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Respiratory Function ESRDRespiratory Function, ESRD, and Nocturnal Hemodialysis
Mark Unruh MD MSRenal-Electrolyte DivisionUniversity of Pittsburgh Medical CenterQuotidian DialysisQuotidian Dialysis ASN 2009
•Normal and abnormal sleep in d ltadults
•Measurement and consequences of sleep apnea•Recognize the prevalence of•Recognize the prevalence of sleep disorders among those with ESRD•Nocturnal Dialysis and SleepNocturnal Dialysis and Sleep
Fun Pittsburgh fact
Identify the neurophysiologist who theorized that the reticular activating gsystem has an amplifying and sustaining feature for sensory g ystimulation transduction (otherwise, we would fall asleep with sensory p yreduction)?
SFun Pittsburgh Sleep Fact
Dr. Starzl began his career as a neurophysiologist before becomingneurophysiologist before becoming interested in surgery and immunology.
Sleep quality: an important and persistent problem for ESRD
An increase in energyAn increase in energy level (94%) and improvement in sleep p p(57%) were the most common potential benefits that would justify DHD
19% ld d19% would undergo DHD for an increase in survival of < or =3 years.
Unruh JAGS 2008Ramkumar et. al. HI 2005
?What is sleep?
BehavioralPostureClosed eyesReduced response to external stimuli
A complex collection of
to external stimuliReversible
Physiologicalphysiological and behavioral processes that are organized around behaviors such as
PhysiologicalPolysomnography criteriaaround behaviors such as
quiet recumbency with closed eyes -Carskadon
f SDefining Sleep
Behavioral Rest – Activity CyclesD d i l dit iDecreased visual, auditory responsivenessEyes closedRhythmic breathingRhythmic breathing
PhysiologicEEG: stages 1-4, REMEOG: to characterize REM, other stagesEMG: to characterize REM; measure pathological movements during sleeppathological movements during sleep
STAGE 1 SLEEP
Stage 1Usually first stage of sleep encounteredUsually first stage of sleep encounteredSleep onset is usually NOT sharp; lack full consensus on what constitutes sleep onsetLower voltage mixed amplitudeLower voltage, mixed amplitude
Note: slow, rolling eye- movementsmixed frequency EEG
S G SSTAGE 2 SLEEP
K complex Sleep spindle
S GSTAGE 3 AND 4EEG
EEG
EOG
Note slo (delta) a es in EEG and EOG channels
EOG
Note slow (delta) waves in EEG and EOG channelsKnown as slow wave sleep or Delta sleepMost prominent in children and adolescents D ith ft 30Decreases with age after ~30Defined by frequency and voltage criteria
S GSTAGE REM
Small amplitude, desynchronized waves (replacement of higher amplitude“synchronous” EEG waves with lower amplitude higher frequencysynchronous EEG waves with lower amplitude, higher frequency waves) Rapid eye movements (phasic REM) and periods of minimal (tonic)eye movementSkeletal muscle inhibition
?Why we sleep?
Avoid sleepiness and drowsinessMetabolic effects –energy conservationImmunologicMemory and learningCardiovascular h l hhealth
Subjective and objective sleep findings may have a substantial impact
Health and functioning (Bliwise). Poor cognitive performance, increased l i f di b t dsleepiness, presence of diabetes and
hypertension, and premature death [IOM REPORT].REPORT]. Few studies have examined subjective and objective sleep among the community dwelling aged population.
My Home ExperienceMy Home Experience
Unruh AJKD 2008
Short and disturbed sleep in SESRD
SSummary
HD shorter sleep, less efficient sleep, and insomnia
Poor sleep was not explained by agePoor sleep was not explained by age or chronic health conditions
Implications
Poor sleep multi-factorialN t l hi t fNatural history of sleep in ESRD remains unclearremains unclearPoor sleep may contribute to morbidity and mortality of patients with ESRDwith ESRD
f SImpact of Dialysis on Sleep
Timing –DiurnalTemperatureTemperature Type – Hemodialysis vs. Peritoneal DialysisDialysisTiming –Nocturnal with Automated P it l Di l i d N t lPeritoneal Dialysis and Nocturnal Hemodialysis
Sleep Apnea in ESRD
“Very lazy …
p p
y yjust eats and sleeps
… rotund and l hf l”slothful” Pokemon et
al, 2000Obesity, neck size y,>17 inchesMale genderAgeAgeSnoringCraniofacial abnormalities
What is Obstructive Sleep Apnea?
Repetitive episodes of upper airway obstruction.Reduction in blood oxygen saturation.Arousal from sleep.pSymptoms of snoring and sleepiness.
SSleep Apnea: A Primer
Apnea: cessation in breathing > 10 secObstructive if there is effortCentral if effort is absent
Hypopnea: reduction in breathingHypopnea: reduction in breathing AHI: Apnea + Hypopnea IndexOb t ti Sl A HObstructive Sleep Apnea Hypopnea Syndrome: 5 or more respiratory event / hr of sleepevent / hr of sleep
f OSPrevalence of OSA
Women 30-60 yrs Men 30-60 yrs
AHI >5/hr 9.0%AHI>10/hr 5.0%
AHI >5/hr 24%AHI>10/hr 15%
AHI>15/hr 4.0% AHI>15/hr 9.1%
Young, et al., NEJM 1993
SSleep apnea outcomes
Sleepiness
S i
Depression
Snoring
Hypertension
Quality of Life
Hypertension
Cardiovascular
Impotence/loss of libido
diseaseAnxiety
Cognitive Deficits
Cardiovascular sleep apnea consequencesCardiovascular sleep apnea consequences
Copyright restrictions may apply.Shamsuzzaman, A. S. M. et al. JAMA 2003;290:1906-1914.
Sleep apnea associated with premature death
Punjabi et. al. PLOS MED 2009
How common is sleep apnea among hemodialysis patients?
Sl l i tSleep complaints common
Sleep apnea improves with treatment of uremic patients
SA 60% from symptomatic populations. y p p p
SLEEP APNEA AND KIDNEY FAILURE
Highly prevalent in hemodialysis patients (Kimmel 1989)
Not associated with typical risk factors (Kimmel 1989)Not associated with typical risk factors (Kimmel 1989)
Sleep doctors can treat: Short-term response to CPAP (Pressman 1993)(Pressman 1993)
Kidney doctors can treat: Improvement with nocturnal h di l i (H l 2001)hemodialysis (Hanly 2001)
Zoccali et al – JASN 2002
G SGGraphic PSG DataREM
MOV AWK11234
100
SaO2
100
70Cn.A +5
Ob.AMx.AHyp
+5+5+5Hyp
Uns +5
Unruh – JASN 2006
Predictors of severe sleep apnea in HD population
HD Crude Severe SHHS Crude SA Severe SA
Age per year 0.96 (0.90-1.02) 1.02 (0.97,1.07)
Sex (Female vs. male)
0.19 (0.04-1.01) 0.28 (0.06,1.27)
Race (white vs. black)
0.69 (0.21-2.33) 1.58 (0.53,4.7)
BMI 1 08 (0 96-1 21) 1 17 (1 07 1 28)BMI 1.08 (0.96-1.21) 1.17 (1.07,1.28)
DM meds 2.4 (0.68-8.49) 0.58 (0.07,4.7)
CVD 1.06 (0.30-3.72) 4.9 (1.5,15.7)
Non traditional Risk Factors for Sleep Apnea in Patients with Kidney Failure?
Neuropathy secondary to uremic toxin(s)
Myopathy secondary to uremic t i ( )toxin(s)
Effect of acid/base disturbances on ventilatory drive
Altered lung volumes
Upper airway edema Beecroft 2007
Or is it simply that we see older patients or patients with shared risk factors
Beecroft Sleep Med 2008
fTreatment of sleep apnea
Alcohol cessation and weight lossSleep position – HMO solutionSleep position HMO solutionMandibular advancementP iti AiPositive Airway pressureNocturnal Dialysis?
“Never, ever, think outside of the box.”
Peritoneal dialysis, nocturnal hemodialysis, kidney tx
Nocturnal Dialysis Improves Sleep Apnea
Hanly NEJM 2001
NHD IncreasesIn pharyngeal size
3.17 ± 0.68 to 3.86 ± 0.67 cm2
Beecroft et al – NDT 2008
Bradley et al – Am J Resp Crit Care Med 2009
Peritoneal dialysis at home, now can be done during sleep
Sleep apnea in peritoneal dialysis
Determined whether nocturnal PD was associated with lessassociated with less sleep apnea
Uremia clearance similarNo change in pulmonary functionNPD decreased body water
Tang JASN 2006
Tang et al CJASN 2009
ECF volume overload: upper airway edema?
Normal Subject Sleep Apnea
Change in apnoea-hypopnoea index following kidney transplantation (post) in patients with apnoea-hypopnoea index >10 prior to transplantation (pre)apnoea-hypopnoea index >10 prior to transplantation (pre)
Beecroft, J. M. et al. Nephrol. Dial. Transplant. 2007 22:3028-3033; doi:10.1093/ndt/gfm309
Copyright restrictions may apply.
SummarySummary
Long-term Implications f Sl T t t i ESRDof Sleep Treatment in ESRD
Need To Diagnose and MonitorScreen for Sleep Apnea, Sleepiness, PLMD, RLS
Informed treatment selectionKidney TransplantationNocturnal DialysisUse of CPAP
Treatment EffectsImproved daytime functioningImproved BP and LVH
GGrant support
NKF Western PennsylvaniaNKF Young Investigator GrantNKF Young Investigator GrantNIDDK ASN ASP HARTFORD FOUNDATIONASN-ASP HARTFORD FOUNDATIONPaul Teschan Research Foundation (DCI)Satellite Research Coplonp
Thanks for all of the helpp
Christos Argyropolous MD, PhD
Manisha Jamb MD
Lee Anne MandichSheena DoharLauren Kester
Anne NewmanMaria-Eleni Roumelioti MD
Khaled Abdel-Kader MD
Sarah Ramer
Anne Newman Beth PirainoDan BuysseMary Amanda DewMark Sanders
Tom Rice MD
Nizar Younas MD
Pat Strollo/Charlie AtwoodChris Chan Tica HallHEMO Study InvestigatorsCHOICE STUDY
Manju Mavanur MDCHOICE STUDYSleep Heart Health StudyFHN StudyCKID Study InvestigatorsParticipants
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