Hemodialysis is the first choice for the treatment of end-stage renal disease. There are currently millions of people in dialysis treatment and the number will double by 2030.1 patients' survival times are extended when hemodialysis becomes more advanced and used. However, the long-term sickness will result in physical discomfort, significant financial and emotional pressure, which will cause insomnia, anxiety and sadness, mental instability, and an inclination toward suicide.2,3

Poor sleep quality is a common problem in patients receiving dialysis treatment.4 The prevalence of insomnia has been reported to be as high as 60%-80%, and symptoms such as daytime sleepiness and mental depression exist in 51%-77% of these patients,5,6 which may lead to a decrease in health seeking behavior. Physiologically, urea tends to be deposited in the skin as urea creams, which causes dryness and irritation.7 Moreover, concomitant peripheral neuropathy and secondary hyperthyroidism can result in restless legs syndrome,8 which can be uncomfortable and lead to conditions such as difficulty in falling asleep or having trouble falling asleep again after waking up. Furthermore, the quick elimination of urea nitrogen from the blood the night after dialysis results in a rapid drop in blood osmolarity, which generates a dialysis imbalance that forms cerebral edema and induces sleeplessness.9 Psychologically, Regular dialysis limits patients' social activities, which makes it difficult to release negative emotions. Also, the expensive cost of dialysis puts a burden on families' finances. All of the above stressors are detrimental to the patient's sleep.

Many physiological, psychological, cognitive, and medicinal strategies are available to improve the quality of sleep in hemodialysis patients. The most popular of these is cognitive behavioral therapy (CBT). CBT has shown promising outcomes in treating sleep disturbances, poor compliance, and other psychological issues in people with diabetes, stroke, and chronic obstructive pulmonary disease.10 CBT has been applied as an adjunctive therapy for hemodialysis patients in recent years.11 However, its acceptance in China is not high due to the lack of health care professionals, the need for equipment, the long duration of the intervention, and the pressure of treatment costs, so patients are reluctant to actively or long-term accept the therapy.12

Exercise therapy, an easy-to-implement sleep quality intervention, has been demonstrated in trials to improve exercise endurance and sleep quality while reducing stress and negative emotions.13,14 However, due to the requirement for expert supervision and reduced exercise ability, it is not frequently used among Chinese patients.

In the last 10 years, meditation has gradually spread in China as a way to reduce stress and anxiety. Patients who use meditation techniques can better comprehend and accept themselves as well as self-adjust their emotions. As a result, it is possible to achieve the effects of reducing negative emotions and enhancing sleep quality.15 However, meditation calls for specialized instruction under qualified supervision as well as a high level of patient education, making it difficult to be widely promoted.

Using sleeping tablets or other medications, such as blood perfusion,16 can be helpful for those with more severe sleep disturbances. But there are concerns about safety, the potential of addiction, and financial strain. Therefore, it is particularly important to construct an effective, affordable and simple intervention program for sleep quality in maintenance hemodialysis patients.

Emotional freedom therapy (EFT) is a psychophysiological intervention that combines elements of cognitive-behavioral therapy, exposure therapy, and somatic stimulation using acupuncture points.17 EFT has been used worldwide by therapists, psychologists, practitioners, and counseling workers18 to address certain problems such as emotional,19 psychological, or physical disturbances in patients with diabetes, hypertension, PTSD and Hwabyung.20 Systematic reviews and meta-analyses have demonstrated its efficacy in treating both mental and physical conditions.21 EFT's acupoint tapping technique, which is a component of traditional Chinese medicine, is more well-received by Chinese patients, especially those who are elderly.

Based on the aforementioned factors, we attempted to apply EFT technology to patients with nephropathy receiving maintenance hemodialysis. We hypothesized that EFT can (1) lessen patients' anxiety and depression; (2) enhance hemodialysis patients' quality of sleep; and (3) improve patients' response to treatment.