Sleep Apnea in Maintenance Hemodialysis: A Mixed Methods Study

Abstract Rationale and objective More than 50% of hemodialysis patients experience sleep disturbance and the majority have coexisting sleep apnea. However, how sleep apnea affects sleep and the overall experience of chronic kidney disease patients treated by hemodialysis has not been evaluated. Study Design A mixed-methods design, incorporating a cross-sectional observational and descriptive qualitative methodologies. Setting & Participants Patients receiving maintenance hemodialysis in Newcastle, New South Wales Australia with newly diagnosed sleep apnea (Apnea-hypopnea index (AHI) ≥5/h). Assessments An in-laboratory polysomnography to assess sleep apnea and objective sleep parameters. Epworth Sleepiness Scale to assess daytime symptoms. A semi-structured qualitative interview to explore patient experience. Analytical approach Descriptive and iterative thematic-analysis. Results We analyzed 36 patients with newly diagnosed sleep apnea and interviewed 26 (mean age: 62 years, median AHI: 32/h). Severity of sleep apnea did not affect patients' sleep duration, sleep efficiency or self-reported Epworth Sleepiness Scale score. From the qualitative interviews four themes emerged: "Broken sleep" related to short sleep duration; with waking and dozing off a common sleep cycle; caused by uncontrolled pain and dialysis. Many participants reported regularly "feeling unrefreshed" upon waking: "Impact of sleep disturbance" included reduced physical, mental and self-management capacity. Finally, interviewees described the need to employ strategies to "soldier on" with symptoms Limitations Participants' views are only transferrable to hemodialysis patients with sleep apnea. Conclusion Our findings suggest that severity of sleep apnea does not affect sleep time nor patient-reported daytime sleepiness; however, hemodialysis patients with sleep apnea report disturbed and unrefreshed sleep and the debilitating effects of sleep disturbance is profound. Complaints of broken and unrefreshed sleep were the dominant symptoms of sleep apnea and should be assessed routinely to identify patients with sleep apnea and to improve quality of life in patients with chronic kidney disease treated with hemodialysis.