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

Effects of Sodium-Glucose Cotransporter-2 Inhibitors on Body Composition and Fluid Status in Cardiovascular Rehabilitation Patients with Coronary Artery Disease and Heart Failure

Background and Objectives: Sodium glucose cotransporter-2 (SGLT-2) inhibitors have emerged as integral therapeutic tools in the management of patients with cardiovascular-kidney-metabolic (CKM) syndrome. In addition to their well-documented effects on lowering glucose levels and cardiovascular- and reno-protective actions, SGLT-2 inhibitors, through a reduction in body weight (BW), generate changes in the body composition and volume status that have not been clearly studied. Materials and Methods: This retrospective, observational longitudinal cohort, single-center study analyzed and compared body composition and fluid status measured by bioelectrical impedance analysis (BIA) from weeks 0 to 12 after the initiation of the cardiac rehabilitation (CR) program for coronary artery disease and heart failure in 59 patients who started treatment with SGLT-2 inhibitors (SGLT-2iG) and 112 patients without SGLT-2 inhibitors (non-SGLT-2iG). Results: Changes between the baseline and week 12 in the SGLT-2iG and non-SGLT-2iG were -0.3 L (p = 0.003) and -0.03 L (p = 0.82) in extracellular water (ECW) (p = 0.05), -0.39 L (p < 0.001) and -0.14 L (p = 0.33) in intracellular water (ICW) (p = 0.12), -0.69 (p < 0.001) and -0.16 (p = 0.52) in total body water (TBW) (p = 0.08), and -0.01 (p = 0.37) and -0.001 (p = 0.25) in the ECW/TBW ratio, respectively. After 3 months of exercise therapy in the CR program, patients in the SGLT-2iG showed a greater decrease than the non-SGLT-2iG in weight (-1.34 kg, p < 0.001 vs. -0.99, p = 0.02), body mass index (BMI) (-0.45 kg/m2, p < 0.001 vs. -0.38, p = 0.004), arm circumference (-0.57 cm, p = 0.008 vs. -0.12 cm, p = 0.21), waist circumference (-1.5 cm, p = 0.04 vs. -0.11 cm, p = 0.83), systolic blood pressure (SBP) (-8.9 mmHg, p = 0.049 vs. -4.19, p = 0.08), and diastolic blood pressure (DBP) (-5.15, p = 0.03 vs. -2.85, p = 0.01). The bioelectrical impedance analysis (BIA) revealed a significant decrease in body fat mass (BFM) and visceral fat area, without a loss of lean body mass (LBM) or skeletal muscle mass in the SGLT-2iG. Conclusions: SGLT-2 inhibitors exert beneficial effects on body compartments and volume status. Although they induce modest weight loss, this appears to be mainly directed at ECW, BFM, and visceral fat, without a loss of LBM nor skeletal muscle mass, which could contribute to the observed CKM benefits.

Association between triglyceride-glucose index and cardiovascular disease in US adults with chronic kidney disease: a population-based study

OBJECTIVES

Triglyceride-glucose (TyG) index, which is a valuable measure of insulin resistance, has been found to have predictive value for cardiovascular disease (CVD). However, its relationship with CVD among individuals with chronic kidney disease (CKD) has not been thoroughly investigated. This study focused on examining the relationship of the TyG index and CVD among CKD patients in United States.

METHODS

3507 eligible participants from the National Health and Nutrition Examination Survey (2003-2018) were surveyed in this study. Methods such as multivariable logistic regression analysis and smooth curve fitting were employed to estimate how the TyG index is linked to CVD in CKD populations. Subgroup and interaction analyses were conducted in order to figure out potential moderating effects of various factors.

RESULTS

In this cross-sectional study which based on a population with CKD, 29.5% of patients also had CVD. An independent and positive link of TyG and CVD was revealed (OR 1.213, 95% CI 1.059, 1.389). This association was nonlinear, with a threshold effect observed at a TyG index of 8.98. The results of subgroup analysis suggested that the relationships of TyG and CVD differed according to CKD stage: (OR 1.048, 95% CI 0.857, 1.282) in CKD stages 1-2; (OR 1.267, 95% CI 1.030-1.560) in stage 3; and (OR 2.131, 95% CI 1.224-3.709) in stages 4-5. Interaction analyses further suggested the potential moderating effects of CKD stage. Additionally, among specific CVD types, only coronary heart disease (CHD) had a significant and positive relationship with TyG (OR 1.617, 95% CI 1.123, 2.327).

CONCLUSIONS

TyG index was identified to be independently and positively related to the likelihood of CVD, specifically in populations with an eGFR < 60 mL/min/1.73 m². The association had a threshold effect. The results highlight the potential of the TyG index as a tool for screening and risk assessment of CVD in populations suffering from CKD, warranting further investigation.

Association of serum Klotho with the severity and mortality among adults with cardiovascular-kidney-metabolic syndrome

BACKGROUND

Cardiovascular-kidney-metabolic (CKM) syndrome is characterized as a systemic disease resulting from the pathophysiological interplay among metabolic risk factors, chronic kidney disease (CKD), and cardiovascular disease (CVD). The Klotho protein may serve as a novel biomarker. However, the utility of serum Klotho levels as an indicator of severity and mortality risk in CKM syndrome remains uncertain.

METHODS

This study involved 9,871 participants from the National Health and Nutrition Examination Survey (NHANES) conducted between 2007 and 2016. Serum Klotho levels were measured using an enzyme-linked immunosorbent assay kit. The optimal cutoff value was established through the maximum Youden's index. Multivariable weighted regression models were employed to calculate the odds ratio and hazard ratio, along with the 95% confidence interval, to evaluate the association between serum Klotho levels and the severity of CKM syndrome, as well as all-cause and cardiovascular mortality. Additionally, the receiver operating characteristic curve and restricted cubic spline curves were utilized to assess predictive efficacy and to explore nonlinear relationships.

RESULTS

After adjusting for potential confounding factors, a non-linear relationship was seen between the Klotho protein, and CKM syndrome. In the multivariable, piecewise logistic regression, when the Serum klotho was less than 801, the risk of CKM syndrome decreased with the increase in Serum klotho (OR = 0.82, 95%CI 0.70, 0.96; p < 0.001). Furthermore, we observed the association when the Serum klotho was greater than 801 (OR = 0.94, 95%CI 0.89, 0.99; p = 0.035). The relationship between serum Klotho levels and all-cause mortality was U-shaped, while the relationship with cardiovascular mortality was L-shaped. Specifically, low serum Klotho levels were associated with an increase in all-cause mortality by 21% and cardiovascular mortality by 76% among patients with CKM syndrome. Furthermore, serum Klotho levels demonstrated excellent predictive efficacy for both the severity and mortality associated with CKM syndrome.

CONCLUSIONS

This study indicates that low serum Klotho levels serve as reliable indicators of both the severity of CKM syndrome and the associated risk of mortality.

Predictive value of fine fibrillatory wave for declining eGFR in patients with persistent atrial fibrillation: Long-term follow-up study

BACKGROUND

Renal dysfunction has been identified as a risk factor for both stroke and bleeding events in atrial fibrillation (AF) patients, yet the mechanisms remain unclear. We examines the connection between fine fibrillatory wave and estimated glomerular filtration rate (eGFR) decline, alongside chronic kidney disease (CKD).

METHODS

Persistent AF patients admitted to Jinan University's First Affiliated Hospital from January 2019 to June 2023 were enrolled. Kaplan-Meier analysis explored kidney endpoints for coarse and fine fibrillatory wave. A multivariate Cox model estimated adjusted hazard ratios (HR) and 95 % confidence intervals (95 % CI) to determine the correlation between fine fibrillatory wave and eGFR decline, as well as CKD.

RESULTS

Of the 3521 AF patients, 229 were ultimately included in the analysis of this study. The median age of these patients was 75 years, with 58 % being male. The median follow-up time was 23 months, and the mean eGFR was 70 ± 19 mL/min/1.73 m2. Multivariate COX regression analysis revealed fine fibrillatory wave (HR = 8.311, 95 % CI 3.418-20.211, p < 0.001) as an independent risk factor associated with a ≥ 30 % decline in eGFR. Among 166 AF patients with eGFR >60 mL/min/1.73 m2, 40 cases (24 %) experienced a decline to <60 mL/min/1.73 m2. In comparison to coarse fibrillatory wave, the risk of fine fibrillatory wave causing eGFR decline to <60 mL/min/1.73 m2 was approximately 4.6 times higher (HR = 4.645, 95 % CI 2.127-10.142, p<0.001).

CONCLUSIONS

Fine fibrillatory wave was independently associated with the risk of eGFR decline ≥30 % and eGFR decline to <60 mL/min/1.73 m2.

The association of RBP4 with chronic kidney diseases in southern Chinese population

Background

Retinol binding protein 4 (RBP4), as a novel adipokine, has been proven to be highly related to insulin resistance, obesity, diabetes, hypertension, hyperuricemia and other metabolic diseases, which are all risk factors for chronic kidney disease (CKD). However, there is a lack of sufficient studies to explore the relationship between RBP4 and CKD, and no reports have described the predictive value of RBP4 for CKD. This study was designed to clarify the relationship between RBP4 and CKD and its potential predictive value.

Methods

Our team has conducted a large-scale cross-sectional survey that contained 2117 individuals on the southern coast of China. Correlation test, logistic regression analysis were used to evaluate the association between RBP4 and CKD. Receiver operating characteristic (ROC) were used to evaluate the optimal cut-off and predictive value of RBP4 for predicting CKD.

Results

By using the quartile grouping method, the population was divided into four groups according to the RBP4 level. As the RBP4 level increased, the prevalence of CKD also gradually increased among different groups. RBP4 was also correlated with various metabolic risk factors, such as blood glucose, blood lipids, blood pressure, waist circumference, uric acid, and with kidney function indicators such as creatinine, urine protein. Logistic regression analysis found that after adjusting for confounders, RBP4 remained significantly associated with CKD, independent of metabolic risk factors. ROC analysis showed that RBP4 as a single index, AUC (0.666) was superior to Scr, FBG, Log HOMA-IR, WC, TG, VLDL-C, UA, HDL-C, LDL-C, and that combining RBP4 indicator and other common risk factors of CKD can improve the accuracy for predicting CKD.

Conclusion

This study found that the RBP4 was strongly correlated with CKD, RBP4 may become a valuable marker and have strong power for predicting CKD.

GLP-1 receptor agonists in patients with chronic kidney disease and either overweight or obesity

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as game-changers across the cardiovascular-kidney-metabolic (CKM) spectrum: overweight/obesity, type 2 diabetes mellitus (T2DM) and associated chronic kidney disease (CKD) and cardiovascular disease (CVD). Liraglutide, semaglutide and tirzepatide are European Medicines Agency approved to improve metabolic control in T2DM and to decrease weight in persons with obesity [body mass index (BMI) ≥30 kg/m2] or with overweight (BMI ≥27 kg/m2) associated with weight-related comorbidities such as hypertension, dyslipidaemia, CVD and others. Additionally, liraglutide and semaglutide are approved to reduce CVD risk in patients with CVD and T2DM. Semaglutide is also approved to reduce CVD risk in patients with CVD and either obesity or overweight and in phase 3 clinical trials showed kidney and cardiovascular protection in patients with T2DM and albuminuric CKD (FLOW trial) as well as in persons without diabetes that had CVD and overweight/obesity (SELECT trial). Thus, nephrologists should consider prescribing GLP-1 RAs to improve metabolic control, reduce CVD risk or improve kidney outcomes in three scenarios: patients with overweight and a related comorbid condition such as hypertension, dyslipidaemia or CVD, patients with obesity and patients with T2DM. This review addresses the promising landscape of GLP-1 RAs to treat persons with overweight or obesity, with or without T2DM, within the context of CKD, assessing their safety and impact on weight, metabolic control, blood pressure and kidney and cardiovascular outcomes, as part of a holistic patient-centred approach to preserve CKM health.

Outdoor light at night is a modifiable environmental factor for metabolic syndrome: The 33 Communities Chinese Health Study (33CCHS)

Metabolic syndrome (MetS) is a significant public health problem and presents an escalating clinical challenge globally. To combat this problem effectively, urgent measures including identify some modifiable environmental factors are necessary. Outdoor artificial light at night (LAN) exposure garnered much attention due to its impact on circadian rhythms and metabolic process. However, epidemiological evidence on the association between outdoor LAN exposure and MetS remains limited. To determine the relationship between outdoor LAN exposure and MetS, 15,477 adults participated the 33 Communities Chinese Health Study (33CCHS) in 2009 were evaluated. Annual levels of outdoor LAN exposure at participants' residential addresses were assessed using satellite data from the Defense Meteorological Satellite Program (DMSP) Operational Linescan System (OLS). Generalized linear mixed effect models were utilized to assess the association of LAN exposure with MetS and its components, including elevated waist circumference (WC), triglycerides (TG), blood pressure (BP), fasting blood glucose (FBG), and reduced high-density lipoprotein cholesterol (HDL-C). Effect modification by various social demographic and behavior factors was also examined. Overall, 4701 (30.37 %) participants were defined as MetS. The LAN exposure ranged from 6.03 to 175.00 nW/cm2/sr. The adjusted odds ratio (OR) of MetS each quartile increment of LAN exposure were 1.43 (95 % CI: 1.21-1.69), 1.44 (95 % CI: 1.19-1.74) and 1.52 (95 % CI: 1.11-2.08), respectively from Q2-Q4. Similar adverse associations were also found for the components of MetS, especially for elevated BP, TG and FBG. Interaction analyses indicated that the above associations were stronger in participants without habitual exercise compared with those with habitual exercise (e.g. OR were 1.52 [95 % CI: 1.28-1.82] vs. 1.27 [95 % CI, 1.04-1.55], P-interaction = 0.042 for MetS). These findings suggest that long-term exposure to LAN can have a significant deleterious effect on MetS, potentially making LAN an important modifiable environmental factor to target in future preventive strategies.

Increased prevalence of cardiovascular-kidney-metabolic syndrome during COVID-19: A propensity score-matched study

A recent presidential advisory from the American Heart Association (AHA) has introduced the term cardiovascular-kidney-metabolic (CKM) syndrome to describe the complex interplay among health conditions linking heart, kidney, and metabolism. The aim of our study was to compare the prevalence of concurrent CKM syndrome components before and during the COVID-19 pandemic and identify associated risk factors. We conducted a study utilizing data from a real-world population obtained from a primary care database. The study cohort comprised a closed group followed over a 6-year period (2017-2022). A total of 81,051 individuals were included: 32,650 in the pre-pandemic period and 48,401 in the 2020-2022 triennium. After propensity-score matching for sex, age, and BMI, the study included 30,511 participants for each period. 3554 individuals were diagnosed with type 2 diabetes in the pre-pandemic period, compared to 7430 during the pandemic. Hypertension, dyslipidemia, and obesity displayed significant increases in prevalence during the pandemic, and prediabetes had a particularly sharp rise of 170%. Age-stratified analyses revealed a higher burden of CKM conditions with advancing age. Our findings indicate a substantial increase in the prevalence of CKM syndrome during the COVID-19 pandemic, with nearly half of the patients exhibiting one or more CKM syndrome components.

SGLT2 inhibitors, cardiovascular outcomes, and mortality across the spectrum of kidney disease: A systematic review and meta-analysis

AIMS

To evaluate the effects of SGLT2 inhibitors on cardiovascular outcomes and mortality across KDIGO and urinary albumin-to-creatinine ratio [UACR] groups.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL up to August 8th, 2023. In pairs, researchers selected large randomized placebo-controlled trials of SGLT2 inhibitors, with minimum duration of one year. Researchers independently extracted study-level data and assessed within-study risk of bias with RoB 2.0 and certainty of evidence with GRADE. Meta-analyses employed a random-effects model.

RESULTS

We included 14 trials, encompassing 97,412 participants and a median follow-up of 2.5 years. Risk of bias was overall low. Overall, SGLT2 inhibitors reduced major adverse cardiovascular events (MACE) (HR 0.89, 95 %-CI 0.85-0.93), cardiovascular death or hospitalization for heart failure (HHF) (HR 0.78, 95 %-CI 0.75-0.82), all-cause death (HR 0.89, 95 %-CI 0.83-0.94), and HHF (HR 0.71, 95 %-CI 0.67-0.75). The effect of SGLT2 inhibitors on MACE was different across KDIGO (Pinteraction = 0.038) and UACR (Pinteraction = 0.008) groups, with greater benefits in KDIGO Very High (HR 0.72, 95 %-CI 0.61-0.86) and UACR > 300 mg/g (HR 0.76, 95 %-CI 0.68-0.86) groups.

CONCLUSIONS

SGLT2 inhibitors are associated with reductions in cardiovascular outcomes and mortality. Greater reductions in MACE are expected in subjects in high-risk groups for kidney disease.

The impact of weight loss on fat-free mass, muscle, bone and hematopoiesis health: Implications for emerging pharmacotherapies aiming at fat reduction and lean mass preservation

Similar to bariatric surgery, incretin receptor agonists have revolutionized the treatment of obesity, achieving up to 15-25 % weight loss in many patients, i.e., at a rate approaching that achieved with bariatric surgery. However, over 25 % of total weight lost from both surgery and pharmacotherapy typically comes from fat-free mass, including skeletal muscle mass, which is often overlooked and can impair metabolic health and increase the risk of subsequent sarcopenic obesity. Loss of muscle and bone as well as anemia can compromise physical function, metabolic rate, and overall health, especially in older adults. The myostatin-activin-follistatin-inhibin system, originally implicated in reproductive function and subsequently muscle regulation, appears to be crucial for muscle and bone maintenance during weight loss. Activins and myostatin promote muscle degradation, while follistatins inhibit their activity in states of negative energy balance, thereby preserving lean mass. Novel compounds in the pipeline, such as Bimagrumab, Trevogrumab, and Garetosmab-which inhibit activin and myostatin signaling-have demonstrated promise in preventing muscle loss while promoting fat loss. Either alone or combined with incretin receptor agonists, these medications may enhance fat loss while preserving or even increasing muscle and bone mass, offering a potential solution for improving body composition and metabolic health during significant weight loss. Since this dual therapeutic approach could help address the challenges of muscle and bone loss during weight loss, well-designed studies are needed to optimize these strategies and assess long-term benefits. For the time being, considerations like advanced age and prefrailty may affect the choice of suitable candidates in clinical practice for current and emerging anti-obesity medications due to the associated risk of sarcopenia.

Landscape of cardiorenal syndrome research: A bibliometric analysis

To comprehensively review cardiorenal syndrome (CRS)-related research, this study analyzes its whole landscape and future trends from a bibliometric perspective. Using "cardiorenal syndrome" as the key word, a representative dataset of CRS was constructed in the Web of Science Core Collection (Science Citation Index Expanded) database up to November 2023. VOSviewer (version 1.6.18) and R-Studio (version 1.4) were used to visualize CRS-related author and national collaboration networks, hotspot distribution clustering and historical citation networks. The annual number of publications shows an upward trend, especially since 2009. The United States is the most active country and closely cooperates with European countries. Cardiorenal Medicine is the journal that publishes the most CRS-related research. Urology & Nephrology and Cardiovascular System & Cardiology are the most prominent areas of CRS literature output. The leaders in CRS-related research are Ronco C from Italy and Mccullough PA, from the United States. Combined with keyword co-occurrence, theme evolution, and strategic distribution analysis, it was found that centering on the mechanism of CRS (cardiovascular lesions, venous congestion, and fibrosis), prognosis (transplantation, dialysis, hospitalization, mortality) and cardiac function management (b-type natriuretic peptide, diastolic dysfunction, left ventricular hypertrophy) is a possible research direction for a long time to come. Although CRS has a relatively short history, it has received a lot of attention and is currently enjoying a high level of overall acceptance. In conclusion, this study explores the major research areas, frontiers and trends in CRS, which are important for future research.

Prevalence of Cardiovascular-Kidney-Metabolic Stages in US Adolescents and Relationship to Social Determinants of Health

Importance

Given that many risk factors for atherosclerotic cardiovascular disease (ASCVD) begin in childhood, knowledge of the prevalence of cardio-kidney metabolic syndrome (CKM) in adolescents and its risk factors is critical to understanding the etiology of ASCVD risk burden.

Objective

To calculate the proportion of US adolescents with CKM stages 0, 1, and 2 and to assess the social factors and behaviors most strongly associated with advanced CKM stage.

Design

Cross-sectional analysis of 2017-2020 US National Health and Nutrition Examination Survey (NHANES) sample data.

Setting

United States.

Participants

Adolescents.

Exposure

Social determinants of health, including family income to poverty ratio, health insurance, routine healthcare access, and food security, as well as behaviors including smoking, physical activity, and diet.

Main Outcomes and Measures

The prevalence of CKM stages 0, 1, and 2 in adolescents was measured using survey-weighted data. Generalized linear models were used to quantify associations between social factors, behaviors, and CKM staging.

Results

Of the 1,774 surveyed adolescents ages 12-18 years, representing 30,327,145 US adolescents, 56% (95% CI 52-60%) had CKM stage 0, 37% (33-40%) had CKM stage 1, and 7% (5-9%) had CKM stage 2. Physical activity score (1 to 100, 100=highest) was lowest among adolescents with CKM stage 2 (physical activity score for CKM 0: 60 (31), CKM 1: 60 (32), and CKM 2 49 (33); p=0.025). Other health behaviors, such as the DASH diet and nicotine scores, did not differ according to the CKM stage (p=0.477 and p=0.932, respectively). According to sex, race, ethnicity, and age-adjusted multivariate logistic regression analyses, a ratio of income to poverty level >1.85, having health insurance, and food security, were associated with a 32% (OR 0.68 [95% CI:0.52,0.89]), 40% (OR 0.60 [95% CI: 0.37, 0.99]), and 45% (OR 0.55 [95% CI: 0.41,0.73]) lower odds of CKM stage 1-2, respectively. After adjustment for all sociodemographic factors, only food security was associated with 41% lower odds of CKM stage 1-2 (OR 0.59 [0.43, 0.81]).

Conclusions and Relevance

CKM stage 1-2 in adolescents is most strongly associated with food insecurity. Improved access to healthy food and policies to address food security may help prevent higher CKM stage, beginning in adolescence.

Correlation and Agreement Between the SCORE2 and PREVENT 10-Year Atherosclerotic Cardiovascular Disease Risk Scores: Insights from Coronary Computed Tomography Angiography

Background: We aimed to evaluate the correlation and agreement between the Systemic Coronary Risk Estimation 2 (SCORE2) and Predicting Risk of CVD EVENTs (PREVENT) 10-year ASCVD risk scores by incorporating computed tomographic (CT) data to assess differences between the scoring systems. Methods: The PREVENT risk score was calculated for 171 patients, while the SCORE2 and SCORE2 Older Persons (OP) risk scores were calculated for 113 patients. Coronary artery calcium (CAC) scores were calculated, and the grading of coronary artery disease (CAD) was assessed according to these scores. Results: According to the PREVENT risk category, 79 patients (46.2%) were in the low-risk category, 32 (18.7%) were in the borderline-risk category, and 51 (29.8%) were in the intermediate-risk category. In contrast, the SCORE2 systems placed 32 patients (28.3%) in the low- to moderate-risk categories. Only 9 patients (5.3%) were classified as being at high risk by PREVENT, while SCORE2 categorized 39 patients (34.5%) as being at high risk and 42 patients (37.2%) as being at very high risk. There was a strong correlation between the scores (r = 85, p < 0.001), with a Bland-Altman plot analysis showing a bias of -3.71 points and the limits of agreement ranging from -16.06 to 8.64. The total CAC score and CAD grading were significantly different across the PREVENT risk groups (p < 0.001 for all) but were similar across the SCORE2 groups (p = 0.3 and p = 0.051, respectively). Conclusions: There is a strong correlation and agreement between the two risk scores. However, SCORE2 tends to categorize more patients as high-risk than PREVENT does. Additionally, the PREVENT risk categories are more effective than SCORE2 in determining the likelihood of CAD based on CT results.

Male Wistar Rats Chronically Fed with a High-Fat Diet Develop Inflammatory and Ionic Transport Angiotensin-(3-4)-Sensitive Myocardial Lesions but Preserve Echocardiographic Parameters

The central aim of this study was to investigate whether male Wistar rats chronically fed a high-fat diet (HFD) over 106 days present high levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), and Na+ and Ca2+ transport alterations in the left ventricle, together with dyslipidemia and decreased glucose tolerance, and to investigate the influence of Ang-(3-4). The rats became moderately overweight with an expansion of visceral adiposity. Na+-transporting ATPases, sarco-endoplasmic reticulum Ca2+-ATPase (SERCA2a), and the abundance of Angiotensin II receptors were studied together with lipid and glycemic profiles from plasma and left-ventricle echocardiographic parameters fractional shortening (FS) and ejection fraction (EF). IL-6 and TNF-α increased (62% and 53%, respectively), but returned to normal levels with Angiotensin-(3-4) administration after 106 days. Significant lipidogram alterations accompanied a decrease in glucose tolerance. Angiotensin II receptors abundance did not change. (Na+ + K+)ATPase and ouabain-resistant Na+-ATPase were downregulated and upregulated, respectively, but returned to normal values upon Angiotensin-(3-4) administration. SERCA2a lost its ability to respond to excess ATP. Echocardiography showed no changes in FS or EF. We conclude that being overweight causes an increase in Ang-(3-4)-sensitive IL-6 and TNF-α levels, and ion transport alterations in the left ventricle that could evolve into future heart dysfunction.

Association between cardiorenal syndrome and depressive symptoms among the US population: a mediation analysis via lipid indices

BACKGROUND

Cardiovascular diseases (CVD), chronic kidney disease (CKD), and lipids are positively correlated with the presence of depressive symptoms. However, investigation into the complex link that exists between cardiorenal syndrome (CRS) and lipid indices and depression remains scarce.

METHODS

This study analyzed data from 11, 729 adults in the National Health and Nutritional Examination Surveys from 2005 to 2018. Weighted regression analysis was employed to examine the relationships between CRS and depression, CRS and the Patient Health Questionnaire-9 score, and lipid indices with depression. The restricted cubic spline analysis was used to determine whether there is a linear association between lipid indices and depression. Smooth curve fitting was employed to illustrate the relationship between lipids, depression, and cardiorenal diseases. Subgroup and sensitivity analyses were also conducted to enhance the stability of the results. Finally, we applied mediation analysis to explore whether the Atherogenic Index of Plasma (AIP), triglyceride glucose (TyG) index, and remnant cholesterol (RC) mediate the association between CRS and depression.

RESULTS

After applying propensity score matching (PSM), 1,509 adults remained in the study. After PSM, more remarkable results were rendered that CRS was associated with depression compared with non-CRS (OR: 1. 240, 95% CI: 1. 237 ~ 1. 243), only-CVD (OR: 0. 646, 95% CI: 0. 644 ~ 0. 649), and only-CKD (OR: 1.432, 95% CI: 1.428 ~ 1.437) in a fully corrected model. Smooth curve fitting shows that the intersection point of the lines of CRS and non-CRS occurs at a higher value on the horizontal axis than the intersection point of the lines representing CVD and non-CVD. In the fully corrected model, AIP, TyG, and RC did not independently mediate the association between CRS and depression.

CONCLUSION

There was a significant association between CRS and depression and a linear relationship between AIP, TyG, and RC and depression. However, the above lipid indicators did not mediate the association between CRS and depression.

Recurrent Hospitalizations for Fluid Overload in Diabetes with Kidney Failure Treated with Dialysis

INTRODUCTION

Diabetes mellitus is the most common cause of end-stage kidney disease (ESKD) in Singapore. ESKD patients have high disease burden and are at increased risk of recurrent hospitalizations, including fluid overload. This study aimed to characterize the risk factors associated with readmissions for fluid overload that will identify high-risk hospitalizations for interventions to reduce readmissions.

METHODS

Retrospective cohort study of all hospitalizations for fluid overload in adults with diabetes and ESKD on dialysis in SingHealth hospitals between 2018 and 2021. Fluid overload was defined by discharge codes for fluid overload, heart failure, pulmonary edema, and generalized edema. Multivariable Cox regression analysis using the Prentice, Williams and Peterson Total Time model was performed for the outcomes of readmissions for fluid overload within 30 days and 90 days of discharge.

RESULTS

Among 3,234 hospitalizations for fluid overload, readmission for fluid overload within 30 days and 90 days occurred in 585 (18.1%) and 967 (29.9%) hospitalizations, respectively. Ischemic heart disease, peripheral vascular disease, and lower hemoglobin level were independently associated with readmissions for fluid overload within 30 and 90 days. Additionally, heart failure, hemodialysis (compared to peritoneal dialysis), and lack of statin at discharge were associated with increased 90-day readmission risk.

CONCLUSION

Modifiable (hemoglobin level, statin use) and non-modifiable factors (ischemic heart disease, peripheral vascular disease, and heart failure) influenced the risk of readmission for fluid overload. These results may guide risk stratification and inform targeted interventions to reduce avoidable, unplanned readmissions for recurrent fluid overload among individuals with diabetes and ESKD.

Cardiac Troponin to Adjudicate Subclinical Heart Failure in Diabetic Patients and a Murine Model of Metabolic Syndrome

BACKGROUND

Cardiovascular disease, kidney health, and metabolic disease (CKM) syndrome is associated with significant morbidity and mortality, particularly from congestive heart failure (CHF). Guidelines recommend measurement of cardiac troponin (cTn) to identify subclinical heart failure (HF) in diabetics/CKM. However, appropriate thresholds and the impact from routine screening have not been elucidated.

METHODS

cTnI was assessed using the Abbott high sensitivity (hs)-cTnI assay in outpatients with physician-ordered hemoglobin A1c (Hb A1c) and associated with cardiac comorbidities/diagnoses, demographics, and estimated glomerular filtration rate (eGFR). Risk thresholds used in CKM staging guidelines of >10 and >12 ng/L for females and males, respectively, were used. Multivariate logistic regression was applied. hs-cTnI was assessed in a high-fat-diet induced murine model of obesity and diabetes.

RESULTS

Of 1304 patients, 8.0% females and 15.7% males had cTnI concentrations above the risk thresholds. Thirty-one (4.2%) females and 23 (4.1%) males had cTnI above the sex-specific 99% upper reference limit. A correlation between hs-cTnI and Hb A1c (R = 0.2) and eGFR (R = -0.5) was observed. hs-cTnI concentrations increased stepwise based on A1C of <5.7% (median = 1.5, IQR:1.3-1.8), 5.7%-6.4% (2.1, 2.0-2.4), 6.5%-8.0% (2.8, 2.5-3.2), and >8% (2.8, 2.2-4.3). Male sex (P < 0.001), eGFR (P < 0.001), and CHF (P = 0.004) predicted elevated hs-cTnI. Obese and diabetic mice had increased hs-cTnI (7.3 ng/L, 4.2-10.4) relative to chow-fed mice (2.6 ng/L, 1.3-3.8).

CONCLUSION

A high proportion of outpatients with diabetes meet criteria for subclinical HF using hs-cTnI measurements. Glucose control is independently associated with elevated cTnI, a finding replicated in a murine model of metabolic syndrome.

A novel model of cardiovascular-kidney-metabolic syndrome combining unilateral nephrectomy and high-salt-sugar-fat diet in mice

The aim of this study was to explore biological interaction and pathophysiology mechanisms in a new mouse model of cardiovascular-kidney-metabolic (CKM) syndrome, induced by chronic moderate renal failure in combination with consumption of a customized Western diet rich in carbohydrates, fat and salt. Male C57BL/6J mice were subjected to unilateral nephrectomy, fed a customized Western diet rich not only in sugar and fat but also in salt, and followed for 12 weeks or 20 weeks. Sham-operated mice on a standard chow served as healthy controls. Body composition, weight gain, glucose metabolism, fat distribution, blood pressure, cardiac function, vascular reactivity, renal function, inflammation and mitochondrial function were measured and combined with biochemical and histopathological analyses. The novel triple-hit model of CKM syndrome showed signs and symptoms of metabolic syndrome, disturbed glucose metabolism, impaired adipocyte physiology and fat redistribution, cardiovascular dysfunction, renal damage and dysfunction, systemic inflammation, elevated blood pressure and cardiac remodeling. The pathological changes were more pronounced in mice after prolonged exposure for 20 weeks, but no deaths occurred. In the present mouse model of CKM syndrome, profound and significant metabolic, cardiac, vascular and renal dysfunctions and injuries emerged by using a Western diet rich not only in fat and carbohydrates but also in salt. This multisystem disease model could be used for mechanistic studies and the evaluation of new therapeutic strategies.

Cardiovascular phenotypes in type 2 diabetes: Latent class analysis of the CANVAS Program and CREDENCE trial

AIM

To identify unique clinical phenotypes in type 2 diabetes (T2D) and investigate their treatment response to canagliflozin using latent class analysis.

METHODS

This was a pooled latent class analysis of the individuals in the CANVAS Program and CREDENCE trial. The co-primary endpoints were hospitalization for heart failure (HHF) and the composite of cardiovascular death (CVD) or HHF. Secondary endpoints included three-point major adverse CV events, its individual components, and all-cause mortality. We completed Cox proportional hazards models to evaluate the effect of canagliflozin across phenotypes.

RESULTS

Four distinct phenotypes were identified: Phenotype 1 (n = 966, 6.6%), with the lowest prevalence of heart failure, kidney dysfunction and hypertension; Phenotype 2 (n = 4169, 28.7%), primarily comprising females with a high prevalence of atherosclerotic vascular disease (ASCVD); Phenotype 3 (n = 7108, 48.9%), predominately males with a high prevalence of ASCVD; and Phenotype 4 (n = 2300, 15.8%), possessing the highest prevalences of HF and renal dysfunction. A hierarchical increase in the risk of the primary endpoint was observed across the phenotypes, with the highest CV risk observed for Phenotype 4 (hazard ratio for HHF: 7.57 [95% CI: 4.19-13.69]). Canagliflozin significantly reduced HHF and the composite CVD or HHF across phenotypes (all P values for interaction > .05).

CONCLUSION

We identified four clinically distinct T2D phenotypes with differential CV risks. Canagliflozin reduced the risk of CV events, irrespective of the phenotype, emphasizing its broad therapeutic acceptability.

[Cardiovascular preventive recommendations. PAPPS 2024 thematic updates]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of vascular diseases (VD) are presented. New in this edition are new sections such as obesity, chronic kidney disease and metabolic hepatic steatosis, as well as a 'Don't Do' section in the different pathologies treated. The sections have been updated: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; vascular risk (VR) and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Cardiovascular-kidney-metabolic syndrome - An integrative review

The American Heart Association recently defined the complex interactions among the cardiovascular, renal, and metabolic systems as CKM syndrome. To promote better patient outcomes, having a more profound understanding of CKM pathophysiology and pursuing holistic preventative and therapy strategies is critical. Despite many gaps in understanding CKM syndrome, this study attempts to elucidate two of these gaps: the new emerging biomarkers for screening and the role of inflammation in its pathophysiology. For this review, an extensive search for specific terms was conducted in the following databases: PubMed, Scopus, Web of Science, and Google Scholar. Studies were first assessed by title, abstract, keywords, and selected for portfolio according to eligibility criteria, which led to 38 studies. They provided background information about CKM syndrome; data suggested that serum uric acid, leptin, aldosterone, bilirubin, soluble neprilysin, lipocalin-type-prostaglandin-D-synthase, and endocan could be valuable biomarkers for CKM screening; and finally, the inflammation role in CKM.

Cardiovascular-kidney-metabolic syndrome definition and its role in the prevention, risk staging, and treatment. An opportunity for the Nephrology

The recent conceptualization of the cardiovascular-kidney-metabolic (CKM) syndrome by the American Heart Association (AHA) opens an opportunity for a multidisciplinary and lifelong approach in the risk stratification, early prevention, and treatment of the vicious circle generated by the interaction of cardiovascular, renal and metabolic risk factors and aggravated by the development of cardiovascular diseases (including their full spectrum: heart failure, atrial fibrillation, coronary heart disease, stroke, and peripheral arterial disease), chronic kidney disease or type 2 diabetes mellitus, with the excess or dysfunctional adiposity as the trigger. Three publications offer the rational basis of a conceptual decalogue and action plan and a new cardiovascular risk stratification equation since the age of 30 that includes measures of renal function/damage, among others, to promote effective cardiovascular, renal, and metabolic prevention. In Spain, we must leverage this momentum to adapt these new concepts to our reality with greater and improved collaboration between primary care and the specialties involved in CKM syndrome, including the formation of multidisciplinary units for the optimal management using a patient-centred approach.

Mitigating Increased Cardiovascular Risk in Patients with Obstructive Sleep Apnea Using GLP-1 Receptor Agonists and SGLT2 Inhibitors: Hype or Hope?

Obstructive sleep apnea (OSA) is a prevalent condition associated with increased cardiovascular risk, particularly in individuals with comorbid obesity and type 2 diabetes (T2D). Despite the widespread use of continuous positive airway pressure (CPAP) for OSA management, adherence remains suboptimal, and CPAP has not consistently demonstrated reductions in surrogate cardiovascular events. Recently, attention has focused on glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors as potential therapeutic agents for mitigating cardiovascular risk in OSA patients. These agents, originally developed for T2D management, have demonstrated pleiotropic effects, including significant weight loss, blood pressure reduction, and amelioration of endothelial dysfunction and arterial stiffness, along with anti-inflammatory benefits, which may be particularly beneficial in OSA. Emerging clinical evidence suggests that GLP-1RAs and SGLT2 inhibitors can reduce OSA severity and improve daytime sleepiness, potentially reversing the adverse cardiovascular effects observed in OSA. This review explores the pathophysiological mechanisms linking OSA with cardiovascular disease and evaluates the potential therapeutic roles of GLP-1RAs and SGLT2 inhibitors in addressing cardiovascular risk in OSA patients. Further research, including long-term clinical trials, is necessary to establish the effectiveness of these therapies in reducing cardiovascular events and improving patients' reported outcomes in this population.

Integrated Cardiorespiratory Rehabilitation and Its Impact on Cardio-Renal-Metabolic Profile After Cardiac Surgery

BACKGROUND

Cardiovascular diseases (CVDs) and chronic kidney disease (CKD) are common causes of morbidity and mortality. However, the impact of changes in lifestyle and rehabilitation programs on the progression of cardiovascular, renal, and metabolic (CRM) conditions, remains unclear.

METHODS

In a retrospective manner, we analyzed charts of 200 patients admitted for cardiorespiratory rehabilitation at our facility in 2023. A 6 min walk test, echocardiographic features, and laboratory values were investigated to evaluate the impact of cardiorespiratory rehabilitation in patients post cardiac surgery. This study examined the impact of combined lifestyle and exercise scores (diet, alcohol consumption, smoking, aerobic physical activity, sedentary behavior, sleep duration, and social connection) on cardio-renal-metabolic profiles and on a quality-of-life score measured by the Borg Scale.

RESULTS

During the rehabilitation program, left ventricular ejection fraction (LVEF) significantly increased (51.2 vs. 54.3%, SEM 0.51 p = 0.001). The six-minute walk test (6 MWT) significantly improved in terms of meters (133 vs. 373 m, SEM 6.41, p < 0.001) and Borg scale (6.6 vs. 2.5, SEM 0.06, p < 0.001). Glycemia levels reduced significantly (114.5± vs. 107.4± mg/dL, SEM 2.45, p = 0.001). While total cholesterol levels (119.4 vs. 129.6 mg/dL, SEM 2.4, p < 0.001) as well as HDL levels (29.9 vs. 40 mg/dL, SEM 0.62, p < 0.001) significantly increased, triglyceride levels significantly decreased (128.5 vs. 122.1 mg/dL, SEM 3.8, p = 0.048). There was no change in LDL levels. Creatinine levels remained stable throughout the period of rehabilitation.

CONCLUSIONS

Cardiorespiratory rehabilitation has a significant impact on myocardial function, quality of life in terms of exercise capacity and symptoms (6 MWT) as well as laboratory levels relevant for cardiovascular prevention such as glycemia and lipid profile.

The association between county-level premature cardiovascular mortality related to cardio-kidney-metabolic disease and the social determinants of health in the US

Cardio-kidney-metabolic (CKM) syndrome is defined by the American Heart Association as the intersection between metabolic, renal and cardiovascular disease. Understanding the contemporary estimates of CKM related mortality and recent trends in the US is essential for developing targeted public interventions. We collected state-level and county-level CKM-associated age-adjusted premature cardiovascular mortality (aaCVM) (2010-2019) rates from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER). We linked the county-level aaCVM with a multi-component social deprivation metric: the Social Deprivation Index (SDI: range 0-100) and grouped them as follows: I: 0-25, II: 26-50, III: 51-75, and IV: 76-100. We conducted pair-wise comparison of aaCVM between SDI groups with the multiplicity adjusted Wilcoxon test; we compared aaCVM in men versus women, metropolitan versus nonmetropolitan counties, and non-hispanic white versus non-hispanic black residents. In 3101 analyzed counties in the US, the median CKM associated aaCVM was 61 [interquartile range (IQR): 45, 82]/100 000. Mississippi (99/100 000) and Minnesota (33/100 000) had the highest and lowest values respectively. CKM associated aaMR increased across SDI groups [I - 45 (IQR: 36, 55)/100 000, II- 61 (IQR: 49, 77)/100 000, III- 77 (IQR: 61, 94)/100 000, IV- 89 (IQR: 70, 110)/100 000; all pair-wise p-values < 0.001]. Men had higher rates [85 (64, 91)/100 000] than women [41 (28, 58)/100 000](p-value < 0.001), metropolitan counties [54 (40, 72)/100 000] had lower rates than non-metropolitan counties [66 (49, 90)/100 000](p-value < 0.001), and non-Hispanic Black [110 (86, 137)/100 000] had higher aaMR than non-Hispanic White residents [59 (44, 78)/100 000](p-value < 0.001). In the US, CKM mortality remains high and disproportionately occurs in more socially deprived counties and non-metropolitan counties. Our inability to reduce CKM mortality rates over the study period highlights the need for targeted policy interventions to curb the ongoing high burden.

Comprehensive Evaluation of the Cardiovascular Protective Effects of Sodium-Glucose Cotransporter 2 Inhibitors in Patients with Advanced Chronic Kidney Disease: A Real-World Evidence

INTRODUCTION

Diabetes, kidney disease, and cardiovascular disease have complex interactions and coexistences that significantly worsen a patient's overall health. Previous research results have shown that SGLT2i hypoglycemic drugs can not only effectively control blood sugar in diabetic patients but also protect the kidneys and heart. This study further focuses on diabetic patients with kidney disease to explore the effectiveness of using SGLT2i hypoglycemic drugs in avoiding heart-related complications or death.

METHODS

This is a multicenter retrospective cohort study using the Taipei Medical University Clinical Research Database (TMUCRD) as the data source. This study selected patients who suffered from both type 2 diabetes and chronic kidney disease from 1 January 2008 to 31 December 2020, as the research team. Integrated or separate 4-point major adverse cardiovascular events (4P-MACE) and mortality were the outcomes of this study. The Kaplan-Meier curves method and Cox proportional hazard regression analysis were used to explore the association between each influencing factor and the outcome.

RESULTS

A total of 5,005 patients with type 2 diabetes and CKD were included in this study, of which 524 patients were stably treated with SGLT2i, 3,952 patients were treated with DPP4i, and 529 patients were treated with TZD. The results showed that the SGLT2i user group had a significantly lower risk of 4P-MACE compared with the SGLT2i nonuser group (hazard ratio [HR]: 0.68, 95% CI [0.49, 0.95], p = 0.024). The SGLT2i group had a significantly lower risk of cardiovascular mortality compared with the DPP4i and TZD groups (HR: 0.37, 95% CI [0.21, 0.65], p < 0.001; HR: 0.42, 95% CI [0.20, 0.90], p = 0.025).

CONCLUSION

This study found that for patients with both diabetes and kidney disease, SGLT2i is a better option than other oral hypoglycemic medications because it can significantly avoid the occurrence of heart-related complications. The results of this study can be used as a reference for clinical medication selection practice.

Metabolic syndrome

The metabolic syndrome (MetS) is a multiplex modifiable risk factor for cardiovascular disease, type 2 diabetes mellitus and other health outcomes, and is a major challenge to clinical practice and public health. The rising global prevalence of MetS, driven by urbanization, sedentary lifestyles and dietary changes, underlines the urgency of addressing this syndrome. We explore the complex underlying mechanisms, including genetic predisposition, insulin resistance, accumulation of dysfunctional adipose tissue and ectopic lipids in abdominal obesity, systemic inflammation and dyslipidaemia, and how they contribute to the clinical manifestations of MetS. Diagnostic approaches vary but commonly focus on abdominal obesity (assessed using waist circumference), hyperglycaemia, dyslipidaemia and hypertension, highlighting the need for population-specific and phenotype-specific diagnostic strategies. Management of MetS prioritizes lifestyle modifications, such as healthy dietary patterns, physical activity and management of excess visceral and ectopic adiposity, as foundational interventions. We also discuss emerging therapies, including new pharmacological treatments and surgical options, providing a forward-looking perspective on MetS research and care. This Primer aims to inform clinicians, researchers and policymakers about MetS complexities, advocating for a cohesive, patient-centred management and prevention strategy. Emphasizing the multifactorial nature of MetS, this Primer calls for integrated public health efforts, personalized care and innovative research to address this escalating health issue.

Exploring Adiposity and Chronic Kidney Disease: Clinical Implications, Management Strategies, Prognostic Considerations

Obesity poses a significant and growing risk factor for chronic kidney disease (CKD), requiring comprehensive evaluation and management strategies. This review explores the intricate relationship between obesity and CKD, emphasizing the diverse phenotypes of obesity, including sarcopenic obesity and metabolically healthy versus unhealthy obesity, and their differential impact on kidney function. We discuss the epidemiological evidence linking elevated body mass index (BMI) with CKD risk while also addressing the paradoxical survival benefits observed in obese CKD patients. Various measures of obesity, such as BMI, waist circumference, and visceral fat assessment, are evaluated in the context of CKD progression and outcomes. Mechanistic insights into how obesity promotes renal dysfunction through lipid metabolism, inflammation, and altered renal hemodynamics are elucidated, underscoring the role of adipokines and the renin-angiotensin-aldosterone system. Furthermore, the review examines current strategies for assessing kidney function in obese individuals, including the strengths and limitations of filtration markers and predictive equations. The management of obesity and associated comorbidities like arterial hypertension, type 2 diabetes mellitus, and non-alcoholic fatty liver disease in CKD patients is discussed. Finally, gaps in the current literature and future research directions aimed at optimizing the management of obesity-related CKD are highlighted, emphasizing the need for personalized therapeutic approaches to mitigate the growing burden of this intertwined epidemic.

Association between different stages of cardiovascular-kidney-metabolic syndrome and the risk of all-cause mortality

BACKGROUND AND AIMS

Poor cardiovascular-kidney-metabolic (CKM) health is a major determinant of all-cause mortality, which poses a significant burden on global public health systems and socio-economics. However, the association between different stages of CKM syndrome and the risk of all-cause mortality remains unclear. This study aimed to evaluate the association between different stages of CKM syndrome and risk of all-cause mortality.

METHODS

A total of 97,777 adults from the Kailuan Study were included. Cox proportional hazards regression models were applied to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) of all-cause mortality according to different stages of CKM syndrome.

RESULTS

Over a median follow-up of 15.0 (14.7-15.2) years, we identified 14,805 all-cause mortality cases. The stage of CKM syndrome was positively associated with the risk of all-cause mortality (p-trend <0.001). Compared with Stage 0, the multivariable-adjusted HRs (95 % CIs) of all-cause mortality were 1.24 (1.06-1.45) for Stage 1, 1.72 (1.48-2.00) for Stage 2, 2.58 (2.22-3.01) for Stage 3 and 3.73 (3.19-4.37) for Stage 4. Moreover, the observed associations were more pronounced in younger adults (aged <60 years) compared with older adults (p for interaction <0.001).

CONCLUSIONS

Our data showed that a higher stage of CKM syndrome was associated with a higher risk of all-cause mortality, with a particularly pronounced association observed in younger adults. The study emphasized the need for targeted public health strategies and clinical management tailored to the stages of CKM syndrome, aiming to alleviate its burden on individuals and healthcare systems.

Comparative effectiveness of positron emission tomography and single-photon emission computed tomography myocardial perfusion imaging for predicting risk in patients with cardiometabolic disease

BACKGROUND

The epidemiology of coronary artery disease (CAD) has shifted, with increasing prevalence of cardiometabolic disease and decreasing findings of obstructive CAD on myocardial perfusion imaging (MPI). Coronary microvascular dysfunction (CMD), defined as impaired myocardial flow reserve (MFR) by positron emission tomography (PET), has emerged as a key mediator of risk. We aimed to assess whether PET MFR provides additive value for risk stratification of cardiometabolic disease patients compared with single-photon emission computed tomography (SPECT) MPI.

METHODS

We retrospectively followed patients referred for PET, exercise SPECT, or pharmacologic SPECT MPI with cardiometabolic disease (obesity, diabetes, or chronic kidney disease) and without known CAD. We compared rates and hazards of composite major adverse cardiovascular events (MACEs) (annualized cardiac mortality or acute myocardial infarction) among propensity-matched PET and SPECT patients using Poisson and Cox regression. Normal SPECT was defined as a total perfusion deficit (TPD) of <5%, reflecting the absence of obstructive CAD. Normal PET was defined as a TPD of <5% plus an MFR of ≥2.0.

RESULTS

Among 21,544 patients referred from 2006 to 2020, cardiometabolic disease was highly prevalent (PET: 2308 [67%], SPECT: 9984 [55%]) and higher among patients referred to PET (P < 0.001). Obstructive CAD findings (TPD > 5%) were uncommon (PET: 21% and SPECT: 11%). Conversely, impaired MFR on PET (<2.0) was common (62%). In a propensity-matched analysis over a median 6.4-year follow-up, normal PET identified low-risk (0.9%/year MACE) patients, and abnormal PET identified high-risk (4.2%/year MACE) patients with cardiometabolic disease; conversely, those with normal pharmacologic SPECT remained moderate-risk (1.6%/year, P < 0.001 compared to normal PET).

CONCLUSIONS

Cardiometabolic disease is common among patients referred for MPI and is associated with a heterogenous level of risk. Compared with pharmacologic SPECT, PET with MFR can detect nonobstructive CAD including CMD and can more accurately discriminate low-risk from higher-risk individuals.

Impact of primary aldosteronism on kidney function: results from the SPAIN-ALDO registry

AIM

To evaluate the impact of aldosterone excess on renal function in individuals with primary aldosteronism and to compare its evolution after surgery or mineralocorticoid receptor antagonist (MRA) treatment.

METHODS

A multicentre, retrospective cohort study of primary aldosteronism patients in follow-up in 36 Spanish tertiary hospitals, who underwent specific treatment for primary aldosteronism (MRA or adrenalectomy).

RESULTS

A total of 789 patients with primary aldosteronism were included, with a median age of 57.5 years and 41.8% being women. At primary aldosteronism diagnosis, the prevalence of chronic kidney disease (CKD) was 10.7% ( n  = 84), with 75% of cases classified as state 3a ( n  = 63). Primary aldosteronism patients with CKD had a longer duration of hypertension, a higher prevalence of type 2 diabetes, dyslipidaemia, cardiovascular events, hypokalaemia, and albuminuria. Unilateral adrenalectomy was performed in 41.8% of cases ( n  = 330), and 459 patients were treated with MRA. After a median follow-up of 30.7 months (range 13.3-68.4), there was a significant decline in the estimated glomerular filtration rate (eGFR) in operated patients and those receiving MRA. During follow-up, 24.4% of patients with CKD at the time of primary aldosteronism diagnosis had normalized renal function, and 39% of those with albuminuria had albuminuria remission. There were no differences in renal function or albuminuria regression between the two therapy groups. However, development of albuminuria was less common in operated than in medically treated patients (0 vs. 6.0%, P  = 0.009).

CONCLUSION

CKD affects around 10% of the patients with primary aldosteronism, with a higher risk in individuals with long-term hypertension, type 2 diabetes, dyslipidaemia, cardiovascular events, hypokalaemia, and albuminuria. At short-term, both MRA and surgical treatment lead to a reduction of renal function, but adrenalectomy led to higher renal protection.

High-intensity interval training improves cardiomyocyte contractile function and myofilament sensitivity to intracellular Ca2+ in obese rats

High-intensity interval training (HIIT) has shown significant results in addressing adiposity and risk factors associated with obesity. However, there are no studies that investigate the effects of HIIT on contractility and intracellular Ca2+ handling. The purpose of this study was to explore the impact of HIIT on cardiomyocyte contractile function and intracellular Ca2+ handling in rats in which obesity was induced by a saturated high-fat diet (HFD). Male Wistar rats were initially randomized into a standard diet and a HFD group. The experimental protocol spanned 23 weeks, comprising the induction and maintenance of obesity (15 weeks) followed by HIIT treatment (8 weeks). Performance was assessed using the maximum oxygen consumption test (V ̇ O 2 max ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{max}}}}$ ). Evaluation encompassed cardiac, adipose and skeletal muscle histology, as well as contractility and intracellular Ca2+ handling. HIIT resulted in a reduction in visceral area, an increase inV ̇ O 2 max ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{max}}}}$ , and an augmentation of gastrocnemius fibre diameter in obese subjects. Additionally, HIIT led to a decrease in collagen fraction, an increase in percentage shortening, and a reduction in systolic Ca2+/percentage shortening and systolic Ca2+/maximum shortening rates. HIIT induces physiological cardiac remodelling, enhancing the contractile function of cardiomyocytes and improving myofilament sensitivity to Ca2+ in the context of obesity. This approach not only enhances cardiorespiratory and physical performance but also reduces visceral area and prevents interstitial fibrosis.

Metabolic dysfunction-associated fatty liver disease: bridging cardiology and hepatology

Non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver diseases, affecting approximately 30% of the global adult population, with a rise largely attributed to increasing rates of obesity and diabetes worldwide. Historically, the term “NAFLD” did not explicitly link the condition to its most common causes, such as obesity and diabetes, or its principal pathophysiological mechanisms, including insulin resistance and low-grade chronic metabolic inflammation. This semantic laxity has potentially reduced attempts at screening, diagnosis, and management. The shift to using the terms metabolic-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) reflects a more accurate understanding of the condition’s metabolic origins and highlights its broader implications, particularly its link to cardiovascular diseases. MAFLD/MASLD represents a convergence point between hepatology and cardiology, with metabolic dysfunction serving as the bridge between liver pathology and increased cardiovascular risk. Growing clinical evidence reveals a strong association between MAFLD/MASLD and cardiovascular morbidity and mortality. Despite this, cardiovascular risks associated with MAFLD/MASLD are often underestimated, especially among cardiologists. This narrative review explores the potential clinical implications of MAFLD/MASLD for cardiology practice, examining diagnostic criteria, cardiovascular risk assessment, adjustments in clinical practice, collaborative care strategies, treatment options, and directions for future research.

Projected Changes in Statin and Antihypertensive Therapy Eligibility With the AHA PREVENT Cardiovascular Risk Equations

Importance

Since 2013, the American College of Cardiology (ACC) and American Heart Association (AHA) have recommended the pooled cohort equations (PCEs) for estimating the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). An AHA scientific advisory group recently developed the Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations, which incorporated kidney measures, removed race as an input, and improved calibration in contemporary populations. PREVENT is known to produce ASCVD risk predictions that are lower than those produced by the PCEs, but the potential clinical implications have not been quantified.

Objective

To estimate the number of US adults who would experience changes in risk categorization, treatment eligibility, or clinical outcomes when applying PREVENT equations to existing ACC and AHA guidelines.

Design, Setting, and Participants

Nationally representative cross-sectional sample of 7765 US adults aged 30 to 79 years who participated in the National Health and Nutrition Examination Surveys of 2011 to March 2020, which had response rates ranging from 47% to 70%.

Main Outcomes and Measures

Differences in predicted 10-year ASCVD risk, ACC and AHA risk categorization, eligibility for statin or antihypertensive therapy, and projected occurrences of myocardial infarction or stroke.

Results

In a nationally representative sample of 7765 US adults aged 30 to 79 years (median age, 53 years; 51.3% women), it was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories (53.0% [95% CI, 51.2%-54.8%]) and very few US adults to higher risk categories (0.41% [95% CI, 0.25%-0.62%]). The number of US adults receiving or recommended for preventive treatment would decrease by an estimated 14.3 million (95% CI, 12.6 million-15.9 million) for statin therapy and 2.62 million (95% CI, 2.02 million-3.21 million) for antihypertensive therapy. The study estimated that, over 10 years, these decreases in treatment eligibility could result in 107 000 additional occurrences of myocardial infarction or stroke. Eligibility changes would affect twice as many men as women and a greater proportion of Black adults than White adults.

Conclusion and Relevance

By assigning lower ASCVD risk predictions, application of the PREVENT equations to existing treatment thresholds could reduce eligibility for statin and antihypertensive therapy among 15.8 million US adults.

A comprehensive review of finerenone-a third-generation non-steroidal mineralocorticoid receptor antagonist

Multiple studies have shown that finerenone (BAY 94-8862), a third-generation non-steroidal mineralocorticoid receptor antagonist (MRA), possesses different or superior mechanisms of action to traditional MRAs. Specifically, animal and cell-based experiments have demonstrated that this compound exerts multiple effects including fibrosis inhibition, reduced pulmonary artery pressure, improved diabetic retinopathy, enhanced endothelial functions, metabolic optimization as well as reduced oxidative stress, thereby exerting overall positive effects on renal and cardiovascular diseases. Consequently, clinical research, such as the FIGARO-DKD and FIDELIO-DKD trials, has demonstrated dual benefits for patients with type 2 diabetes mellitus and chronic kidney disease (T2DM-CKD), especially by validating MRAs' potential in reducing risks of renal and cardiovascular composite endpoints. Currently, cardiovascular indications for finerenone are limited to patients with T2DM-CKD, while its use in non-T2DM CKD patients remains at clinical trial stages. Despite showing good safety and efficacy in T2DM-CKD patients, there are insufficient corresponding data for those presenting chronic kidney disease without diabetes (ndCKD). Furthermore, the application of this compound in diseases such as primary aldosteronism and its association with cancer risk need to be further validated through larger-scale and longer-term clinical studies. Nevertheless, the development of finerenone provides an additional option for treating cardiovascular and renal diseases. With further research, it is expected that finerenone will be relevant to a broader range of CKD patient populations by addressing current knowledge gaps to comprehensively evaluate its clinical value and potentially alter existing treatment strategies. The current review aims to comprehensively analyze the basic research and clinical advancements involving finerenone in order to explore its prospects for treating cardiovascular and renal diseases, while addressing unmet needs in current treatment strategies. Additionally, through a comprehensive analysis of relevant research findings, a deeper understanding of finerenone's drug characteristics will be provided alongside scientific guidance for future treatment strategies and their clinical significance.

A Risk Prediction Model for New-Onset Chronic Kidney Disease in the Elderly

INTRODUCTION

Worsening renal function poses a significant health risk to elderly individuals. This study aimed to construct a simple risk prediction model for new-onset chronic kidney disease (CKD) among elderly populations.

METHODS

In this retrospective cohort study, 5,416 elderly residents (aged ≥65 years) who underwent physical examinations as part of the National Basic Public Health Service project at least twice between January 2017 and July 2021 were included. The endpoint was new-onset CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 during the follow-up period. Predictors of new-onset CKD were selected using multivariable Cox regression and a stepwise approach. A risk prediction model based on the selected predictors was constructed and evaluated using the concordance index (C-index) and area under curve (AUC). External validation was conducted to verify the model's performance.

RESULTS

During the median follow-up period of 2.3 years, the incident of new-onset CKD was 20.1% (n = 1,088). Age, female gender, diabetes, elevated triglyceride levels, and baseline eGFR were selected as predictors. The model demonstrated good predictive performance across the cohort, with a C-index of 0.802. The AUCs for 2-year, 3-year, and 4-year predictions were 0.831, 0.829, and 0.839, respectively. External validation confirmed the model's efficacy, with a 2-year AUC of 0.735.

CONCLUSION

This study developed a simple yet effective risk prediction model for new-onset CKD among elderly populations. The model facilitates prompt identification of elderly individuals at risk of renal function decline in primary care, enabling timely interventions.

Research hotspots and future trends in lipid metabolism in chronic kidney disease: a bibliometric and visualization analysis from 2004 to 2023

Background

Disorders of lipid metabolism play a key role in the initiation and progression of chronic kidney disease (CKD). Recently, research on lipid metabolism in CKD has rapidly increased worldwide. However, comprehensive bibliometric analyses in this field are lacking. Therefore, this study aimed to evaluate publications in the field of lipid metabolism in CKD over the past 20 years based on bibliometric analysis methods to understand the important achievements, popular research topics, and emerging thematic trends.

Methods

Literature on lipid metabolism in CKD, published between 2004 and 2023, was retrieved from the Web of Science Core Collection. The VOSviewer (v.1.6.19), CiteSpace (v.6.3 R1), R language (v.4.3.2), and Bibliometrix (v.4.1.4) packages (https://www.bibliometrix.org) were used for the bibliometric analysis and visualization. Annual output, author, country, institution, journal, cited literature, co-cited literature, and keywords were also included. The citation frequency and H-index were used to evaluate quality and influence.

Results

In total, 1,285 publications in the field of lipid metabolism in CKD were identified in this study. A total of 7,615 authors from 1,885 institutions in 69 countries and regions published articles in 466 journals. Among them, China was the most productive (368 articles), and the United States had the most citations (17,880 times) and the highest H-index (75). Vaziri Nosratola D, Levi Moshe, Fornoni Alessia, Zhao Yingyong, and Merscher Sandra emerged as core authors. Levi Moshe (2,247 times) and Vaziri Nosratola D (1,969 times) were also authors of the top two most cited publications. The International Journal of Molecular Sciences and Kidney International are the most published and cited journals in this field, respectively. Cardiovascular disease (CVD) and diabetic kidney disease (DKD) have attracted significant attention in the field of lipid metabolism. Oxidative stress, inflammation, insulin resistance, autophagy, and cell death are the key research topics in this field.

Conclusion

Through bibliometric analysis, the current status and global trends in lipid metabolism in CKD were demonstrated. CVD and DKD are closely associated with the lipid metabolism of patients with CKD. Future studies should focus on effective CKD treatments using lipid-lowering targets.

Appropriateness of Ketoanalogues of Amino Acids, Calcium Citrate, and Inulin Supplementation for CKD Management: A RAND/UCLA Consensus

BACKGROUND

Current treatment for chronic kidney disease (CKD) focuses on improving manifestations and delaying progression. Nutritional approaches play a crucial role in CKD management, and various supplements have become available. Ketoanalogues of amino acids (KAs), calcium citrate, and inulin have been proposed as suitable supplements, yet their widespread use has been limited due to insufficient evidence. This study aimed to generate general guidance statements on the appropriateness of these supplements through a RAND/UCLA consensus process.

METHODS

A RAND/UCLA consensus panel was convened to evaluate the appropriateness of these supplements in different clinical scenarios. In this study, we present a subgroup analysis focusing on a panel of eleven clinical nephrologists from among the experts.

RESULTS

Supplementation of low-protein diets (LPDs) and very low-protein diets (VLPDs) with KA was considered appropriate to reduce manifestations and delay CKD outcomes, supplementation with calcium citrate is considered appropriate to reduce CKD manifestations, and supplementation with inulin is considered appropriate to delay CKD outcomes and manage comorbidities.

CONCLUSIONS

Based on a combination of clinical experience and scientific evidence, the panel reached a consensus that KA supplementation of LPD and VLPD, calcium citrate, and inulin are appropriate in patients with CKD across various scenarios.

Predicted Cardiovascular Risk by the PREVENT Equations in US Adults With Stage 1 Hypertension

BACKGROUND

The 2017 American College of Cardiology/American Heart Association blood pressure guideline recommends initiation of antihypertensive medication for adults with stage 1 hypertension (systolic blood pressure, 130-139 mm Hg, or diastolic blood pressure, 80-89 mm Hg) and 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10% estimated by the pooled cohort equations (PCEs). In 2023, the American Heart Association published the predicting risk of cardiovascular disease events (PREVENT) equations to estimate ASCVD and total cardiovascular disease risk.

METHODS

We analyzed US National Health and Nutrition Examination Survey data from 2013 to 2020 for 1703 adults aged 30 to 79 years without self-reported cardiovascular disease with stage 1 hypertension. We estimated 10-year ASCVD risk by the PCEs and 10-year ASCVD and total cardiovascular disease risk by the base PREVENT equations. Analyses were weighted to represent noninstitutionalized US adults with stage 1 hypertension.

RESULTS

Mean 10-year ASCVD risk was 5.4% (95% CI, 5.0%-5.9%) and 2.9% (95% CI, 2.7%-3.1%) using the PCEs and PREVENT equations, respectively. The proportion with 10-year ASCVD risk of 10% to <15% and ≥15% was 8.1% and 7.8% estimated by the PCEs, respectively, and 3.0% and 0.3% estimated by the PREVENT equations, respectively. No participants had a 10-year ASCVD risk ≥10% on the PREVENT equations and <10% on the PCEs, while 12.5% had a 10-year ASCVD risk ≥10% on the PCEs and <10% on the PREVENT equations. The mean 10-year total cardiovascular disease risk estimated by the PREVENT equations was lower than the mean 10-year ASCVD risk on the PCEs.

CONCLUSIONS

Among US adults with stage 1 hypertension, the 10-year predicted ASCVD risk estimated by the PREVENT equations was approximately half the risk estimated by the PCEs.

Cyy-272, an indazole derivative, effectively mitigates obese cardiomyopathy as a JNK inhibitor

Obesity has shown a global epidemic trend. The high-lipid state caused by obesity can maintain the heart in a prolonged low-grade inflammatory state and cause ventricular remodeling, leading to a series of pathologies, such as hypertrophy, fibrosis, and apoptosis, which eventually develop into obese cardiomyopathy. Therefore, prolonged low-grade inflammation plays a crucial role in the progression of obese cardiomyopathy, making inflammation regulation an essential strategy for treating this disease. Cyy-272, an indazole derivative, is an anti-inflammatory compound independently synthesized by our laboratory. Our previous studies revealed that Cyy-272 can exert anti-inflammatory effects by inhibiting the phosphorylation and activation of C-Jun N-terminal kinase (JNK), thereby alleviating lipopolysaccharide (LPS)-induced acute lung injury (ALI). The current study aimed to evaluate the potential of Cyy-272 to mitigate the occurrence and progression of obese cardiomyopathy through the inhibition of the JNK signaling pathway. Our results indicate that the compound Cyy-272 has encouraging therapeutic effects on obesity-induced cardiac injury. It significantly inhibits inflammation in cardiomyocytes and heart tissues induced by high lipid concentrations, further alleviating the resulting hypertrophy, fibrosis, and apoptosis. Mechanistically, the protective effect of Cyy-272 on obese cardiomyopathy can be attributed to its direct inhibition of JNK protein phosphorylation. In conclusion, we identified a novel compound, Cyy-272, capable of alleviating obese cardiomyopathy and confirmed that its effect is achieved through direct inhibition of JNK.

The impact of population ageing on the burden of chronic kidney disease

The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.

Integrating liver endpoints in clinical trials of cardiovascular and kidney disease

The intersection of cardiovascular disease, metabolic disorders and chronic kidney disease represents a complex clinical picture challenging healthcare systems worldwide. Metabolic-dysfunction-associated steatotic liver disease (MASLD) often manifests sequentially or concomitantly with these diseases, and may share underlying mechanisms and risk factors. Growing evidence suggests that new therapies could have benefits across these diseases, but trial sponsors and investigators tend to be reluctant to include patients with comorbidities-particularly liver diseases-in clinical trials. In this Perspective, we call for inclusion of patients with MASLD and measurement of liver outcomes in cardio-kidney-metabolic trials, when data suggest mechanistically plausible benefits and liver and cardiovascular safety. We discuss the implications of this new paradigm for clinical trial design and considerations for regulatory approval. Finally, we outline the challenges to implementing such an approach and provide recommendations for future clinical trial conduct.

Combination of Cardiovascular, Kidney, and Metabolic Diseases in a Syndrome Named Cardiovascular-Kidney-Metabolic, With New Risk Prediction Equations

Associations of chronic kidney disease (CKD) with metabolic syndrome and cardiovascular disease (CVD) have long been recognized. Until recently, such associations were mainly limited to interrelationships between either heart and kidney, heart and metabolic syndrome, or metabolic syndrome and kidney. It is the merit of the American Heart Association (AHA) to have set up a work group of cardiologists, endocrinologists, and nephrologists for the purpose of combining all 3 disorders in a single entity, as an appreciation of their pathophysiological interrelatedness. To this end, they proposed the term cardiovascular-kidney-metabolic (CKM) syndrome, which reflects multidirectional relationships among metabolic risk factors, CKD, and the cardiovascular system. Following a consensus approach in defining CKM with 5 stages, the work group subsequently developed new risk prediction equations, named predicting risk of CVD events (PREVENT) equations, which included estimated glomerular filtration rate (eGFR) and albuminuria as variables in addition to traditional cardiovascular and metabolic factors. Despite several limitations, this development is a major step forward in cardiovascular risk prediction. Its clinical application should translate into earlier, more appropriate treatment and prevention of CKM syndrome.