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Draft: not yet reviewed by a clinician

Use this page to prepare questions for your care team. It does not replace their advice. Your own targets and doses come from your nephrologist, diabetes team and renal dietitian.

Sleep, restless legs and itch

In short

About half of people with kidney disease who are not on dialysis sleep poorly, and almost as many are bothered by itch (KDIGO 2024, Figure 49). Common causes are restless legs, itch, sleep apnea, waking to pass urine, worry, and with type 1 diabetes, lows at night. Most of these can be treated, so tell your team: KDIGO asks kidney teams to ask about symptoms at every visit, and the ADA asks diabetes teams to ask about sleep (KDIGO 2024, practice point 5.2.2.1; ADA 2026 §5). For restless legs, the first steps are a simple iron test and looking for things that make it worse (AASM 2024).

Your numbers

How common (KDIGO 2024, Figure 49): in people with CKD who are not on dialysis, tiredness about 70 %; poor sleep about 49 %; itch about 46 %.

Iron and restless legs (AASM 2024):

Who Iron treatment is considered when
Adults with restless legs ferritin 75 ng/mL or less, or transferrin saturation (TSAT) under 20 %
Restless legs with kidney failure ferritin under 200 ng/mL and TSAT under 20 % (iron given into a vein)
Who Iron treatment is considered when
Adults with restless legs ferritin 75 µg/L or less, or transferrin saturation (TSAT) under 20 %
Restless legs with kidney failure ferritin under 200 µg/L and TSAT under 20 % (iron given into a vein)

These thresholds are for restless legs. Your kidney team also checks iron for anemia, with its own numbers (KDIGO 2026 anemia; Hemoglobin and iron).

Night-time lows on a CGM report (time-in-range consensus):

Measure Most adults Older or higher-risk adults
Time below 70 mg/dL under 4 % (about 1 hour a day) under 1 %
Time below 54 mg/dL under 1 % (about 15 minutes a day) —
Measure Most adults Older or higher-risk adults
Time below 3.9 mmol/L under 4 % (about 1 hour a day) under 1 %
Time below 3.0 mmol/L under 1 % (about 15 minutes a day) —

Restless legs

Restless legs cause an uncomfortable urge to move your legs, mostly in the evening or at night when you are still. Moving eases it for a while (AASM 2024).

What your team may do (AASM 2024; KDIGO 2024, Table 38):

  • Check your iron (ferritin and TSAT), ideally in the morning, and treat low iron. AASM advises testing without iron pills or iron-rich food in the 24 hours before, so ask your team whether to skip them before the test.
  • Look for things that make it worse: caffeine, alcohol, sedating antihistamines (ask your pharmacist whether a sleep or allergy aid contains one), some antidepressants and anti-sickness medicines, and untreated sleep apnea. A high phosphate level can also play a part.
  • Medicines: gabapentin-type medicines are now a first choice. Older dopamine-type medicines (such as pramipexole, ropinirole and rotigotine) are no longer the standard choice, because over time they can make restless legs worse. With kidney failure, the AASM also suggests vitamin C. Doses must be set for your kidney function, so never start or change one on your own.

Itch

  • Itch is common and can wreck sleep. Tell your team; do not just put up with it (KDIGO 2024, practice point 5.2.2.1).
  • For dry skin, use a moisturiser every day. Other options your team may suggest include gabapentin-type medicines and light therapy (UVB) (KDIGO 2024, Table 38).
  • Severe itch that nothing helps can be a sign that kidney failure needs treatment, such as starting or adjusting dialysis (KDIGO 2024, Table 41).

Sleep apnea and waking at night

  • Loud snoring, stopping breathing in your sleep, gasping, morning headaches or falling asleep in the day are reasons to ask for a sleep test. Untreated sleep apnea also makes restless legs worse (AASM 2024; ADA 2026 §5).
  • Waking often to pass urine is worth raising with your kidney and diabetes teams, who can look for the cause. Keep a note of how often it happens in your sleep diary.

Night-time lows

Kidney disease makes lows more likely, because failing kidneys clear less insulin and make less glucose (Pecoits-Filho 2016). Lows at night are easy to miss. Signs include nightmares or crying out, sheets or pyjamas damp with sweat, and waking tired, irritable or confused (NIDDK).

  • A CGM can alarm when glucose drops below your target (NIDDK; ADA 2026 §7). Keep the alarm on and loud enough to wake you, or share alerts with a family member.
  • Keep glucose tablets by the bed. They work fast and add no potassium, phosphorus or fluid (Treating a low).
  • Always treat a low at night, even if you are tired: 15 g, recheck in 15 minutes (ADA 2026 §6).
  • If you have lows at night, tell your diabetes team. Your plan may need to change. Never change your insulin on your own because of this page.

What to do

  • Keep a one-week sleep diary: bedtime, waking, what woke you (legs, itch, toilet, a low), and how you felt in the day.
  • Ask your team for an iron test if you have restless legs (AASM 2024).
  • Cut down on caffeine and alcohol, which can make restless legs worse (AASM 2024).
  • Bring every medicine and sleep aid you take, including over-the-counter ones, to your next visit.
  • Keep a regular bedtime, a dark, cool room, and screens out of bed (ADA 2026 §5; KDIGO 2024, Table 38).
  • Moisturize dry skin every day.
  • Turn on your CGM's low alert and keep glucose tablets within reach of the bed.

Examples

Restless legs on dialysis. You cannot sit still in the evenings. Your team checks your iron: ferritin 150 ng/mL (150 µg/L) and TSAT 15 %. That is below the AASM threshold for people with kidney failure, so they give iron into a vein during dialysis (AASM 2024). You also stop the over-the-counter sleep aid you were taking, after your pharmacist explains that its antihistamine can make restless legs worse.

Sweaty sheets. You wake up with damp sheets and a headache. Your CGM shows 3 hours under 70 mg/dL (3.9 mmol/L) overnight. You tell your diabetes team the next day, and they change your plan (NIDDK; ADA 2026 §6).

Ask your care team

  1. Could my restless legs be from low iron? Can you check ferritin and TSAT?
  2. Do any of my medicines or sleep aids make restless legs or sleep worse?
  3. What can I do about itch? Is my dialysis or phosphate playing a part?
  4. Should I have a sleep test for sleep apnea?
  5. How should my CGM low alert be set at night?

Get help now if…

Call 911 (or your local emergency number)

You cannot breathe lying flat or wake up gasping and breathless (this can be fluid on the lungs); someone cannot be woken up or has a low they cannot treat (give glucagon, then call); chest pain. Full list: Get help now.

Call your team today

Lows at night that keep coming back, or itch, restless legs or sleeplessness that suddenly get much worse.

Sources

Not yet reviewed by a clinician. Facts and sources last checked 2026-10-06.