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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
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