Association between Hepatic Steatosis and Obstructive Sleep Apnea in Children and Adolescents with Obesity

Risk factors of high inflammatory state in pediatric obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) may induce chronic systemic inflammation, which may serve as a potential mechanism contributing to multiple complications. The timely identification of high inflammatory status (HIS) in pediatric OSA is crucial for effective clinical diagnosis and management. This study aimed to evaluate influencing factors in hsCRP levels, and further investigated the risk factors associated with HIS in pediatric OSA patients.

METHODS

Children aged 3 to 15 years who presented with snoring symptoms and underwent polysomnography (PSG) at the sleep center were included in this study. All participants completed a comprehensive questionnaire, a physical examination, nasopharyngeal X-ray imaging and a blood test. The physical examination included measurements of height, weight, and visual evaluation of tonsillar hypertrophy.

RESULTS

A total of 1,171 children were enrolled, with 562 cases diagnosed with OSA. Utilizing threshold for hsCRP generated via ROC curve, 299 and 872 children exhibited HIS and Low Inflammatory Status, respectively. Compared to the control group, the hsCRP levels in the OSA group were significantly elevated. Pediatric OSA with HIS had higher BMI and a greater proportion of both overweight and obese. Logistic regression analysis demonstrated that HIS was independently positively correlated with BMI and mean time of obstructive apnea, and negatively associated with minimum SpO2.

CONCLUSIONS

HsCRP in pediatric OSA patients were notably elevated, whilst identifying BMI, mean time of obstructive apnea, and minimum SpO2 as independent factors leading to HIS. HsCRP may function as an effective blood index capable of identifying individuals exhibiting HIS linked to OSA.

Elastography as a non-invasive method of screening non-alcoholic fatty liver disease in the adult phenotype of paediatric obstructive sleep apnoea

PURPOSE

The high prevalence of non-alcoholic fatty liver disease (NAFLD) in obese children with obstructive sleep apnoea (OSA) calls for early non-invasive screening. The aim of this study was to use ultrasonographic liver echogenicity and elasticity to evaluate the early stages of liver injury in obese children with OSA.

METHODS

Fifty-five obese children with OSA aged 12 to 15 years were included. The control group (n = 56) consisted of healthy, non-obese children. All children underwent ultrasound examination to assess liver echogenicity using the hepatorenal index (HRI) and real-time elastography to determine the liver fibrosis index (LFI). Polysomnographic parameters, sonographic values, and clinical-biochemical assessment were statistically analysed according to OSA and its severity. Subgroup 1 was obese children with OSA and AHI < 5 and subgroup 2 was obese children with OSA and AHI ≥ 5.

RESULTS

Higher average values of HRI and LFI were recorded in the group of obese paediatric patients with OSA (mean age ± SD, 14.1 ± 2.2 year; 53% male; BMI z-score, 2.6 ± 0.35) compared to the control group (1.37 ± 0.19 vs. 1.12 ± 0.07, p < 0.001 and 1.82 ± 0.31 vs. 1.02 ± 0.27, p < 0.001). A significantly higher LFI was recorded in subgroup 2 compared to subgroup 1 (2.0 ± 0.3 vs. 1.6 ± 0.2, p < 0.001) while laboratory parameters and HRI (1.4 ± 0.2 vs. 1.4 ± 0.2, p = 0.630) did not change significantly. A strong positive correlation was found between the severity of OSA and the LFI (r = 0.454; p < 0.01).

CONCLUSIONS

These findings suggest that ultrasound elastography is a useful non-invasive screening test for OSA-related steatohepatitis in obese adolescents, but other clinical studies are needed to confirm this result.

Sleep duration is associated with liver steatosis in children depending on body adiposity

Sleep is a factor associated with overweight/obesity risk, wherein interactions with fatty liver should be ascertained. The aim of this cross-sectional study was to analyze the possible relationships of sleep with liver health and whether this interplay is related to body adiposity distribution in children and adolescents. Anthropometric, clinical, and biochemical measurements were performed in children and adolescents (2-18 years old) with overweight/obesity (n = 854). Body fat distribution was clinically assessed, and several hepatic markers, including hepatic steatosis index, were calculated. Sleep time mediation (hours/day) in the relationship between the hepatic steatosis index and body fat distribution was investigated. Differences among diverse fatty liver disease scores were found between children with overweight or obesity (p < 0.05). Linear regression models showed associations between hepatic steatosis index and lifestyle markers (p < 0.001). Hepatic steatosis index was higher (about + 15%) in children with obesity compared to overweight (p < 0.001). Pear-shaped body fat distribution may seemingly play a more detrimental role on liver fat deposition. The association between sleep time and hepatic steatosis index was dependent on body mass index z-score. Post hoc analyses showed that 39% of the relationship of body fat distribution on hepatic steatosis index may be explained by sleep time.  Conclusion: An association of sleep time in the relationship between body fat distribution and hepatic steatosis index was observed in children and adolescents with overweight/obesity, which can be relevant in the prevention and treatment of excessive adiposity between 2 and 18 years old.

CLINICAL TRIAL

NCT04805762.    Import: As part of a healthy lifestyle, sleep duration might be a modifiable factor in the management of fatty liver disease in children.

WHAT IS KNOWN

• Sleep is an influential factor of overweight and obesity in children. • Excessive adiposity is associated with liver status in children and adolescents.

WHAT IS NEW

• Sleep time plays a role in the relationship between body fat distribution and liver disease. • Monitoring sleep pattern may be beneficial in the treatment of hepatic steatosis in children with excessive body weight.

Linear Relationship between Hepatic Steatosis Index and Major Adverse Cardiovascular Events in Hypertensive Patients with Obstructive Sleep Apnea: A Real-World Cohort Study from China

Background

Hypertensive patients with obstructive sleep apnea (OSA) are at a high risk of cardiovascular disease (CVD), but assessments of CVD risk in this population are frequently constrained by the presence of comorbid medical conditions. The noninvasive and convenient hepatic steatosis index (HSI) can not only predict the degree of fatty liver degeneration but also correlates well with the severity of numerous diseases. However, the relationship between the HSI and CVD in hypertensive patients with OSA remains unclear.

Methods

This retrospective cohort study included patients aged ≥ 18 years with hypertension and a primary diagnosis of OSA and grouped them according to their baseline HSI. The primary outcome was new or recurrent major adverse cardiovascular and cerebrovascular events (MACCE), while the secondary outcomes were cardiac and cerebrovascular events. The relationship between the baseline HSI and the risk of endpoint events was evaluated using Kaplan-Meier curves, risk-factor graphs, and Cox regression models, while generalized additive models were used to identify linear relationships. The C-statistic, integrated discrimination improvement (IDI), and net reclassification index (NRI) were used to evaluate the predictive value of HSI increments for endpoint events.

Results

A total of 2467 participants were included in the analysis and separated into four groups (Q1-Q4) based on their HSI quartiles. Kaplan-Meier survival curves indicated that patients in the Q4 group had the lowest survival time. The Q4 group also showed a significantly higher risk of MACCE (HR [hazard ratio], 2.95; 95% CI [confidence interva]: 1.99-4.39; p < 0.001), cardiac events (HR, 2.80; 95% CI: 1.68-4.66; p < 0.001), and cerebrovascular events (HR, 3.21; 95% CI: 1.71-6.03; p < 0.001). The dose-response curve revealed a linear association between the HSI and the occurrence of endpoint events. For every unit increase in the HSI, the risks of MACCE, cardiac events, and cerebrovascular events increased by 43%, 38%, and 51%, respectively. The C-statistic, IDI, and NRI all indicated that the model including the HSI showed better discriminatory and classification efficacy for endpoint events in comparison with the conventional model (p < 0.05).

Conclusions

The HSI showed a linear relationship with the risk of MACCE in hypertensive OSA patients.

Obstructive sleep apnea (OSA) is associated with the impairment of beta-cell response to glucose in children and adolescents with obesity

BACKGROUND

The main purpose of the study is to assess the association between obstructive sleep apnea (OSA) and insulin secretion in children with obesity.

METHODS

We enrolled children and adolescents who attended our pediatric clinic because of obesity and OSA. Glucose homeostasis was assessed through standard 2-h oral glucose tolerance test (OGTT). Nocturnal cardio-respiratory polygraphy was performed for OSA diagnosis. Twenty-two patients underwent a 3-h OGTT to investigate insulin secretion and sensitivity through the oral-minimal model.

RESULTS

seventy-seven children and adolescents were included in the study. Based on OSA severity, the cohort was divided into three groups (29 mild, 29 moderate, and 19 severe OSA). The group with mild OSA showed lower levels of 30-min glucose (p = 0.01) and 60-min glucose (p = 0.03), and lower prevalence of elevated 1-h glucose (10.4% versus 44.8% in moderate and 31.6% in severe OSA, p = 0.01). The odds for elevated 1-h plasma glucose was 6.2-fold (95%CI 1.6-23.4) higher in subjects with moderate and severe OSA compared to mild OSA (p = 0.007) independent of confounders. Spearman correlation test revealed a positive correlation between 30-min plasma glucose and apnea-hypopnea index (AHI, r = 0.31, p = 0.01), oxygen desaturation index (ODI, r = 0.31, p = 0.009), and mean desaturation (r = 0.25, p = 0.04). The 3-h OGTT study included 22 participants (7 mild, 9 moderate, and 6 severe OSA). The group with mild OSA showed a higher dynamic, static, and total insulin secretion compared to those with moderate and severe OSA (p < 0.0001, p = 0.007, p = 0.007, respectively). AHI was significantly correlated to dynamic insulin secretion (r = -0.48, p = 0.02).

CONCLUSIONS

OSA might impair beta-cell function reducing the pool of promptly releasable insulin in children and adolescents with obesity, in the absence of an effect on insulin sensitivity.

Current Concepts in Pediatric Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is described as intermittent partial or complete upper airway obstruction that can disrupt respiratory and ventilatory patterns during sleep [...]

Pediatric Sleep Questionnaire Predicts Moderate-to-Severe Obstructive Sleep Apnea in Children and Adolescents with Obesity

Pediatric obesity is associated with an increased risk of morbidity during childhood. Alongside the well-known metabolic syndrome, during the last decades scientific research has deeply investigated the risk of sleep breathing disorders. Among them, obstructive sleep apnea (OSA) commonly affects children with obesity. The presence of OSA heightens the risk of metabolic impairment and weight gain. Therefore, it deserves specific treatment. However, polysomnography (PSG) is not always available in clinical settings, and alternative diagnostic tools are needed. This study aimed to investigate the predictivity of the pediatric sleep questionnaire (PSQ) for moderate-to-severe OSA diagnosis. Children and adolescents with obesity and suspected OSA with available full-night cardiorespiratory PSG were retrospectively enrolled. Receiver operating curve analysis was performed to test the ability of PSQ in predicting moderate-to-severe OSA (AHI > 5 episode/h). The final sample included 60 children and adolescents. The PSQ showed a good area under the curve (AUC) of 0.88 (95% CI 0.78−0.98, p < 0.0001). Moreover, a value above or equal to 0.65 showed an 80% sensitivity and 100% specificity for moderate and severe OSA. These findings suggest that PSQ might be used in clinical settings with limited access to PSG for stratifying disease severity and for selecting children with urgent need of sleep study.