**13. Treatment**

General treatment measures include reducing potential exacerbating factors such as excess caffeine, alcohol, nicotine, medical conditions (anemia, iron deficiency), and medications

delayed sleep onset latency, decreased total sleep time, increased use of sleep medications and self reported nocturnal leg movements (36). Polysomnographic studies of dialysis patients with RLS and or PLMD showed increase in sleep latency, Stage 1 and Stage 2 sleep,

The pathophysiological mechanisms involved in RLS and PLMD are not very clear. Anemia, iron, and vitamin deficiencies, disturbance in peripheral and central nervous system (CNS) functioning and musculoskeletal abnormalities have all been proposed. It is likely that

Correction of anemia by treatment with erythropoietin has been associated with reduction in the frequency of PLMD, improvement in sleep quality and day time alertness (44).Iron deficiency probably plays a dual role in that it causes anemia and is also a co-factor in the metabolism of dopamine in the brain. Treatment with intravenous iron is associated with a significant improvement in RLS and PLMD(45).Peripheral neuropathy, secondary to uremia or the underlying cause of renal disease such as diabetes may also predispose to develop RLS and or PLMD. Data regarding the clinical and laboratory correlation of RLS and PLMD is inconsistent. Higher predialysis urea and creatinine levels have been associated with increase RLS complaints in one study (1) but no relationship was detected in others (36, 41). Higher intact parathyroid hormone(PTH) levels has been found in dialysis patients with PLMD vs. those without the disorder(46), but lower levels have been noted in uremic

RLS is diagnosed clinically. PLMD is diagnosed objectively with polysomnography, which

PLMD can be identified on a polysomnogram by examining spiked activity coming from the electromyogram (EMG), which measures muscle movement during sleep. Specifically, anterior tibialis recording is usually sufficient in detecting the periodic limb movement episodes. Periodic limb movements typically last 0.5-5 seconds in duration and usually occurs approximately every 20-40seconds. The severity is described in terms of leg movement per hour of sleep (periodic limb movement index, PLMI). PLMI >5 is considered abnormal. Additionally, the examination of EEG test results will indicate micro-arousals, which can also lead to a diagnosis. PLMD can occur independently of RLS, and is more common with advancing age (35). RLS is almost always associated with PLMD, but PLMD

RLS is associated with difficulty initiating sleep, poor sleep quality, and impaired health quality of life (48) (FIGURE-5). RLS has been associated with depression. PLMD has been

General treatment measures include reducing potential exacerbating factors such as excess caffeine, alcohol, nicotine, medical conditions (anemia, iron deficiency), and medications

alteration of dopamine activity in the nervous system plays a role (42-43).

and decreased total sleep time and efficiency (38-41).

patient with RLS in comparison without symptoms(47).

reveals periodic, involuntary movements of the legs during sleep.

associated with increased mortality in patient with ESRD (49).

**12. Diagnosis/Clinical significance** 

can occur in the absence of RLS.

**13. Treatment** 

**11. Pathophysiology** 

Fig. 5. RLS, Insomnia and quality of life in patients on maintenance dialysis.

(tricylcic antidepressants, Serotonin reuptake inhibitors, dopamine antagonists). Medical therapy includes L-Dopa and dopamine agonists such as pramipexole and ropirinole (64). These medications are favored over benzodiazepines. Gabapentin can also be used as alternative. The frequency of PLMD is not affected by switching from CHD to NHD (28). Kidney transplantation has been associated with an improvement in both RLS and PLMD in several small studies (50, 51).
