Sleep Disturbances In Chronic Kidney DiseaseⅥ

Treatment of sleep apnea in patients with CKD

In the general population, sleep apnea is treated to improve sleep quality and reduce daily symptoms of fatigue and sleepiness. Treatment options for sleep apnea include weight loss, positional therapy to reduce the time spent in the supine position during sleep, oral appliances or mandibular advancement devices to increase the size of the oropharyngeal space, and occasionally surgery, which may include removal of tonsils or other soft tissue in the oropharyngeal space. However, the gold standard and most effective treatment is continuous positive airway pressure (CPAP), which prevents upper airway collapse during sleep by delivering air at a specific pressure.

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Effect of CPAP Therapy on Symptoms and Progression of CKD.

For patients with OSA who have poor sleep quality, nonrestorative sleep, and/or excessive daytime sleepiness, CPAP therapy is effective in reducing daytime sleepiness, improving quality of life and neurocognitive function, and reducing the risk of motor vehicle accidents133,134. CPAP therapy also reduces the risk of cardiovascular morbidity and mortality in hospitalized patients with CKD and OSA and may have a positive effect on renal function. In a study of 20 non-CKD patients (mean AHI 42 ± 4) with newly diagnosed severe OSA who were normotensive at baseline, 1 month of CPAP therapy resulted in an increase in the renal plasma flow response to angiotensin 2, indicating downregulation of RAAS activity, while mean arterial pressure, plasma aldosterone, and urinary protein excretion decreased.135 Interestingly, in a subsequent study, the same group found potential sex differences in the response to CPAP therapy; CPAP was associated with improved renal hemodynamics in both sexes, but downregulation of renal RAAS activity occurred only in women and not in men.136 Another study showed an increase in the filtration fraction in patients with moderate to severe OSA compared with healthy controls, followed by a decrease in the filtration fraction after CPAP in OSA patients. This finding suggests that CPAP therapy could mitigate the progression of CKD by reducing glomerular hyperfiltration.137 In a retrospective combined study of 42 patients with CKD (stages 3–5) and OSA, those who adhered to CPAP (i.e., average use of >4 h/night on >70% of nights) had a significantly slower median rate of eGFR decline and significantly less proteinuria than those with lower CPAP use138. However, these findings have not been consistently observed in other studies. A meta-analysis of eight studies (240 individuals) of patients treated with PAP, CPAP, or adaptive servo-ventilation showed no overall change in eGFR before and after PAP treatment in patients with sleep apnea139. However, in subgroup analyses of the data, longer duration of PAP use and increased age were associated with significant improvements in eGFR139. Subsequently, a prospective nonrandomized study of nearly 2000 patients with OSA from the Sleep Apnea Network-European Sleep Apnea Database cohort showed that CPAP treatment attenuated the decline in eGFR compared with data from untreated OSA patients with a median follow-up of 541 days140.

The Sleep Apnea Cardiovascular Endpoints Trial was a randomized controlled trial of CPAP versus no treatment in more than 2,000 patients with moderate to severe OSA and a history of cardiovascular and cerebrovascular disease to determine whether CPAP treatment could prevent major cardiovascular events.141 A post hoc analysis of this study was subsequently performed to assess the effect of CPAP on eGFR in 200 patients.142 The mean eGFR at baseline was normal, and there was no difference in the rate of eGFR decline between groups over a median follow-up of 4.4 years. However, the majority of patients in the study did not have CKD at baseline, and patients with severe nocturnal hypoxia were excluded.143 A subsequent pilot randomized randomized controlled trial randomized patients with CKD (stages 3 and 4) and OSA to CPAP instead of usual care.144 At one year of follow-up, there was no difference in eGFR or urine albumin-to-creatinine ratio between groups, but a trend toward improved eGFR with CPAP treatment was observed in patients at lower baseline risk for CKD progression.

Effects of Intensive Dialysis Therapy, Ultrafiltration, and Transplantation on Sleep Apnea Severity

In patients with renal failure, intensive dialysis therapy, either switching from CHD to NHD or from continuous ambulatory peritoneal dialysis to nocturnal peritoneal dialysis, significantly reduces sleep apnea.58,145 A meta-analysis of nine studies evaluating the effect of KRT mode on sleep apnea severity showed that intensive KRT was superior to conventional KRT in terms of AHI reduction (OR 0.66, CI 95% 0.51-0.84, P < 0.001) and improvement in sleep quality.146

In one study, patients who started nocturnal peritoneal dialysis in the hospital before switching to continuous outpatient peritoneal dialysis after discharge had increased severity of sleep apnea after switching to outpatient peritoneal dialysis, accompanied by worsening uremic clearance, decreased pharyngeal volume and cross-sectional area, and tongue enlargement measured by volumetric MRI.147 In a study of 14 patients with renal failure who were on thrice weekly CHD, switching to NHD reduced the AHI from 25 ± 25 to 8 ± 8 (P = 0.03)58. Further supporting the important role of fluid overload is a study of 15 CHD patients with moderate to severe sleep apnea (including OSA and CSA), where AHI was reduced by 36% after fluid removal during a single ultrafiltration session (mean removal of 2.2 liters); uremia and metabolic status did not change. 148 This study also suggested a correlation between the reduction in AHI and the reduction in total body fluid volume (measured by bioelectrical impedance). Of note, low transcutaneous CO2 levels also normalized with the reduction in fluid volume, suggesting a reduction in respiratory drive and possible improvement in ventilatory stability. 148

With regard to renal transplantation, some case series have suggested that it can reduce the severity of sleep apnea, while other case reports have reported that all but a few patients continued to have sleep apnea after transplantation. 149–152 Another prospective cohort study evaluated the effect of renal transplantation on sleep apnea severity (cohort of 39 patients). 153 PSGs were performed before and after transplantation, with a mean interval of 19 months, and no significant changes in AHI were observed. 153 However, the mean increase in BMI after transplantation was 2 units, which may have attenuated the positive effect of improved renal function on AHI, as increased BMI itself is an independent predictor of sleep apnea severity.

How Does Cistanche Treat Kidney Disease?

Cistanche is a traditional Chinese herbal medicine used for centuries to treat various health conditions, including kidney disease. It is derived from the dried stems of Cistanche deserticola, a plant native to the deserts of China and Mongolia. The main active components of cistanche are phenylethanoid glycosides, echinacoside, and acteoside, which have been found to have beneficial effects on kidney health.

Kidney disease, also known as renal disease, refers to a condition in which the kidneys are not functioning properly. This can result in a buildup of waste products and toxins in the body, leading to various symptoms and complications. Cistanche may help treat kidney disease ase through several mechanisms.

Firstly, cistanche has been found to have diuretic properties, meaning it can increase urine production and help eliminate waste products from the body. This can help relieve the burden on the kidneys and prevent the buildup of toxins. By promoting diuresis, cistanche may also help Reduce high blood pressure, a common complication of kidney disease.

Moreover, cistanche has been shown to have antioxidant effects. Oxidative stress, caused by an imbalance between the production of free radicals and the body's antioxidant defenses, plays a key role in the progression of kidney disease. ies help neutralize free radicals and reduce Oxidative stress, thereby protecting the kidneys from damage. The phenylethanoid glycosides found in cistanche have been particularly effective in scavenging free radicals and inhibiting lipid peroxidation.

Additionally, cistanche has been found to have anti-inflammatory effects. Inflammation is another key factor in the development and progression of kidney disease. Cistanche's anti-inflammatory properties help reduce the production of pro-inflammatory cytokines and inhibit the activation of inflammation mandatory pathways, thus alleviating inflammation in the kidneys.

Furthermore, cistanche has been shown to have immunomodulatory effects. In kidney disease, the immune system can be dysregulated, leading to excessive inflammation and tissue damage. Cistanche helps regulate the immune response by modulating the production and activity of immune cells, such as T cells and macrophages. This immune regulation helps reduce inflammation and prevent further damage to the kidneys.

Moreover, cistanche has been found to improve renal function by promoting the regeneration of renal tubes with cells. Renal tubular epithelial cells play a crucial role in the filtration and reabsorption of waste products and electrolytes. In kidney disease, these cells can be damaged, leading to damaged renal function. Cistanche's ability to promote the regeneration of these cells helps restore proper renal function and improve overall kidney health.

In addition to these direct effects on the kidneys, cistanche has been found to have beneficial effects on other organs and systems in the body. This holistic approach to health is particularly important in kidney disease, as the condition often affects multiple organs and systems. che has been shown to have protective effects on the liver, heart, and blood vessels, which are commonly affected by kidney disease. By promoting the health of these organs, cistanche helps improve overall kidney function and prevent further complications.

In conclusion, cistanche is a traditional Chinese herbal medicine used for centuries to treat kidney disease. Its active components have diuretic, antioxidant, anti-inflammatory, immunomodulatory, and regenerative effects, which help improve renal function and protect the kidneys from further damage. , cistanche has beneficial effects on other organs and systems, making it a holistic approach to treating kidney disease.