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

Waist-to-Height Ratio, Waist Circumference, and Body Mass Index in Relation to Full Cardiometabolic Risk in an Adult Population from Medellin, Colombia

Background/Objectives: Few studies have compared the associations of different adiposity markers with cardiometabolic risk factors in individuals without diabetes or cardiovascular disease (CVD), particularly in South America. Moreover, the associations with more severe cardiometabolic risk, defined by the simultaneous presence of altered glycemia, blood pressure, and dyslipidemia, remain unknown. We examined whether the waist-to-height ratio (W-HtR), waist circumference (WC), and BMI were independently associated with cardiometabolic risk in a chronic disease prevention program in Medellín, Colombia. Methods: A cross-sectional study was conducted in 29,236 adults (age: 19-121 years) without diabetes or CVD. Exposures included increased W-HtR (>0.5), increased WC (≥80 cm for women, ≥90 cm for men), and overweight/obesity. The outcomes were dyslipidemia, elevated glycemia, high blood pressure, and full cardiometabolic risk (FCMR), defined as the presence of all three factors. Logistic regressions adjusted for sociodemographic and lifestyle covariates and additional adiposity markers were used. Cubic spline analyses examined the shape of associations. Results: Most individuals were over 40 years old (97.6%), only 40 were ≥100 years, and 16.5% (n = 4821) had FCMR. Increased W-HtR tripled the odds of FCMR compared with normal W-HtR (OR: 3.04, 95%CI: 2.45-3.77, p < 0.001). Increased WC doubled the odds of FCMR (p < 0.001). W-HtR remained the strongest predictor after adjusting for WC (OR: 1.99, 95%CI: 1.59-2.50) and BMI (OR: 2.48, 95%CI: 1.99-3.08). Cubic spline analyses showed a linear association between W-HtR and FCMR, whereas the BMI-FCMR association plateaued at approximately 30 kg/m2. Conclusions: In this cross-sectional study of a large middle-to-older-aged cohort, W-HtR was the strongest adiposity marker correlated with cardiometabolic risk.

Metabolic-Dysfunction-Associated Steatotic Liver Disease: Molecular Mechanisms, Clinical Implications, and Emerging Therapeutic Strategies

Metabolic-dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is a highly prevalent metabolic disorder characterized by hepatic steatosis in conjunction with at least one cardiometabolic risk factor, such as obesity, type 2 diabetes, hypertension, or dyslipidemia. As global rates of obesity and metabolic syndrome continue to rise, MASLD is becoming a major public health concern, with projections indicating a substantial increase in prevalence over the coming decades. The disease spectrum ranges from simple steatosis to metabolic-dysfunction-associated steatohepatitis (MASH), fibrosis, cirrhosis, and hepatocellular carcinoma, contributing to significant morbidity and mortality worldwide. This review delves into the molecular mechanisms driving MASLD pathogenesis, including dysregulation of lipid metabolism, chronic inflammation, oxidative stress, mitochondrial dysfunction, and gut microbiota alterations. Recent advances in research have highlighted the role of genetic and epigenetic factors in disease progression, as well as novel therapeutic targets such as peroxisome proliferator-activated receptors (PPARs), fibroblast growth factors, and thyroid hormone receptor beta agonists. Given the multifaceted nature of MASLD, a multidisciplinary approach integrating early diagnosis, molecular insights, lifestyle interventions, and personalized therapies is critical. This review underscores the urgent need for continued research into innovative treatment strategies and precision medicine approaches to halt MASLD progression and improve patient outcomes.

Fabry Disease: Insights into Pathophysiology and Novel Therapeutic Strategies

Fabry disease (FD) is an X-linked lysosomal storage disorder characterized by deficiency of α-galactosidase A (α-GalA), leading to the accumulation of glycosphingolipids and multi-organ dysfunction, particularly affecting the cardiovascular and renal systems. Disease-modifying treatments such as enzyme replacement therapy (ERT) and oral chaperone therapy (OCT) have limited efficacy, particularly in advanced disease, prompting a need for innovative therapeutic approaches targeting underlying molecular mechanisms beyond glycosphingolipid storage alone. Recent insights into the pathophysiology of FD highlights chronic inflammation and mitochondrial, lysosomal, and endothelial dysfunction as key mediators of disease progression. Adjunctive therapies such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, and mineralocorticoid receptor antagonists (MRAs) demonstrate significant cardiovascular and renal benefits in conditions including heart failure and chronic kidney disease. These drugs also modulate pathways involved in the pathophysiology of FD, such as autophagy, oxidative stress, and pro-inflammatory cytokine signaling. While theoretical foundations support their utility, dedicated trials are necessary to confirm efficacy in the FD-specific population. This narrative review highlights the importance of expanding therapeutic strategies in FD, advocating for a multi-faceted approach involving evidence-based adjunctive treatments to improve outcomes. Tailored research focusing on diverse FD phenotypes, including females and non-classical variants of disease, will be critical to advancing care and improving outcomes in this complex disorder.

The Human Energy Balance: Uncovering the Hidden Variables of Obesity

Obesity has emerged as a global epidemic, creating an increased burden of weight-related diseases and straining healthcare systems worldwide. While the fundamental principle of energy balance-caloric intake versus expenditure-remains central to weight regulation, real-world outcomes often deviate from simplistic predictions due to a multitude of physiological and environmental factors. Genetic predispositions, variations in basal metabolic rates, adaptive thermogenesis, physical activity, and nutrient losses via fecal and urinary excretion contribute to interindividual differences in energy homeostasis. Additionally, factors such as meal timing, macronutrient composition, gut microbiota dynamics, and diet-induced thermogenesis (DIT) further modulate energy utilization and metabolic efficiency. This Perspective explores key physiological determinants of the energy balance, while also highlighting the clinical significance of thrifty versus spendthrifty metabolic phenotypes. Key strategies for individualized weight management include precision calorimetry, circadian-aligned meal timing, the use of protein- and whole food diets to enhance DIT, and increases in non-exercise activity, as well as mild cold exposure and the use of thermogenic agents (e.g., capsaicin-like compounds) to stimulate brown adipose tissue activity. A comprehensive, personalized approach to obesity management that moves beyond restrictive caloric models is essential to achieving sustainable weight control and improving long-term metabolic health. Integrating these multifactorial insights into clinical practice will enhance obesity treatment strategies, fostering more effective and enduring interventions.