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Obstructive sleep apnea is an important predictor of hepatic fibrosis in patients with nonalcoholic fatty liver disease in a tertiary care center

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Abstract

Background

The association of obstructive sleep apnea (OSA) with nonalcoholic fatty liver disease (NAFLD) has only been studied in selected subgroups such as the morbidly obese. We aimed to determine the prevalence and effect of OSA on NAFLD and vice versa in unselected patients attending the outpatient department.

Methods

OSA was diagnosed by polysomnography, done in patients having symptoms of OSA, in patients with NAFLD attending the liver clinic. Polysomnography-proven patients with OSA attending the chest clinic were evaluated for NAFLD by ultrasonography. Anthropometry, liver function tests, metabolic syndrome evaluation and transient elastography were performed in all patients.

Results

Three (3 %; 95 % CI 1.03–8.45 %) out of 100 patients with NAFLD (mean age 41 ± 11 years) had symptomatic OSA. Of 23 patients with OSA (mean age 46 ± 12 years,), 3 (13 %) had mild, 5 (22 %) moderate and 15 (65 %) severe OSA. Twenty-one (91.3 %; 95 % CI 73.2–97.6 %) patients with OSA had NAFLD, while raised hepatic transaminase levels were seen in seven (30.4 %; 95 % CI 15.6–50.9 %). Body mass index (OR 1.21, 95 % CI 1.02–1.44) and male gender (OR 4.79, 95 % CI 1.12–20.48) were significant independent predictors of OSA in NAFLD. The apnea-hypopnea index (OR 1.084, 95 % CI 1.002–1.172), a marker of OSA severity, was the only significant independent predictor of significant fibrosis in patients with NAFLD.

Conclusions

Prevalence of symptomatic OSA in patients with NAFLD is low and is predicted by male gender and obesity. Prevalence of NAFLD in patients with OSA is very high. Significant hepatic fibrosis in patients with NAFLD is predicted by OSA independent of obesity and metabolic syndrome.

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Abbreviations

AASM:

American Academy of Sleep Medicine

AHI:

Apnea-hypopnea index

ALT:

Alanine aminotransferase

AST:

Aspartate aminotransferase

AUROC:

Area under the receiver-operating curve

BIA:

Bioelectrical impedance analyzer

BMI:

Body mass index

BP:

Blood pressure

EDS:

Excessive daytime somnolence

ESS:

Epworth sleepiness scale

HDL:

High-density lipoprotein

HIF:

Hypoxia-inducible factor

HOMA-IR:

Homeostasis model assessment of insulin resistance

LDL:

Low-density lipoprotein

LSM:

Liver stiffness measurement

NCEP-ATP:

National cholesterol education program-adult treatment panel

NAFLD:

Nonalcoholic fatty liver disease

NASH:

Nonalcoholic steatohepatitis

NAS:

NAFLD activity score

OSA:

Obstructive sleep apnea

OSAS:

Obstructive sleep apnea syndrome

Sat <90 %:

Percentage of total sleep time spent in hypoxia

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Compliance with Ethical Requirements

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study. Written informed consent was taken from all participants, and the study was approved by the institute’s ethics committee. This article does not contain any studies with animal subjects.

Conflict of interest

Swastik Agrawal, Ajay Duseja, Ashutosh Aggarwal, Ashim Das, Manu Mehta, Radha K Dhiman and Yogesh Chawla declare that they have no conflict of interest.

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Authors and Affiliations

  1. Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India

    Swastik Agrawal, Ajay Duseja, Manu Mehta, Radha K. Dhiman & Yogesh Chawla

  2. Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    Ashutosh Aggarwal

  3. Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    Ashim Das

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  1. Swastik Agrawal
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  2. Ajay Duseja
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Correspondence to Ajay Duseja.

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Agrawal, S., Duseja, A., Aggarwal, A. et al. Obstructive sleep apnea is an important predictor of hepatic fibrosis in patients with nonalcoholic fatty liver disease in a tertiary care center. Hepatol Int 9, 283–291 (2015). https://doi.org/10.1007/s12072-015-9615-3

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