Respiratory Function ESRDRespiratory Function, ESRD,
and Nocturnal Hemodialysis
Mark Unruh MD MS
Renal-Electrolyte Divisio...
•Normal and abnormal sleep in
d ltadults
•Measurement and
consequences of sleep apnea
•Recognize the prevalence of•Recogni...
Fun Pittsburgh fact
Identify the neurophysiologist who
theorized that the reticular activatingg
system has an amplifying a...
SFun Pittsburgh Sleep Fact
Dr. Starzl began his career as a
neurophysiologist before becomingneurophysiologist before beco...
Sleep quality: an important and
persistent problem for ESRD
An increase in energyAn increase in energy
level (94%) and
imp...
?What is sleep?
Behavioral
Posture
Closed eyes
Reduced response
to external stimuli
A complex collection of
to external st...
f SDefining Sleep
Behavioral
Rest – Activity Cycles
D d i l dit iDecreased visual, auditory responsiveness
Eyes closed
Rhy...
STAGE 1 SLEEP
Stage 1
Usually first stage of sleep encounteredUsually first stage of sleep encountered
Sleep onset is usua...
S G SSTAGE 2 SLEEP
K complex Sleep spindle
S GSTAGE 3 AND 4
EEG
EEG
EOG
Note slo (delta) a es in EEG and EOG channels
EOG
Note slow (delta) waves in EEG and EOG chan...
S GSTAGE REM
Small amplitude, desynchronized waves (replacement of higher amplitude
“synchronous” EEG waves with lower amp...
?Why we sleep?
Avoid sleepiness
and drowsiness
Metabolic effects –
energy conservation
Immunologic
Memory and
learning
Car...
Subjective and objective sleep findings
may have a substantial impact
Health and functioning (Bliwise).
Poor cognitive per...
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 explai...
Implications
Poor sleep multi-
factorial
N t l hi t fNatural history of
sleep in ESRD
remains unclearremains unclear
Poor ...
f SImpact of Dialysis on Sleep
Timing –Diurnal
TemperatureTemperature
Type – Hemodialysis vs. Peritoneal
DialysisDialysis
...
Sleep Apnea in ESRD
“Very lazy …
p p
y y
just eats and sleeps
… rotund and
l hf l”slothful” Pokemon et
al, 2000
Obesity, n...
What is Obstructive Sleep Apnea?
Repetitive episodes of upper airway
obstruction.
Reduction in blood oxygen saturation.
Ar...
SSleep Apnea: A Primer
Apnea: cessation in breathing > 10 sec
Obstructive if there is effort
Central if effort is absent
H...
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....
SSleep apnea outcomes
Sleepiness
S i
Depression
Snoring
Hypertension
Quality of Life
Hypertension
Cardiovascular
Impotence...
Cardiovascular sleep apnea consequencesCardiovascular sleep apnea consequences
Copyright restrictions may apply.Shamsuzzam...
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...
SLEEP APNEA AND KIDNEY FAILURE
Highly prevalent in hemodialysis patients (Kimmel 1989)
Not associated with typical risk fa...
Zoccali et al – JASN 2002
G SGGraphic PSG DataREM
MOV AWK
11
2
3
4
100
SaO2
100
70
Cn.A
+5
Ob.A
Mx.A
Hyp
+5
+5
+5
Hyp
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....
Non traditional Risk Factors for Sleep
Apnea in Patients with Kidney Failure?
Neuropathy secondary to uremic
toxin(s)
Myop...
fTreatment of sleep apnea
Alcohol cessation and weight loss
Sleep position – HMO solutionSleep position HMO solution
Mandi...
“Never, ever, think outside of the box.”
Peritoneal dialysis, nocturnal
hemodialysis, kidney tx
Nocturnal Dialysis Improves Sleep
Apnea
Hanly NEJM 2001
NHD Increases
In 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 apne...
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...
SummarySummary
Long-term Implications
f Sl T t t i ESRDof Sleep Treatment in ESRD
Need To Diagnose and Monitor
Screen for Sleep Apnea,
Sl...
GGrant support
NKF Western Pennsylvania
NKF Young Investigator GrantNKF Young Investigator Grant
NIDDK
ASN ASP HARTFORD FO...
Thanks for all of the helpp
Christos Argyropolous MD, PhD
Manisha Jamb MD
Lee Anne Mandich
Sheena Dohar
Lauren Kester
Anne...
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Microsoft PowerPoint - 103009_markunruh_sleep [Read-Only ...
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  1. 1. Respiratory Function ESRDRespiratory Function, ESRD, and Nocturnal Hemodialysis Mark Unruh MD MS Renal-Electrolyte Division University of Pittsburgh Medical Center Quotidian DialysisQuotidian Dialysis ASN 2009
  2. 2. •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
  3. 3. Fun Pittsburgh fact Identify the neurophysiologist who theorized that the reticular activatingg system has an amplifying and sustaining feature for sensoryg y stimulation transduction (otherwise, we would fall asleep with sensoryp y reduction)?
  4. 4. SFun Pittsburgh Sleep Fact Dr. Starzl began his career as a neurophysiologist before becomingneurophysiologist before becoming interested in surgery and immunology.
  5. 5. Sleep quality: an important and persistent problem for ESRD An increase in energyAn increase in energy level (94%) and improvement in sleepp 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 2008 Ramkumar et. al. HI 2005
  6. 6. ?What is sleep? Behavioral Posture Closed eyes Reduced response to external stimuli A complex collection of to external stimuli Reversible Physiological physiological and behavioral processes that are organized around behaviors such as Physiological Polysomnography criteriaaround behaviors such as quiet recumbency with closed eyes -Carskadon
  7. 7. f SDefining Sleep Behavioral Rest – Activity Cycles D d i l dit iDecreased visual, auditory responsiveness Eyes closed Rhythmic breathingRhythmic breathing Physiologic EEG: stages 1-4, REM EOG: to characterize REM, other stages EMG: to characterize REM; measure pathological movements during sleeppathological movements during sleep
  8. 8. STAGE 1 SLEEP Stage 1 Usually first stage of sleep encounteredUsually first stage of sleep encountered Sleep onset is usually NOT sharp; lack full consensus on what constitutes sleep onset Lower voltage mixed amplitudeLower voltage, mixed amplitude Note: slow, rolling eye- movements mixed frequency EEG
  9. 9. S G SSTAGE 2 SLEEP K complex Sleep spindle
  10. 10. S GSTAGE 3 AND 4 EEG EEG EOG Note slo (delta) a es in EEG and EOG channels EOG Note slow (delta) waves in EEG and EOG channels Known as slow wave sleep or Delta sleep Most prominent in children and adolescents D ith ft 30Decreases with age after ~30 Defined by frequency and voltage criteria
  11. 11. 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 movement Skeletal muscle inhibition
  12. 12. ?Why we sleep? Avoid sleepiness and drowsiness Metabolic effects – energy conservation Immunologic Memory and learning Cardiovascular h l hhealth
  13. 13. 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.
  14. 14. My Home ExperienceMy Home Experience
  15. 15. Unruh AJKD 2008
  16. 16. Short and disturbed sleep in SESRD
  17. 17. 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
  18. 18. Implications Poor sleep multi- factorial N t l hi t fNatural history of sleep in ESRD remains unclearremains unclear Poor sleep may contribute to morbidity and mortality of patients with ESRDwith ESRD
  19. 19. f SImpact of Dialysis on Sleep Timing –Diurnal TemperatureTemperature Type – Hemodialysis vs. Peritoneal DialysisDialysis Timing –Nocturnal with Automated P it l Di l i d N t lPeritoneal Dialysis and Nocturnal Hemodialysis
  20. 20. Sleep Apnea in ESRD “Very lazy … p p y y just eats and sleeps … rotund and l hf l”slothful” Pokemon et al, 2000 Obesity, neck sizey, >17 inches Male gender AgeAge Snoring Craniofacial abnormalities
  21. 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. 22. SSleep Apnea: A Primer Apnea: cessation in breathing > 10 sec Obstructive if there is effort Central if effort is absent Hypopnea: reduction in breathingHypopnea: reduction in breathing AHI: Apnea + Hypopnea Index Ob t ti Sl A HObstructive Sleep Apnea Hypopnea Syndrome: 5 or more respiratory event / hr of sleepevent / hr of sleep
  23. 23. 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
  24. 24. SSleep apnea outcomes Sleepiness S i Depression Snoring Hypertension Quality of Life Hypertension Cardiovascular Impotence/loss of libido disease Anxiety Cognitive Deficits
  25. 25. Cardiovascular sleep apnea consequencesCardiovascular sleep apnea consequences Copyright restrictions may apply.Shamsuzzaman, A. S. M. et al. JAMA 2003;290:1906-1914.
  26. 26. Sleep apnea associated with premature death Punjabi et. al. PLOS MED 2009
  27. 27. 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
  28. 28. 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)
  29. 29. Zoccali et al – JASN 2002
  30. 30. G SGGraphic PSG DataREM MOV AWK 11 2 3 4 100 SaO2 100 70 Cn.A +5 Ob.A Mx.A Hyp +5 +5 +5 Hyp Uns +5
  31. 31. Unruh – JASN 2006
  32. 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. 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)
  33. 33. 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
  34. 34. fTreatment of sleep apnea Alcohol cessation and weight loss Sleep position – HMO solutionSleep position HMO solution Mandibular advancement P iti AiPositive Airway pressure Nocturnal Dialysis?
  35. 35. “Never, ever, think outside of the box.”
  36. 36. Peritoneal dialysis, nocturnal hemodialysis, kidney tx
  37. 37. Nocturnal Dialysis Improves Sleep Apnea Hanly NEJM 2001
  38. 38. NHD Increases In pharyngeal size 3.17 ± 0.68 to 3.86 ± 0.67 cm2 Beecroft et al – NDT 2008
  39. 39. Bradley et al – Am J Resp Crit Care Med 2009
  40. 40. Peritoneal dialysis at home, now can be done during sleep
  41. 41. Sleep apnea in peritoneal dialysis Determined whether nocturnal PD was associated with lessassociated with less sleep apnea Uremia clearance similar No change in pulmonary function NPD decreased body water Tang JASN 2006
  42. 42. Tang et al CJASN 2009
  43. 43. ECF volume overload: upper airway edema? Normal Subject Sleep Apnea
  44. 44. 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.
  45. 45. SummarySummary
  46. 46. Long-term Implications f Sl T t t i ESRDof Sleep Treatment in ESRD 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. 47. GGrant support NKF Western Pennsylvania NKF Young Investigator GrantNKF Young Investigator Grant NIDDK ASN ASP HARTFORD FOUNDATIONASN-ASP HARTFORD FOUNDATION Paul Teschan Research Foundation (DCI) Satellite Research Coplonp
  48. 48. Thanks for all of the helpp Christos Argyropolous MD, PhD Manisha Jamb MD Lee Anne Mandich Sheena Dohar Lauren Kester Anne Newman Maria-Eleni Roumelioti MD Khaled Abdel-Kader MD Sarah Ramer Anne Newman Beth Piraino Dan Buysse Mary Amanda Dew Mark Sanders Tom Rice MD Nizar Younas MD Pat Strollo/Charlie Atwood Chris Chan Tica Hall HEMO Study Investigators CHOICE STUDY Manju Mavanur MD CHOICE STUDY Sleep Heart Health Study FHN Study CKID Study Investigators Participants

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