Sleep Quality and Its Correlates in the First Year of Dialysis Mark L. Unruh,* Daniel J. Buysse, † Mary Amanda Dew, † Idris V. Evans, ‡ Albert W. Wu, § Nancy E. Fink, § Neil R. Powe, § and Klemens B. Meyer,  for the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study *Renal-Electrolyte Division, University of Pittsburgh Medical Center, and † Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ‡ Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania; § Welch Center for Prevention, Epidemilogy, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; and  Division of Nephrology, Tufts-New England Medical Center, Boston, Massachusetts Although sleep problems are thought to be prevalent among patients who undergo dialysis, there is only limited information on the determinants of sleep quality and the change in sleep quality during the first year of dialysis treatment. This report uses data from a national cohort study of incident hemodialysis and peritoneal dialysis patients to identify the correlates of sleep quality and to determine the extent to which sleep quality is related to patients’ health-related quality of life and survival. This report includes 909 incident dialysis patients who responded to questions about sleep quality. Three quarters of incident dialysis patients reported impaired sleep, and 14% had a decline in sleep quality in the first year of treatment. Poor sleep quality was significantly related to black race, higher serum phosphate, current smoking, benzodiazepine prescription, and complaints of severe restless legs. Poor baseline sleep quality was associated with lower SF-36 physical and mental component summary scores, vitality scores, and bodily pain scores (all P < 0.001). Younger age, current smoking, and benzodiazepine prescription were associated with decreases in sleep quality at 1 yr. There was no association between baseline sleep quality and survival; however, a decline in sleep quality during the first year on dialysis was associated with shorter survival (hazard ratio 1.44; 95% confidence interval 1.13 to 1.83; P  0.003). Future work should examine the link between sleep quality and daytime functioning in the kidney failure population and the extent to which improving sleep quality will improve dialysis patient outcomes. Clin J Am Soc Nephrol 1: 802– 810, 2006. doi: 10.2215/CJN.00710206 S elf-reported sleep problems are strongly associated with dialysis patients’ disability days, health care utilization, and health-related quality of life (HRQOL) (1). In the general population, those who report poor sleep quality use more health services (2), more hypnotic drugs (3), report re- duced functional capabilities and lower HRQOL (4). In addi- tion, studies in the general population have found that self- reported long and short sleepers have a higher risk for death and disability when compared with individuals who report average sleep duration (5,6). Those with ESRD have been shown to have high rates of sleep apnea, periodic limb move- ments, insomnia, and restless legs syndrome (7–10). Because sleep problems are associated with lower HRQOL (11) and may be related to progression of cardiovascular disease (12), iden- tifying and treating dialysis patients who sleep poorly may significantly improve their lives (13,14). Although many chronic dialysis patients complain of poor sleep, we know little about the natural history of sleep prob- lems as patients adjust to maintenance dialysis, and the causes of these problems are uncertain: Dialysis patients have many physiologic disorders that might explain disordered sleep (15). A number of studies on ESRD have demonstrated the impor- tance of sleep quality using individual items rather than using a scale score to assess sleep complaints (16 –18), and most reports have been limited to cross-sectional analysis that rep- resents the experience of a single clinical practice (11,19,20). Because both race and comorbidity influence self-reported sleep quality, it is particularly important to study sleep quality in a diverse, nationally representative population in which the burden of comorbid illness is well described (21). This study uses data from the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study to assess sleep quality among incident peritoneal dialysis (PD) and hemodialysis (HD) patients. In this report, we first examine the predictors of sleep quality among the dialysis participants in CHOICE at baseline and then determine the factors that are related to a longitudinal change in sleep quality. Last, we examine the relationship of sleep quality to HRQOL and sur- vival. Materials and Methods Study Design and Population The study patients were a subpopulation of patients who partici- pated in CHOICE (22). CHOICE is a national, prospective cohort study of incident HD and PD patients. From October 1995 to June 1998, 1041 Received February 28, 2006. Accepted April 24, 2006. Published online ahead of print. Publication date available at www.cjasn.org. Address correspondence to: Dr. Mark L. Unruh, University of Pittsburgh Medical Center, Renal-Electrolyte Division, 3550 Terrace Street, A909 Scaife Hall, Pitts- burgh, PA 15261. Phone: 412-647-2561; Fax: 412-647-6891; E-mail: unruh@pitt.edu Copyright © 2006 by the American Society of Nephrology ISSN: 1555-9041/104-0802