Cardiorenal Biomarkers, Canagliflozin, and Outcomes in Diabetic Kidney Disease: The CREDENCE Trial

A validated multivariable machine learning model to predict cardio-kidney risk in diabetic kidney disease

BACKGROUND

Individuals with diabetic kidney disease (DKD) often suffer cardiac and kidney events. We sought to develop an accurate means by which to stratify risk in DKD.

METHODS

Clinical variables and biomarkers were evaluated for their ability to predict the adjudicated primary composite endpoint of CREDENCE (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation) by 3 years. Using machine learning techniques, a parsimonious risk algorithm was developed.

RESULTS

The final model included age, body-mass index, systolic blood pressure, and concentrations of N-terminal pro-B type natriuretic peptide, high sensitivity cardiac troponin T, insulin-like growth factor binding protein-7 and growth differentiation factor-15. The model had an in-sample C-statistic of 0.80 (95% CI = 0.77-0.83; P < 0.001). Dividing results into low, medium and high risk categories, for each increase in level the hazard ratio increased by 3.43 (95% CI = 2.72-4.32; P < 0.001). Low risk scores had negative predictive value of 94%, while high risk scores had positive predictive value of 58%. Higher values were associated with shorter time to event (log rank P < 0.001). Rising values at 1 year predicted higher risk for subsequent DKD events. Canagliflozin treatment reduced score results by 1 year with consistent event reduction across risk levels. Accuracy of the risk model was validated in separate cohorts from CREDENCE and the generally lower risk Canagliflozin Cardiovascular Assessment Study.

CONCLUSIONS

We describe a validated risk algorithm that accurately predicts cardio-kidney outcomes across a broad range of baseline risk.

TRIAL REGISTRATION

CREDENCE (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation; NCT02065791) and CANVAS (Canagliflozin Cardiovascular Assessment Study; NCT01032629/NCT01989754).

Intensive Lifestyle Intervention, Cardiac Biomarkers, and Cardiovascular Outcomes in Diabetes: Look AHEAD Cardiac Biomarker Ancillary Study

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) are associated with cardiovascular outcomes and are recommended for measurement in type 2 diabetes (T2D). However, the effects of an intensive lifestyle intervention (ILI) targeting weight loss on cardiac biomarkers and the prognostic association of changes in these biomarkers with risk of adverse cardiovascular outcomes in T2D are not well-established.

OBJECTIVES

This study sought to evaluate the effects of an ILI on cardiac biomarkers and the association of changes in cardiac biomarkers with risk of cardiovascular outcomes in T2D.

METHODS

Participants of the Look AHEAD (Action for Health in Diabetes) trial underwent NT-proBNP and hs-cTnT measurement at baseline (N = 3,984) and 1 and 4 years. The effects of the ILI (vs diabetes support and education [DSE]) on cardiac biomarkers were assessed using adjusted linear mixed-effect models and summarized as geometric mean ratios (GMRs). Associations of longitudinal changes in cardiac biomarkers with risk of cardiovascular outcomes were assessed using adjusted Cox models.

RESULTS

Average baseline NT-proBNP and hs-cTnT was 77 and 10.7 ng/L, respectively. The ILI (vs DSE) led to an increase in NT-proBNP at 1 year (GMR: 1.14; 95% CI: 1.08-1.20), but this difference was attenuated by 4 years (GMR: 1.01; 95% CI: 0.96-1.07). The ILI (vs DSE) led to lower hs-cTnT at 1 year (GMR: 0.94; 95% CI: 0.91-0.97) and 4 years (GMR: 0.93; 95% CI: 0.90-0.96). Participants with meaningful weight loss by 1 year (≥5% vs <5%) had a significant increase in NT-proBNP in the short term (year 1), which attenuated in the long-term follow-up (year 4). Meaningful 1-year weight loss was significantly associated with reduction in hs-cTnT in the long term. In adjusted Cox models, increase in NT-proBNP was significantly associated with higher risk of the composite atherosclerotic cardiovascular disease (ASCVD) outcome and incident heart failure independent of baseline measure of the cardiac biomarker and changes in risk factors. In contrast, longitudinal increase in hs-cTnT was significantly associated with higher risk of the composite ASCVD outcome but not incident heart failure in the most adjusted model.

CONCLUSIONS

Among adults with T2D, an ILI led to a significant reduction in hs-cTnT on follow-up but a transient increase in NT-proBNP levels at 1 year that attenuated over time. Longitudinal assessment of NT-proBNP and hs-cTnT provide prognostic information for ASCVD risk, whereas only changes in NT-proBNP predicted HF risk.

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.

N-terminal pro-B-type natriuretic peptide, eGFR, and progression of kidney disease in chronic kidney disease patients without heart failure

Background

Cardiorenal syndrome highlights the bidirectional relationship between kidney and heart dysfunction. N-terminal pro-B-type natriuretic peptide (NT-proBNP), which is the gold standard biomarker in heart failure (HF), may be an important biomarker for chronic kidney disease (CKD) progression. However, NT-proBNP is negatively related with estimated glomerular filtration rate (eGFR). In this study, we investigated the association of NT-proBNP, eGFR, and progression of kidney disease in CKD patients without HF.

Methods

This multicentric retrospective cohort study recruited 23 860 CKD patients without HF, who had at least one NT-proBNP record from China Renal Data System database. Linear regression model evaluated the relationship between eGFR and NT-proBNP. Cox regression analysis assessed the association between NT-proBNP and CKD progression. Sensitivity analysis examined the robustness of the main findings.

Results

This study involved 23 860 CKD patients without HF, distributed across different CKD stages: 10 526 in stages G1-2, 4665 in G3a, 3702 in G3b, 2704 in G4, and 2263 in G5. NT-proBNP was negatively correlated with eGFR, particularly in stages 4-5 CKD. A 15-unit decrease in eGFR was associated with increases in log (NT-proBNP) levels by 1.04-fold, 1.27-fold, 1.29-fold, 1.80-fold, and 3.50-fold for stages 1-2, 3a, 3b, 4, and 5, respectively. After excluding patients who developed CKD progression within 1 year, the Cox regression analysis revealed that the relationship between NT-proBNP and CKD progression was not significant in stages 4 and 5. However, for stages 1-3, each standard deviation increase in log (NT-proBNP) was associated with a 26%, 36%, and 28% higher risk of CKD progression, with P interaction ≤.001. The hazard ratios were 1.26 (95% confidence intervals (CI), 1.18 to 1.35), 1.36 (95% CI, 1.22 to 1.51), and 1.28 (95% CI, 1.14 to 1.43) for stages 1-2, stage 3a, and stage 3b, respectively.

Conclusions

Despite its strong inverse association with eGFR, NT-proBNP was positively associated with the risk of progression of kidney disease in CKD patients with stages 1-3 without HF. Future studies should investigate the effectiveness of NT-proBNP as a predictive biomarker for the progression of kidney disease across diverse racial groups and healthcare settings.

Insulin-like growth factor binding protein-7 concentrations in chronic heart failure: Results from the EMPEROR programme

AIMS

Insulin-like growth factor binding protein-7 (IGFBP7) is a biomarker of tissue senescence with a role in cardio-renal pathophysiology. The role of IGFBP7 as a prognostic biomarker across the full ejection fraction (EF) spectrum of heart failure (HF) remains less well understood. We examined associations between IGFBP7 and risk of cardio-renal outcomes regardless of EF and the effect of empagliflozin treatment on IGFBP7 concentrations among individuals with HF.

METHODS AND RESULTS

IGFBP7 was measured in 1125 study participants from the EMPEROR-Reduced and EMPEROR-Preserved trials. Cox regression was used to study associations with outcomes. Study participants with IGFBP7 levels in the highest tertile had a higher-risk clinical profile. In Cox proportional hazards models adjusted for clinical variables, N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T, baseline IGFBP7 values in the highest tertile predicted an increased risk of HF hospitalization or cardiovascular death (hazard ratio [HR] 2.00, 95% confidence interval [CI] 1.28-3.10, p = 0.002, p for trend <0.001) and higher risk of the renal composite endpoint (HR 4.66, 95% CI 1.61-13.53, p = 0.005, p for trend = 0.001), regardless of EF. Empagliflozin reduced risk for cardiovascular death/HF hospitalization irrespective of baseline IGFBP7 (p for trend across IGFBP7 tertiles = 0.26). Empagliflozin treatment was not associated with meaningful change in IGFBP7 at 12 or 52 weeks.

CONCLUSION

Across the entire left ventricular EF spectrum in the EMPEROR Programme, concentrations of the senescence-associated biomarker IGFBP7 were associated with higher risk clinical status and predicted adverse cardio-renal outcomes even in models adjusted for conventional biomarkers. Empagliflozin did not significantly affect IGFBP7 levels over time.

Changes in Cardiovascular and Renal Biomarkers Associated with SGLT2 Inhibitors Treatment in Patients with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a major health problem worldwide with a steadily increasing prevalence reaching epidemic proportions. The major concern is the increased morbidity and mortality due to diabetic complications. Traditional but also nontraditional risk factors have been proposed to explain the pathogenesis of type 2 diabetes mellitus and its complications. Hyperglycemia has been considered an important risk factor, and the strict glycemic control can have a positive impact on microangiopathy but not macroangiopathy and its related morbidity and mortality. Thus, the therapeutic algorithm has shifted focus from a glucose-centered approach to a strategy that now emphasizes target-organ protection. Sodium-glucose transporter 2 inhibitors is an extremely important class of antidiabetic medications that, in addition to their glucose lowering effect, also exhibit cardio- and renoprotective effects. Various established and novel biomarkers have been described, reflecting kidney and cardiovascular function. In this review, we investigated the changes in established but also novel biomarkers of kidney, heart and vascular function associated with sodium-glucose transporter 2 inhibitors treatment in patients with type 2 diabetes mellitus.