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Zhao J, Ji Y, Zuo Y, Zhang L, Ku C, Wang W, Wang P, Yang Y, Kang Y, Wang F. Association of Oxidative Stress and Proinflammation with Insomnia in Perimenopause. J Womens Health (Larchmt) 2024; 33:379-387. [PMID: 38394165 DOI: 10.1089/jwh.2023.0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
Background: The levels of oxidative stress and proinflammatory factors in perimenopausal females increased, and they were also deeply troubled by insomnia. The occurrence of insomnia is related to the changes of oxidative stress and inflammation levels in the body. Perimenopausal insomnia may be related to mild systemic inflammation, and oxidative stress can promote chronic inflammation. However, the underlying mechanism behind the phenomenon is still unclear. Objective: The aim was to investigate whether the occurrence of perimenopausal insomnia disorder is related to higher levels of oxidative stress and inflammation in the body, and to explore the role of inducible nitric oxide synthase (iNOS) in perimenopausal insomnia. Methods: A total of 127 perimenopausal participants were recruited in this study. Participants with global scores of the Pittsburgh sleep quality index (PSQI) >7 were diagnosed with insomnia (n = 54). The patient health questionnaire-9 (PHQ-9) and generalized anxiety disorder-7 (GAD-7) were evaluated, and sociodemographic data were obtained. The serum concentrations of iNOS, interleukin 6 (IL6), and tumor necrosis factor α (TNFα) were measured using commercial assays. Results: In the insomnia group, IL6 levels were positively correlated with scores of component 5 and component 7 of PSQI, respectively. PHQ-9 and GAD-7 were positively correlated with the global score of PSQI component 7 and PSQI, respectively; PHQ-9 was positively correlated with the global score of PSQI component 1. Finally, PHQ-9, iNOS, and IL6 were found to be independent predictors of perimenopausal insomnia using logistic regression. Conclusions: Moderate oxidative stress caused by a certain concentration of iNOS plays a protective role in perimenopausal insomnia, while proinflammation and depression are potential risk factors.
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Affiliation(s)
- Jing Zhao
- Medical Neurobiology Lab, Inner Mongolia Medical University, Huhhot, China
- Department of Basic Medical Teaching and Research, Ordos Institute of Technology, Ordos, China
| | - Yubo Ji
- Department of Medical Psychology, Inner Mongolia Medical University, Huhhot, China
| | - Yanni Zuo
- Physical Examination Center, Beijing Changping Hospital of Chinese Medicine, Beijing, China
| | - Long Zhang
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Inner Mongolia Medical University, Huhhot, China
| | - Congwen Ku
- Dongzhimen Hospital, the First Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Wenyan Wang
- School of Pharmacy, Yantai University, Yantai, China
| | - Pengxiang Wang
- Medical Neurobiology Lab, Inner Mongolia Medical University, Huhhot, China
| | - Yan Yang
- Urumqi Fourth People's Hospital, Urumqi, China
| | - Yimin Kang
- Medical Neurobiology Lab, Inner Mongolia Medical University, Huhhot, China
| | - Fan Wang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
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2
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Hui Y, Guo G, Mao L, Li Y, Sun M, Wang X, Yang W, Fan X, Jiang K, Cui B, Sun C. Associations of Multiple Serum Trace Elements with Abnormal Sleep Duration Patterns in Hospitalized Patient with Cirrhosis. Biol Trace Elem Res 2022; 201:3202-3209. [PMID: 36136288 DOI: 10.1007/s12011-022-03425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 11/02/2022]
Abstract
The associations of circulating trace elements with sleep health have attracted increasing attention given their potential link. However, there is scant data on the relationship between serum trace elements and abnormal sleep duration patterns in cirrhosis. We aimed to investigate these associations with the purpose of identifying modifiable risk factors. The blood samples were collected from inpatients with cirrhosis, and serum levels of several trace elements were assessed by inductively coupled plasma mass spectrometry. Self-reported sleep duration was categorized to short- (< 7 h/night), optimal (7-8 h/night), and long-sleep duration (> 8 h/night). The dose-response trends and associations of trace elements levels with sleep duration were determined by restricted cubic splines (RCS) and logistic regression, respectively. Cirrhotic patients with optimal sleep duration experienced the highest levels of serum Zinc (Zn) and the lowest values of copper to zinc ratio (CZr). RCS model corroborated non-linear associations of serum Zn and CZr against sleep duration. Multiple regression analysis showed that both CZr (short vs optimal sleep duration: OR 4.785, P < 0.001; long vs optimal sleep duration: OR 4.150, P = 0.019) and serum Zn levels (short vs optimal sleep duration: OR 0.985, P = 0.040; long vs optimal sleep duration: OR 0.956, P = 0.008) serve as independent risk factors for sleep duration abnormalities. In conclusion, our findings unraveled a close relationship of serum Zn and CZr with sleep duration in cirrhosis. Further trace element-based therapy such as Zn supplementation may be novel approach to reverse this sleep problem.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Lihong Mao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Yifan Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Mingyu Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Kui Jiang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China
| | - Binxin Cui
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin Airport Economic Area, East Street 6, Tianjin, 300308, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China.
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Heping District, Anshan Road 154, Tianjin, 300052, China.
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin Airport Economic Area, East Street 6, Tianjin, 300308, China.
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3
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Hansen MKG, Kjærgaard K, Eriksen LL, Grønkjær LL, Mikkelsen ACD, Sandahl TD, Vilstrup H, Thomsen KL, Lauridsen MME. Psychometric methods for diagnosing and monitoring minimal hepatic encephalopathy -current validation level and practical use. Metab Brain Dis 2022; 37:589-605. [PMID: 35102491 DOI: 10.1007/s11011-022-00913-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
Abstract
Hepatic encephalopathy (HE) is cerebral dysfunction caused by liver failure and inflicts 30-40% of patients with liver cirrhosis during their disease course. Clinically manifest HE is often preceded by minimal HE (MHE) - a clinically undetectable cognitive disturbance closely associated with loss of quality of life. Accordingly, detecting and treating MHE improve the patients' daily functioning and prevent HE-related hospital admissions. The scope of this review article is to create an overview of the validation level and usage of psychometric tests used to detect MHE: Portosystemic hepatic encephalopathy test, continuous reaction time test, Stroop EncephalApp, animal naming test, critical flicker frequency test, and inhibitory control test. Our work is aimed at the clinician or scientist who is about to decide on which psychometric test would fit best in their clinic, cohort, or study. First, we outline psychometric test validation obstacles and requirements. Then, we systematically approach the literature on each test and select well-conducted studies to answer the following questions:• Which percentage of patients with cirrhosis does the test deem as having MHE?• Is the test able to predict clinically manifest HE?• Is there a well-known test-retest variation and inter-observer variation?• Is the test able to detect a treatment response?• Is the test result affected by age, educational level, gender, or comorbidities?
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Affiliation(s)
- Mads Kingo Guldberg Hansen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark.
| | - Kristoffer Kjærgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lotte Lindgreen Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Lea Ladegaard Grønkjær
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Anne Catrine Daugaard Mikkelsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Mette Munk Enok Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital South Denmark, Finsensgade 35, 6700, Esbjerg, Denmark
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Association between sleep disturbance and multidimensional frailty assessed by Frailty Index in hospitalized cirrhosis. Eur J Gastroenterol Hepatol 2021; 33:e727-e733. [PMID: 34101682 DOI: 10.1097/meg.0000000000002231] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Both sleep disturbance and frailty are common in patients with cirrhosis, but their correlation remains elusive. We aimed to investigate whether dysregulated sleep [as estimated by Pittsburgh Sleep Quality Index (PSQI)] is independently associated with frailty and their relationship in distinct subgroups. METHODS In total 105 adult cirrhotic patients were recruited. The frailty phenotype was identified by a self-reported scale (Frailty Index) which demonstrates good validity and moderate performance based on our previous publication. Patients were categorized into frailty and nonfrailty groups according to a cut-point of 0.38 by Frailty Index. Multiple linear regression was performed to determine independent factors associated with frailty. RESULTS The median PSQI was 6.0 in the entire cohort and sleep disturbance was observed in 61 patients with cirrhosis (58.1%). Poor sleepers had a significantly higher Frailty Index than that in good sleepers (0.11 vs. 0.08; P = 0.025). In univariate analysis, PSQI score was markedly associated with the Frailty Index (β = 0.012; 95% CI, 0.006-0.018; P < 0.001), and remained significantly associated with frailty phenotype in multivariate adjustment (β = 0.010; 95% CI, 0.004-0.015; P = 0.001). The escalating PSQI scores were more prominent in frail patients, with female gender or aged 65 years and over. CONCLUSIONS Poor sleep quality is strongly associated with frailty in patients with cirrhosis. Given that sleep disturbance is modifiable, our data suggest that efficient interventions to mitigate frailty should incorporate strategies by reversing sleep dysfunction in cirrhotics with poor sleep quality.
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5
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Sleep and liver disease: a bidirectional relationship. Lancet Gastroenterol Hepatol 2021; 6:850-863. [PMID: 34273289 DOI: 10.1016/s2468-1253(21)00169-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023]
Abstract
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.
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6
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Hui Y, Wang X, Yu Z, Feng H, Li C, Mao L, Fan X, Lin L, Cui B, Chen X, Sun L, Wang B, Sun C. Relationship Between Sleep-Wake Disturbance and Risk of Malnutrition in Hospitalized Patients With Cirrhosis. Front Nutr 2021; 8:719176. [PMID: 34532336 PMCID: PMC8439378 DOI: 10.3389/fnut.2021.719176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/09/2021] [Indexed: 01/05/2023] Open
Abstract
Both sleep-wake disturbance and malnutrition are common in cirrhosis and might be associated with similar adverse outcomes, such as impaired health-related quality of life, hepatic encephalopathy, and sarcopenia, but there is no study investigating the relationship between these two. We aimed to explore the relationship between sleep-wake disturbance [estimated by the Pittsburgh Sleep Quality Index (PSQI)] and malnutrition risk [estimated by the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT)]. About 150 patients with cirrhosis were prospectively recruited. The nutritional risk is classified as low (0 points), moderate (1 point), and high (2-7 points) according to the RFH-NPT score. A global PSQI >5 indicated poor sleepers. Furthermore, multivariate linear regression analyses were performed to determine the relationship between sleep-wake disturbance and malnutrition. The median PSQI was seven, and RFH-NPT was two in the entire cohort, with 60.67 and 56.67% rated as poor sleep quality and high malnutrition risk, respectively. Patients with cirrhosis with poor sleep quality had significantly higher RFH-NPT score (3 vs. 1, P = 0.007). Our multivariate analyses indicated that male patients (β = 0.279, P < 0.001), ascites (β = 0.210, P = 0.016), and PSQI (β = 0.262, P = 0.001) were independent predictors of malnutrition. In addition, the differences regarding PSQI score were more significant in male patients, as well as those >65 years or with Child-Turcotte-Pugh class A/B (CTP-A/B) or the median model for end-stage liver disease (MELD) <15. Taken together, the sleep-wake disturbance is strongly correlated with high malnutrition risk in patients with cirrhosis. Given sleep-wake disturbance is remediable, it is tempting to incorporate therapies to reverse poor sleep quality for improving nutritional status in patients with cirrhosis.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Zihan Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Hongjuan Feng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Department of Nutriology, Tianjin Third Central Hospital, Tianjin, China
| | - Chaoqun Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Department of Internal Medicine, Tianjin Hexi Hospital, Tianjin, China
| | - Lihong Mao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Lin Lin
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Longhao Sun
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Medical University General Hospital, Tianjin Institute of Digestive Disease, Tianjin, China.,Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
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7
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Balakrishnan M, Falker C, Conley S, Ciarleglio M, Deng Y, Redeker NS, Garcia-Tsao G. Sleep Disturbance Is Associated With the Presence of Portosystemic Collaterals in Patients With Compensated Cirrhosis. Hepatol Commun 2021; 5:491-501. [PMID: 33681681 PMCID: PMC7917284 DOI: 10.1002/hep4.1636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/30/2020] [Accepted: 10/10/2020] [Indexed: 12/20/2022] Open
Abstract
Disturbed sleep is common among patients with cirrhosis. The extent to which this is associated with the different stages of compensated cirrhosis is unknown. This study examines whether the presence of portosystemic collaterals, an indicator of clinically significant portal hypertension, is associated with sleep disturbance in compensated cirrhosis. We conducted a cross-sectional study among patients with compensated cirrhosis, comparing sleep characteristics, sleep quality, and excessive daytime sleepiness between 21 patients without and 21 patients with portosystemic collaterals. Patients were assessed with wrist actigraphy, Pittsburgh Sleep Quality Index, and the Epworth Sleepiness Scale. Collateral presence was determined by imaging and esophagogastroduodenoscopy. Differences in sleep characteristics were analyzed using t tests and computed effect sizes. Multivariable linear regression analysis was used to evaluate the association between collaterals and sleep disturbance while controlling for possible confounders. The group of patients with collaterals had greater beta-blocker and tobacco use, lower albumin, and higher international normalized ratio compared to the group without collaterals. Patients with collaterals had more sleep fragmentation (Cohen's d = -0.86), lower sleep efficiency (Cohen's d = 0.59), and lower total sleep time (Cohen's d = 0.75) than patients without collaterals. The presence of collaterals was independently associated with greater sleep fragmentation (P = 0.046) and greater daytime sleepiness (P = 0.030). Conclusion: Patients with compensated cirrhosis complicated by portosystemic collaterals experienced more sleep disturbance than those without collaterals.
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Affiliation(s)
- Maya Balakrishnan
- Section of Gastroenterology and HepatologyBaylor College of MedicineHoustonTXUSA.,Digestive Diseases SectionYale School of MedicineNew HavenCTUSA.,Digestive Diseases SectionVA-Connecticut Healthcare SystemWest HavenCTUSA
| | - Caroline Falker
- Digestive Diseases SectionYale School of MedicineNew HavenCTUSA.,Digestive Diseases SectionVA-Connecticut Healthcare SystemWest HavenCTUSA
| | | | - Maria Ciarleglio
- Yale Center for Analytical SciencesYale University School of Public HealthNew HavenCTUSA
| | - Yanhong Deng
- Yale Center for Analytical SciencesYale University School of Public HealthNew HavenCTUSA
| | | | - Guadalupe Garcia-Tsao
- Digestive Diseases SectionYale School of MedicineNew HavenCTUSA.,Digestive Diseases SectionVA-Connecticut Healthcare SystemWest HavenCTUSA
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8
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Shah NM, Malhotra AM, Kaltsakas G. Sleep disorder in patients with chronic liver disease: a narrative review. J Thorac Dis 2020; 12:S248-S260. [PMID: 33214928 PMCID: PMC7642630 DOI: 10.21037/jtd-cus-2020-012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Sleep disturbance is a common feature of chronic liver disease (CLD) with impact on health-related quality of life; 60-80% of patients with CLD report subjective poor sleep; frequent presentations of sleep disturbance include insomnia, reduced sleep efficiency, increased sleep latency, reduced time in rapid eye movement (REM) sleep, restless leg syndrome and excessive daytime sleepiness (EDS). Key contributors to sleep disturbance include hepatic encephalopathy (HE) and circadian rhythm imbalance due to altered melatonin metabolism. Specific conditions causing CLD, such as non-alcoholic fatty liver disease (NAFLD), chronic viral hepatitis and primary biliary cholangitis (PBC) result in different types of sleep disturbance, and the treatment of these conditions can often also lead to sleep disturbance. There are currently limited management options for sleep disturbance in CLD. Obstructive sleep apnoea (OSA) is a common condition that causes chronic intermittent hypoxia due to airway collapse during sleep. This chronic intermittent hypoxia appears to contribute to the development of NAFLD. The presence of reactive oxygen species and the overexpression of hypoxia inducible factor 1-alpha secondary to hypoxia may be responsible for the second 'hit' of the 'two-hit' hypothesis of NAFLD. Treatment of the intermittent hypoxia with continuous positive airway pressure therapy has limited efficacy against liver dysfunction. There remain many outstanding areas of investigation in the management of sleep disturbance in CLD, and of liver dysfunction in OSA.
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Affiliation(s)
- Neeraj Mukesh Shah
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Akanksha Mimi Malhotra
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
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9
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Bruyneel M, Sersté T. Sleep disturbances in patients with liver cirrhosis: prevalence, impact, and management challenges. Nat Sci Sleep 2018; 10:369-375. [PMID: 30464664 PMCID: PMC6220431 DOI: 10.2147/nss.s186665] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Marie Bruyneel
- Sleep Unit, Department of Pneumology, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium,
| | - Thomas Sersté
- Department of Hepato-gastroenterology, Centre Hospitalier Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Liver Transplantation Unit, Department of Hepato-gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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10
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Labenz C, Baron JS, Toenges G, Schattenberg JM, Nagel M, Sprinzl MF, Nguyen-Tat M, Zimmermann T, Huber Y, Marquardt JU, Galle PR, Wörns MA. Prospective evaluation of the impact of covert hepatic encephalopathy on quality of life and sleep in cirrhotic patients. Aliment Pharmacol Ther 2018; 48:313-321. [PMID: 29863286 DOI: 10.1111/apt.14824] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 04/23/2018] [Accepted: 05/07/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Minimal hepatic encephalopathy (HE) and HE grade 1 (HE1) according to the West Haven criteria have recently been grouped as one entity named-covert HE- (CHE). Data regarding the impact of CHE on health-related quality of life (HRQoL) and sleep quality are controversial. AIM First, to determine whether CHE affects HRQoL and sleep quality of cirrhotic patients and second, whether minimal HE (MHE) and HE1 affect HRQoL and sleep quality to a comparable extent. METHODS A total of 145 consecutive cirrhotic patients were enrolled. HE1 was diagnosed clinically according to the West Haven criteria. Critical flicker frequency and the Psychometric Hepatic Encephalopathy Score were used to detect MHE. Chronic Liver Disease Questionnaire (CLDQ) was used to assess HRQoL and Pittsburgh Sleep Quality Index (PSQI) was applied to assess sleep quality. RESULTS Covert HE was detected in 59 (40.7%) patients (MHE: n = 40; HE1: n = 19). Multivariate analysis identified CHE (P < 0.001) and female gender (P = 0.006) as independent predictors of reduced HRQoL (CLDQ total score). CHE (P = 0.021), low haemoglobin (P = 0.024) and female gender (P = 0.003) were identified as independent predictors of poor sleep quality (PSQI total score). Results of CLDQ and PSQI were comparable in patients with HE1 and MHE (CLDQ: 4.6 ± 0.9 vs 4.5 ± 1.2, P = 0.907; PSQI: 11.3 ± 3.8 vs 9.9 ± 5.0, P = 0.3). CONCLUSION Covert HE was associated with impaired HRQoL and sleep quality. MHE and HE1 affected both outcomes to a comparable extent supporting the use of CHE as a clinically useful term for patients with both entities of HE in clinical practice.
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Affiliation(s)
- C Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - J S Baron
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - G Toenges
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - J M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - M Nagel
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - M F Sprinzl
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - M Nguyen-Tat
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - T Zimmermann
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Y Huber
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - J U Marquardt
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - P R Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - M-A Wörns
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Centre Mainz (CCM), University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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11
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Wake-up Call to Clinicians: The Impact of Sleep Dysfunction on Gastrointestinal Health and Disease. J Clin Gastroenterol 2018; 52:194-203. [PMID: 29189428 DOI: 10.1097/mcg.0000000000000963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Sleep dysfunction is an epidemic affecting a large portion of the adult population. Recent studies have linked sleep dysfunction with an upregulation of proinflammatory cytokines (eg, tumor necrosis factor-α, interleukin-1 and interleukin-6), the implications of which can have a profound impact on a variety of gastrointestinal disease. In particular, sleep dysfunction seems to accelerate disease states characterized by inflammation (eg, gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia, chronic liver disease, inflammatory bowel disease, and colorectal cancer). This article evaluates the complex interplay between sleep dysfunction and gastrointestinal health and disease.
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12
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Serigado JM, Barboza KC, Marcus P, Sigal SH. Clinical Impact of Depression in Cirrhosis. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s11901-018-0386-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Xiao G, Ye Q, Han T, Yan J, Sun L, Wang F. Study of the sleep quality and psychological state of patients with hepatitis B liver cirrhosis. Hepatol Res 2018; 48:E275-E282. [PMID: 28888081 DOI: 10.1111/hepr.12981] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/19/2017] [Accepted: 09/05/2017] [Indexed: 12/14/2022]
Abstract
AIM We aimed to investigate sleep quality, mild hepatic encephalopathy, anxiety, and depression in patients with hepatitis B cirrhosis by using a variety of scales and questionnaires. METHOD A cohort of 341 patients with hepatitis B liver cirrhosis were categorized by Child-Pugh grading (A, B, and C) in this cross-sectional study. Pittsburgh Sleep Quality Index (PSQI), Number Connection Test-A (NCT-A), and Hospital Anxiety and Depression (HAD) evaluated the questionnaires and statistically analyzed the intrinsic correlation. The control group included 50 healthy individuals. Of 341 patients, 213 had a PSQI index >5 points. RESULTS The PSQI, NCT-A, anxiety scale (HAD [a]), and depression scale (HAD [d]) of the patients were significantly different. The NCT-A-positive patients revealed 214 cases of possible minimal hepatic encephalopathy (MHE) during a preliminary screening of patients. The PSQI score of NCT-A-positive patients was significantly elevated compared to NCT-A-negative patients (P < 0.001). HAD (a) and HAD (d) were significantly different between the NCT-A-positive and NCT-A-negative groups (P = 0.002 and P = 0.006, respectively). Univariate Pearson's correlation analysis found that NCT-A and HAD (a) were positively correlated with PSQI (P < 0.001 and P = 0.045, respectively); however, Child-Pugh score and HAD (d) were not correlated with PSQI (P = 0.061 and P = 0.059, respectively). CONCLUSION These results indicated that patients with hepatitis B liver cirrhosis have a disturbed sleep, which might be an MHE symptom, further causing considerable anxiety. Thus, the evaluation of sleep quality and psychological state of patients with hepatitis B liver cirrhosis necessitates further investigation to guide positive intervention.
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Affiliation(s)
- Guoqing Xiao
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China
| | - Qing Ye
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Tao Han
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Junqing Yan
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Lixia Sun
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Fengmei Wang
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cells, Tianjin, China.,The Third Central Clinical College of Tianjin Medical University, Tianjin, China
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14
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Rogal SS, Udawatta V, Akpan I, Moghe A, Chidi A, Shetty A, Szigethy E, Bielefeldt K, DiMartini A. Risk factors for hospitalizations among patients with cirrhosis: A prospective cohort study. PLoS One 2017; 12:e0187176. [PMID: 29149171 PMCID: PMC5693413 DOI: 10.1371/journal.pone.0187176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/14/2017] [Indexed: 12/13/2022] Open
Abstract
This study was designed to assess unique baseline factors associated with subsequent hospitalizations in a cohort of outpatients with cirrhosis. A cohort of 193 patients with cirrhosis was recruited from an outpatient liver disease clinic at a single, tertiary medical center. Comorbidities, prescription medications, liver disease symptoms and severity, and psychiatric and pain symptoms were assessed at baseline using validated instruments. Inflammatory markers were measured using standardized Luminex assays. Subsequent hospitalizations and the primary admission diagnoses were collected via chart review. Multivariable models were used to evaluate which baseline factors were associated with time to hospitalization and number of hospitalizations. The cohort consisted of 193 outpatients, with an average age of 58±9 and model for end-stage liver disease (MELD) score of 12±5. Over follow-up, 57 (30%) were admitted to the hospital. The factors associated with time to hospitalization included the severity of liver disease (HR/MELD point:1.10, 95% CI:1.04,1.16), ascites (HR: 1.90, 95% CI: 1.01, 3.58), baseline symptoms of depression (HR:2.34, 95% CI:1.28,4.25), sleep medications (HR:1.81, 95% CI:1.01, 3.22) and IL-6 (HR:1.43, 95% CI: 1.10, 1.84). Similarly the number admissions was significantly associated with MELD (IIR: 1.08, CI: 1.07,1.09), ascites (IIR: 4.15, CI:3.89, 4.43), depressive symptoms (IIR:1.54, CI:1.44,1.64), IL-6 (IIR:1.26, CI:1.23,1.30), sleep medications (IIR:2.74, CI:2.57, 2.93), and widespread pain (IIR: 1.61, CI: 1.50, 1.73). In conclusion, consistent with prior studies, MELD and ascites were associated with subsequent hospitalization. However, this study also identified other factors associated with hospitalization including inflammation, depressive symptoms, sleep medication use, and pain.
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Affiliation(s)
- Shari S. Rogal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
| | - Viyan Udawatta
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Imo Akpan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Akshata Moghe
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Alexis Chidi
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Amit Shetty
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States of America
| | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Klaus Bielefeldt
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Andrea DiMartini
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States of America
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