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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 1080-1083
Metabolic syndrome in chronic renal failure


Department of Internal Medicine, Faculty of Medicine, Aleppo University Hospitals, Aleppo, Syrian Arab Republic

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Date of Web Publication13-Sep-2012
 

How to cite this article:
Al-Bitar S, Hawoot Z, Farhood S, Salman S. Metabolic syndrome in chronic renal failure. Saudi J Kidney Dis Transpl 2012;23:1080-3

How to cite this URL:
Al-Bitar S, Hawoot Z, Farhood S, Salman S. Metabolic syndrome in chronic renal failure. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 May 30];23:1080-3. Available from: http://www.sjkdt.org/text.asp?2012/23/5/1080/100961
To the Editor,

Metabolic syndrome (MS), a clustering of common clinical and laboratory features that together confer a high risk for diabetes, cardio­vascular events and cardiovascular-event mor­tality, is now recognized as highly prevalent in both developing and industrialized nations, with prevalence estimates ranging from 9 to 17% in China to 34% in the United States. [1] The pa­rallel increase in the worldwide prevalence of obesity, MS and chronic kidney disease (CKD) has sparked great interest in the role of MS as a novel risk factor for both cardiovascular disease (CVD) and CKD. [2] In 1998, the World Health Organization (WHO) proposed the first internationally accepted definition of MS. [3] The International Diabetes Federation (IDF) and the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) followed suit. [4],[5] The NCEP ATP III criteria are the most widely used in epidemiological studies, and diagnosis requires three of the following five criteria: impaired fasting glucose, central obe­sity, hypertension, elevated triglycerides or reduced high-density lipoprotein cholesterol (HDL). [5] Because hypertension is a core feature of MS and diabetes is a common consequence, there is considerable debate as to whether MS is a novel risk factor for CKD. [6]

We did a cross-sectional study to determine the prevalence of MS in patients with varying degree of renal failure, enrolling 196 patients with renal failure who attended the Nephrology Department of Aleppo University Hospi­tal, Syria, from June 2008 to April 2010.

Inclusion criteria included patients of chronic renal failure with varying degree of renal fai­lure, including hemodialysis patients. Exclu­ding patients younger than 18 years old, pa­tients with acute renal failure (n = 24) and pa­tients with glomerular filtration rate (GFR) more than 60 mL/min/1.73 m 2 , our study finally had 167 patients.

Demographic data collected included height, weight, waist circumference, body mass index (BMI) and blood pressure, recorded as the ave­rage of three seated measurements taken after 5 min rest. Fasting blood specimens are collec­ted to determine fasting glucose, lipid profile, serum urea and creatinine values. GFRs were estimated using the Cockroft-Gault formula. Kidney function was classified as five stages as per the the National Kidney Foundation Practice Guidelines for Chronic Kidney Disease, [7] and patients in stage 3, 4 and 5 were analyzed. MS was defined according to the NCEP ATP III criteria. [5] Statistical analysis was performed using Statistical Package for Social Sciences, Chicago IL, USA (SPSS 12.0). Chi-square test was used to analyze associa­tions in discrete variables between the groups, and a P-value of <0.05 was considered to be statistically significant.

[Table 1] shows the characteristics of the 167 patients who were included in the study (68 females, 99 males), with mean age 45.8 ± 14.6 years. Fifty of the patients were receiving hemodialysis and there was no patient on peritoneal dialysis. The number and gender, of the patients according to their GFR groups are shown in [Table 2]. 55.7% of the patients with chronic renal failure were found to have MS, 42.5% of the patients had CKD or two criteria for MS and 2.4% of the patients did not fulfill any criteria. MS was more prevalent among women than among men, 61.8% and 51.5%, respectively, but this was statistically not sig­nificant (P = 0.190). Overall, low HDL cho­lesterol was the most common abnormality (68.9%), followed by hypertension (67.7%), abnormal glucose metabolism (49.1%), evid­ence of abdominal obesity (45.5%) and ele­vated triglycerides (32.9%) [Table 3]. Patients were sub-classified by age into three categories: <40 years old, 40-60 years, >60 years old, and MS increased significantly with age and was more prevalent among the elderly (P = 0.001) [Table 4]. There was a positive correlation between decreased GFR and pre­valence of MS (P = 0.041), and the prevalence of MS in patients with different GFR stages was 60.4% (stage 5), 53.7% (stage 4) and 43.3% (GFR stage 3). When low HDL-cholesterol, elevated triglycerides and impaired fas­ting glucose were evaluated as MS parameters, no significant differrence was found among GFR stages (P = 0.355), (P = 0.423) and (P = 0.199), respectively [Table 4]. On the other hand, there was a positive correlation between prevalence of hypertension and decrease of GFR (P = 0.001). In contrast, the prevalence of abdominal obesity was significantly de­creased with decrease in GFR (P = 0.001) [Table 4]. The results of the present study demonstrate that MS, as defined by the NCEP ATP III criteria, occurs in 55.7% of CKD patients. As the GFR decreases, the prevalence of MS increases; these results are similar to those of Beddhu, who performed a cross-sectional ana­lysis of 15,134 participants in the Third National Health and Nutrition Examination Survey and observed that the prevalence of MS of 18% among patients with a creatinine clearance of >90 mL/min increased to 21% and 33% among patients with a creatinine clearance of 45-89 mL/min and <45 mL/min, respectively. [8] A likely explanation for the rising prevalence of MS in more advanced stages of CKD may be that MS is an inde­pendent predictor of CKD development and progression. Chen et al, in an observational cohort study of 6217 patients, found that the multivariate adjusted odds ratio (AOR) of CKD in subjects with MS was 2.60 (95% CI 1.68- 4.03) compared with those without MS. [1]
Table 1: Characteristics of the study population.

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Table 2: Number and gender of the patients according to GFR groups.

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Table 3: Association between metabolic syndrome and GFR groups.

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Table 4: Association between metabolic syndrome and age.

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We found that MS risk in CKD patients was predicted by older age. In the National Health and Nutrition Examination Survey 1999-2000, the age-specific prevalence of MS increased from 10.7% of men and 18.0% of women aged 20-39 years to 39.7% of men and 46.1% of women aged 60 years and older. [9] Similar trends have been found in European and Chinese populations. [10],[11]

When individual MS risk factors were ana­lyzed, we found that hypertension increased with decreasing GFR, which was similar to the study by Sarnak, who declared an inverse rela­tionship with systolic blood pressure and level of GFR. [12] Foley et al did not find any asso­ciation between higher levels of blood pressure and low GFR stage. [13]

Patients with GFR <15 had lower HDL cho­lesterol levels than patients in the other GFR groups. But, this result was not found to be statistically significant (P = 0.355). This result was parallel to the results of Wheeler et al. [14] Patients with GFR <15 were more malnou­rished than the patients in the other groups; therefore, they had lower waist circumference and their fasting plasma glucose levels were lower than the patients with GFR <30. How­ever, when low HDL-cholesterol, elevated tri­glycerides and impaired fasting glucose were evaluated as MS parameters, no significant difference was found among the GFR stages.

In our study, only 2.4% of the patients have no criteria for MS; therefore, more than 95% of the patients have one or more risk factor for CVD. An association between MS and CVD risk has been demonstrated in several small studies of persons with advanced CKD. In a study of 183 non-diabetic end-stage renal dis­ease patients on hemodialysis, measured insulin resistance was associated with a four-fold increased risk for CVD mortality, even after adjustment for other traditional risk factors, such as age and dyslipidemia. [15] Similar results were seen in a mixed cohort of pre-dialysis participants with stage 4-5 CKD and those on dialysis, as well as in a post kidney transplant population. [16],[17]

In 714 ARIC participants with stage 3 CKD, MS was associated with a 40-50% higher risk of CV events and death, similar to the results seen in non-CKD populations; therefore, im­plementation of risk factor reduction strategies earlier and aggressively in the course of renal failure may provide an opportunity to prevent CVD in CKD patients who also suffer from dialysis-related risk factors. [18]

At present, most guidelines recommend the­rapies targeted at lifestyle modification and treatment of individual risk factors, whereas the role of pharmacological therapies targeting insulin resistance needs further study. [19]

Acknowledgment

The authors would like to acknowledge Dr. Saleh Salman and Saleh Farhood with grati­tude for their assistance in this work as a whole as well as the nephrologists, medical staff and nurses of the dialysis centers for their collaboration.

 
   References Top

1.Chen J, Muntner P, Hamm LL, et al. The meta­bolic syndrome and chronic kidney disease in U.S. adults. Ann Intern Med 2004;140:167-74.  Back to cited text no. 1
    
2.Lucove J, Vupputuri S, Heiss G, North K, Russell M. Metabolic syndrome and the deve­lopment of CKD in American Indians: the Strong Heart Study. Am J Kidney Dis 2008; 51:21-8.  Back to cited text no. 2
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3.Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classifica­tion of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:539-53.  Back to cited text no. 3
    
4.Alberti KG, Zimmet P, Shaw J. Metabolic syndrome-a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006;23:469-80.  Back to cited text no. 4
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5.Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/Na­tional Heart, Lung, and Blood Institute Scien­tific Statement. Circulation 2005;112:2735-52.  Back to cited text no. 5
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6.Kurella M, Lo JC, Chertow GM. Metabolic syndrome and the risk for chronic kidney disesase among nondiabetic adults. J Am Soc Nephrol 2005;16:2134-40.  Back to cited text no. 6
[PUBMED]    
7.Levey AS, Coresh J, Balk E, et al. National Kidney Foundation. National Kidney Founda­tion practice guidelines for chronic kidney disease: Evaluation, classification, and stratifi­cation. Ann Intern Med 2003;139:137-47.  Back to cited text no. 7
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8.Beddhu S, Kimmel PL, Ramkumar N, Cheung AK. Associations of metabolic syndrome with inflammation in CKD: Results from the Third National Health and Nutrition Examination Survey (NHANES III). Am J Kidney Dis 2005;46:577-86.  Back to cited text no. 8
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9.Ford ES, Giles WH, Mokdad AH. Increasing prevalence of the metabolic syndrome among U.S. adults. Diabetes Care 2004;27:2444-9.  Back to cited text no. 9
    
10.Gu D, Reynolds K, Wu X, et al. Prevalence of the metabolic syndrome and overweight among adults in China. Lancet 2005;365:1398-405.  Back to cited text no. 10
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11.Hu G, Qiao Q, Tuomilehto J, Balkau B, Borch-Johnsen K, Pyorala K. Prevalence of the metabolic syndrome and its relation to all cause and cardiovascular mortality in non-diabetic European men and women. Arch Intern Med 2004;164:1066-76.  Back to cited text no. 11
    
12.Sarnak MJ, Coronado BE, Greene T, et al. Cardiovascular disease risk factors in chronic renal insufficiency. Clin Nephrol 2002;57:327-35.  Back to cited text no. 12
[PUBMED]    
13.Foley RN, Wang C, Collins AJ. Cardiovas­cular risk factor profiles and kidney function stage in the US general population: The NHANES III study. Mayo Clin Proc 2005; 80:1270-7.  Back to cited text no. 13
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14.Wheeler DC, Townend JN, Landray MJ. Cardiovascular risk factors in predialysis patients: Baseline data from the Chronic Renal Impairment in Birmingham (CRIB) study. Kýdney Int Suppl 2003;84:S201-3.  Back to cited text no. 14
    
15.Shinohara K, Shoji T, Emoto M, et al. Insulin resistance as an independent predictor of car­diovascular mortality in patients with end­stage renal disease. J Am Soc Nephrol 2002; 13:1894-900.  Back to cited text no. 15
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16.Johnson DW, Armstrong K, Campbell SB, et al. Metabolic syndrome in severe chronic kidney disease: prevalence, predictors, prog­nostic significance and effects of risk factor modification. Nephrology (Carlton) 2007;12: 391-8.  Back to cited text no. 16
    
17.Courivaud C, Kazory A, Simula-Faivre D, Chalopin JM, Ducloux D. Metabolic syndrome and atherosclerotic events in renal transplant recipients. Transplantation 2007;83:1577-81.  Back to cited text no. 17
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18.Ramkumar N, Murtaugh MA, Cheung AK, Beddhu S. Lack of synergistic effects of metabolic syndrome and plasma fibrinogen on coronary events and mortality in moderate CKD. Am J Kidney Dis 2007;49:356-64.  Back to cited text no. 18
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19.Agrawal V, Shah A, Rice C, Franklin BA, McCullough PA. Impact of treating the metabolic syndrome on chronic kidney disease. Nat Rev Nephrol 2009;5:520-8.  Back to cited text no. 19
[PUBMED]    

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Correspondence Address:
Zakaria Hawoot
Department of Internal Medicine, Faculty of Medicine, Aleppo University Hospitals, Aleppo
Syrian Arab Republic
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DOI: 10.4103/1319-2442.100961

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