Post on 18-Nov-2014
description
Sleep Apnea & Kidney Disease
Ed Charnock, M.DJack Gardner, M.D.
Medical Sleep Solutionswww.medicalsleep.com
O
SA DISCUSSIO
NS
OSA DISCU
SSION
S
• Prevalence of Sleep Apnea
• Medical complications of Sleep Apnea
• Renal complications of Sleep Apnea
• Screening for Sleep Apnea
• Treatment- Does it make a difference?
O
SA & O
BESITYO
SA & O
BESITY
General Population 2 – 4 % Wisconsin Cohort Study 1988 6% Female – 10% Male Young, et al 1993 5% Female – 17% Male Bixler, et al 2001
Obesity is the major cause of OSA
50% of obese people have OSA
O
BESITY O
BESITY
No data <10% 10%-14% 15%-19%
O
BESITY O
BESITY
No Data < 10% 10%-14% 15%-19% 20%-24% 25%-29% ≥ 30%
O
SA & O
BESITYO
SA & O
BESITY
• 72 Million Obese Adults• 36 Million have OSA• 12% of Adults with OSA• This estimate does not include non-
obese adults with OSA
Javaheri, Univ. Cinncinati, NWPSA Conference
SLEEP APN
EASLEEP APN
EA
• Hypertension• Heart attack• Stroke• CHF• Cardiac arrhythmia• Inflammatory factors
• Glucose intolerance – Insulin resistance
• Increased incidence of MVA’s
• Progression of chronic kidney disease?
HTN
- OSA
HTN - O
SA
• OSA is a primary cause of hypertension JNC 7 REPORT; JAMA, 2003
• OSA is an independent risk factor for hypertension Pankow Chest 1997 Nov 5, 112(5): 1253-8
Curr Opin Neprol & Hypertens. 2004 May 13(3) 359-364
• OSA may be responsible for 30% of cases of essential hypertension Silverberg Curr Opin Nephrol Hypertens. 1998 Jul;7(4):353-7
• 41 patients – BP 140/90 on 3 or more anti-hypertensives
• 96% of the men and 65% of the women had OSA with AHI > 10.Logan et al J Hypertension 2001 Dec;19(12):2271-7
O
SA - HTNO
SA - HTN
Epidemiological studies showing association of OSA with HTN are not the proof of causality.
Only well done randomized placebo- controlled trials showing that elimination of OSA improves HTN prove that OSA is a cause of HTN.
O
SA - HTNO
SA - HTN
•Pepperell et al, Lancet 2001
•Becker et al, Circulation 2003
•Coughlin et al, ERJ, 2007
O
SA - HTNO
SA - HTN
1. In hypertensive patients with moderate to severe OSA, there is a BP drop of about 5-10mm Hg with CPAP therapy
2. The key is effective therapy and adherence to CPAP
3. The short term reduction in BP occurs within a few weeks
O
SA - HTNO
SA - HTN
9 Prospective Studies; N= 420,000; Mean F/U 10 Y
Decrease in DB, mm Hg 5 7.5 10
Decrease in CHD, % 21 29 37
Decrease in stroke, % 34 46 56
Mac Mahon et al. Lancet. 1999
ATHERO
SCLEROSIS
Kohler, AJRCCM, 2007
Drager, AJRCCM, 2005
Savransky, AJRCCM, 2007
Atherosclerosis
Atherosclerosis
•Reduction of early signs of atherosclerosis
•Reduction on arterial stiffness
•Reduction of intima-media thickness
Drager, AJRCCM, 2007
ARRHYTHM
IAARRHYTHM
IA
Tachy-brady arrhythmias: Most commonAtrial: Sinus Arrest, Atrial FibrillationAV nodal: Complete Heart BlockVentricular: PVC’s. VT
Effective CPAP therapy decreases nocturnal arrhythmias (CSA & OSA)
ARRHYTHM
IAARRHYTHM
IA
45 patients with OSA- mean AHI 508 had nocturnal pathologic rhythm Severity of rhythm disturbance correlated with OSA severityRhythm normalized in 7of 8 patientsThe 8th patient had severe aortic valve disease. Harbison Chest 2000 Sep;118(3):591-5
100 out of 114 consecutive patients100 out of 114 consecutive patients
AHI AHI ≥ 5/h (mild) 68% AHI AHI ≥ 15/h (moderate) 49%
Javaheri:Ann Intern Med 1995Circulation 1998Int J Cardiol 2006
O
SA - SHFO
SA - SHF
•Our screen
N
PSGN
PSG
•Our screen
CPAP
CPAP
•Our screen
AU
TO-SV
AUTO
-SV
SLEEP APN
EASLEEP APN
EA
•50–73% on dialysis have sleep apneaChest 2009; 135:710-716
•Strong association with severe OSA•More sleep time with oxygen <90%•Sleepiness often attributed to uremia•Higher incidence of HTN & DM •Increased cTnT and CRP indicating cardiac stress and inflammation
SLEEP APN
EASLEEP APN
EA
Sleep Apnea is complex with central and obstructive componentsTraditional risk factors, plus –
Decreased pharyngeal cross section Increased chemosensitivity causing
destabilization of respiratory control Accumulation of toxins and cytokines,
particularly TNF-alpha and IL-680% have sleep disorders including insomnia, PLMS, RLS, circadian rhythm disturbance
CKD
CKD
•20-40% increased risk of sleep apnea in early CKDChest 2009:135: 710-716
•CKD – an independent risk factor for OSA•30% increase in CKD in past decade•Mostly attributed to rising rates of DM and HTN•Association -- sleep apnea and earlier CKD???•Known pathologic mechanisms make it conceivable that sleep apnea may contribute to the development and progression of CKD
CKD
CKD
•Reactive oxidative stress is associated with recurrent hypoxia with ischemia•OSA is associated with “non-dippers”•Progression of CKD is greater in “non-dippers”•CPAP reverses “non-dippers”•CPAP therapy reduces inflammatory factors associated with endothelial dysfuntion •CPAP therapy may reduce proteinurea
HTN
RATEHTN
RATE
28% in pts without OSA or CKD
50% in pts with OSA
70% in pts with OSA and CKD
Numerous RCT’s in DM & non-DM pts with early renal
insufficiency reveal that lowering blood pressure is
associated with slowing the progression of CKD.
Early intervention is KEY to preservation of renal function.
Does CPAP therapy stabilize and prevent or slow the progression of kidney disease?
CLIN
ICAL CLIN
ICAL
•Less likely to be obese
•Frequently don’t snore
•Daytime sleepiness often attributed
to uremia
•Underdiagnosed
PRO
CESSPRO
CESS
IN
TERFACESIN
TERFACES
BEN
EFITSBEN
EFITS
• Better blood pressure control• Lower MI and CVA risk• Fewer arrhythmias• Lower mortality• Slow the progression of renal failure• Improved diabetes control• Better quality of life
ACCREDITED AASM
ACCREDITED AASM
•Improve health and QOL of your patients•Management of associated sleep disorders•Board Certified Sleep Specialists•Accredited Sleep Disorders Center by the AASM•20 years experience in sleep medicine•Education / Compliance Program•Complete management – dental, DME, follow-up•Research Opportunities
Ed Charnock, M.Decharnock@medicalsleep.com
Jack Gardner, M.D.jgardner@medicalsleep.com
Medical Sleep Solutionswww.medicalsleep.com