High prevalence of sleep disturbance in cirrhosis

Abstract

Sleep disturbance is a classic sign of hepatic encephalopathy. However, there are limited data regarding its prevalence in cirrhotic patients without overt hepatic encephalopathy. We assessed the characteristics of sleep in cirrhosis using a sleep questionnaire (n ‫؍‬ 44) and actigraphy (n ‫؍‬ 20). The results were compared with those of subjects with chronic renal failure and those of healthy controls. Presence of subclinical hepatic encephalopathy, chronotypology profile, and individual's affective state were also analyzed. The questionnaire indicated an elevated number of cirrhotic patients (47.7%) and patients with chronic renal failure (38.6%) who complained of unsatisfactory sleep compared with healthy controls (4.5%, P F .01). Actigraphy corroborated the deterioration of sleep parameters in cirrhotic patients with unsatisfactory sleep. The sleep disturbance in cirrhosis was not associated with clinical parameters nor with cognitive impairment. Cirrhotic subjects and patients with chronic renal failure with unsatisfactory sleep showed higher scores for depression and anxiety, raising the possibility that the effects of chronic disease may underlie the pathogenesis of sleep disturbance. However, in contrast to chronic renal failure, unsatisfactory sleep in cirrhosis was associated with delayed bedtime, delayed wake-up time, and evening chronotypology. In conclusion, a sleep disturbance is frequent in cirrhotic patients without hepatic encephalopathy and may be related to abnormalities of the circadian timekeeping system. (HEPATOLOGY 1998;27:339-345.)A disturbance of sleep is recognized as one of the early signs of hepatic encephalopathy. 1 However, there are limited data regarding its prevalence in patients with cirrhosis without signs of overt hepatic encephalopathy. Results from a quality of life questionnaire indicated that disturbance in sleep was significantly higher in nonalcoholic cirrhotic patients compared with subjects with another chronic illness, such as Crohn' s disease. 2 In this survey and subsequent data, 3 up to 35% of cirrhotic individuals had difficulties in the area of sleep and rest.The mechanisms responsible for these findings are poorly understood. One possibility is that abnormalities in circadian function may underlie its pathogenesis. The sleep-wake cycle is one of the functions regulated by the circadian clock, the suprachiasmatic nucleus of the anterior hypothalamus, 4 which has efferent connections that influence a large array of biological functions including the secretion of melatonin from the pineal gland. Previous studies from our laboratory have shown that rats subjected to a portacaval anastomosis experience an alteration in the rhythm of circadian locomotor activity as well as the rhythm of pineal melatonin content. 5 In patients with cirrhosis, the diurnal plasma melatonin profile showed a significant delay in the onset of plasma melatonin increase and in its peak nocturnal level. 6 This displacement of the melatonin profile could be a reflection of an alteration in the ...

Minimal Hepatic Encephalopathy Impairs Quality of Life

“…[52][53][54][55][56] Studies have confirmed higher frequency of sleep disturbances in patients of cirrhosis with MHE compared to those without MHE. 11,52 Sleep is maintained by two processes namely, 'Homeostatic process' that determines sleep propensity in relation to waking hours and 'Circadian process' under the control of suprachiasmatic nucleus and its retino-hypothalamic axis which responds to light-dark cues by melatonin secretion. 57 Patients with cirrhosis have unsatisfactory night sleep due to delayed sleep onset and multiple night awakenings resulting in reduced sleep time and excessive daytime sleepiness.…”

“…57 Night time sleep disturbances are not related to HE and are caused by circadian rhythm abnormalities due to toxic effect on suprachiasmatic nucleus and impaired melatonin clearance. 52 However, excessive daytime sleepiness correlates with ammonia levels and is associated with increased risk of HE related hospitalization and presence of portosystemic shunts. 58 Sleep disturbances contribute to impairment in HRQOL in MHE patients.…”

Sleep disturbance and daytime sleepiness in patients with cirrhosis: a case control study

“…Sleep disturbance and excessive daytime somnolence are common in patients with cirrhosis [1,2,3,4]. In addition, a disturbance of sleep is recognized as one of the early signs of hepatic encephalopathy [5,6,7].…”

“…The most common feature of the sleep pattern in patients with cirrhosis is fragmented nocturnal sleep caused by frequent nocturnal awakenings, and a daytime functioning affected by frequent episodes of undesired sleepiness and more prolonged napping time [1,2]. The sleep-wake cycle was also shifted with activity toward the later hours of the day.…”

Hepatic Encephalopathy and Sleepiness: An Interesting Connection?

“…While there is evidence for this in animal models, human studies provide a considerably more heterogeneous picture. [22][23][24][25][26] This may be due to a number of factors, including cultural and environmental confounders, the heterogeneity of the patient populations studied, and a certain tendency of hepato-gastroenterologists and internists to group all kinds of sleep disturbances together, and to study them with tools such as quality of life and psychological well-being questionnaires. 23 In more recent years, some work has been devoted to defining the sleepwake disturbances exhibited by these patients in a more formal, systematic fashion, in collaboration with sleep scientists and chronobiologists.…”