Sleep Disorders and Restless Legs Syndrome among Patients on Maintenance Hemodialysis in Pakistan: A Multicentre Cross-Sectional Study

Authors

  • Fatima Nazir Rawalpindi medical University
  • Ayesha Ahmad Khyber Medical University
  • Rameen Khalid Rawalpindi Medical University
  • Farhan Nazir Sargodha Medical College
  • Muhammad Ahmad Khalid Rawalpindi Medical University
  • Haseeba Mukhtar Khyber Medical University
  • Tabraiz Amin Malik CMH Kharian Medical College
  • Musfira Abu Bakar CMH Kharian Medical College
  • Muskan Kumari Liaquat University of Medical & Health Sciences (LUMHS) - Jamshoro.
  • Faraz Iqbal KhaskheliP Liaquat University of Medical & Health Sciences (LUMHS) - Jamshoro.
  • Muhammad Younas Gomal Medical College
  • Shaheryar Khan Bolan university of medical and health sciences, Quetta

Keywords:

dialysis, insomnia, sleep disorders, restless legs syndrome, obstructive sleep apnea

Abstract

Background

Sleep disorders are highly prevalent yet underdiagnosed among patients receiving maintenance hemodialysis, contributing to impaired quality of life, poor treatment adherence, and increased morbidity. Evidence from Pakistan is limited, especially across multiple provinces.

Aim

This study aims to determine the prevalence of insomnia, high obstructive sleep apnea (OSA) risk, and restless legs syndrome (RLS), and to identify their associated demographic and clinical predictors among hemodialysis patients in Pakistan.

Methods

This study was a multicentre cross-sectional study conducted between May 15th and November 25th, 2025, in 12 dialysis centres, public (n=8) and private (n=4). located across all four provinces. The participants were a total of 361 adults, estimated via OpenEpi (version 3.01), and an estimated prevalence of sleep disorders of 62.5%. Patients with hemodialysis for at least 3 months were included. Exclusion criteria consisted of having active psychiatric conditions, cognitive deficits, or an acute medical condition at the time of assessment. Data collection was performed by convenience sampling through structured interviews using tools: the Athens Insomnia Scale for insomnia, Berlin Questionnaire for OSA, and IRLSSG diagnostic and Rating Scale. Data were analysed using R version 4.5.0. Continuous data were compared using the Wilcoxon rank sum test; categorical data were compared using chi-square tests. A multivariable logistic regression model was used to determine which variables predicted insomnia, obstructive sleep apnoea, and restless legs syndrome (RLS). Adjusted odds ratios (AOR) and associated 95% confidence intervals were reported. Tukey’s Honestly Significant Difference was used to adjust for multiple comparisons. The fit and discrimination of the models were evaluated using Nagelkerke’s R², receiver operating characteristic (ROC) curves, and corresponding Hosmer-Lemeshow tests.

Results

The median age was 47 years (IQR 36–59); 59.6% were male. The prevalence of sleep disorders was high: insomnia 63.2%, high OSA risk 46.0%, and RLS 67.0%. Among RLS cases, 45% had moderate and 21% had severe/very severe symptoms. Use of hypnotic medications (AOR 3.93, p = 0.015) significantly increased RLS likelihood. There was a greater likelihood of RLS for participants with lower educational attainment (i.e., completed years of schooling of ≤ 9 or 10-12) as compared to participants with ≥ 12 years of completed schooling. Age, gender, BMI, hypertension, and diabetes were not significant predictors. Severe RLS (AOR 4.72, p < 0.001), older age (AOR 1.02/year, p = 0.028), overweight BMI (AOR 3.85, p = 0.001), and insulin use (AOR 3.86, p = 0.010) significantly increased the odds of insomnia. While for high OSA risk, older age was the strongest determinant (AOR 1.04/year, p < 0.001). Female sex showed a trend toward higher risk (AOR 1.53, p = 0.068). Education levels did not significantly influence risk after adjustment.
Model discrimination was acceptable (AUCs: insomnia 0.775, OSA 0.679, RLS 0.669), with excellent calibration across all models.

Conclusion

Sleep disorders are highly prevalent among hemodialysis patients in Pakistan, with RLS emerging as a major contributor to insomnia. Routine screening with validated tools and implementation of targeted, low-cost interventions are essential to improve patient well-being in resource-limited dialysis settings.

References

1. Perl J, Unruh ML, Chan CT. Sleep disorders in end-stage renal disease:‘Markers of inadequate dialysis?’. Kidney international. 2006 Nov 2;70(10):1687-93.

2. Finan PH, Smith MT. The comorbidity of insomnia, chronic pain, and depression: dopamine as a putative mechanism. Sleep medicine reviews. 2013 Jun 1;17(3):173-83.

3. Elder SJ, Pisoni RL, Akizawa T, Fissell R, Andreucci VE, Fukuhara S, Kurokawa K, Rayner HC, Furniss AL, Port FK, Saran R. Sleep quality predicts quality of life and mortality risk in haemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrology Dialysis Transplantation. 2008 Mar 1;23(3):998-1004

4. Stergiannis P, Govari M, Jahaj E, et al. Sleep disorders and restless legs syndrome in hemodialysis patients in Greece: a cross-sectional study. Adv Exp Med Biol. 2020;1237:21–30.

5. Losso RL, Minhoto GR, Riella MC. Sleep disorders in patients with end-stage renal disease undergoing dialysis: comparison between hemodialysis, continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. International urology and nephrology. 2015 Feb;47(2):369-75.

6. Anwar N, Mahmud SN. Quality of sleep in CKD patients on chronic hemodialysis and the effect of dialysis shift. Journal of the College of Physicians and Surgeons Pakistan. 2018 Aug 1;28(8):636-40.

7. Rehman IU, Munib S, Ramadas A, Khan TM. Prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in Pakistan. PloS one. 2018 Nov 29;13(11):e0207758.

8. Joshwa B, Khakha DC, Mahajan S. Fatigue and depression and sleep problems among hemodialysis patients in a tertiary care center. Saudi Journal of Kidney Diseases and Transplantation. 2012 Jul 1;23(4):729-35.

9. Mirghaed MT, Sepehrian R, Rakhshan A, Gorji H. Sleep quality in Iranian hemodialysis patients: a systematic review and meta-analysis. Iranian Journal of Nursing and Midwifery Research. 2019 Nov 1;24(6):403-9.

10. Soldatos CR, Dikeos DG, Paparrigopoulos TJ. Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria. Journal of psychosomatic research. 2000 Jun 1;48(6):555-60.

11. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Annals of internal medicine. 1999 Oct 5;131(7):485-91.

12. Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS, Montplaisi J. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology: a report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep medicine. 2003 Mar 1;4(2):101-19.

13. International Restless Legs Syndrome Study Group. Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep medicine. 2003 Mar 1;4(2):121-32.

14. Xu R, Miao L, Ni J, Ding Y, Song Y, Yang C, Zhu B, Jiang R. Risk factors and prediction model of sleep disturbance in patients with maintenance hemodialysis: A single center study. Frontiers in neurology. 2022 Jul 26;13:955352.

15. Chu G, Matricciani L, Russo S, Viecelli AK, Jesudason S, Bennett P, Fernandez R. Sleep disturbances in adults with chronic kidney disease: an umbrella review. Journal of Nephrology. 2025 Mar;38(2):353-69.

16. Zhou XH, Zhang P, Yang Y, et al. Prevalence of restless legs syndrome in hemodialysis patients: a systematic review and meta-analysis. Brain Behav. 2024;14:e3378.

17. Hashem RE, Abdo TA, Sarhan II, Mansour AM. Sleep pattern in a group of patients undergoing hemodialysis compared to control. Middle East Current Psychiatry. 2022 Jan 10;29(1):3.

18. Wang G, Yi X, Fan H, Cheng H. Anxiety and sleep quality in patients receiving maintenance hemodialysis: multiple mediating roles of hope and family function. Scientific reports. 2024 Jul 2;14(1):15073.

19. Robinson KA, Wei Z, Radcliffe J, Taylor HG, Baldassari CM, Chervin RD, Ishman S, Mitchell RB, Tapia IE, Garetz S, Hassan F. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. Journal of Clinical Sleep Medicine. 2023 Sep 1;19(9):1595-603.

20. Khalil A, Choyi J, Hossenbux K, Taha A. Recurrent Generalized Seizures with Postictal Todd’s Paralysis Caused by Medication-Associated Severe Hypomagnesemia: A Case Report. Case Reports in Acute Medicine. 2021 Dec 28;4(3):85-90.

21. Giannaki CD, Hadjigeorgiou GM, Karatzaferi C, Pantzaris MC, Stefanidis I, Sakkas GK. Epidemiology, impact, and treatment options of restless legs syndrome in end-stage renal disease patients: an evidence-based review. Kidney international. 2014 Jun 1;85(6):1275-82.

22. Resnick HE, Redline S, Shahar E, Gilpin A, Newman A, Walter R, Ewy GA, Howard BV, Punjabi NM. Diabetes and sleep disturbances: findings from the Sleep Heart Health Study. Diabetes care. 2003 Mar 1;26(3):702-9.

23. Ni Y, Ni L, Zhuge F, Xu L, Fu Z, Ota T. Adipose tissue macrophage phenotypes and characteristics: the key to insulin resistance in obesity and metabolic disorders. Obesity. 2020 Feb;28(2):225-34.

24. Stead TG, Banerjee P, Ganti L. Real-world field performance of the Los Angeles motor scale as a large vessel occlusion screen: a prospective muticentre study. Cerebrovascular Diseases. 2021 May 18;50(5):543-50.

25. Pisano A, et al. Prevalence of sleep apnea in chronic kidney disease: a systematic review and meta-analysis. Clin Kidney J. 2024;17:sfad179.

26. Kim W, Prokopenko D, Sakornsakolpat P, Hobbs BD, Lutz SM, Hokanson JE, Wain LV, Melbourne CA, Shrine N, Tobin MD, Silverman EK. Genome-wide gene-by-smoking interaction study of chronic obstructive pulmonary disease. American journal of epidemiology. 2021 May;190(5):875-85.

27. Allen RP, Picchietti DL, Garcia-Borreguero D, et al. Restless legs syndrome: diagnostic criteria and epidemiology. Sleep Med. 2014;15(8):860–873.

28. Trenkwalder C, Paulus W. Restless legs syndrome: pathophysiology, clinical presentation and management. Nature Reviews Neurology. 2010 Jun;6(6):337-46.

29. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Annals of internal medicine. 2011 Jul 19;155(2):97-107.

30. Unruh ML, Buysse DJ, Dew MA, Evans IV, Wu AW, Fink NE, Powe NR, Meyer KB. Sleep quality and its correlates in the first year of dialysis. Clinical Journal of the American Society of Nephrology. 2006 Jul 1;1(4):802-10.

31. Lyons OD. Sleep disorders in chronic kidney disease and end-stage kidney disease. Nat Rev Nephrol. 2024;20:690–700.

32. Wong B, Tong JY, Schulz AM, Graham SL, Farah CS, Fraser CL. The impact of continuous positive airway pressure treatment on retinal vascular changes in obstructive sleep apnea. Journal of Clinical Sleep Medicine. 2021 May 1;17(5):983-91

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Published

2026-08-18

How to Cite

Nazir, F., Ahmad, A., Khalid, R., Nazir, F., Khalid , M. A., Mukhtar, H., … Khan, S. (2026). Sleep Disorders and Restless Legs Syndrome among Patients on Maintenance Hemodialysis in Pakistan: A Multicentre Cross-Sectional Study. International Journal of Medical Students. Retrieved from https://ijms.pitt.edu/IJMS/article/view/4775

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Copyright (c) 2026 Fatima Nazir, Ayesha Ahmad, Rameen Khalid, Farhan Nazir, Muhammad Ahmad Khalid , Haseeba Mukhtar, Tabraiz Amin Malik, Musfira Abu Bakar , Muskan Kumari, Faraz Iqbal KhaskheliP, Muhammad Younas , Shaheryar Khan

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