Sleep Irregularity is Associated with Reduced Wellbeing in Patients with Cirrhosis

Health-related quality of life (HRQoL) is frequently impaired in cirrhosis. Among the most critical components of reduced HRQoL in cirrhosis is disturbed sleep. Despite the importance of sleep in cirrhosis and overall health, sleep is rarely clinically assessed and the specific aspects of sleep which drive reduced wellbeing are understudied. Remote monitoring with wearable technology may facilitate sleep assessment and targeted intervention.

We enrolled 119 participants with cirrhosis across two academic medical centers and collected baseline clinical, cognitive and laboratory assessment and 6 months of longitudinal wearable tracking with an Oura Ring. HRQoL was assessed with the Chronic Liver Disease Questionnaire (CLDQ) and subjective sleep quality with the Pittsburgh Sleep Quality Index. Association of sleep metrics with HRQoL and subjective sleep was assessed in multivariable mixed effects model, with mediation analysis further analyzing the relationship.

Across analysis of 12516 sleep episodes in 88 participants who completed all assessments and ≥14 valid sleep nights, there was a strong association between measured sleep and reported sleep quality as well as HRQoL, with reduction in sleep efficiency, overall sleep time, and sleep regularity index (SRI). In adjusted mediation analyses, SRI was the strongest mediator (49.9% total mediation effect, ACME = - 0.093, p<0.001) of the relationship between liver disease severity (as measured by Child-Turcotte-Pugh Score) and CLDQ.

In a large prospective study of remote sleep monitoring in liver disease, we found that sleep regularity had a strong association with patient-reported sleep quality and wellbeing, and was the strongest sleep metric mediating the relationship between progressive liver disease and overall HRQoL. These findings suggest the potential for circadian-targeted interventions in patients with cirrhosis.

Sleep impairment is a major contributor to reduced wellbeing in cirrhosis, but existing sleep assessments often are too cumbersome to be used clinically and fail to capture long-term sleep patterns and circadian disruption. Using six months of wearable-derived sleep data, this study identifies sleep irregularity, as captured by the Sleep Regularity Index, as the sleep metric most strongly associated with patient reported sleep and overall wellbeing impairment. These findings suggest that sleep regularity, a marker of circadian rhythm dysfunction, may be an important digital biomarker for progressive worsening in cirrhosis and highlight a possible target for future interventions. If validated in future studies, wearable monitoring of sleep could provide clinicians and researchers a scalable approach for identifying patients with cirrhosis at increased risk for impaired wellbeing through sleep disturbance and monitor response to treatment.