Abstract
Introduction
Obstructive sleep apnea (OSA) has been estimated to affect 4–11% of the population and causes systemic inflammation which leads to metabolic syndrome (MS). Non-alcoholic fatty liver disease (NAFLD) is also associated with MS whether NAFLD is an additional risk factor for the systemic inflammation that occurs in OSA is unclear.
Objective
In this study, we aimed to analyze the association of OSA and NAFLD with MS and systemic inflammation in Asian Indians.
Methods
Total 240 (132 males and 108 females) overweight/obese subjects [body mass index (BMI > 23 kg/m2)] were recruited; of these, 124 subjects had OSA with NAFLD, 47 had OSA without NAFLD, 44 did not have OSA but had NAFLD and 25 had neither OSA nor without NAFLD. Severity of NAFLD was based on abdomen ultrasound and of OSA on overnight polysomnography. Clinical examinations, anthropometry, body composition, metabolic parameters, and inflammatory biomarkers were recorded.
Results
Serum levels of leptin, macrophage migration inhibitory factor (MIF), interleukin-6 (IL-6), high sensitive C-reactive protein (Hs-CRP), and tumor necrosis factor alpha (TNF-α) were significantly higher, and adiponectin levels were significantly lower in OSA with NAFLD subjects. Prevalence of MS was significantly increased in OSA and NAFLD subjects (p = 0.001). There was a strong association and correlation between leptin, IL-6, Hs-CRP, MIF, and TNF-α in OSA and NAFLD subjects. Multivariate logistic regression showed that OSA was positively associated with the NAFLD [odds ratio (OR), (95% confidence interval (CL) 3.12 (2.58–7.72), (P = 0.002)].
Conclusion
NAFLD is an additional risk factor in OSA subject which contributes to systemic inflammation in Asian Indians.
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References
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328(17):1230–1235
Punjabi NM, Sorkin JD, Katzel LI et al (2002) Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med 165(5):677–682
Tufik S, Santos-Silva R, Taddei JA, Bittencourt LRA (2010) Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med 11(5):441–446
Polotsky VY, Patil SP, Savransky V, Laffan A, Fonti S, Frame LA, Steele KE, Schweizter MA, Clark JM, Torbenson MS, Schwartz AR (2009) Obstructive sleep apnea, insulin resistance, and steatohepatitis in severe obesity. Am J Respir Crit Care Med 179:228–234
Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM, Kales A, Chrousos GP (2000) Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab 85:1151–1158
Manco M, Fernandez-Real JM, Equitani F, Vendrell J, Valera Mora ME, Nanni G, Tondolo V, Calvani M, Ricart W, Castagneto M, Mingrone G (2007) Effect of massive weight loss on inflammatory adipocytokines and the innate immune system in morbidly obese women. J Clin Endocrinol Metab 92:483–490
Matsuzawa Y (2006) Therapy insight: adipocytokines in metabolic syndrome and related cardiovascular disease. Nat Clin Pract Cardiovasc Med 3:35–42
Iiyori N, Alonso LC, Li J, Sanders MH, Garcia-Ocana A, O'Doherty RM, Polotsky VY, O’Donnell CP (2007) Intermittent hypoxia causes insulin resistance in lean mice independent of autonomic activity. Am J Respir Crit Care Med 175(8):851–857
Misra A, Khurana L (2008) Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab 93:S9–S30
Misra A, Khurana L (2009) The metabolic syndrome in south Asians: epidemiology, determinants, and prevention. Metab Syndr Relat Disord 7:497–514
Bhatt SP, Guleria R (2014) Obstructive sleep apnea and non alcoholic fatty liver disease: the growing link and management issues. World Journal of Respirology 4(2):1–7
Vikram NK, Misra A, Dwivedi M, Sharma R, Pandey RM, Luthra K, Chatterjee A, Dhingra V, Jailkhani BL, Talwar KK, Guleria R (2003) Correlations of C-reactive protein levels with anthropometric profile, percentage of body fat and lipids in healthy adolescents and young adults in urban North India. Atherosclerosis 168:305–313
Nigam P, Bhatt SP, Misra A et al (2013) Non-alcoholic fatty liver disease is closely associated with sub-clinical inflammation: a case-control study on Asian Indians in North India. PLoS One 8(1)
Bhushan B, Guleria R, Misra A, Pandey RM, Luthra K, Vikram NK (2009) Obstructive sleep apnoea correlates with C-reactive protein in obese Asian Indians. Nutr Metab Cardiovasc Dis 19(3):184–189
Tam KM, Wu JS (1986) Ultrasonographic diagnosis of fatty liver. Taiwan Yi Xue Hui Za Zhi 85:45–53
Bhatt SP, Nigam P, Misra A, Guleria R (2013) Independent associations of low 25 hydroxy vitamin D and high parathyroid hormonal levels with non alcoholic fatty liver disease in Asian Indians residing in North India. Athroscorosis 230(1):157–163
Bajaj P, Nigam A, Luthra RM et al (2009) A case-control study on insulin resistance, metabolic co-variates & prediction score in non-alcoholic fatty liver disease. Indian J Med Res 129:285–292
Vikram NK, Misra A, Pandey RM, Dwivedi M, Luthra K (2004) Adiponectin, insulin resistance, and C-reactive protein in postpubertal Asian Indian adolescents. Metabolism 53:1336–1341
Bhushan B, Guleria R, Misra A, Luthra K, Vikram NK (2009) TNF-alpha gene polymorphism and TNF-alpha levels in obese Asian Indians with obstructive sleep apnea. Respir Med 103:386–392
BaHammam AS, Obeidat A, Barataman K et al (2014) A comparison between the AASM 2012 and 2007 definitions for detecting hypopnea. Sleep Breath 18(4):767–773
Musso G, Olivetti C, Cassader M, Gambino R (2012) Obstructive sleep apnea-hypopnea syndrome and nonalcoholic fatty liver disease: emerging evidence and mechanisms. Semin Liver Dis 32:49–64
Piguet A-C, Stroka D, Zimmermann A, Dufour JF (2010) Hypoxia aggravates non-alcoholic steatohepatitis in mice lacking hepatocellular PTEN. Clin Sci 118(6):401–410
Musso G, Cassader M, Olivetti C, Rosina F, Carbone G, Gambino R (2013) Association of obstructive sleep apnoea with the presence and severity of NAFLD. A systematic review and meta-analysis. Obes Rev 14:417–431
Ridker PM, Cannon CP, Morrow D, Rifai N, Rose LM, McCabe C, Pfeffer MA, Braunwald E (2005) Pravastatin or atorvastatin evaluation and infection therapy-thrombolysis in myocardial infarction 22 (PROVE IT-TIMI 22) investigators. N Engl J Med 352(1):20–28
Trayhurn P, Wood IS (2005) Signalling role of adipose tissue: adipokines and inflammation in obesity. Biochem Soc Trans 33(5):1078–1081
Xu H, Barnes GT, Yang Q, Tan G, Yang D, Chou CJ, Sole J, Nichols A, Ross JS, Tartaglia LA, Chen H (2003) Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Investig 112(12):1821–1830
Heinrich PC, Castell JV, Andus T (1990) Interleukin-6 and the acute phase response. Biochem J 265(3):621–636
Drager LF, Li J, Reinke C, Bevans- Fonti S, Jun et al (2011) Intermittent hypoxia exacerbates metabolic effects of diet-induced obesity. Obesity (Silver Spring) 19:2167–2174
Kim JK, Kim YJ, Fillmore JJ, Chen Y, Moore I, Lee J, Yuan M, Li ZW, Karin M, Perret P, Shoelson SE, Shulman GI (2001) Prevention of fat-induced insulin resistance by salicylate. J Clin Invest 108:437–446
Sinha S, Perdomo G, Brown NF, O’Doherty RM (2004) Fatty acid-induced insulin resistance in L6 myotubes is prevented by inhibition of activation and nuclear localiza- tion of nuclear factor kappa B. J Biol Chem 279:41294–41301
Boden G, She P, Mozzoli M, Che- ung P, Gumireddy K, Reddy P et al (2005) Free fatty acids produce insulin resistance and activate the proinflammatory nuclear factor- kappaB pathway in rat liver. Diabetes 54:3458–3465
Imeri L, Opp MR (2009) How (and why) the immune system makes us sleep. Nat Rev Neurosci 10(3):199–210
Tasali E, Ip MSM (2008) Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation. Proc Am Thorac Soc 5(2):207–217
Savvidou S, Hytiroglou P, Orfanou-Koumerkeridou H, Panderis A, Frantzoulis P, Goulis J (2009) Low serum adiponectin levels are predictive of advanced hepatic fibrosis in patients with NAFLD. J Clin Gastroenterol 43(8):765–772
Hosogai N, Fukuhara A, Oshima K, Miyata Y, Tanaka S, Segawa K, Furukawa S, Tochino Y, Komuro R, Matsuda M, Shimomura I (2007) Adipose tissue hypoxia in obesity and its impact on adipocytokine dysregulation. Diabetes 56(4):901–911
Mathiesen UL, Franzén LE, Aselius H et al (2002) Increased liver echogenicity at ultrasound examination reflects degree of steatosis but not of fibrosis in asymptomatic patients with mild/moderate abnormalities of liver transaminases. Dig Liver Dis 34:516–522
Hernaez R, Lazo M, Bonekamp S, Kamel I, Brancati FL, Guallar E, Clark JM (2011) Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis. Hepatology 54(3):1082–1090
Acknowledgements
The authors acknowledge the contribution of Mr. Kirti Pratap who performed many of the biochemical investigations. Finally, the cooperation of the subjects who took part in the study is greatly appreciated.
Financial disclosure
Funding for this study was provided through the Ministry of Science and Technology, Department of Science and Technology (Ref: SR/SO/HS-0146/2010), Government of India. The sponsors had no role in the design or conduct of this research.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Informed consent was obtained from all individual participants included in the study.
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Bhatt, S.P., Guleria, R., Vikram, N.K. et al. Non-alcoholic fatty liver disease is an independent risk factor for inflammation in obstructive sleep apnea syndrome in obese Asian Indians. Sleep Breath 23, 171–178 (2019). https://doi.org/10.1007/s11325-018-1678-7
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DOI: https://doi.org/10.1007/s11325-018-1678-7