Hepatology International

, Volume 9, Issue 2, pp 283–291 | Cite as

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

  • Swastik Agrawal
  • Ajay DusejaEmail author
  • Ashutosh Aggarwal
  • Ashim Das
  • Manu Mehta
  • Radha K. Dhiman
  • Yogesh Chawla
Original Article



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.


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.


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.


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.


Obstructive sleep apnea Nonalcoholic fatty liver disease Metabolic syndrome Liver fibrosis Obesity Transient elastography 



American Academy of Sleep Medicine


Apnea-hypopnea index


Alanine aminotransferase


Aspartate aminotransferase


Area under the receiver-operating curve


Bioelectrical impedance analyzer


Body mass index


Blood pressure


Excessive daytime somnolence


Epworth sleepiness scale


High-density lipoprotein


Hypoxia-inducible factor


Homeostasis model assessment of insulin resistance


Low-density lipoprotein


Liver stiffness measurement


National cholesterol education program-adult treatment panel


Nonalcoholic fatty liver disease


Nonalcoholic steatohepatitis


NAFLD activity score


Obstructive sleep apnea


Obstructive sleep apnea syndrome

Sat <90 %

Percentage of total sleep time spent in hypoxia


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.

Supplementary material

12072_2015_9615_MOESM1_ESM.pdf (181 kb)
Supplementary material 1 (PDF 182 kb)


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Copyright information

© Asian Pacific Association for the Study of the Liver 2015

Authors and Affiliations

  • Swastik Agrawal
    • 1
  • Ajay Duseja
    • 1
    Email author
  • Ashutosh Aggarwal
    • 2
  • Ashim Das
    • 3
  • Manu Mehta
    • 1
  • Radha K. Dhiman
    • 1
  • Yogesh Chawla
    • 1
  1. 1.Department of HepatologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
  2. 2.Department of Pulmonary MedicinePostgraduate Institute of Medical Education and ResearchChandigarhIndia
  3. 3.Department of HistopathologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia

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