Insomnia in Dialysis Population Tied With Adverse Outcomes, Ineffective Treatment – Renal and Urology News

Insomnia may increase cardio-cerebrovascular disease and all-cause mortality risk among patients on maintenance dialysis and some popular conventional treatments are not effective, according to recent research.

Among 79,420 Korean patients with kidney failure transitioning to maintenance dialysis, 13.2% experienced insomnia. The risk for major adverse cardiac and cerebrovascular events (MACCE) was significantly increased 26%, 31%, and 39% for patients who newly experienced insomnia after dialysis start, those with previous insomnia during CKD, and those with persistent insomnia before and after dialysis initiation, respectively, Eun Lee, MD, PhD, of Yonsei University College of Medicine, Seoul, South Korea, and colleagues reported in Nephrology Dialysis Transplantation. Younger men were particularly susceptible to insomnia. Insomnia was defined by ICD codes as well as the prescription of sleep medications.

MACCE included all-cause mortality, stroke, nonfatal myocardial infarction, acute coronary syndrome (including unstable angina), and heart failure requiring hospital admission. The risk for all-cause mortality alone was significantly increased 31%, 41%, and 47% of the de novo insomnia, previous insomnia, and persistent insomnia groups, respectively, the investigators reported.

Separately, in the double-blind randomized controlled SLEEP-HD trial (ClinicalTrials.gov: NCT03534284), Rajnish Mehrotra, MD, MS, of the Kidney Research Institute at the University of Washington School of Medicine in Seattle, and colleagues found that trazadone and cognitive behavioral therapy (CBT) are no more effective than placebo for improving insomnia among patients receiving maintenance dialysis. The investigators randomly assigned 126 patients with chronic insomnia to 6 weeks of CBT, trazadone, or placebo. At baseline, patients had an Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months. Insomnia severity was considered mild to moderate for most.

ISI scores at week 7 and 25 declined slightly and comparably across the 3 groups, demonstrating no significant effect of either CBT or trazadone in the dialysis population, Dr Mehrotra’s team reported in the Annals of Internal Medicine.

Trazadone recipients experienced more frequent serious adverse events than the other groups. The annualized rate of serious cardiovascular events was 0.64 in the trazodone group compared with 0.05 for the CBT group and 0.21 for the placebo group. The trazadone group had longer dialysis vintage and higher prevalence of ischemic heart disease than the other groups at baseline.

“These findings are highly relevant to inform clinical care and future research in this population,” according to Dr Mehrotra’s team. “In that insomnia can also lead to or exacerbate fatigue, depression, pain perception, and poor quality of life, patients place a high priority on finding effective treatments for this condition.”

In an accompanying editorial, Ronald B. Postuma, MD, MSc, of Montreal Neurological Institute at McGill University in Montreal, Quebec, Canada, reiterated that the “take-home message of this study is that not all insomnia is the same.” He suggested that future studies in the dialysis population examine medications specifically for insomnia, such as benzodiazepine receptor antagonists and orexin antagonists, and treatments for restless legs and neuropathic pain, such as pregabalin.