Bader AlMasaad

Restless leg syndrome in CKD

Restless leg syndrome.

Neurological movement disorder often

accompanied by sleep disorder.

Characterized by an irresistible urge to move

ones body to stop an uncomfortable or odd

sensation.

Moving the body provides temporary relief.

Often under diagnosed

RLS affects 5-15% of the general population in

the US.

Can occur at any age, even infants.

More common in women 2:1

Restless leg syndrome

Pathogenesis is unknown.

Most accepted theory is impairment of cortical

and sub cortical dopamine pathways and iron

homeostasis, with a genetic component.

Primary or secondary

Primary : 50-75% are familial (autosomal

dominant or recessive)

Restless leg syndrome Secondary:

Iron deficiency

Peripheral neuropathy

Folate or magnesium deficiency

Amyloidosis

DM

Rheumatoid arthritis

MGUS

Uremia

Vitamin B12 deficiency

Restless leg syndrome

Morbidity:

Decreased quality of life

85% have sleep disturbance ( deprivation,

fragmentation)

Chronic headache

Prone to developing hypertension

Learning and memory difficulties

More prone to developing pneumonia and

myocardial infarctions.

Restless leg syndrome Clinical presentation

"pins and needles," an "internal itch," or a "creeping or crawling" sensation.

Criteria for diagnosis of RLS are based on those developed by the International RLS Study Group in 1995. The following 4 basic elements must be present to make the diagnosis:

A compelling urge to move the limb

Motor restlessness

Symptoms that worsen or are exclusively present at rest with temporary relief on movement

Circadian variation in symptoms.

Restless leg syndrome

Treatment is symptomatic.

Secondary RLS can by cured

Dopaminergic agents ( eg pramipexole,

ropinirole)

Benzodiazepines

Opioids

Anticonvulsants ( eg gabapentin and pregabalin)

Iron replacement vital in patients with iron

deficiency

Prevalence of RLS in CKD Much higher than the general population, all of these

had end stage renal disease on regular hemodialysis.

50.22%, riyadh, saudi arabia (1)

21%, Italy (2)

14%, Hungary (3)

48%, Brazil (4)

1. Saudi J Kidney Dis Transpl. 2009 May;20(3):378-85.

2. Sleep Med. 2004 May;5(3):309-15

3. Nephrol Dial Transplant. 2005 Mar;20(3):571-7. Epub 2005 Jan 25

4. Rev Assoc Med Bras. 2007 Nov-Dec;53(6):492-6

Imptact of short daily hemodialysis on restless

legs syndrome and sleep disturbances

Observational studies have linked restless leg syndrome to premature discontinuation of dialysis, impaired QOL, increased risk of cardiovascular events and increased risk of death.

Poor sleep quality is also common among patients on conventional HD. Ranging from 41-83%.

The FREEDOM study (1) is an ongoing multi-centre , prospective , cohort study of SDHD with a planned 12 month follow up.

The aim is to assess if SDHD ( 6 treatments per week) was beneficial in improving RLS and sleep disturbances.

Method

Inclusion criteria:

Adults (age >18) with ESRD requiring dialysis

who were being initiated on SDHD.

Exclusion criteria:

Current use of SDHD

Current enrollment in an investigational drug or

device trial.

Low likelihood of surviving the first 4-6 months

Method At enrollment demographic data was collected as well

as clinical data on co-morbid conditions, duration of dialysis, vascular access type, prior renal replacement therapy, laboratory data, prescribed medications related to RLS.

The presence of RLS was evaluated at enrollment, at 4 months and at 12 months.

This was done using the IRLS ( international restless leg syndrome study group rating scale)

Scored from 0 to 24, depending on severity of symptoms. Moderate to severe RLS defined as IRLS score above 15.

Assessment of sleep disturbances was through the MOS sleep scale manual.

Baseline characteristics were compared using the chi-squared test and variables were compared using the paired t test.

Population

Between Jan. 2006 and Dec 2008, 235

participants were enrolled from 28 different sites

108 discontinued before the 12 months follow up

period. This was due to death, renal transplant,

recovery of kidney function, transfer to another

centre.

Mean age was 52 yrs, 65% were men, 66%

were white, 43% were diabetic and 55% had an

AV fistula.

At enrollment, 40% of the participants had RLS.

These participants had worst scores on the MOS

sleep scale manual.

Results At enrollment, the mean IRLS score was 9, with

65 % of the RLS participants with a score of >15.

SDHD resulted in a decrease in IRLS score from baseline of 5 points at 4 months (p=0.002) and 7 points at 12 months ( p=0.0001)

In moderate to severe RLS, SDHD resulted in a larger decrease in IRLS score of 8-9 points at 4 and 12 months.

SDHD resulted in a significant improvement in the majority of the individual components of the sleep survey at 4 months and 12 months.

Percentage reporting RLS symptoms

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 12 months

RLS

no RLS

Percentage suffering moderate to severe RLS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

baseline 12 months

RLS

no RLS

Conclusion

SDHD resulted in sustained and clinically

significant improvement in restless leg symptoms

and sleep disturbances, especially in those with

moderate to severe RLS. (IRLS score above 15)

Among those with moderate to severe RLS, a

switch to SDHD resulted in an impressive

improvement of 8-9 points on the IRLS compared

to 6 points that was the average improvement

found in trials studying the medications used in

RLS treatment.

Conclusion

Strengths of study: large population size, from 28

different sites across the US, the use of 2

validated surveys to asses QOL measures of

interest and the 12 months follow up.

Limitations of the study: selection bias as evident

by the recruitment of relatively younger

population, and the absence of a control group.

1. Clin J Am Soc Nephrol. 2011 May; 6(5): 1049-

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