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Sleep in Patients with Type 2 Diabetes: the Impact of Sleep Apnoea, Sleep Duration, and Sleep Quality on Clinical Outcomes by Dr Quratul-Ain Altaf (MBBS, MRCP)

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Sleep in Patients with Type 2 Diabetes: the Impact of Sleep Apnoea, Sleep Duration, and Sleep Quality on Clinical Outcomes by Dr Quratul-Ain Altaf (MBBS, MRCP) Sleep in patients with Type 2 Diabetes: The impact of sleep apnoea, sleep duration, and sleep quality on clinical outcomes by Dr Quratul-ain Altaf (MBBS, MRCP) A thesis submitted to the University of Birmingham for the degree of DOCTOR OF MEDICINE School of Clinical and Experimental Medicine University of Birmingham May 2017 1 | P a g e University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder. Abstract Introduction Type 2 Diabetes (T2DM) and sleep-related disorders share common risk factors such as obesity; but the inter-relationships between T2DM and sleep disorders are not well examined. Aims In this thesis I aimed to assess: 1. The longitudinal impact of obstructive sleep apnoea (OSA) on microvascular complications in patient with T2DM. 2. The relationship between sleep quality, sleep duration and adiposity in patients with T2DM Methods To examine the first aim, I utilised the data collected from a previous project that examined the cross-sectional associations between OSA and microvascular complications in patients with T2DM and followed up the study participants longitudinally using 1-2-1 interviews and electronic health records. For aim 2, I conducted a cross-sectional study in patients with young-onset T2DM who were recruited from Heart of England NHS Foundation Trust. Result For Aim 1: Depending on the microvascular outcome examined, we had approximately 200 patients in the analysis. Patients were followed up for 2.5 years for renal outcomes, and 4- 4.5 years for retinopathy and neuropathy outcomes. The prevalence of OSA was 63%. I found that baseline OSA was significantly associated with greater decline of eGFR and 2 | P a g e greater progression to pre-proliferative and proliferative retinopathy. I also found that OSA was associated with progression to a combined outcome of foot insensitivity or diabetic foot ulceration but this was a non-significant trend (p=0.06). In addition, I found that patients who received and were compliant with continuous positive airway pressure (CPAP) treatment (delivered during routine care) had improvements in heart rate variability parameters by study end. For Aim 2: Poor sleep quality and shorter sleep duration were associated with increased total body fat% after adjustment for potential confounders. Conclusion I found that OSA plays an important role in the progression of microvascular complications in patients with T2DM. Whether treatment with CPAP has a favourable impact on microvascular complications is currently being examined in a randomised controlled trial. I also found that sleep duration and quality are associated with increased adiposity. The direction of this relationship need to be examined in longitudinal studies and interventional trials. 3 | P a g e Acknowledgement I am indebted to a large number of people, without whom, it would not be possible to complete this work. First and foremost, I would like to say a big thank you to my husband and 2 young children who stood by me throughout all the long hours and lost weekends. Secondly, I would like to thank Dr Abd Tahrani who helped me through thick and thin and was a constant source of support and inspiration throughout this journey. I would also like to thank my research team at Birmingham Heartlands Hospital especially Safia Begum, who became a friend. I am thankful to Dr Asad Ali and Mr Nicholls in their help in analysing the sleep studies. I would also like to thank Dr Neil Raymonds, University of Warwick; for helping me with statistical analysis. In the end, I would like to thank all the patients who devoted their time and support in lifting this project up and carrying it to the finishing line. This project would not have been completed without them. I hope that this piece of research forms the basis of many other trials to come and translate into excellent clinical practice. 4 | P a g e Outputs This project has been translated into following data papers, reviews and oral presentations. Data Papers Foot insensitivity is associated with renal function decline in patients with type 2 diabetes: a cohort study. Quratul A. Altaf, Hamed Sadiqi, Milan K. Piya and Abd A. Tahrani. BMC Endocr Disord. 2016 Nov 22; 16(1):64. The relationship between obstructive sleep apnea and intra-epidermal nerve fibre density, PARP activation and foot ulceration in patients with type 2 diabetes. Quratul A. Altaf, Asad Ali, Milan K. Piya, Neil T.Raymond, Abd A.Tahrani. J Diabetes Complications. 2016 Sep-Oct; 30(7):1315-20. Cardiac autonomic neuropathy predicts renal function decline in patients with type 2 diabetes: a cohort study. Abd A. Tahrani, Kiran Dubb, Neil T. Raymond, Safia Begum, Quratul A. Altaf, Hamed Sadiqi, Milan K. Piya, Martin J. Steven. Diabetologia. 2014 Jun; 57(6):1249-56. Obstructive sleep apnea and diabetic nephropathy: a cohort study. Abd A. Tahrani, Asad Ali, Neil T. Raymond, Safia Begum, Kiran Dubb, Quratul A. Altaf, Milan K. Piya, Anthony H. Barnett, Martin J. Stevens. Diabetes Care. 2013 Nov; 36 (11):3718-25. Obstructive Sleep Apnoea and retinopathy in patients with Type 2 Diabetes: A longitudinal Study. Quratul A. Altaf, Paul Dodson, Asad Ali, Neil T. Raymond, Helen Wharton, Hannah Fellows, Rachel Hampshire-Bancroft, Mirriam Shah, Emma Shepherd, Jamili Miah, Anthony H. Barnett, Abd A Tahrani. American Journal of Respiratory and Critical Care Medicine Vol 196, No. 7, 2017. Review Article Novel therapeutics for type 2 diabetes: insulin resistance. Quratul A. Altaf, AH Barnett, AA Tahrani. Diabetes Obes Metab. 2015 Apr; 17 (4):319-34. Oral Presentation Shorter sleep duration and poor sleep quality are associated with increased adiposity in patients with young type 2 diabetes: a cross-sectional study An oral presentation in DUK 2017. Also presented as a poster. 5 | P a g e Table of Contents Chapter One: Introduction .................................................................................................................... 17 1.1 Type 2 Diabetes Mellitus ................................................................................................................. 18 1.1.1 Overview and epidemiology ..................................................................................................... 18 1.1.2 Pathogenesis of Type 2 Diabetes Mellitus ................................................................................ 20 1.1.2.1 Insulin Resistance .............................................................................................................. 20 1.1.2.2 Beta Cell Dysfunction......................................................................................................... 22 1.1.2.3 Other Important Considerations ....................................................................................... 25 1.1.3 Diabetes-related microvascular complications ......................................................................... 27 1.1.3.1 Diabetic Nephropathy and Chronic Kidney Disease........................................................... 28 1.1.3.2 Diabetic Retinopathy ......................................................................................................... 29 1.1.3.3 Diabetic Peripheral Neuropathy ........................................................................................ 30 1.1.3.4 Cardiac Autonomic Neuropathy ........................................................................................ 30 1.1.4 Pathogenesis of Microvascular Complications ......................................................................... 31 1.1.4.1 Advanced Glycation End Products ..................................................................................... 32 1.1.4.2 Protein Kinase C Pathway .................................................................................................. 35 1.1.4.3 Aldose Reductase activation (polyol pathway) .................................................................. 36 1.1.4.4 Hexosamine pathway ........................................................................................................ 38 1.1.4.5 Oxidative stress ……………………………………………………………………………………………………………39 1.1.4.6 Glyceraldehyde-3 Phosphate Dehydrogenase Inhibition .................................................. 41 1.1.4.7 Polymers of ADP-ribose polymerase Activation …………………………………………………………….41 1.1.4.8 Role of Hyperglycaemia………………………………………………………………………………………………. 42 1.1.4.9 Role of Hypertension ......................................................................................................... 43 1.1.4.10 Role of Lipids ................................................................................................................... 44 1.1.4.11 Role of Obesity ................................................................................................................ 45 1.2 Obstructive Sleep Apnoea ............................................................................................................... 46 1.2.1 Overview .............................................................................................................................
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