Written By: W. Joseph Newman, MD
Eastern Nephrology Associates, New Bern NC
Dealing with Obstructive Sleep Apnea (OSA) is as easy as learning your ABC’s (with an added D):
A: Awareness of symptoms suggestive of OSA
B: Be tested if such symptoms exist
C: Comply with treatment, if diagnosed with OSA
D: Direct your own health care
Awareness of symptoms of OSA is clearly the most important of the three ABC’s, as without it the other two would not exist. Snoring, “night-time” startle snore, daytime somnolence, and fatigue may all suggest the likelihood of OSA. Diabetes, obesity and inactivity make OSA all the more likely. These symptoms apply equally to chronic kidney disease (CKD) as well as non-CKD patients. There are numerous self-testing systems available as STOPBANG which may assess one’s risk of OSA, here is one:
However, CKD patients need to be aware of symptoms suggestive of OSA that non-CKD patients may be less likely to experience. Coining the term, the “Perfect Storm” (PS) (see my blog which discusses this in depth here), which irrevocably links OSA and CKD, taught me to recognize three phases in CKD patients that may imply the presence of, and progressive effects of, untreated OSA. These phases signal that the “Elephant in the Room”, OSA induced right heart strain and pulmonary hypertension, has affected a CKD patient, and may represent the beginning of a progression down a spectrum of a full-blown PS leading to dialysis.
The first such phase involves swelling, either new onset, or perhaps an unexplained increase in chronic swelling. CKD patients have numerous reasons to explain the presence of swelling, such as weight, diet, medications, and perhaps protein wasting by diseased kidneys. New or increased swelling should also prompt an assessment for OSA, and include an echocardiogram to assess the status of the right heart ventricle, and the existence of pulmonary hypertension. If OSA is present, but not properly diagnosed and treated, the second phase will follow.
The second phase involves shortness of breath, especially in patients without known chest pain or heart failure. Such patients are likely to pass off such symptoms as “getting older" and are also likely to have swelling. Again, an OSA assessment and echocardiogram are indicated. The typical response of most physicians would be to link dyspnea (shortness of breath) and swelling to congestive heart failure and to start a diuretic to diminish swelling. Most non-CKD patient’s symptoms respond well to the diuretics. However, CKD patients, especially those hampered by right heart ventricle strain from OSA, may have issues from such therapy, which leads to the third phase.
The third phase, an increase in serum creatinine in response to diuretics, is a clear indication of right ventricular strain, most likely from OSA. Most PCPs usually refer such patients to nephrology for progressive CKD, not recognizing the right ventricular heart strain from OSA, as the cause of the increase creatinine. This finding suggests that without appropriate intervention, progressive CKD toward dialysis will be highly likely.
It is imperative for all CKD patients to learn about and maintain an awareness of OSA, as it is a major risk factor for progressive CKD. Researchers say that CKD/OSA have a bi-directional cycle effect … that is, one begets the other.
To break that cycle, one must be AWARE.
B: Be tested
My single recommendation for all CKD patients: BE TESTED FOR OSA … regardless of symptoms or CKD stage.
The availability of in-home testing kits for OSA, such as “WatchPat”, should remove any excuse not to be tested.
My single recommendation regarding the treatment of OSA: COMPLY. Recognize that in as short as 4-6 months of treatment of OSA, right ventricular heart strain, if present, can be diminished. That helps to break the CKD/OSA cycle that could lead to dialysis. That breaks the PS.
D: Direct your own health care
Make no mistake about it, the delivery of health care has become a business. That is because a competitive free-market system does not exist in medicine. Doctor fees are regulated by bureaucratic insurance companies, both private and governmental. The only answer for a medical practice to be productive requires an increase in volume of patient encounters.
Unfortunately, a productivity-based practice means less time for patient-doctor interaction. OSA evaluation by a PCP adds time to an already jammed schedule. Studies show that most doctors DO NOT diagnose OSA until symptoms have advanced to a serious degree and have become clearly obvious. By then, the “horse is out of the barn”, and closing the barn-door may not help.
OSA needs to be, and can be, diagnosed in stage 1 CKD. Unfortunately (but it should be seen as fortunate), your PCP is unlikely to make the diagnosis. Nephrology hasn't done much of better in making the diagnosis either, which explains the existence of this blog.
If you, the CKD patient, wishes to avoid CKD progression and eventual dialysis, then you, the CKD patient, must become the Director of your own health care. This day in time, there is simply no excuse for a motivated CKD patient to be un-AWARE of OSA and its role in progression of CKD.
OSA is front and center in that progression.