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1. Respiratory Function ESRD Function, ESRD, and Nocturnal Hemodialysis Mark Unruh MD MS Renal-Electrolyte Division University of Pittsburgh Medical Center Quotidian Dialysis ASN 2009 2. Normal and abnormal sleep in adults d lt Measurement and consequences of sleep apnea Recognize the prevalence of sleep disorders among those with ESRD Nocturnal Dialysis and Sleep Nocturnal 3. Fun Pittsburgh fact Identify the neurophysiologist who theorized that the reticular activating g system has an amplifying and sustaining feature for sensory g y stimulation transduction (otherwise, we would fall asleep with sensory p y reduction)? 4. Fun Pittsburgh S Sleep Fact Dr. Starzl began his career as a neurophysiologist before becoming interested in surgery and immunology. 5. Sleep quality: an important and persistent problem for ESRD An increase in energy level (94%) and improvement in sleep p p (57%) were the most common potential benefits that would justify DHD 19% would undergo ld d DHD for an increase in survival of < or =3 years. Ramkumar et. al. HI 2005 Unruh JAGS 2008 6. What is sleep? ? Behavioral Posture Closed eyes Reduced response to external stimuli Reversible A complex collection of Physiological physiological and behavioral processes that are organized Polysomnography around behaviors such as criteria quiet recumbency with closed eyes -Carskadon 7. Defining S f Sleep Behavioral Rest Activity Cycles Decreased visual, auditory responsiveness D d i l dit i Eyes closed Rhythmic breathing Physiologic EEG: stages 1-4, REM EOG: to characterize REM, other stages EMG: to characterize REM; measure pathological movements during sleep 8. STAGE 1 SLEEP Stage 1 Usually first stage of sleep encountered Sleep onset is usually NOT sharp; lack full consensus on what constitutes sleep onset Lower voltage, mixed amplitude voltage Note: slow, rolling eye- movements mixed frequency EEG 9. STAGE S S G 2 SLEEP K complex Sleep spindle 10. STAGE S G 3 AND 4 EEG EEG EOG EOG Note slo (delta) waves in EEG and EOG channels slow a es Known as slow wave sleep or Delta sleep Most prominent in children and adolescents Decreases with age after ~30 D ith ft 30 Defined by frequency and voltage criteria 11. STAGE S G REM Small amplitude, desynchronized waves (replacement of higher amplitude synchronous EEG waves with lower amplitude higher frequency synchronous amplitude, waves) Rapid eye movements (phasic REM) and periods of minimal (tonic) eye movement Skeletal muscle inhibition 12. Why we sleep? ? Avoid sleepiness and drowsiness Metabolic effects energy conservation Immunologic Memory and learning Cardiovascular health h lh 13. Subjective and objective sleep findings may have a substantial impact Health and functioning (Bliwise). Poor cognitive performance, increased sleepiness, presence of di b t and l i f diabetes d hypertension, and premature death [IOM REPORT]. Few studies have examined subjective and objective sleep among the community dwelling aged population. 14. My Home Experience 15. Unruh AJKD 2008 16. Short and disturbed sleep in ESRD S 17. Summary HD shorter sleep, less efficient sleep, and insomnia Poor sleep was not explained by age or chronic health conditions 18. Implications Poor sleep multi- factorial Natural history of N t l hi t f sleep in ESRD remains unclear Poor sleep may contribute to morbidity and mortality of patients with ESRD 19. Impact of Dialysis on Sleep f S Timing Diurnal Temperature Type Hemodialysis vs. Peritoneal Dialysis Timing Nocturnal with Automated Peritoneal Di l i and N t P it l Dialysis d Nocturnall Hemodialysis 20. Sleep Apnea in ESRD p p Very lazy y y just eats and sleeps rotund and slothful Pokemon et l hf l al, 2000 Obesity, neck size y, >17 inches Male gender Age Snoring Craniofacial abnormalities 21. What is Obstructive Sleep Apnea? Repetitive episodes of upper airway obstruction. Reduction in blood oxygen saturation. Arousal from sleep. p Symptoms of snoring and sleepiness. 22. Sleep Apnea: A Primer Apnea: cessation in breathing > 10 sec Obstructive if there is effort Central if effort is absent Hypopnea: reduction in breathing AHI: Apnea + Hypopnea Index Obstructive Sl Ob t ti Sleep Apnea Hypopnea A H Syndrome: 5 or more respiratory event / hr of sleep 23. Prevalence of OSA f OS Women 30-60 yrs Men 30-60 yrs AHI >5/hr 9.0% AHI >5/hr 24% AHI>10/hr 5.0% AHI>10/hr 15% AHI>15/hr 4.0% AHI>15/hr 9.1% Young, et al., NEJM 1993 24. Sleep apnea outcomes Sleepiness Depression Snoring S i Quality of Life Hypertension Impotence/loss of libido Cardiovascular disease Anxiety Cognitive Deficits 25. Cardiovascular sleep apnea consequences Copyright restrictions may apply. Shamsuzzaman, A. S. M. et al. JAMA 2003;290:1906-1914. 26. Sleep apnea associated with premature death Punjabi et. al. PLOS MED 2009 27. How common is sleep apnea among hemodialysis patients? Sleep complaints common Sl l i t Sleep apnea improves with treatment of uremic patients SA 60% from symptomatic p p y p populations. 28. SLEEP APNEA AND KIDNEY FAILURE Highly prevalent in hemodialysis patients (Kimmel 1989) Not associated with typical risk factors (Kimmel 1989) Sleep doctors can treat: Short-term response to CPAP (Pressman 1993) Kidney doctors can treat: Improvement with nocturnal hemodialysis (H l 2001) h di l i (Hanly 29. Zoccali et al JASN 2002 30. Graphic PSG Data G REM SG MOV AWK 1 2 3 4 100 SaO2 70 +5 Cn.A +5 Ob.A +5 Mx.A +5 Hyp +5 Uns 31. Unruh JASN 2006 32. 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. 0.19 (0.04-1.01) 0.28 (0.06,1.27) male) Race (white vs. 0.69 (0.21-2.33) 1.58 (0.53,4.7) black) BMI 1.08 (0.96-1.21) 1 08 (0 96-1 21) 1.17 (1.07,1.28) 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) 33. Non traditional Risk Factors for Sleep Apnea in Patients with Kidney Failure? Neuropathy secondary to uremic toxin(s) Myopathy secondary to uremic toxin(s) t i ( ) 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 34. Treatment of sleep apnea f Alcohol cessation and weight loss Sleep position HMO solution Mandibular advancement Positive Airway pressure P iti Ai Nocturnal Dialysis? 35. Never, ever, think outside of the box. 36. Peritoneal dialysis, nocturnal hemodialysis, kidney tx 37. Nocturnal Dialysis Improves Sleep Apnea Hanly NEJM 2001 38. NHD Increases In pharyngeal size 3.17 0.68 to 3.86 0.67 cm2 Beecroft et al NDT 2008 39. Bradley et al Am J Resp Crit Care Med 2009 40. Peritoneal dialysis at home, now can be done during sleep 41. Sleep apnea in peritoneal dialysis Determined whether nocturnal PD was associated with less sleep apnea Uremia clearance similar No change in pulmonary function NPD decreased body water Tang JASN 2006 42. Tang et al CJASN 2009 43. ECF volume overload: upper airway edema? Normal Subject Sleep Apnea 44. Change in apnoea-hypopnoea index following kidney transplantation (post) in patients with 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. 45. Summary 46. Long-term Implications of Sleep T t f Sl Treatment in ESRD ti Need To Diagnose and Monitor Screen for Sleep Apnea, Sleepiness, PLMD, RLS Informed treatment selection Kidney Transplantation Nocturnal Dialysis Use of CPAP Treatment Effects Improved daytime functioning Improved BP and LVH 47. Grant support NKF Western Pennsylvania NKF Young Investigator Grant NIDDK ASN-ASP ASN ASP HARTFORD FOUNDATION Paul Teschan Research Foundation (DCI) Satellite Research Coplon p 48. Thanks for all of the help p Lee Anne Mandich Christos Argyropolous MD, PhD Sheena Dohar Lauren Kester Manisha Jamb MD Anne Newman Maria-Eleni Roumelioti MD Beth Piraino Khaled Abdel-Kader MD Dan Buysse Mary Amanda Dew Sarah Ramer Mark Sanders Pat Strollo/Charlie Atwood Tom Rice MD Chris Chan Tica Hall Nizar Younas MD HEMO Study Investigators CHOICE STUDY Manju Mavanur MD Sleep Heart Health Study FHN Study CKID Study Investigators Participants