Effects of obstructive sleep apnea on sleep quality, cognition, and driving performance in patients with cirrhosis

Non-alcoholic fatty liver disease and sleep disorders

Studies have shown that non-alcoholic fatty liver disease (NAFLD) may be associated with sleep disorders. In order to explore the explicit relationship between the two, we systematically reviewed the effects of sleep disorders, especially obstructive sleep apnea (OSA), on the incidence of NAFLD, and analyzed the possible mechanisms after adjusting for confounding factors. NAFLD is independently associated with sleep disorders. Different sleep disorders may be the cause of the onset and aggravation of NAFLD. An excessive or insufficient sleep duration, poor sleep quality, insomnia, sleep-wake disorders, and OSA may increase the incidence of NAFLD. Despite that some research suggests a unidirectional causal link between the two, specifically, the onset of NAFLD is identified as a result of changes in sleep characteristics, and the reverse relationship does not hold true. Nevertheless, there is still a lack of specific research elucidating the reasons behind the higher risk of developing sleep disorders in individuals with NAFLD. Further research is needed to establish a clear relationship between NAFLD and sleep disorders. This will lay the groundwork for earlier identification of potential patients, which is crucial for earlier monitoring, diagnosis, effective prevention, and treatment of NAFLD.

A specialized HE testing clinic improves rational decision-making for therapy in cirrhosis

BACKGROUND

Cognitive complaints in cirrhosis are often attributed to HE with reflexive therapy if specialized tests are not performed. The aim was to determine the utility of a specialized HE clinic for management decisions.

METHODS

Cirrhosis patients with cognitive complaints were referred through a dedicated consult pathway to a specialized clinic and followed for 6 months. This clinic included detailed history, medication review, standardized tests [Mini-Mental Status Exam (MMSE), Psychometric HE Score, and others], and obstructive sleep apnea screening. Results were communicated with patients and referring providers. A subset was offered repeat testing.

RESULTS

A total of 286 patients were tested between 2012 and 2022. Of the 286 patients, 4 patients who showed a Mini-Mental State Exam <25 were referred to neurology. Thirty-nine percent had normal Psychometric HE Score (higher in younger patients, without prior HE, depression, and lower Model for End-Stage Liver Disease-Sodium), while 172 (61%) patients had cognitive impairment. Of the 172 patients, 51 did not want management change, 84 were started on HE therapy, and 37 were considered impaired due to other causes. In 51 without management change, 32 refused lactulose, while the remaining were counseled regarding lactulose titration. Of the 84 patients with HE-therapy initiation, lactulose was initiated in 56 and rifaximin in 28; most therapies continued over 6 months. The ones who were retested improved their Psychometric HE Score. The 37 with other causes (obstructive sleep apnea, mood disorders, substance use, and mild cognitive impairment) led to specialized referrals. No overt HE was found over 6 months in those without HE-related impairment. The clinic was billed for.

CONCLUSIONS

A specialized HE clinic for patients with cirrhosis and cognitive complaints established through a dedicated consult pathway showed that 39% of referred patients had normal cognitive performance, while the results guided management changes, including for HE and other causes in the remaining patients.

Poor quality sleep is associated with greater carotid intima media thickness among otherwise healthy resident doctors

Background

Sleep is important for maintaining the metabolic processes in the body, and hence, disruption in sleep leads to metabolic derangement and accelerated atherosclerosis. The effect of sleep duration on subclinical atherosclerosis has been examined in several studies; however, data regarding sleep quality is lacking. The study aimed to assess the association between sleep quality and carotid intima-media thickness among healthy young doctors.

Materials and Methods

This was an observational cross-sectional study among 110 healthy young resident doctors. Anthropometric data were recorded and morning fasting venous blood samples were collected to assess fasting blood sugar, lipid profile and glycosylated haemoglobin (HbA1c). Pittsburgh Sleep Quality Index and Berlin questionnaire assessed subjective sleep quality and risk for obstructive sleep apnea, respectively. Carotid ultrasonography was done to detect the intima-media thickness.

Results

Average age of the participants was 26.45 (±1.43) years, and 51.8% were male. Self-reported poor sleep quality was found in 54.5%. Carotid intima-media thickness (CIMT) was increased among 44.5% of participants. In the multivariate analysis, only poor sleep quality appeared to be associated with higher CIMT (P < 0.001, OR = 7.4; 95% CI = 2.70-20.32). When different components of sleep quality was analyzed through multivariate logistic regression, subjective sleep onset latency (>30 min), sleep efficiency (<85%) and sleep disturbance was found to be associated with the increased CIMT.

Conclusion

Poor sleep quality, especially prolonged sleep onset latency, poor sleep efficiency, and sleep disturbance are associated with increased carotid intima-media thickness among healthy young adults.

Lack of direct association between viral hepatitis and sleep disturbances

Background

Individuals with chronic viral hepatitis are at increased risk of experiencing poor sleep quality and sleep disturbances. However, it remains unclear whether the sleep disorders associated with viral hepatitis are secondary to the comorbidities related to viral hepatitis or the direct effect of hepatitis viruses on sleep. This study investigated the direct impact of viral hepatitis B and C on sleep quality.

Methods

Individuals with viral hepatitis B or C and their healthy counterparts were recruited for the present study, and they were evaluated with the Parkinson's Disease Sleep Scale-2, the Epworth Sleepiness Scale, and the Pittsburgh Sleep Quality Index in the absence of common comorbidities associated with viral hepatitis.

Results

Neither hepatitis B nor hepatitis C was found to cause significant differences in insomnia symptoms or excessive daytime sleepiness. However, individuals with hepatitis C, but not hepatitis B, tended to be less likely to experience restlessness of the legs or arms at night.

Conclusions

This study suggests that hepatitis viruses B and C may not cause a significant impact on sleep quality and related disorders directly. Sleep disturbances in individuals with chronic viral hepatitis may instead be attributable to hepatic decompensation or the comorbid factors associated with viral hepatitis.

The Usefulness of the Athens Insomnia Scale for Evaluating Sleep Disturbance in Patients with Chronic Liver Disease Comparing with Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale

Background and Objectives: Sleep disturbance due to muscle cramps or hepatic encephalopathy in patients with chronic liver disease (CLD) can lead to a reduced quality of life. The Pittsburgh sleep quality index (PSQI) is commonly used for evaluating sleep disturbance; however, this questionnaire is time-consuming owing to the large number of questions. As the usefulness of the Athens insomnia scale (AIS) in patients with CLD is not sufficiently known, the present study aimed to determine whether the AIS and Epworth sleepiness scale (ESS) could be used as simple alternative questionnaires for evaluating sleep disturbances in patients with CLD. Materials and Methods: A total of 117 patients with CLD were retrospectively evaluated. Patients with overt hepatic encephalopathy were excluded. All patients were examined using the AIS, PSQI, and ESS, and their responses to these questionnaires were statistically analyzed. Results: The number of patients diagnosed with sleep disturbance using the AIS, PSQI, and ESS were 39 (33.3%), 37 (31.6%), and 9 (7.7%), respectively. There was no correlation between PSQI and ESS scores (r = 0.011, p = 0.910); in contrast, the AIS scores showed a significant correlation with the PSQI scores (r = 0.689, p < 0.001). When the PSQI was considered as the standard for evaluating sleep disturbance, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the AIS were 76.9%, 91.0%, 81.1%, and 88.8%, respectively. In the sleep medication group, the sensitivity, specificity, PPV, and NPV of the AIS were 100%, 70%, 78.6%, and 100%, respectively. Conclusions: This is the first report to indicate that the AIS is an alternative questionnaire to the PSQI and that it can be a useful tool for detecting cirrhosis-related complications in patients with CLD.

The association of salivary alpha-amylase, heart rate variability, and psychological stress on objectively measured sleep behaviors among college students

Objective

This study aimed to evaluate sleep behaviors among college students, to assess salivary alpha-amylase (sAA) and heart rate variability (HRV) in association with stress, and to investigate sleep-related factors including sAA, HRV, and stress among them.

Methods

Saliva samples for sAA assessment and HRV measurements in the supine position were taken between 3 PM and 6 PM. The level of prolonged psychological stress for the previous week was evaluated using the Korean version of the Global Assessment of Recent Stress (GARS-K), and sleep behaviors were assessed using an actigraphy device.

Results

A total of 86 healthy college students participated in this study. Sleep behaviors of the college students were not good, with 84% sleep efficiency (SE) and 62.7 min wake after sleep onset (WASO). The average sAA level was 65.8 U/mL in the participants. Although neither the sAA level nor HRV indices were significantly correlated with prolonged psychological stress, decreased normalized high frequency (nHF) on HRV was independently associated with a higher level of stress when adjusted for age and sex. Higher stress (r = −0.276, P = 0.011) and lower sAA (r = 0.266, P = 0.030) had significant correlations with shorter time in bed; however, it was sAA that was independently associated with time in bed (β = 0.244, p = 0.044). Decreased nHF (β = 0.245, P = 0.027) and higher body mass index (BMI) (β = −0.224, P = 0.043) were independently related to and poorer SE.

Conclusions

Poor sleep behaviors were associated with decreased parasympathetic activity, a physiological change to psychological stress, rather than with psychological stress itself among college students. Thus, sAA and HRV should be considered as significant factors for impaired sleep behaviors in relation to psychological stress.

Animal Naming Test Is Associated With Poor Patient-Reported Outcomes and Frailty in People With and Without Cirrhosis: A Prospective Cohort Study

INTRODUCTION

Cognitive dysfunction is a major driver of care complexity, poor patient-reported outcomes, and frailty for people with cirrhosis. The performance and clinical associations of the animal naming test (ANT) in the general population are unknown. We evaluated ANT performance in a representative sample of older Americans with and without chronic liver disease (CLD).

METHODS

We analyzed 6,661 subjects enrolled in the 2010-2016 Health and Retirement Survey, a representative cohort of >30,000 US adults. Average age of participants was 75 years. We evaluated 3 subject subgroups: (i) without CLD, (ii) noncirrhosis CLD, and (iii) cirrhosis. We determined the association between the ANT (overall) and S-ANT1 <10 (adjusted for age and education) and health status, basic and instrumental activities of daily living, healthcare utilization (care hours received and hospitalizations), and frailty measures (hand grip and walk speed).

RESULTS

Overall, 8.2% of the sample had noncirrhotic CLD and 1.3% had cirrhosis. CLD or cirrhosis was not independently associated with ANT. Poor ANT performance was associated with poor health status and frailty overall. An S-ANT <10 was associated with fair-poor self-reported health (odds ratio [OR] 1.37; 95% confidence interval [CI]: 1.20-1.56), care hours received (incidence rate ratio [IRR] 2.39; 95% CI: 1.79-3.19), and hospitalizations (IRR 1.14; 95% CI: 1.03-1.26). S-ANT <10 was also associated with activities of daily living disability (OR 1.31; 95% CI: 1.13-1.51), instrumental activities of daily living disability (OR 1.85; 95% CI: 1.59-2.14), weaker hand grip (IRR 0.94; 95% CI: 0.92-0.96), and time to walk 2.5 m (IRR 1.23; 95% CI: 1.17-1.29).

DISCUSSION

ANT performance is not specific to CLD/cirrhosis but is associated with patient-reported outcomes and frailty in a nationally representative sample of elderly subjects with and without CLD.

Elevated thyroid-stimulating hormone levels are associated with poor sleep: a cross-sectional and longitudinal study

PURPOSE

Poor sleep accompanied by elevated TSH (thyroid stimulating hormone) levels is not uncommon since TSH secretion is controlled by the circadian rhythm. However, the relationship between poor sleep and TSH elevation is unclear; hence, we aimed to elucidate this relationship by conducting a cross-sectional and longitudinal study.

METHODS

Participants with isolated elevated (N = 168) and normal (N = 119) TSH concentrations were recruited, and the Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep status. Subjects with an isolated TSH elevation were followed up longitudinally. The serum TSH concentration was remeasured after sleep status improved.

RESULTS

The proportions of poor sleep and occasional poor sleep in subjects with isolated TSH elevation were significantly higher than those with normal TSH levels (70.24% vs. 49.58%, p = 0.001; 9.52% vs. 1.68%, p = 0.006). Subjects with isolated TSH elevation had significantly higher PSQI scores in the subjective sleep quality, sleep latency, sleep duration, and habitual sleep efficiency dimensions than those with normal TSH levels (all p < 0.05). Poor sleep was significantly associated with isolated TSH elevation in the multiple logistic regression analysis [odds ratio (OR) = 2.396, p = 0.001]. Among subjects with an isolated TSH elevation at baseline, the percentage of TSH normalization was significantly higher in those who slept better than in those who still slept poorly (85.42% vs. 6.45%, p < 0.001).

CONCLUSIONS

This study revealed that isolated elevated TSH concentrations normalize when the sleep status is improved; hence, we recommend that clinicians thoroughly assess the sleep status of patients and remeasure TSH concentrations after sleep status improves.

Sleep and liver disease: a bidirectional relationship

Sleep is a complex, highly regulated process essential for human health and wellbeing. Increasingly, sleep-wake disturbance has been implicated in the pathogenesis of chronic liver disease, particularly the development and progression of non-alcoholic fatty liver disease and alcohol-related liver disease. Patients with cirrhosis also have a high burden of sleep abnormalities with substantial implications for their quality of life and physical health. This Review summarises the epidemiology and pathophysiology of sleep-wake disturbance in liver disease and discusses the multiple converging pathways leading to abnormal sleeping patterns in patients with cirrhosis. This includes contributions from altered melatonin metabolism, neuromuscular complications, and aberrant thermoregulation. In turn, a vicious cycle is established whereby disrupted sleep can further contribute to liver disease progression. We also begin to unravel the complex, interlinking relationship between sleep-wake disturbance and hepatic encephalopathy, discussing both overlapping and distinct mechanisms and clinical features. Finally, we summarise the current and future therapeutic approaches aiming to improve sleep quality in patients with cirrhosis.

Effect of continuous positive air pressure on cognitive impairment associated with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a kind of sleep-related breathing disorder, involving multiple organs and systems, which can lead to cognitive impairment. At present, the pathophysiological mechanism of cognitive impairment related to OSA is not clear. It is still unknown whether continuous positive airway pressure (CPAP) has therapeutic effect on cognitive impairment in patients with OSA. These patients repeatedly experience intermittent hypoxia and have sleep fragmentation, which results in abnormal brain structure and function, characterizing by extensive cognitive impairment. Appropriate CPAP can correct the abnormal pathophysiological process of OSA patients, restore brain structure and function to a certain extent, and improve cognitive function. Domestic OSA patients have poor acceptance and compliance to CPAP, while the therapeutic effect of CPAP depends on the timing of treatment and compliance, so many patients do not get effective treatment. Systematically expounding the influence of CPAP on the cognitive function of patients with OSA can help clinicians and patients improve their understanding of CPAP treatment and establish a correct concept of early and standardized treatment.

Comprehensive Overview of Sleep Disorders in Patients with Chronic Liver Disease

The impact of sleep disorders (SDs) on patients with chronic liver diseases (CLD) is tremendous. SDs are frequently encountered among these patients and interfere with their quality of life. This review aims to present the data available so far about the prevalence, phenotypes, and proposed pathophysiological mechanisms of SDs in CLD. Moreover, we proposed to search the literature regarding the most reliable methods to assess SDs and the possible therapeutic options in patients with CLD. The main results of this review show that when it comes to prevalence, the percentages reported vary widely between studies performed among populations from the USA or Europe and those coming from Asian countries. Furthermore, it has been proven that SDs may also be present in the absence of neurocognitive disorders attributable to hepatic encephalopathy (HE), which contradicts traditional suppositions where SDs were considered part of the clinical scenario of HE. Currently, there are no specific recommendations or protocols to assess SDs in CLD patients and data about the therapeutic management are limited. Taking into consideration their impact, a protocol for diagnosing and managing SDs should be developed and included in the daily practice of hepatologists.

Prevalence of and Factors Associated with Sleep-Wake Abnormalities in Patients with Cirrhosis

BACKGROUND & AIMS

Sleep-wake abnormalities [poor nighttime sleep and excessive daytime sleepiness (EDS)] are common in patients with cirrhosis. The aim of this study was to assess the prevalence of sleep-wake abnormalities and clinical factors associated with these abnormalities in a group of patients with cirrhosis.

METHODS

1098 patients with cirrhosis [Child Turcotte Pugh (CTP) class A, 22.2%; CTP class B, 29.2% and CTP class C, 48.6%], with either no ascites or mild ascites controlled on diuretics, and no history of or current overt hepatic encephalopathy were included in the study.

RESULTS

Poor nighttime sleep and EDS were found in 569 (51.8%) and 489 (44.5%) patients respectively. On multivariate analysis, factors associated with poor nighttime sleep were CTP class C (vs. class A), presence of minimal hepatic encephalopathy (MHE), intermediate or evening type of diurnal preference category (vs. morning type), high risk for obstructive sleep apnea (OSA), diuretic use, presence of major depression, and presence of generalized anxiety disorder (GAD). Factors associated with EDS on multivariate analysis were CTP class B and C (vs. class A), intermediate or evening type of diurnal preference category (vs. morning type), high risk for OSA, presence of major depression, and presence of GAD.

CONCLUSIONS

Sleep-wake abnormalities are common in patients with cirrhosis. CTP status, diurnal preference chronotype, risk of OSA, major depression and GAD are associated with both poor nighttime sleep and EDS. MHE and diuretic use are associated with poor nighttime sleep, but not with EDS.

European Respiratory Society statement on sleep apnoea, sleepiness and driving risk

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

How frequent is sleep-disordered breathing among Egyptian cirrhotic adults?

AIM OF THE STUDY

Liver cirrhosis is an irreversible destructive liver disease that is associated with a wide range of complications. Among the recognized comorbidities of liver cirrhosis are sleep-disordered breathing (SDB), which is being more and more often described among cirrhotics. This study aimed to detect the prevalence of SDB among Egyptian post-viral cirrhotic adults.

MATERIAL AND METHODS

This study enrolled 48 post-viral cirrhotic patients and 16 apparently healthy control subjects. All patients and controls were evaluated by thorough history taking, full clinical examination, laboratory investigations, the Epworth Sleepiness Scale questionnaire, the Berlin Questionnaire and polysomnography.

RESULTS

Patients and controls were comparable as regards baseline demographics. Patients with liver cirrhosis had higher frequency of SDB compared to controls (56.2% vs. 12.5%, p = 0.002). The most frequently encountered SBD patterns among cirrhotics were obstructive sleep apnea and apnea hypopnea index. Moreover, SDB was more severe among cirrhotics (25% were mild, 16.6% were moderate and 14.6% were severe obstructive sleep apnea - OSA) compared to the healthy controls (all were mild).

CONCLUSIONS

It seems that post-viral cirrhotic patients had a wide range of SDB with variable degrees of severity compared to the healthy controls.

Understanding the impact of neurologic complications in patients with cirrhosis

Patients with cirrhosis may experience neurologic complications, including hepatic encephalopathy. Hepatic encephalopathy may be classified as covert (mild symptoms (e.g. lack of awareness)) or overt (moderate to severe symptoms (e.g. confusion or coma)), and symptoms may overlap with other neurologic conditions (e.g. epilepsy, stroke). Managing hepatic encephalopathy includes identifying and treating precipitating factors (e.g. dehydration). First-line treatment for patients with overt hepatic encephalopathy is typically lactulose; to reduce the risk of overt hepatic encephalopathy recurrence, lactulose plus the nonsystemic antibiotic rifaximin is recommended. Rifaximin reduced the risk of breakthrough overt hepatic encephalopathy by 58% versus placebo over 6 months (p < 0.001; 91% of patients in each group were on concomitant lactulose). However, neither pharmacologic hepatic encephalopathy treatment nor liver transplantation may completely reverse neurologic impairment in patients with hepatic encephalopathy. Additional neurologic considerations for patients with cirrhosis include preventing falls, as well as managing sleep-related issues, hyponatremia, and cerebral edema. Thus, monitoring neurologic impairment is an important component in the management of patients with cirrhosis.

Association of CTRP13 With Liver Enzymes and Cognitive Symptoms in Nonalcoholic Fatty Liver Disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease in which patients present with metabolic dysregulation and obesity as well as fat accumulation in the liver. Those with NAFLD frequently have symptoms of fatigue, sleep disturbance, depression, and cognitive dysfunction. C1q/TNF-related protein 13 (CTRP13) regulates glucose metabolism and obesity in mice, yet the role of CTRP13 in human NAFLD has not been elucidated.

AIMS

Our aims were to examine whether the plasma levels of CTRP13 are (a) increased in patients with NAFLD; (b) associated with metabolic dysregulation, obesity, liver enzymes, and dyslipidemia; and (c) associated with putative symptoms of NAFLD.

METHODS

An observational study was conducted with 23 adults with confirmed NAFLD. Plasma levels of CTRP13, insulin resistance, insulin sensitivity, HbA1C, lipid profile, and liver enzymes were collected. Anthropometric analysis (body mass index, waist-hip circumference ratio) and bioelectrical impedance analysis of body composition were used to assess obesity. Symptom questionnaires were used to assess putative symptoms of NAFLD. Plasma levels of CTRP13 were measured in 21 age- and sex-matched control samples from a biobank. Paired t test was used for comparison of the CTRP13 between NAFLD and controls. Pearson's correlation coefficients were used to examine associations among variables.

RESULTS

Plasma levels of CTRP13 were significantly higher in patients with NAFLD than in normal controls (p < .001), were associated with higher levels of aspartate aminotransferase, alanine aminotransferase (both p < .05), triglycerides (p < .001), and poorer cognitive function, particularly visuospatial memory (p < .001).

CONCLUSIONS

CTRP13 may be a surrogate biomarker of NAFLD symptoms and associated with hepatocellular damage, dyslipidemia, and cognitive dysfunction.

Treatment with Melatonin Improves Cognitive Behavior and Motor Skills in a Rat Model of Liver Fibrosis

INTRODUCTION AND AIM

Patients with liver cirrhosis (LC) and minimal hepatic encephalopaty have a higher accident rate. LC impairs the normal sleep-awake cycle and produces disturbances in behavior, cognition and motor skills. Abnormal melatonin (MT) levels have also been identified in LC. Administration of MT may regulate circadian rhythms and prevent the oxidative damage. We studied the effects of MT on spatial memory acquisition (SMA) and motor skills in a liver fibrosis model (LF)s.

MATERIALS AND METHODS

Forty-five rats, divided into 4 groups. [G1: LF; G2: LF + MT; G3: MT; G4: Healthy control (HC)]. LF was induced by carbon tetrachloride intraperitoneal injection (0.2 mL/kg) for 5 months. MT was administered during 5 weeks (0.4 mg/kg/day). SMA was evaluated by using the Morris Water Maze protocol where the escape latency (EL) and mean speed were measured. Data were registered by SMART®.

RESULTS

The EL measurement analyzed by two way ANOVA: cirrhosis presented a higher EL than controls or those treated with MT suggesting impaired memory acquisition which is rescued by MT treatment. The mean speed analysis revealed that LF presented higher speed than LF+MT or HC, suggesting that LF affects motor skills, which are improved by MT. To discard whether EL is affected by altered motor skills in LF treated with MT, we compared the average EL and speed between days 2 and 6 of the training protocol. Speed was not improved during the trials unlike EL, suggesting that memory acquisition is independent of motor skills.

CONCLUSION

These findings suggest that MT improves cognition and motor skills in the LF model.

Sleep disturbances in patients with liver cirrhosis: prevalence, impact, and management challenges

Sleep-wake disturbances are common in liver cirrhosis and associated with impaired quality of life. The most common abnormalities are insomnia (difficulties falling asleep and maintaining sleep, or unrefreshing sleep), excessive daytime sleepiness, and sleep-wake inversion (disturbances of circadian rhythmicity). The underlying pathophysiological mechanisms for sleep disturbances in cirrhosis are complex and may include disturbed metabolism of melatonin and glucose, alterations in thermoregulation, and altered ghrelin secretion profiles. Sleep-wake abnormalities are related to the presence of hepatic encephalopathy (HE) and improvement in sleep parameters can be observed when HE is properly managed. A few non-specific treatments for sleep-wake abnormalities have been tried with encouraging results for hydroxyzine and modafinil. However, due to the potential for medication toxicity in these disabled patients, further studies are needed to address the potential role of non-drug therapies in this population (eg, cognitive behavioral therapy, mindfulness, yoga) that have demonstrated usefulness in insomnia disorders.

Symptoms of Daytime Sleepiness and Sleep Apnea in Liver Cirrhosis Patients

Background/propose. Sleep disturbance and excessive daytime sleepiness (EDS) have been reported in patients with hepatic cirrhosis with no hepatic encephalopathy (HE). The objective of this study was to evaluate daytime sleepiness and risk of obstructive sleep apnea (OSA) among liver cirrhosis patients.

MATERIAL AND METHODS

A cross-sectional study was conducted at King Abdulaziz Medical City (KAMC)-Riyadh over a period of six months, using a structured questionnaire that investigated: 1) Sleep patterns and daytime sleepiness using the Epworth Sleeping Scale (ESS), and 2) The risk for sleep apnea using the Berlin Questionnaire (BQ). We enrolled patients with a confirmed diagnosis of liver cirrhosis who were being followed at the hepatology and pre-liver transplant clinics.

RESULTS

We enrolled 200 patients with liver cirrhosis, 57.5% of whom were male. The mean age was 60 (± SD 12.2). The reported prevalence of EDS, OSA, and both EDS and OSA were 29.5%, 42.9%, and 13.6%, respectively. The prevalence of EDS was higher in patients with Hepatitis-C and patients with DM, who experienced short sleep duration. We did not find any association between the severity of liver disease and EDS or OSA as measured by Child-Pugh scores (CPS).

CONCLUSIONS

The risk of OSA and EDS is high among liver cirrhosis patients. Those patients with cirrhosis secondary to Hepatitis C are at higher risk of EDS and OSA. Both EDS and OSA affect patients designated as CPS Class A more frequently than patients designated as CPS Class B.

Assessment and Management of Sleep Disturbance in Cirrhosis

Purpose of Review

This review presents an in-depth overview of the sleep–wake phenotype of patients with cirrhosis, together with available pharmacological and non-pharmacological treatment strategies. A set of simple, practical recommendations is also provided.

Recent Findings

The understanding of the pathophysiology of sleep disorders in this patient population has improved over the past decade, especially in relation to the interplay between homeostatic and circadian sleep regulation. In addition, new tools have been utilised for both screening and in-depth investigation of the sleep–wake profile of these patients. Finally, a number of studies have evaluated the efficacy of novel treatment strategies, often with encouraging results.

Summary

Since sleep disturbances are common in patients with cirrhosis, more so than in patients with other chronic diseases of similar severity, their assessment should become routine hepatological practice, along with the initiation of adequate treatment.

Symptom Domain Groups of the Patient-Reported Outcomes Measurement Information System Tools Independently Predict Hospitalizations and Re-hospitalizations in Cirrhosis

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) tools can identify health-related quality of life (HRQOL) domains that could differentially affect disease progression. Cirrhotics are highly prone to hospitalizations and re-hospitalizations, but the current clinical prognostic models may be insufficient, and thus studying the contribution of individual HRQOL domains could improve prognostication.

AIM

Analyze the impact of individual HRQOL PROMIS domains in predicting time to all non-elective hospitalizations and re-hospitalizations in cirrhosis.

METHODS

Outpatient cirrhotics were administered PROMIS computerized tools. The first non-elective hospitalization and subsequent re-hospitalizations after enrollment were recorded. Individual PROMIS domains significantly contributing toward these outcomes were generated using principal component analysis. Factor analysis revealed three major PROMIS domain groups: daily function (fatigue, physical function, social roles/activities and sleep issues), mood (anxiety, anger, and depression), and pain (pain behavior/impact) accounted for 77% of the variability. Cox proportional hazards regression modeling was used for these groups to evaluate time to first hospitalization and re-hospitalization.

RESULTS

A total of 286 patients [57 years, MELD 13, 67% men, 40% hepatic encephalopathy (HE)] were enrolled. Patients were followed at 6-month (mth) intervals for a median of 38 mths (IQR 22-47), during which 31% were hospitalized [median IQR mths 12.5 (3-27)] and 12% were re-hospitalized [10.5 mths (3-28)]. Time to first hospitalization was predicted by HE, HR 1.5 (CI 1.01-2.5, p = 0.04) and daily function PROMIS group HR 1.4 (CI 1.1-1.8, p = 0.01), independently. In contrast, the pain PROMIS group were predictive of the time to re-hospitalization HR 1.6 (CI 1.1-2.3, p = 0.03) as was HE, HR 2.1 (CI 1.1-4.3, p = 0.03).

CONCLUSIONS

Daily function and pain HRQOL domain groups using PROMIS tools independently predict hospitalizations and re-hospitalizations in cirrhotic patients.

Managing Sleep Disturbances in Cirrhosis

Sleep disturbances, particularly daytime sleepiness and insomnia, are common problems reported by patients suffering from liver cirrhosis. Poor sleep negatively impacts patients' quality of life and cognitive functions and increases mortality. Although sleep disturbances can be an early sign of hepatic encephalopathy (HE), many patients without HE still complain of poor quality sleep. The pathophysiology of these disturbances is not fully understood but is believed to be linked to impaired hepatic melatonin metabolism. This paper provides an overview for the clinician of common comorbidities contributing to poor sleep in patients with liver disease, mainly restless leg syndrome and obstructive sleep apnea. It discusses nondrug and pharmacologic treatment options in these patients, such as the use of light therapy and histamine (H1) blockers.