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Annotated Abstracts of Journal Articles
2015, 3rd Quarter


Annotations by Paula Zimbrean, MD, FAPM and Marta Novak, MD, PhD
September 2015

PUBLICATION #1 — Psychonephrology
Non-pharmacological interventions for improving sleep quality in patients on dialysis: systematic review and meta-analysis
Yang B, Xu J, Xue Q, et al
Sleep Med Rev 2015; 23:68-82

ANNOTATION (Zimbrean & Novak)

The Finding:  This is a meta-analysis of 13 randomized control studies (423 patients) looking at non-pharmacological interventions for sleep disorders in patients on dialysis. The analysis shows that cognitive behavioral therapy, exercise, and acupressure are helpful for sleep disturbances in dialysis patients.

Strengths and Weaknesses: The analysis selected only randomized controlled studies, which is a strength. The limitations come from the heterogeneity of the studies analyzed in terms of medical comorbidities and dialysis parameters which may confound the results.

Relevance: Sleep disorders are common in dialysis patients. Pharmacological options are limited due to dialysis. Non-pharmacological interventions can be helpful without side effects and should be attempted.


We conducted a meta-analysis to summarise and quantify the effects of non-pharmacological interventions on sleep quality improvement in uraemic patients on dialysis. We defined the primary outcome as the change of sleep quality before and after interventions (evaluated by polysomonography or subjective questionnaires such as Pittsburgh sleep quality index, PSQI). The change of fatigue scales, inflammatory cytokines and adverse events were analysed as secondary outcomes. Twelve eligible randomised controlled trials and one prospective cohort study were identified. All three identified non-pharmacological interventions could result in a greater PSQI score reduction compared to controls: 1) cognitive-behavioural therapy (CBT) versus sleep hygiene education (standardised mean difference (SMD) 0.85, 95% CI 0.37-1.34); 2) physical training versus no training (SMD 3.36, 95% CI 2.16-4.57) and 3) Acupressure (including other acupoints massages) versus control (SMD 1.77, 95% CI 0.80-2.73). In terms of subscores, we found that CBT may shorten sleep latency, alleviate sleep disturbance and reduce the use of sleep medications. The finding of the cohort study suggested that intradialytic aerobic exercise training improved sleep quality in haemodialysis patients with restless leg syndrome. In conclusion, in dialysis-dependent patients, CBT could shorten sleep latency, alleviate sleep disturbance and reduce the use of sleep medications. Acupressure (including other acupoints massages) and exercise training are promising interventions but the results in these subgroups should be interpreted cautiously due to the concern of methodological quality and potential confounding factors.

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PUBLICATION #2 — Psychonephrology
The relation of Complementary-Alternative Medicine use with glomerular filtration rate and depression in patients with chronic kidney disease at predialysis stage
Esen B, Atay AE, Gokmen ES, et al
Nephrology 2015 May 8

ANNOTATION (Zimbrean & Novak)

The Finding:  A cross-sectional study of over 1000 patients with chronic kidney disease pre-dialysis showed that over 40% of patients use complementary-alternative medicine and that its use is higher in females and in patients with depression.

Strengths and Weaknesses: This was a large cohort of patients with chronic kidney disease. The authors created a questionnaire aimed at assessing the use of complementary medicine. Limitations of this study include the lack of validation of the questionnaire about alternative medicine use and in the questionable generalizability of the results to other cultural and geographical populations.

Relevance: Use of complementary-alternative medicine may impact the traditional treatment so it is important that medical providers are aware of this in patients with chronic illness such as CKD.


Aim: Complementary and alternative medicine is a broad field of health including all health care practices and methods; and their accompanying theories and beliefs. In the present study, we aimed to examine the frequency of complementary-alternative medicine use, and its relation with glomerular filtration rate and depression in patients with chronic kidney disease at predialysis stage.

Material and Methods: A total of 1053 predialysis patients; 518 female and 535 male, that were followed up with chronic kidney disease for at least 3 months were enrolled into the study. Demographic features, biochemical parameters and findings of physical examination were recorded. Their compliance to diet, and knowledge about disease were questioned. Beck depression inventory and questionnaire regarding to complementary-alternative medicine use were performed.

Findings: The overall frequency of complementary-alternative medicine use was 40.3% . Total ratio of herbal products was 46%. Complementary-alternative medicine use was significantly more frequent in female or single patients, and patients that informed about chronic kidney disease or under strict diet (p:0.007, p:0.016, p:0.02, p:0.016; respectively). When glomerular filtration rate of participants were considered, complementary-alternative medicine use was similar in different stages of kidney disease. Depression was observed in 41.9% of patients and significantly frequent in patients with alternative method use (p:0.002). Depression score was higher as creatinine increases and glomerular filtration rate decreases (p:0.002; r: 0,093).

Conclusion: We determined that complementary-alternative medicine use gradually increases at predialysis stage as glomerular filtration rate decreases and there is a strict relation between complementary-alternative medicine use and depression or female gender. Disorder related stressors may lead to seeking of alternative methods.

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