REVIEW JURNAL

KEPERAWATANN MEDIKAL BEDAH

GAGAL GINJAL KRONIK (GGK)

Kelompok 7A& B :

1. Firda Fitri Anggraini 1130017078

2. Lailatul Masrurah 1130017079
3. Tuhfatul Aliyah 1130017038
4. Lilis Ayu Solehati 1130017039
5. Novi Widiyanti 1130017040

Pembimbing Akademik :

Chilyatiz Zahro S.Kep.,Ns.,M.Kep

PROGRAM STUDI S1 KEPERAWATAN

FAKULTAS KEPERAWATAN DAN KEBIDANAN
UNIVERSITAS NAHDLATUL ULAMA SURABAYA
2021
 JURNAL NASIONAL DAN JURNAL INTERNASIONAL

1. JURNAL NASIONAL

Judul Problem Intervention Comparation Outcome

Intervensi edukasi Data yang didapatkan Intervensi yang dilakukan Edukasi kesehatan yang Intervensi edukasi secara
kesehatan pada tahun 2007-2017 tercatat adalah edukuasi HD pada dilakukan secara online langsung memiliki manfaat besar
pasien gagal pasien baru yang penderita PGK yang pasien mudah untuk bagi pasien gagal ginjal kronik
ginjal kronik yang didiagnosis mengalami menjalani hemodialisis, selain mengakses materi edukasi, seperti menimbulkan
menjalani gagal ginjal akut pemberian terapi medikasi meningkatkan pemahaman keingintahuan, dapat memotivasi
hemodialisis berjumlah 25.854 diperlukan pula terapi dan kepatuhan, bisa pasien secara langsung untuk tetap
pasien, dan pasien aktif pendamping demi mengurangi berkonsultasi langsung menjalankan terapi pengobatan
yang sudah tingkat keparahan penyakit dengan tenaga kesehatan, yang dijalaninya. Pada pasien
mendapatkan dan peningkatan kualitas konsultasi gizi, konseling pre yang memiliki pengetahuan
terapi hemodialisis pelayanan kesehatan. dialisis dan bisa mengakses teknologi yang rendah edukasi
sebanyak 76.007 pasien. Adekuasi proses hemodialisis selama 24 jam kapan saja dan offline sangat memberi manfaat
Angka penyakit gagal akan memberikan rasa dimana saja sedangkan untuk bagi mereka yang kurang
ginjal kronik di dunia nyaman pada pasien dalam edukasi secara offline pasien memahami teknologi informasi
masih tinggi. menjalani kehidupannya bisa diberikan edukasi pada yang berbasis online. Intervensi
terlepas dari gejala uremia saat menjalani terapi yang diberikan baik secara offline
hemodialisis atau pada saat maupun secara online memiliki
rawat jalans manfaat yang berbeda pada pasien
gagal ginjal kronik tergantung
tingkat keefektifan sehingga
penerapan
edukasi juga tergantung pada
 kondisi kesehatan klien dalam
menerima sebuah intervensi
edukasi kesehatan

2. JURNAL INTERNASIONAL

Judul Problem Intervention Comparation Outcome

Chronic Kidney Kami mempelajari Laju filtrasi glomerulus Jurnal: Penyakit Ginjal Di antara pasien dengan CKD ada
Disease Is 1805 pasien, dirujuk diperkirakan (eGFR) Kronis Ditandai dengan tekanan darah sistolik (SBP) yang
Characterized by ke Pusat Hipertensi menggunakan persamaan 'Masalah Ganda' Tekanan lebih tinggi selama malam hari,
‘‘Double kami, di antaranya MDRD dan CKD Darah Tinggi dan Tekanan prevalensi non-dippers yang
Trouble’’ Higher didefinisikan sebagai Darah Sistolik Malam Hari lebih besar (OR: 1,8) dan
Pulse Pressure ABPM, tes darah, dan eGFR,60 mL / mnt / 1,73 m2. dan Kerusakan Jantung peningkatan tekanan nadi (PP)
plus Night-Time ekokardiografi secara Kerusakan organ jantung Lebih Berat: Pengolahan selama periode 24 jam, siang
Systolic Blood klinis diindikasikan dievaluasi dengan data dilakukan dengan dan malam hari (semua
Pressure and ekokardiografi. menggunakan tabel hal,0,001). Pasien dengan CKD
More Severe penelitian berdasarkan memilikiLVM / h2,7 yang lebih
Cardiac Damage Prevalensi tahapan CKD, besar indeks, dan prevalensi
Korelasi antara parameter hipertrofi ventrikel kiri dan
Penyakit Ginjal ABPM dan disfungsi diastolik yang lebih
Kronis Ditandai tinggi (semua p,0,001). SBP
dengan 'Masalah eGFR dinilai dengan regresi dan PP nokturnal berkorelasi
Ganda' Tekanan linier, SBP malam hari terkait lebih kuat dengan kerusakan
Darah Tinggi dan dengan LVM / jam 2,7 organ jantung (p,0,001). Pasien
Tekanan Darah padalinier, 24 jam PP dengan CKD memiliki Skor
Sistolik Malam terkait dengan LVM / jam Intensitas Pengobatan yang lebih
Hari dan 2,7 dalam model regresi besar (p,0,001) tanpa adanya
Kerusakan linier model regresi kontrol BP yang secara
Jantung Lebih signifikan lebih besar.
Berat

3. JURNAL INTERNASIONAL

Judul Problem Intervention Comparation Outcome

Penelitian ini Prosedur pelaksanaan Program pmr menyebabkan

Effect of mengitervensi 100 Seratus pasien hemodialisis (64
Progressive program dijelaskan kepada pengurangan yang signifikan
pasien CRF yang dirujuk dari kecemasan umum, wanita dan 36 pria) dirawat di
Muscle pasien pertama kali saat
Relaxation ke ruang hemodialisis kecemasan sifat, kecemasan bangsal hemodialisis rumah
and Aerobic rumah sakit hajar mereka menjalani beck, dan kelelahan rhoten
Exercise on sakit hajar terdaftar dalam uji
hemodialisis, dan cd dan peningkatan kualitas tidur
Anxiety, pada pasien hemodialisis. klinis ini dan secara acak dibagi
Sleep rekaman dibagikan kepada
Latihan aerobik menjadi tiga kelompok: latihan
Quality, and
pasien sehingga program menyebabkan kelegaan yang
Fatigue in aerobik (n: 32), pmr (n: 33), dan
Patients with pmr dilakukan selama sesi signifikan dari kecemasan
Chronic beck dan peningkatan kontrol (n: 35). Usia rata-rata
kualitas tidur
 Renal hemodialisis dan di bawah pada pasien. Secara pasien pada kelompok pmr
Failure
Undergoing supervisi peneliti. Dengan keseluruhan, program pmr adalah 56,12 tahun dan pada
lebih banyak efisien
Hemodialysis cara ini, kinerja pasien yang latihan aerobik adalah 54,31
dibandingkan dengan senam
Pengaruh rusak dapat diperbaiki; aerobik untuk menurunkan tahun dan pada kelompok
Relaksasi Otot selain itu juga diberikan tingkat kecemasan, kelelahan, kontrol adalah 55,22 tahun. Para
Progresif dan dan gangguan tidur pada
nomor telepon peneliti pasien melakukan latihan
Latihan Aerobik pasien hemodialisis
terhadap kepada pasien agar dapat aerobik dan pmr program setiap
Kecemasan, menghubungi peneliti untuk hari selama delapan minggu.
Kualitas Tidur,
mengatasi potensi masalah Tabel 1 menunjukkan
dan Kelelahan
pada Pasien yang terkait dengan karakteristik demografis dari
Gagal Ginjal pelaksanaan program. pasien yang diteliti. Skor rata-
Kronis
Kemudian, pasien diminta rata untuk kecemasan, depresi
yang Menjalani
Hemodialisis untuk melakukan program dan kualitas tidur sebelum dan
pmr dengan cara yang sama sesudah intervensi ditunjukkan
di rumah setiap hari selama pada tabel 2. Menurut temuan,
60 hari dengan kecemasan umum, kecemasan
menggunakan cd. Untuk sifat, kecemasan keadaan, dan
mencapai tujuan ini, kecemasan beck secara
sebelum tidur malam, pasien signifikan lebih rendah setelah
menunjukkan cd dan intervensi dibandingkan
berkontraksi kemudian sebelumnya pada kelompok
mengendurkan otot masing- pmr. (p<0,05). Pada kelompok
masing bagian secara latihan aerobik, kecemasan beck
terpisah saat berbaring secara signifikan lebih rendah
sesuai dengan instruksi setelah intervensi dibandingkan
masing-masing. Pada sebelumnya (p<0,05) tetapi
kelompok senam aerobik, kelelahan piper tidak berbeda
senam yang ditentukan nyata antara sebelum dan
sebelumnya dilakukan di sesudah intervensi. Rerata skor
hadapan peneliti untuk kualitas tidur menurun secara
pertama kalinya dan signifikan setelah dilakukan
kemudian setelah intervensi pada kelompok pmr
memberikan penjelasan dan senam aerobik, yang
awal saat pasien menjalani merepresentasikan peningkatan
hemodialisis. Jika perlu, kualitas tidur yang bermakna (p
kinerja pasien yang rusak <0,05).
diperbaiki dan pasien
diminta untuk melakukan
latihan dengan cara yang
sama selama delapan
minggu berikutnya. Untuk
memastikan bahwa pasien
tidak melupakan prosedur
melakukan latihan, daftar
latihan dikembangkan dan
dikirimkan kepada pasien.
Nomor telepon peneliti
diberikan kepada pasien
sehingga mereka dapat
menghubungi peneliti untuk
menyelesaikan masalah
potensial yang berkaitan
dengan kinerja latihan. Para
pasien diminta untuk
melakukan latihan pada
waktu tertentu dalam sehari
sehingga mereka memiliki
waktu yang cukup untuk
menyelesaikan program
tersebut. Peneliti mengawasi
pelaksanaan program latihan
dan menindaklanjuti pasien
setiap dua minggu sekali
melalui panggilan telepon
atau secara langsung
sehingga pasien akan
didorong untuk terus
melaksanakan program
latihan atau dikeluarkan dari
penelitian jika mereka tidak
mematuhinya selama ini.
Lebih dari dua hari
seminggu.

Skor rata-rata untuk kualitas

tidur, kecemasan, dan
kelelahan sebelum dan
sesudah intervensi
ditentukan. Untuk
menyelidiki kualitas tidur,
pittsburgh sleep quality
index dengan validitas dan
reliabilitas telah
dikonfirmasi oleh ağargün et
al.18 digunakan. Untuk
menyelidiki kecemasan,
spielberger dan beck anxiety
inventory dengan validitas
dan reliabilitas yang telah
dikonfirmasi19,20 digunakan.
Selain itu, skala kelelahan
piper dan rhoten yang
validitas dan reliabilitasnya
telah dikonfirmasi dalam
sejumlah penelitian21-22
digunakan untuk mengukur
kelelahan. Data yang
terkumpul dianalisis dengan
software stata versi 13
menggunakan anova, chi-
square dan t-test.
 Jurnal Health Sains: p–ISSN : 2723-4339 e-ISSN : 2548-1398
Vol. 1, No. 5, November 2020

INTERVENSI EDUKASI KESEHATAN PADA PASIEN GAGAL GINJAL KRONIK

YANG MENJALANI HEMODIALISIS

Sri Purwanti Ariani, Syamsul Firdaus dan Hiryadi

Universitas Muhammadiyah Banjarmasin dan Poltekes Kemenkes Banjarmasin
Email: purwantis681@gmail.com, syamsulfirdaus1966@gmail.com, hiryadi_mb@yahoo.com

INFO ARTIKEL ABSTRAK

Tanggal diterima: 5 November
2020
Tanggal revisi: 15 November
2020
Tanggal yang diterima: 25
November 2020
Kata kunci:
Intervensi; Edukasi Kesehatan;
Penyakit Gagal Ginjal Kronik.
Jumlah Penderita Chronic Kidney Disease semakin tahun
semakin meningkat. Terapi yang bisa lakukan oleh
penderita CKD adalah dengan Hemodialisis. Peran perawat
dalam proses hemodialisis sangat besar karena buruknya
dampak komplikasi tersebut, maka intervensi keperawatan
harus dilakukan dengan tepat. Studi ini bertujuan untuk
mencari berbagai bukti terkait intervensi edukasi kesehatan
pada pasien gagal ginjal kronik. Pencarian beberapa
literatur berdasarkan pada PRISMA checklist dengan
menggunakan 4 database yaitu Scopus, Pubmed,
Sciencedirect dan google scholar. Jurnal dipilih sesuai
dengan kriteria insklusi menggunakan JBI Critical
Appraisal Tools. Sebanyak 15 jurnal dan artikel yang
membahas tentang intervensi edukasi kesehatan pada pasien
gagal ginjal kronik. Hasil studi dapat disimpulkan bahwa
intervensi edukasi offline maupun online memiliki manfaat
yang berbeda tergantung tingkat keefektifannya sehingga
penerapannya juga tergantung
individu yang akan menerima intervensi edukasi tersebut.

Pendahuluan dunia masih tinggi. Prevalensi gagal ginjal

Chronic kidney disease (CKD) adalah
kelainan progresif non reversibel yang
diakibatkan hilangnya kemampuan tubuh
untuk mempertahankan keseimbangan cairan
dan elektrolit tubuh sehingga menyebabkan
uremia dan azotemia. Salah satu tahap akhir
penyakit ginjal kronis disebut dengan End
Stage Renal Disease (ESRD) yang
memerlukan terapi pengganti ginjal seperti
dialisis atau transplantasi ginjal (Hassanzadeh
et al., 2018). Indonesia diperikirakan jumlah
pasien gagal ginjal meningkat dari 19.612
hingga 100.000 antara tahun 2014 sampai
2019 (Perkumpulan Nefrologi Indonesia
(PERNEFRI), 2014). Data yang didapatkan
tahun 2007-2017 tercatat pasien baru yang
didiagnosis mengalami gagal ginjal akut
berjumlah 25.854 pasien, dan pasien aktif
yang sudah mendapatkan terapi hemodialisis
sebanyak 76.007 pasien. (Infodatin et al.
2017). Angka penyakit gagal ginjal kronik di
270
kronik pada tahun 2011 di Amerika Serikat
sebesar 1901 per juta penduduk, Prevalensi
penyakit gagal ginjal kronik di indonesia pada
tahun 2013 sebesar 2% (499.800) orang,
prevalensi terendah adalah 1% dan tertinggi
sebesar 4%, pada tahun 2018 terjadi
peningkatan dengan prevalensi gagal ginjal
kronik 3,8% (995.600), prevalensi terendah
1,8% dan prevalensi tertinggi sebesar 6,4%.
(The United State Renal Data System
(USRDS), 2013). Berdasarkan hal tersebut
diperlukan intervensi edukasi kesehatan yang
berkesinambungan melalui program edukasi
yang kompherenshif.
Peran perawat dalam proses HD sangat
besar, dan karena buruknya dampak
komplikasi tersebut, maka intervensi
keperawatan harus dilakukan dengan tepat.
Agar dapat terwujud status kesehatan yang
optimal bagi pasien hemodialisis dengan cara
memberikan asuhan keperawatan
komprehensif dan holistik yang meliputi bio-
psiko-sosio dan spiritual (Potter et al., 2017).
Atas pertimbangan adekuasi HD pada
penderita PGK yang menjalani hemodialisis,
selain pemberian terapi medikasi diperlukan
pula terapi pendamping demi mengurangi
tingkat keparahan penyakit dan peningkatan
kualitas pelayanan kesehatan. Adekuasi
proses hemodialisis akan memberikan rasa
nyaman pada pasien dalam menjalani
kehidupannya terlepas dari gejala uremia
(Kidney Disease Outcomes Quality Initiative,
2015).
Dengan tercapainya adekuasi HD maka
perawat dapat memastikan kondisi
kenyamanan pasien sebagai langkah untuk
meningkatkan kualitas pelayanan kesehatan
dan intervensi keperawatan. Untuk fase
intradialitik sendiri, perawat berperan dalam
pencegahan komplikasi lanjut pada pasien
(Sakitri et al., 2017). Namun komplikasi yang
sering kali muncul saat proses hemodialisa
masih menyebabkan tingginya tingkat
mortalitas. Oleh karena itulah systematik
review ini bertujuan untuk menentukan jenis-
jenis intervensi keperawatan yang dapat
dilakukan demi memaksimalkan pelayanan
dan mencegah komplikasi proses
hemodialisis (Sitoresmi et al 2020).
Metode Penelitian
Desain studi dengan menggunakan
literature review dengan tahapan beberapa
studi pustaka dari jurnal dan artikel terkait.
Pertanyaan studi dirumuskan untuk
mengetahui berbagai intervensi edukasi
kesehatan pada pasien CKD. Kata kunci yang
digunakan Hemodialysis ‘OR’Chronic
Kidney Disease ‘AND’ Education Healthy
‘OR’ Offline ‘OR’ Online dengan
menggunakan 4 database yaitu Scopus,
Pubmed, Sciencedirect dan google scholar.
Kriteria inklusi pada studinini adalah jurnal
dan artikel yang telah di duplikasi dengan
rentang waktu 2015-2020 yang tertulis dalam
bahasa inggris dan bahasa Indonesia dan
dapat diakses secara full teks dan merupakan
original research dengan berbagai desain
penelitian. Artikel akan di esklusi apabila
tidak menggunakan bahasa inggris dan
Indonesia, tidak sesuai dengan tujuan dan
rumusan masalah, fokus masalah dalam studi
ini adalah tentang intervensi edukasi
kesehatan pada pasien gagal ginjal
Jurnal Health Sains Vol. 1, No. 5, November 2020
kronik baik itu dilakukan secara online
maupun offline.
Pengkajian dari kualitas evidence
nursing untuk menentukan intervensi
kesehatan dengan menggunakan critical
appraisal The Joana Briggs Insitute Critical
Appraisal Tools (2016). Hasil seleksi artikel
dan jurnal studi sesuai tema yang diambil
dapat digambarkan pada Diagram Flow
dibawah ini.
Studi
Esklusi yang
(n=98)didapat dari beberapa
database terkait diantaranya Scopus,
Populations
Pubmed, Science in Direct dan
Tidak berfokus
google
pada permasalahan
Scholar n = 167
intervensi edukasi kesehatan pada pasien gagal ginjal kronik y
Intervention
Intervensi tidak sesuai /spesifik dengan intervensi edukasi kesehatan pada pasien gagal ginjal kro
Outcome
Tidak membahas mengenai intervensi edukasi keperawatan (n=18)
Artikel dan jurnal
diidentifikasi berdasarkan
duplikasi (n = 69)
Skrinning berdasarkan identifikasi judul (n = 27)
Excluded (n = 4)
SkrinningPopulations
berdasarkan identifikasi Abstrak (n = 19)
Tidak berfokus pada permasalahan intervensi edukasi keperawatan pada pasien gagal ginjal kronik
Intervention
Intervensi tidak sesuai /spesifik dengan intervensi edukasi keperawatan pada pasien gagal ginjal k
Outcome
Assesment berdasarkan full text
Tidak membahas
dan mengenai( nintervensi
kriteria kelayakan = 15) edukasi keperawatan (n= 1)
Artikel dan jurnal sesuai
yang bisa digunakan (n= 15)
Hasil Penelitian
Hasil literature dari 4 database yang
digunakan, ditemukan 15 artikel dan jurnal
yang sesuai dengan tema yang sudah
ditentukan peneliti, 1 Systematic Review, 4
Randomized Controlled Trial, 5 Pre
Experiment, 5 Qualitative Study. Ekstrasi
data jurnal dan artikel dapat dilihat pada tabel
1. Jurnal dan artikel tersebut juga telah
memenuhi kriteria berdasarkan pada The JBI
Critical Appraisal Tools 2016. Studi yang
sudah dipilih pada artikel maupun jurnal
dalam systematic review ini adalah 2 studi
dilakukan di California Francisco yang
dilakukan di insitut biomedis informatika, 5
studi dilakukan di Indonesia yaitu beberapa
rumah sakit yang
ada di indonesia. Penelitian dan studi ini juga ada
271
yang dilakukan sms, aplikasi android, pasien. Tindakan yang tujuan, sesuaikan
di China, mobile health, dapat dilakukan adalah pengajaran
Kanada, Brasil, telehealth. Sedangkan hargai tingkat
Jepang, Australia intervensi yang dengan
pengetahuan dan kebutuhan
yaitu dilakukan dilakukan yang
pada lembaga dilakukan secara Offline pemahaman pasien, pasien, pilih
penelitian khusus untuk perhatikan tingkat materi edukasi
maupun dirumah penelitiannya seperti pendidikan pasien, yang sesuai,
sakit. pada jurnal dan artikel perkuat kesiapan pasien sesuaikan isi
Berdasarkan Andri et al., (2018). untuk belajar tetapkan pembelajaran
hasil studi Hartati et al., (2019), tujuan yang
ditemukan bahwa Loritta et al., (2018), dengan
menguntungkan bagi kemampuan atau
intervensi Nguyet et al., (2018),
edukasi Yoshihiko et al., (2018), pasien, identifikasi ketidakmampuan
kesehatan yang Amy et al., (2019), kognitif,
diberikan melalui Luana et al., (2018) psikomotor dan
cara online meliputi berbasis video, afektif pasien,
berjumlah 8 studi buklet, virtual reality
siapkan
dan 7 studi dan dukungan sosial
dengan dilakukan pada pasien CKD. lingkungan yang
intervensi secara Edukasi kesehatan yang kondusif,
(offline). dilakukan secara online evaluasi
Beberapa pasien mudah untuk pencapaian
intervensi mengakses materi pasien terhadap
edukasi edukasi, meningkatkan
tujuan dari
kesehatan yang pemahaman dan
mampu kepatuhan, bisa edukasi tersebut,
memberikan berkonsultasi langsung berikan
penanganan pada dengan tenaga penguatan
pasien gagal kesehatan, konsultasi perilaku, berikan
ginjal kronik gizi, konseling pre waktu untuk
dengan dialisis dan bisa diskusi, sertakan
keberhasilan mengakses selama 24
keluarga atau
yang berbeda jam kapan saja dan
diantaranya dimana saja sedangkan orang terdekat
seperti intervensi untuk edukasi secara (Dochterman &
edukasi secara offline pasien bisa Bulechek, 2014).
online khusus diberikan edukasi pada Intervensi
untuk saat menjalani terapi edukasi secara
penelitiannya hemodialisis atau pada langsung
seperti pada saat rawat jalan.
memiliki
jurnal dan artikel
Jaimon et al., manfaat besar
Pembahasan
(2019), Delphine bagi pasien gagal
Memberikan
et al., (2016), ginjal kronik
edukasi atau pendidikan
Lianne et al., seperti
(2017), Joanna et kesehatan kepada
menimbulkan
al., (2016), Ying individu yaitu
keingintahuan,
et al., (2018), merencanakan,
dapat
Fery et al., mengimplementasikan
(2019), Ann memotivasi
dan mengevaluasi
Bonner et al., pasien secara
program edukasi yang
(2018) meliputi langsung untuk
dirancang untuk
konseling tetap
melalui telepon, kebutuhan khusus
272 Jurnal Health Sains Vol. 1, No. 5, November 2020
m da kronik menggunakan
e pasien tergantu intervensi yang
n yang ng sudah ada untuk
j memili tingkat dijadikan sebuah
a ki keefekti perbandingan,
l pengeta fan tetapi menurut
a huan sehingg peneliti untuk
n teknolo a penelitian
k gi yang penerap kualitatif
a rendah an memiliki
n edukasi edukasi kelebihan seperti
offline juga data desriptif,
t sangat tergantu pengumpulan
e membe ng pada data dilakukan
r ri kondisi secara fleksibel
a manfaat kesehat sesuai dinamika
p bagi an klien dilapangan,
i mereka dalam interaksi
p yang meneri dilakukan
e kurang ma dengan bahasa
n memah sebuah partisipan sehari-
g ami interven hari.
o teknolo si
b gi edukasi Kesimpulan
a informa kesehat Intervensi
t si yang an. yang sudah
a berbasi Perband diberikan baik
n s ingan secara offline
maupun online
online. efektivi
memiliki
y Interve tas manfaat yang
a nsi sebuah berbeda
n yang interven tergantung
g diberik si tidak tingkat
an baik bisa keefektifannya
sehingga
d secara dibandi
penerapannya
i offline ngkan juga tergantung
j maupun jika individu yang
a secara tidak akan menerima
l online melalui intervensi
a memili penguji edukasi tersebut.
n ki an atau Perbandingan
intervensi
i manfaat peneliti
edukasi tersebut
n yang an lebih tidak bisa
y berbeda lanjut dibandingkan
a pada dengan jika tidak melalui
. pasien pengujian atau
P gagal penelitian lebih lanjut intervensi yang sudah ada untuk
a ginjal dengan menggunakan dijadikan pembandingnya. Oleh
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276 Jurnal Health Sains Vol. 1, No. 5, November 2020
 Chronic Kidney Disease Is Characterized by ‘‘Double
Trouble’’ Higher Pulse Pressure plus Night-Time Systolic
Blood Pressure and More Severe Cardiac Damage
Massimiliano Fedecostante1*, Francesco Spannella1, Giovanna Cola2, Emma Espinosa1, Paolo Dessı`-
Fulgheri1, Riccardo Sarzani1
1 Internal Medicine and Geriatrics and ‘‘Hypertension Excellence Centre’’ of the European Society of Hypertension, Department of Clinical and Molecular Sciences,
University ‘‘Politecnica delle Marche’’, Italian National Research Centre on Aging ‘‘U. Sestilli’’, IRCCS-INRCA, Ancona, Italy, 2 Cardiology Clinic, Department of Cardiovascular
Sciences, University ‘‘Politecnica delle Marche’’, ‘‘Ospedali Riuniti’’, Ancona, Italy

of cardiac organ damage.

uation and CKD was defined as eGFR,60 mL/min/1.73 m2. Cardiac organ damage was evaluated by echocardiography.
night-time (all p,0.001). Patients with CKD had a greater LVM/h2.7 index, and a higher prevalence of left ventricular hypertrophy and diastolic dysfunctio

was similar to patients without CKD. Our findings indicate the need of a better antihypertensive therapy in CKD, better selected drugs, dosages and posol

E, Dess`ı-Fulgheri P, et al. (2014) Chronic Kidney Disease Is Characterized by ‘‘Double Trouble’’ Higher Pulse Pressure plus Night-Time Systolic Blood Pressure and More Severe Cardiac Damage. PL
alth, United States of America
ublished January 23, 2014
access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author a
ort.
competing interests exist.

Introduction of CKD [2]. Considering also the role of BP in diabetes, high BP is

believed to be the leading cause of end-stage renal disease
Chronic kidney disease (CKD) is a major health problem and its (ESRD). Every year, high BP causes more than 25,000 new cases of
prevalence is increasing worldwide [1]. A GFR lower than kidney failure in the United States [6]. A recent study shows that
60 mL/min/1.73 m2 for 3 months indicates CKD, regardless of even pre-hypertension is significantly associated with an
the presence or absence of kidney damage [2]. More than 10% of increased risk
the adult population of U.S. has some degree of renal
impairment and almost half of these subjects (5–6%) are
affected by a significant reduction of renal function (GFR
,60 ml/min/
1.73 m2) [3]. Data available from many European Countries are
similar regarding prevalence and incidence of CKD [4] whereas
only limited data concerning the prevalence of CKD in Italy have
been published [5].
High blood pressure (BP) can be either a cause or a consequence
PLOS ONE | www.plosone.org 1 January 2014 | Volume 9 | Issue 1 | e86155
of CKD and it can be considered one of the relevant causes of
CKD in the general population because of its high frequency [7].
In any case, when CKD is established BP increases. The results of
Modification of Diet in Renal Disease (MDRD) study confirmed
previous reports indicating that, in renal disease, hypertension
is determined by the level of renal function [8].
Moreover, CKD is strongly associated with inadequate BP
control. Many individuals with CKD are hypertensive and
receive medications for controlling BP. However, the majority of
these patients seem to be undertreated. Optimizing blood
pressure treatment in this high-risk population can have a great
potential in decreasing renal disease incidence and
cardiovascular mortality [9].
Several studies reported that patients with an altered
circadian blood pressure pattern, as non-dippers, have a higher risk
of major cardiovascular events compared with patients with a
normal pressure pattern [10–13].
Patients with CKD may have a non-dipping BP pattern. The
explanation for this is not clear, but many factors have
been

PLOS ONE | www.plosone.org 2 January 2014 | Volume 9 | Issue 1 | e86155


proposed (e.g. defective natriuresis during daytime and increased
blood pressure/natriuresis during the night) [14,15].
To date, to the best of our knowledge, there is little data
available, especially for the Italian population, regarding the
inter- relationships between estimated glomerular filtration rate
(eGFR), BP values and patterns (dipper, non-dipper) and
echocardio- graphic parameters. Therefore, the rationale of our
study was to investigate the associations between eGFR, BP values
and patterns and echocardiographic parameters, to see how
CKD and BP values and patterns may correlate with the
presence of a cardiac organ damage.
The main aim of our study was to assess 24-h BP values and
patterns and their relationship with eGFR and cardiac damage, in
a population referred to a single ‘‘Hypertension Excellence
Centre’’ for BP evaluation, in the hope to improve the clinical
management of these patients in the absence of similar published
data.
Materials and Methods
All participants have given their informed written consent and
clinical investigations have been conducted according to the
principles expressed in the Declaration of Helsinki. This study
was approved by the local institutional ethics committee
(Comitato di Bioetica, Ospedali Riuniti, Ancona). We studied
outpatients referred to our Hypertension Centre for BP related
problems Inclusion criteria were: clinical indication to undergo
ABPM, plasma creatinine measurement and echocardiography.
Main exclusion criteria were: age,18 years, low-quality of
pressure monitoring (rate of artifacts .25% and/or recording
duration less than 20 continuous hours and/or ,2 record per
hour at daytime and 1 record per hour at night-time), and
unreliable data regarding anti-hypertensive treatment. After
exclusions, 1805 patients were studied; eGFR was estimated
using the MDRD study equation [8] taking into account the
dosage of creatinine by the Jaffe´ reaction.
CKD was defined as the presence of confirmed eGFR ,60 ml/
min/1.73 m2 in patients having the clinical indication to at least
two creatinine determinations, the second one obtained 3 to 6
months after the first one (n = 962, 53.5% of the studied
population, 100% of patients with eGFR ,60 ml/min/
1.73 m2). No significant differences in creatinine/eGFR were
found between the two time points (assessed by paired t-Test),
supporting the notion that 15% of our patients truly had CKD.
CKD stages were defined according to the international
classification of National Kidney Foundation [2]. For each subject
24-h BP, daytime BP (defined as the BP values from 6 a.m. to 10
p.m.), night-time BP (defined as the BP values from 10 p.m. to 6
a.m) and pulse pressure (PP) [defined as systolic blood pressure
(SBP) - diastolic blood pressure (DBP)] were evaluated. Daytime
and night-time periods were defined based on a questionnaire,
in which patients were asked about their sleeping behavior.
Among patients under anti-hypertensive treatment, those with
mean 24-h BP ,130/80 mmHg, mean daytime BP ,135/85
mmHg, and mean night-time BP ,120/70 mmHg were defined
as controlled hypertensive. Among untreated patients we labeled
not-hyperten- sive those patients with mean 24-h BP ,130/80
mmHg, mean daytime BP ,135/85 mmHg, and mean night-
time BP ,120/ 70 mmHg [16]. We considered dippers those
patients with a change in mean awake SBP to sleep SBP equal to
or grater than 10%. We considered as night-to-day ratio the ratio
between medium night-time and daytime values recorded
performing ABPM. Night-to-day ratios were multiplied by 100,
expressing night-time BP as a percentage of a daytime level. A
ratio of 100%
CKD, Blood Pressure and Cardiac Damage
or higher indicated the absence of a BP fall at night [17]. After
evaluating drug therapy adherence by MMAS [18] a treatment
intensity score (TIS) was calculated to compare many different
drug associations. As previously reported [19], the recorded daily
dose taken by the patients was divided by the maximum
recommended daily dose to obtain a proportional dose (called
‘‘intensity’’) for that medication. The maximum recommended
daily doses set by the Italian National Drug Agency (AIFA) were
used for calculations. For completeness, dual-class drugs were
separated into their components, and intensity was calculated
separately for each chemical compound. The sum of all the
different values was recorded as the TIS.
Statistical analysis
Data were analyzed with the Statistical Package for Social
Science version 13 (SPSS Inc. Chicago, Illinois, USA). A value of
p,0.05 was defined as statistically significant. Quantitative
variables were checked for normality. Normally distributed
continuous variables were described as a mean 6 standard
deviation (SD). The unpaired t-test and ANOVA (for multiple
comparisons) were used to compare normally distributed quanti-
tative variables with Bonferroni correction for multiple compar-
isons. The x2 test was used to analyze the differences between the
categorical variables. Logistic and linear regression analysis and
ANCOVA were used to create adjusted models.
Results
General characteristics of the population with reliable ABPM
and drug therapy are shown in Table 1. We studied 1805
patients: 1012 men (56.1%) and 793 women (43.9%). There were
1535 (85.0%) patients with eGFR $60 ml/min/1.73 m2 and 270
(15.0%) CKD patients. Hypertension was present in 1680
(93.1%) patients; 1194 (71.1%) were on drug treatment: 311
(26.0%) were controlled, 883 (74.0%) were not controlled. CKD
stages are shown in Table 2. Only 10 patients (3.7%) of CKD
subgroup had stages 4–5 (eGFR ,30 ml/min/1.73 m2).
Among the CKD patients 264 (almost all: 97.8%) were
hypertensives, 218 (82.6%) were currently drug-treated, but only
63 (28.9%) had controlled BP.
CKD and BP values
As shown in Figure 1. Panel A-Panel B, 24-h and daytime
SBP did not differ significantly between patients with or without
CKD, but CKD patients had higher night-time SBP (127.6617.6
vs. 123.4615.2 mmHg; p,0.001; Figure 1. Panel C). On
the contrary, lower 24 hours (75.6610.4 vs. 80.6610.6
mmHg;
Figure 1. Panel A), daytime (77.9610.8 vs. 83.7610.9 mmHg;
Figure 1. Panel B), and night-time (69.8610.3 vs.
73.0610.9 mmHg; Figure 1. Panel C) DBP were found in CKD
where PP was higher in 24 hours (57.5613.3 vs.
 CKD, Blood Pressure and Cardiac Damage
Table 1. General characteristics of 1805 patients studied with
ABPM, echocardiography, and eGFR.

eGFR $ 60 ml/min/
1.73 m2 CKD P

Age (years 6 SD) 53.6613.2 66.2611.4 ,0.001

BMI (Kg/m2 6 SD) 27.464.4 27.764.7 n.s.
eGFR 79.0612.3 51.268.9 ,0.001

doi:10.1371/journal.pone.0086155.t001
 Table 2. Prevalence of CKD stages.

eGFR (ml/min/
1.73 m2) Mean ± Sd. 95% CI n6 %

45#eGFR,60 54.964.2 54.4–55.5 215 79.6%

30#eGFR,45 39.363.7 38.1–40.4 45 16.7%
eGFR,30 24.265.3 20.4–28.1 10 3.7%

doi:10.1371/journal.pone.0086155.t002

50.869.8 mmHg), daytime (57.6613.5 vs. 51.0610.0 mmHg)

and night-time (57.7614.0 vs. 50.3610.3 mmHg) periods (all
p,0.001) (Figure 2). These results were confirmed within
worsening CKD stages (Figure 3 panel A–D), after adjustment
for age and TIS, and in the linear regression model (Table 3): a
significant relationship between the 24-h pressure profile and
CKD was found only for nocturnal pressure values and for
daytime, night-time and 24-h PP.
CKD, dipping pattern, and night-to-day ratio
Along with higher night-time SBP, patients with CKD
showed higher prevalence of non-dipping pattern (72.6% vs.
59.4%; OR: 1.8, CI: 1.36–2.41; p,0.001) (Figure 4) and
CKD was an
Figure 2. Difference in PP between patients with CKD and the
rest of the population.
doi:10.1371/journal.pone.0086155.g002
independent risk factor for non- dipping pattern even after
adjusting for sex, age, BMI, and TIS in a logistic regression model
(Table 4). Patients with CKD also showed a linear association
between eGFR reduction and night-to-day ratio (b = 20.123;
p,0.001), another index of altered nocturnal BP.

Figure 1. ABPM values in CKD patients vs. the rest of the population. Panel A. Difference in 24-h BP between patients with CKD and the rest
of the population. Panel B. Difference in daytime BP between patients with CKD and the rest of the population. Panel C. Difference in night-time BP
between patients with CKD and the rest of the population.
doi:10.1371/journal.pone.0086155.g001

PLOS ONE | www.plosone.org 3 January 2014 | Volume 9 | Issue 1 | e86155

Figure 3. Correlation between ABPM values and CKD stages. Panel A. Difference in night-time BP between CKD stages. Panel B. Difference
in 24 h PP between CKD stages. Panel C. Difference in daytime PP between CKD stages. Panel D. Difference in night-time PP between CKD
stages. doi:10.1371/journal.pone.0086155.g003

CKD, BP values and patterns and cardiac damage night-time PP were independently associated with LVM/h 2.7 after
Considering the association with cardiac organ damage, adjusting for age, sex, BMI, TIS and the presence/absence of
patients with CKD had greater LVM/h2.7 (60.9621.9 vs. CKD (Tables 5, 6, 7, 8). A higher prevalence of an index of
51.8613.1 g/m2.7, p,0.001) and higher prevalence of left diastolic dysfunction that was available in all patients, was also
ventricular hypertrophy (79.0% vs. 61.4%, OR 2.48 CI:1.58– found in patients with CKD (E/A ratio ,1: 79.3% vs. 54.5%, OR
3.56; p,0.001) (Figure 5 Panel A–B). Indeed, linear regression 3.2 CI:1.97–5.18; p,0.001).
model showed that night-time SBP as well as 24-h, daytime and
CKD and BP control
Table 3. Correlation between ABPM parameters and Patients with CKD had a greater TIS (1.5660.91 vs.
eGFR assessed by linear regression. 1.1960.72; p,0.001) without significantly better BP control
but, on the contrary, a tendency toward worse control (25.4% vs.
28.9%; p = n.s.). Among hypertensive patients treated but with BP
B P not controlled, there was a significantly higher percentage
24-h SBP 20.019 0.413 (87.3%) of CKD with uncontrolled night-time SBP; OR = 2.4
(CI:1.11– 5.33; p = 0.022). Isolated uncontrolled night-time SBP
24-h DBP 0.172 ,0.001
were also increased in CKD (prevalence 20.6%) vs patients
Daytime SBP 0.007 0.765
with eGFR $ 60 ml/min/1.73 m2 (12.9%; p = 0.012) OR = 1.7
Daytime DBP 0.192 ,0.001 (CI:1.12–2.74).
Night-time SBP 20.066 0.005
Night-time DBP 0.118 ,0.001 Discussion
24-h PP 20.197 ,0.001
We studied a large patient population with clinical indication
Daytime PP 20.186 ,0.001 to perform ABPM, lab test for plasma creatinine and
Night-time PP 20.205 ,0.001 echocardiog- raphy. The main findings in patients with CKD were
doi:10.1371/journal.pone.0086155.t003
an altered SBP profile at night-time (higher BP and a more
frequent non dipper-pattern) and a higher PP which depends
also on a significantly lower DBP. Higher SBP values in patients
with
Figure 4. Prevalence of non dipping pattern in CKD.
doi:10.1371/journal.pone.0086155.g004
CKD could be merely due to the higher prevalence of
hypertension in these patients, as well as to a higher prevalence
of severe hypertension in CKD. However, 24-hours and daytime
pressures were not different between patients with and without
CKD. Only night-time SBP and the dipper pattern were
altered, leading to the hypothesis of a direct influence of CKD
on nocturnal blood pressure profile. Impaired natriuresis in
daytime may increase nocturnal SBP in order to compensate
the diminished natriuresis with pressure natriuresis. Fujii et al
[20] showed that the circadian rhythm of natriuresis is disturbed
in patients with a non-dipper type of essential hypertension, in
whom BP was usually sodium sensitive [21,22]. Since the
sodium sensitivity of blood pressure is considered to be caused by
reduced GFR and/or increased tubular reabsorption of sodium
[23,24], such disarrangement may be clearly recognized in CKD in
which renal function is deteriorated. In line with these findings,
Fukuda et al [25] showed that, in the impaired renal function
character- izing glomerulopathy, the nocturnal dipping of blood
pressure is lost, resulting in enhanced urinary sodium and
protein excretion during night-time. An important role seems to
be played by the autonomic nervous system, since renal
denervation has resulted in improvement of the nocturnal blood
pressure profile in patients with moderate to severe CKD, leading
to a reduction in night-to- day ratio and a restoration of the
physiological circadian BP rhythm [26].
In our study, the association between non-dipping pattern and
CKD was independent of age, sex, BMI and TIS, highlighting a
direct influence of CKD on circadian pressure profile. The rise in
differential pressures and the reduction in DBP were
independent of age and TIS; in patients with CKD, this could
be due to an
Table 4. CKD is an indipendent risk factor for non
dipping pattern after adjusting for sex, age, BMI, and TIS
(logistic regression).
OR 95% CI P our present work. Despite greater intensity of treatment in CKD,
Sex (male vs female) 0.855 0.659–1.109 n.s.
Age 1.013 1.002–1.023 0.016
TIS* 1.072 0.916–1.255 n.s.
BMI 1.055 1.024–1.087 ,0.001
CKD (CKD vs eGFR$60) 1.803 1.200–2.707 0.005
*TIS = Treatment Intensity Score.
doi:10.1371/journal.pone.0086155.t004
increase in arterial stiffness. Increased atherosclerosis and arterio-
sclerosis, as well as the metabolic alteration present in CKD with
secondary calcifications of the intima and media layers of the
artery wall, are likely contributors to this process [27]. This is
probably of great relevance in the population with CKD as the
patients with CKD are likely to be older (in our study the medium
age of CKD patients was 66.2611.4). Franklin et al [28]
demonstrated that, from age 60 and above, DBP was negatively
related to coronary heart disease (CHD) risk, when considered
together with SBP, and PP emerged as the best predictor. The
increased CHD risk due to isolated systolic hypertension may
depend not only on the elevated peak of SBP reached in the
aorta (ie, increased afterload) but also on the low DBP (ie,
potentially favoring a decreased coronary blood flow) [29]. In
patients older than 60, with central and peripheral PPs
approximating each other, PP becomes the dominant predictor
of CHD risk, incorporating both the positive predictive role of
SBP and the negative predictive role of DBP. In this way CKD
worsens the age- related arterial stiffness and potentiates its
effects. Our data overall strongly support the concept that once
CKD appears and worsens, some aspects of blood pressure worsen
too, as a consequence of CKD implications. These BP aspects
(higher night-time BP, more non-dippers and higher PP) are
known as important cardiovascu- lar risk factors [30–32] and
they translate in greater severity of cardiac damage in CKD.
Our patients with CKD had a higher prevalence of both
myocardial hypertrophy and diastolic dysfunction, suggesting that
the higher PP and the night-time SBP significantly increased the
heart load. Linear regression analysis revealed a strong association
between nocturnal blood pressure, PP and cardiac organ
damage. CKD itself was also independently associated with
cardiac damage, suggesting that other factors (such as CKD-
related metabolic alterations) in addition to BP are involved in
the higher prevalence of cardiac damage and cardiovascular risk
in these patients. Ad-hoc designed studies will be needed to
investigate the association between metabolic alterations in CKD
and cardiac damage, relevant aspects that were not the focus of
BP control is similar in the overall distribution. However, during
night-time, there is a higher percentage of subjects with poor
nocturnal control in CKD, a finding enlightened only by ABPM.
Because of the lack of recognized pressure target for ABPM, we
had to use arbitrary cut offs to define BP control, referring to the
values in the range of normotension for ABPM in general
population. Notwithstanding, according to initial evidences [33],
ABPM target pressure values in patients with CKD should be
lower than the one we considered.
Figure 5. CKD and cardiac damage. Panel A. Difference in left ventricular mass/h2.7 between patients with CKD and the rest of the
population. Panel B. Prevalence of ventricular hypertrophy in patients with CKD vs the rest of the population.
doi:10.1371/journal.pone.0086155.g005

Conclusions plasma creatinine value in the initial evaluation of outpatients.

Our ‘‘real-life patient’’ data are relevant for clinicians that Our study shows that patients with a reduced eGFR (,60
often evaluate BP-related clinical problems on the basis of a ml/ min/1.73 m2) had an altered 24-hour BP profile, especially
single at

Table 5. Night-time SBP associated with LVM/h2.7 in a

linear regression model.

B p

AGE 0.262 ,0.001

SEX 0.074 0.005
CKD 0.098 ,0.001
Night-time SBP 0.200 ,0.001
TIS* 0.092 0.001
BMI 0.358 ,0.001

BMI and age were also two other important independent factors for LVM/h2.7.
*TIS = Treatment Intensity Score.
doi:10.1371/journal.pone.0086155.t005
Table 6. 24-h PP associated with LVM/h2.7 in a
linear regression model.

B p

AGE 0.217 ,0.001

SEX 0.097 ,0.001
CKD 0.097 0.001
24-h PP 0.173 ,0.001
TIS* 0.082 0.003
BMI 0.351 ,0.001

BMI and age were also two other important independent factors for LVM/h2.7.
*TIS = Treatment Intensity Score.
doi:10.1371/journal.pone.0086155.t006
 Table 7. Daytime PP associated with LVM/h2.7 in a
linear regression model.

B p

AGE 0.219 ,0.001

SEX 0.096 ,0.001
CKD 0.099 ,0.001
Daytime PP 0.169 ,0.001
TIS* 0.082 0.003
BMI 0.353 ,0.001

BMI and age were also two other important independent factors for LVM/h2.7.
*TIS = Treatment Intensity Score.
doi:10.1371/journal.pone.0086155.t007

Table 8. Night-time PP associated with LVM/h2.7 in a

linear regression model.

B p

AGE 0.218 ,0.001

SEX 0.097 0.001
CKD 0.094 0.001
Night-time PP 0.170 ,0.001
TIS* 0.084 0.002
BMI 0.347 ,0.001

BMI and age were also two other important independent factors for LVM/h2.7.
*TIS = Treatment Intensity Score.
doi:10.1371/journal.pone.0086155.t008

night-time. Higher night-time SBP, a more frequent non-dipper
pattern and higher PP are related with more severe cardiac
organ damage.
Hypertension is the main cause of CKD and an accurate
measurement of BP is the critical first step for the proper
management of hypertensive patients. Our data highlight the
fundamental role of ABPM in optimizing antihypertensive
therapy when eGFR is low. The altered night-time BP pattern in
CKD suggests the need of improving BP therapy in these
subjects, by choosing drugs, dosages and timing to cover the 24
hour period, taking at least one drug at bedtime, and using
effective diuretics. ABPM should be the preferred method in the
clinical management of patients with CKD as well as in clinical
studies.
Study limits
The main limitation of our study is the use of post-hoc analysis
of consecutive ABPM recordings that were performed for usual
clinical reasons (including/excluding hypertension diagnosis,
verify the BP control in treated hypertensive patients). Although
a selection of patients was unavoidable (e.g. the three ‘‘inclusion
criteria’’: ABPM, creatinine and echocardiography), patient
selection was based only on the best clinical practice for the
management of arterial hypertension.
Overall, our analysis is based on one creatinine/eGFR and this
is certainly a limitation. Nevertheless, our data fit in the context
of current literature because most of the data available have
been obtained with a similar approach. Our ‘‘real-life patient’’
data are relevant for clinicians that make their decisions most
often on the basis of a single creatinine determination during
the initial
evaluation of ‘‘stable’’ outpatients coming for BP related problems.
Moreover, patients having the clinical indication for at least two
creatinine determinations, had the second one taken 3 to 6 months
apart. There were no significant differences in creatinine values/
eGFR between the two time points, supporting the notion that
15% of our patients truly had CKD.
Our study is based on ‘‘real-life’’ clinical practice, and we have
not been able to include all potential causes of non-dipping pattern
in the statistical adjustments (e.g. presence of obstructive sleep
apnoea documented by cardio-pulmonary monitoring), a limita-
tion similar to other studies that investigated the relationship
between lower eGFR and ABPM patterns. Moreover, we didn’t
study some CKD biochemical factors (e.g. regarding Ca, P
metabolism) and their role in influencing the association between
CKD, BP profile and cardiac damage. This was because some
metabolic parameters of CKD are not routinely assessed when
patients are referred for BP evaluation in a cardiovascular
setting. However, the overall night-time results (night-time SBP,
night- time PP, non dipping pattern) and increased 24 h PP in our
large population, even after statistical adjustments, strongly indicate
an altered pattern of night-time BP in CKD patients, with a
negative impact on the heart and therefore with important
clinical implications.
Author Contributions
Conceived and designed the experiments: RS MF. Performed the
experiments: MF FS. Analyzed the data: MF FS. Contributed reagents/
materials/analysis tools: GC. Wrote the paper: MF FS. Reviewed the
manuscript: PDF EE RS.
References
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 Elham et al. / Effect of Progressive
International Journal of Muscle…
Pharmaceutical and Clinical Research 2016; 8(12): 1634-1639

ISSN- 0975 1556

Research Article

Effect of Progressive Muscle Relaxation and Aerobic Exercise on

Anxiety, Sleep Quality, and Fatigue in Patients with Chronic Renal
Failure Undergoing Hemodialysis
Elham Amini1, Iraj Goudarzi2*, Reza Masoudi3, Ali Ahmadi4, Ali Momeni1
1
Faculty of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran;
2
Department of Psychiatry, Shahrekord University of Medical Sciences, Shahrekord,
Iran; 3Faculty of Nursing, Shahrekord University of Medical Sciences, Shahrekord, Iran;
4
Faculty of Public Health, Shahrekord University of Medical Sciences, Shahrekord, Iran;

Available Online: 25th December, 2016

ABSTRACT
Insomnia, anxiety, and fatigue are more common in hemodialysis patients than in healthy people and affect patients'
quality of life. In the present study, the effects of progressive muscle relaxation (PMR) and aerobic exercise on anxiety,
sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis were evaluated. In this double-
blind clinical trial, 100 hemodialysis patients were randomly assigned to three groups: PMR, aerobic exercise, and
control. Patients performed relaxation and aerobic exercise daily for 60 days. Questionnaires of anxiety, sleep quality,
and fatigue were completed by participants before and after the interventions. Data were analyzed by Stata software.
PMR program significantly decreased general anxiety, trait anxiety, state anxiety, and Beck anxiety and aerobic exercise
significantly reduced beck anxiety. PMR program and aerobic exercise both significantly improved sleep quality in
hemodialysis patients. PMR program significantly reduced Rhoten fatigue but did not affect Piper fatigue. Aerobic
exercise had no effect on Rhoten and Piper fatigue. Results showed better function of PMR compared to aerobic exercise
in improving the symptoms of anxiety, sleep disorders, and fatigue in hemodialysis patients. Given that fatigue and sleep
quality cause severe anxiety and somehow undermine quality of life in hemodialysis patients, taking into account non-
pharmacological treatments such as aerobic exercise particularly PMR is a highly economical but efficient and
efficacious strategy to manage several problems of these patients. Healthcare teams can incorporate these safe programs
in care designs.

Keywords: Progressive muscle relaxation, Aerobic exercise, Sleep quality.

INTRODUCTION dysfunction and adversely affects daily life and quality of

Incidence and prevalence of chronic renal failure (CRF)
is increasing worldwide and has recently been threatening
global health. Currently, over 5.1 million people
worldwide are able to survive only through hemodialysis,
peritoneal dialysis, and kidney transplant and are
estimated to double within the following decade. Over
360000 patients with end stage renal disease, increasing
by 5.12% each year, are living In Iran with 80 million
population1,2. Although enhanced dialysis techniques in
the recent years has caused increase in the longevity of
the patients with CRF, these techniques may bring about
several physical and mental complications prevention of
which can lead to improved quality of life among the
patients3.
Fatigue is one of the most common side effects of
hemodialysis and the most important nursing diagnosis in
CRF patients. The prevalence of this debilitating
symptom which is the leading stressor among
hemodialysis patients has been reported to be 60-90% 3.
Fatigue causes physical, social, and psychological
life4. Different studies have demonstrated significant
association between fatigue and demographic, laboratory,
clinical, and social variables such as underlying diseases
particularly diabetes, taking hypnotic drugs, low sleep
quality, nutritional deficiencies, physiological changes,
abnormal serum levels of urea, hemoglobin, and albumin,
hemodialysis-related concerns including low-sodium
dialysis solution and high-speed ultrafiltration as well as
psychological factors such as depression5.
Certain factors in hemodialysis patients such as dietary
restrictions, reduction in physical function, changes in
social life, job loss, impotence, feeling unwell, pain,
medications, treatment costs, and fear of death are
associated with prevalence of psychiatric disorders
particularly depression and anxiety1. Besides that, the
levels of albumin and pro-inflammatory cytokines have
been reported to be significantly and positively associated
with development of psychiatric disorders in
hemodialysis patients6. A study reported the prevalence
of anxiety, depression, and stress in hemodialysis patients

IJPCR, Volume 8, Issue 12: December 2016 Page 1635

to be 63.9%, 60.5%, and 51.7% and in patients
undergoing kidney transplantation to be 48.6%, 39%, and
38.4%, respectively7. Anxiety and depression in these
patients cause declined quality of life and increased risk
of mortality6.
Sleep is needed to remain healthy and restore
neurological, immune, and musculoskeletal systems.
Approximately, 25-36% of healthy adults suffer from
sleep disorders while 40-85% of CRF patients suffer from
these disorders that is much higher than its prevalence
rate in general population8. Accumulation of uremic
toxins, anemia, and nightly hypoxia are some of the
reasons for sleep disorders among these patients. Some of
the effective factors are anxiety, sadness, worry, and
history of depression 9. Sleep disorders affect individual
physical and mental function adversely and cause
executive, cognitive, and memory dysfunctions2.
Given that management and treatment of fatigue, sleep
disorders, and mental problems due to hemodialysis using
chemical drugs are mainly costly and are associated with
side effects, it is necessary to seek out appropriate
alternative treatments. Recently, supplementary and side
effect-free therapies such as aerobic exercise and
progressive muscle relaxation (PMR) to treat physical
and mental disorders due to chronic diseases have
attracted researchers' attention. Programs of PMR and
aerobic exercise are inexpensive and accessible
treatments whose efficacy has been demonstrated for
patients with multiple sclerosis disease10 and cancer11,12
as well as the elderly13-15. These programs could be
beneficial for hemodialysis patients as well. The effects
of PMR program in relieving anxiety and improving
quality of life have been demonstrated in some
studies16,17. The present study was conducted to
investigate the effect of aerobic exercise on relief of
anxiety, fatigue, and sleep disorders in comparison with a
PMR program.
MATERIALS AND METHODS
In this double-blind clinical trial, 100 patients with CRF
referred to the Hemodialysis Ward of Hajar Hospital,
Shahrekord in 2016 were selected according to
convenience sampling and randomly assigned to three
groups: aerobic exercise, PMR, and control. The
inclusion criteria were signing the informed consent form
to participate in the study, history of undergoing regular
hemodialysis for at least 12 months, lack of suffering
from severe neuromuscular diseases, depression, severe
and unmanaged underlying diseases, lack of taking
antidepressants and anti-anxiety and hypnotic medicines,
lack of participating in exercise or non-pharmacological
programs within the past 6 months, and being able to
perform interventional exercises. All patients signed the
informed consent form of participation in the study and
the study protocol was approved by the Ethics Committee
of the Shahrekord University of Medical Sciences.
After making necessary coordinations, the data on
demographic characteristics such as age, gender, marital
status, educational level, occupation, and history of
undergoing hemodialysis in month and year were
gathered. To conduct intervention in the PMR group, the
procedure of performing the program was explained to
the patients for the first time as they were undergoing
hemodialysis, and recorded CDs were distributed among
the patients so that the PMR program was conducted
during hemodialysis session and under the supervision of
the researcher. By this way, the defective performance of
the patients could be corrected; besides that, the
researcher's phone number was given to the patients so
that they could call the researcher to resolve the potential
problems related to implementation of the program. Then,
the patients were asked to perform the PMR program in
the same way at home every day for 60 days using the
CD. To achieve this purpose, before going to sleep at
night, the patients displayed the CD and contract and then
relax the muscles of each part separately as they were
lying down with accordance to the respective instructions.
In the aerobic exercise group, the predetermined exercise
was performed in the presence of researcher for the first
time and then after delivering initial explanations as the
patients were undergoing hemodialysis. If necessary, the
defective performance of the patients was corrected and
the patients were asked to perform the exercise in the
same manner for the next eight weeks. To ensure that the
patients do not forget the procedure of performing the
exercise, a checklist of the exercise was developed and
delivered to the patients. The researcher's phone number
was given to the patients so that they could call the
researcher to resolve the potential problems related to
performance of the exercise. The patients were asked to
perform the exercise at a certain time of the day so that
they had enough time to complete the program. The
researcher supervised the implementation of the exercise
program and followed up the patients once every two
weeks through telephone call or in person so that the
patients would be encouraged to continue implementing
the exercise program or excluded from the study if they
did not adhere to it for more than two days a week.
The mean scores for sleep quality, anxiety, and fatigue
before and after the interventions were determined. To
investigate sleep quality, Pittsburgh Sleep Quality Index
with validity and reliability already confirmed by
Ağargün et al.18 was used. To investigate anxiety,
Spielberger and Beck Anxiety Inventory with already
confirmed validity and reliability19,20 was used. In
addition, Piper and Rhoten Fatigue Scale whose validity
and reliability had been confirmed in a number of
studies21-22 was used to measure fatigue. Data collected
analyzed by Stata software version 13 using ANOVA,
chi-square and t-test.
RESULTS
One hundred hemodialysis patients (64 women and 36
men) hospitalized in the Hemodialysis Ward of Hajar
Hospital were enrolled in this clinical trial and randomly
assigned to three groups: aerobic exercise (n: 32), PMR
(n: 33), and control (n: 35). The patients’ Mean ages in
PMR group was 56.12 year and in aerobic exercise was
54.31 years and in control group was 55.22 years. The
patients performed the aerobic exercise and the PMR
 Elham et al. / Effect of Progressive
Muscle…

Table 1: Demographic characteristics of the studied hemodialysis patients.

Variable Groups Significance
CD Case Control
Sex male 22 21 21 0.826
female 11 11 14
Education Illiterate 11 7 14 0.117
Primary education 9 7 11
Secondary education 4 8 3
High school diploma 9 8 3
Academic 0 2 4
Occupation Civil servant 0 1 1 0.206
Labor 2 0 2
Farmer 3 5 7
Retired 6 4 4
Self-employed 11 9 7
Miscellaneous 2 2 1
Housewife 9 11 13
History of .00 10 11 11 0.937
hospitalization
1.00 8 10 9
2.00 2 3 3
3.00 5 4 3
4.00 2 0 3
5.00 6 4 6
Smoking yes 14 12 8 0.206
no 19 20 27
Marriage Single 2 3 1 0.080
Married 29 27 26
Divorced 0 2 0
Widow/Widower 1 0 5
Miscellaneous 0 0 1
* Significant difference at p<0.05.

program on a daily basis for eight weeks. Table 1 shows
the demographic characteristics of the studied patients.
The mean scores for anxiety, depression and sleep quality
before and after the interventions are shown in Table 2.
According to the findings, general anxiety, trait anxiety,
state anxiety, and Beck anxiety were significantly lower
after the intervention than before in the PMR group
(p<0.05). In the aerobic exercise group, Beck anxiety was
significantly lower after the intervention than before
(p<0.05) but Piper fatigue was not significantly different
between before and after the intervention. The mean
score for sleep quality decreased significantly after the
intervention in the PMR and aerobic exercise groups,
which represents the significant improvement of sleep
quality (p<0.05).
DISCUSSION
The present study investigated the effects of aerobic
exercise and PMR on anxiety, sleep quality, and fatigue
in CRF patients undergoing hemodialysis. The findings of
this study indicated that aerobic exercise caused
significant relief of Beck anxiety and improvement of
sleep quality in the hemodialysis patients but had no
significant effect on these patients' fatigue. It has been
argued that aerobic exercise causes increase in oxygen
intake and intensification of the process of producing
energy. The beneficial effects of aerobic exercise on
atherosclerosis, insulin sensitivity and increased HDL-C
level have been demonstrated23. In addition, aerobic
exercise has been reported to exert beneficial effects on
the functioning of the body, quality of life, cardiovascular
diseases, anemia, cholesterol levels, and insulin resistance
in CRF patients24.
Kouidi et al. reported that aerobic exercise was associated
with reduced symptoms of anxiety and depression and
enhanced quality of life in hemodialysis patients25. Reid
et al. study indicated that aerobic exercise exerted
beneficial effects on sleep disorders and consequently
quality of life among the elderly15. A clinical trial showed
that bicycle ergometer, treadmill, and stationary bike of
upper limb three 60-minute sessions per week for four
months caused significant relief of anxiety and depression
as well as significant improvement of quality of life in
hemodialysis patients26. In the current study, consistent
with previous studies, the aerobic exercise caused
significant relief of anxiety and improvement of sleep
quality in the hemodialysis patients. This study is the first
to provide evidence on the beneficial effects of aerobic
exercise on sleep quality of hemodialysis patients.
In the light of the findings of the current study, the PMR
program caused significant relief of general anxiety, trait
anxiety, state anxiety, Beck anxiety, and Rhoten fatigue,
and improvement of sleep quality in the hemodialysis
patients, which is consistent with previous studies.

IJPCR, Volume 8, Issue 12: December 2016 Page 1636

 Table 2: Comparison of mean scores of anxiety, fatigue, and sleep quality between before and after the intervention
in the groups of the study.
Variable Groups of study Before intervention After intervention Significance
Mean (standard Mean (standard
deviation) deviation)
General Anxiety Progressive muscle 80.45±21.59 62.87±12.59 <0.001
relaxation
Aerobic exercise 75.32±22.76 68.87±11.83 0.13
Control 77.14±18.03 74.34±11.67 0.44
State anxiety Progressive muscle 39.03±11.93 30.12±8.05 <0.001
relaxation
Aerobic exercise 36.83±11.12 33.51±5.92 0.09
Control 58.51±20.59 36.68±6.10 <0.001
Trait anxiety Progressive muscle 43.09±13.06 32.93±5.99 <0.001
relaxation
Aerobic exercise 38.25±12.13 35.15±7.67 0.21
Control 43.96±11.73 37.81±7.11 0.01
Beck anxiety Progressive muscle 41.60±12.97 30.21±5.56 <0.001
relaxation
Aerobic exercise 37.80±13.12 31.73±13.17 0.01
Control 41.45±10.76 31.61±7.58 <0.001
Piper fatigue Progressive muscle 63.71±49.35 42.26±22.74 0.055
relaxation
Aerobic exercise 57.67±39.33 59.92±28.87 0.77
Control 83.85±35.89 81.17±32.55 0.33
Rhoten fatigue Progressive muscle 6.28±2.67 3.96±2.23 <0.001
relaxation
Aerobic exercise 5.46±2.89 4.37±1.62 0.08
Control 6.65±2.66 6.2±2.15 0.40
Sleep quality Progressive muscle 11.26±2.53 4.57±1.74 <0.001
relaxation
Aerobic exercise 10.92±1.81 4.26±1.65 <0.001
Control 11.74±2.39 11.09±2.72 <0.001
* Significant difference at p<0.05.

Yildrim et al. investigated the effect of a PMR program
(PMRT) on anxiety level and sleep quality among
hemodialysis patients. The mean score for anxiety before
and after the PMR program was derived 43.6±5.9 and
31.1±5.6, respectively, with a significant difference.
Yildrim et al. study demonstrated that the PMR program
caused a significant improvement of quality of life and
relieved anxiety among CRF patients16. A study
investigated 38 hemodialysis patients undergoing PMR
program self-training using videotape and reported
significant reduction in anxiety levels compared to
controls27.
Saeedi et al. investigated the effect of PMR on sleep
quality of hemodialysis patients, and found that the mean
total score for sleep quality after the PMR was
significantly lower than that before the PMR. Moreover,
the scores for dimensions of sleep quality (except for
taking hypnotic drugs) were significantly lower before
the PMR than after17. Rambod et al. study indicated that
PMR program caused significant improvement of sleep
quality and decreased use of hypnotic drugs 8. There are
some controversies about the action mechanism of PMR
effect on insomnia in hemodialysis patients. It is argued
that uremia, anxiety, worry, and depression play an
important role in emergence and development of
insomnia in hemodialysis patients. Given that PMR can
relieve anxiety, depression, and stress in hemodialysis
patients, this type of exercise seems to help improve sleep
quality of these patients as well.
The effects of the PMR on fatigue in hemodialysis
patients have not yet been investigated. Dimeo et al.
reported that the PMR exercise program could improve
physical function and reduce fatigue levels in cancer
patients undergoing surgery12. Demirlap et al. study
demonstrated the positive effects of PMR in reducing
fatigue among patients with breast cancer undergoing
chemotherapy11. The present study too demonstrated the
positive effects of the PMR program in reducing fatigue
in the hemodialysis patients.
CONCLUSION
The PMR program caused significant relief of general
anxiety, trait anxiety, Beck anxiety, and Rhoten fatigue
and improvement of sleep quality in the hemodialysis
patients. The aerobic exercise caused significant relief of
Beck anxiety and improvement of sleep quality in the
patients. Taken together, the PMR program was more
efficient than the aerobic exercise to reduce anxiety level,
fatigue, and sleep disorders in the hemodialysis patients.
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