What are the management strategies for drowsiness in patients with Chronic Kidney Disease (CKD) on hemodialysis?

Management of Drowsiness in CKD Patients on Hemodialysis

Optimize dialysis adequacy first by ensuring adequate frequency (minimum three times weekly, 3+ hours per session) and achieving target dry weight, as inadequate dialysis is the primary driver of uremic symptoms including drowsiness; then use gabapentin 100-300 mg post-dialysis as the preferred pharmacologic agent if symptoms persist. 1

Immediate Priority: Optimize Dialysis Prescription

• Increase dialysis frequency to at least three times weekly if the patient is currently on a less frequent schedule, as twice-weekly dialysis is only appropriate for patients with substantial residual kidney function, which is unlikely in advanced CKD 1
• Extended or more frequent hemodialysis (4-6 times weekly) may further improve uremic symptoms and quality of life, though evidence certainty is low 1
• Achieve and maintain target dry weight through adequate ultrafiltration, as volume overload contributes to cardiovascular symptoms and overall symptom burden 2, 3
• Periodically reassess target dry weight as it changes over time, particularly in diabetic and elderly patients whose muscle mass may decline 2

Systematic Assessment of Drowsiness and Contributing Factors

• Use validated screening tools to quantify drowsiness severity and identify concurrent symptoms 1
• The Edmonton Symptom Assessment System-revised: Renal (ESAS-r:R) rates 13 symptoms on a 0-10 severity scale 1
• The Pittsburgh Sleep Quality Index (PSQI) with scores ≥5 indicates poor sleep quality, which affects 65-83% of dialysis patients and contributes to daytime drowsiness 1
• Systematically evaluate coexisting uremic symptoms that perpetuate drowsiness: uremic pruritus, depression, pain, hyperphosphatemia, restless legs syndrome, and sleep disorders 1, 3

Pharmacologic Management

First-Line Agent

• Gabapentin 100-300 mg administered after each dialysis session is the preferred pharmacologic agent for neurologic and sleep-related symptoms in dialysis patients, with proven efficacy and favorable safety profile 1, 3
• Maximum daily dose in ESRD is 200-300 mg 1

Alternative Options for Refractory Cases

• Ramelteon 8 mg at bedtime for refractory insomnia after optimizing dialysis and trying gabapentin 1
• Zolpidem 5 mg requires dose adjustment and should be used cautiously 1

Agents to Avoid

• Avoid long-acting benzodiazepines (e.g., flurazepam) due to risk of accumulation and cognitive impairment in uremic patients, which would worsen drowsiness 1, 3
• Do not use sedating antihistamines long-term due to limited efficacy and increased dementia risk 3

Non-Pharmacologic Interventions

• Cognitive behavioral therapy (CBT) has proven efficacy in reducing depression and may improve sleep quality, thereby reducing daytime drowsiness 1
• Aerobic exercise decreases depressive symptoms and may improve sleep quality (moderate certainty evidence) 1
• Music therapy with calming and uplifting lyrics can effectively reduce stress, anxiety, and depressive symptoms, which often contribute to drowsiness 4
• Music therapy lacks adverse effects unlike pharmacological approaches and can be implemented during intradialytic intervals 4

Medication Timing Considerations

• Administer cardiovascular medications at night to avoid intradialytic hypotension, which can cause post-dialysis fatigue and drowsiness 2, 5
• Caution with nitrates in low preload states (e.g., end of HD session) as hypotensive effects may potentiate drowsiness 2
• For noncompliant patients, renally eliminated agents (lisinopril, atenolol) can be given three times weekly following hemodialysis 5

Monitoring and Follow-Up

• Reassess drowsiness severity at each dialysis visit using standardized tools 1
• Evaluate medication efficacy and adverse effects, especially cognitive changes and falls 1, 3
• Monitor for progression of symptoms despite treatment 3

Red Flags Requiring Urgent Escalation

Escalate care urgently if drowsiness is accompanied by:

• Altered mental status or confusion 1, 3
• Seizure activity 1, 3
• Severe electrolyte abnormalities 1, 3
• Volume overload refractory to current dialysis prescription 1, 3
• Progressive nutritional deterioration 1

Common Pitfalls to Avoid

• Do not attribute drowsiness solely to "being on dialysis" without optimizing the dialysis prescription first - inadequate dialysis is a correctable cause 1
• Avoid polypharmacy by reviewing the entire medication regimen, as patients with ESKD are at high risk for medication-related problems that can cause or worsen drowsiness 6, 7
• Do not overlook concurrent depression, which is highly prevalent in dialysis patients and manifests as fatigue and drowsiness 4, 1
• Avoid using SSRIs as first-line for depression in dialysis patients, as they have not shown consistent benefits over placebo and have documented increased adverse effects, particularly gastrointestinal issues 4