Metabolic Syndrome in Perionial Dialysis

1. Metabolic Syndrome in Perionial Dialysis Dr. Sreelatha Calicut

2. Introduction • Metabolic syndrome (MES) • Medical condition with a clustering of major risk factors for cardiovascular diseases and type 2 diabetes • Previously termed syndrome X or syndrome of insulin resistance • Several definitions of MES worldwide NDT Plus 2008; 4: 206–214

3. NDT Plus 2008; 4: 206–214

4. Introduction • Metabolic syndrome (MES) • Pathophysiology NDT Plus 2008; 4: 206–214

5. Proposed diagnostic criteria for metabolic syndrome in PD patients • Based on both scientific evidence and practical use of the criteria for making the diagnosis NDT Plus 2008; 4: 206–214

6. Epidemiology of MES in PD patients • Epidemiologic studies shown • Patients with CKD, especially those undergoing long-term PD, exhibit an increased prevalence of MES • Using the proposed modified NCEP criteria • One cohort of 212 CAPD patients showed a prevalence of 53.3% (113/212) having MES NDT Plus 2008; 4: 206–214

7. Epidemiology of MES in PD patients • One recent study • Prevalence of MES in non-diabetic PD patients increased considerably, from 40 to 65%, after an average follow-up period of 4 years • In addition, ~ 5% of non-diabetic patients developed de novo diabetes NDT Advance Access May 12, 2011

8. Outcome of MES in PD patients • MES is associated with • A raised level of pro-inflammatory cytokines such as IL-6, TNF-α and a reduced level of nitric oxide and adiponectin • This leads to increased inflammation, vasoconstriction and thrombosis, and hence, an • Accelerated process of atherosclerosis formation • Among subjects with chronic kidney disease stages 4 and 5, those with MES have a • Significantly higher risk of mortality NDT Plus 2008; 4: 206–214

9. Outcome of MES in PD patients • Patients on PD, compared with those on haemodialysis, might be more at risk of glucose dysregulation, and thus MES • PD solutions contain a sizable amount of glucose • 60-80% of the glucose instilled into the peritoneal cavity is absorbed, corresponding to 100–300 g of glucose per day • Increased subcutaneous insulin is required in diabetic patients recently commenced on PD NDT Plus 2008; 4: 206–214

10. TREATMENT OPTIONS FOR MES • In discussing the potential therapeutic options for MES • Nephrologists need to be aware that, • To date, no large-scale randomized controlled trial has linked a patient survival benefit to treatment for MES Perit Dial Int 2009; 29(S2):S149–S152

11. TREATMENT OPTIONS FOR MES • Lifestyle modification • One of the major proposals for managing patients with MES • Includes • Appropriate dietary restriction and exercise • Specific treatment for each of the components of MES is also indicated in selected patients Perit Dial Int 2009; 29(S2):S149–S152

12. TREATMENT OPTIONS FOR MES • In PD patients • General measures to reduce weight— preferably fat mass—are similar to those in the nondialysis population • A multidisciplinary approach to weight reduction is more likely to be successful and includes • Individualized meal plans according to energy and nutrition requirements and • Increased physical activity Perit Dial Int 2009; 29(S2):S149–S152

13. TREATMENT OPTIONS FOR MES • Exercise • To reduce fat mass and to improve muscle mass is obviously encouraged, especially in light of other beneficial effects of exercise on dialysis patients • Surgical approaches such as • Laparoscopic banding should be considered only for extreme obesity • Oral anti-obesity drugs are currently • Notan option for PD patients because of their limited safety profiles among patients on dialysis Perit Dial Int 2009; 29(S2):S149–S152

14. TREATMENT OPTIONS FOR MES • In PD patients, avoiding or minimizing peritoneal dialysate glucose by using • Icodextrinand amino-acid solutions may aid weight control • A trial using icodextrinas compared with 2.5% dextrose PD fluid showed • Patients receiving icodextrin had no increase in weight after 52 weeks, in contrast to a weight gain of almost 2 kg in the dextrose group Perit Dial Int 2009; 29(S2):S149–S152

15. TREATMENT OPTIONS FOR MES • Recommendations for weight reduction, especially fat mass, in PD patients with MES have theoretical advantages • Unfortunately, there is little evidence so far that weight reduction is associated with improved patient survival in PD patients Perit Dial Int 2009; 29(S2):S149–S152

16. TREATMENT OPTIONS FOR MES • Glucose control in PD patients includes • Lifestyle changes, hypoglycemic agents, and non–glucose-based dialysis solutions • As in managing obesity, lifestyle modification works through diet, exercise, and body weight control Perit Dial Int 2009; 29(S2):S149–S152

17. TREATMENT OPTIONS FOR MES • Many of our PD patients tend to have hypertension that usually requires treatment with antihypertensive agents • In one cohort of CAPD patients, 80% had hypertension • Elevation of BP in PD patients is obviously multifactorial, but is partly related to fluid status and salt intake • Restriction in salt and fluid intake is important Perit Dial Int 2009; 29(S2):S149–S152

18. TREATMENT OPTIONS FOR MES • We still aim to achieve a BP of 130/85 mmHg in our PD patients • Multidrug treatment is usually required to manage BP, and not uncommonly, • Many PD patients require ≥ 3 antihypertensive medications to control BP • One study using an angiotensinconverting- enzyme inhibitor in patients on PD showed the • Additional benefit of preservation of residual renal function, which is also important in overall outcome for PD patients Perit Dial Int 2009; 29(S2):S149–S152

19. TREATMENT OPTIONS FOR MES • Dyslipidemia can be treated with • Reduction in the amount of dietary cholesterol or fats • Exercise, and use of • Lipid-modifying drugs such as statins or fibrates • However, no large survival outcome studies have looked at the use of these drugs in PD patients Perit Dial Int 2009; 29(S2):S149–S152

20. Conclusions • The prevalence of MES in PD patients is in the range of ≥ 50% • In PD patients, MES seems to predict poor survival • Increased cardiovascular risk in the PD population is likely a result of the interaction between traditional and nontraditionalcardiovascular risk factors and inflammation

21. Conclusions • Evidence in PD patients that interventions targeting the individual elements of MES can improve outcomes is still lacking • Appropriate diet and fluid control with exercise are advisable • However, we are still waiting for large-scale interventional research studies to provide clinical outcome data in this area

22. Thank You!