Sleep Apnea in Early and Advanced Chronic Kidney Disease Kaiser Permanente Southern California Cohort

Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, 4700 Sunset Blvd., Los Angeles, CA 90027, USA.
Chest (Impact Factor: 7.13). 12/2008; 135(3):710-6. DOI: 10.1378/chest.08-2248
Source: PubMed

ABSTRACT Sleep apnea (SA) has been reported to be highly prevalent in the dialysis population. The reported rates of SA in dialysis are severalfold greater than the 2 to 4% estimated in the general population. This study sought to determine whether an association exists between SA and early stages of chronic kidney disease (CKD) where SA may represent an important comorbidity and potential risk factor in kidney disease.
Cross-sectional study of adults from an integrated health plan with documented serum creatinine levels in the period January 1, 2002, through December 31, 2004. SA diagnosis determined by International Classification of Diseases, ninth revision, coding for SA and Current Procedural Terminology coding for positive airway pressure devices. Kidney function was determined by the estimated glomerular filtration rate (eGFR). Logistic was regression used to estimate the relative risk for SA.
The overall prevalence of SA was 2.5% in the study population that included subjects with normal renal function and those with CKD. The odds ratios (ORs) for SA by eGFRs of 75 to 89, 60 to 74, 45 to 59, 30 to 44, and 15 to 29 mL/min per 1.73 m(2), respectively, compared to normal kidney function, after adjustment for age, sex, and number of visits, were as follows: 1.22 (95% confidence interval [CI], 1.18 to 1.25); 1.32 (95% CI, 1.27 to 1.37); 1.42 (95% CI, 1.35 to 1.50); 1.37 (95% CI, 1.25 to 1.50); and 1.32 (95% CI, 1.13 to 1.55). The increased ORs for eGFRs > 45 mL/min per 1.73 m(2) were sustained even after controlling for diabetes, heart failure, and hypertension.
This study demonstrated an increased risk of SA in patients with early CKD. Further evidence of a causal relationship should be sought in the hope that the detection and management of SA may improve the course of CKD.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Patients with chronic kidney disease (CKD) have a high prevalence of sleep disorders. The association between sleep duration and self-reported CKD was examined in a population of Americans who participated in a national survey over a 3-year period. A cross-sectional study using survey data from the National Health Interview Survey (NHIS) from the year 2004-2006 was carried out. A retrospective examination of data from a community-based survey of 128,486 noninstitutionalized US civilian residents over the age of 18 years was conducted. Self-reported CKD was defined as having 'weak or failing kidneys'. The sleep duration was defined by a self-reported estimate of habitual sleep duration. The prevalence of participants self-reporting kidney disease was higher in those with short (≤6 h per night) and long (≥8 h per night) sleep durations when compared to those sleeping 7 h per night. Self-reported information about sleep, demographic information, and information on comorbidities were assessed using standardized validated questionnaires which reported no kidney disease. A multivariate logistic regression analysis showed increased odds of self-reported kidney disease in study participants with both short and long sleep durations compared to healthy sleepers (sleeping >7-8 h per night). Observational data do not permit examination of causality, although possible confounders in observations of interest can be adjusted. Among Americans surveyed in the NHIS (2004-2006), those with short or long sleep duration had higher odds of reporting that they had CKD.
    American Journal of Kidney Diseases 12/2014; 4(3-4):210-6. DOI:10.1159/000368205 · 5.76 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Study Objectives: Diabetes mellitus (DM) is associated with obstructive sleep apnea (OSA) and nephropathy. The hypoxemia associated with OSA may exacerbate renal deterioration in DM nephropathy. We examined the role of hypoxemia in the development of DM nephropathy in severely obese patients. Methods: This cross-sectional study examined anonymized data from 90 DM patients with extreme obesity attending a weight management service. All patients underwent a routine overnight sleep study. Respiratory parameters measured included apnea-hypopnea index (AHI), mean and minimum oxygen (O-2) saturations, and time spent under 90% O-2 saturation (% TST < 90%). Chronic kidney disease (CKD+) was defined as estimated glomerular filtration rate (eGFR) <= 60 mL/min/1.73 m(2). Results: Twenty (22%) patients were CKD+. These patients were 7 years older (mean age +/- SD 57 +/- 11 years, p = 0.003) and had greater adiposity (mean body mass index [BMI] +/- SD 50.6 +/- 8.7 kg/m(2), p = 0.012). No signifi cant differences were found for median AHI and minimum O 2 saturation. %TST <90% was 4 times greater in CKD+ group (p = 0.046). Multivariate regression analysis showed that AHI (beta = -0.17, 95% CI: -0.316 to -0.024) and % TST < 90% (beta = -0.215, 95% CI: -0.406 to -0.023) were negatively correlated with eGFR after adjustment for age, gender, BMI, comorbidities, insulin treatment, and drugs affecting the renin-angiotensin system. No associations were found between mean and minimum O-2 saturations, and eGFR. Conclusion: Apnea and hypopnea events as well as duration of nocturnal hypoxemia were inversely associated with renal function after adjusting for potential confounders. Given the signifi cant burden of renal disease in diabetes, greater vigilance is required in identifying OSA in DM patients with extreme obesity.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 01/2014; 10(7):773-8. DOI:10.5664/jcsm.3870 · 2.93 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The prevalence of chronic kidney disease (CKD) is increasing, which presents challenges for both patients and health-care budgets. Although this phenomenon has been attributed to the growth in diabetes, hypertension, and obesity, sleep apnea and nocturnal hypoxemia may also contribute to the pathogenesis of CKD and its progression to kidney failure. Two pathophysiologic mechanisms responsible for CKD are glomerular hyperfiltration and chronic intrarenal hypoxia, resulting in tubulointerstitial injury, the final common pathway to end-stage kidney disease (ESKD). Multiple descriptive studies have demonstrated an association between CKD and sleep apnea. Although sleep apnea is common in patients with CKD and associated with significant nocturnal hypoxemia, it is often relatively free of sleep-related symptoms, making it difficult to detect without objective nocturnal monitoring. Nevertheless, sleep apnea and nocturnal hypoxemia have been associated with loss of kidney function and kidney injury, suggesting that they contribute to the pathogenesis of continued deterioration in kidney function. There are several pathways through which sleep apnea may achieve this, including a direct effect of intrarenal hypoxia and activation of the systemic and renal renin-angiotensin system. Further research is required to better understand these relationships and determine whether specific interventions in patients with sleep apnea have an impact on clinical outcomes, such as reducing the prevalence of CKD and delaying its progression to ESKD.
    Chest 10/2014; 146(4):1114-22. DOI:10.1378/chest.14-0596 · 7.13 Impact Factor