In Patients with Chronic Kidney Disease Short Term Blood Pressure Variability is Associated with the Presence and Severity of Sleep Disorders

Abstract

Background/Aims: In chronic kidney disease (CKD) patients blood pressure variability (BPV) is associated with poor outcome. Sleep disturbances alter BP profiles in hypertensives but their influence on BPV in CKD patients is unknown. We screened a cohort of CKD/ESRD patients to investigate whether sleep quality impacts on BPV. Methods: Consecutive CKD patients’ sleep quality was assessed using validated questionnaires (Epworth Sleepiness Scale-ESS); International Restless legs scale-IRLS; Functional Outcomes of Sleep Questionnaire-FOSQ: Insomnia Severity Index-ISI; STOP-Bang). All patients underwent ambulatory blood pressure measurement. Results: 104 out of 143 enrolled patients (78.32% stage-3 CKD; 10.49% Stage-4; 11.19% Stage-5; 6.99% ESRD-under dialysis) completed all the questionnaires. 95.8% were hypertensives, 70% were non-dippers and 27.8% had resistant hypertension. STOP-Bang>4 proved sleep disorders in 84.84% of patients. Patients with IRLS>10 had greater diastolic nocturnal standard deviation (DNSD) and a trend (p=0.05) for systolic nocturnal SD (SNSD). Patients with ISI>14 had greater SNSD and in 28.8% FOSQ showed severely impaired sleep quality. Their systolic nocturnal BPV was significantly greater. ISI was independently associated with SNSD. FOSQ and diastolic nocturnal BPV were negatively correlated at the bivariate analysis and FOSQ independently predicts systolic nocturnal BPV at multivariate regression analysis. Conclusions: In CKD patients impaired sleep quality increases BPV, might contribute to their disease progression and worsen prognosis. Searching for sleep problems in CKD patients could help planning their treatment of sleep problems contributing to CV risk reduction. Our data provide the rationale working hypothesis for the need of studies with larger number of patients aimed to demonstrate improved outcome of CKD progression and CV risk with the treatment also of sleep disorders.

The Pivotal Role of Oxidative Stress in the Pathophysiology of Cardiovascular-Renal Remodeling in Kidney Disease

“…Together with chronic uncontrolled hypertension, BP variability is also associated to a high risk of renal outcomes [38,39]. Observations from our cohort of CKD patients linked BP variability with a prevalence of sleep disorders such as obstructive sleep apnea, insomnia and restless leg syndrome further supporting the hypothesis that endothelial dysfunction and glomerular damage play a crucial role in the development of BP variation and in worsen disease progression in these patients [40][41][42]. Evidences for the correlation of oxidative stress and BP variability can be observed in population at high cardiovascular risk such as subjects with familial history of essential hypertension and myocardial infarction and type 2 diabetes mellitus and hypertension where BP variations significantly correlate with 8-hydroxydeoxyguanosine, 8-isoprostane and diacron-reactive oxygen metabolites respectively [43,44].…”

Impact of different stages of chronic kidney disease on the severity of Willis–Ekbom disease

“…[28] Also, there were studies that showed higher prevalence of RLS among CKD population. [29] Patients with CKD stages I, II, and III were on conservative management, and in stage IV only a few patients went for hemodialysis. Patients on stage V were mostly on hemodialysis.…”

Pathomechanism of oxidative stress in cardiovascularrenal remodeling and therapeutic strategies

“…Arterial remodeling and stiffness progress rapidly in CKD and hemodialysis patients, causing not only chronically elevated blood pressure but also increased blood pressure variability [ 4 ]. There is some debate as to the role of blood pressure variability in the progression of renal dysfunction; however, there is evidence that patients with CKD have a greater prevalence of sleep disorders, such as obstructive sleep apnea and restless leg syndrome, that are associated with increased blood pressure variability in CKD patients, progression of CKD, and enhanced mortality in ESRD patients [ 40 ].…”