How to manage increased yawning in the evening in a patient with Chronic Kidney Disease (CKD) stage 5 on Hemodialysis (HD)?

Management of Increased Evening Yawning in CKD Stage 5 Hemodialysis Patients

Increased evening yawning in a hemodialysis patient most likely represents a sleep disturbance or uremic symptom that requires systematic assessment of dialysis adequacy, concurrent uremic symptoms, and consideration of gabapentin as first-line pharmacologic therapy if non-pharmacologic measures fail.

Immediate Assessment and Dialysis Optimization

Yawning, particularly in the evening, is a manifestation of sleep disturbance or excessive daytime drowsiness, which affects 60-83% of dialysis patients and significantly impacts quality of life 1, 2. Your first priority is to evaluate whether the patient is receiving adequate dialysis:

• Verify dialysis adequacy: Ensure the patient is receiving at least three times weekly hemodialysis with adequate small-solute clearance (spKt/V ≥1.3 per dialysis session) 1. Twice-weekly dialysis is inadequate for most CKD stage 5 patients and directly contributes to uremic symptoms including sleep disorders 2.

• Consider more frequent or extended dialysis: Extended or more frequent hemodialysis (4-6 times weekly) may improve sleep quality and overall quality of life, though evidence certainty is low 2. This addresses the root cause of uremic symptoms 2.

• Assess timing of dialysis sessions: Evening dialysis sessions may disrupt normal sleep-wake cycles and contribute to evening symptoms 1.

Systematic Symptom Evaluation

Use validated screening tools to quantify the severity and identify concurrent symptoms 1, 2:

• Pittsburgh Sleep Quality Index (PSQI): Scores ≥5 indicate poor sleep quality, with prevalence of 65-83% in dialysis patients 1, 2.

• Edmonton Symptom Assessment System-revised: Renal (ESAS-r:R): This 13-symptom tool rated 0-10 for severity helps identify coexisting uremic symptoms 2.

Specifically assess for concurrent symptoms that perpetuate sleep disturbance and may manifest as yawning 1, 2:

• Restless legs syndrome (10-20% prevalence, with 80% also experiencing periodic limb movements) 1
• Uremic pruritus (40.6% prevalence) 1
• Depression (39.3% prevalence in dialysis patients) 1
• Pain (53% prevalence in stage 5 CKD) 3
• Hyperphosphatemia 1, 2

Non-Pharmacologic Interventions

Implement these evidence-based strategies before or alongside pharmacologic treatment 1, 2:

• Sleep hygiene measures: Establish consistent sleep-wake schedules, optimize bedroom environment, and remove stimulants 1, 2.

• Aerobic exercise: Decreases depressive symptoms and may improve sleep quality with moderate certainty evidence 2.

• Cognitive behavioral therapy (CBT): Has proven efficacy in reducing depression and may improve sleep in dialysis patients 2.

• Correct metabolic abnormalities: Address hyperphosphatemia and iron deficiency, which contribute to restless legs syndrome and sleep disturbance 1.

Pharmacologic Management

Gabapentin is the preferred first-line pharmacologic agent for sleep disorders in dialysis patients 2:

• Dosing: 100 mg post-dialysis or at bedtime, with a maximum of 200-300 mg daily in ESRD 2.

• Monitoring: Reassess sleep quality at each dialysis visit using standardized tools, and evaluate for adverse effects, especially cognitive changes and falls 2.

Alternative pharmacologic options if gabapentin is ineffective or not tolerated 2:

• Ramelteon 8 mg at bedtime for refractory insomnia 2
• Zolpidem 5 mg (requires dose adjustment and use cautiously) 2

Avoid long-acting benzodiazepines (e.g., flurazepam) due to risk of accumulation and cognitive impairment in uremic patients 2.

Management of Concurrent Symptoms

Systematically address coexisting symptoms that perpetuate sleep disturbance 1, 2:

• Uremic pruritus: Topical agents (capsaicin, emollients), oral gabapentinoids, or ultraviolet B therapy 1.

• Restless legs syndrome: Correct hyperphosphatemia and iron deficiency, consider levodopa, nonergot dopamine agonists, or low-dose gabapentinoids 1.

• Depression: Consider pharmacologic treatment (though fluoxetine and escitalopram showed limited efficacy in RCTs) or non-pharmacologic interventions including CBT and exercise 1.

Red Flags Requiring Urgent Escalation

Escalate care immediately if evening yawning accompanies 2:

• Altered mental status or confusion
• Seizure activity
• Severe electrolyte abnormalities
• Volume overload refractory to current dialysis prescription
• Progressive nutritional deterioration

Ongoing Monitoring

• Reassess sleep quality at each dialysis visit using PSQI or similar validated tools 2.
• Monitor hemoglobin weekly until stable if anemia is contributing to fatigue 4.
• Evaluate medication efficacy and adverse effects, particularly cognitive changes and fall risk 2.