| Abstract|| |
To determine the prevalence of metabolic syndrome (MS) in chronic kidney disease (CKD) patients as well as its effects on the progression of CKD, we conducted a prospective, longitudinal study including 180 patients with chronic renal failure followed at the outpatient service of Nephrology at the Saloul's University Hospital of Sousse (Tunisia) over six months. Our study population consisted of 101 men and 79 women. Chronic glomerulonephritis (36.6%) was the most frequent nephropathy. The mean serum creatinine was 249 ± 200 mmol/L and the mean estimated glomerular filtration rate (eGFR) was 55.8 ± 49.2 mL/min. Cardiovascular (CV) impairment was found in 27.2% of the patients. The prevalence of MS was 42.2%. Women had significantly more abdominal obesity than men. Subjects with MS were significantly older and predominantly females who had higher blood pressure and body mass index (BMI). CV complications were more frequent among the MS subjects than among the controls. Glycemia, triglycerides, total cholesterol and low-density lipoprotein-cholesterol (LDL-c) were significantly higher in the group of CKD patients with MS. However, the occurrence of MS was not influenced by the nature of nephropathy, the degree of the CKD and the use of renin-angiotensin blockers or statins. In multivariate analysis, predictors of occurrence of MS in our series included older age, female gender and higher BMI and LDL-c levels. The prevalence of MS in patients with CKD is higher than the general population. These patients should receive special multidisciplinary care to limit CV complications.
|How to cite this article:|
Belarbia A, Nouira S, Sahtout W, Guedri Y, Achour A. Metabolic syndrome and chronic kidney disease. Saudi J Kidney Dis Transpl 2015;26:931-40
|How to cite this URL:|
Belarbia A, Nouira S, Sahtout W, Guedri Y, Achour A. Metabolic syndrome and chronic kidney disease. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 Feb 28];26:931-40. Available from: http://www.sjkdt.org/text.asp?2015/26/5/931/164573
| Introduction|| |
Chronic kidney disease (CKD) and metabolic syndrome (MS) are worldwide public health problems. The most important established risk factors for CKD are diabetes and hypertension. In addition, obesity and MS are independent predictors of CKD.  Microalbuminuria and CKD are also considered as cardiovascular (CV) risk factors. Several studies have discussed the relationship between MS and CKD. ,,,,,,,,,,,, The pathophysiology of this condition is not well understood. The risk of renal disease in individuals with MS can be related to the presence of two factors: Hypertension and hyperglycemia. However, some data suggest that MS is an independent cause of CKD. ,,,, Few studies have reported that persons with mildly reduced kidney function are at greater risk for CV disease, but it remains unclear whether CKD contributes to prevalent MS in the non-diabetic population. No studies have focused on the elderly to evaluate the relationship between the level of kidney function and the prevalence of MS.
The aim of the present study is to determine the prevalence and independent predictors of MS in patients with CKD, in addition to factors and conditions associated with MS and to explore the relationship with CKD and its progression.
| Subjects and Methods|| |
The current study is a cross-sectional survey conducted in CKD patients enrolled between April and June 2009. Patients with diabetes mellitus were excluded from the study.
Basic data of the patients included age, gender, systolic (S) blood pressure (BP), diastolic (D) BP, cholesterol (chol), triglycerides (TG), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, fasting blood glucose, proteinuria, serum creatinine (Cr), albumin, calcium and phosphate, uric acid and albumin, as well as estimated glomerular filtration rate (eGFR), from the simplified equation developed using Modification of Diet in Renal Disease (MDRD) and Cockroft-Gault (CG) formula data, Cr levels and eGFR at baseline and after six months. Other data collected included family and personal history (diabetes, hypertension, family nephropathy), type of nephropathy, CV complications including left ventricular hypertrophy (LVH), coronary heart disease: Angina or myocardial infarction (MI), stroke, heart failure (HF) and arrhythmias (using cardiothoracic index on chest radiograph, signs of LVH on EKG, the sonographic cardiac ejection fraction, impaired relaxation and presence of septal hypertrophy) as well as medications: Inhibitor of angiotensin-converting enzyme (ACE), inhibitors of AT1 receptor of angiotensin II (ARBs) and statins.
Hypertension was defined as a history of hypertension (BP ≥140/90 mm Hg) that required the initiation of antihypertensive therapy by the primary physician.
MS was defined according to the revised criteria of the National Cholesterol Education Program Adult Treatment Panel (NCEPATPIII), which included individuals with three or more of the following five components:
- Central obesity: Waist circumference >102 cm in men or >88 cm in women with body mass index (BMI) ≥25 kg/m 2 .
- Hypertriglyceridemia: TG ≥150 mg/dL (1.7 mmol/L).
- Low HDL-c <40 mg/dL (1 mmol/L) if the patient is male and <50 mg/dL (1.3 mmol/ L) if female.
- High BP ≥130/85 mm Hg and/or
- High fasting glucose ≥110 mg/dL (6.11 mmol/L).
CKD was defined with an eGFR according to the K/DOQI 2002 classification using the CG formula:
Clearance of Cr = K × weight (kg) × (140-age (y))/Cr (μmol/L); K = 1.04 for women and K = 1.23 for men.
For men = 186 × (creatinine (μmol/L) × 0.0113) -1,154 × age 0,203 (× 1.21 if African origin); × 0.742 if woman
eGFR by MDRD was not calculated in five patients who had Cr above 700 μmol/L who were considered to be at Stage 5 of CKD.
Schwartz formula (for children):
Clearance of Cr = K × height (cm)/serum Cr (μmol/L)
K = 29 (newborns); 40 (infants); 49 (children under 12 years); 53 (girls aged between 12 and 21 years); 62 (boys aged between 12 and 21 years).
BMI: The International Classification.
| Statistical Analysis|| |
All statistical analyses were performed using SPSS and Excel softwares. Continuous data are reported as mean ± SD (standard deviation). P <0.05 is considered statistically significant.
The analytical study was conducted using chi-square and chi-square-corrected (Fisher) tests to compare qualitative variables, one-way analysis of variance (ANOVA) to compare quantitative variables for more than two groups, independent-sample t test to compare quantitative variables between two groups depending on the assumed equality of variances tested by the Levene's test F.
For the multivariate data analysis, we selected variables with a threshold ≤15% (P ≤0.150). A logistic regression using the step-down procedure was applied to the collected data to quantify the observed connections.
Only the parameters significantly related to MS are presented as odds ratio, terminals of the confidence interval at 95% and the value of P.
| Results|| |
The average age of our patients was 52.8 ± 18.3 years, ranging from 15 to 83 years. The average age was similar between genders (52.5 ± 19.6 years for men and 53.2 ± 16.7 years for women); patients older than 65 years represented 29.4% of the total number of patients. In our study, 101 (56.1%) patients were male, with a sex ratio of 1.27; males were more frequently represented in the age group >65 years. Family history of diabetes was found in 26 (14.4%) cases, which was the same for history of family nephropathy. History of hypertension was found in 46 patients (25.5%). No history of disease was found in 79 (43.9%) patients, 119 (66.1%) patients had hypertension, 14 (7.7%) patients had dyslipidemia and 12 (12%) patients had gout.
Analysis of the measurements of the anthropometric parameters showed that the average BMI was 27.3, with a range of 16.5-42, and the average tissue thickness (TT) was 93.3 cm, with a range from 62 to 130. The TT average in males was 91.1 ± 13.5 cm and that in females was 96.2 ± 14.2 cm. Most of our patients were overweight (35.6%) or obese (28.3%). The mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the anthropometric characteristics of the patients are summarized in [Table 1].
The average of serum creatinine levels was 249 μmol/L, with a Cr clearance of 55.8 (by CG) and 46.7 (by MDRD). The average of HDL levels was 0.98 mmol/L. The average of TG levels was 1.38 mmol/L and the average of fasting glucose was 5.27 mmol/L.
As for the used medications, 87 (48.3%) patients were on ACE inhibitors, 29 (16.1%) patients were on ARB and 22 (12.2%) patients were on statins.
Major CV complications are summarized in [Figure 1]. LVH was the most common complication observed in 33 (21.5%) of the study patients.
|Figure 1: The frequency of cardiovascular complications in the study patients.|
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MS was found in 76 (42%) patients. A more detailed analysis of the number of criteria per person revealed that the majority of the study patients (34%) had two criteria of MS. In patients with MS, criteria associations of MS most frequently found were, in descending order: 29 (38.15%) patients with TT + HDL + hypertension, 11 (14.5%) patients with TT + HDL + hypertension + TG and eight (10.5%) patients with HDL + hypertension + TG.
The criterion of MS most common among our patients was low HDL-c (67.8%), followed by SBP (59.4%) and waist (46.1). In cases with MS, the most frequent criteria were represented by the waist (75.9%), followed closely by the SBP (73.6%) and TG (72.7%).
A study of the frequencies of the MS criteria by gender found that SBP ≥130 mm Hg and HDL <1.3 mmol/L were the two most commonly represented criteria, respectively, in men and women. Women had more abdominal obesity (P = 0.000), whereas men had more hyperglycemia and high SBP.
MS was more frequently found in female patients, with a statistically significant difference (P = 0.000). [Table 1] compares the averages of several physical and biological parameters studied according to the presence or absence of MS.
The study of MS, based on the initial nephropathy, showed no significant difference. The patients with vascular nephropathy had more MS: 60% versus 40% (P = 0.06).
Comparing the frequency of MS according to the stage of CKD revealed no significant difference, regardless of the method of eGFR (CG or MDRD, P = 0.8 and 0.28, respectively). There was no significant difference in the frequency of the use of ACE inhibitors, ARBs or statins between the MS and non-MS groups. The frequency of CV complications was 35.5% versus 21% for the MS and non-MS groups, respectively [Table 2].
The logistic multi-regression analysis identified four independent predictors for the occurrence of MS in the CKD patients [Table 3]. The significant independent predictors of MS included gender, age, BMI and HDL-c. However, there were no strong and significant correlations between MS and the initial nephropathy.
|Table 3: Comparison of metabolic syndrome (MS) in the general population and our study.|
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Serum Cr and its clearance were reassessed after six months in only 148 patients. Comparing the evolution of renal function according to the presence or absence of the MS did not show any significant difference [Table 4].
|Table 4: Comparison between the averages of various physical and biological parameters studied according to the presence or absence of metabolic syndrome (MS).|
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| Discussion|| |
It is now clear that CKD increases the risk of occurrence of CV complications. On the other hand, MS is a powerful CV risk factor. Current studies have demonstrated the deleterious effect of this syndrome on the kidney. However, the relationship of cause and effect between MS and CKD is still a subject of debate.
Using the NCEP ATPIII definition, MS was found in 42.2% of our patients. We choose this definition because it is the most commonly used definition in the medical literature. Concerning the other definitions, the "World Health Organization" or WHO's definition is not adapted to our population. The definition of "International Diabetes Federation" or "IDF" with lower values of TT and blood sugar may overestimate the prevalence of MS.  This prevalence was lower in the general Tunisian population. Indeed, the Tunisian studies estimated that 18% of women and 13% of men had MS. 
According to the WHO definition, David  found that the prevalence of MS was 30.5%, while knowing that he had included patients with diabetes and dialyzed patients. The AASK study  found a prevalence of 41.7% among African-Americans with vascular nephropathy, which is consistent with our results.
There is variability in the prevalence of MS that could be explained by ethnic differences and the different definitions of the disease, ,,,,,,,, which results in the difficulty in comparing studies that do not use the same definition. ,
Patients with MS were older in our study. These results were found in most of the series. ,,,,,,,,,, Age was an independent risk factor for the occurrence of MS in our study. MS was significantly more common in females in our study, as those included in other Tunisian studies. ,,,,,, However, MS was significantly more common among men in other Asian series ,, and in the French DESIR study.  In contrast, there was no significant difference in gender in the ARIC study,  African Americans  and the Australian study.  In our study, female gender was an independent risk factor for the occurrence of MS in the CKD patients.
The SBP and DBP were significantly higher in patients who had MS in our study. These results are consistent with the literature data. ,,,,,,,,,, However, there was no significant difference in the BP in two studies of MS in CKD patients. ,
In our study, the mean BMI was significantly higher in patients with MS. Most previous studies found similar results. ,,,,,,,,,,, BMI was also an independent factor for the occurrence of MS in our patients. Recent studies have shown that obesity may be an independent risk factor for the progression of CKD ,, even without diabetes and hypertension. This could be explained by glomerular hyperfiltration, which results in glomerular sclerosis.  Pro-inflammatory cytokines secreted by adipose tissue (interleukin-6, tumor necrosis factor-alfa) and angiotensin II  can also play an important role in the genesis of glomerulosclerosis. 
Waist was significantly higher in patients with MS in our study, which is consistent with the results from the literature. ,,,,,,,, Abdominal obesity by the measured waist is considered in some studies as the initiator of MS, as it would cause insulin resistance. ,,,,,,,
Abdominal obesity differs from the other types of obesity because of its metabolic characteristics. Indeed, it is composed of larger adipocytes, more insulin resistance and higher TG. Abdominal obesity is also associated with an increase in free fatty acids, reduction of adiponectin, resistance of peripheral tissues to the action of leptin and infiltration of adipose tissue by macrophage cells with release of inflammatory cytokines. 
Our patients had low average eGFR compared with those in the literature because of the type of population with CKD. ,,,,, In our study, the analysis of renal function did not find a significant difference of the frequency of MS between the CKD and nonCKD patients. The studies performed in patients without CKD found the same result. , Similarly, in the AASK cohort,  whose purpose was to evaluate the influence of MS on the progression of CKD in hypertensive African-Americans, the CL Cr was 45.5 ± 13.6 mL/min for those with MS versus 46 ± 12.7 mL/min for those without MS. In contrast, other series ,,,,,,,,, found that patients with MS had significantly lower Cl Cr compared with those without MS. These studies concluded that MS is an independent risk factor for the occurrence of CKD. In fact, after a few years of follow-up (5-12 years depending on the study), patients with MS had a higher incidence of CKD, ,,,,,, even in the absence of diabetes ,, or hypertension. 
Unlike the data from several studies, there was no significant difference in HDL-c between patients with MS and patients with-out MS, may be because of the CKD. In our series, LDL-c was an independent risk factor for the occurrence of MS. Now, it is well known that LDL-c and persistent inflammatory stimuli result in the formation of foam cells and mesangial cells that do not properly contract and secrete an extracellular matrix that eventually contributes to glomerulosclerosis. 
In our study, the patients with MS had significantly more CV complications than those without MS. This is consistent with the literature data. ,,,,,, Indeed, several cohorts studied the relationship between MS and the occurrence of CV events. These studies found that MS patients were two to three times more likely to develop CV events independently of the presence of diabetes, regardless of gender and tobacco. ,, Although MS is a vascular risk situation, some authors ,,,,,, believe that this concept is not a better predictor of the CV risk than the different individual parameters used to define it. They also think that it adds nothing in terms of predicting events in relation to the use of the classical risk equations such as the Framingham's equation. ,, In a British study,  this score was even a better predictor of coronary heart disease and stroke compared with MS. The reason for this superiority of the Framingham score is that it quantifies the risk. Indeed, the amplitude of anomalies contributes to the risk level. This amplitude is not taken into account in the definition of MS. 
In our study, the majority of the patients had two criteria of MS (34%). The patients without any criteria accounted for 6.1%, and those with more than four criteria accounted for 15%. Other studies reported similar results. ,,
Finally, there was selection bias related to the reduced number of patients and the heterogeneity of the population (we included in the study patients with different stages of CKD). In addition, the duration of follow-up is short (6 months).
We conclude that the prevalence of MS in patients with chronic renal failure is high. Predictors of the occurrence of MS in our study included older age, female gender and higher BMI and LDL-c levels. The CV complications were more frequent among the MS patients. Furthermore, larger prospective studies to analyze the effect of the overall management of MS on the progression of CKD are warranted.
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Department of Nephrology, Dialysis and Transplantation, Sahloul's University Hospital, 4054, Sousse
[Table 1], [Table 2], [Table 3], [Table 4]