M ETABOLIC S YNDROME IN P ERIONIAL D IALYSIS Dr. Sreelatha Calicut

I NTRODUCTION 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

I NTRODUCTION Metabolic syndrome (MES) Pathophysiology NDT Plus 2008; 4: 206–214

P ROPOSED 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

E PIDEMIOLOGY 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

E PIDEMIOLOGY 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

O UTCOME 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

O UTCOME 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

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

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

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

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 Not an option for PD patients because of their limited safety profiles among patients on dialysis Perit Dial Int 2009; 29(S2):S149–S152

TREATMENT OPTIONS FOR MES In PD patients, avoiding or minimizing peritoneal dialysate glucose by using Icodextrin and amino-acid solutions may aid weight control A trial using icodextrin as 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

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

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

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

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 angiotensin converting- 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

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

C ONCLUSIONS 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 nontraditional cardiovascular risk factors and inflammation

C ONCLUSIONS 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