**9. Treatment**

Sleep apnea should be treated if the patient has symptoms such as fragmented sleep and day time sleepiness or significant oxygen desaturation. In patients without sleep related symptoms who have PSG suggestive of severe sleep apnea, consideration should be given to treat patients with severe disease (Apnea/hypopnea index >30), since sleep apnea of this severity has been associated with increased cardiovascular morbidity and mortality. Sleep apnea should also be treated if it is exacerbating co-existing medical condition such as hypertension, myocardial ischemia, and respiratory failure or nocturnal hypoxemia.

Management of sleep apnea includes treatment of any underlying medical conditions such as obesity or hypothyroidism, correction of aggravating factors such as use of alcohol or sedatives close to the bedtime. Continuous Positive Airway Pressure (CPAP) is a method of respiratory ventilation used primarily in the treatment of sleep apnea . The CPAP machine delivers a stream of compressed air via a hose to a nose mask, full-face mask, or hybrid, splinting the airway (keeping it open under air pressure) so that unobstructed breathing becomes possible, therefore reducing and/or preventing apneas and hypopnea. Pressman and Benz first reported in 1993 that CPAP improves both OSA and central apnea in ESRD patients, suggesting that CPAP eliminates the repetitive cyclical pattern of apnea followed by deep breathing, then followed by another central apnea.(28) The degree of hypopnea following apnea may be a function of the magnitude of respiratory drive necessary to overcome upper air way occlusion at the end of apnea. By preventing air way collapse, CPAP probably eliminates the deep breathing that results in hyperventilation and then lowered respiratory drive, thus setting the stage for next central sleep apnea. Also high levels of CPAP are successful in treatment of central sleep apnea due to the fact that central sleep apnea probably occurred following passive airway closure, which in turn caused stimulation of mucosal sensory receptors and reflex apnea. (28)

Fig. 3. CPAP Machine and Mask.

Sleep apnea is not corrected by conventional hemodialysis or peritoneal dialysis. Apnea frequency has been reduced by the use of bicarbonate rather than acetate based dialysate (29). Intensive daily dialysis has been shown to resolve sleep apnea in one critically ill patient (30). Nocturnal Hemodialysis(see glossary) that enables patients to receive hemodialysis 6-8 hours per night for 6 nights has been shown to improve sleep apnea (31). (Figure 4) Improvements are usually more significant in patients with more severe sleep apnea.

Sleep apnea should be treated if the patient has symptoms such as fragmented sleep and day time sleepiness or significant oxygen desaturation. In patients without sleep related symptoms who have PSG suggestive of severe sleep apnea, consideration should be given to treat patients with severe disease (Apnea/hypopnea index >30), since sleep apnea of this severity has been associated with increased cardiovascular morbidity and mortality. Sleep apnea should also be treated if it is exacerbating co-existing medical condition such as

Management of sleep apnea includes treatment of any underlying medical conditions such as obesity or hypothyroidism, correction of aggravating factors such as use of alcohol or sedatives close to the bedtime. Continuous Positive Airway Pressure (CPAP) is a method of respiratory ventilation used primarily in the treatment of sleep apnea . The CPAP machine delivers a stream of compressed air via a hose to a nose mask, full-face mask, or hybrid, splinting the airway (keeping it open under air pressure) so that unobstructed breathing becomes possible, therefore reducing and/or preventing apneas and hypopnea. Pressman and Benz first reported in 1993 that CPAP improves both OSA and central apnea in ESRD patients, suggesting that CPAP eliminates the repetitive cyclical pattern of apnea followed by deep breathing, then followed by another central apnea.(28) The degree of hypopnea following apnea may be a function of the magnitude of respiratory drive necessary to overcome upper air way occlusion at the end of apnea. By preventing air way collapse, CPAP probably eliminates the deep breathing that results in hyperventilation and then lowered respiratory drive, thus setting the stage for next central sleep apnea. Also high levels of CPAP are successful in treatment of central sleep apnea due to the fact that central sleep apnea probably occurred following passive airway closure, which in turn caused

Sleep apnea is not corrected by conventional hemodialysis or peritoneal dialysis. Apnea frequency has been reduced by the use of bicarbonate rather than acetate based dialysate (29). Intensive daily dialysis has been shown to resolve sleep apnea in one critically ill patient (30). Nocturnal Hemodialysis(see glossary) that enables patients to receive hemodialysis 6-8 hours per night for 6 nights has been shown to improve sleep apnea (31). (Figure 4) Improvements are usually more significant in patients with more severe sleep

hypertension, myocardial ischemia, and respiratory failure or nocturnal hypoxemia.

stimulation of mucosal sensory receptors and reflex apnea. (28)

Fig. 3. CPAP Machine and Mask.

apnea.

**9. Treatment** 

Fig. 4. Improvement of Sleep Apnea with Nocturnal Hemodialysis.

Although case reports have indicated correction of sleep apnea after successful kidney transplantation (32), preliminary results from case series suggest that sleep apnea resolves only in a minority of patients after kidney transplantation (33). The administration of branched chain amino acids has shown improvement in apnea index in one patient, although the mechanism and implications are not understood. (34).
