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have had a crucial contribution in the benefits of this therapeutic modality&#46; Obviously&#44; these facts have made KT with a living donor to significantly increase around the world&#44; currently representing among 20-30&#37; of the global activity of KT&#46;</p><p class="elsevierStylePara">An exhaustive clinical evaluation of the donor reduces the risks of donation and ensures the success of the procedure&#46; In this respect&#44; the Amsterdam Forum establishes that the purpose of the evaluation is to check the health of the donor and rule out all the clinical comorbidities from the donor&#44; including metabolic alterations and heart disorders which may increase post-donation risks&#46;<span class="elsevierStyleSup">7</span> Usually&#44; diabetes&#44; high blood pressure and obesity are considered potential contraindications for a living donor&#44; but it is unknown with certainty what is the individual risk for a donor regarding these post-donation changes&#46; In other words&#44; it is unknown if the fact of having only one kidney may accelerate the progression of nephropathy due to these changes in case they are diagnosed after the donation&#46; These clinical entities are classified in the Metabolic Syndrome &#40;MS&#41; according to criteria of ATPIII-NCEP &#40;The Adult Panel of the National Cholesterol Education Program&#41; and the World Health Organization &#40;WHO&#41;<span class="elsevierStyleSup">8&#44;9</span> &#40;table 1&#46;&#41; Indeed&#44; the MS is an ensemble of risk factors with a metabolic origin &#40;dyslipemia&#44; high blood pressure&#44; hyperglycaemia&#44; prothrombotic&#44; and inflammatory state&#41; which may lead to the development of DM type-2 and CV disease&#44; where abdominal obesity and resistance to insulin constitute the basic pillars of the pathogenesis &#40;figure 1&#46;&#41; From this point of view&#44; before a living donation&#44; one should question&#58; 1&#41; The MS should be considered a contraindication for living donation given its relation with diabetes&#44; atheromatosis and CV disease&#63; The answer may be positive&#46; During this review these aspects will be fully analysed by approaching the following questions&#58; 1&#41; What is the real prevalence of MS in the general population and&#44; potentially&#44; in the living kidney donor&#63;&#59; 2&#41; What is the impact of MS over DM&#44; renal function and other CV complications&#63;&#59; 3&#41; Who should be evaluated and how should the living donor be evaluated to unmask MS&#63;&#59; and 4&#41; Which modifiable risk factors can intervene to minimize the clinical impact of MS after the donation&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PREVALENCE OF THE METABOLIC SYNDROME IN THE GENERAL POPULATION</span></p><p class="elsevierStylePara">The prevalence of MS is variable and depends on age&#44; race and Body Mass Index &#40;BMI&#46;&#41; The American population is estimated to have a prevalence of this syndrome oscillating between 20-30&#37; according to the criteria established by ATPIII-NCEP&#46;<span class="elsevierStyleSup">10</span> Also&#44; in the European population without DM the prevalence of MS is nearly 15&#37;&#44; according to WHO&#44; as shown in an observational study of cohorts from more than 11&#46;000 individuals&#44; where MS increased 1&#46;4 times the risk of death from any cause as compared with those that did not present this alteration&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">In the Spanish population&#44; the prevalence of MS&#44; according to the ATPIII-NCEP criteria&#44; is around 17-23&#37; with a slight predominance in the general population from the Canary Islands and Madrid over the rest<span class="elsevierStyleSup">12-18</span> &#40;table 2&#46;&#41; In any case&#44; the high prevalence of MS in the general population and its important comorbidity justify a deep evaluation of MS before considering a living donation&#44; in order to avoid harmful longterm clinical consequences after the donation&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IMPACT OF THE METABOLIC SYNDROME ON DIABETES MELLITUS&#44; RENAL FUNCTION AND OTHER CV COMPLICATIONS</span></p><p class="elsevierStylePara">The MS represents a group of vascular risk factors&#44; which have insulin resistance as a common pathogenic link&#46; Epidemiological studies have demonstrated an association between MS and the development of CV diseases and DM type-2&#46;<span class="elsevierStyleSup">19</span> In fact&#44; a recent study of prospective cohorts showed that the global and cardiovascular mortality were considerably higher in patients with MS after an average monitoring period of 9 years&#46; This syndrome provided additional prognostic information&#59; therefore&#44; MS can be considered an independent risk factor for mortality after adjusting other classic cardiovascular risk factors&#46;<span class="elsevierStyleSup">20</span> In this line&#44; a metanalysis of 21 studies of prospective cohorts demonstrated that the MS&#44; determined by ATPIII-NCEP and WHO criteria&#44; was an important death and CV disease risk factor&#46; In particular those individuals with MS had a overall increase of 61&#37; of the risk of CV disease&#46;<span class="elsevierStyleSup">21</span> This was confirmed in a systematic review with its corresponding meta-analysis of 38 longitudinal studies which included 172&#46;573 individuals&#44; in order for those with MS to have 1&#46;78 more risk of some cardiovascular event and death than those without this alteration&#46;<span class="elsevierStyleSup">22</span> So&#44; early detection and treatment of modifiable risk factors for MS should reduce cardiovascular morbidity associated to this syndrome&#44; which can be of considerable importance in potential living kidney donors&#46;</p><p class="elsevierStylePara">Transversal studies have shown an association between the biological resistance phenomenon to insulin and subclinical atheromatosis&#44; evaluated by performing a carotid intima-media thickness ultrasound test&#59; this was documented in the general population and in renal patients&#44; including those with KT&#46;<span class="elsevierStyleSup">23</span> It is very likely that the endothelial dysfunction associated to metabolism alterations of glucose may have a decisive contribution to vascular damage&#44; as observed in patients with DM type-2 after an increase of urinary excretion of 8-iso PGF2a&#44; which is a significant marker of oxidative stress&#46;<span class="elsevierStyleSup">24</span></p><p class="elsevierStylePara">In an observational study carried out in a Portuguese population&#44; the MS was related to structural and functional alterations of the heart&#46; The left ventricular mass and the risk of ventricular disorder increased progressively with the number of MS components &#40;associated to the MS&#8217;s severity&#41;&#44; regardless the score of the vascular risk of Framingham&#8217;s study&#46;<span class="elsevierStyleSup">25</span> Also&#44; this syndrome was associated with the development of left ventricular hypertrophy and early changes in the diastolic function in the European population&#44; adjusting the clinical factors that may change the ventricular mass according to age and gender&#46;<span class="elsevierStyleSup">26</span> It is possible that the increase of the values of systolic and diastolic arterial pressure may have contributed to these cardiac abnormalities as demonstrated in a recent meta-analysis in healthy individuals that were subjected to an unilateral nephrectomy for a living donation&#46;<span class="elsevierStyleSup">27</span> These alterations could justify a larger number of cardiovascular events in individuals with MS&#46; Undoubtedly&#44; this demands a thorough evaluation of the possible existence of MS in potential living renal donors in order to avoid future cardiovascular complications after a donation&#46;</p><p class="elsevierStylePara">What is the clinical impact of MS over the renal function&#63; Individuals with MS present early hyperfiltration and progressive increase of the Glomerular Filtration Rate &#40;GFR&#41; according to the number of criteria or severity of the MS itself&#46; Possibly this effect is induced through the release of growth factors such as insulin&#44; IGF-1 or the leptin involved in the MS&#8217;s pathogenesis&#44; which predispose the emergence of a situation of glomerular hyperfiltration&#46; At the same time&#44; this hyperfiltration was undoubtedly an early marker of the emergence of proteinuria and progressive deterioration of GFR&#46;<span class="elsevierStyleSup">28</span> In fact&#44; epidemiological studies demonstrated the narrow relation between MS and expressed renal damage&#44; evidenced as proteinuria and reduction of GFR&#46;<span class="elsevierStyleSup">29&#44;30</span> In this sense&#44; it was observed in longitudinal studies that nondiabetic individuals with MS suffer a greater risk of developing chronic renal failure after several years of monitoring&#44; regardless of other risk factors&#46;<span class="elsevierStyleSup">31</span></p><p class="elsevierStylePara">Furthermore&#44; individuals subjected to a unilateral nephrectomy suffer a greater risk of developing proteinuria and reduction of GFR when compared to the controlled ones&#46; This was observed in a systematic review of 48 studies which included 5&#46;048 living kidney donors&#46;<span class="elsevierStyleSup">32</span> However&#44; how are these processes connected&#63; In other words&#44; what is the natural history of these changes&#63; Theoretically&#44; in individuals with MS subjected to nephrectomy for living donation&#44; insulin resistance and reduction of renal mass can induce hyperfiltration in the remnant kidney&#46; This is associated to proteinuria and progressive renal disease &#40;figure 2&#46;&#41; Therefore&#44; the combination of these risk factors of renal failure &#40;insulin resistance and reduction of nephron mass&#41; should be avoided in individuals who are candidates to living donation of a kidney in order to minimize the risk of suffering long-term renal complications&#46; In addition&#44; obese patients undergoing a nephrectomy suffer a greater risk of proteinuria and renal disorder than non-obese patients&#46;<span class="elsevierStyleSup">33</span> In a similar way&#44; in non-diabetic patients with KT and stable renal function beyond the first year of post-KT&#44; the emergence of MS is more frequently associated with graft loss and mortality than those without this condition&#46; Furthermore&#44; MS was an independent risk factor for loss of renal function during monitoring&#44; which supports the harmful effects that this syndrome causes in renal structure and function&#46;<span class="elsevierStyleSup">34</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Who should be evaluated and how should the living donor be evaluated in order to rule out the presence of metabolic syndrome&#63;</span></p><p class="elsevierStylePara">Amsterdam Forum establishes that individuals with a strong family history of DM type-2 or with a definitive diagnosis of it should not be donors due to the potential risk of development and progression of diabetic nephropathy&#46;<span class="elsevierStyleSup">7</span> Therefore&#44; it is crucial to evaluate the risk of developing DM type 2 in a potential living donor&#44; especially if there is MS&#46; The American Diabetes Association &#40;ADA&#41; recommends a systematic screening of DM type-2 in the following situations&#58; 1&#41; individuals with family history of DM type-2&#59; 2&#41; obese patients with BMI &#62;30 kg&#47;m<span class="elsevierStyleSup">2</span>&#59; 3&#41; excessive alcohol consumption&#59; 4&#41; Individuals originating from the black population &#40;African Americans&#41;&#44; Native Americans &#40;Hispanic origin&#41; or American Indigenous peoples&#59; 5&#41; and in patients with high blood pressure&#44; dyslipidemia and an age over 40 years old&#46; With these in mind&#44; it is possible to reasonably rule out DM type-2 in an important number of individuals&#44; but on many occasions&#44; the beginning of DM type-2 is uncertain and asymptomatic&#46; Hence&#44; it is crucial to estimate more precisely the probability of developing this disease after the donation&#46;</p><p class="elsevierStylePara">Several risk indices have been developed for estimating the probability of developing DM type-2&#44; but their predictive ability has been highly variable due to the exclusion of important risk factors regarding the development of DM type- 2&#46;<span class="elsevierStyleSup">35-40</span> Recently&#44; a European prospective cohorts study with 25&#44;167 individuals determined with precision the risk of developing DM type-2&#46; This risk score was based on the calculation of the statistical weight &#40;&#946; coefficient&#41; of those risk factors that in the multivariate analysis were associated with the emergence of DM type-2 &#40;anthropometric clinical data&#44; diet factors and lifestyle&#41;&#44; neatly ranking individuals in different risk levels regarding the development DM type-2 during a five-year period from a certain score&#46;<span class="elsevierStyleSup">41</span> For example&#44; for a total score of 300&#44; the probability of developing DM type-2 is 0&#46;3&#37;&#44; while at the other end&#44; with a score of 750&#44; the probability is 23&#37;&#46; Undoubtedly&#44; this risk index is a very useful clinical tool for identifying individuals in risk of DM type-2 or those who have this condition and remain undiagnosed&#46;</p><p class="elsevierStylePara">With these premises&#44; the detection of prediabetes is critical to the medical evaluation process of a potential living donor&#46; There are several biochemical and hormonal conditions for the screening of DM type-2&#44; but in clinical practice&#44; basal fasting glucose and Oral Glucose Tolerance Test &#40;OGTT&#41; are standard tests recommended for the diagnosis of DM type-2 including kidney patients&#46;<span class="elsevierStyleSup">42</span> For this purpose&#44; these have been adopted by the ADA and WHO&#46; Table 3 shows the criteria for the diagnosis of DM type-2&#44; Basal Fasting Glycaemia &#40;BFG&#41; and Oral Altered Glucose Tolerance Test &#40;OAGTT&#41; from the conditions set by these international organizations&#46;<span class="elsevierStyleSup">43</span> A recent report by the UNOS &#40;United Network for Organ Sharing&#41; about living donations showed that most centres in the USA&#46; use OGTT for detecting DM type-2&#44; especially in individuals at risk&#46; This same report also documented that the use of such screening has developed over the years in different centres&#46;<span class="elsevierStyleSup">44</span> It is important to consider that certain medical institutions and some drugs may provide a BFG or an OAGTT&#44; which is very important towards the evaluation of the living donor &#40;Table 4&#46;&#41; Figure 3 shows a flow chart for detecting DM type-2 before a living kidney donation&#46; BFG &#40;basal glycaemia &#62; 126mg&#47;dl&#41; or glycaemia &#62; 200 mg&#47;dl at any moment of the day is a contraindication for living donation&#46; If basal glycaemia &#60;100mg&#47;dl and there are no risk factors for developing MS&#44; the donation could be performed with minimum long-term risks to the donor&#46; In the case of a BFG &#40;basal glycaemia 100-126mg&#47;dl&#41;&#44; an OGTT should be performed&#46; Furthermore&#44; in individuals with risk of developing MS &#40;obese&#44; hypertensive&#44; etc&#46;&#41; or those with evident MS according to the ATPIII-NCEP or WHO criteria&#44; it should also be performed an OGTT&#46; If this test is normal &#40;glycaemia after two hours of an overload &#60; 140mg&#47;dl&#41; and there are no other additional risk factors &#40;HbA1c &#60; 6&#44;1&#37;&#44; negative HOMA&#44; etc&#46;&#41; a donation could be performed&#44; or if not&#44; carry out a prophylactic measure &#40;weight loss&#44; physical exercise&#44; balanced diet&#44; etc&#46;&#41; to minimize any risk factor in case there are any&#46; However&#44; before performing a OAGTT &#40;glycaemia 140-200 mg&#47;dl after two hours of oral glucose overload&#41; and the possible presence of additional risk factors for the development of MS &#40;HbA1c &#62; 6&#44;1&#37;&#44; positive HOMA&#44; etc&#46;&#41; therapeutic interventions and&#47;or prophylactic measures should be performed to normalize the levels of glycaemia and significantly decrease the risk factors of this syndrome&#46; In any case&#44; if this objective is reached in individuals of risk &#40;MS clinical criteria or OAGTT&#41;&#44; it would be advisable to perform an OGTT every year after the donation in order to make an early detection of any glycaemia alteration&#46; However&#44; even if with prophylactic measures it is not possible to normalize the levels of glycaemia&#44; performing a living donation is not advisable given the risk of developing DM type-2 or any of its complications in the future&#46; Finally&#44; if OGTT shows a 200mg&#47;dl glycaemia&#44; then its DM type-2 and therefore the donation is not advisable&#46;</p><p class="elsevierStylePara">The HbA1c levels do not comprise the criteria established for the diagnosis of DM type-2&#44; but previous studies have shown that this determination can be a simple measure and with low economical costs for the screening of this condition&#46; In particular&#44; a HbA1c &#62; 6&#44;1&#37; has a higher sensitivity &#40;61&#37;&#41; than basal glycaemia levels &#40;45&#37;&#41; when using OGTT to identify patients of the risk of developing DM type-2&#46;<span class="elsevierStyleSup">45</span></p><p class="elsevierStylePara">The biochemistry methods&#44; which detect the insulin resistance phenomenon&#44; a MS common pathogenic mechanism&#44; could provide a useful determination to detect prediabetic states before living donation&#46; In this respect&#44; the euglycemichyperinsulinemic clamp is a reference method for quantifying insulin sensitivity in humans&#44; but requires a high time consumption and of resources useful for daily clinical practice&#46; Currently&#44; simpler valid methods used to determine insulin sensitivity are HOMA &#40;Fasting Insulin and Homeostasis Model Assessment&#41; and QUICKI &#40;Quantitative Insulin-Check Sensitivity Index&#41;&#44; which evaluate insulin sensitivity from mathematical transformations of fasting glycaemia and insulin levels&#46; These determinations have proved to be good predictors of insulin sensitivity in individuals with and without obesity&#44; as well as in patients with DM type-2 and high blood pressure&#44; using as gold standard the glucose euglycemic-hyperinsulinemic clamp&#46;<span class="elsevierStyleSup">46&#44;47</span> There is a narrow relation between obesity and inflammation&#44; in such a way that some inflammatory markers such as TNFalpha&#44; IL-6 and PCR are associated with insulin resistance and involved in the pathogenesis of DM type-2&#44; mainly in the obese population&#46; Furthermore&#44; low levels of adiponectin are closely related with the development of DM type-2&#46;<span class="elsevierStyleSup">48</span> In this sense&#44; several reviews have shown that genetic polymorphisms of TNF-alpha &#40;G-308A&#41;&#44; IL-6 &#40;174 G&#47;C&#41; and adiponectin &#40;11391 G&#47;A and 276 G&#47;T&#41; are strictly associated to the development of DM type-2&#44;<span class="elsevierStyleSup">49-51</span> which can be a very useful clinical tool for detecting individuals at risk of this disease&#46;</p><p class="elsevierStylePara">Lastly&#44; given the close relation between MS and cardiovascular disease&#44; it should be carried out a thorough evaluation of potential injuries in target organs from potential living donors with this syndrome&#46; This would include an echocardiography&#44; evaluation of the renal function and levels of microalbuminuria&#44; a carotid echography to determine the carotid artery intima-media thickness and assess the presence of peripheral vascular disease&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">APPLICATION OF RISK FACTORS OF THE METABOLIC SYNDROME TO REDUCE ITS CLINICAL IMPACT</span></p><p class="elsevierStylePara">Presumably&#44; the therapeutic intervention of MS risk factors may modulate the clinical impact of this syndrome in a long term&#46; However&#44; what modifiable factors may be involved to achieve this objective&#63; At present&#44; it is unknown if whether reducing insulin resistance per se can prevent the emergence of diabetes&#44; cardiovascular complications and renal disease&#46; However&#44; it is feasible to believe that improving insulin sensitivity through exercise&#44; weight loss&#44; stop smoking and a balanced diet are appropriate strategies to minimize the negative consequences of this clinical syndrome&#46; Furthermore&#44; the administration of drugs that reduce insulin resistance or appetite and the blockage of the Reninangiotensin system &#40;RAS&#41; can contribute to this goal&#46; Figure 4 shows some therapeutic measures that can improve insulin sensitivity in individuals with MS&#46; Regarding this issue&#44; a controlled European study that included randomized individuals with OAGTT&#44; showed a reduced risk of DM of nearly 58&#37; with non-pharmacological measures such as changes in daily life&#44; diet and physical exercise after a threeyear monitoring&#46;<span class="elsevierStyleSup">52</span></p><p class="elsevierStylePara">Drugs that increase insulin sensitivity may reduce considerably the clinical risks inherent to MS&#46; In a randomized study with 3&#44;234 individuals with OAGTT or BFG &#40;basal glycaemia 100-126mg&#47;dl&#41;&#44; the administration of metformin significantly decreased the incidence of DM after four years of monitoring compared to the placebo&#46; However&#44; changes in daily life also mimic the beneficial effects of metformin&#46;<span class="elsevierStyleSup">53</span> Also&#44; thiazolidinedione &#40;such as rosiglitazone&#41; also represent new drugs known to increase insulin sensitivity&#46; In this respect&#44; a controlled study showed that the administration of rosiglitazone &#40;8mg&#47;day&#41; decreased the incidence of DM or death &#40;60&#37;&#41; after three years of monitoring in individuals with BFG or OAGTT versus the placebo&#46;<span class="elsevierStyleSup">54</span></p><p class="elsevierStylePara">Rimonobant is a drug that blocks cannabinoid receptors B1&#44; considerably reducing the appetite&#44; which translates into a reduction in body weight&#46; In a randomized clinical trial performed with obese individuals &#40;BMI &#62; 27kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; this drug was able to significantly reduce body weight and the abdominal perimeter&#44; as well as improve the metabolic and lipid profile when compared to the placebo&#46;<span class="elsevierStyleSup">55</span></p><p class="elsevierStylePara">Other drugs such with sibutramine &#40;anorectic&#41;&#44; acarbose &#40;inhibitor of intestinal absorption of carbohydrates&#41; or orlistat &#40;inhibitor of fat absorption&#41;&#44; amongst others&#44; can prevent or delay the development of DM in individuals with MS&#46; In this respect&#44; a meta-analysis that included 17 randomized clinical trials and 8&#44;084 individuals with OAGTT showed that the majority of the drugs used for MS&#44; as well as changes in daily life&#44; could achieve these objectives in a similar way &#40;risk reduction of 56&#37; and 49&#37;&#44; respectively&#41;&#46;<span class="elsevierStyleSup">56</span></p><p class="elsevierStylePara">Recently&#44; it has been observed that co-administration of metformin and dipeptidyl peptidase-4 inhibitors &#40;sitagliptin&#41; prevents enzymatic degradation and lethargy of incretins &#40;GLP-1 and insulinotropic peptides involved in glucose homeostasis&#41; and can improve the levels of glycaemia and HbA1c in individuals with carbohydrate alterations&#46; This behaviour could also be an alternative therapy to temporarily improve insulin resistance in individuals with MS before the donation&#46;<span class="elsevierStyleSup">57</span></p><p class="elsevierStylePara">Furthermore&#44; other measures such as controlling blood pressure&#44; administration of statins&#44; avoid the abuse of alcohol and smoking&#44; as well as blocking SRA&#44; can help reduce the risk of progression of MS&#46; Indeed&#44; drugs that block SRA &#40;ACE inhibitors and ARBs&#41; increased hepatic glucose production and improved insulin sensitivity&#44; reducing the risk of DM type-2 in individuals with MS&#46; A meta-analysis of 11 clinical trials involving 66&#44;608 patients showed that the use of ACE inhibitors &#47; ARBs prevented the emergence of DM&#44; regardless of the indication for high blood pressure&#44; ischemic heart disease or ventricular disorder&#46;<span class="elsevierStyleSup">58</span> Therefore&#44; these drugs may be indicated for living donors at the risk of developing DM after donation&#46; If to this is added the selective modulation activity &#40;partial agonist&#41; of PPAR-g &#40;peroxisomes proliferator-activated receptor gamma&#41;&#44; improving insulin sensitivity of some ARBs such as telmisartan&#44; could provide an additional clinical benefit for preventing DM&#46;<span class="elsevierStyleSup">59</span></p><p class="elsevierStylePara">To summarise&#44; MS is very common in the general population and&#44; presumably&#44; in living kidney donors &#40;evidence level B&#41;&#46; This syndrome prompts the development of DM type-2&#44; cardiovascular disease and renal disorders &#40;evidence level A&#46;&#41; These facts&#44; along with a small renal mass after donation&#44; could accelerate the development of proteinuria and longterm progressive renal failure &#40;evidence level B&#46;&#41; Therefore&#44; a thorough evaluation of the donor for an early detection of this syndrome&#44; the treatment of this alteration with proper medication and changes in daily life will make these individuals viable for living donation &#40;evidence level B&#46;&#41;</p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;t1&#95;p21&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_t1_p21.jpg" alt="Clinical criteria for diagnosis of metabolic syndrome according to ATPIII-NCEP criteria &#40;The Adult Panel of the National Cholesterol Education Program&#41; and the World Health Organization &#40;WHO&#41;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Clinical criteria for diagnosis of metabolic syndrome according to ATPIII-NCEP criteria &#40;The Adult Panel of the National Cholesterol Education Program&#41; and the World Health Organization &#40;WHO&#41;</p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;f1&#95;p22&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_f1_p22.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;t2&#95;p22&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_t2_p22.jpg" alt="Prevalence of the metabolic syndrome in Spain&#191;s general population"></img></a></p><p class="elsevierStylePara">Table 2&#46; Prevalence of the metabolic syndrome in Spain&#191;s general population</p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;f2&#95;p23&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_f2_p23.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;t3&#95;p24&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_t3_p24.jpg" alt="Criteria from the American Diabetes Association and World Health Organization for the diagnosis of alterations in carbohydrates"></img></a></p><p class="elsevierStylePara">Table 3&#46; Criteria from the American Diabetes Association and World Health Organization for the diagnosis of alterations in carbohydrates</p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;t4&#95;p24&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_t4_p24.jpg" alt="Clinical entities and drugs that can provide a basal fasting glycaemia or a positive oral glucose tolerance test"></img></a></p><p class="elsevierStylePara">Table 4&#46; Clinical entities and drugs that can provide a basal fasting glycaemia or a positive oral glucose tolerance test</p><p class="elsevierStylePara"><a href="grande&#47;22518078&#95;f3&#95;p25&#46;jpg" class="elsevierStyleCrossRefs"><img src="22518078_f3_p25.jpg"></img></a></p><p class="elsevierStylePara">Figure 3&#46; </p>"
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        "resumen" => "<p class="elsevierStylePara">El trasplante renal con donante vivo constituye el tratamiento de elecci&#243;n para la insuficiencia renal cr&#243;nica y la evaluaci&#243;n exhaustiva del donante garantiza el &#233;xito del procedimiento&#46; La diabetes mellitus &#40;DM&#41;&#44; la hipertensi&#243;n arterial y la obesidad representan contraindicaciones cl&#237;nicas para la donaci&#243;n de vivo&#44; pero no se sabe con claridad cual es el riesgo individual a largo plazo de un potencial donante que presenta alguna de estas alteraciones de origen metab&#243;lico agrupadas en el denominado s&#237;ndrome metab&#243;lico &#40;SM&#41;&#44; donde la resistencia a la insulina constituye el nexo com&#250;n etiopatog&#233;nico&#46; El SM es muy prevalente en el mundo occidental &#40;20-30&#37;&#41; y se asocia al desarrollo de enfermedad cardiovascular&#44; DM y alteraciones renales&#46; De ah&#237;&#44; la importancia de su detecci&#243;n antes de la donaci&#243;n en aras de evitar tales complicaciones&#46; Independientemente de la aplicaci&#243;n de los criterios cl&#237;nicos para el diagn&#243;stico del SM&#44; realizar un test de sobrecarga oral de la glucosa&#44; medir los niveles de HbA1c y evaluar la resistencia a la insulina mediante la determinaci&#243;n del HOMA pudieran ayudarnos a desenmascarar este s&#237;ndrome antes de las donaci&#243;n&#46; En esta revisi&#243;n profundizaremos en&#58; 1&#41; la prevalencia del SM en la poblaci&#243;n general&#59; 2&#41; el impacto del SM sobre la DM&#44; la funci&#243;n renal y otras complicaciones cardiovasculares&#59; 3&#41; la evaluaci&#243;n que debe llevarse a cabo para descartar el SM ante la sospecha cl&#237;nica del mismo&#59; y 4&#41; el tratamiento de los factores de riesgo del SM para disminuir las consecuencias a largo plazo de esta complicaci&#243;n metab&#243;lica tras la donaci&#243;n&#46; En cualquier caso&#44; la detecci&#243;n del SM antes de la donaci&#243;n obliga a tomar las medidas profil&#225;ctica y terap&#233;uticas oportunas para evitar su progresi&#243;n&#46; De no conseguirse este objetivo&#44; el SM pudiera ser considerado una contraindicaci&#243;n para la donaci&#243;n de vivo&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Living donor kidney transplantation &#40;KT&#41; is the treatment of choice for end-stage renal disease patients and exhaustive assessment of the potential live kidney donor leads to successful KT in most occasions&#46; Diabetes mellitus &#40;DM&#41;&#44; hypertension and obesity make up contraindications to donation because all of them are associated with postsurgical complications and future development of renal failure and cardiovascular &#40;CV&#41; disorders&#46; However&#44; it is unclear how much risk there is for individuals who donate a kidney and then develop some of these complications&#44; which are grouped under the metabolic syndrome &#40;MS&#46;&#41; Indeed&#44; MS is a cluster of CV risk factors such as obesity&#44; dyslipidemia&#44; hypertension where the insulin resistance is the pathogenic mainstay&#46; MS is an entity very prevalent in the western countries &#40;20-30&#37;&#41; and has been associated with the development of CV disorders&#44; DM and renal disease&#46; Thus&#44; it is crucial to detect MS before living donation in order to avoid these complications in the long-term&#46; Regardless of clinical criteria to diagnosis MS&#44; both oral glucose tolerance test and HbA1c levels may be useful clinical tools for unmasking MS before donation&#46; Moreover&#44; determination of insulin resistance by HOMA could help to achieve this objective&#46; This review will outline the next issues&#58; 1&#41; frequency of MS in the general population &#40;potentially&#44; living kidney donor&#41;&#59; 2&#41; the impact of MS on DM&#44; renal function and other CV complications&#59; 3&#41; assessment of living donor to unmask MS before donation&#59; and 4&#41; interventions on risk factors for minimizing MS-related threatening complications in the long-term&#46; In any case&#44; if MS is detected prior to donation&#44; prophylactic and therapeutic measurement should be performed to avoid its progression&#46; By contrast&#44; MS could be considered a contraindication to donation&#46;</p>"
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