Estimated Glomerular Filtration Rate and Sleep Quality in Stage 3-5 Non-Dialysis Chronic Kidney Disease Patients: Is There a Correlation?

ABSTRACT


Introduction
Kidney Disease Improving Global Outcomes (KDIGO) defines chronic kidney disease (CKD) as a persistent impairment in kidney structure or function that lasts longer than 3 months.This condition can present as functional or structural abnormalities, with or without a decline in glomerular filtration rate (GFR), and include pathological manifestations indicating kidney abnormalities.These include, regardless of kidney damage, abnormalities in the composition of blood or urine, abnormal imaging tests, and GFR below 60 ml/min/1.73m2for 3 months. 1With CKD prevalence increasing to 57% per year, it is becoming a growing health concern.In the United States, the incidence of chronic kidney failure has reached 10% or 1 in 10 people, with a high mortality rate of 615,000 patients experiencing chronic kidney failure, of which 92,000 patients died from chronic kidney failure in 2011. 2 The incidence of chronic kidney failure in Indonesia is increasing.This disease is described as an iceberg phenomenon, where only about 0.   Poor sleep quality often occurs in CKD patients, especially those who undergo hemodialysis.Daily sleepiness was the most frequently reported symptom, affecting 80% of CKD patients who experienced sleep disturbance at night. 4 This condition leads to negative impacts on hemodynamic changes, thus posing a significant risk for hypertension and complicating the process of hemodialysis.Previous studies have also shown that sleep apnea is linked to a higher risk of heart problems and increased mortality in patients with end-stage renal disease (ESRD). 4[7][8] One parameter used to assess an individual's sleep quality is the Pittsburgh Sleep Quality Index (PSQI).It includes 19 items grouped into 7 components, generates a single global score, and takes about 5 to 10 minutes to complete.Researchers at the University of Pittsburgh developed it.Components assessed in the PSQI include total sleep time, amount of time spent asleep, types of disturbances that may cause awakenings during sleep, whether medications influence sleep, and whether there is daytime drowsiness during daily activities. 9or health-related quality of life remains a challenge for patients with advanced CKD.The purpose of this study is to determine the relationship between glomerular filtration rate (GFR) in non-dialysis CKD patients and sleep quality.

Design and participants
The research design is an analytical observational study using a cross-sectional approach.The study subjects are non-dialysis CKD patients in stages 3 to 5, aged between 38 and 59, treated at Prof. Dr. R. D. Kandou

Study covariates Chronic Kidney Disease
Chronic Kidney Disease (CKD) is a significant health issue worldwide.According to the Kidney Disease Improving Global Outcomes (KDIGO), CKD is defined as an abnormality in kidney function or structure lasting for more than 3 months, characterized by structural or functional abnormalities, with or without a decrease in glomerular filtration rate (GFR) with pathological manifestations, indicating signs of kidney abnormalities, including abnormalities in blood or urine composition, or abnormalities in imaging tests; and GFR less than 60 ml/min/1.73m2for 3 months, with or without kidney damage. 10The CKD staging was based eGFR levels (CKD-EPI) using KDIGO classification: eGFR 45-59 ml/min/1.73m 2 was classified as stage 3a, eGFR 30-44 ml/min/1.73m 2 was classified as stage 3b, eGFR 15-29 ml/min/1.73m 2 was classified as stage 4, and eGFR less than 15 ml/min/1.73m 2 was classified as stage 5. 11

Quality of Sleep
Sleep quality disturbances are a collection of symptoms experienced by patients, including symptoms related to sleep duration, sleep latency, medications needed for sleep, and daytime complaints expressed by the patient. 12

Statistical analysis
Data analysis is conducted using SPSS version 27.0.0.A distributive statistic was used to calculate the means and standard deviation of the variables.The Shapiro-Wilk test was used to perform a normality test because the sample size was less than 50.If the data have a normal distribution (p > 0.05), the correlation analysis will be done using Pearson's test.Otherwise, Spearman's rank correlation test will be used.A 95% confidence interval was set, and a p-value less than 0.05 was considered significant.

Results
This study identified 30 non-dialysis CKD patients, comprising 20 males and 10 females, with an average age of 59.80 ± 9.86 years.The mean PSQI score was 9.50 ± 5.10 for males and 10.70 ± 4.97 for females.The mean eGFR for males and females was 18.30 ±12.85 and 20.60 ±35.09, respectively.Shapiro-Wilk test showed that the patient samples were not normally distributed (p=.000).As a result, Spearman's rank correlation test revealed a significant negative correlation between eGFR and PSQI score (r=-0.554,p=0.002).

Discussion
The direct effect of insomnia on CKD progression is associated with the dysregulation of blood pressure and the renal-angiotensinaldosterone system (RAAS).During a normal sleep cycle, which is defined as 90 minutes of alternating between non-rapid eye movement (NREM) and rapid eye movement (REM), there is a slight fall in the blood pressure that triggers plasma renin activity (PRA).Later, this increase in PRA and aldosterone levels is observed in healthy subjects with sufficient night sleep and absent in sleep-deprived subjects.Thus, reduced sleep quality can lead to blood pressure dysregulation and contribute to CKD progression.Restless leg syndrome, characterized by involuntary limb movement, can cause sleep fragmentation and shorten the NREM/REM cycle. 13is study found that low eGFR levels are associated with poor sleep quality.This is consistent with the findings of Tan et al. (2022), who reported that approximately half of CKD patients have poor sleep quality.CKD patients are prone to insomnia due to increased sleep latency, obstructive sleep apnea, restless leg syndrome, and a disturbed sleeping cycle. 14ecreased production of serotonin and melatonin hormones in individuals over 60 can affect sleep processes and patterns, leading to sleep difficulties.A previous study conducted in Jakarta, Indonesia, in 2019 revealed that more than half of the hemodialysis subjects had experienced insomnia, and the main factors contributing to the sleep disturbance were depression and the duration of hemodialysis. 15nxiety in non-dialysis CKD patients is one of the problems affecting their sleep quality.Uremia conditions can disrupt melatonin hormone levels, affecting patient sleep quality. 16is finding is also consistent with the previous study by Shafi et al. (2017), which suggests that the sleep quality of dialysis and nondialysis patients does not differ and indicates the presence of sleep quality disturbances in CKD patients. 17It was found that there was a U-shaped association between sleep duration and the worsening of CKD.Sleeping less than 5 hours or more than 8 hours contributed to the progression of the renal disease. 7However, another study conducted by Cao W et al. (2022) showed no direct relationship between decreased eGFR and sleep quality. 13This contradictory result with the current study could also be possible because the researchers did not include patients over 60 years old, as these physiological processes experienced by geriatric patients are considered normal.Another study by Luca G. (2015) indicated that with increasing age, sleep quality improves. 18

Conclusion
This study found a significant positive correlation between eGFR and PSQI score, indicating that a decrease in eGFR worsens sleep quality in non-dialysis CKD patients in stages 3-5.

Limitations of the Study
This study has several limitations.Further elaboration on the specific sleep disturbances experienced by patients is needed, which could provide a clearer understanding of the relationship.Therefore, the researchers suggest further research to explain better the association between eGFR and sleep disturbances in CKD patients.These varying research results indicate that sleep quality assessments should continue to be conducted to monitor patients' quality of life.
1% of cases are detected, and 11-16% are undetected.Based on statistical data collected by the Indonesian Nephrology Association Estimated Glomerular Filtration Rate and Sleep Quality in Stage 3-5 Non-Dialysis Chronic Kidney Disease Patients: Is There a Correlation?Octavianus Umboh 1 , Stella Palar 1 , Emma Syarifih Moeis Teaching Hospital between March and May 2022.The Pittsburgh Sleep Quality Index (PSQI), which consists of 19 items, was used to assess sleep quality.It is a self-administered questionnaire that evaluates patients' sleep quality for the previous 30 days.

Table 1 .
Baseline characteristics of patients included in our study