Sleep Apnea And Kidney Disease
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Sleep Apnea & Kidney Disease
Ed Charnock, M.DJack Gardner, M.D.
Medical Sleep Solutionswww.medicalsleep.com
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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?
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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
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O
BESITY O
BESITY
No data <10% 10%-14% 15%-19%
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O
BESITY O
BESITY
No Data < 10% 10%-14% 15%-19% 20%-24% 25%-29% ≥ 30%
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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
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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?
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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
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• 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
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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.
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O
SA - HTNO
SA - HTN
•Pepperell et al, Lancet 2001
•Becker et al, Circulation 2003
•Coughlin et al, ERJ, 2007
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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
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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
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ATHERO
SCLEROSIS
Kohler, AJRCCM, 2007
Drager, AJRCCM, 2005
Savransky, AJRCCM, 2007
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Atherosclerosis
Atherosclerosis
•Reduction of early signs of atherosclerosis
•Reduction on arterial stiffness
•Reduction of intima-media thickness
Drager, AJRCCM, 2007
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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)
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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
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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
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O
SA - SHFO
SA - SHF
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•Our screen
N
PSGN
PSG
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•Our screen
CPAP
CPAP
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•Our screen
AU
TO-SV
AUTO
-SV
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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
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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
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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
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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
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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.
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Early intervention is KEY to preservation of renal function.
Does CPAP therapy stabilize and prevent or slow the progression of kidney disease?
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CLIN
ICAL CLIN
ICAL
•Less likely to be obese
•Frequently don’t snore
•Daytime sleepiness often attributed
to uremia
•Underdiagnosed
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PRO
CESSPRO
CESS
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IN
TERFACESIN
TERFACES
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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
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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
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Ed Charnock, [email protected]
Jack Gardner, [email protected]
Medical Sleep Solutionswww.medicalsleep.com