A Preliminary study on the improvement of sleep disorders in hemodialysis patients through stellate ganglion blockade

Hemodialysis (HD) serves as the primary renal replacement therapy for patients with end-stage renal disease. According to data from the Chinese National Renal Data System (CNRDS, http://www.cnrds.net), the number of HD patients in China has shown a rapid increasing trend in recent years, reaching 1.027 million by the end of 2024. Studies indicate that 41%~85% of HD patients experience varied sleep disorders, such as difficulty falling asleep, nocturnal awakenings, and early morning awakenings, which are significantly higher than those in the general population, resulting in substantially increased mental disorders, poor quality of life, cognitive dysfunction, immune system disorders, and high cardiovascular risk and mortality. However, conventional treatments have limited efficacy and carry risks such as drug dependence and associated adverse effects like falls and neuropsychiatric abnormalities. Ultrasound-guided stellate ganglion blockade, by modulating autonomic nervous function, melatonin secretion, immune response, and cerebral cortical excitability, can help restore disrupted sleep rhythms. This study preliminarily investigates the efficacy and feasibility of a single session of stellate ganglion blockade for improving sleep disorders in HD patients. 

The patients undergoing maintenance HD in the Blood Purification Center of Beijing Friendship Hospital were recruited. The inclusion criteria were: (1) age between 18 and 60 years; (2) presence of chronic insomnia (occurring ≥3 times per week and lasting ≥3 months); (3) poor response to pharmacotherapy, cognitive behavioral therapy, or cool dialysate therapy; (4) absence of severe cardiopulmonary diseases; (5) no coagulation disorders. The exclusion criteria included: (1) history of stroke within the last 3 months; (2) comorbid restless legs syndrome; (3) comorbid sleep apnea syndrome; (4) glaucoma. After comprehensive evaluation by a specialized anesthesiology and pain management team, ultrasound-guided stellate ganglion block was performed. Under real-time ultrasound guidance, the stellate ganglion was localized, and a needle was inserted via the posterior or lateral border of the sternocleidomastoid muscle to the deep fascia of the longus colli muscle. Then, 5 ml of 2% lidocaine was slowly injected. Questionnaire surveys were conducted before the intervention and at 1, 3, and 6 months post-treatment to assess the Pittsburgh Sleep Quality Index (PSQI), non-dialysis day blood pressure, and usage of antihypertensive medications. Paired sample t-tests or non-parametric tests were employed for pre- and post-treatment comparisons. P of <0.05 was considered statistically significant.

Eight patients were included, comprising 7 males (87.5%), with a mean age of 52.3 ± 6.8 years. The primary renal diseases were chronic glomerulonephritis (n=5), diabetic nephropathy (n=2), and autosomal dominant polycystic kidney disease (n=1). The median dialysis vintage was 84 months (IQR: 60-144), and the mean Kt/V was 1.347 ± 0.199. Following stellate ganglion block treatment, a significant reduction in the PSQI score was observed, indicating improved sleep quality. This improvement persisted throughout the 6-month follow-up period (Baseline: 16.6 ± 2.7; 1 month: 13.3 ± 3.0 (P=0.017); 3 months: 13.8 ± 3.7 (P=0.023); 6 months: 14.4 ± 2.9 (P=0.038)). Significant improvements in interdialytic blood pressure were also noted. Systolic blood pressure decreased from 155 ± 13 mmHg at baseline to 143 ± 13 mmHg at 1 month (P<0.001), 143 ± 13 mmHg at 3 months (P<0.001), and 143 ± 11 mmHg at 6 months (P<0.001). Diastolic blood pressure decreased from 103 ± 10 mmHg at baseline to 92 ± 11 mmHg at 1 month (P=0.003), 89 ± 10 mmHg at 3 months (P=0.003), and 90 ± 9 mmHg at 6 months (P=0.003). The intensity of antihypertensive medication use, expressed as the Defined Daily Dose (DDD), showed a significant decrease at 3 and 6 months compared to baseline (Baseline: 3.5 [3.0-4.8]; 1 month: 2.5 [2.0-4.8] (P=0.102); 3 months: 2.5 [2.0-4.0] (P=0.014); 6 months: 3.0 [2.0-4.0] (P=0.025)). All patients tolerated the procedure well, with no reports of significant discomfort or adverse events.

This preliminary small-sample investigation suggests that ultrasound-guided stellate ganglion block is feasible and well-tolerated in HD patients with chronic insomnia. The intervention was associated with significant and sustained improvements in sleep quality, maintained at the 6-month follow-up, alongside enhanced blood pressure control. Ultrasound-guided stellate ganglion block represents a promising non-pharmacological intervention for managing sleep disturbances in this population. The present beneficial effects warrant further validation through large-scale, multicenter, randomized controlled trials with extended follow-up periods.