Authors: Desai et al.
Anesthesia & Analgesia, April 2026, 142(4):709-719
The Effect of Sleep Disorder Interventions in Patients With Obstructive Sleep Apnea Undergoing Solid-Organ Transplants: A Systematic Review
Key Points
Obstructive sleep apnea is common in patients undergoing solid-organ transplantation and may contribute to postoperative and long-term complications.
This systematic review found very limited evidence on whether OSA treatment improves outcomes in transplant patients.
Of 1,407 studies identified, only 3 met criteria for data extraction.
CPAP improved some sleep parameters in heart transplant patients, including apnea-hypopnea index, arousal index, and time spent with oxygen saturation below 90%.
Untreated OSA was associated with earlier graft dysfunction in one heart transplant study, but CPAP did not clearly improve mortality or long-term survival.
Summary
This systematic review examined whether interventions for obstructive sleep apnea, particularly continuous positive airway pressure, improve outcomes in adult patients undergoing solid-organ transplantation. Poor sleep is common before and after transplantation, and OSA is especially relevant because it is associated with respiratory failure, cardiovascular events, intensive care transfer, and long-term cardiovascular risk. Solid-organ transplant patients may be particularly vulnerable because immunosuppressants, corticosteroids, comorbid disease, and end-stage organ dysfunction can all worsen sleep quality and sleep-disordered breathing.
The authors conducted a PRISMA-guided systematic review registered through PROSPERO. Databases searched included MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO. Eligible studies included adult patients with OSA undergoing solid-organ transplantation who received an intervention such as CPAP. The primary outcome was improvement in sleep-disordered breathing, including sleep quality, sleep duration, sleep interruption, apnea-hypopnea index, sleep efficiency, and related measures. Secondary outcomes included mortality, length of stay, major adverse cardiac events, graft-related outcomes, and surgical morbidity.
The review found a major gap in the literature. Although 1,407 studies were initially identified and 38 underwent full-text review, only 3 studies were eligible for data extraction. These studies included heart transplant and kidney transplant populations only. No eligible studies were found for liver or pancreatic transplant patients. All 3 included studies were single-center retrospective cohort studies, and the overall certainty of evidence was rated as very low.
Only one study evaluated changes in objective sleep parameters after nasal CPAP. That study, involving heart transplant patients, found that CPAP was associated with significant improvement in apnea-hypopnea index, arousal index, and total sleep time with oxygen saturation below 90%. However, sleep efficiency did not significantly improve. The study also noted low long-term CPAP compliance, with only 2 of 8 patients remaining in follow-up continuing to use nasal CPAP.
Mortality outcomes were inconsistent and did not show a clear survival benefit from CPAP. Across the included studies, there was no detectable impact of CPAP on 1-year mortality or 5-year overall survival after adjustment. In kidney transplant recipients, pretransplant OSA was associated with higher unadjusted long-term mortality, but this association was no longer significant after adjustment.
Graft-related outcomes were reported in 2 studies. One heart transplant study found that untreated OSA was associated with a higher risk of late graft dysfunction compared with treated OSA or no OSA. Patients with untreated OSA also appeared to develop graft dysfunction earlier. In contrast, the kidney transplant study did not find significant differences in death-censored graft failure or biopsy-proven acute rejection among patients with pretransplant OSA compared with those without OSA.
The authors emphasized that solid-organ transplantation does not necessarily improve sleep apnea and may contribute to new-onset sleep-disordered breathing. Prior studies cited in the review found high rates of sleep apnea in kidney, heart, lung, and liver transplant populations. This suggests that sleep-disordered breathing should not be overlooked during transplant evaluation or follow-up.
The review also found that existing perioperative OSA guidelines offer little transplant-specific guidance. Guidelines from organizations such as the Canadian Anesthesiologists’ Society, the American Society of Anesthesiologists, the Society of Anesthesia and Sleep Medicine, and the American Academy of Sleep Medicine apply broadly to perioperative patients, but do not provide specific recommendations for solid-organ transplant populations. In the absence of transplant-specific evidence, the authors suggest that existing perioperative OSA recommendations may still be useful for screening, referral, diagnosis, and management.
A major practical issue is timing. Transplant candidates often undergo extensive preoperative evaluation, and the authors note that there may be 6 to 8 weeks of lead time before surgery in many cases. That period may create an opportunity to identify undiagnosed OSA and begin treatment before transplantation. However, the benefit of this approach needs to be tested in better prospective studies.
The authors concluded that while the evidence is limited and low certainty, identifying and treating OSA in solid-organ transplant patients may improve sleep parameters and possibly graft-related outcomes. They called for prospective studies, randomized controlled trials, systematic screening of transplant candidates, better data on CPAP tolerability and adherence, and evaluation of alternative treatments such as automatic positive airway pressure, positional therapy, dental appliances, and hypoglossal nerve stimulation.
What You Should Know
This review highlights an important but underdeveloped area in perioperative transplant care. OSA is common in solid-organ transplant patients, yet there is surprisingly little evidence on whether treating OSA improves transplant outcomes.
For anesthesia providers, the practical message is that OSA should be considered during transplant evaluation, especially because untreated OSA may worsen cardiopulmonary risk and may be associated with graft dysfunction in some patients. However, the current evidence is not strong enough to prove that CPAP improves survival or major transplant outcomes.
The review also reminds clinicians that CPAP only helps if patients can tolerate and continue using it. Low compliance was a major limitation in the available studies. Future approaches may need to be more patient-centered and include alternatives for patients who cannot tolerate CPAP.
Overall, this article supports more systematic screening for sleep-disordered breathing in transplant candidates and better research on treatment strategies. Solid-organ transplant evaluation may be a valuable opportunity to identify OSA, begin appropriate therapy, and potentially improve both perioperative recovery and long-term outcomes.
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