A recent AJKD In Practice article by Scherer et al highlight common troublesome symptoms affecting dialysis patients: sleep disorders, restless legs syndrome, and uremic pruritus. The following questions based on the article will test your knowledge on this topic.
Which of the following has been shown to be effective in improving sleep quality in patients on renal replacement therapy?
Long term melatonin use
6 times weekly home hemodialysis treatment after one year
Employing peritoneal dialysis vs hemodialysis
Short term pharmacotherapy with benzodiazepine receptor agonists
Correct! Only pharmacotherapy is the correct answer. In a randomized, double-blinded, placebo controlled trial of 14 maintenance HD patients in Italy using an agent of this class at a dose of 10 mg (5 mg if age > 65), there was significant improvement of the total score of sleep quality versus placebo (p < 0.03) without significant side effects (Sabbatini et al).
True or False: Cognitive behavioral therapy (CBT) for sleep disorders in patients treated with hemodialysis is only effective if carried out in person by trained practitioners.
Correct! A trial of 103 chronic HD patients randomized to CBT-I (n = 52) versus control (n = 51, conventional HD) showed improvement in depression, anxiety, and sleep quality in the treatment group (Hou et al). A meta-analysis of 11 randomized controlled trials (n = 1460) showed improved sleep characteristics with internet-based CBT-I (eCBT-I) with results comparable to face-to-face CBT-I, representing a viable and easily delivered treatment option.
The following parameters have been associated with the pathogenesis of restless legs syndrome (RLS), EXCEPT:
Positive family history
Cerebral iron deficiency
Dopamine deficiency and increased glutamate levels
Correct! Restless legs syndrome is characterized as an uncontrollable urge to move one’s legs, with symptoms predominantly at night or at periods of rest. It has a prevalence of 12%-25% in dialysis patients. Serotonin deficiency has not been associated with the pathogenesis of RLS. A positive family history is present in 40% of cases. The BTBD9 gene has been implicated in idiopathic RLS, as well as cerebral iron deficiency, dopamine deficiency, and increased glutamate levels.
Long-term use of dopaminergic therapies such as ropinirole and pramipexole is associated with what serious complication?
Long-term memory impairment
RLS symptoms augmentation
Correct! The long term use of dopaminergic therapies has been associated with a risk of RLS symptoms augmentation. Augmentation is defined as earlier onset of more severe symptoms, either by time, onset, shorter relief, or spreading of symptoms to other body parts. Treating physicians should be aware of this complication which may require discontinuation of this entire class of drugs.
As part of the approach to the management of restless legs syndrome, what is the recommended starting dose and frequency of gabapentin?
300-600 mg po TID, no adjustment is necessary
Gabapentin is contraindicated in dialysis patients
200 mg BID, reduced dose for reduced creatinine clearance
Starting at 100 mg after each dialysis session to a max of 300 mg after each dialysis session
Correct! Scherer et al recommend starting a low dose of non-ergot dopamine agonists or low-dose gabapentin (100 mg after each dialysis session to a max of 300 mg three times a week) with careful evaluation for side effects.
Which of the following pharmacological interventions have not been shown to be effective for the treatment of uremic pruritus?
Correct! According to epidemiologic data from DOPPS, 41.7% of dialysis patients report moderate to extreme pruritis (Pisoni et al). Antihistamines have not been shown to be effective for the treatment of CKD pruritus. They are not recommended in recent reviews. A recent MRI study revealed that the central transmission of itch in uremic pruritus is through a non-histaminergic pruritus pathway. This could explain the lack of benefit with the use of this class of agents.
Quiz prepared by Miguel A. Cota Vargas (Instituto Mexicano del Seguro Social UMAE 25, AJKD Blog Guest Contributor) and Jean Francis (AJKD Blog Contributor).
For a PDF version of the questions & answers, please click here.
To view the Scherer et al article abstract or full-text (subscription required), please visit AJKD.org.
All AJKD In Practice articles are available in this collection.