Iron deficiency anemia is associated with renal function decline in obstructive sleep apnea: a multi-institutional cohort study

Background Obstructive sleep apnea (OSA) is associated with an increased risk of chronic kidney disease through mechanisms including intermittent hypoxia and systemic inflammation. Iron deficiency anemia (IDA) may synergistically worsen renal vulnerability in patients with OSA through overlapping hypoxic and oxidative pathways; however, this relationship remains poorly characterized. Methods This retrospective cohort study utilized the TriNetX Research Network to identify and analyze adult patients with a first diagnosis of obstructive sleep apnea (OSA) between 2010 and 2022. After propensity score matching, 38,064 patients with pre-existing IDA were compared with 38,064 matched controls without IDA. The primary outcome was the 5-year cumulative incidence of composite renal function decline, defined as progression to chronic kidney disease stage 4 or 5, end-stage renal disease, or hemodialysis initiation. Secondary outcomes included acute kidney injury (AKI), pulmonary hypertension, all-cause mortality, and intensive care unit (ICU) admission. Results At five-year follow-up, IDA was associated with increased cumulative incidence of composite renal function decline compared to controls [2.0% versus 1.6%; hazard ratio (HR): 1.23, 95% confidence interval (CI):1.10–1.37, p < 0.001]. Significant associations were also observed for AKI (10.7% vs. 8.6%; HR: 1.22, p < 0.001), pulmonary hypertension (4.5% vs. 3.7%; HR:1.22, p < 0.001), all-cause mortality (6.4% vs. 5.0%; HR:1.29, p < 0.001), and ICU admission (6.9% vs. 6.0%; HR:1.17, p < 0.001). These associations persisted at seven-year follow-up and across sensitivity analyses. Conclusion IDA is associated with an increased risk of renal function decline and adverse clinical outcomes in patients with OSA, suggesting a potentially modifiable risk factor that warrants further investigation. Given the retrospective design and reliance on electronic health record data, prospective studies are required to confirm these findings and elucidate the underlying mechanisms.