Prevalence of and Factors Associated with Sleep-Wake Abnormalities in Patients with Cirrhosis

Manoj Kumar; Sumeet Kainth; Sachin Kumar; Ankit Bhardwaj; Hemant KumarAggarwal; Rakhi Maiwall; Kapil D Jamwal; Saggere M Shasthry; Ankur Jindal; Ashok Choudhary; Lovkesh Anand; Ravinder M Dhamija; Guresh Chibbar; Barjesh Chander Sharma; Shiv K Sarin

doi:10.1016/j.jceh.2020.10.006

Prevalence of and Factors Associated with Sleep-Wake Abnormalities in Patients with Cirrhosis

J Clin Exp Hepatol. 2021 Jul-Aug;11(4):453-465. doi: 10.1016/j.jceh.2020.10.006. Epub 2020 Oct 24.

Authors

Affiliations

¹ Department of Hepatology and Liver Transplantation, New Delhi, India.
² Department of Pulmonary Medicine, New Delhi, India.
³ Department of Clinical Research, New Delhi, India.
⁴ Department of Respiratory Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India.
⁵ Department of Neurology, New Delhi, India.
⁶ Department of Biostatistics, Institute of Liver & Biliary Sciences, New Delhi, India.

Abstract

Background & aims: Sleep-wake abnormalities [poor nighttime sleep and excessive daytime sleepiness (EDS)] are common in patients with cirrhosis. The aim of this study was to assess the prevalence of sleep-wake abnormalities and clinical factors associated with these abnormalities in a group of patients with cirrhosis.

Methods: 1098 patients with cirrhosis [Child Turcotte Pugh (CTP) class A, 22.2%; CTP class B, 29.2% and CTP class C, 48.6%], with either no ascites or mild ascites controlled on diuretics, and no history of or current overt hepatic encephalopathy were included in the study.

Results: Poor nighttime sleep and EDS were found in 569 (51.8%) and 489 (44.5%) patients respectively. On multivariate analysis, factors associated with poor nighttime sleep were CTP class C (vs. class A), presence of minimal hepatic encephalopathy (MHE), intermediate or evening type of diurnal preference category (vs. morning type), high risk for obstructive sleep apnea (OSA), diuretic use, presence of major depression, and presence of generalized anxiety disorder (GAD). Factors associated with EDS on multivariate analysis were CTP class B and C (vs. class A), intermediate or evening type of diurnal preference category (vs. morning type), high risk for OSA, presence of major depression, and presence of GAD.

Conclusions: Sleep-wake abnormalities are common in patients with cirrhosis. CTP status, diurnal preference chronotype, risk of OSA, major depression and GAD are associated with both poor nighttime sleep and EDS. MHE and diuretic use are associated with poor nighttime sleep, but not with EDS.

Keywords: ACLF, Acute on chronic liver failure; BQ, Berlin questionnaire; CFF, Critical flicker frequency; CLDQ, Chronic liver disease questionnaire; CSM, Composite scale of morningness; CTP, Child Turcotte Pugh; EDS, Excessive daytime sleepiness; ESS, Epworth sleepiness scale; GAD, generalized anxiety disorder; HE, Hepatic encephalopathy; HRQOL, Health related quality of life; MHE, Minimal hepatic encephalopathy; NASH, Non-alcoholic steatohepatitis; OSA, Obstructive sleep apnea; PHQ, Patient health questionnaire; PSQI, Pittsburgh sleep quality index; cirrhosis; insomnia; sleep disturbances; sleep-wake abnormalities.