Acta Nephrologica 25(3): 97-104, 2011

97

Original Article

Sleep Quality and Associated Factors

in Hemodialysis Patients
Shu-Yu Chang and Te-Cheng Yang
Division of Nephrology, Department of Internal Medicine
Kuang-Tien General Hospital, Taichung, Taiwan, Republic of China

Abstract
BACKGROUND: Many patients on regular hemodialysis have sleep disorders, which affect not
only their quality of life but also their immune function, thus causing inflammatory disorders and cardiovascular disease. The aim of this study was to assess the sleep quality and related risk factors of sleep
disorder in hemodialysis patients from a rural area in central Taiwan.
METHODS: The Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS)
were adopted to assess sleep quality in hemodialysis patients and the associated factors. These two
questionnaires were translated into Chinese and were completed by the participants under the assistance
of the nursing staff during dialysis session.
RESULTS: Most of the patients with PSQI > 6 (poor sleep quality) were female (60.5%) with
longer dialysis history. Age was positively correlated with PSQI and ESS scores. The serum triglyceride
level and Kt/V had a positive relation with PSQI scores, and the serum albumin level had an inverse
relation with PSQI scores. In multivariate logistic regression analysis, female gender was a significant
predictor of poor sleep quality.
CONCLUSION: Most dialysis patients in Taiwan are elders, who were generally more susceptible
to sleep disorder. We should pay more attention to sleep disorders and the ensuing clinical burden.
Patient management protocols should include improving sleep quality, in addition to managing common
medical problems. (Acta Nephrologica 2011; 25: 97-104)
KEY WORDS: Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, sleep disorder, age, female
gender

Introduction
With advances in dialysis techniques and medical care, mortality and morbidity rates of patients on
regular hemodialysis have markedly decreased, and
further improvement of dialysis clearance is no longer
the sole goal for these patients. On the contrary, improvement in life quality of patients has become the
new aim of medical practitioners today. In order to
achieve both physical and mental health, basic human
needs must be first satisfied. Beyond doubt, a good
sleep is very important to the life quality of everyone.
However, many patients on dialysis suffer from sleep
disorders. According to previous studies, around 50-

80% of dialysis patients have problems associated

with sleep disorders, including difficulty in falling
asleep, waking up early, daytime sleepiness, leg jerking and trembling (1). All these sleep disorders lead
to a reduction of life quality. Moreover, some studies
showed that sleep disturbance alters innate functional
cellular immune response (2, 3). Sleep disturbance
brings about inflammatory disorders such as autoimmune disease, infection, and cardiovascular disease.
In Taiwan, the prevalence rate of hemodialysis is
high. In this study, we explore the sleep quality of a
group of hemodialysis patients living in a rural area of
central Taiwan, and try to elucidate possible contributory factors.

Corresponding author: Dr. Te-Cheng Yang, Division of Nephrology, Department of Internal Medicine, Kuang-Tien General Hospital, No. 321,
Jingguo Rd., Dajia, Taichung 43761, Taiwan, R.O.C. Tel: +886-4-26889138, Fax: +886-4-26889138, E-mail: hhh6689@yahoo.com.tw
Received: September 4, 2009; Revised: September 28, 2010; Accepted: April 28, 2011.

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Chang and Yang

Methods
Selection of Patients
A total of 278 patients receiving regular hemodialysis in three different dialysis centers of a teaching
hospital in central Taiwan were selected to participate
in a questionnaire-assessment of sleep quality. Patients included in the study were older than 18 years,
and had received hemodialysis therapy for more than
three months. We excluded patients who had severe
heart failure (New York Heart Association Functional
Class IV), respiratory distress (severe chronic obstructive pulmonary disease), psychological problems
or patients who had been admitted to a hospital within
a month prior to our study. Most important, they had
to be capable of understanding the questionnaire and
communicating with investigators without linguistic
problems. The objective of the study was explained
in detail to all the patients, and informed consent was
obtained from all participants. The Certificate of Approval was granted by the Institutional Review Board
of Kuang Tien General Hospital. Three patients were
excluded from the study due to lack of complete data
(no longer receiving dialysis in the same dialysis center). In the end, complete data of 275 patients were
collected for statistical analysis.
Sleep Quality Assessment
The two questionnaires we adopted were the
Pittsburgh Sleep Quality Index (PSQI) and the Epworth
Sleepiness Scale (ESS). PSQI is a questionnaire for
assessing multiple dimensions of sleep over a onemonth time period. Nineteen individual items generate
seven component scores: duration of sleep, subjective
sleep quality, sleep latency, sleep disturbances, sleep
efficiency, use of sleeping medication, and daytime
dysfunction. The sum of the seven component scores
yields one global score of subjective sleep quality (range
0-21), with higher scores denoting poorer subjective
sleep quality (4). ESS is a useful tool for evaluating
adults with an average sleep propensity in daily life.
Each score of the eight items can range from 0-3 and
the total Epworth score is between 0 and 24 (lowest to
highest sleep propensity, respectively) (5). A validity
and reliability study of PSQI had been performed by
Agargun (6) in 1996. The total score of PSQI ranges
from 0 to 21. A total score exceeding 5 indicates poor
quality of sleep. However, in 2005, Tsai et al. conducted
a validity and reliability study of the Chinese version
of PSQI (cPSQI) and concluded that a cPSQI exceeding
5 yielded a sensitivity and specificity of 98% and 55%,
respectively for primary insomnia, and a cPSQI exceeding 6 resulted in a sensitivity and specificity of
90% and 67%, respectively (7). Hence, we adopted

the study results obtained by Tsai et al. and defined

cPSQI > 6 as the standard for analysis of poor sleep
quality. On the contrary, the Chinese version of the
ESS did not significantly differ from the English ESS.
ESS scores exceeding 10 have often been employed
to define abnormal subjective daytime sleepiness, and
an ESS score of less than 10 was considered nonpathological daytime sleepiness. With this cut off
point, ESS is employed to distinguish between excessive
and normal daytime sleepiness (8-10).
Demographic and Laboratory Data
Nursing staff were bedside assistants and took
care of patients throughout the dialysis session during
which they helped participants complete the questionnaires. Laboratory data, such as biochemistry
test were provided by the monthly routine examination
at dialysis centers. Pressure waveforms of the brachial
and tibial arteries were recorded by an oscillometric
method using occlusion/sensory cuffs attached to
both arms and ankles. The automatic waveform analyzer (model P-203RPE, Colin, Komaki City, Japan)
yields ankle-brachial pressure index (ABI) for extremities of both sides (11). ABI of less than 0.9 was
defined as abnormal (12) and it is the standard for the
diagnosis of lower extremity peripheral arterial disease
(PAD). We collected these laboratory data including
the ABI and completed the questionnaires in the same
time period.
Statistics
Continuous variables are presented as means 1
standard deviation (SD) in normal distribution. Differences in variables were tested by the 2 test and
Fisher Exact test. The Spearman correlation test was
employed to examine the non-normally distributed
variables. The significant risk factors of poor sleep
quality was analyzed by stepwise logistic regression.
All analyses were performed with SPSS, version 11
(SPSS Inc., Chicago, IL, USA). A P value < 0.05 was
considered statistically significant.

Results
A total of 275 hemodialysis patients enrolled in
this study completed the questionnaires. Table 1 demonstrates the socio-demographic and clinical characteristics of these patients. The age distribution was
between 24 and 88 years, with a mean age of 61.0
12.4 years. Among the participants, 46.2% were male
and 53.8% were female. Patients with poor sleep
quality (PSQI > 6) made up more than half (57.1%) of
the participants. According to the Spearman correlation analysis results, age is positively correlated with

Sleep in Hemodialysis Patients

99

Table 1. General Characteristics of all patients

means SD

N (%)
Gender
Male
Female
Education
Junior education
Senior education
Dialysis vintage
< 1 year
1-3 years
3-7 years
> 7 years
Dialysis session
Morning
Afternoon
Evening
Hypertension
Negative
Positive
HBsAg
Negative
Positive
Anti-HCV
Negative
Positive
Atherosclerosis (ABI < 0.9)
Negative
Positive
Hypertension
Diabetes mellitus
CHF
COPD
Use of Medication
Hypnotics
Anti-depression drugs
Anti-anxiety drugs

127 (46.2)
148 (53.8)
179 (65.1)
96 (34.9)
52 (18.9)
66 (24.0)
80 (29.1)
77 (28.0)
130 (47.3)
116 (42.2)
29 (10.5)
136 (49.5)
139 (50.5)
254 (92.7)
20 (7.3)
203 (73.8)
72 (26.2)

Age (years)
Height (cm)
Weight (kg)
BMI (kg/m2)
Dialysis vintage (years)
ESS
PSQI
Hemoglobin (g/dL)
Albumin (g/dL)
AST (IU/L)
Glucose [AC] (mg/dL)
Creatinine (mg/dL)
Sodium (mmol/L)
Potassium (mmol/L)
Total serum calcium (mg/dL)
Phosphate (mg/dL)
Cholesterol (mg/dL)
Triglyceride (mg/dL)
BUN
Kt/V
Ferritin (ng/L)
Transferrin saturation (%)
C/T ratio
intact PTH (pg/mL)

61.0 12.4
159.0 8.4
61.3 11.2
24.2 3.7
5.0 4.5
4 (1, 7)#
8 (5, 12)#
10.5 1.1
3.9 0.3
22.2 10.6
127.7 63.1
10.0 2.4
137.3 3.7
4.6 0.6
9.1 0.6
4.9 1.4
171.4 40.3
147.7 107.2
56.3 20.9
1.4 0.30
590.3 481.6
30.4 13.8
0.5 0.1
294.8 328.0

194 (75.2)
64 (24.8)
139 (50.5)
129 (46.9)
24 (8.7)
5 (1.8)
72 (26.2)
22 (8.0)
39 (14.2)

ABI: ankle-brachial index; AST: alanine transferases; BMI: body mass index; BUN: blood urea nitrogen; C/T ratio:
cardiac-thoracic cage ratio; CHF: less than New York functional class IV; COPD: chronic obstructive pulmonary disease;
ESS: Epworth sleepiness scale; HCV: hepatitis C virus; PSQI: Pittsburgh sleep quality index; PTH: parathyroid hormone.
#: shown as median (interquatile range).

both PSQI and ESS scores (r = 0.18, P = 0.002 and

r = 0.12, P = 0.05). Distribution of the ESS and PSQI
scores is shown in Fig. 1. Of all patients, 26.2%, 8%
and 14.2% stated that they used hypnotics, anti-depression drugs and anti-anxiety drugs, respectively,

to improve their sleep. In the group with poor sleep

quality (PSQI > 6), 36.9% used hypnotics. The percentage was much higher than that in the group with
good sleep quality (11.9%, P < 0.001).
As shown in Table 2, most of the patients with

100

Chang and Yang

50
40

N = 275
Mean = 4.94
Std.Dev = 4.74

30
20
10
0

Patient Numbers

Patient Numbers

60

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

40
35
30
25
20
15
10
5
0

N = 275
Mean = 8.44
Std.Dev = 4.42

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Epworth Sleepiness Score

PSQI

Fig. 1. The distribution of Epworth Sleepiness Scale (ESS) and distribution of Pittsburgh Sleep Quality Index (PSQI).

Table 2. Patients sleep quality, daytime hypersomnia and relative factors

Sleep quality
Normal
(PSQI 6)
n = 118
Gender
Male
65 (55.1%)
Female
53 (44.9%)
Education
Junior education
76 (64.4%)
Senior education
42 (35.6%)
Dialysis session
Morning
60 (50.8%)
Afternoon
44 (37.3%)
Evening
14 (11.9%)
Dialysis vintage
< 1 year
27 (22.9%)
1-3 years
30 (25.4%)
3-7 years
32 (27.1%)
> 7 years
29 (24.6%)
HTN
61 (51.7%)
Low extremity PAD
25/110 (22.7%)
DM
52 (44.1%)
CHF
6 (5.1%)
COPD
0 (0.0%)
Use of Medication
Hypnotics
14 (11.9%)
Anti-depression drugs
7 (5.9%)
Anti-anxiety drugs
13 (11.0%)

Poor
(PSQI > 6)
n = 157

Daytime hypersomnia

P value

No
(ESS < 10)
n = 231

Yes
(ESS 10)
n = 44
P value

103 (44.6%)
128 (55.4%)

24 (54.5%)
20 (45.5%)

0.014
62 (39.5%)
95 (60.5%)

0.294

0.937
103 (65.6%)
54 (34.4%)

0.694
152 (65.8%)
79 (34.2%)

27 (61.4%)
17 (38.6%)

107 (46.3%)
98 (42.4%)
26 (11.3%)

23 (52.3%)
18 (40.9%)
3 (6.8%)

0.354
70 (44.6%)
72 (45.9%)
15 (9.6%)

0.610

0.385
25 (15.9%)
36 (22.9%)
48 (30.6%)
48 (30.6%)
79 (49.7%)
39/148 (26.4%)
77 (49.0%)
18 (11.5%)
5 (3.2%)

0.834
0.602
0.486
0.101
0.078

58 (36.9%)
15 (9.6%)
26 (16.6%)

< 0.001
0.386
0.258

0.068
50 (21.6%)
2 (4.5%)
53 (22.9%)
13 (29.5%)
65 (28.1%)
15 (34.1%)
63 (27.3%)
14 (31.8%)
112 (48.5%)
27 (61.4%)
51/117 (23.5%) 13/41 (31.7%)
102 (44.2%)
24 (58.5%)
17 (7.4%)
7 (15.9%)
3 (1.3%)
2 (4.5%)
58 (25.1%)
17 (7.4%)
30 (13.0%)

14 (31.8%)
5 (11.4%)
9 (20.5%)

0.161
0.358
0.053
0.079
0.182
0.458
0.366
0.286

By Yates correlation 2 test, 2 test, Fisher Exact test; P < 0.05.

CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus; HTN: hypertension;
PAD: peripheral arterial disease; low-extremity PAD: ABI < 0.9.

PSQI > 6 were women (60.5%), and their history of

dialysis was also longer, with up to 30.6% of all patients having a dialysis history of more than 7 years.
The mean dialysis duration in the groups with good

and poor sleep quality were nearly equal. The prevalence rate of hypertension and other chronic disease,
such as low-extremity PAD, diabetes mellitus, congestive heart failure, was slightly higher among pa-

Sleep in Hemodialysis Patients

101

Table 3. PSQI, ESS and relative risks

PSQI

Age (years)
Dialysis vintage (years)
Hemoglobin (g/dL)
Albumin (g/dL)
AST (IU/L)
Glucose [AC] (mg/dL)
BUN
Creatinine (mg/dL)
Total serum calcium (mg/dL)
Phosphate (mg/dL)
Intact-PTH (pg/mL)
Triglyceride (mg/dL)
Cholesterol (mg/dL)
Kt/V
Ferritin (ng/L)
Transferrin saturation (%)
C/T ratio

ESS

P value

P value

275
275
275
275
275
274
275
272
274
275
275
274
274
275
274
275
275

0.18
0.11
-0.05
-0.14
0.04
0.04
-0.03
-0.06
0.03
-0.04
-0.05
0.13
0.00
0.12
0.05
0.00
0.11

0.002
0.081
0.363
0.016
0.471
0.540
0.633
0.352
0.674
0.549
0.409
0.034
0.996
0.039
0.397
0.988
0.081

275
275
275
275
275
274
275
272
274
275
275
274
274
275
274
275
275

0.14
0.05
-0.07
-0.05
-0.04
-0.02
0.05
0.01
-0.04
0.07
0.07
-0.04
-0.06
-0.03
0.00
-0.10
-0.03

0.021
0.427
0.270
0.445
0.534
0.769
0.400
0.842
0.459
0.236
0.261
0.513
0.313
0.649
0.982
0.106
0.672

By Spearman correlation.

Table 4. Stepwise logistic regression analysis for poor sleep quality (PSQI > 6)
Univariate

Multivariate

Variable

OR

95% CI

P value

Age (years)
Sex (female)
Albumin
Triglyceride
Kt/V

1.02
1.88
0.77
1.00
1.20

1.00 - 1.04
1.16 - 3.05
0.38 - 1.57
0.99 - 1.00
0.53 - 2.70

0.025*
0.011*
0.471
0.456
0.657

OR

95% CI

P value

1.88

1.16 - 3.05

0.011*

OR: odds ratio; *: Significance level for Wald Statistics.

tients with daytime sleepiness.

The serum albumin level was inversely proportional to PSQI scores according to the Spearman
correlation analysis (r = -0.14, P = 0.016). On the
other hand, the serum triglyceride level and Kt/V had
a positive relationship with PSQI scores. These results
are shown in Table 3. Under univariate analysis, the
variable factor of sex (female gender) had odds ratio
(O.R) = 1.88 (95% confidence interval (C.I) = 1.163.05; P = 0.011), while the variable factor of age had
O.R = 1.02 (95% C.I = 1.00-1.04; P = 0.025). For other
variable factors such as serum albumin, triglyceride
and Kt/V, the P values of the above results were not

significant according to Wald statistics analysis. However, under stepwise logistic regression analysis for
poor sleep quality (PSQI > 6), only gender was found
to be an independent predictor of poor sleep quality.
These results are depicted in Table 4.

Discussion
Normal sleep is divided into two primary stages,
rapid eye movement and non-rapid eye movement
sleep. They bundled together and occur in cycles
throughout the sleep period. In general, sleep occupied
approximately 1/3 of our lives. Sleep is a biological

102

Chang and Yang

imperative, because it is a time when the body repairs

and restores itself from damage that occurs during
wakefulness. Sleep disorder is a common problem in
the general population, over 30% of all adults have a
current symptom of insomnia, and chronic insomnia
occur in 10% of general adult population (13, 14). In
persons older than 65 years, almost 50% complain of
disturbed sleep (13).
Many studies have reported that changes in
sleeping habit were related to age (15, 16). Many elders complained of having trouble falling asleep,
waking up or waking too early, needing to nap, and
not feeling rested. Some studies considered sleep disorder, particularly in people over 65 years old, secondary to coexisting diseases. A recent cross-sectional
study of a large cohort in Tennessee found that the
prevalence of both heart disease and hypertension
were higher in those with insomnia (17). In our study,
the majority of participants were older than 65 and
most of them had coexisting diseases like DM, hypertension, heart disease or old stroke. It could be said
that from the results shown, age has a positive relation
with poor sleep quality (18-20), especially when the
elders also have other chronic diseases.
Previous studies using PSQI and other indices
like HRQoL (health-related quality of life; a lifequality index) found that patients with higher PSQI
scores exhibited a lower HRQoL (21). Some studies
(22, 23) demonstrated the positive relationship between the serum albumin level and sleep quality or
albumin level and life quality. In this study, we also
found that patients with higher serum albumin level
had better sleep quality. In a study by Sabbatini (24),
the risk of insomnia was found to be higher in patients
with a longer history of dialysis (more than one year).
However, the questionnaire on insomnia they adopted
was not the PSQI. In our study, we found that a large
proportion of patients with a dialysis history longer
than seven years had insomnia .
The CARDIA study (25) (Coronary Artery Risk
development in young adults study) showed that short
sleep duration was associated with a greater risk of
cardiovascular disease. The incidence or prevalence
of a high triglyceride or low HDL cholesterol level is
high among individuals who sleep too much or too
little, especially among women (26). One study also
demonstrated that shorter sleep duration had significantly higher body mass index, total cholesterol
and triglyceride level (27). In our study, we recorded
actual sleeping hours in the PSQI questionnaire. A
large proportion of patients have short sleep duration.
We also found a positive correlation between serum
triglyceride level and PSQI scores. In other words,
patients with poor sleep quality and short sleep duration may be at greater risk of cardiovascular disease.
Using multivariate stepwise logistic regression

analysis in our study, we found that the female gender

was an independent predictor of poor sleep quality.
This is compatible with many previous findings (2830). Some studies also found that the problem of sleep
loss enhanced inflammatory processes in females as
compared with males, and increased the risk profile
for inflammatory disorder in females (2). The prevalence rate of hypnotics users in this study is 26.18%.
Most of these users are in the group with poor sleep
quality (36.9%; P < 0.001). The proportion of use of
other drugs, like anti-depression and anti-anxiety
drugs, for sleep disorder was higher in the group with
poor sleep quality. Insomnia and daytime sleepiness
are often associated with depression. Insomnia and
other sleep disturbances can be precursors to the onset of major depressive disorders. Hence, they may
act as risk factors for or predictors of depression (31).
Such result may reflect underestimated prevalence
rate of patients with poor sleep quality, with some of
them diagnosed with depression, rather than sleep
disorder. ESS is usually related to sleep apnea. High
scores of ESS indicate a high risk of sleep apnea (32,
33). Patients with sleep apnea have a tendency towards
hypertension, stroke and cardiovascular disease. All
these are common clinical manifestations of vessel
atherosclerosis. Many recent studies (34, 35) reported
that PAD should play an important role in predicting
the possibility of cardiovascular disease and the degree
of coronary artery lesion. Whether the symptoms related to PAD, such as pain at rest, induce insomnia requires further study.
Unlike previous studies, we translated two questionnaires, the Pittsburgh Sleep Quality Index and
Epworth Sleepiness Scale, into Chinese to assess sleep
quality and daytime sleepiness of uremia patients.
The significant association of risk factors and poor
sleep quality was demonstrated by stepwise logistic
regression analysis. Nevertheless, there are still some
shortcomings in this study. First, we did not adopt the
Berline Questionnaire or polysomnography to evaluate
the incidence of sleep apnea syndrome and restless
leg syndrome in our patients with poor sleep quality.
Furthermore, the sample size is small and many other
variants such as comorbidity and different dialysis
modalities were not included for further analysis. In
addition, the participants we selected was limited to a
rural area in central Taiwan, the results may not be deservedly generalized to the dialysis population as a
whole. Consequently, we need more large-scale and
longitudinal studies in the future to confirm our observations and results and to establish a stronger relationship between sleep disorder and its associated
factors. In spite of these limitations, the present study
attempts to highlight the high prevalence and negative
impact of sleep quality, raising the awareness of the
importance of recognizing and managing sleep dis-

Sleep in Hemodialysis Patients

order in dialysis patients.

Conclusion
Hemodialysis patients have many disease-associated complications, and sleep disorder is one of
the most important complications. In long-term dialysis patients, the prevalence rate of sleep disorders is
much higher than the general population. Many studies had demonstrated that sleep disorder may be a
potential early diagnostic marker for psychiatric disease, such as depression and anxiety. The effect of insomnia on health, safety, and quality of life results in
a substantial social and economic burden. According
to the results, we need to pay much more attention to
long-term female dialysis patients. Although the implication of early recognition and treatment of sleep
disorder for clinical outcomes remains undefined, it
is suggested that patient management should include
improving sleep quality in addition to managing common medical problems.

Acknowledgments
We wish to express our thanks to Dr. Chiu WenYuan and Miss. Nian for their help in this study.

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