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• W2920797790 abstract "Free AccessSleep Quality - Sleep Duration - CommentaryCan Poor Sleep Cause Kidney Disease? Another Step Closer to the Answer Karel Calero, MD, William McDowell Anderson, MD Karel Calero, MD Address correspondence to: Karel Calero, MD, 2 Tampa General Cir, Tampa, FL 33606 E-mail Address: [email protected] College of Medicine, Pulmonary, Critical Care and Sleep Medicine, University of South Florida, Tampa, Florida Search for more papers by this author , William McDowell Anderson, MD College of Medicine, Pulmonary, Critical Care and Sleep Medicine, University of South Florida, Tampa, Florida Search for more papers by this author Published Online:March 15, 2019https://doi.org/10.5664/jcsm.7652SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONInflammatory mediators and sympathetic overtone contribute to the development of cardiovascular and renovascular disorders.1,2 Obstructive sleep apnea, circadian rhythm disorders, hypersomnia, and insomnia have been linked to a multitude of metabolic disturbances. A growing body of evidence suggests that sleep disturbances affect the development of kidney disease, possibly as a result of the inflammatory milieu and sympathetic activation occurring at the renal vascular bed that damage the glomerular basement membrane and the kidney tubular apparatus.3–6 Most current evidence linking kidney disease and sleep disorders has originated from small epidemiological studies. A previous study by Choi et al. linked longer sleep duration to the development of chronic kidney disease (CKD) in Korean women but findings were not replicated in men.7 Yamamoto et al. found a U-shaped relationship between sleep duration and progression of CKD to end stage renal disease (ESRD), with individuals sleeping less than 5 hours and over 8 hours at greatest risk for disease progression. This study also revealed that poor sleep quality was associated with the incidence of ESRD.8 A meta-analysis suggested an association between short sleep duration and proteinuria, a surrogate marker of kidney disease progression.9 Renal hyperfiltration, a marker of early renal damage, has been linked to short (less than 6 hours) and long (more than 10 hours) sleep duration.10,11A study by Bo et al. in this issue of the Journal of Clinical Sleep Medicine adds to the existing body of evidence linking poor sleep quality and the development of CKD.12 This appears to be the largest epidemiological study of its kind. The development of kidney disease was analyzed in almost 200,000 patients (after excluding preexisting CKD or proteinuria as well as metabolic risk factors such as hypertension, diabetes, cardiovascular disease and cancer). Short sleep and long sleep duration as well as poor sleep quality were associated with the incident development of CKD. CKD was defined using the modification of diet in renal disease (MDRD) study equation. Despite some limitations outlined below, the study has important global health implications and once again emphasizes the importance of good quality and quantity of sleep to overall health. Another important observation is the link of insomnia and/or the use of sedative agents with the development of CKD.The study population was Asian and mostly well-educated and non-smoking. It is unknown whether the findings of the study carry equally across other populations. Most previous evidence linking sleep and CKD also comes from studies in Asian populations.7,8,10 Some potential study pitfalls were related to the definition of CKD and the use of a nonvalidated sleep questionnaire. The MDRD calculations used in this study have shown inaccuracy when applied to a Taiwanese population and the MDRDc (MDRD for Chinese) is favored as a more accurate calculation.13 It is possible that some of the problems with calculation of eGFR and the overestimation and later exclusion of study subjects could have been avoided if additional correction had been performed for the Asian population. Lack of accounting for some of these subjects is of further concern, since glomerular hyperfiltration has been linked to eventual progression of kidney disease and it has been linked to sleep disturbances in prior studies.10 Furthermore, it would have been appropriate to have serial measurements confirming the existence of CKD instead of a single value with eGFR under 60 mL/min/1.73m2. As a result, some patients would have had the development of reversible acute kidney injury at the time that laboratory measurements were taken, and these could have been potentially excluded with subsequent measurements.Sleep quality and quantity were obtained through questionnaires, which is characteristic of a study of this size. The patients were not screened for sleep-disordered breathing, which is a drawback, given the high body of evidence linking obstructive sleep apnea and the development of cardiovascular disease, including renovascular hypertension, diabetes, and progression of CKD.14–19 The authors used a nonvalidated questionnaire that generated a scale of sleep quality. This presents bias since its validity is unknown and some of the measurements reported may not be additive. It is hard to assign a number to a particular sleep problem and compare it with another, much less compare it between patients. The Epworth Sleepiness Scale, for example, is very good in tracking any given patient over time or patient populations but may become problematic when comparing individual patients.20Benjamin Franklin said, “an ounce of prevention is worth a pound of cure.”21 Health campaigns with widespread ramifications should be a priority for society. This study offers us the hope that if we improve sleep quantity and quality, we can have an impact on the development of CKD. More work needs to be done in the field to validate these findings as identification and treatment of sleep disorders becomes a priority and the natural history of renal disease is better defined.DISCLOSURE STATEMENTAll authors have seen and approved the manuscript. The authors report no conflicts of interest.CITATIONCalero K, Anderson WM. Can poor sleep cause kidney disease? Another step closer to the answer. J Clin Sleep Med. 2019;15(3):371–372.REFERENCES1 Kingma JG, Simard D, Rouleau JR, Drolet B, Simard CThe physiopathology of cardiorenal syndrome: a review of the potential contributions of inflammationJ Cardiovasc Dev Dis201744E21 CrossrefGoogle Scholar2 Abdulla MH, Johns EJThe innervation of the kidney in renal injury and inflammation: a cause and consequence of deranged cardiovascular controlActa Physiol (Oxf)20172204404416 CrossrefGoogle Scholar3 D'Elia JA, Roshan B, Maski M, Weinrauch LAManifestation of renal disease in obesity: pathophysiology of obesity-related dysfunction of the kidneyInt J Nephrol Renovasc Dis200923949 Google Scholar4 Bastard JP, Maachi M, Lagathu C, et al.Recent advances in the relationship between obesity, inflammation, and insulin resistanceEur Cytokine Netw2006171412 Google Scholar5 Poonit ND, Zhang YC, Ye CY, et al.Chronic intermittent hypoxia exposure induces kidney injury in growing ratsSleep Breath2018222453461 CrossrefGoogle Scholar6 Zhang L, Huang X, Li X, Wu QAlterations in renal function in patients with obstructive sleep apnea syndrome and effects of continuous positive airway pressureChin Med J (Engl)199711012915918 Google Scholar7 Choi H, Kim HC, Lee JY, Lee JM, Choi DP, Suh ISleep duration and chronic kidney disease: the Korean Genome and Epidemiology Study (KoGES)-Kangwha studyKorean J Intern Med2017322323334 CrossrefGoogle Scholar8 Yamamoto R, Shinzawa M, Isaka Y, et al.Sleep quality and sleep duration with CKD are associated with progression to ESKDClin J Am Soc Nephrol2018131218251832 CrossrefGoogle Scholar9 Cheungpasitporn W, Thongprayoon C, Gonzalez-Suarez ML, et al.The effects of short sleep duration on proteinuria and chronic kidney disease: a systematic review and meta-analysisNephrol Dial Transplant2017326991996 Google Scholar10 Lin M, Su Q, Wen J, et al.Self-reported sleep duration and daytime napping are associated with renal hyperfiltration in general populationSleep Breath2018221223232 CrossrefGoogle Scholar11 Petrov ME, Buman MP, Unruh ML, et al.Association of sleep duration with kidney function and albuminuria: NHANES 2009-2012Sleep Health2016217581 CrossrefGoogle Scholar12 Bo Y, Yeoh EK, Guo C, et al.Sleep and the risk of chronic kidney disease: a cohort studyJ Clin Sleep Med2019153393400 LinkGoogle Scholar13 Kuo CF, Yu KH, Shen YM, See LCThe Chinese version of the modification of diet in renal disease (MDRD) equation is a superior screening tool for chronic kidney disease among middle-aged Taiwanese than the original MDRD and Cockcroft-Gault equationsBiomed J2014376398405 CrossrefGoogle Scholar14 Yayan J, Rasche K, Vlachou AObstructive sleep apnea and chronic kidney diseaseAdv Exp Med Biol201710221118 CrossrefGoogle Scholar15 Abuyassin B, Sharma K, Ayas NT, Laher IObstructive sleep apnea and kidney disease: a potential bidirectional relationship?J Clin Sleep Med2015118915924 LinkGoogle Scholar16 Pedrosa RP, Drager LF, Gonzaga CC, et al.Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertensionHypertension2011585811817 CrossrefGoogle Scholar17 Zalucky AA, Nicholl DD, Hanly PJ, et al.Nocturnal hypoxemia severity and renin-angiotensin system activity in obstructive sleep apneaAm J Respir Crit Care Med20151927873880 CrossrefGoogle Scholar18 Tanigawa TObstructive sleep apnea: its prevention and screening may contribute to the prevention of hypertension, diabetes and cardiovascular diseasesEPMA J2011218389 CrossrefGoogle Scholar19 Koo CY, Drager LF, Sethi R, et al.Obstructive sleep apnea and diabetes independently add to cardiovascular risk after coronary revascularizationDiabetes Care2018412e12e14 CrossrefGoogle Scholar20 Bonzelaar LB, Salapatas AM, Yang J, Friedman MValidity of the Epworth Sleepiness Scale as a screening tool for obstructive sleep apneaLaryngoscope20171272525531 CrossrefGoogle Scholar21 Tegg TA Present for an Apprentice18482nd edCheapside, LondonWilliam Tegg & Co. Google Scholar Next article FiguresReferencesRelatedDetails Volume 15 • Issue 03 • March 15, 2019ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationFebruary 28, 2019Submitted in final revised formFebruary 28, 2019Accepted for publicationFebruary 28, 2019Published onlineMarch 15, 2019 Information© 2019 American Academy of Sleep MedicinePDF download" @default.
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