Sleep-wake disorders are common among populations with liver disease

According to a review of the literature published in The Lancet, sleep-wake disorders are very common in populations with liver disease.

The aim of this review was to summarize the mutual interactions between sleep and liver diseases, including cirrhosis, and to investigate possible approaches for therapeutic interventions. In this review, sleep-wake disorder encompassed all types of changes in normal sleep that have been reported in patients with liver disease.

Sleep-wake disorders have been epidemiologically linked to obesity and metabolic disorders, including non-alcoholic fatty liver (NAFLD). Previous experimental studies show the impact of sleep in several pathways that are known to drive liver steatosis, inflammation, and fibrogenesis. Based on these results, sleep-wake disorders should be viewed as a significant and potentially modifiable risk factor for the development and progression of NAFLD.

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Sleep-wake disorders are common in alcohol abuse patients. It can also increase the severity of underlying alcohol-related liver diseases. However, there is a lack of longitudinal observational studies in humans that investigate the influence of sleep-wake disorders on the development and progression of alcohol-related liver diseases.

There are often overlapping risk factors for both poor sleep and acquiring the hepatitis C virus (HCV). These risk factors include intravenous drug use and premorbid mental disorders. Sleep-wake disorders are often a dominant factor in determining health-related quality of life in patients with HCV who may develop without severe underlying liver disease.

Compared to a number of chronic liver diseases, fatigue can be particularly debilitating in patients with primary biliary cholangitis. Fatigue occurs in over 50% of primary biliary cholangitis cases. A prominent feature of primary biliary cholangitis is excessive daytime sleepiness, which is closely related to fatigue.

Sleep-wake disorders are common in patients with cirrhosis, with around 50 to 80% of patients reporting a Pittsburgh sleep quality index of> 5. Sleep-wake disorders are more common in cirrhosis than in other long-term health conditions such as chronic kidney disease and inflammatory bowel disease.

Despite the high frequency of sleep-wake disorders in cirrhosis of the liver, targeted sleep interventions remain limited in patients with advanced liver disease. Previous clinical studies of targeted sleep interventions have been inadequate.

Because of the relationship between the quality of sleep and the severity of liver disease, sleep-wake disorder is very common in patients waiting for a liver transplant, affecting approximately 50 to 73% of these patients. Sleep seems to improve after a liver transplant. In a prospective study of 201 patients before and after liver transplantation, the frequency of self-reported poor sleep decreased from 50% before the transplant to 36% after 6 months, 32% after 12 months and 23% after 24 months after the transplant. Further research is needed to assess whether targeted sleep intervention in liver transplant candidates has an impact on perioperative or long-term outcomes.

Overall, sleep-wake disorders are widespread in people with liver disease. Sleep abnormalities are likely both a cause and an effect of the underlying liver pathology. Hepatologists should seek to understand the clinical implications of poor sleep and develop strategies for treating sleep-wake disorders.

Disclosure: A study author stated links with pharmaceutical companies. For a full list of the author’s disclosures, see the original reference.


Marjot T., Ray DW, Williams FR, Tomlinson JW, Armstrong MJ. Sleep and liver disorders: a two-way relationship. Lancet. Published online July 15, 2021. doi: 10.1016 / S2468-1253 (21) 00169-2

This article originally appeared on Gastroenterology Advisor

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