68 Original article

Epidemiology of sleep disorders in patients with chronic renal

disease in Cairo, Egypt
Jehan M. Ibrahima and Omar M. Wegdanb
a
Department of Community, Environmental and
Occupational Medicine, Faculty of Medicine,
Ain Shams University and bMinistry of Health
and Population, Cairo, Egypt
Correspondence to Jehan Mohamed Ibrahim,
Public Health, Department of Community,
Environmental and Occupational Medicine, Faculty of
Medicine, Ain Shams University, Cairo, Egypt
Tel: + 2 01 73050449; fax: + 2 02 4837888;
e-mail: drjehanibrahim@yahoo.com
Received 23 March 2011
Accepted 4 May 2011
Journal of the Egyptian Public Health
Association 2011, 86:6872
Background
Many patients with end-stage renal disease undergoing dialysis therapy suffer from
sleep disturbances. The aims of this study were to determine the prevalence of sleep
disorders in patients with end-stage renal disease on maintenance dialysis and to
determine the risk factors underlying these disorders.
Patients and methods
A total of 264 patients on maintenance dialysis were enrolled in the study.
Demographic, renal, and dialysis data were recorded. Using Personal Professional
Interviews, we assessed the presence of the following sleep disorders: insomnia,
restless leg syndrome (RLS), and obstructive sleep apnea syndrome (OSAS).
Moreover, to determine the prevalence of sleep disturbances and the possible effect
of demographic or clinical data on sleep, we divided our population into two groups:
with and without sleep disorders.
Results
The prevalence of sleep disorders was 61.4%. The survey revealed the presence
of insomnia (57.6%), RLS (56.4%), and OSAS (21.2%). Insomnia, RLS, and OSAS
were significantly associated with inadequate dialysis, hyperphosphatemia, and
hypoalbuminemia. Insomnia and RLS were also significantly associated with anemia.
Significant independent association was observed between insomnia and both RLS
and OSAS as well as between RLS and OSAS.
Conclusion
The survey showed a high prevalence of sleep disruption in dialytic populations.
Our data might help nephrologists to deal with patients with uremia with possible
sleep disorders.

Keywords:
dialysis, end-stage renal disease, insomnia, restless legs syndrome, sleep apnea

J Egypt Public Health Assoc 86:6872

c 2011 Egyptian Public Health Association
0013-2446

The objectives of this study were to determine the

Introduction
The prevalence of end-stage chronic renal disease (ESRD)
in Egypt has been rising from 225 per 1 million population
in 1996 to 483 per 1 million population in 2004 [1]. Sleep
complaints are common in patients with ESRD on dialysis
and include delayed sleep onset, frequent awakening,
restlessness, and daytime sleepiness [2].
Many studies have been carried out recently to under-
stand the real impact of sleep disorders on dialytic
patients and to discover whether these complaints are
correlated with clinical and/or demographic data. How-
ever, most of these studies were conducted on small
groups of patients recruited from single dialysis units
[3,4]. Therefore, the results obtained could have been
influenced by the specific dialysis techniques used in the
individual units and/or by demographic or clinical
peculiarities. Only one study was performed on a large
population of dialytic patients coming from different
dialysis units, but the questionnaire used in this
investigation did not include recognized criteria for
diagnosis of common sleep disorders [5].
c 2011 Egyptian Public Health Association
0013-2446
prevalence of sleep disorders in patients with ESRD on
maintenance dialysis and to determine the risk factors
underlying these disorders.
Patients and methods
Study design and setting
A cross-sectional survey was conducted during the period
from September to November 2010. All dialysis units
were pooled from all the districts of Cairo (capital of
Egypt) and categorized into private and public units. A
random sample was then selected from each category to
include 16 hemodialysis units, as nine from public and
seven from private units.
Population
The calculated sample size was at least 234 patients,
based on the prevalence of insomnia, in patients with
chronic renal failure, of 65.9 and 60.8% reported in
Mansoura University, Egypt [6], and Saudi Arabia, [7]
respectively.
DOI: 10.1097/01.EPX.0000399136.00486.4e

Copyright Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.

A proportionate sample was then calculated to include at
least 131 patients from public units and 103 patients from
private units.
An 80% power, 5% significance level, and 95% confidence
interval (CI) were used in the sample size calculation by
Epi Info, 6 software (CDC, Atlanta, USA).
Patients were randomly selected from the patients list to
include every other patient. Dialysis units were visited
three times weekly, on alternative days and shifts.
Patients inclusion criteria included adults (age: > 18
years) of both sexes, who were stable, who were on
regular dialysis three times per week for at least 3
months, and who accepted to participate in the survey.
Our population was divided into two groups: patients with
at least one sleep disorder and those without sleep
disorders. Patients were classified as positive for each
disorder according to their responses to the questionnaire.
Questionnaire
A questionnaire-based survey was used to examine the pre-
valence of symptoms that reflect sleep disorders, which
included insomnia, restless leg syndrome (RLS), and
obstructive sleep apnea syndrome (OSAS). Personal pro-
fessional interviews were carried out by trained medical
students. Enrolled patients completed our questionnaire
during the dialysis sessions or while waiting for their
treatment.
Data on medical history, laboratory, and pharmacological in-
formation were collected by careful inspection of the
patients files. The questionnaire consisted of the following
parts:
(1) Demographic characteristics: age, sex, marital status,
and employment;
(2) Medical history: patients were asked about under-
lying causes of chronic renal disease and clinical data
(including type of renal replacement);
(3) Laboratory and pharmacological data included main
biochemical and hematological parameters as well as
current medications;
(4) Evaluation of insomnia was made by the Athens
Insomnia Scale (AIS), which is a self-administered
psychometric instrument, based on the International
Classification of Diseases, tenth version (ICD-10)
[WHO (1994) insomnia criteria]. It consists of eight
items AIS and the total score ranges from 0 to 24. The
original validation study demonstrated good internal
testretest reliability and external validity [8]. A cut-off
value of six to determine those suffering from insomnia
among the general population was chosen following the
creators recommendations as it provides us with the
highest positive predictive value of 90%, while still
offering a high-negative predictive value of 94% [9].
(5) Evaluation of RLS was made by the International
Restless Legs Syndrome Study Group [10] for the
clinical diagnosis of RLS. The International Restless
Legs Syndrome Study Group Rating Scale describes
severity of RLS as mild: 110 points, moderate: 1120
Copyright Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Epidemiology of sleep disorders Ibrahim et al. 69
points, severe: 2130 points, and very severe: 3140
points;
(6) Evaluation of OSAS was made by using Berlin
Questionnaire [11] for sleep apnea (high-risk group
score = 1, low-risk group score = 0).
Data management and analysis
Data were stored and analyzed using SPSS software
version 13 (Chicago, Illinois, USA). Data were summarized
as mean standard deviation or number and percentage
as appropriate. Nominal variables were analyzed by means
of contingency tables and the w2-test. Likelihood ratio
was performed when minimum expected count in cells
was less than 5 in contingency tables. Spearmans rank
correlation (r) test was used to examine the relationship
between levels of insomnia and other parameters as well
as between grades of RLS and other parameters.
The levels of insomnia were recoded dichotomously in
patients without insomnia for those scoring 06 and
patients with insomnia for those scoring 724. The
levels of RLS were also dichotomized into negative for
those scoring 0 and positive for those scoring 140.
Multivariate logistic regression analysis was used to
evaluate the risk of insomnia, RLS, and OSAS, while
controlling for all other variables. A P value of less than
0.05 was considered statistically significant.
Risk factor analysis was completed for a summary score of
sleep disorders. A score was developed based on giving
one point for each sleep disorder. Bivariate analyses were
completed examining each of the following groups: those
who scored a three (i.e., having 3 sleep disorders, those
who have two sleep disorders, and those who have one
sleep disorder as compared those who scored a zero (i.e.,
do not have any sleep disorders). All variables with a
P value less than 0.10 in the bivariate analyses were
entered into the full model for each comparison. Only
variables that were significant at P r 0.01 (to correct for
multiple comparisons) were left in the final models.
Ethical consideration
The survey was reviewed and approved by the Research
Ethics Committee of Ain Shams University, Cairo, Egypt.
Results
The number of patients that satisfied our inclusion
criteria and enrolled in our study was 264. Eighteen
patients were excluded because of refusal or intercurrent
illness. No statistically significant difference with regard
to demographic and dialytic parameters was found
between patients included in the study and in those
who were not included.
The mean age of the patients was 50.83 14.48 years,
55.7% were men, 75.4% were married, and 39.4% were
employed. Mean dialysis duration was 25.41 16.21
months (Table 1).
 70 Journal of the Egyptian Public Health Association

Table 1. Demographic characteristic, medical condition, dialysis dialysis, (P < 0.001), hyperphosphatemia (P = 0.004),
shift, type, and duration among patients stratified by sleep hypoalbuminemia (P = 0.001), and anemia (P = 0.002).
disorders status
Total Restless leg syndrome
[N = 264, Patients with sleep P
(%)] disorders (N = 162) value As shown in Table 2, 149 patients (56.4%) were
considered to be RLS-positive. RLS was found to be
Age significantly related to inadequate dialysis (P < 0.001),
Mean SD 50.83 14.5 51.9 13.9 0.5
Sex hyperphosphatemia (P = 0.001), hypoalbuminemia (P =
Male 147 (55.7) 89 (54.9) 0.4 0.003), and anemia (P = 0.001).
Female 117 (44.3) 73 (45.1)
Marital status
Married 199 (75.4) 129 (79.6) 0.03 Obstructive sleep apnea syndrome
Unmarried 65 (24.6) 33 (20.4) According to the Berlin Questionnaire, 56 (21.2%)
Occupation patients were considered to be at high risk for sleep
Employed 104 (39.4) 61 (37.7) 0.3
Unemployed 160 (60.6) 101 ( 62.3) apnea. There were significant associations between
Medical condition presence of OSAS and inadequate dialysis (P < 0.001),
DM 161 (60.9) 107 (66.5) 0.02
hyperphosphatemia (P = 0.002), and hypoalbuminemia
Hypertension 120 (45.5) 74 (61.7) 0.5
Obstructive 88 (33.3) 49 (55.7) 0.1 (P < 0.001) (Table 2). They also showed a significant
uropathy association with obesity (BMI Z 30), hypertension, and
Chronic 129 (48.9) 79 (61.2) 0.5
glomerulonephritis
morning headache (P = 0.002, 0.001, and 0.002, respec-
Dialysis shift tively) (Table 3).
Morning 222 (84.4) 138 (85.7) 0.5
Evening 15 (5.7) 7 (4.3)
Associations among sleep disorders
Alternative 26 (9.9) 16 (9.9)
Dialysis type The multivariate analysis showed a significant indepen-
Hemodialysis 140 (53.0) 90 (64.3) 0.3 dent association between insomnia and both RLS [odds
Peritoneal 124 (47.0) 72 (58.1)
Dialysis duration (months)
ratio (OR) = 34.9, 95% CI = 13.392.1, P < 0.001] and
36 26 (9.8) 17 (65.4) 0.4 OSAS (OR = 4.8, 95% CI = 2.210.2, P = 0.000) and
612 19 (7.2) 9 (47.4) between RLS and OSAS (OR = 4.2, 95% CI = 2.18.4,
> 12 219 (83.0) 136 (62.1)
P < 0.001).
DM, diabetes mellitus; SD, standard deviation.
Table 4 presents the results of risk factor models
comparing patients with three, two, and one sleep
Sleep disorders (total population)
disorders with those who had no sleep disorder (i.e.
According to the proposed criteria, 162 patients (61.4%)
zero). Only variables that were significant at P = 0.01
were considered to have at least one sleep disorder. The
were left in the final models. Across the three models,
prevalence of sleep disorders was not significantly different
inadequate dialysis and hyperphosphatemia were signifi-
among dialysis centers (range: 51.683.8%, P = 0.5).
cantly associated with an increased risk of having sleep
Patients with at least one sleep disorder and those disorders. Meanwhile, hypoalbuminemia and anemia
without sleep disorders did not significantly differ as were significantly associated with an increased risk of
regards age, sex, employment, dialysis shift, type, or having three sleep disorders as well as having two sleep
duration. However, sleep disorders were significantly
associated with marital status (w2 = 4.1, P = 0.03),
Figure 1.
diabetes mellitus (w2 = 4.5, P = 0.02) (Table 1).
Figure 1 presents the sleep disorders reported by dialysis 57.6% 56.4%
patients. 60%

50%
Insomnia
The prevalence of insomnia was 57.6%. There were 92
40%
(34.8%) low-grade patients with insomnia, 45 (17%)
moderate-grade patients with insomnia, and 15 (5.7%)
high-grade patients with insomnia. The grades of 30%
21.2%
insomnia correlated with inadequate dialysis, as measured
by the Kt/V index [Kt/V is a number used to quantify 20%
hemodialysis and peritoneal dialysis treatment adequacy. K,
dialyzer clearance of urea; t, dialysis time; V, volume of dis- 10%
tribution of urea, approximately equal to patients total body
water.] (r = 0.8, P = 0.000), hyperphosphatemia (r = 0.6, 0%
P < 0.001), hypoalbuminemia (r = 0.5, P = 0.001), and Insomnia RLS OSAS
anemia (r = 0.3, P < 0.001).
Table 2 shows that there was significant association Prevalence of sleep disorders in dialytic patients. OSAS, obstructive
sleep apnea syndrome; RLS, restless leg syndrome.
between the presence of insomnia and inadequate

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 Epidemiology of sleep disorders Ibrahim et al. 71

Table 2. Indicators of insomnia, RLS, and OSAS among dialytic patients

Risk factors Total [N = 264 (%)] Patients with insomnia (N = 152) OR 95% CI P value
Inadequate dialysis 146 (55.3) 141 (96.6) 26.5 11.262.8 0.000
Hyperphosphatemia 140 (53.0) 128 (91.4) 9.4 5.416.3 0.004
Hypoalbuminemia 168 (63.6) 130 (77.4) 3.4 2.54.6 0.001
Anemia 245 (92.8) 151 (61.6) 2.5 2.03.0 0.002
Risk factors Total [N = 264 (%)] Patients with RLS (N = 149) OR 95% CI P value
Inadequate dialysis 146 (55.3) 134 (91.8) 10.6 6.118.3 0.000
Hyperphosphatemia 140 (53.0) 122 (87.1) 6.1 3.99.5 0.001
Hypoalbuminemia 168 (63.6) 127 (75.6) 3.2 2.34.2 0.003
Anemia 245 (92.8) 145 (59.2) 1.9 1.52.6 0.001
Risk factors Total [N = 264 (%)] Patients with OSAS (N = 56) OR 95% CI P value
Inadequate dialysis 146 (55.3) 50 (34.2) 9.7 4.023.7 0.000
Hyperphosphatemia 140 (53.0) 48 (28.6) 4.4 2.09.8 0.002
Hypoalbuminemia 168 (63.6) 46 (32.9) 5.6 2.711.7 0.000
Anemia 245 (92.8) 55 (22.4) 5.2 0.739.9 0.6
CI, confidence interval; OR, odds ratio; OSAS, obstructive sleep apnea syndrome; RLS, restless leg syndrome.

disorders, both compared with not having any sleep
disorder (i.e. zero).
Discussion
To our knowledge, this study was the only one carried out in
a sample of patients with ESRD coming from different
dialysis centers in Egypt, to evaluate the prevalence and risk
factors of some sleep disorders in this specific population.
The results of our study showed high prevalence of sleep
disorders among dialytic patients. The multicentric study of
Sabbatini et al. [5] reported that 45% of patients with ESRD
were affected by insomnia. In other studies, conducted in
single dialysis units, the prevalence of insomnia ranged
between 45 and 59% [1214].
In our survey, we observed an even higher percentage
(61.4%) confirming the strong impact of this specific
complaint in dialytic patients.
Our results should be considered by nephrologists to
identify factors predisposing patients to sleep complaint
in dialysis centers. We underline that among causes of
ESRD only diabetes was associated with sleep disorders.
In contrast, dialytic parameters (i.e. hematological and
biochemical data) showed that inadequate dialysis,
hyperphosphatemia, and hypoalbuminemia were asso-
ciated with insomnia, OSAS, and RLS. Unruh et al. [15]
noted that sleep disordered breathing was more common
in dialytic patients with diabetes mellitus. In contrast,
other studies found no difference between patients
with diabetes and nondiabetic patients regarding the
associated sleep disorders [6,7].
Multiple factors contribute to insomnia complaints in
patients with diabetes. In type 1 diabetes, rapid changes
in glucose levels during sleep have been postulated to
cause awakenings [16]. For individuals with type 2
diabetes, sleep disturbances may be related to obesity
or obesity-associated sleep disorders, such as sleep apnea
[17]. Another common source of disturbed sleep in
diabetics is discomfort or pain associated with peripheral
neuropathy [18].
In consistency with our results, Sabry et al. [6], found that
risk factors for insomnia among dialytic patients were
inadequate dialysis and hypoalbuminemia.
Multiple hypotheses have been proposed to account for
uremia-induced sleep disorders, including (a) subclinical
uremic encephalopathy [19], (b) abnormal metabolism
and retention of melatonin, [20] (c) tyrosine deficiency
leading to diminished neurotransmitters associated with
arousal [21], (d) alteration in body temperature rhythm
resulting in a perturbation of the sleepwakefulness cycle
[22], (e) release of sleep-inducing inflammatory cyto-
kines during dialysis [23], (f) the effects of dialysate
temperature on sleep [22], and (g) coexistent OSAS [24].

Table 3. Variables associated with high-risk OSAS among dialytic patients

Total
Variables [N = 264 (%)] Patients with high-risk OSAS (N = 56) OR 95% CI P value

BMI
< 30 174 (65.9) 16 (9.1) 3.7 2.56.8 0.002
Z 30 90 (34.1) 40 (44.4)
Hypertension
No 146 (54.5) 20 (13.7) 2.1 1.24.3 0.001
Yes 120 (45.5) 36 (30)
Morning headache
No 101 (38.3) 10 (9.9) 2.9 1.64.9 0.002
Yes 163 (61.7) 46 (28.2)
Daytime sleepiness
No 46 (17.4) 11(23.9) 0.89 0.581.6 0.3
Yes 218 (82.6) 45 (20.6)
CI, confidence interval; OR, odds ratio; OSAS, obstructive sleep apnea syndrome.

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 72 Journal of the Egyptian Public Health Association
Table 4. Relationship between inadequate dialysis, hyperphosphatemia, hypoalbuminemia, anemia, and sleep disorders among
dialytic patients
OR for having three sleep disorders OR for having two sleep disorders
Risk factors compared with 0 (95% CI)
Inadequate dialysis 24.0 (10.157.0)
Hyperphosphatemia 9.3 (5.216.6)
Hypoalbuminemia 3.4 (2.44.6)
Anemia 2.1 (1.52.8)
CI, confidence interval; OR, odds ratio.
In contrast, another study found no association between
insomnia and dialysis adequacy and other biochemical
parameters, including hemoglobin, ferritin, phosphorus,
and calcium levels [3].
Our results showed that OSAS was also associated with a
BMI > 30, hypertension, and morning headache. Similarly,
Merlino et al. [14] reported that patients with OSAS
showed a significant association with frequent nocturnal
awakening, morning headache, and transient memory or
concentration disturbances. Moreover, Nieto et al. [25]
found that mean systolic and diastolic blood pressure and
prevalence of hypertension increased significantly with
increasing sleep disordered breathing measures, and some
of this association was explained by BMI.
One study found that risk factors for RLS included
anemia, hypoalbuminemia, and hyperphosphatemia [6],
which is comparable with our results. Another study
found that there was no significant correlation between
RLS and adequacy of dialysis [26].
Interestingly, our results showed a significant indepen-
dent association between insomnia and both RLS and
OSAS. Comparable results were obtained in other studies
where RLS was found to be related to EDS and insomnia
and other sleep measures [15,27].
Conclusion and recommendations
Patients with ESRD have a high prevalence of sleep
disorders in dialysis centers. Considering that the most
frequent sleep complaints such as insomnia, OSAS, and
RLS are related to a significant negative impact on
functional health status in patients with uremia, nephrol-
ogists should improve their recognition and treatment of
these conditions to restore the quality of life of their
patients.
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