慢性腎臟病患者的睡眠困擾：未透析與血液透析患者之比較

Sleep Disturbances in Chronic Kidney Disease Patients: A Comparison between Patients with and without Hemodialysis

研究目的：對於慢性腎臟病患者而言，睡眠困擾是十分常見的問題。過去相關的研究大多著重於探討人口學及臨床變項，而忽略了心理及行為因素對患者睡眠的影響。本研究試圖改善過去研究之不足，釐清心理及行為因子在慢性腎臟病患者的睡眠問題中所扮演之角色。研究方法：本研究採橫斷性調查研究，在2013年7月至11月間，於腎臟科門診及血液透析室招募第三期到第五期的慢性腎臟病患者，先由林姓研究者施測MMSE以排除具有認知問題的患者，符合納入條件的患者再完成匹茲堡睡眠品質量表、失眠嚴重度量表、睡眠衛生行為量表、睡前激發狀態量表、醫院焦慮與憂鬱量表，以及和不寧腿症候群、疼痛及皮膚癢程度相關的問題。本研究亦從病歷紀錄中抄錄相關檢驗數値及共病情形。最終納入分析的共有152人，其中77人為未達尿毒症、不需透析治療的患者，75人為穩定接受血液透析治療（3個月以上）的患者。研究結果：未透析患者約有29.9%睡眠品質不佳、23.4%有失眠問題；血液透析患者約有57.3%睡眠品質不佳、28.0%有失眠的問題。對於未透析患者，在控制其他影響因素後，焦慮相關行為仍可預測睡眠品質，而認知激發程度可預測失眠嚴重度；對於血液透析患者，則是共病、疼痛程度可預測睡眠品質，而疼痛程度、皮膚癢程度、和焦慮與憂鬱情緒可預測失眠嚴重度。研究結論：焦慮相關行為或認知激發程度對於未透析慢性腎臟病患者的睡眠具有顯著的影響，但對於血液透析患者，反而是共病情形以及因腎臟病帶來的身體症狀及情緒較具影響力。這些結果顯示，對於不同階段的慢性腎臟病患者，可能需要有不同的失眠處置，相關解釋尚待進一步的研究澄清。

Purpose: Sleep problems are common in chronic kidney disease (CKD) patients. Prior studies have shown that these sleep problems are associated with various demographic and disease-related characteristics. However, few studies have examined the impact of psychological and behavioral factors. The present study investigated whether CKD patients’ poor sleep quality is related to psychological and behavioral factors. Methods: This research used a cross-sectional, questionnaire-based design. Stage 3-5 CKD patients were recruited from July to November, 2013. First, the MMSE was used to rule out those with cognitive impairment, and then all patients completed a survey of demographic data, severity of pain and pruritus, and restless leg symptoms. Patients also completed the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Sleep Hygiene Practice Scale, Pre- Sleep Arousal Scale, and Hospital Anxiety and Depression Scale. Laboratory parameters and comorbid conditions were abstracted from each patient’s medical report. After eliminating those who did not meet the inclusion criteria (with MMSE scores under 26 or who did not complete all questions or had missing data in the medical report), data from 152 patients, including 77 not on dialysis and 75 on maintenance hemodialysis, were analyzed. Results: The prevalence of poor sleep quality and insomnia were 29.9% and 23.4% in patients not on dialysis, and 57.3% and 28.0% in hemodialysis patients. Multiple regression analysis revealed that MMSE, comorbid conditions, pain severity, and arousal-related behaviors are associated with sleep quality; and that anxiety and depression, arousal-related behaviors, and cognitive arousal were associated with insomnia severity. Among patients not on dialysis, arousal-related behaviors were associated with sleep quality, and cognitive arousal was associated with insomnia severity, even after controlling for other factors. In contrast, among hemodialysis patients, comorbidity and pain severity were associated with sleep quality, and pain severity, pruritus severity, anxiety and depression were associated with insomnia severity. Conclusions: Arousal-related behaviors and cognitive arousal influence sleep in patients not on dialysis. Comorbidity, disease-related symptoms, and mood disturbance are more influential in hemodialysis patients. The findings suggest that effective interventions may be different in these two groups and that further exploration is warranted.