 56 0.000 0.56 (0.32–0.99)
No 74 44

others have reported such associations.6,12 In
our study, EDS as measured by the ESS was
reported by 43% of the patients in general, 94%
of patients at high risk for SA, 56% of habitual
snorers, and 71% of those patients with RLS.
There are a few weak points of this study. One
is the fact that this is an observational rather
than a prospective study, with the known
limitations of observational studies. Another is
the stratification for high risk of SA based on the
BQ without confirmation by PSG. However, the
BQ has high pretest probability for SA; it was
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258 Al-Jahdali H

Table 5. Reported prevalence of sleep apnea in previous studies, including the current study.
Total No. Prevalence of sleep Method of
Author (years) (ref.)
of patients apnea (%)
Country diagnosis
1 Al-Jahdali H (2010) current study 227 71% Saudi Arabia Questionnaire
2 Sabry AA et al (2010)48 88 31.8% Egypt Questionnaire
71 (moderate to high
3 Argekar P et al (2007)9 270 USA Questionnaire
probability)
34
4 Beecroft JM (2009) 134 60% (AHI>10) Canada PSG
5 Jurado-Gamez B et al (2007)49 32 44% Spain PSG
6 Tada T et al (2007)37 119 34.4% Japan PSG
7 Beecroft J et al (2007)39 18 61% Canada PSG
Chinese
8 Chen WC (2006)7 700 20% Questionnaire
(Taiwanese)
38
9 Beecroft J et al (2006) 58 66% Canada PSG
42 52% (AHI>15) NPD* Hong Kong
10 Tang SC et al (2006) 46 91% (AHI>15) CAPD China
PSG
Home,
11 Unruh M et al (2006)50 46 27.2% USA unattended PSG
12 Merlino G et al (2006)6 883 23.6% Italy Questionnaire
13 Markou N et al (2006)51) 35 54% Greece PSG
14 de Oliveira Rodrigues CJ (2005)52 45 31% Brazil PSG
15 Jung HH et al (2005)33 26 65% (AHI>15) Korea PSG
16 Mucsi I et al (2004)29 78 32 Canada Questionnaire
17 Hanly PJ et al (2001)53 14 57% (AHI>15) Canada PSG
18 Kuhlmann U et al (2000)54 77 30.9% Germany Pulse oximetry
Stepanski E et al (1995)28 18 61% USA PSG
19 Walker S et al (1995) (2) 54 13% Canada Questionnaire
20 Mendelson WB et al (1990)55 11 55% USA PSG
21 Erten Y et al (2005)56 9 66% Turkey PGM
62% all patients
22 Kimmel PL et al (1989)41 26 73% symptomatic USA PSG
patients
57 41% Questionnaire
23 Millman RP et al (1985) 29 27%
Switzerland PGM
*NPD: nocturnal peritoneal dialysis; CAPD: continuous ambulatory peritoneal dialysis.

found previously to predict an RDI of >5 with a
sensitivity of 86%, a specificity of 77%, a posi-
tive predictive value of 89% and a likelihood
ratio for SA of 3.79,13 The other weak point that
may be noted is the fact that the questionnaires
were not validated; however, in this study we
did not devise any of our own instrument for
assessment of sleep disorders but, used ques-
tionnaires that was validated in the general
population. We believe that there was no com-
ponent in any of the questionnaires that might
make them inapplicable to our patients. In addi-
tion, this survey was conducted by a profes-
sional interviewer. Furthermore as explained in
the methodology section, these questionnaires
were translated from English to Arabic and
back-translated to English by a professional trans-
lator, verified by sleep specialists, tested for
clarity in a pilot study and then used in the sleep
lab questionnaires and two published studies.31,32
Strength of our study is that it is the first study
in the Saudi population addressing sleep dis-
orders in dialysis patients, and it may help
health care providers become more aware of
common sleep disorders in their patients. This
increased awareness is important because studies
have shown that sleep disorders in dialysis
patients lead to poor life quality and increase
morbidity and mortality.23,45-47
SA and EDS are common in hemodialysis
patients and are significantly associated with
other sleep disorders. While taking care of dia-
lysis patients, greater attention needs to be given
to the diagnosis and management of SA and other
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Prevalence of sleep apnea in patients on dialysis
causes associated with EDS.
Acknowledgement
I would like to thank Dr. Abdullah Al-Sayarri,
Dr. Fayz Al-Hejali and Dr. Said Al-Gamedi for
their help to arrange the interview with the
patients, provide me with pertinent laboratory
result, to thank Dr. Waleid AlQadi, and Dr.
Hithm Khogair for their support. Also thank Dr.
Hani Tamimi for reviewing all statistics and
data analysis and all dialysis staff in both
hospitals. Special thanks for King Abdullah
International Research centre for funding and
supporting this study and editing the
manuscript.
References
1. Holley JL, Nespor S, Rault R. Characterizing
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