Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

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.

From Metabolic Syndrome to Cardio-Kidney-Metabolic Syndrome in the SIMETAP Study: Prevalence Rates of Metabolic Syndrome and Its Independent Associations with Cardio-Renal-Metabolic Disorders Other than Its Defining Criteria

Background/Objectives: Metabolic syndrome (MetS) is a highly prevalent entity defined according to cardiometabolic criteria. Other disorders related to MetS could help assess the comprehensive risk of diabetes, cardiovascular disease, and chronic kidney disease (CKD). This study aimed to update the prevalence rates of MetS and to assess its relationship with other disorders and clinical conditions other than the criteria defining MetS. Methods: A cross-sectional observational study was conducted with a random population-based sample of 6588 study subjects between 18 and 102 years of age. Crude and sex- and age-adjusted prevalence rates of MetS were calculated, and their associations with comorbidities and clinical conditions other than their defining criteria were assessed by bivariate and multivariate analysis. Results: The adjusted prevalence rates were 36.0% for MetS (39.8% in men; 33.5% in women), 21.5% for premorbid Mets, and 14.5% for morbid MetS. Considering only clinical conditions other than the criteria defining MetS, the independent disorders associated with premorbid MetS were hypercholesterolemia, hypertension, high levels of lipid accumulation product, high triglyceride-glucose index (TyG), high visceral adiposity index, high fatty liver index, and high waist-to-height ratio (WtHR), highlighting excess adiposity (EA). The independent disorders associated with morbid MetS were hypercholesterolaemia, high-WtHR, EA, high-TyG index, heart failure, atrial fibrillation, CKD, and albuminuria, highlighting hypertension. Conclusions: One-fifth of the adult population has premorbid MetS, and almost one-sixth has morbid MetS. Almost two-fifths of people with MetS are at moderate, high, or very high risk of CKD, and four-fifths are at high or very high cardiovascular risk. In addition to the criteria defining MetS, other cardiovascular-renal-metabolic disorders show an independent association with MetS, highlighting EA for premorbid MetS and hypertension for morbid MetS.

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.

Time-varying cost-effectiveness analysis of sodium-glucose cotransporter-2 inhibitors in Chinese patients with heart failure and reduced ejection fraction: A microsimulation of the real-world population

Objective

Sodium-glucose cotransporter-2 (SGLT2) inhibitors showed time-varying effects in heart failure and reduced ejection fraction (HFrEF), but corresponding cost-effectiveness in different timeframes remained poorly understood. This study estimated the time-varying cost-effectiveness of SGLT2 inhibitors in HFrEF from the perspective of the Chinese healthcare system.

Methods

Based on real-world individual patient data, a 2-year microsimulation model was constructed to evaluate the cost-effectiveness of adding SGLT2 inhibitors to standard therapy compared with standard therapy alone among patients with HFrEF. A published prediction model informed transition probabilities for all-cause death and hospitalization for heart failure. The time-varying effects of SGLT2 inhibitors, medical costs, and utility values were derived from the published literature. Scenario analyses in different timeframes were conducted to assess the trend of cost-effectiveness over time.

Results

Compared with standard therapy alone, SGLT2 inhibitors plus standard therapy were found cost-effective at a willingness-to-pay (WTP) threshold of $12,741 per quality-adjusted life year (QALY) gained in 2 years. The incremental cost-effectiveness ratio (ICER) decreased from $12,346.07/QALY at 0.5 years to $9,355.66/QALY at 2 years. One-direction sensitivity analysis demonstrated that the cost-effectiveness of SGLT2 inhibitors was most sensitive to the cost of SGLT2 inhibitors, the cost of hospitalization for heart failure, the cost of standard therapy for heart failure, and the baseline risks of all-cause death and hospitalization for heart failure. Probabilistic sensitivity analysis proved the robustness of the results.

Conclusion

Adding SGLT2 inhibitors to standard therapy was found to be cost-effective in Chinese patients with HFrEF. Longer treatment appeared to be more economically favorable, but further explorations are warranted.

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.

Protective effect of serum carotenoids on mortality among metabolic syndrome patients: attenuated by lipid-lowering drugs

BACKGROUND

Limited evidence exists about the relationship between serum carotenoid and mortality in metabolic syndrome (MetS) patients, and the effects of medication use on this association remains unclear.

METHODS

The study encompassed 2,521 MetS patients from the National Health and Nutrition Examination Survey (NHANES) 2001-2006 and 2017-2018. A total of 7 serum carotenoids were evaluated. Death data were sourced from the National Death Index, with causes assessed using ICD-10 codes. Bayesian kernel machine regression (BKMR) and random survival forest (RSF) were utilized to investigate serum carotenoid mixture on mortality and identify key carotenoids. "Qgcompint" R package was used to explore the modifying effects of medication use.

RESULTS

The serum carotenoid levels at baseline ranged from 0.04 to 1.37 µmol/L. During a follow-up of 15.1 years, there were 696 deaths (27.61%), with 247 (35.49%) by cardiovascular disease (CVD), 148 (21.26%) by cancer, and 301 (43.25%) by other diseases. Individual and combined serum carotenoids were negatively associated with all-cause mortality (HR range:0.70-0.88, 95%CI range:0.56-0.99, all P < 0.05). α-carotene (VIMP = 0.223 in RSF) and lutein/zeaxanthin (PIP = 1.000 in BKMR) emerged as the greatest contributors to all-cause mortality. Lipid-lowering drugs attenuate the negative effect of serum carotenoids on MetS patients' mortality (Pint = 0.014).

CONCLUSION

The present study identified a protective effect of serum carotenoid on mortality in MetS patients, which was probably weakened by lipid-lowering drugs. Early dietary interventions for MetS patients taking lipid-lowering drugs, particularly those rich in carotenoids like α-carotene and lutein/zeaxanthin, could help reduce mortality.

Association between estimated glucose disposal rate and prediction of cardiovascular disease risk among individuals with cardiovascular-kidney-metabolic syndrome stage 0-3: a nationwide prospective cohort study

BACKGROUND

Insulin resistance is a crucial factor in the development of cardiovascular diseases (CVD), yet the relationship between the estimated glucose disposal rate (eGDR), an index reflecting insulin resistance, and the risk of new-onset CVD among individuals with cardiovascular-kidney-metabolic (CKM) syndrome stage 0-3 remains underexplored, and large-scale prospective cohort studies are needed to clarify this relationship.

METHODS

All data for this study were extracted from the China Health and Retirement Longitudinal Study (CHARLS). The primary outcome was the incidence of new-onset CVD (including heart diseases (HD) and stroke) during the follow-up period (from 2013 to 2020). Multivariable logistic regression models were applied to elucidate the relationship between the eGDR and the risk of developing CVD. The restricted cubic splines (RCS), mediation analysis, and stratified analyses were also employed.

RESULTS

This study included 6752 participants, of whom 1495 (22%) developed CVD. Odds ratios and 95% confidence intervals from lowest eGDR level (<7.37 mg/kg/min) to highest eGDR level (≥ 11.16 mg/kg/min) were 1.00 (reference), 0.81 (0.68, 0.96), 0.72 (0.58, 0.88), and 0.74 (0.58, 0.94) respectively, for the occurrence of CVD; 1.00 (reference), 0.81 (0.67,0.97), 0.72 (0.57,0.90), and 0.75 (0.58,0.97) respectively, for the occurrence of HD; 1.00 (reference), 0.91 (0.74,1.12), 0.80 (0.62,1.04), and 0.71 (0.52,0.97) respectively, for the occurrence of stroke after adjusting for all potential covariates. The RCS analysis discovered an approximately inverse "L" correlation between eGDR and the occurrence of CVD and HD across all individuals with CKM syndrome stages 0-3 (All P for overall < 0.001, All P for nonlinear = 0.005), while there was a negative linear correlation between eGDR and the risk of new-onset stroke (P for overall = 0.026, P for nonlinear = 0.098). Furthermore, the proportions mediated through BMI were 41.98%, 43.05%, and 43.23% for CVD, HD and stroke, respectively. No significant interactions were found.

CONCLUSIONS

The eGDR was a novel indicator of new-onset CVD in individuals with CKM syndrome stages 0-3, with BMI serving as a partial mediator in the association between eGDR and CVD risk. Addressing insulin resistance may represent a viable strategy for reducing the risk of CVD in this population.

Animal Models for Studying Developmental Origins of Cardiovascular-Kidney-Metabolic Syndrome

Cardiovascular-kidney-metabolic syndrome (CKMS) has become a significant global health challenge. Since CKMS often originates early in life, as outlined by the developmental origins of health and disease (DOHaD) concept, prevention is a more effective strategy than treatment. Various animal models, classified by environmental exposures or mechanisms, are used to explore the developmental origins of CKMS. However, no single model can fully replicate all aspects of CKMS or its clinical stages, limiting the advancement of preventive and therapeutic strategies. This review aims to assist researchers by comparing the strengths and limitations of common animal models used in CKMS programming studies and highlighting key considerations for selecting suitable models.

Association between Chinese visceral adiposity index and cardiovascular events risk in individuals with cardiovascular-kidney-metabolic syndrome stage 0-3: a nationwide cohort study

BACKGROUND

The population with cardiovascular-kidney-metabolic (CKM) syndrome has a higher risk of cardiovascular events. Chinese visceral adiposity index (CVAI), an index of both visceral obesity and surrogate insulin resistance, has been linked to cardiovascular events. However, the nature of this relationship remains unclear in individuals with CKM syndrome.

METHODS

All data came from the China Health and Retirement Longitudinal Study (CHARLS). The association between CVAI and cardiovascular events risk was explored using Cox regression models, restricted cubic spline (RCS) curves, and multiple sensitivity analyses. To compare the predictive abilities of various indices, receiver operating characteristic (ROC) analyses were employed.

RESULTS

7744 participants were in final analysis. During 9 year follow-up, 1679 cases of cardiovascular disease (CVD), 1,255 cases of heart disease, and 604 cases of stroke were recorded. Cox regression analyses revealed that per-SD (standard deviation) increase in CVAI, the risk of CVD, heart disease, and stroke increased by 22% (95% CI 1.13-1.32), 22% (95% CI 1.13-1.32), and 32% (95% CI 1.19-1.47). In participants at CKM stage 3 with CVD, a J-shaped curve was observed in the RCS analyses (P non-linearity = 0.036). Subgroup analysis revealed an interaction between age and each 10-unit increase in CVAI in CVD (P interaction = 0.0173) and stroke risk (P interaction = 0.028). The AUC (area under curve) value for CVAI was highest compared to other indicators (all DeLong Test P values < 0.05).

CONCLUSIONS

This research demonstrates a higher CVAI was linked to increased cardiovascular risk in individuals with CKM syndrome stage 0-3. Monitoring CVAI can help identify high-risk individuals early and improve the effectiveness of disease management.

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.

Miracle

Obesity is a complex and growing global concern, affecting one in eight individuals and compromising health, quality of life and life expectancy. It carries significant metabolic, cardiovascular, oncological, hepatorenal, skeletal and psychiatric risks, imposing substantial costs on health‐care systems. Traditional treatments have often been ineffective or have led to relapse after lifestyle changes. Whereas bariatric surgery is effective, it also involves risks such as mortality and hospitalisation. Semaglutide, licensed in 2018, is a synthetic analogue of glucagon‐like peptide 1 which regulates glucose metabolism and gastrointestinal (GI) motility. Studies show that semaglutide, administered either weekly and subcutaneously, or daily orally, induces an average weight loss of −11.62 kg compared to placebo and reduces waist circumference by up to −9.4 cm. It also improves blood pressure, fasting glucose levels, C‐reactive protein levels and lipid profiles. The most common adverse events are mild‐to‐moderate GI complaints occurring more frequently with daily administration than weekly doses; hypoglycaemia is more common without lifestyle intervention. Weight regain often follows semaglutide withdrawal. Furthermore, semaglutide offers cardiovascular benefits for patients with established atherosclerotic cardiovascular disease (CVD), lowers the risk of kidney outcomes and cardiovascular‐related death, resolves nonalcoholic steatohepatitis in many cases, and positively impacts mental health and quality of life. In conclusion, semaglutide therapy could significantly benefit many adults regarding CVD and mortality if made widely accessible. Ethical and financial considerations must be addressed for personalised obesity treatment approaches.

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 nomogram for predicting mortality risk in geriatric patients with hip fractures complicated by pneumonia: A multicenter study

Objectives

Pneumonia is a common perioperative complication in geriatric patients with hip fractures. This study aimed to analyze demographic characteristics, mortality rates, postoperative outcomes, and perioperative comorbidities, identify risk factors for mortality, and develop a nomogram for predicting the prognosis of these patients.

Methods

Data on patients hospitalized for arthroplasty for hip fractures from 2020 to 2023 at three hospitals were retrospectively analyzed. Patients were divided into the P group (patients with hip fractures complicated with pneumonia) and the C group (patients with hip fractures without pneumonia) and demographic characteristics, mortality, postoperative outcomes, and perioperative comorbidities of the patients were analyzed. Multiple logistic regression was then used to identify independent risk factors for inpatient mortality in the P group and a nomogram was constructed to predict inpatient mortality. The predictive performance of the nomogram was assessed using receiver operating characteristic curves, decision curve analysis, and calibration curves.

Results

A total of 311 patients participated in the study. Patients in the P group had longer hospitalization (p = 0.001), higher inpatient mortality (p < 0.001), higher mortality (30 days) (p < 0.001), and a poorer recovery of hip function (p < 0.001). Multiple logistic regression showed that age, BMI, total hip arthroplasty, diabetes, and chronic obstructive pulmonary disease were independent risk factors for inpatient mortality in the P group; these factors were incorporated in the nomogram. The C-index of the nomogram was 0.868 (95% CI: 0.802-0.933), and the C-index of internal bootstrapping validation was 0.851 (95% CI: 0.793-0.908), indicating the effectiveness of the nomogram in predicting patient prognosis.

Conclusions

Coinfection with pneumonia adversely affected both recovery of hip function and survival in geriatric patients with hip fractures. Age, BMI, total hip arthroplasty, diabetes, and chronic obstructive pulmonary disease were found to be independent risk factors for mortality in this patient population.

Combination therapy as a new standard of care in diabetic and non-diabetic chronic kidney disease

Combination therapy, involving the use of multiple medications together, is becoming a new standard of care for chronic kidney disease (CKD). For people with CKD, combination therapy offers the promise of preventing kidney failure and reducing the risk of heart problems. This approach is appealing because different drugs target distinct mechanisms involved in CKD progression. For instance, some target immune responses, others reduce kidney inflammation and scarring, while others improve blood pressure within the kidneys. Data from large clinical trials suggest that each treatment works effectively on its own, regardless of other medications people are taking. Combining therapies can also reduce the risk of side effects of individual medications. This review highlights the evidence for combination therapy in CKD, explores how to improve its use, and discusses how future studies may answer remaining questions.

ABSTRACT

A range of therapies now exists to reduce the risk of kidney failure and cardiovascular events in people with type 2 diabetes, including renin-angiotensin system blockade, sodium-glucose cotransporter 2 (SGLT2) inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists. With multiple clinical trials underway, it is likely that at least some of these therapies-as well as additional agents such as endothelin receptor antagonists-will further demonstrate kidney-protective effects in people with CKD who do not have diabetes in the near future. For conditions such as IgA nephropathy, several therapies have recently been approved or are being evaluated in late phase trials. Thus combination therapy is emerging as a new standard for diabetic and non-diabetic chronic kidney disease (CKD). This approach is supported by randomized data suggesting that each therapeutic class offers independent and additive benefits in diabetic kidney disease, regardless of background therapy. Notably, the reduction in hyperkalaemia and fluid retention with SGLT2 inhibitors may enhance the tolerability and safety of other treatments. In this review, we present the rationale for combination therapy with evidence-based kidney therapies in diabetic and non-diabetic CKD. We also summarize randomized evidence supporting a multi-medicine approach, address safety considerations, review ongoing trials, and propose frameworks for implementing treatments aligned with patient risk to optimize person-centred care and reduce long-term risks of kidney failure and related complications.

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.

Effects of tirzepatide on circulatory overload and end-organ damage in heart failure with preserved ejection fraction and obesity: a secondary analysis of the SUMMIT trial

Patients with obesity-related heart failure with preserved ejection fraction (HFpEF) display circulatory volume expansion and pressure overload contributing to cardiovascular-kidney end-organ damage. In the SUMMIT trial, patients with HFpEF and obesity were randomized to the long-acting glucose-dependent insulinotropic polypeptide receptor and glucagon-like peptide-1 receptor agonist tirzepatide (n = 364, 200 women) or placebo (n = 367, 193 women). As reported separately, tirzepatide decreased cardiovascular death or worsening heart failure. Here, in this mechanistic secondary analysis of the SUMMIT trial, tirzepatide treatment at 52 weeks, as compared with placebo, reduced systolic blood pressure (estimated treatment difference (ETD) -5 mmHg, 95% confidence interval (CI) -7 to -3; P < 0.001), decreased estimated blood volume (ETD -0.58 l, 95% CI -0.63 to -0.52; P < 0.001) and reduced C-reactive protein levels (ETD -37.2%, 95% CI -45.7 to -27.3; P < 0.001). These changes were coupled with an increase in estimated glomerular filtration rate (ETD 2.90 ml min-1 1.73 m-2 yr-1, 95% CI 0.94 to 4.86; P = 0.004), a decrease in urine albumin-creatinine ratio (ETD 24 weeks, -25.0%, 95% CI -36 to -13%; P < 0.001; 52 weeks, -15%, 95% CI -28 to 0.1; P = 0.051), a reduction in N-terminal prohormone B-type natriuretic peptide levels (ETD 52 weeks -10.5%, 95% CI -20.7 to 1.0%; P = 0.07) and a reduction in troponin T levels (ETD 52 weeks -10.4%, 95% CI -16.7 to -3.6; P = 0.003). In post hoc exploratory analyses, decreased estimated blood volume with tirzepatide treatment was significantly correlated with decreased blood pressure, reduced microalbuminuria, improved Kansas City Cardiomyopathy Questionnaire Clinical Summary Score and increased 6-min walk distance. Moreover, decreased C-reactive protein levels were correlated with reduced troponin T levels and improved 6-min walk distance. In conclusion, tirzepatide reduced circulatory volume-pressure overload and systemic inflammation and mitigated cardiovascular-kidney end-organ injury in patients with HFpEF and obesity, providing new insights into the mechanisms of benefit from tirzepatide. ClinicalTrials.gov registration: NCT04847557 .

GLP-1RA based therapies in the young and old

PURPOSE OF REVIEW

Obesity is recognized as a "gateway" chronic, progressive disease of dysfunctional adipocytes. Glucagon-like peptide-1 receptor agonist-based therapies (GLP1BTs), including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with/without glucose-dependent insulinotropic polypeptide (GIP), have demonstrated clinically significant weight loss and health gains in adults, hence interest in using them in younger and older people. Therefore, reviewing the role of GLP1BTs in these populations is pertinent and timely.

RECENT FINDINGS

Recent American Pediatric Guidelines emphasize the need for early introduction of obesity-management medication (OMM). This review evaluates the recently published data evaluating use of GLP1BTs in young people with obesity and/or youth onset Type 2 diabetes (YOT2D).Large studies of GLP1BTs in adults included those over 65, however no separate trial has looked at this heterogeneous group. This review translates the evidence, as it pertains to those over 65 where possible.

SUMMARY

Newer-generation GLP1BTs specifically target pathways involved in energy balance, glycaemic control and other metabolic functions, heralding a new era for the management of younger people.Published cardiovascular outcome trial (CVOT) data presented in this review support the utility of GLP1BTs in the management of older people living with obesity and/or Type 2 diabetes (T2D), with the reassurance of no new safety signals identified. Maturation of the longer-term data and publication of the additional CVOT data in cohorts of differing health complexity will provide further insights.

Type 2 Diabetes Mellitus: A Comprehensive Review of Pathophysiology, Comorbidities, and Emerging Therapies

Humans are perhaps evolutionarily engineered to get deeply addicted to sugar, as it not only provides energy but also helps in storing fats, which helps in survival during starvation. Additionally, sugars (glucose and fructose) stimulate the feel-good factor, as they trigger the secretion of serotonin and dopamine in the brain, associated with the reward sensation, uplifting the mood in general. However, when consumed in excess, it contributes to energy imbalance, weight gain, and obesity, leading to the onset of a complex metabolic disorder, generally referred to as diabetes. Type 2 diabetes mellitus (T2DM) is one of the most prevalent forms of diabetes, nearly affecting all age groups. T2DM is clinically diagnosed with a cardinal sign of chronic hyperglycemia (excessive sugar in the blood). Chronic hyperglycemia, coupled with dysfunctions of pancreatic β-cells, insulin resistance, and immune inflammation, further exacerbate the pathology of T2DM. Uncontrolled T2DM, a major public health concern, also contributes significantly toward the onset and progression of several micro- and macrovascular diseases, such as diabetic retinopathy, nephropathy, neuropathy, atherosclerosis, and cardiovascular diseases, including cancer. The current review discusses the epidemiology, causative factors, pathophysiology, and associated comorbidities, including the existing and emerging therapies related to T2DM. It also provides a future roadmap for alternative drug discovery for the management of T2DM.

Long-term trends in the prevalence of cardiovascular-kidney-metabolic syndrome in South Korea, 2011-2021: a representative longitudinal serial study

Background

The American Heart Association recently introduced a new framework, known as cardiovascular-kidney-metabolic (CKM) syndrome, aimed at the early prevention of cardiovascular disease. However, this syndrome has not been studied extensively outside of the United States. Thus, this study aimed to examine the long-term trends in CKM syndrome and its associated demographic features in South Korea.

Methods

This nationwide, cross-sectional study analyzed data from 61,106 Korean adults aged ≥20 years using the Korea National Health and Nutrition Examination Survey from 2011 to 2021. CKM syndrome was defined using the PREVENT equations, categorizing individuals into five stages (0-4). Age-standardized prevalence rates, annual percent changes (APC), and sociodemographic disparities were analyzed using multinomial logistic regression and Joinpoint regression.

Findings

Among the 61,106 participants (50.4% females [95% CI, 50.0-50.8%] and 49.6% males [95% CI, 49.2-50.0%]), stage 2 CKM syndrome was the most prevalent (43.4% [42.9-43.9]), followed by stages 1 (25.4% [25.0-25.8]), 0 (21.1% [20.7-21.6]), 3 (7.3% [7.0-7.5]), and 4 (2.8% [2.6-2.9]). From 2011 to 2021, advanced stages showed significant increases (APC for stage 4: 3.2%; 95% CI, 1.5-5.2), while stage 0 declined (APC: -1.9%; 95% CI, -3.8 to 0.0). Advanced stages were more common among vulnerable subgroups, including males, older adults, rural residents, smokers, drinkers, individuals with obesity, lower education levels, and lower household incomes.

Interpretation

This is the first study to investigate the long-term prevalence of CKM syndrome based on stages at the national level in an Asian population. Our findings emphasize the urgent need for tailored public health strategies targeting metabolic risk factors, particularly in vulnerable subgroups, to prevent progression to advanced CKM stages.

Funding

National Research Foundation of Korea.

Associations Between Lead and Cadmium Exposure and Subclinical Cardiovascular Disease in U.S. Adults

The impact of lead and cadmium exposure on subclinical cardiovascular disease (CVD), indicated by elevated high-sensitivity cardiac troponin (hs-cTnT) and N-terminal pro b-type natriuretic peptide (NT-proBNP) remains uncertain. We analyzed data from participants aged 20 and older, without overt CVD, in the National Health and Nutrition Examination Survey (NHANES; 1999-2004). Elevated lead and cadmium levels were defined as 3.5 μg/dL and 1.0 μg/L (inductively coupled plasma mass spectrometry) and 3.8 μg/dL and 0.9 μg/L (atomic absorption spectrometry), respectively. Elevated hs-cTnT was ≥ 19 ng/L, and elevated NT-proBNP was ≥ 125 pg/mL. Multivariate logistic regression estimated the odds ratios (OR) and 95% confidence intervals (CI) for elevated biomarkers. Among 10,197 participants (mean age 48.8 years; 50.3% female), 5.3% had elevated hs-cTnT and 19.4% had elevated NT-proBNP. Elevated blood lead was associated with increased ORs for elevated hs-cTnT (OR 1.45, 95% CI 1.15-1.84) and NT-proBNP (OR 1.66, 95% CI 1.40-1.97). The corresponding ORs (95% CI) for elevated blood cadmium were 1.33 (1.02, 1.74) and 1.39 (1.18, 1.65). The effect of elevated blood lead on NT-proBNP was particularly pronounced among non-Hispanic Blacks (OR [95% CI], 3.26 [2.24, 4.74]) compared to Mexican Americans (1.46 [0.99, 2.17]) and non-Hispanic Whites (1.31 [1.02, 1.68]) and was stronger in individuals with impaired kidney function (OR [95% CI], 2.31 [1.43, 3.75]) compared to those with normal kidney function (1.44 [1.18, 1.75]). This study first reveals the association between lead and cadmium exposure and subclinical CVD, underscoring the need for targeted preventive measures to reduce cardiovascular risk and improve health outcomes.

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.

Effects of Sodium-Glucose Cotransporter-2 Inhibitors on Kidney Outcomes across Baseline Cardiovascular-Kidney-Metabolic Conditions: A Systematic Review and Meta-Analyses

Key Points

Sodium-glucose cotransporter-2 (SGLT2) inhibitors slowed the rate of eGFR slope decline in patients with heart failure, CKD, and type 2 diabetes mellitus and in all combinations of multimorbid conditions among these diseases. SGLT2 inhibitors decreased kidney composite outcomes among all disease states and different combinations of multimorbidity, except in patients with heart failure with preserved ejection fraction and heart failure without type 2 diabetes mellitus. SGLT2 inhibitors were found to decrease the risk of kidney failure in patients with type 2 diabetes mellitus and also in those with CKD.

Background

The effects of sodium-glucose cotransporter-2 inhibitors (SGLT2is) on kidney outcomes in patients with varying combinations of heart failure, CKD, and type 2 diabetes mellitus have not been quantified.

Methods

PubMed and Scopus were queried up to December 2023 for primary and secondary analyses of placebo-controlled trials of SGLT2is in patients with heart failure, CKD, or type 2 diabetes mellitus. Outcomes of interest were composite kidney end point (combination of eGFR <15 ml/min per 1.73 m2, sustained doubling of serum creatinine, varying percent change in eGFR, and need for KRT), rate of eGFR slope decline, and albuminuria progression. Hazard ratios (HRs) and mean differences with their 95% confidence intervals (CIs) were extracted onto an Excel sheet, and the results were then pooled using a random-effect model through Review Manager (version 5.3, Cochrane Collaboration).

Results

Eleven trials (n =80,928 patients) were included. Compared with the placebo, SGLT2is reduced the risk of the composite kidney end point by 41% (HR, 0.59; 95% CI, 0.42 to 0.83) in heart failure with reduced ejection fraction, 36% (HR, 0.64; 95% CI, 0.55 to 0.73) in CKD, and 38% (HR, 0.62; 95% CI, 0.56 to 0.69) in type 2 diabetes mellitus. A similar pattern of benefit was observed in combinations of these comorbidities and in patients without baseline heart failure, CKD, or type 2 diabetes mellitus. SGLT2is slowed the rate of eGFR slope decline and reduced the risk of sustained doubling of serum creatinine by 36% (HR, 0.64; 95% CI, 0.56 to 0.72) in the overall population, and a consistent effect on kidney outcomes was observed in most subpopulations with available data.

Conclusions

SGLT2i improved kidney outcomes in cohorts with heart failure, CKD, and type 2 diabetes mellitus, and these effects were consistent across patients with different combinations of these comorbidities.

Beyond Guideline-Directed Medical Therapy: Nonpharmacologic Management for Patients With Heart Failure

Heart failure (HF) is a leading cause of cardiovascular morbidity, mortality, and health care expenditure. Guideline-directed medical therapy and device-based therapy in HF are well established. However, the role of nonpharmacologic modalities to improve HF care remains underappreciated, is underused, and requires multimodal approaches to care. Diet, exercise and cardiac rehabilitation, sleep-disordered breathing, mood disorders, and substance use disorders are potential targets to reduce morbidity and improve function of patients with HF. Addressing these factors may improve symptoms and quality of life, reduce hospitalizations, and improve mortality in heart failure. This state-of-the-art review discusses dietary interventions, exercise programs, and the management of sleep-disordered breathing, mood disorders, and substance use in individuals with heart failure. The authors review the latest data and provide optimal lifestyle recommendations and recommended prescriptions for nonpharmacologic therapies.

Enhancing clinical service design for multimorbidity management: A comprehensive approach to joined-up care for diabetes, chronic kidney disease, and heart failure

BACKGROUND AND AIMS

Multimorbidity is becoming the norm rather than the exception, especially among the ageing population and people with lower socio-economic status. In addition to the rising healthcare cost, multimorbidity poses considerable difficulty in the delivery of adequate holistic care for affected patients.

METHODS

This review presents a discussion of the current barriers to delivering holistic care to people with multimorbidity and proposes a model of clinical care for people living with cardiovascular-kidney-metabolic (CKM) syndrome as an exemplar of a multimorbidity cluster.

RESULTS

Single organ/disease services may not be able to provide optimum care to people with multimorbidity due to the potential complex interactions between multiple disease symptoms and management. In addition, people with multimorbidity may be required to attend multiple appointments in different healthcare centres. This may negatively impact access to services due to time and financial burden. Other barriers include co-ordinating communication between healthcare professionals and reduced continuity of care. Optimising CKM health requires patient-centred care led by an interdisciplinary care team who ideally should possess CKM competencies utilising a shared care protocol to coordinate evidence-based care and use of telehealth to empower patients. Stakeholders and policymakers need to adapt new policy models to establish and enhance CKM care models by allocating funds and implementing frameworks for educational reforms.

CONCLUSIONS

A CKM service has the potential to increase the uptake of cardiac and renal protective medications as well as optimising metabolic care, increase capacity in both primary and secondary care, improve quality of life and clinical outcomes, reduce patient inconvenience, and importantly allow rapid translation of advances in cardiorenal metabolic diseases into clinical practice.

Effects of a Digital Intervention to Improve DASH and Blood Pressure Among US Adults

BACKGROUND

Dietary Approaches to Stop Hypertension (DASH) is a recommended first-line treatment for adults with hypertension, yet adherence to DASH is low. To evaluate the efficacy of a digital health intervention (DHI), compared with attention control, on changes in DASH adherence and blood pressure among adults with hypertension.

METHODS

Nourish was a 12-month, parallel, 2-arm, randomized controlled trial of a virtually delivered DHI. Participants had a previous diagnosis of hypertension. The primary outcome was a 6-month change in DASH adherence. The secondary outcome was a change in blood pressure. We used linear mixed models to compare 6 and 12-month changes in DASH adherence, systolic blood pressure, and diastolic blood pressure.

RESULTS

Nourish randomized 301 adults who averaged 54.4 (SD, 13.4) years and predominately identified as female (65%), White (53%), or Black (31%). Adjusted mean baseline DASH score was 2.30 (95% CI, 2.03-2.58). The adjusted mean baseline systolic blood pressure and diastolic blood pressure were 123.2 (95% CI, 119.5-126.9) and 77.1 (95% CI, 74.6-79.6) mm Hg. DASH score change was not significantly different between arms at 6 months (Mdiff, 0.02 [95% CI, -0.37 to 0.40]). Yet, DHI participants had significantly greater 12-month changes in DASH score, relative to control (Mdiff, 0.62 [95% CI, 0.16-1.08]). Between-group differences in 6-month changes were insignificant for systolic blood pressure and marginally significant for diastolic blood pressure, despite the DHI group showing significant blood pressure reductions from baseline.

CONCLUSIONS

A DHI led to modest improvements in DASH and blood pressure among adults with hypertension but did not outperform the attention control. Further research is needed to understand the utility of DHIs to promote DASH and identify intervention components that support long-term behavior change.

Lessons learned from the FinnDiane Study: Epidemiology and metabolic risk factors for diabetic kidney disease in type 1 diabetes

AIMS

Across its operational span of more than 25 years, the observational, nationwide, multicentre Finnish Diabetic Nephropathy (FinnDiane) Study has aimed to unravel mechanisms underlying diabetic kidney disease, with a special focus on its metabolic risk factors. We sought to compile key findings relating to this topic and to offer a current perspective on the natural course of diabetic kidney disease among individuals with type 1 diabetes.

METHODS

In this narrative review, articles relevant to the subject published by the FinnDiane Study were identified and summarized together with work published by others, when relevant.

RESULTS

The FinnDiane Study has underscored the significance of dysglycaemia and insulin resistance, increased visceral fat mass, hypertension and dyslipidaemia-particularly high triglycerides and remnant cholesterol-as risk factors for diabetic kidney disease. Factors like abdominal obesity seem to influence the early stages of the disease, while the presence of the metabolic syndrome becomes implicated at later stages. Epidemiological reports have revealed that after an initial decline, the cumulative incidence of albuminuria plateaued post-1980s, with the progression rate to kidney failure remaining high. Fortunately, 23% of the FinnDiane cohort regressed to less advanced stages of albuminuria, improving their overall prognosis.

CONCLUSION

A substantial burden of albuminuria associated with type 1 diabetes persists, and therefore, novel kidney-protecting therapies are highly awaited. In addition, given that metabolic factors influence the progression of diabetic kidney disease both in its early and advanced stages, emphasis should be placed on ensuring that their treatment targets are met.

Spatiotemporal landscape of kidney in a mouse model of hyperuricemia at single-cell level

Serum uric acid is an end-product of purine metabolism. Uric acid concentrations in excess of the physiological range may lead to diseases such as gout, cardiovascular disease, and kidney injury. The kidney includes a variety of cell types with specialized functions such as fluid and electrolyte homeostasis, detoxification, and endocrine functions. Two-thirds of uric acid is excreted through kidney, however, the exploration of markers and new therapeutic targets in renal tissue of hyperuricemia is still lacking. Single-cell and spatial omics techniques represent major milestones in life sciences. The combined measurement of the physical structure and molecular characteristics of tissues facilitates the exploration of the pathophysiological processes underlying disease development and the discovery of possible therapeutic targets. Here, the spatiotemporal atlas of hyperuricemic nephropathy was investigated using single-cell RNA sequencing, spatial transcriptomics, spatial proteomics, and spatial metabolomics in a urate oxidase knockout mouse model. Several emerging targets and pathways especially ribosome and metabolism related to uric acid excretion were discovered and will be investigated further in studies on lowering uric acid.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Obesity Phenotypes, Lifestyle Medicine, and Population Health: Precision Needed Everywhere!

The worldwide prevalence of obesity is a key factor involved in the epidemic proportions reached by chronic societal diseases. A revolution in the study of obesity has been the development of imaging techniques for the measurement of its regional distribution. These imaging studies have consistently reported that individuals with an excess of visceral adipose tissue (VAT) were those characterized by the highest cardiometabolic risk. Excess VAT has also been found to be accompanied by ectopic fat deposition. It is proposed that subcutaneous versus visceral obesity can be considered as two extremes of a continuum of adiposity phenotypes with cardiometabolic risk ranging from low to high. The heterogeneity of obesity phenotypes represents a clinical challenge to the evaluation of cardiometabolic risk associated with a given body mass index (BMI). Simple tools can be used to better appreciate its heterogeneity. Measuring waist circumference is a relevant step to characterize fat distribution. Another important modulator of cardiometabolic risk is cardiorespiratory fitness. Individuals with a high level of cardiorespiratory fitness are characterized by a lower accumulation of VAT compared to those with poor fitness. Diet quality and level of physical activity are also key behaviors that substantially modulate cardiometabolic risk. It is proposed that it is no longer acceptable to assess the health risk of obesity using the BMI alone. In the context of personalized medicine, precision lifestyle medicine should be applied to the field of obesity, which should rather be referred to as 'obesities.'

Protein-bound uremic toxins as therapeutic targets for cardiovascular, kidney, and metabolic disorders

Cardiovascular-kidney-metabolic (CKM) syndrome is a systemic clinical condition characterized by pathological and physiological interactions among metabolic abnormalities, chronic kidney disease, and cardiovascular diseases, leading to multi-organ dysfunction and a higher incidence of cardiovascular endpoints. Traditional approaches to managing CKM syndrome risk are inadequate in these patients, necessitating strategies targeting specific CKM syndrome risk factors. Increasing evidence suggests that addressing uremic toxins and/or pathways induced by uremic toxins may reduce CKM syndrome risk and treat the disease. This review explores the interactions among heart, kidney, and metabolic pathways in the context of uremic toxins and underscores the significant role of uremic toxins as potential therapeutic targets in the pathophysiology of these diseases. Strategies aimed at regulating these uremic toxins offer potential avenues for reversing and managing CKM syndrome, providing new insights for its clinical diagnosis and treatment.

Correlation between atherogenic index of plasma and cardiovascular disease risk across Cardiovascular-kidney-metabolic syndrome stages 0-3: a nationwide prospective cohort study

BACKGROUND

The Cardiovascular-kidney-metabolic (CKM) syndrome, a concept recently proposed by the American Heart Association (AHA), highlights the intricate connection between metabolic, renal, and cardiovascular illnesses. Furthermore, the Atherogenic Index of Plasma (AIP), a useful biomarker for evaluating the risk of Cardiovascular Diseases (CVDs), has been associated with the risk of Adverse Cardiovascular Events (ACEs). Nonetheless, its precise function in populations in CKM syndrome Stages 0-3 remains unknown.

METHODS

This prospective study analyzed the data of 7,708 eligible participants (aged ≥ 45 years) from the Chinese Longitudinal Research of Ageing (CHARLS), particularly the 2011-2012 baseline survey (Wave 1). The primary exposure variable was AIP-a natural logarithm of the ratio of Triglycerides (TGs) to High-Density Lipoprotein Cholesterol (HDL-C). On the other hand, the primary endpoint was CVD incidence, which was determined based on self-reported past diagnoses. The relationship between AIP and CVD risk in the population in CKM syndrome stages 0-3 was examined using a Cox proportional risk model. Subgroup and mediation analyses were performed to further elucidate the interactions among these factors.

RESULTS

This study involved 7,708 participants in the CKM syndrome stages 0-3 [Mean age = 58.00 years; Interquartile Range (IQR) = 52.00-65.00 years]. The risk of developing CVD increased significantly with higher AIP levels. Specifically, the risk ratio for each unit increase in AIP was 1.31 (95% CI 1.11-1.55), while the Hazard Ratio (HR) for the group with the highest AIP levels compared to the group with the lowest AIP levels was 1.22 (95% CI 1.08-1.39). Mediation analysis revealed that metabolic syndrome accounted for 12.3% of the association between AIP levels and CVD risk (p = 0.024), highlighting its significance in CVD risk assessment.

CONCLUSION

Herein, AIP levels correlated significantly positively with CVD risk in individuals in CKM stages 0-3, with metabolic syndrome as a key mediating factor. These findings suggest that AIP levels could be valuable not only for CVD risk assessment but also for clinical screening.

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.

Closing the Gap: Digital Innovations to Address Hypertension Disparities

PURPOSE OF REVIEW

Significant inequities persist in hypertension detection and control, with minoritized populations disproportionately experiencing organ damage and premature death due to uncontrolled hypertension. Remote blood pressure monitoring combined with telehealth visits (RBPM) is proving to be an effective strategy for controlling hypertension. Yet there are challenges related to technology adoption, patient engagement and social determinants of health (SDoH), contributing to disparities in patient outcomes. This review summarizes the evidence to date for RBPM, focusing on the potential to advance health equity in blood pressure control and the existing levers for largescale implementation.

RECENT FINDINGS

Several studies demonstrate the promise of RBPM programs to address health disparities through: (1) the use of cellular-enabled blood pressure machines that do not require internet access or smart devices to connect readings into the medical record; (2) emphasis on home blood pressure monitoring to illuminate the daily factors that influence blood pressure control, thereby increasing patient empowerment; (3) adoption of standardized algorithms for hypertension management; and (4) integration of services to address SDoH. Multidisciplinary, non-physician care teams that include nurses, pharmacists, and community health workers are integral to this model. However, most studies have not embraced all aspects of RBPM, and implementation is challenging as current payment models do not support the digital components of RBPM or a diverse workforce of hypertension providers.

CONCLUSION

To address hypertension disparities, RBPM programs need to integrate digital technology that is accessible to all users as well as multidisciplinary care teams that attend to the medical and social needs of populations experiencing health inequities.

Associations between cardiovascular-kidney-metabolic syndrome and disability in activities of daily living: a nationwide longitudinal study among the middle-aged and older adults in China

Background

Activities in daily living (ADLs) disability triggered by aging population and chronic diseases in the middle-aged and older adults has become a major public health challenge. Cardiovascular-kidney-metabolic (CKM) syndrome, as a combination of several chronic conditions, has not yet been studied to explore its association with ADLs disability. We examined the association between CKM syndrome and ADLs disability among middle-aged and older adults in China and whether it varied by age and socioeconomic status.

Methods

Participants were from China Health and Retirement Longitudinal Study (CHARLS), which conducted four waves of surveys from 2011 to 2018. CKM stage was calculated through disease and physical examination data from CHARLS database. Meanwhile, the degree of disability was assessed through the ADL scale. Generalized linear mixed model was used to perform multivariate analysis to explore the association between CKM syndrome and the risk of ADLs disability.

Results

The proportion of CKM stage 0, 1, 2, and 3 among the 5,898 eligible participants (median age 60 years, 60.27% women) in 2011 were 14.70, 30.23, 41.39, and 13.68%. The risk of ADL disability was increased by 16% (odds ratio [95% confidence interval]; 1.16 [1.00-1.33]) and 33% (1.33 [1.12-1.58]) in CKM stages 2 and 3 compared with stage 0. In addition, there was a greater risk of BADL disability in 75+ age group compared to other age groups, but no significant association with IADL disability. In the subgroup aged 75+, the risk of BADL disability was increased for CKM stage 2/3 (1.48 [1.01-2.18]/1.67 [1.06-2.64]) compared with stage 0. Only in the lowest quartile of socioeconomic status group CKM stage rise was strongly associated with the risk of disability. The risk of ADL disability was greater for CKM stage 2/3 (1.45 [1.15-1.83]/1.48 [1.11-1.98]) compared to CKM stage 0 in the lowest economic status quartile.

Conclusion

For middle-aged and older adults in China, CKM syndrome is a key risk factor for ADLs disability. Therefore, effective measures should be taken to manage CKM stage at the lowest possible level, especially in older and economically disadvantaged populations.

Promotion of Cardiometabolic Health: A Personal Journey

PURPOSE OF REVIEW: Narrative review of the author's main contributions to the field of cardiovascular health spanning four decades, with a focus on findings related to 1- the pathophysiology of obesity, insulin resistance, type 2 diabetes and cardiovascular disease, and 2- the management/prevention of these conditions. Particular attention is given to the importance of regular physical activity. RECENT FINDINGS: Because behaviors and their physiological consequences are still not measured in clinical practice, it is proposed to systematically assess and target "lifestyle vital signs" (waist circumference, cardiorespiratory fitness, food-based diet quality and level of leisure-time physical activity) in primary care. However, cardiometabolic health of the population will not be substantially improved until our living and economic conditions are permissive to the adoption of healthy behaviors. Closing the gap between primary care and public health should be a priority to address the socioeconomic determinants of cardiometabolic health.

EMCREG-International Multidisciplinary Consensus Panel on Management of Hyperkalemia in Chronic Kidney Disease and Heart Failure

BACKGROUND

Hyperkalemia, generally defined as serum potassium levels greater than 5.0 mEq/L, poses significant clinical risks, including cardiac toxicity and muscle weakness. Its prevalence and severity increase in patients with chronic kidney disease (CKD), diabetes mellitus, and heart failure (HF), particularly when compounded by medications like angiotensin converting inhibitors, angiotensin receptor blockers, and potassium sparing diuretics. Hyperkalemia arises from disruptions in potassium regulation involving intake, excretion, and intracellular-extracellular distribution. In CKD and acute kidney injury, these regulatory mechanisms are impaired, leading to heightened risk. The management of chronic hyperkalemia presents a challenge due to the necessity of balancing effective cardiovascular and renal therapies against the risk of elevated potassium levels.

SUMMARY

The emergency department management of acute hyperkalemia focuses on preventing cardiac complications through strategies that stabilize cellular membranes and shift potassium intracellularly. Chronic management often involves dietary interventions and pharmacological treatments. Pharmacological management of acute hyperkalemia includes diuretics, which enhance kaliuresis, and potassium binders such as patiromer and sodium zirconium cyclosilicate, which facilitate fecal excretion of potassium. While diuretics are commonly used, they carry risks of volume contraction and renal function deterioration. The newer potassium binders have shown efficacy in lowering chronically elevated potassium levels in CKD and HF patients, offering an alternative to diuretics and other older agents such as sodium polystyrene sulfonate, which has significant adverse effects and limited evidence for chronic use.

KEY MESSAGES

We convened a consensus panel to describe the optimal management across multiple clinical settings when caring for patients with hyperkalemia. This consensus emphasizes a multidisciplinary approach to managing hyperkalemia, particularly in patients with cardiovascular kidney metabolic syndrome, to avoid fragmentation of care and ensure comprehensive treatment strategies. The primary goal of this manuscript is to describe strategies to maintain cardiovascular benefits of essential medications while effectively managing potassium levels.