Impact of APD on Sleep

Transcription

1 Impact of APD on Sleep Sydney C.W. Tang The University of Hong Kong, Queen Mary Hospital, Hong Kong, China APD Symposium: Peritoneal Dialysis Update 26 Mar 2017, Hong Kong

2 Sleep apnea in ESRD General population: 4% of men 2% of women ESRD: >50% survey questionnaires: 60% (Lui SL et al. PDI 2002) Overnight polysomnography: 80-90% (Tang SC et al. JASN 2006)

3 Outline What is Sleep Apnea & its CV complications Impact of nocturnal dialysis on Sleep apnea in the ESRD population Sleep apnea in the CKD population Impact of APD on Sleep

4 Definition of sleep apnea Intermittent episodes of breathing interruption during sleep Either from airway collapse (obstructive type), cessation of respiratory effort (central type), or a combination of the two (mixed type) Described in terms of the number of apneic events per hour of sleep, or the apnea-hypopnea index (AHI)

5 Overnight polysomnography

6 Obstructive sleep apnea (Snorer)

7 Central Sleep Apnea (Non-snorer)

8 Obstructive Sleep Apnea Excessive daytime sleepiness Concentration difficulties & reduced performance at work Increased risk for motor vehicle accident Hypertension Coronary artery disease Stroke Progression of CHF Systemic inflammatory state that predisposes to cardiac and cerebrovascular conditions Sudden cardiac death Tang SC et al. J Nephrol 2010

9 Nocturnal Hypoxemia Predicts Incident Cardiovascular Complications in Hemodialysis Patients N=50 (HD) ) Zoccali C et al. JASN 2002 Zoccali C, et al. JASN 2002

10 2001 corrective potential of nocturnal HD [5 to 6x/wk, 8 h per treatment]

11 Obstructive apnea index (episodes per hour of sleep) On NPD On CAPD P<

12

13 Tang SC et al. Kidney Int 2010

14 Fixed sequence intervention Incident ESRD subjects N=38 In-hospital Nocturnal PD PSG + MRI upper airway + overnight Kt/V CAPD Training Home CAPD 2 nd PSG + MRI upper airway + overnight Kt/V

15 KT/V (per night) P<0.001 P< Creatinine clearance (L/night) Dialysis mode: NPD CAPD NPD CAPD Peritoneal KT/V Peritoneal CrCl

16 Change in AHI upon conversion from NPD to CAPD (episodes/hr of sleep) r = P= Decrease in overnight pkt/v upon conversion from NPD to CAPD (per night)

17 Mechanism of OSA in ESRD: Upper airway edema during sleep Oropharynx, nasopharynx, hypopharynx Tongue volume and MPXA Tang SC, et al. CJASN 2009

18 LBPP control Am J Respir Crit Care Med 2006

19 Chiu KL et al. Am J Respir Am Crit J Care Respir Med Crit 2006 Care Med 2006

20 These studies suggest the importance of rostral fluid shift in the pathogenesis of OSA in healthy subjects But these artificial scenarios do not happen in real life! To strengthen this hypothesis, it is imperative to demonstrate whether 1. Lower limb fluid accumulation in diseased states increases OSA; and 2. alleviation of fluid accumulation, may indeed attenuate the severity of or even reverse OSA.

21 23 patients diagnosed clinically with primary nephrotic syndrome, and underwent one PSG 20 patients eligible for 2 nd PSG after induction of disease remission 3 patients met exclusion criteria due to subsequent diagnosis of: lupus nephritis (n=1) lipoprotein glomerulopathy (n=1) malignancy (n=1) 3 patients excluded from 2 nd PSG: lost to follow-up: one to private physician (n=1), one to overseas center (n=1) failure to achieve any disease remission (n=1) 17 subjects completed two sets of PSG before and after disease remission 1 patient with TST < 4h on 1 st PSG 16 subjects with 2 sets of evaluable PSGs

22 Apnea-hypopnea index (episodes per hour of sleep) 100 At diagnosis of nephrotic syndrome (101) At remission of nephrotic syndrome * 0 At 1 st PSG At 2 nd PSG Tang SC, et al. NDT 2012

23 SA across different CKD stages in a homogenous Chinese population Male subjects with CKD aged y Targeting 30 subjects in each CKD category to undergo home PSG Patients with known history of SA were excluded Other exclusions: CHF, COPD, steroid therapy and use of hypnotics

24 Lack of progression of SA or nocturnal hypoxemia across different CKD stages prevalence of SA: 35.5% and nocturnal hypoxemia: 10.6% Chan GC, et al. NDT 2015

25 Degree of proteinuria is correlated with the severity of SA Chan GC, et al. NDT 2015 Chou YT, et al. NDT 2011

26 APD may have a therapeutic edge over CAPD in terms of sleep apnea correction There is a paucity of head-to-head comparisons between CAPD and APD Further studies are needed Tang SC and Lai KN. Nat Clin Pract Nephrol 2007

27 APD group: significantly greater stages 3 to 4 sleep compared to the CKD patients

28 APD patients had significantly lower AHI compared to HD and the least %TST with nocturnal hypoxemia compared to CKD patients

29 Chan GC et al. NDT 2015 Summary and Conclusion (1) Sleep apnea is prevalent among PD and HD patients, and in nonuremic nephrotic patients Volume overload upper airway congestion during recumbency NHD NPD RTx Uremia destabilization of central ventilatory control Comorbid conditions such as cardiovascular disease, diabetes mellitus, and obesity Sleep Apnea (Central and Obstructive) proteinuria Tang SC et al. CJASN 2009

30 Summary and Conclusion (2) Significant sleep apnea at the inception of PD impacts upon cardiovascular and long-term survival APD patients had significantly lower AHI vs HD And less nocturnal hypoxemia vs CKD

31 Acknowledgments KN Lai, G Chan, D Yap, M Ma, M Mok, L Kwan M Ip, PP Ku, A Lai, KM Lo, J Lam, J Cheung H Leung, P Chan, LY Lee, F Chiu PL Khong, AS Lai, C Pang, WK Tso RYH Yu Clinical Team Sleep Laboratory Renal Nurses Radiology Funding via donating the Yu Professorship in Nephrology

32