Sleep disturbances in patients with liver cirrhosis: prevalence, impact, and management challenges

Figures & data

Figure 1 Typical 24h-hypno of a cirrhotic patient, showing four naps over day and a disturbed sleep with several wake periods after sleep onset.

Notes: Real time is showed on the lower timeline.
Abbreviations: N1, sleep stage 1; N2, sleep stage 2; N3, sleep stage 3; W, wake; hypno, hypnogram; U, unknown sleep stage; R, rapid eye movement sleep.

Table 1 Comparison of sleep–wake parameters between cirrhotic patients and healthy controls

	Study	Cirrhotic patients			Controls
PSQI
Normal sleep: score >5	Montagnese et al^Citation13	8*			5
	Marques et al^Citation24	5			6
	Heeren et al^Citation2	13*			5
ESS
>10: excessive daytime sleepiness	Marques et al^Citation24	4			5
	Heeren et al^Citation2	10*			7
SF-36
<50: impaired QoL		Physical component summary	Mental component summary		Physical component summary		Mental component summary
	Montagnese et al^Citation13	36*	46*		50		50
	Marques et al^Citation24	41*	51		50		51
	Heeren et al^Citation2 (sum score, max value: 400)	181*	164*		330		304
Actigraphy
	TIB (min)	SE (%)		WASO (min)	TIB (min)	SE (%)		WASO (min)
Córdoba et al^Citation25	434	80*		59*	434	94		16
Marques et al^Citation24	NA	69*		NA	NA	81		NA
Heeren et al^Citation2	500*	81*		86*	441	85		58

Note:

* P<0.05.

Abbreviations: PSQI, Pittsburgh Sleep Quality Index; ESS, Epworth Sleepiness Score; SF-36, 36-question shortform instrument; QoL, quality of life; TIB, time in bed; SE, sleep efficiency; WASO, wake after sleep onset; NA, not assessed.

Table 2 Polysomnographic parameters of cirrhotic patients

Study	Patients	Polysomnographic parameters
		TST (min)	SE (%)	SL (min)	N1 + N2 (%)	N3 (%)	REM (%)	WASO (min)
Teodoro et al^Citation33	Controls	357	84	14	62	17	21	52
Teodoro et al^Citation33	Cirrhotics	330↓	74↓	28↑	68↑	19	14↓	115↑
Bajaj et al^Citation31	Covert HE					0↓	19↓
Watanabe et al^Citation32	Covert HE	291↓					14↓	36
Singh et al^Citation7	Covert HE	231↓	59↓	48↑	51	35	13↓	160↑
Bruyneel et al^Citation28	Recurrent HE	475	78↓	12	64↑	33	3↓	146↑
Liu et al^Citation30	Covert HE	516	80↓	36↑	70↑	14↓

Notes: For information, values of control subjects are shown.

↓ represents decreased and

↑ represents increased values, when related to the control group of Teodoro et al.³³ Bold values indicate normal values in controls, to be able to compare with patient values on the next lines.

Abbreviations: HE, hepatic encephalopathy; TST, total sleep time; SE, sleep efficiency; SL, sleep latency; REM, rapid eye movement sleep; WASO, wake after sleep onset; N1, sleep stage 1; N2, sleep stage 2; N3, sleep stage 3.

Table 3 Possible pathophysiological mechanisms explaining sleep–wake abnormalities in cirrhotic patients

Clinical features	Pathophysiological mechanisms
Delayed sleep onset	Decreased melatonin clearance Delayed melatonin peak Altered circadian variation of core body temperature
Excessive daytime sleepiness	Hepatic encephalopathy (HE)
Short total sleep time, low sleep efficiency, frequent awakenings	HE Increased interleukin-6 Glucose level fluctuations Low values of ghrelin

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