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