Cardiovascular Disease in Diabetes and Chronic Kidney Disease

Glycemic, Cardiorenal, and Weight Implications on Noninsulin Pharmacotherapy for the Management of Type 2 Diabetes

CONTEXT

The incidence of diabetes is growing at an alarming rate globally. Most of these projected individuals will develop type 2 diabetes (T2DM), raising their risk of cardiovascular disease and chronic kidney disease. This mini-review examines current noninsulin and noninjectable pharmacotherapy focused in T2DM, highlighting the effect on glycemic control and importance of cardiovascular and renal outcomes.

EVIDENCE ACQUISITION

We included population level data and searched the PubMed database for recent systematic reviews, meta-analyses, and original research articles.

EVIDENCE SYNTHESIS

There is a pharmacologic menu of noninsulin-based medications for the treatment of diabetes. Through varying mechanisms, all agents ultimately lead to glycemic improvement to varying degrees. Only a select number of agents are shown to improve important clinical cardiovascular and renal outcomes. Of note, sodium-glucose cotransporter-2 inhibitors have improved cardiovascular mortality and time to dialysis in people with diabetes. Likewise, incretin-based therapies have improved important cardiovascular and renal composite outcomes in those with diabetes and cardiovascular disease. As a result, agents with proven cardiovascular and renal benefits should be prioritized based on patient risk.

CONCLUSION

Despite the availability of new medications and technology, published clinical guidelines, and treatment algorithms, most people with diabetes remain above glycemic targets. We encourage clinicians to follow the guidelines and use appropriate medications to lower cardiovascular risk, delay progression of chronic kidney disease, reach glycemic targets, and manage weight.

Association of aberrant mineral metabolic markers with fracture risk in chronic kidney disease: a comprehensive meta-analysis

BACKGROUND

This meta-analysis aims to investigate the impact of abnormalities in mineral metabolic markers, including serum phosphate and calcium, intact parathyroid hormone (iPTH), and fibroblast growth factor 23 (FGF23) on the risk of fractures in patients with chronic kidney disease (CKD).

METHODS

A systematic search was conducted across MEDLINE, Web of Science, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register for Controlled Trials. The outcomes were association of mineral metabolic markers with the risk of fractures in patients with chronic kidney disease. Pooled risk estimates and 95% confidence intervals (CIs) were calculated using fixed-effects or random-effects models.

RESULTS

Thirty-two studies were included in the meta-analysis. High and low levels of serum phosphate in hemodialysis (HD) patients were both associated with an increased risk of fractures (RR = 1.08, 95% CI 1.02-1.15, P = 0.013; RR = 1.13, 95% CI 1.02-1.25, P = 0.022, respectively). Similarly, abnormal levels of iPTH in CKD patients, both high and low, were associated with increased fracture risk (RR = 1.25, 95% CI 1.20-1.31, P < 0.001; RR = 1.41, 95% CI 1.10-1.82, P = 0.007, respectively). Elevated FGF23 levels were also linked to an increased risk of fractures (RR = 1.32, 95% CI 1.06-1.66, P = 0.015). While a higher level of calcium exhibited a trend towards reduced fracture incidence without statistical significance (RR = 0.90, 95% CI 0.77-1.05, P = 0.181), lower calcium levels tended to increase fracture risk without statistical significance (RR = 1.11, 95% CI 0.99-1.24, P = 0.087). Notably, subjects treated with calcium and phosphorus modulating drugs demonstrated a statistically significant reduction in fractures among CKD patients undergoing dialysis (phosphate binders, RR = 0.79, 95% CI 0.70-0.89; cinacalcet, RR = 0.74, 95% CI 0.59-0.93; vitamin D analogues, RR = 0.82, 95% CI 0.74-0.92, respectively).

CONCLUSION

This meta-analysis underscores the association between abnormal mineral metabolic markers, including high serum phosphate, iPTH, and FGF23, and an increased risk of fractures in CKD patients. Notably, both elevated and decreased levels of phosphate and iPTH contribute to fracture risk. The efficacy of active vitamin D, phosphorus binders, and cinacalcet in preventing fractures was observed in HD patients but not in the non-dialysis CKD population.

TRIAL REGISTRATION

PROSPERO CRD42023493951.

Use of Statins for Primary Prevention Among Individuals With CKD in the United States: A Cross-Sectional, Time-Trend Analysis

RATIONALE & OBJECTIVE

Chronic kidney disease (CKD) populations face an elevated risk of cardiovascular disease (CVD), yet many remain undertreated with statins for primary prevention of CVD despite meeting eligibility criteria. We examined trends in statin use for primary prevention among individuals with CKD before and after the release of the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommending statin use for lipid management in selected adults with CKD.

STUDY DESIGN

Cross-sectional time-trend analysis.

SETTING & PARTICIPANTS

The 2001-2020 National Health and Nutrition Examination Survey (NHANES) data permitted identification of individuals eligible for statin therapy per the 2013 KDIGO guidelines based on (1) age≥50 without self-reported CVD; (2) CKD, defined as estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2 or albumin-creatinine ratio≥30mg/g; and (3) no dialysis in the previous 12 months.

OUTCOME

Statin use.

ANALYTICAL APPROACH

Poisson regression to estimate prevalence ratios (PR) comparing the periods before and after KDIGO guideline release and after accounting for NHANES's complex survey design and sampling weights.

RESULTS

Among eligible individuals, statin use approximately doubled from 18.6% in 2001-2002 to 36.1% in 2007-2008, increased modestly to 40.1% in 2013-2014, then subsequently plateaued. Multivariable analyses controlling for sociodemographic and clinical characteristics and secular trends demonstrated statin use for primary prevention was higher among the insured (PR, 2.48 [95% CI 1.66-3.69]), those with hypertension (PR, 1.49 [95% CI 1.28-1.74]), and those with diabetes (PR, 1.71 [95% CI 1.52-1.92]). Statin use was more common with lower eGFR (P=0.009) and higher body mass index (P=0.003) but did not differ by sex, race, or ethnicity.

LIMITATIONS

Statin use and CVD were self-reported, and our data did not capture statin intolerance nor patient-provider decision making information.

CONCLUSIONS

Statin use for primary prevention in CKD substantially increased before the 2013 release of KDIGO guidelines and subsequently plateaued. Use was higher among the insured and those with hypertension or diabetes.

PLAIN-LANGUAGE SUMMARY

Chronic kidney disease (CKD) affects many Americans, increasing their heart disease risk. Statins effectively reduce this risk in individuals with CKD but are underused. Our study examined statin use in individuals with CKD before and after the release of the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommending statin use for selected adults with CKD. It also examined factors influencing usage patterns. Using years of US National Health and Nutrition Examination Survey data, we found that while statin use doubled over the study period, fewer than half of eligible individuals with CKD received statins for primary prevention. Statin use was more common among those with health insurance, high blood pressure, or diabetes. This underuse highlights potential opportunities for improved risk monitoring and preventive use of statin therapy for individuals with CKD.

Evaluating Risk Factors and the Burden of Silent Myocardial Ischemia Among Diabetic Patients

INTRODUCTION

Silent myocardial ischemia (SMI) is a significant concern for diabetic patients, often remaining undetected until severe complications arise. Prolonged hyperglycemia, poor glycemic control, and lifestyle factors contribute to its risk, with older adults and those with long-standing diabetes particularly vulnerable.

OBJECTIVE

To assess the prevalence and predictors of SMI in adults with diabetes, emphasizing long-term management and monitoring.

METHODOLOGY

A longitudinal observational study was conducted at Nishtar Medical University, Multan, from October 2020 to September 2022, involving 388 adults with diabetes for at least five years. Patients with significant cardiovascular diseases or recent medication-affecting biomarkers were excluded. Data collection included demographics, medical history, and clinical assessments such as HbA1c levels, 12-lead resting ECGs, and treadmill exercise stress tests, with myocardial perfusion imaging (MPI) for those unable to perform stress tests. Statistical analyses using IBM SPSS (version 22) incorporated univariate and multivariate logistic regression to identify predictors of SMI, adjusting for confounders such as age, sex, smoking, and blood pressure. Thresholds included microalbuminuria at 30-300 mg/24 hours and HbA1c ≥7%, with missing data addressed through multiple imputations.

RESULTS

Among the participants, the prevalence of SMI was 48%, increasing to 58% in those with microalbuminuria. Significant predictors included the duration of diabetes (OR 1.28, 95% CI: 1.08-1.52, p=0.001), HbA1c levels (OR 1.75, 95% CI: 1.42-2.16, p<0.001), age (OR 1.05, 95% CI: 1.01-1.09, p=0.035), and smoking status (OR 1.42, 95% CI: 1.05-1.92, p=0.025). Smoking status was based on self-report. Notably, microalbuminuria showed a strong association with SMI (OR 2.89, 95% CI: 2.10-3.98, p<0.001). The distribution of participants was balanced in terms of age and gender, with a mean age of 58 years (SD 9.4), and 52% were male. No unexpected findings were observed, and the results aligned with the anticipated relationships between the variables.

CONCLUSION

This study highlights a concerning prevalence of SMI among diabetic patients, emphasizing the importance of monitoring diabetes duration and glycemic control, particularly in individuals with microalbuminuria. Regular follow-up care, including routine ECGs, stress tests, and biomarker assessments, is crucial for improving cardiovascular outcomes in this high-risk population. Limitations such as the observational design and potential self-report bias in smoking status may affect the generalizability of the findings. Future research should focus on large-scale, multicenter studies to validate these findings and explore interventions that could reduce the burden of SMI in diabetic patients.

Association between renal dysfunction and outcomes of lung cancer: A systematic review and meta‑analysis

Renal insufficiency and/or chronic kidney disease are common comorbidities in patients with lung cancer, potentially affecting their prognosis. The aim of the present study was to assess the existing evidence on the association between renal insufficiency (RI)/chronic kidney disease (CKD) and the overall survival (OS) and disease-free survival (DFS) of patients with lung cancer (LC). Comprehensive electronic searches in the PubMed, Embase and Scopus databases were performed for observational cohort and case-control studies and randomized controlled trials that investigated the association between RI/CKD and the OS and/or DFS of patients with LC. Random-effect models were used, and the combined effect sizes were reported as either standardized mean differences or relative risks, along with 95% confidence intervals (CI). A total of 10 studies were included. The duration of follow-up in the included studies ranged from 12 months to 5 years. Compared with patients with normal renal function, patients with LC with RI/CKD had worse OS rates [hazard ratio (HR), 1.38; 95% CI, 1.16-1.63] but similar DFS rates (HR, 1.12; 95% CI, 0.75-1.67) at follow-up. Subgroup analysis demonstrated a significant association between poor OS and RI/CKD in patients with stage I/II LC [HR, 1.76; 95% CI, 1.30-2.37] but not in patients with stage III/IV LC [HR, 1.18; 95% CI, 0.91, 1.54]. Furthermore, irrespective of the treatment modality i.e., surgery [HR, 1.78; 95% CI, 1.40-2.27] or medical management [HR, 1.37; 95% CI, 1.25-1.50], RI/CKD was notably associated with a poor OS at follow-up. The findings of the present study underscore the adverse impact of RI/CKD on the long-term survival of patients with LC.

Effect of GLP-1 receptor agonists on weight and cardiovascular outcomes: A review

Diet and lifestyle modifications remain the foundation of obesity treatment, but they have historically proven insufficient for significant, long-term weight loss. As a result, there is a high demand for new pharmacologic treatments to promote weight loss and prevent life-threatening diseases associated with obesity. Researchers are particularly interested in 1 type of drug, glucagon-like peptide 1 receptor agonists (GLP-1 RAs), because of its promising potential in addressing the limitations of non-pharmacologic treatments. In addition to their role in weight loss, these drugs have shown promising early evidence of cardiovascular benefits in obese patients, further enhancing their clinical relevance. Semaglutide and liraglutide, which were initially approved for the treatment of type 2 diabetes, have since been approved by the Food and Drug Administration as weight loss medications due to their effectiveness in promoting significant and sustained weight loss. In this narrative review, we will explore the mechanism of GLP-1 RAs, their effects on weight loss, cardiovascular risk factors and outcomes, common adverse effects, and strategies for managing these effects.

A Comparative Analysis of the SARC-F Questionnaire and the Malnutrition-Inflammation Score for Sarcopenia Risk Assessment and Negative Outcome Probability in Chronic Hemodialysis Patients

Background/Objectives: Protein-energy wasting (PEW) and sarcopenia are common in chronic hemodialysis (HD) patients, leading to numerous complications and increased mortality. This study aimed to compare the reliability of the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) and the Malnutrition-Inflammation Score (MIS) in assessing sarcopenia and predicting negative outcomes in HD patients. Methods: This cross-sectional study enrolled 109 HD patients. Nutritional assessments were performed, and blood samples were taken for routine blood laboratory investigations. The MIS was used as a scoring system to represent the severity of PEW, while the SARC-F was applied as an indicator of sarcopenia risk and general functional capacity. A multivariable logistic regression was conducted to analyze the association of several predictors with a negative cross-sectional outcome (death). Results: Patients with SARC-F scores ≥ 4 and MISs ≥ 6 were older, had significantly lower albumin and prealbumin levels, and more severe anemia. They were also more likely to report weight loss and poor appetite. A higher MIS was closely associated with unfavourable nutritional status according to the International Society of Renal Nutrition and Metabolism (ISRNM) criteria for PEW. However, in 71.25% of patients with satisfactory functional capacity (SARC-F scores 0-3), some form of PEW was still observed. After performing logistic regression modelling, only the MIS remained strongly associated with the probability of a negative outcome. Conclusions: The SARC-F alone often did not correspond to an increased sarcopenia risk or clear clinical and biochemical indicators of PEW in HD patients. When assessing nutritional risk in this group, it is recommended to use more detailed tools, such as the MIS, to ensure the accurate identification of those at the highest risk for negative outcomes.

When Does Primary Prevention Encroach on Secondary Prevention?

PURPOSE OF REVIEW

The risk of incident atherosclerotic cardiovascular disease (ASCVD) in primary prevention is typically lower than in secondary prevention. However, there is a spectrum of risk among individuals undergoing primary prevention with the risk in some individuals approaching those of secondary prevention. We review the clinical conditions wherein the risk in primary prevention is similar to that observed in secondary prevention.

RECENT FINDINGS

Among individuals without established ASCVD, coronary artery calcium (CAC) scores ≥ 300 AU are associated with ASCVD event rates similar to secondary prevention populations. CAC score ≥ 1,000 AU are associated with an ASCVD risk seen in very high-risk secondary prevention populations. Interpretation of these observations must however consider differences in the risk reduction strategies. Current guidelines dichotomize ASCVD prevention into primary and secondary prevention, but certain primary prevention patients have an ASCVD risk equivalent to that of secondary prevention populations. Identifying higher risk primary prevention populations will allow for better risk mitigation strategies.

Patient Characteristics and Outcomes of Hospitalized Chronic Kidney Disease Patients with and without Type 2 Diabetes Mellitus: Observations from the German Claims Data-Based Cohort of the CaReMe-CKD Multinational Study

Introduction

Type 2 diabetes mellitus (T2DM) is a leading cause of chronic kidney disease (CKD) globally. Both conditions substantially worsen patients' prognosis. Current data on German in-hospital CKD cohorts are scarce. The multinational CaReMe study was initiated to evaluate the current epidemiology and healthcare burden of cardiovascular, renal and metabolic diseases. In this substudy, we share real-world data on CKD inpatients stratified for coexisting T2DM derived from a large German hospital network.

Methods

This study used administrative data of inpatient cases from 89 Helios hospitals from 01/01/2016 to 28/02/2022. Data were extracted from ICD-10-encoded discharge diagnoses and OPS-encoded procedures. The first case meeting a previously developed CKD definition (defined by ICD-10- and OPS-codes) was considered the index case for a particular patient. Subsequent hospitalizations were analysed for readmission statistics. Patient characteristics and pre-defined endpoints were stratified for T2DM at index case.

Results

In total, 48,011 patients with CKD were included in the present analysis (mean age ± standard deviation, 73.8 ± 13.1 years; female, 44%) of whom 47.9% had co-existing T2DM. Patients with T2DM were older (75 ± 10.6 vs 72.7 ± 14.9 years, p < 0.001), but gender distribution was similar to patients without T2DM. The burden of cardiovascular disease was increased in patients with T2DM, and index and follow-up in-hospital mortality rates were higher. Non-T2DM patients were characterised by more advanced CKD at baseline. Patients with T2DM had consistently higher readmission numbers for all events of interest, except for readmissions due to kidney failure/dialysis, which were more common in non-T2DM patients.

Conclusion

In this study, we present recent data on hospitalized patients with CKD in Germany. In this CKD cohort, nearly half had T2DM, which substantially affected cardiovascular disease burden, rehospitalization frequency and mortality. Interestingly, non-diabetic patients had more advanced underlying renal disease, which affected renal outcomes.

Underuse of GLP-1 receptor agonists in the management of type 2 diabetes despite a favorable benefit-safety profile

INTRODUCTION

Patients with type 2 diabetes (T2DM) are at high risk of atherosclerotic cardiovascular disease (ASCVD) and cardiovascular death. Cardiovascular protection is a key objective in T2DM.

AREAS COVERED

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM in placebo-controlled trials, a finding confirmed in observational studies compared with other glucose-lowering agents. Overall, GLP-1RAs have a good safety profile associated with a favorable benefit/risk ratio for the management of T2DM, even if their cost-effectiveness might be questionable. International guidelines recommend GLP-1RAs as preferred glucose-lowering agents in patients with ASCVD and as a valuable alternative in overweight/obese patients with T2DM. However, real-life studies worldwide revealed that only a minority of patients receive a GLP-1RA, despite a positive trend for increased prescriptions in recent years. Surprisingly, however, fewer patients with established ASCVD are treated with these cardioprotective antihyperglycemic agents versus patients without ASCVD.

EXPERT OPINION

The reasons for GLP-1RA underuse in clinical practice are multiple. Multifaceted and coordinated interventions targeting all actors of the health-care system must be implemented to stimulate the adoption of GLP-1RAs as part of routine cardiovascular care among patients with T2DM, especially in those with ASCVD.

Finerenone: From the Mechanism of Action to Clinical Use in Kidney Disease

Diabetic kidney disease is a frequent microvascular complication of diabetes and is currently the leading cause of chronic kidney disease and end-stage kidney disease worldwide. Although the prevalence of other complications of diabetes is falling, the number of diabetic patients with end-stage kidney disease in need of kidney replacement therapy is rising. In addition, these patients have extremely high cardiovascular risk. It is more than evident that there is a high unmet treatment need in patients with diabetic kidney disease. Finerenone is a novel nonsteroidal mineralocorticoid receptor antagonist used for treating diabetic kidney disease. It has predominant anti-fibrotic and anti-inflammatory effects and exhibits several renal and cardiac protective effects. This review article summarizes the current knowledge and future prospects of finerenone in treating patients with kidney disease.

Renal Rehabilitation: Present and Future Perspectives

Chronic kidney disease (CKD) is a global health problem. In patients with CKD, exercise endurance is decreased, especially as renal dysfunction advances. This is due to the combined effects of protein-energy wasting, uremic acidosis, and inflammatory cachexia, which lead to sarcopenia and are aggravated by a sedentary lifestyle, resulting in a progressive downward spiral of deconditioning. Renal rehabilitation (RR) is a coordinated, multifaceted intervention designed to optimize a patient's physical, psychological, and social functioning, as well as to stabilize, slow, or even reverse the progression of renal deterioration, improving exercise tolerance and preventing the onset and worsening of heart failure, thereby reducing morbidity and mortality. This review focused on the history and benefits of RR in patients with CKD. Based on current evidence, RR is an effective, feasible, and safe secondary prevention strategy in CKD. RR is a promising model for a new field of rehabilitation. Therefore, efforts to increase RR implementation rates are urgently needed.