A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

Impact of Multimorbidity on Mortality in Heart Failure With Mildly Reduced and Preserved Ejection Fraction

BACKGROUND

How different combinations of comorbidities influence risk at the patient level and population level in patients with heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction is unknown. We aimed to investigate the prevalence of different combinations of cardiovascular and noncardiovascular comorbidities (ie, multimorbidity) and associated risk of death at the patient level and population level.

METHODS

Using patient-level data from the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) and PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction), we investigated the 5 most common cardiovascular and noncardiovascular comorbidities and the resultant 45 comorbidity pairs. Cox proportional hazard models were used to calculate the population-attributable fractions for all-cause mortality and the relative excess risk due to interaction for each comorbidity pair.

RESULTS

Among 6504 participants, 95.2% had at least 2 of the 10 most prevalent comorbidities. The comorbidity pair with the greatest patient-level risk was stroke and peripheral artery disease (adjusted hazard ratio, 1.88 [95% CI, 1.27-2.79]), followed by peripheral artery disease and chronic obstructive pulmonary disease (1.81 [95% CI, 1.31-2.51]), and coronary artery disease and stroke (1.67 [95% CI, 1.33-2.11]). The pair with the highest population-level risk was hypertension and chronic kidney disease (CKD; adjusted population-attributable fraction, 14.8% [95% CI, 9.2%-19.9%]), followed by diabetes and CKD (13.3% [95% CI, 10.6%-16.0%]), and hypertension and diabetes (11.9% [95% CI, 7.1%-16.5%). A synergistic interaction (more than additive risk) was found for the comorbidity pairs of stroke and coronary artery disease (relative excess risk due to interaction, 0.61 [95% CI, 0.13-1.09]), diabetes and CKD (relative excess risk due to interaction, 0.46 [95% CI, -0.15 to 0.77]), and obesity and CKD (relative excess risk due to interaction, 0.24 [95% CI, 0.01-0.46]).

CONCLUSIONS

The risk associated with comorbidity pairs differs at the patient and population levels in heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction. At the population level, hypertension, CKD, and diabetes account for the greatest risk, whereas at the patient level, polyvascular disease and chronic obstructive pulmonary disease are the most important.

Rostafuroxin, the inhibitor of endogenous ouabain, ameliorates chronic undernutrition-induced hypertension, stroke volume, cardiac output, left-ventricular fibrosis and alterations in Na+-transporting ATPases in rats

Our aim has been to investigate the effect of Rostafuroxin, an inhibitor of endogenous cardiotonic steroids (EO/CTS), on cardiac structure and function and cardiac Na+ transport in undernourished hypertensive Wistar rats, and to determine whether chronic undernutrition is a modifiable risk factor for cardiovascular-kidney-metabolic (CKM) syndrome. Echocardiographic studies evaluated stroke volume cardiac output, ejection fraction, mitral valve early diastolic blood flow/late diastolic blood flow (E/A) ratio, and right renal resistive index. The cardiomyocyte area and collagen infiltration of cardiac tissue were investigated, as also the activities of the cardiac ouabain-sensitive (Na++K+)ATPase ((Na++K+)ATPase Sens) and ouabain-resistant Na+-ATPase (Na+-ATPase Res). Undernourished hypertensive rats presented tachycardia, reduced stroke volume, decreased cardiac output, preserved fractional shortening and ejection fraction, unmodified mitral valve E/A ratio, and increased right renal resistive index. Cardiomyocyte size decreased and intense collagen infiltration had occurred. The (Na++K+)ATPase Sens activity decreased, whereas that of Na+-ATPase Res increased. Rostafuroxin selectively modified some of these echocardiographic and molecular parameters: it increased stroke volume and cardiac output and prevented histopathological alterations. The drug decreased and increased the activities of (Na++K+)ATPase Sens and Na+-ATPase Res, respectively, in normonourished rats, and the opposite trend was found in the undernourished group. It is concluded that chronic undernutrition in rats can provoke structural, functional, histological, and molecular cardiovascular alterations that, with the simultaneous changes in renal parameters described in this and in previous studies, configure an undescribed type of CKM syndrome. The data also demonstrate that the blockade of EO/CTS ameliorates stroke volume and cardiac output, thus preventing or delaying the worsening of the syndrome.

Type 2 diabetes and chronic kidney disease as long-term predictors of cardiovascular events in patients with coronary artery disease

BACKGROUND

Both chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) confer a high risk of cardiovascular disease and mortality. These entities frequently coincide. The separate and joint impact of CKD and T2DM on the risk of major cardiovascular events (MACE) and survival is unclear.

METHODS

In this prospective cohort study, patients with angiographically proven coronary artery disease were investigated according to their CKD and T2DM status (T2DM-/CKD-, T2DM+/CKD-, T2DM-/CKD+, T2DM+/CKD+) and followed for up to 18 years.

RESULTS

A total of 1441 patients were included in the study of whom 39% experienced MACE (T2DM-/CKD-: 31%, T2DM+/CKD-: 43%, T2DM-/CKD+: 53%, T2DM+/CKD+: 61%) and 53% died. A log-rank test revealed significant differences between the event-free time period of the four groups (χ2 (3) = 112.57, p < 0.001). The presence of T2DM and CKD was associated with a 2.72-fold increase [1.98-3.73] in MACE compared to patients who suffered from neither condition (p < 0.001). T2DM alone led to a 1.37-fold increase [1.1-1.7], (p = 0.004), CKD alone to a 1.71-fold increase [1.31-2.25], (p < 0.001).

CONCLUSION

T2DM and CKD in patients with coronary artery disease are mutually independent predictors of cardiovascular events. Patients with both CKD and T2DM are at an extremely high risk for cardiovascular events.

Are Your Kidneys Ok? Detect Early to Protect Kidney Health

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk, and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index. This World Kidney Day we assert that case-finding in high-risk populations, or even population level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic and simple to test for, and recent paradigm shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, health care funding, health care infrastructure, and health care professional and population awareness of kidney disease. Coordinated efforts by major kidney nongovernmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Are your kidneys Ok? Detect early to protect kidney health

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk, and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index. This World Kidney Day we assert that case-finding in high-risk populations, or even population level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic and simple to test for, and recent paradigm shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, health care funding, health care infrastructure, and health care professional and population awareness of kidney disease. Coordinated efforts by major kidney nongovernmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Social Determinants of Health in the Development of Cardiovascular-kidney-metabolic Syndrome

Cardiovascular-kidney-metabolic (CKM) syndrome is characterized by the interactions among the metabolic risk factors, chronic kidney diseases (CKD) and cardiovascular diseases (CVD). Social determinants of health (SDOH) include society, economy, environment, community and psychological factors, which correspond with cardiovascular and kidney events of the CKM population. SDOH are integral components throughout the entire spectrum of CKM, acting as key contributors from initial preventative measures to ongoing management, as well as in the formulation of health policies and the conduct of research, serving as vital instruments in the pursuit of health equity and the improvement of health standards. This article summarizes the important role of SDOH in CKM syndrome and explores the prospects of comprehensive management based on SDOH. It is hoped that these insights will offer valuable contributions to improving CKM-related issues and enhancing health standards.

Serum autotaxin positively associates with hypertension in postmenopausal women: a single center study in China

AIM

Autotaxin is an adipokine involved in metabolic disorders. The aim of the current study was to evaluate serum autotaxin levels in hypertensive postmenopausal women and establish a relationship between autotaxin and other comorbidities in this special group.

METHODS

This single-center study included postmenopausal women who received annual health examinations at the First Affiliated Hospital, College of Medicine, Zhejiang University in Zhejiang, China. The metabolic and demographic characteristics of the subjects, including age, sex, height, weight, blood pressure, and biochemical indices, were collected. The serum autotaxin level was measured via ELISA. The Kolmogorov-Smirnov test, Student's t test, Mann-Whitney U test, χ2 test, receiver operating characteristic (ROC) curve analysis, Spearman correlation analysis and multivariate logistic regression analysis were adopted for statistical analysis.

RESULTS

This pilot observational study included 25 hypertensive postmenopausal women and 25 age-matched normotensive controls. Hypertensive patients presented significant metabolic disturbances with greater comorbidities such as nonalcoholic fatty liver disease, obesity, overweight, diabetes, hypertriglyceridemia and hyperuricemia ( P  < 0.05), impaired renal health with higher uric acid levels ( P  < 0.001), and slightly elevated creatinine levels ( P  = 0.156) with lower estimated glomerular filtration rates (eGFRs) ( P  = 0.195). The serum autotaxin level was markedly greater in the hypertensive group (239.0±59.6 ng/ml vs. 192.7 ± 49.0 ng/ml; P  < 0.01) and was positively associated with systolic blood pressure; diastolic blood pressure; and alanine transaminase, triglycerides (TG), creatinine, and uric acid levels and inversely associated with the eGFR ( P  < 0.05) among postmenopausal women. Serum autotaxin levels positively predicted hypertension, with an AU-ROC of 0.750 [95% confidence interval (CI): 0.613-0.888] and a Youden index of 0.480 at a cutoff of 225 ng/ml. In the multivariate logistic regression analysis, after adjustment for demographic and metabolic parameters (including age, BMI, ALT, TB, uric acid, FBG, TG, LDL and creatinine), autotaxin (ATX) remained independently positively correlated with the risk of hypertension [odds ratio: 1.016, 95% CI 1.001-1.031; P  < 0.05).

CONCLUSIONS

Among postmenopausal women, the serum autotaxin level is significantly elevated in the hypertensive group compared with age-matched normotensive controls. ATX is related to multiple metabolic disorders and renal health, suggesting that autotaxin has potential as a multiorgan therapeutic target for cardiovascular-metabolic-renal disorders.

Association Between Life's Essential 8 and Diabetic Kidney Disease in Patients With Diabetes Mellitus: Evidence From National Health and Nutrition Examination Survey 2005-2018

BACKGROUND

Diabetic kidney disease (DKD) is often connected with an elevated cardiovascular disease risk. A novel index, the Life's Essential 8 (LE8), was developed with the American Heart Association to ascertain cardiovascular health. In people with diabetes mellitus, we aimed to estimate if LE8 possessed a connection with DKD risk.

METHODS

We implemented data from the National Health and Nutrition Examination Survey from 2005 to 2018. The correlation between LE8 and DKD was evaluated with weighted multivariate logistic regression models and restricted cubic spline models with covariate adjustments. In addition, we performed subgroup analyses and interaction tests.

RESULTS

After taking into account relevant confounding factors, the findings indicated that higher levels of LE8 was linked to a decreased probability of developing DKD (per 10-point increase in LE8, OR = 0.75, 95%CI = 0.68-0.84, P < .001). The subscales of the LE8 similarly demonstrated negative associations with DKD risk. After grouping the LE8 scores, it was found that individuals with high LE8 were significantly less likely to develop DKD compared to those with low LE8 (OR = 0.32, 95%CI = 0.15-0.70, P = .005). The association between LE8 and DKD was consistent across different subgroups.

CONCLUSION

LE8 scores were shown to have a significantly negative association with the risk of DKD in people with diabetes mellitus. By concentrating on the state of cardiovascular health, it may be possible to lessen the impact of DKD.

Comparison of triglyceride glucose index and modified triglyceride glucose indices in predicting cardiovascular diseases incidence among populations with cardiovascular-kidney-metabolic syndrome stages 0-3: a nationwide prospective cohort study

BACKGROUND

Cardiovascular-kidney-metabolic (CKM) syndrome has been recently proposed by American Heart Association recently. The triglyceride glucose (TyG) index and TyG-related indices combined with obesity indicators have proven to be associated with the incidence of cardiovascular diseases (CVD). However, there are few studies to explore whether these associations exist among people with CKM syndrome stages 0-3.

METHODS

A total of 7,364 participants from the China Health and Retirement Longitudinal Study were included. Cox hazard regression and restricted cubic spline regression were used to analyze the associations of these indices with CVD incidence. To compare predictive performance, time-dependent Harrell's C-indices, net reclassification index and integrated discrimination improvement were conducted.

RESULTS

The CVD incidence was 20.55% over nine years. The TyG single index and all the modified TyG indices were capable of predicting CVD incidence. RCS regression analyses showed that all indicators had linear relationships with CVD incidence and these linear relationships of TyG combined with waist circumference (TyG-WC) or waist-to-height ratio (TyG-WHtR) still existed in CKM stage 1, stage 2 and stage 3. TyG-WC (C-index: 0.621, p < 0.001) and TyG-WHtR (C-index: 0.621, p < 0.001) almost had the highest C-indices in predicting CVD incidence, compared to single TyG index (C-index: 0.611, p < 0.001) and TyG combined with body mass index (C-index: 0.616, p < 0.001).

CONCLUSION

The TyG index and all the modified TyG indices were independent predictors of CVD incidence among people with CKM syndrome stages 0-3. It was found that modified indices had better predictive performance, especially TyG combined with waist circumference or waist-to-height ratio.

Association between non-highdensity lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and cardiovascular-kidney-metabolic syndrome: evidence from NHANES 2001-2018

Objective

This research is to analyze the connection between NHHR and CKD occurrence using NHANES from 2001 to 2018. It will evaluate the feasibility of NHHR as a tool for predicting CKM syndrome and offer valuable insights for personalized treatment approaches within the U.S. population.

Methods

Data from 16,575 individuals aged 20 to 69 years were analyzed, having excluded those who were pregnant and individuals with incomplete data. CKM syndrome was characterized by the simultaneous presence of CKD and Cardiometabolic Syndrome (CMS). For the statistical analysis, weighted logistic regression models were applied, accounting for variables such as age, gender, ethnicity, educational background, marital status, lifestyle factors, and preexisting health conditions. Differently, restricted cubic splines (RCS) were applied to investigate any possible nonlinear relationships between NHHR and CKM in the study.

Results

The research revealed that the occurrence of CKM syndrome was more prevalent among individuals aged 60 and older, with women representing 55.36% of those affected. Additionally, NHHR levels were notably elevated in CKM patients when compared to those without CKM (p < 0.0001). As NHHR increased, the prevalence of CKM also rose, with the highest prevalence in the highest NHHR quartile (Q4: 36.06%). A positive connection between NHHR and CKM was indicated by multivariable logistic regression, especially in the upper quartiles of NHHR (Q3 and Q4). Moreover, RCS analysis displayed a noteworthy nonlinear connection between NHHR and CKM occurrence. The subgroup analysis uncovered significant interactions influenced by BMI and Hypertension.

Conclusion

With the rising global prevalence of CKM syndrome, early identification of high-risk individuals using NHHR could inform targeted prevention and intervention strategies. Future research should focus on validating NHHR in diverse populations and exploring its clinical utility, as well as examining its relationship with other biomarkers of metabolic dysfunction to better understand CKM syndrome's complex pathophysiology.

Association between triglyceride-glucose related indices and all-cause and cardiovascular mortality among the population with cardiovascular-kidney-metabolic syndrome stage 0-3: a cohort study

BACKGROUND

Cardiovascular-Kidney-Metabolic (CKM) syndrome typically commences with the interaction of insulin resistance (IR), excessive or dysfunctional obesity, and the consequent systemic inflammatory response and oxidative stress. The relationship between the triglyceride-glucose (TyG) index and TyG-related indices that may simply assess IR and obesity, as well as the mortality risk in the CKM syndrome population, remains ambiguous.

METHODS

This study included 6,383 participants from the National Health and Nutrition Examination Survey (NHANES) 2009-2018. The TyG index, TyG-waist-to-height ratio (TyG-WHtR), TyG-waist circumference (TyG-WC), and TyG-body mass index (TyG-BMI) were developed. Cox proportional hazards models, smooth curve fitting, and two-stage Cox proportional hazards models were employed to examine the association of TyG and TyG-related indices with all-cause and cardiovascular mortality in the CKM syndrome population. Subgroup analyses and interaction tests were conducted to evaluate the risk within various demographics.

RESULTS

In survey-weighted multifactorial regression analyses, a significant positive association existed between TyG, TyG-related indices, and both all-cause mortality and cardiovascular mortality, except for the TyG index, which did not demonstrate a significant link with all-cause mortality. Of these indices, the TyG-WC index exhibited the strongest correlation with all-cause mortality, with a hazard ratio (HR) of 1.50 and a 95% confidence interval (CI) of 1.18-1.92, followed by the TyG-WHtR index (HR: 1.45, 95%CI 1.13-1.85). The TyG-WHtR index demonstrated the strongest correlation with cardiovascular mortality (HR: 1.85, 95% CI 1.19-2.86), followed by the TyG-WC index(HR: 1.83, 95%CI 1.21-2.78). An L-shaped association was identified between TyG-WHtR, TyG-BMI, and all-cause mortality in CKM syndrome during the examination of nonlinear relationships (both P for log-likelihood ratio < 0.05). The TyG-WHtR, TyG-WC, and TyG-BMI indices exhibited a more pronounced correlation with all-cause mortality in those with CKM syndrome stages 1 and 3 (P value < 0.05, P for interaction < 0.05).

CONCLUSION

Our study emphasizes the association between TyG and TyG-related indices and mortality in individuals with CKM syndrome stages 0-3. Individuals with CKM syndrome stages 1 and 3 should be more vigilant to abnormal alterations in TyG-related indices.

Weight-adjusted waist index shows superior detection of coronary artery disease than body mass index in NHANES 1999-2020

Coronary artery disease (CAD) is a leading cause of morbidity and mortality globally, highlighting the need for improved risk assessment tools. Traditional measures like body mass index (BMI) do not fully capture the risk associated with body fat distribution. The weight-adjusted waist index (WWI) has emerged as a potential anthropometric measure that may provide a more precise evaluation of central adiposity and its cardiovascular risks. We analyzed data from 49,240 participants in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2020. Participants were stratified into quartiles based on WWI: Q1 (WWI < 10.43), Q2 (10.43 ≤ WWI < 10.99), Q3 (10.99 ≤ WWI < 11.56), and Q4 (WWI ≥ 11.56). The primary outcome was self-reported coronary artery disease (CAD). Multivariate logistic regression, generalized additive models, and stratified analyses were conducted. The predictive performance of WWI versus body mass index (BMI) for CAD was assessed using receiver operating characteristic (ROC) curves, with differences in area under the curve (AUC) evaluated by DeLong's test. Multivariate logistic regression analysis showed a positive association between WWI and CAD prevalence, which persisted after adjusting for confounding variables. Higher WWI was associated with increased risk of CAD, with Group 4 showing the highest risk compared to Group 1 (OR 2.06, 95% CI 1.37-3.09, P < 0.001). This relationship was not observed between BMI and CAD risk. Subgroup analysis revealed that the association between WWI and CAD prevalence was more pronounced in participants aged ≤ 60 years (P for interaction < 0.001). ROC curve analysis demonstrated that WWI had superior predictive ability for CAD compared to BMI (AUC 0.694 vs. 0.547, De-long test P < 0.001). WWI demonstrated a stronger association with CAD prevalence compared to BMI in the US population, with this relationship particularly pronounced among younger adults. Longitudinal studies are needed to establish this relationship.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Glycemic Targets and Prevention of Complications

CONTEXT

Complications of diabetes mellitus have significant impacts on morbidity, mortality, quality of life, and health costs for individuals. Setting and achieving glycemic targets to prevent these complications is a top priority when managing diabetes. However, patients often already have complications when diagnosed with diabetes mellitus. Therefore, methods to prevent disease progression become a crucial component of diabetes management. The purpose of this article is to review glycemic targets and methods of screening and managing diabetes-related complications.

EVIDENCE ACQUISITION

A PubMed review of the literature pertaining to diabetes mellitus, glycemic targets, microvascular complications, and macrovascular complications was conducted. We reviewed articles published between 1993 and 2024. Guidelines published by nationally recognized organizations in the fields of diabetes, nephrology, and cardiology were referenced. Public health statistics obtained by the Center for Disease Control and Prevention and the National Kidney Foundation were used.

EVIDENCE SYNTHESIS

Achieving glycemic targets and screening for diabetes-related complications at appropriate intervals remains the key factor for early detection and intervention. An algorithmic approach to glycemic management based on individual risk factors is beneficial in choosing pharmacotherapy.

CONCLUSION

The consequences of diabetes-related complications can be detrimental. However, achieving and maintaining glycemic targets combined with diligent screening, reduction of risk factors, and prompt treatment can halt disease progression.

Temporal trends in the planetary health diet index and its association with cardiovascular, kidney, and metabolic diseases: A comprehensive analysis from global and individual perspectives

BACKGROUND

Diet plays a critical role in human health and environmental sustainability, particularly in cardiovascular, kidney, and metabolic (CKM) diseases. However, the variations in the Planetary Health Diet Index (PHDI) across populations, regions, and over time, as well as its association with CKM disease burdens, remain insufficiently explored.

METHODS

We assessed PHDI scores using data from 185 countries (1990-2018) from the Global Dietary Database, examining demographic characteristics and temporal trends. The Global Burden of Disease Study was used to evaluate the associations between PHDI and CKM disease burdens, including incidence, prevalence, mortality, and disability-adjusted life years. CKM syndrome was defined by the American Heart Association. Individual-level data from the National Health and Nutrition Examination Survey (NHANES) were also used to assess the impact of PHDI on CKM risks and mortality.

RESULTS

From 1990 to 2018, while overall PHDI scores remained relatively stable between sexes, the composition of PHDI scores shifted across different age groups. In 2018, the mean PHDI score was 42.80 (95% uncertainty interval [UI] 42.49-46.50) for males and 44.65 (95% UI 44.53-47.82) for females. Higher PHDI scores were observed among females, older adults, urban residents, individuals with higher education, and those from South Asia. Globally, consumption of red/processed meat, saturated oils/trans fats, and added sugars substantially exceeded the EAT-Lancet Commission's reference values. Higher PHDI scores were generally associated with lower CKM disease burdens, although these associations varied by disease subtype. In individual-level analysis, including 45,460 NHANES participants (weighted mean age: 47.21 years, 51.4% female), each 10-point increase in PHDI was linked to a 13.7% reduction in stage 3/4 CKM syndrome risk, an 11.1% reduction in stage 4 CKM syndrome risk, and lower incidences and mortality rates for cardiovascular diseases, metabolic diseases, and chronic kidney disease.

CONCLUSIONS

From 1990 to 2018, significant changes occurred in the components of the PHDI, with notable variations by demographics and region. Higher PHDI scores may reduce CKM disease burdens, warranting further investigation into specific disease subtypes.

The Diminished Cardiorespiratory Fitness in Cardiovascular-Kidney-Metabolic Syndrome

Objective

The American Heart Association has recently emphasized the significance of the cardiovascular-kidney-metabolic (CKM) syndrome. However, the cumulative impact of these factors on cardiorespiratory fitness remains inadequately characterized. This study aimed to examine the responses observed during cardiopulmonary exercise testing (CPET) of CKM syndrome patients and explore the potential correlation between cardiorespiratory fitness and hemoglobin concentration in this cohort.

Design

Cross-sectional study.

Methods

We retrospectively collected medical data of 8206 patients who underwent CPET from 2012-2022. Among the 878 individuals enrolled, 12 were healthy controls, 809 had isolated CVD, and 57 were in CKM stage 4. After propensity score matching, 112 patients were included in the matched cohort analysis, with 56 each in the CVD and CKM groups. CPET responses were compared between the groups using propensity matched analysis. Additionally, simple mediation models were employed to investigate the potential mediating role of hemoglobin concentration in the association between CKM syndrome and peak VO2.

Results

After propensity score-matching, CKM stage 4 was associated with diminished cardiorespiratory fitness compared to the other two groups. This included diminished exercise capacity, reflected by shorter exercise time, lower maximum workload (and its percent predicted value), and reduced peak VO2 (including its percent predicted value and peak VO2/kg). Additionally, cardiac autonomic function was impaired, as evidenced by decreased heart rate recovery (HRR) and a reduced slope of HR recovery (all p<0.05). Mediation model regression analysis indicated a significant and direct detrimental effect of CKM syndrome on peak VO2 (β = -228.502; P = 0.003), and a significant indirect partial effect of hemoglobin concentration on the direct effect (β = -335.718; P < 0.001), with the percentage mediated through hemoglobin concentration of 46.9%.

Conclusion

Individuals with CKM syndrome demonstrate compromised responses to CPET manifested by diminished exercise capacity and cardiac autonomic function. While diminished peak oxygen uptake can be partly explained by hemoglobin concentration as we found, further research is necessary to understand other underlying mechanisms.

Glucagon-like peptide 1 receptor agonists and renal outcomes in kidney transplant recipients with diabetes mellitus

AIMS

Glucagon-like peptide-1 receptor agonists (GLP1-RAs) show reno-protective effects in type 2 diabetes. Limited data is available on their use in post-transplant diabetes mellitus. We aimed to explore the effect of GLP1-RAs on renal outcomes in diabetic kidney transplant recipients (KTR).

METHODS

We conducted a cohort retrospective study on adult KTR with diabetes mellitus. KTR treated with GLP1-RAs were matched with non-users. The primary outcome was the first occurrence of graft rejection, start of dialysis, re-transplantation or all-cause mortality. Other outcomes included a composite of the first occurrence of a genitourinary infection or all-cause mortality, and all-cause mortality. Metabolic effects of GLP1-RA treatment and risk for biliopancreatic adverse events were also explored.

RESULTS

We included 272 patients (69 % males, average age 58.3 ± 11.0 years) with a 3.1-year median follow-up. The use of GLP1-RAs lowered the incidence of the composite renal outcome after adjustment for independent risk factors (114 versus 68 events per 1000-patient years in controls versus GLP1-RA users, HR 0.489, 95 % CI 0.271-0.883). GLP-RA users had improved glycemic control, lipid profile and a decrease in body mass index. The treatment was safe without increased genitourinary infections or biliopancreatic events.

CONCLUSION

The use of GLP1-RAs decreased the risk of a composite outcome of renal dysfunction and mortality, improved metabolic control and showed safety of use in a large cohort of diabetic KTR, suggesting reno-protective effects in this high-risk population. Prospective data is further needed in KTR who are excluded from large RCTs.

Cumulative Incidence of Mortality Associated with Cardiovascular-Kidney-Metabolic (CKM) Syndrome

Key Points

Background

It is imperative to critically evaluate the prognostic implications of cardiovascular–kidney–metabolic (CKM) syndrome staging to inform clinical practice. The primary aims of this study were to define the risk of mortality associated with each CKM syndrome stage and to determine the corresponding restricted mean survival time over a 15-year period.

Methods

This was a longitudinal study of 50,678 community-dwelling US adults aged 20 years and older with baseline data for CKM stage determination participating in the 1999–2018 National Health and Nutrition Examination Survey. CKM stages were defined according to the American Heart Association presidential advisory. Fifteen-year adjusted cumulative incidences of cardiovascular mortality were calculated for each stage from confounder-adjusted survival curves using the G-formula.

Results

Over a median 9.5-year follow-up, 2564 participants experienced cardiovascular death. The 15-year adjusted cumulative incidences of cardiovascular mortality were stage 0, 5.5% (95% confidence interval [CI], 1.8 to 9.3); stage 1, 5.7% (95% CI, 3.2 to 8.2); stage 2, 7.9% (95% CI, 6.8 to 9.1); stage 3, 8.7% (95% CI, 6.7 to 10.8); and stage 4, 15.2% (95% CI, 13.6 to 16.8). The absolute risk difference between CKM stage 4 and stage 0 at 15 years was 9.6% (95% CI, 5.6 to 13.6). The survival difference between CKM stage 0 and stage 4 at 15 years was 8.1 (95% CI, 8.0 to 8.2) months.

Conclusions

Our findings reveal a graded risk of cardiovascular mortality associated with higher CKM syndrome stage.

Lipid Biomarkers and Cardiometabolic Diseases: Critical Knowledge Gaps and Future Research Directions

The past decade has witnessed transformative changes in our understanding of various lipid or lipid-related biomarkers (Table 1) and their relationships with cardiometabolic diseases [...].

A Hypothesis That Glucagon-like Peptide-1 Receptor Agonists Exert Immediate and Multifaceted Effects by Activating Adenosine Monophosphate-Activate Protein Kinase (AMPK)

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) reduce bodyweight and blood glucose. Extensive evidence from randomized controlled trials has indicated that GLP-1RAs have benefits well beyond weight loss and glucose control, extending from reductions in cardiovascular mortality to reductions in prostate cancer risk. Notably, some benefits of GLP-1RAs for the cardiovascular-kidney-metabolic (CKM) system arise before weight loss occurs for reasons that are not entirely clear but are key to patient care and drug development. Here, we hypothesize that GLP-1RAs act by inducing calorie restriction and by activating adenosine monophosphate-activated protein kinase (AMPK), which not only provides an explanation for the unique effectiveness of GLP-1RAs but also indicates a common mechanism shared by effective CKM therapies, including salicylates, metformin, statins, healthy diet, and physical activity. Whether AMPK activation is obligatory for effective CKM therapies should be considered. As such, we propose a mechanism of action for GLP-1RAs and explain how it provides an overarching framework for identifying means of preventing and treating cardiovascular, kidney, metabolic and related diseases, as well as informing the complementary question as to the components of a healthy lifestyle.

Combination therapy: an upcoming paradigm to improve kidney and cardiovascular outcomes in chronic kidney disease

In this article the authors review recent advances in the treatment of chronic kidney disease (CKD) with diabetes, and summarize evidence supporting combination therapy approaches to improve patient outcomes. Driven by the global rise in diabetes, the worldwide burden of CKD has nearly doubled since the 1990s. People with CKD have notably increased risks for premature cardiovascular disease (heart and blood vessels disease), kidney failure and death. CKD, diabetes, obesity and cardiovascular disease are closely interrelated and share common risk factors. These health conditions therefore comprise what is now known as cardiovascular-kidney-metabolic (CKM) syndrome. Recently approved medications, including sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and the non-steroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone, represent agents capable of reducing metabolic, kidney and cardiovascular risk through complementary mechanisms of action. Current evidence supports use of these therapies in combination. Besides providing additive protective effects, combination therapy may also help reduce side effects. For instance, using an SGLT2 inhibitor in combination with finerenone helps decrease the risk for high potassium levels. Through the multipronged approach, combination therapy allows tailoring treatment for the individual patient characteristics and needs. Several planned and ongoing clinical trials continue to study the benefits of combination therapy in people with CKM syndrome. With building evidence supporting the use of combination therapy, it is crucial to raise awareness of the importance of this treatment approach and develop processes to incorporate new therapies into every day practice to support optimal care and improved outcomes.

ABSTRACT

The global burden of chronic kidney disease (CKD) increased by nearly 90% in the period spanning 1990 to 2016, mostly attributed to an increase in the prevalence of CKD in diabetes. People living with CKD have an elevated lifetime risk for cardiovascular disease (CVD) when compared with the general population, with risk increasing in parallel with albuminuria and kidney function decline. Metabolic disease, CKD and CVD share common risk factors including neurohumoral activation, systemic inflammation and oxidative stress, thus prompting the introduction of a broader construct of cardiovascular-kidney-metabolic (CKM) syndrome. An important rationale for the introduction of this concept are recent and ongoing therapeutic advancements fundamentally changing CKM management. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and the non-steroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone have shifted the therapeutic paradigm for patients with CKD and have emerged in rapid succession as cornerstones of guideline-directed medical therapy (GDMT). Recently completed clinical trials of aldosterone synthase inhibitors and endothelin receptor antagonists have additionally reported additive antiproteinuric effects on the background of renin-angiotensin system and SGLT2 inhibition, with acceptable safety profiles. The sum of current evidence from both preclinical and clinical studies support combination therapy in the setting of CKD to achieve additive and potentially synergistic kidney and heart protection by addressing metabolic, hemodynamic, and pro-inflammatory and pro-fibrotic mechanistic pathways. This narrative review will discuss available evidence supporting combination GDMT in CKD with diabetes and additionally discuss ongoing and future trials evaluating the efficacy and safety of combination therapies for CKD with or without diabetes.

Atherogenic index of plasma and cardiovascular disease risk in cardiovascular-kidney-metabolic syndrome stage 1 to 3: a longitudinal study

Background

Cardiovascular disease (CVD) remains a major contributor to the global disease burden. Previous studies have established a link between the atherogenic index of plasma (AIP) and CVD. However, it remains unclear whether cumulative AIP and AIP control influence the future incidence of CVD in individuals with Cardiovascular-Kidney-Metabolic (CKM) syndrome. This study aims to explore the association between cumulative AIP, AIP control levels, and the risk of CVD in individuals with CKM syndrome from stages 1 to 3.

Methods

Participants with CKM syndrome were drawn from the China Health and Retirement Longitudinal Study (CHARLS). Cumulative AIP was calculated using triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C), while AIP control levels were categorized into four groups via k-means clustering. CVD was defined by self-reported heart disease or stroke. Multivariable logistic regression and restricted cubic spline analysis were employed to examine the association between AIP and incident CVD in individuals with CKM syndrome.

Results

A total of 793 participants (18.84%) developed CVD. After adjusting for confounders, cumulative AIP were associated with the developing CVD (OR=1.139, 95% CI: 1.017-1.275, P=0.0245). Compared to group 1 (best AIP control), the OR (95% CI) for incident CVD were 1.278 (0.959-1.702) for group 2, 1.329 (1.076-1.641) for group 3, and 1.195 (0.974-1.465) for group 4. Restricted cubic spline regression indicated the relationship between cumulative AIP and CVD risk is linear (P for nonlinear = 0.3377).

Conclusions

In middle-aged and elderly individuals with CKM syndrome, higher cumulative AIP and poorer AIP control were associated with an elevated incidence of CVD. These findings suggest that enhanced assessment of the AIP index could inform targeted prevention strategies for CVD in the context of CKM syndrome.

Prevalence, Disparities, and Mortality of Cardiovascular-Kidney-Metabolic Syndrome in US Adults, 2011-2018

BACKGROUND

Cardiovascular-kidney-metabolic syndrome reflects the complex interplay between metabolic risk factors, cardiovascular and chronic kidney disease. Differences in disease burden by demographics, social determinants of health, and mortality are not well characterized.

METHODS

Data from adults who completed the National Health and Nutrition Examination Survey between 2011 and 2018 were used to estimate age-adjusted prevalence and 95% confidence intervals (CI) for cardiovascular-kidney-metabolic syndrome stages. Joinpoint regression was used to identify linear trends. Kaplan-Meier curves were used to examine all-cause mortality risk by stages.

RESULTS

Among 8474 adults in the study, the median age was 46.8 years, 49.1% were male, and 65.0% were non-Hispanic White. Age-adjusted prevalence of stages 0-4 were 11.2%, 28.1%, 47.4%, 5.3%, and 8.1%, respectively. The highest proportion of stage 4 was among adults aged ≥60 years, males, and non-Hispanic Black individuals. The advanced stages 3-4 were associated with lower educational attainment, income, and employment and higher mortality with a crude death rate of 188.8 per 1000 person-years.

CONCLUSION

Approximately 13% of adults were in advanced stages, which disproportionately affect non-Hispanic Black adult and increased over time. These results provide a roadmap for targeted intervention strategies.

From Cardiovascular-Kidney-Metabolic Syndrome to Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Proposing an Expanded Framework

Cardiometabolic diseases represent an escalating global health crisis, slowing or even reversing earlier declines in cardiovascular disease (CVD) mortality. Traditionally, conditions such as obesity, type 2 diabetes mellitus (T2DM), atherosclerotic CVD, heart failure (HF), chronic kidney disease (CKD), and metabolic dysfunction-associated steatotic liver disease (MASLD) were managed in isolation. However, emerging evidence reveals that these disorders share overlapping pathophysiological mechanisms and treatment strategies. In 2023, the American Heart Association proposed the Cardiovascular-Kidney-Metabolic (CKM) syndrome, recognizing the interconnected roles of the heart, kidneys, and metabolic system. Yet, this model omits the liver-a critical organ impacted by metabolic dysfunction. MASLD, which can progress to metabolic dysfunction-associated steatohepatitis (MASH), is closely tied to insulin resistance and obesity, contributing directly to cardiovascular and renal impairment. Notably, MASLD is bidirectionally associated with the development and progression of CKM syndrome. As a result, we introduce an expanded framework-the Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome-to more comprehensively capture the broader inter-organ dynamics. We provide guidance for an integrated diagnostic approach aimed at halting progression to advanced stages and preventing further organ damage. In addition, we highlight advances in medical management that target shared pathophysiological pathways, offering benefits across multiple organ systems. Viewing these conditions as an integrated whole, rather than as discrete entities, and incorporating the liver into this framework fosters a more holistic management strategy and offers a promising path to addressing the cardiometabolic pandemic.

KDOQI US Commentary on the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD

The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2024 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of chronic kidney disease (CKD). The KDOQI Work Group reviewed the KDIGO guideline statements and practice points and provided perspective for implementation within the context of clinical practice in the United States. In general, the KDOQI Work Group concurs with several recommendations and practice points proposed by the KDIGO guidelines regarding CKD evaluation, risk assessment, and management options (both lifestyle and medications) for slowing CKD progression, addressing CKD-related complications, and improving cardiovascular outcomes. The KDOQI Work Group acknowledges the growing evidence base to support the use of several novel agents such as sodium/glucose cotransporter 2 inhibitors for several CKD etiologies, and glucagon-like peptide 1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists for type 2 CKD in setting of diabetes. Further, KDIGO guidelines emphasize the importance of team-based care which was also recognized by the work group as a key factor to address the growing CKD burden. In this commentary, the Work Group has also assessed and discussed various barriers and potential opportunities for implementing the recommendations put forth in the 2024 KDIGO guidelines while the scientific community continues to focus on enhancing early identification of CKD and discovering newer therapies for managing kidney disease.

Inverse Relationship Between Serum Carotenoid Levels and Cardiovascular-Kidney-Metabolic Syndrome Among the General Adult Population

OBJECTIVE

To examine the relationship between serum carotenoid levels and cardiovascular-kidney-metabolic (CKM) syndrome in a representative sample of US adults.

METHODS

Data from the fasting subsample of the NHANES 2017-2018 were analyzed using a survey-weighted approach to ensure the findings are representative of the broader US adult population. Serum levels of α-carotene, β-carotene, β-cryptoxanthin, lutein/zeaxanthin, and lycopene were measured using high-performance liquid chromatography. CKM syndrome stages were defined according to the 2023 American Heart Association guidelines, with advanced CKM syndrome categorized as stages 3 or 4. Associations between serum carotenoids and advanced CKM syndrome were assessed using logistic regression and weighted quantile sum (WQS) regression.

RESULTS

The study included 1671 adults aged 20 years and older, with a mean age of 48.7 years and a gender distribution of 50.9% female and 49.1% male. Higher serum levels of α-carotene, β-carotene, α-cryptoxanthin, lutein/zeaxanthin, and lycopene were inversely associated with advanced CKM syndrome. Specifically, compared to the lowest quartile, the highest quartile of α-carotene had an odds ratio (OR) of 0.29 (95% CI: 0.16-0.55), β-carotene 0.35 (95% CI: 0.16-0.78), α-cryptoxanthin 0.23 (95% CI: 0.11-0.49), lutein/zeaxanthin 0.26 (95% CI: 0.14-0.48), and lycopene 0.58 (95% CI: 0.35-0.98). However, β-cryptoxanthin did not show a significant association. Moreover, the combined effect of all carotenoids was significantly negatively correlated with advanced CKM syndrome (OR = 0.67, 95% CI: 0.53-0.86), with lutein/zeaxanthin contributing the most (44.56%).

CONCLUSIONS

Elevated serum carotenoid levels are inversely associated with the prevalence of advanced CKM syndrome in a dose-dependent manner, with this association remaining consistent across diverse demographic and health subgroups.

Associations of MAFLD subtypes and air pollutants with multi-system morbidity and all-cause mortality: A prospective cohort study

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) and air pollution are both significant health concerns. However, their combined effects on multi-system morbidity and all-cause mortality remain poorly understood.

METHODS

We analyzed data from 434,417 UK Biobank participants, categorizing them into four groups: non-MAFLD, MAFLD-diabetes, MAFLD-lean, and MAFLD-overweight/obesity. To evaluate the long-term effects of air pollution exposure, we used time-varying Cox proportional hazard models to assess four air pollutants: particulate matter with an aerodynamic diameter < 2.5 μm (PM2.5), PM10, nitrogen dioxide (NO2), and nitrogen oxides (NOx). We examined the associations between these air pollutants, MAFLD subtypes, and their joint impact on multi-system morbidity and all-cause mortality. Furthermore, we explored the additive and multiplicative interactions between air pollutants and MAFLD subtypes.

RESULTS

At baseline, 15,325 participants were classified as MAFLD-diabetes, 3341 as MAFLD-lean, and 140,934 as MAFLD-overweight/obesity. Among these groups, MAFLD-diabetes was most strongly associated with adverse outcomes compared to other subtypes. Air pollution exposure had a synergistic effect on cirrhosis risk across all MAFLD subtypes, with the most pronounced effects observed for PM2.5 [relative excess risk due to interaction (RERI): 2.10 (0.94, 3.26)] and NO2 [RERI:1.85 (0.67, 3.04)] in MAFLD-lean group. Positive additive and multiplicative interactions between air pollutants and MAFLD subtypes were also observed for coronary artery disease (CAD), with the exception of nitrogen oxide in the MAFLD-lean group. Additionally, only the MAFLD-diabetes demonstrated significant positive additive interactions with all four air pollutants in relation to chronic kidney disease (CKD).

CONCLUSIONS

This study highlights the distinct impacts of MAFLD subtypes on multi-system morbidity and all-cause mortality, underscoring the critical need for targeted prevention and treatment strategies, particularly for individuals with MAFLD-diabetes. Our findings reveal significant additive and synergistic effects of air pollution exposure on the risks of cirrhosis, CAD, and CKD among MAFLD patients.

A minimally invasive swine model of chronic kidney disease-associated heart failure

Chronic kidney disease (CKD) is on the rise, and over 50% of patients die from cardiac causes. Patients develop heart failure due to unelucidated reno-cardiac interactions, termed type 4 cardiorenal syndrome (CRS4). The aim of this study is to establish and characterize a reliable model of CRS4 in swine with marked cardiac diastolic dysfunction. Yorkshire pigs (19.9 ± 1.7 kg, 4 females and 5 males) underwent staged renal artery embolization using autologous clot. Echocardiogram, aortic pressure (AoP), renal angiogram, and blood samples were assessed monthly. At 4 mo, animals were euthanized after measuring glomerular filtration rate (GFR) and left ventricular (LV) pressure-volume parameters. Heart and kidneys were collected for postmortem analyses. Size-matched swine (n = 5; 43.7 ± 9.8 kg) served as controls. After three dose-titrated renal embolization, serum creatinine (SCr) and AoP increased by wk 10. At 4 mo, SCr (2.03 ± 0.45 vs. 1.34 ± 0.17 mg/dL, P = 0.013) and AoP (158 ± 16 vs. 121 ± 8 mmHg, P = 0.001) were higher, and GFR was lower (12 ± 3 vs. 131 ± 7 mL/min, P < 0.001) than size-matched controls. Although the LV ejection fraction was similar, the slope of the end-diastolic pressure-volume relationship was steeper in pigs after renal embolization (0.36 ± 0.09 vs. 0.17 ± 0.06, P = 0.003), indicating increased LV stiffness. LV mass index (2.73 ± 0.19 vs. 2.50 ± 0.13 g/kg, P = 0.043) and wall-thickness (11.4 ± 0.8 vs. 8.9 ± 1.2 mm, P = 0.003) increased. These were accompanied by histologically increased fibrosis, cardiomyocyte hypertrophy, and vascular rarefaction. Repeat titrated renal embolization resulted in a model that exhibits advanced CKD and cardiac abnormalities consistent with CRS4.NEW & NOTEWORTHY Cardiac pathological changes consistent with heart failure with preserved ejection fraction can be induced in a large animal model by serial and titrated renal embolization of kidneys with autologous clot, leading to severe renal dysfunction and impaired cardiac diastolic function.

Prevalence of chronic kidney disease among Chinese adults with diabetes: a nationwide population-based cross-sectional study

Background

To date, comprehensive data on the distribution of chronic kidney disease (CKD), the most prevalent comorbidity in diabetes, among Chinese adults with diabetes is lacking. Additionally, research gaps exist in understanding the association between CKD and cardiovascular health (CVH), an integrated indicator of lifestyle and metabolic control, within a nationwide sample of Chinese adults with diabetes.

Methods

A nationally community-based cross-sectional survey was conducted in 2018-2020. 58,560 residents diagnosed with diabetes aged 18-74 years nationwide were invited to participate, and 52,000 participants with complete CKD data were included in this study. CKD was identified by the presence of albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) and/or decreased estimated glomerular filtration rate (eGFR, <60 mL/min/1.73 m2). The latter was calculated using the CKD-EPI equation incorporating serum cystatin C and creatinine. CVH was evaluated using the "life's essential 8" (LE8) score, which ranged from 0 to 100 and included 8 components: diet, sleep duration, physical activity, nicotine exposure, hemoglobin A1c, blood pressure, non-high-density lipoprotein cholesterol, and body mass index. The total LE8 scores were categorized into low (0-49), middle (50-79), and high (80-100) according to the American Heart Association. The associations of albuminuria and decreased eGFR with potential associated factors, including CVH, socioeconomic status, clinical characteristics, sub-regional divisions, comorbidities, treatments, and metabolic controls, were evaluated using survey logistic regression.

Findings

The weighted prevalence rates (95% CI) of CKD, albuminuria, and decreased eGFR were 32.6% (31.3%-33.8%), 30.8% (29.6%-32.1%), and 5.5% (5.1%-5.9%), respectively. Among those with CKD, 25.7% had diabetic retinopathy (DR) and 22.3% had cardiovascular disease (CVD). The weighted prevalence rates of albuminuria and decreased eGFR were consistently higher among southern residents, rural residents, and individuals with more severe DR and a history of CVD than their counterparts (all p < 0.05). After adjustment for age, sex, sub-regional division, setting, educational level, annual household income, family history of diabetes, diabetes duration, glucose-lowering treatment, any DR, CVD, and drinking status, the logistic models showed that the odds ratios (ORs) (95% CI) for albuminuria and decreased eGFR were 0.46 (0.42-0.51) and 0.61 (0.55-0.67) for the participants with moderate scores, and 0.14 (0.10-0.21) and 0.28 (0.19-0.41) for those with high scores, compared with those with low total LE8 scores. Furthermore, the restricted cubic spline curves depicted that the disparities in the odds of having albuminuria or decreased eGFR among subpopulations grouped by sex, age, setting, and geographical region, significantly decreased and even disappeared in some cases as the LE8 scores increased.

Interpretation

Chinese adults with diabetes are heavily burdened by CKD. Optimized CVH is central to reducing CKD risk across different subpopulations.

Funding

National Key Clinical Specialty, the Chinese Academy of Engineering.

Use of glomerular filtration rate to estimate perioperative cardiac risk

Preoperative estimated glomerular filtration rate is an inexpensive but useful tool in predicting cardiovascular perioperative complications. Estimated glomerular filtration rate, especially considering its interaction with age, might act as a proxy for severity of cardiovascular disease. Further studies regarding the predictive power of estimated glomerular filtration rate to identify patients at risk of perioperative cardiovascular complications are essential.

Overview of diabetes agents in cardiovascular disease: it takes an orchestra to play Tchaikovsky in symphony

PURPOSE OF REVIEW

The aim of this review was to discuss the use and concerns of diabetes agents, clinical targets, and key aspects to be considered in the management of patients with type 2 diabetes mellitus (T2DM), and at high risk or established cardiovascular disease (CVD).

RECENT FINDINGS

The recent European and American guidelines recommended SGLT2 inhibitors and GLP-1 receptor agonists as the preferred first-line diabetes agents in patients with T2DM and CVD. This is a paradigm shift from using metformin as first-line therapy. Amid their widespread use, however, there are also concerns about their side effects. With the rapidly growing diabetes regimens available, questions arise about how best to approach the management of patients with T2DM and CVD.

SUMMARY

To reduce CVD morbidity and mortality in patients with T2DM and at high or very high risk for CVD, the two key diabetes agents SGLT2i and/or GLP1-based therapies should be offered. Although lacking cardiovascular benefit, other diabetes agents remain necessary for many patients with T2DM for their glucocentric effects; Metformin and pioglitazone are useful in severe insulin resistance, while insulin therapy is often necessary in advanced diabetes; GLP1-RA is cautioned in patients with active gastrointestinal and mental health conditions, while DPP4 inhibitor is likely a well tolerated option in a challenging psychosocial setting. Other important aspects that should be considered include obesity, chronic kidney disease, women's cardiovascular health, and psychosocial factors.

Sudden cardiac death associated with fatty liver disease

BACKGROUND

Fatty liver disease or steatotic liver disease (SLD) affects 25% of the global population and has been associated with heart disease. However, there is a lack of postmortem studies in the context of sudden cardiac death (SCD).

OBJECTIVES

To investigate the relationship between SLD and SCD.

METHODS

A post-mortem case-case study was conducted in victims of SCD from an ongoing community-based study in Southern California (Ventura, CA, 2015-2023). Diagnosis of SLD was determined from post-mortem liver histopathology reports. For each patient, demographic variables, laboratory values, and presence of co-morbidities were ascertained from medical records and were compared between patients with and without SLD.

RESULTS

Of 162 individuals with SCD, there were 101 SLD cases and 61 without SLD. Individuals with SLD were found to have higher BMI (31.6 ± 7.6 vs. 26.7 ± 5.7, p < 0.001), higher prevalence of heavy drinking (28 % vs. 12 %, p = 0.008), heavier liver weights (2433.6 g ± 940.6 vs 1934.7 g ± 505.3, p < 0.001), and were more often Hispanic (37 vs. 18 %, p = 0.01). Patients with SLD had lower prevalence of coronary artery disease (CAD) (49 % vs. 70 %). Multivariable logistic regression analysis showed that CAD was a negative predictor of SCD with SLD (OR = 0.35, 95 % CI 0.14 - 0.83).

CONCLUSION

Among adults with SCD, SLD was associated with higher prevalence of Hispanic ethnicity and lower prevalence of CAD. Given the major rise in SLD burden, these ethnicity-based differences as well as the specific nature of non-ischemic SCD etiologies warrant urgent further investigation.

The cellular and molecular mechanisms mediating the protective effects of sodium-glucose linked transporter 2 inhibitors against metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly known as nonalcoholic fatty liver disease (NAFLD), is a common, highly heterogeneous condition that affects about a quarter of the world's population, with no approved drug therapy. Current evidence from preclinical research and a number of small clinical trials indicates that SGLT2 inhibitors could also be effective for MAFLD. MAFLD is associated with a higher risk of chronic liver disease and multiple extrahepatic events, especially cardiovascular disease (CVD) and chronic kidney disease (CKD). MAFLD is considered a more appropriate terminology than NAFLD because it captures the complex bidirectional interplay between fatty liver and metabolic dysfunctions associated with disease progression, such as obesity and type 2 diabetes mellitus (T2DM). SGLT2 inhibitors are antidiabetic drugs that block glucose reabsorption in the kidney proximal tubule. In this article, we reviewed current clinical evidence supporting the potential use of SGLT2 inhibitors as a drug therapy for MAFLD and discussed the possible cellular and molecular mechanisms involved. We also reviewed the clinical benefits of SGLT2 inhibitors against MAFLD-related comorbidities, especially CVD, CKD and cardiovascular-kidney-metabolic syndrome (CKM). The broad beneficial effects of SGLT2 inhibitors support their use, likely in combination with other drugs, as a therapy for MAFLD.

Metabolic dysfunction-associated steatotic liver disease: heterogeneous pathomechanisms and effectiveness of metabolism-based treatment

The global epidemic of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide. People with MASLD can progress to cirrhosis and hepatocellular carcinoma and are at increased risk of developing type 2 diabetes, cardiovascular disease, chronic kidney disease, and extrahepatic cancers. Most people with MASLD die from cardiac-related causes. This outcome is attributed to the shared pathogenesis of MASLD and cardiometabolic diseases, involving unhealthy dietary habits, dysfunctional adipose tissue, insulin resistance, and subclinical inflammation. In addition, the steatotic and inflamed liver affects the vasculature and heart via increased glucose production and release of procoagulant factors, dyslipidaemia, and dysregulated release of hepatokines and microRNAs. However, there is substantial heterogeneity in the contributors to the pathophysiology of MASLD, which might influence its rate of progression, its relationship with cardiometabolic diseases, and the response to therapy. The most effective non-pharmacological treatment approaches for people with MASLD include weight loss. Paradoxically, some effective pharmacological approaches to improve liver health in people with MASLD are associated with no change in bodyweight or even with weight gain, and similar response heterogeneity has been observed for changes in cardiometabolic risk factors. In this Review, we address the heterogeneity of MASLD with respect to its pathogenesis, outcomes, and metabolism-based treatment responses. Although there is currently insufficient evidence for the implementation of precision medicine for risk prediction, prevention, and treatment of MASLD, we discuss whether knowledge about this heterogeneity might help achieving this goal in the future.

Association of Liver Fibrosis Markers with Mortality Outcomes in Patients with Chronic Kidney Disease and Coronary Artery Disease: Insights from the NHANES 1999-2018 Data

INTRODUCTION

The objective of this research was to explore the possible link between markers of liver fibrosis and survival rates in a group of adults who have been diagnosed with both chronic kidney disease (CKD) and coronary artery disease (CAD).

METHODS

The National Health and Nutrition Examination Survey (NHANES) data (1999-2018) for participants with both CAD and CKD were analyzed. The fibrosis-4 index (FIB-4), Nonalcoholic Fatty Liver Score (NFS), Forns index, and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio were identified as crucial biomarkers. All-cause and cardiovascular disease (CVD) mortality were primary outcomes, assessed using Cox models, Kaplan-Meier curves, and receiver operating characteristic (ROC) analysis.

RESULTS

A total of 1,192 CKD and CAD patients were included. The Cox regression analysis revealed substantial correlations between elevated FIB-4, NFS, Forns index, and AST/ALT levels and a heightened risk of all-cause (hazard ratio [HR]: 1.188, 95% confidence interval [CI]: 1.108-1.274; HR: 1.145, 95% CI: 1.069-1.227; HR: 1.142, 95% CI: 1.081-1.201; HR: 1.316, 95% CI: 1.056-1.639, respectively) and CVD mortality (HR: 1.133, 95% CI: 1.007-1.275; HR: 1.155, 95% CI: 1.024-1.303; HR: 1.208, 95% CI: 1.109-1.316 and HR: 1.636, 95% CI: 1.203-2.224, respectively). The ROC analysis indicated comparable predictive accuracy for all three biomarkers, with AST/ALT showing slightly superior performance.

CONCLUSION

Liver fibrosis markers, including AST/ALT, NFS, Forns index and FIB-4, are significant mortality predictors in CAD-CKD patients. The AST/ALT ratio, being easily measurable, may serve as an effective predictive tool for risk stratification in this population.

Association between atherogenic index of plasma and future risk of cardiovascular disease in individuals with cardiovascular-kidney-metabolic syndrome stages 0-3: a nationwide prospective cohort study

BACKGROUND

As an emerging concept, Cardiovascular-kidney-metabolic syndrome (CKM) elucidates the intricate interconnection between metabolic disorders(Mets), cardiovascular disease(CVD), and chronic kidney disease(CKD). Within this context, while numerous studies have demonstrated a correlation between the Atherogenic Index of Plasma (AIP) and CVD, the precise relationship between long-term fluctuations in the AIP and the incidence of CVD in patients with CKM syndrome remains unclear.

METHOD

The CKM stages 0-3 population was obtained from the China Health and Retirement Longitudinal Study (CHARLS). The outcome CVD was defined as self-reported heart disease and/or stroke. AIP control level was classified using k-mean cluster analysis. Logistic regression was used to analyse the effect of cumulative AIP (cumAIP) on the incidence of CVD. Restricted cubic spline models (RCS) were used to explore the potential non-linear relationship between cumulative AIP and CVD risk at different CKM syndrome stages.

RESULTS

Of the 3429 CKM stages 0-3 participants, 620 patients developed CVD during the 3-year follow-up period. After adjusting for various confounders, the odds ratio (OR) for the well-controlled class 2 compared with the best AIP control class 1 were 1.37 (1.04, 1.81), the OR for the moderately-controlled class 3 were 1.54 (95% CI, 1.04-2.26), the poorly-controlled class 4 were 1.65 (95% CI, 1.13-2.41), and the worst-controlled class 5 were 2.14 (95% CI, 1.15-3.97). In restricted cubic spline regression analyses, changes in AIP were linearly associated with the occurrence of CVD events. Further weighted quartiles and regression analyses indicated that triglyceride(TG) was a key variable for AIP in predicting CVD events in the CKM stages 0-3 population.

CONCLUSIONS

Poor control level of AIP are associated with an increased risk of CVD events in the population of CKM stages 0-3. Long-term dynamic monitoring of changes in AIP may help in the early identification of patients at high risk of developing CVD in the individuals with CKM stages 0-3.

Cohort profile: the prospective cohort study on the incidence of metabolic diseases and risk factors in Shunde, China (Speed-Shunde cohort)

AIMS

The objective of this prospective cohort study on the incidence of metabolic diseases and risk factors in Shunde (Speed-Shunde cohort) was to evaluate the incidence of cardiovascular-kidney-metabolic (CKM) syndrome and metabolic-associated multimorbidity, such as diabetes, hypertension, dyslipidaemia, and metabolic dysfunction-associated steatotic liver disease in Shunde, Foshan, Guangdong, China. Additionally, the study sought to identify the potential determinants that may impact the development of these conditions and the potential consequences that may result.

METHODS AND RESULTS

In the Speed-Shunde cohort, data were gathered via questionnaires, physical measurements, and laboratory analyses encompassing demographic data, behavioural tendencies, anthropometric assessments, controlled attenuation parameters, and liver stiffness measurement utilizing vibration-controlled transient elastography, as well as serum and urine detection (such as oral 75 g glucose tolerance tests, haemoglobin A1c levels, lipid profiles, liver and renal function tests, urinary microalbumin, and creatinine levels). The baseline data were gathered from October 2021 to September 2022 from over 10 000 Chinese community-based adults and the follow-up surveys would be conducted every 2 or 3 years. Blood and urine samples were obtained and stored for future omics data acquisition. Initial analyses revealed the prevalence and risk factors associated with metabolic-associated multimorbidity.

CONCLUSIONS

The Speed-Shunde cohort study is a longitudinal community-based cohort with comprehensive CKM health and metabolic-associated multimorbidity assessment. It will provide valuable insights into these conditions' development, progression, and interrelationships, potentially informing future prevention and treatment strategies.

Difference between estimated glomerular filtration rate based on cystatin C versus creatinine and cardiovascular-kidney-metabolic health

Background

The difference between the estimated glomerular filtration rate (eGFR) calculated from cystatin C and creatinine (eGFRdiff) serves as a biomarker of kidney function impairment. However, the role of eGFRdiff in cardiovascular-kidney-metabolic (CKM) health and its impact on mortality in CKM syndrome patients has not yet been studied.

Methods

This study included 3,622 participants from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2004. Weighted ordinal logistic regression was used to explore the link between eGFRdiff and CKM health, while weighted Cox regression was used to examine the relationship between eGFRdiff and mortality in CKM syndrome patients. Restricted cubic splines (RCSs) were used to analyze the dose-response relationship.

Results

The common odds ratio (cOR) per 10 mL/min/1.73m2 increase in eGFRdiff was 0.86 [95% confidence interval (CI), 0.81 to 0.91]. Compared to the midrange eGFRdiff, the cOR values for the negative and positive eGFRdiff were 1.88 [95% CI, 1.23 to 2.88] and 0.69 [95% CI, 0.58 to 0.83], respectively. During a median follow-up of 201 months, 853 participants died from all causes, while 265 died due to cardiovascular causes. The hazard ratios (HRs) per 10 mL/min/1.73m2 increase in eGFRdiff were 0.88 [95% CI, 0.83 to 0.93] for all-cause mortality and 0.90 [95% CI, 0.81 to 1.00] for cardiovascular mortality cases. Compared to the participants with a midrange eGFRdiff, those with negative eGFRdiff had a 48% higher risk of all-cause mortality, while those with positive eGFRdiff had a 30% lower risk. No significant non-linear associations were found in these regression analyses.

Conclusion

Our study found that eGFRdiff is associated with CKM health and stratified mortality risk in CKM syndrome patients.

Golgi protein 73: charting new territories in diagnosing significant fibrosis in MASLD: a prospective cross-sectional study

Objectives

To explore the correlation between serum Golgi protein 73 (GP73) levels and the degree of fibrosis in Metabolic dysfunction associated steatotic liver disease (MASLD); to establish a non-invasive diagnostic algorithm based on serum GP73 and liver elasticity.

Methods

This is a prospective cross-sectional study, including 228 patients diagnosed with MASLD from May 2018 to January 2024 at two tertiary hospitals. Clinical data and hepatic pathological features and the correlation between serum GP73 and liver fibrosis were assessed. A new algorithm was conducted after logistic regression. Receiver Operating Characteristic (ROC) curve was used to compare its diagnostic performance with traditional models.

Results

Significant fibrosis was diagnosed in 37.2% (85/228) patients. Serum GP73 levels were markedly higher in patients with significant fibrosis than in those without (128 ng/mL v.s 46 ng/mL, p< 0.001). Serum GP73 levels independently predicted significant liver fibrosis (adjusted odds ratio, aOR 1.028, p< 0.001). A new algorithm based on GP73 was developed with a higher area under ROC (AUC) of 0.840 than that of Fibrosis index-4 (p< 0.001).

Conclusions

Serum GP73 is an independent risk factor for significant liver fibrosis in MASLD, and the GFA (GP73-Fibroscan-Age) model has good diagnostic efficacy for significant liver fibrosis.

Integrated Management of Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Expanding Roles of SGLT2is, GLP-1RAs, and GIP/GLP-1RAs

Cardiovascular-Kidney-Metabolic syndrome, introduced by the American Heart Association in 2023, represents a complex and interconnected spectrum of diseases driven by shared pathophysiological mechanisms. However, this framework notably excludes the liver-an organ fundamental to metabolic regulation. Building on this concept, Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome incorporates the liver's pivotal role in this interconnected disease spectrum, particularly through its involvement via metabolic dysfunction-associated steatotic liver disease (MASLD). Despite the increasing prevalence of CRHM syndrome, unified management strategies remain insufficiently explored. This review addresses the following critical question: How can novel anti-diabetic agents, including sodium-glucose cotransporter-2 inhibitors (SGLT2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dual gastric inhibitory polypeptide (GIP)/GLP-1RA, offer an integrated approach to managing CRHM syndrome beyond the boundaries of traditional specialties? By synthesizing evidence from landmark clinical trials, we highlight the paradigm-shifting potential of these therapies. SGLT2is, such as dapagliflozin and empagliflozin, have emerged as cornerstone guideline-directed treatments for heart failure (HF) and chronic kidney disease (CKD), providing benefits that extend beyond glycemic control and are independent of diabetes status. GLP-1RAs, e.g., semaglutide, have transformed obesity management by enabling weight reductions exceeding 15% and improving outcomes in atherosclerotic cardiovascular disease (ASCVD), diabetic CKD, HF, and MASLD. Additionally, tirzepatide, a dual GIP/GLP-1RA, enables unprecedented weight loss (>20%), reduces diabetes risk by over 90%, and improves outcomes in HF with preserved ejection fraction (HFpEF), MASLD, and obstructive sleep apnea. By moving beyond the traditional organ-specific approach, we propose a unified framework that integrates these agents into holistic management strategies for CRHM syndrome. This paradigm shift moves away from fragmented, organ-centric management toward a more unified approach, fostering collaboration across specialties and marking progress in precision cardiometabolic medicine.

Joint association of the inflammatory marker and cardiovascular-kidney-metabolic syndrome stages with all-cause and cardiovascular disease mortality: a national prospective study

BACKGROUND

Cardiovascular-kidney-metabolic (CKM) syndrome and systemic inflammation significantly contribute to mortality. However, the joint associations of CKM stages and systemic inflammation with all-cause and cardiovascular disease (CVD) mortality remain unclear. This study aimed to evaluate the independent and joint associations of CKM stages and systemic inflammation with all-cause and CVD mortality in a representative cohort of United States adults.

METHODS

We analyzed data from 29,459 adults aged ≥ 20 years from the National Health and Nutrition Examination Survey (1999-2018). CKM stages were classified based on metabolic risk factors, CVD, and chronic kidney disease. Systemic inflammation was assessed using multiple indicators, and time-dependent ROC analysis identified the systemic inflammatory response index (SIRI) as the most effective inflammatory marker. The associations of CKM stages and SIRI with mortality were evaluated.

RESULTS

Over a median follow-up of 109 months, 5,583 all-cause deaths and 1,843 CVD-specific deaths occurred. Both advanced CKM stages and elevated SIRI were associated with higher risks of all-cause and CVD mortality. Individuals with advanced CKM stages (Stages 3-4) and elevated SIRI (> 0.81) had the highest risks of all-cause (HR: 1.84, 95% CI: 1.65-2.05) and CVD mortality (HR: 2.50, 95% CI: 2.00-3.12). These associations were particularly pronounced in adults aged < 60 years (P for interaction < 0.001).

CONCLUSIONS

Advanced CKM stages and elevated SIRI are associated with increased risks of all-cause and CVD mortality, particularly in younger adults. These findings highlight the significance of targeted interventions to address systemic inflammation and CKM progression, potentially improving long-term outcomes in high-risk populations.

Atherosclerosis and the Bidirectional Relationship Between Cancer and Cardiovascular Disease: From Bench to Bedside, Part 2 Management

The first part of this review highlighted the evolving landscape of atherosclerosis, noting emerging cardiometabolic risk factors, the growing impact of exposomes, and social determinants of health. The prominent role of atherosclerosis in the bidirectional relationship between cardiovascular disease and cancer was also discussed. In this second part, we examine the complex interplay between multimorbid cardio-oncologic patients, cardiometabolic risk factors, and the harmful environments that lend a "syndemic" nature to these chronic diseases. We summarize management strategies targeting disordered cardiometabolic factors to mitigate cardiovascular disease and explore molecular mechanisms enabling more tailored therapies. Importantly, we emphasize the early interception of atherosclerosis through multifactorial interventions that detect subclinical signs (via biomarkers and imaging) to treat modifiable risk factors and prevent clinical events. A concerted preventive effort-referred to by some as a "preventome"-is essential to reduce the burden of atherosclerosis-driven chronic diseases, shifting from mere chronic disease management to the proactive promotion of "chronic health".

Effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes: a meta-analysis of randomised controlled trials

BACKGROUND

GLP-1 receptor agonists reduce the risk of major adverse cardiovascular events (MACE) and can also have kidney benefits. However, whether GLP-1 receptor agonists improve clinically important kidney outcomes remains uncertain. We aimed to comprehensively assess the effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes by performing a meta-analysis of randomised controlled trials.

METHODS

For this meta-analysis, we searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for randomised controlled trials that included at least 500 participants with type 2 diabetes, compared a GLP-1 receptor agonist with placebo with at least 12 months of follow-up, and reported a primary clinical kidney or cardiovascular outcome, from database inception to March 26, 2024. Post hoc, we included the SELECT trial (NCT03574597), which enrolled participants with cardiovascular disease and a BMI of 27 kg/m2 or more without diabetes. Study-level summary data were extracted independently by two authors for inclusion in this random-effects analysis. The main kidney outcome was a composite outcome, consisting of kidney failure (kidney replacement therapy or a persistent estimated glomerular filtration rate [eGFR] <15 mL/min per 1·73 m2), a sustained reduction in eGFR by at least 50% or the nearest equivalent, or death from kidney failure. The main cardiovascular outcome was MACE, consisting of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke. This study is registered with PROSPERO, CRD42024528864.

FINDINGS

Of the 5140 records identified through the literature search, 11 trials, involving 85 373 participants (29 386 female, 55 987 male), were included in the meta-analysis. In participants with type 2 diabetes (67 769), GLP-1 receptor agonists reduced the composite kidney outcome by 18% compared with placebo (hazard ratio [HR] 0·82, 95% CI 0·73-0·93; I2 =26·41%), kidney failure by 16% (HR 0·84, 0·72-0·99; I2 =0%), MACE by 13% (HR 0·87, 0·81-0·93; I2 =49·75%), and all-cause death by 12% (HR 0·88, 0·83-0·93; I2 =0%). The effect on the composite kidney outcome (HR 0·81, 95% CI 0·72-0·92; I2 =23·11%), kidney failure (HR 0·84, 0·72-0·98; I2 =0%), MACE (HR 0·86, 0·80-0·92; I2 =48·9%), and all-cause death (HR 0·87, 0·82-0·91; I2 =0%) was similar when the SELECT trial was included, with no evidence of heterogeneity between this trial and those including participants with type 2 diabetes (pheterogeneity >0·05). There was no difference in the risk of serious adverse events, including acute pancreatitis and severe hypoglycaemia, between the GLP-1 receptor agonist and placebo groups (risk ratio [RR] 0·95, 95% CI 0·90-1·01; I2 =88·5%). However, treatment discontinuation due to adverse events occurred more frequently in the GLP-1 receptor agonist groups (RR 1·51, 95% CI 1·18-1·94; I2 =96·3%).

INTERPRETATION

We found evidence that GLP-1 receptor agonists significantly reduce clinically important kidney events, kidney failure, and cardiovascular events.

FUNDING

None.

Impaired Incretin Homeostasis in Nondiabetic Moderate-to-Severe CKD

Key Points

Total incretin levels and incretin response during oral glucose tolerance testing were significantly higher among patients with moderate-to-severe nondiabetic patients with CKD compared with healthy people. Unlike in healthy individuals, increased incretin response was not correlated with insulin response and coincided with persistently greater glucagon levels to oral glucose tolerance testing in CKD. Disruption in the incretin system and glucagon dynamics may contribute to metabolic complications in moderate-to-severe CKD.

Background

Incretins are regulators of insulin secretion and glucose homeostasis metabolized by dipeptidyl peptidase-4 (DPP-4). CKD may modify incretin release, metabolism, or response.

Methods

We performed 2-hour oral glucose tolerance testing in 59 people with nondiabetic CKD (eGFR <60 ml/min per 1.73 m2) and 39 matched controls. We measured total area under the curve and incremental area under the curve (iAUC) of plasma total glucagon-like peptide-1 (GLP-1) and total glucose-dependent insulinotropic polypeptide (GIP). Fasting DPP-4 levels and activity were measured. Linear regression was used to adjust for demographic, body composition, and lifestyle factors.

Results

Mean (SD) eGFR was 38±13 and 89±17 ml/min per 1.73 m2 in patients with CKD and controls, respectively. GLP-1 total area under the curve and GIP iAUC were higher in patients with CKD than controls with a mean of 1531±1452 versus 1364±1484 pM×min and 62,370±33,453 versus 42,365±25,061 pg×min/ml, respectively. After adjustment, CKD was associated with 15,271 pM×min/ml greater GIP iAUC (95% confidence intervals [CIs], 387 to 30,154) compared with controls. Adjustment for covariates attenuated associations of CKD with higher GLP-1 iAUC (adjusted difference, 122; 95% CI, −619 to 864). Plasma glucagon levels were higher at 30 minutes (mean difference, 1.6; 95% CI, 0.3 to 2.8 mg/dl) and 120 minutes (mean difference, 0.84; 95% CI, 0.2 to 1.5 mg/dl) in patients with CKD compared with controls. There were no differences in insulin levels or plasma DPP-4 activity or levels between groups.

Conclusions

Overall, incretin response to oral glucose is preserved or augmented in moderate-to-severe CKD, without apparent differences in circulating DPP-4 concentration or activity. However, neither insulin secretion nor glucagon suppression is enhanced.

Sex Differences in Cardiovascular-Kidney-Metabolic Syndrome: 30-Year US Trends and Mortality Risks-Brief Report

BACKGROUND

The American Heart Association recently published guidelines on how to clinically identify and categorize individuals with cardiovascular-kidney-metabolic (CKM) syndrome. The extent to which CKM syndrome prevalence and prognosis differ by sex remains unknown. This study aimed to examine the impact of sex on trends in prevalence over 30 years and the long-term prognosis of CKM syndrome in the United States.

METHODS

We analyzed nationally representative National Health and Nutrition Examination Survey 1988 to 2018 data collected from 33 868 US adults (aged ≥20 years) who were under surveillance for all-cause mortality through December 31, 2019. We examined the sex-specific prevalence of CKM syndrome and sex-specific CKM associations with all-cause mortality.

RESULTS

Of the 33 868 adults studied, the mean±SD age was 48.4±18.3 years with 52% women and 56% non-White. Overall prevalence of CKM syndrome increased steadily from 1988 to 2018 in both sexes, with a larger temporal rise in prevalent stage 3 CKM seen for men (from 18.9% to 22.4%) compared with women (from 13.9% to 15.2%). Over a median follow-up of 13.3 years, there were 8745 deaths. In the multivariable Cox regression analysis, worsening CKM severity was associated with all-cause mortality (P<0.001 for both sexes), with greater magnitudes of risk seen in women (hazards ratio, 1.24-3.33) compared with men (hazards ratio, 0.85-2.60) across all stages (likelihood ratio test χ2, 19.0; Pinteraction<0.001); results were similar for cardiovascular mortality (likelihood ratio test χ2, 22.3; Pinteraction<0.001).

CONCLUSIONS

Women, compared with men, exhibited a lower prevalence of CKM stage 3 but experienced excess mortality risk across the spectrum of multisystem CKM dysfunction. These findings underscore the importance of identifying mechanisms underlying joint cardiovascular, kidney, and metabolic system pathophysiology to close a potentially widening sex disparities gap in multiorgan disease risk.

Therapeutic Consequences and Prognostic Impact of Multimorbidity in Heart Failure: Time to Act

Background/Objectives: In heart failure (HF) with reduced ejection fraction (HFrEF), the early diagnosis and proper treatment of comorbidities (CMs) are of fundamental relevance. Our aim was to assess the prevalence of CMs among real-world patients requiring hospitalisation for HFrEF and to investigate the effect of CMs on the implementation of guideline-directed medical therapy (GDMT) and on all-cause mortality (ACM). Methods: The data of a consecutive HFrEF patient cohort hospitalised for HF between 2021 and 2024 were analysed retrospectively. Sixteen CMs (6 CV and 10 non-CV) were considered. Patients were divided into three categories: 0-3 vs. 4-6 vs. ≥7 CMs. GDMT at discharge and ACM were compared among CM categories. The predictors of 1-year ACM were also evaluated. Results: From the 388 patients (male: 76%, age: 61 [50-70] years; NT-proBNP: 5286 [2570-9923] pg/mL; ≥2 cardiovascular-kidney-metabolic disease overlap: 46%), a large proportion received GDMT (RASi: 91%; βB: 85%; MRA: 95%; SGLT2i: 59%; triple therapy [TT: RASi+βB+MRA]: 82%; quadruple therapy [QT: TT + SGLT2i]: 54%) at discharge. Multimorbidity was accompanied with a (p < 0.05) lower application ratio of RASi (96% vs. 92% vs. 85%; 0-3 vs. 4-6 vs. ≥7 CMs) and βB therapy (94% vs. 85% vs. 78%), while MRA (99% vs. 94% vs. 94%) and SGTL2i use (61% vs. 59% vs. 57%) did not differ (p > 0.05). Patients with multimorbidity were less likely to be treated with TT (93% vs. 82% vs. 73%, p = 0.001), while no difference was detected in the implementation of QT (56% vs. 54% vs. 50%, p = 0.685). The 1-year ACM of patients with an increased burden of CMs was higher (9% vs. 13% vs. 25%, p = 0.003). The risk of 1-year ACM was favourably affected by the use of TT/QT and less severe left ventricular systolic dysfunction, while having ≥5 CMs had an unfavourable impact on prognosis. Conclusions: According to our real-world analysis, HFrEF patients with an increased burden of CMs can expect a less favourable outcome. However, modern GDMT can even be applied in this patient population, resulting in a significantly improved prognosis. Thus, clinicians should insist on the early, conscious implementation of a prognosis-modifying drug regime in multimorbid HF patients as well.

Elevated triglyceride glucose index is associated with advanced cardiovascular kidney metabolic syndrome

The cardiovascular kidney metabolic (CKM) syndrome is a dynamic geriatric condition that has received limited research attention regarding its potential associations with the triglyceride glucose (TyG) index. This study aims to explore the potential association between the TyG index and advanced CKM syndrome. Data for this cross-sectional study were obtained from the National Health and Nutrition Examination Survey (NHANES) conducted between 2011 and 2018. The association between the TyG index and the risk of advanced CKM syndrome was investigated using multivariable logistic regression models. Additionally, a restricted cubic spline (RCS) analysis was employed to assess the dose-response relationship between the TyG index and the risk of advanced CKM syndrome. A total of 7904 participants were included in this study, with a mean TyG index of 5.04 ± 0.41. The prevalence of advanced CKM syndrome among the participants was 14.85%. Our findings indicated that as the TyG index quartiles increased, the risk of advanced CKM syndrome also increased. The results from the three regression analysis models indicated a positive association between the continuous TyG index and advanced CKM syndrome. Furthermore, the quartiles of the TyG index were significantly associated with an increased prevalence of advanced CKM syndrome in the fully adjusted models (TyG index Q4 vs. Q1, OR = 1.94, 95% CI 1.37-2.75, P < 0.001). The results of the RCS analysis indicated a linear and positive association between the TyG index and advanced CKM syndrome. The results indicated that elevated TyG index is associated with an increased prevalence of advanced CKM syndrome. This suggests that the TyG index may be a useful tool for assessing the risk of advanced CKM syndrome.

Hypertension: A Continuing Public Healthcare Issue

Hypertension is a cardiovascular disease defined by an elevated systemic blood pressure. This devastating disease afflicts 30-40% of the adult population worldwide. The disease burden for hypertension is great, and it greatly increases the risk of cardiovascular morbidity and mortality. Unfortunately, there are a myriad of factors that result in an elevated blood pressure. These include genetic factors, a sedentary lifestyle, obesity, salt intake, aging, and stress. Although lifestyle modifications have had limited success, anti-hypertensive drugs have been moderately effective in lowering blood pressure. New approaches to control and treat hypertension include digital health tools and compounds that activate the angiotensin receptor type 2 (AT2), which can promote cardiovascular health. Nonetheless, research on hypertension and its management is vital for lessening the significant health and economic burden of this condition.