Cardiovascular and Renal Links along the Cardiorenal Continuum

Prevalence and Overlap of Cardiac, Renal, and Metabolic Conditions in US Adults, 1999-2020

Importance

Individually, cardiac, renal, and metabolic (CRM) conditions are common and leading causes of death, disability, and health care-associated costs. However, the frequency with which CRM conditions coexist has not been comprehensively characterized to date.

Objective

To examine the prevalence and overlap of CRM conditions among US adults currently and over time.

Design, Setting, and Participants

To establish prevalence of CRM conditions, nationally representative, serial cross-sectional data included in the January 2015 through March 2020 National Health and Nutrition Examination Survey (NHANES) were evaluated in this cohort study. To assess temporal trends in CRM overlap, NHANES data between 1999-2002 and 2015-2020 were compared. Data on 11 607 nonpregnant US adults (≥20 years) were included. Data analysis occurred between November 10, 2020, and November 23, 2022.

Main Outcomes and Measures

Proportion of participants with CRM conditions, overall and stratified by age, defined as cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes (T2D), or all 3.

Results

From 2015 through March 2020, of 11 607 US adults included in the analysis (mean [SE] age, 48.5 [0.4] years; 51.0% women), 26.3% had at least 1 CRM condition, 8.0% had at least 2 CRM conditions, and 1.5% had 3 CRM conditions. Overall, CKD plus T2D was the most common CRM dyad (3.2%), followed by CVD plus T2D (1.7%) and CVD plus CKD (1.6%). Participants with higher CRM comorbidity burden were more likely to be older and male. Among participants aged 65 years or older, 33.6% had 1 CRM condition, 17.1% had 2 CRM conditions, and 5.0% had 3 CRM conditions. Within this subset, CKD plus T2D (7.3%) was most common, followed by CVD plus CKD (6.0%) and CVD plus T2D (3.8%). The CRM comorbidity burden was disproportionately high among participants reporting non-Hispanic Black race or ethnicity, unemployment, low socioeconomic status, and no high school degree. Among participants with 3 CRM conditions, nearly one-third (30.5%) did not report statin use, and only 4.8% and 3.0% used glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, respectively. Between 1999 and 2020, the proportion of US adults with multiple CRM conditions increased significantly (from 5.3% to 8.0%; P < .001 for trend), as did the proportion having all 3 CRM conditions (0.7% to 1.5%; P < .001 for trend).

Conclusions and Relevance

This cohort study found that CRM multimorbidity is increasingly common and undertreated among US adults, highlighting the importance of collaborative and comprehensive management strategies.

Renal Function Protection as an Important Component of a Comprehensive Approach to the Management of Patients with Atrial Fibrillation

The increase in the life expectancy of the population  is accompanied by an increase in the prevalence of diseases for which old and senile age are risk factors. Atrial fibrillation (AF) and chronic kidney disease (CKD) are two diseases that can coexist in a patient. The risk of ac thromboembolic and hemorrhagic events in this case increases due to the mutual aggravating influence of these diseases. In addition,  these patients have a high incidence of coronary  events, and cardiovascular complications are the main cause of death in patients with AF and CKD. Consequently, such patients require an integrated  approach  to treatment,  and their management is a complex  clinical task. The direct oral anticoagulant rivaroxaban has been most studied in a population  of comorbid  AF and CKD  patients and has proven a high efficacy and safety profile in these patients in randomized controlled trials. In addition,  rivaroxaban has shown  a significant  reduction in the risk of myocardial  infarction  in various patients,  as well as the possibility of preserving renal function to a greater extent compared  with warfarin therapy, and a possible positive effect on reducing  the risk of cognitive impairment.  A single dosing  regimen  can improve adherence  to treatment,  which is one of the key conditions  for achieving  the above effects. Thus, these factors make it possible to achieve comprehensive protection of comorbid  patients with AF and CKD.

Preeclampsia: a gestational cardiorenal syndrome

It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.

Benefical therapeutic effect of Chinese Herbal Xinji'erkang formula on hypertension-induced renal injury in the 2-kidney-1-clip hypertensive rats

BACKGROUND

Increase in evidence shows that the role of kidney injury in hypertension is important. Xinji'erkang (XJEK), a Chinese herbal formula, has been identified as an effective preparation in the treatment of coronary heart disease and myocarditis. We have previously demonstrated that XJEK attenuate oxidative stress and hypertension target organ damage. The aim of this study was to assess the renal protective function of XJEK.

MATERIALS AND METHODS

Two Kidney One Clip (2K1C) model was adopted to induce hypertension in rats. We submitted male Sprague Dawley (150-180) g rats to either renal artery clipping or sham operation. Renal hypertension was established after four weeks of surgery. Rats were randomized divided into the four groups: sham-operated group (Sh-Op) (n=10), two-kidney, one-clip hypertension group (2K1C) (n=10), Xinji'erkang treatment group (XJEK) (n=10) and Fosinopril (n=10) treatment group. Drugs were administered orally daily for four weeks. Systolic pressures were measured every week using the tail-cuff apparatus. 24h before death, urine samples were collected for detect of urinary proteins. The kidney weight (KW) index was expressed as kidney weight/body weight (KW/BW). The histological changes were investigated by hematoxylin and eosin and Van Gieson staining. Immunohistochemical assay was employed to observe the intra-renal transforming growth factor-β1 (TGF-β1) protein expression. Serum creatinine (SCR) and blood urea nitrogen (BUN) were assayed by automatic biochemical analyzer. ELISA kit was used to assay Angiotensin II (Ang II) and TGF-β1 content in serum.

RESULTS

Administration of XJEK markedly alleviated the rise in blood pressure and declined LKW/BW ratio. Histo-pathological injuries including hypertrophic glomerular, glomerular sclerosis, glomerular and interstitial fibrosis were attenuated. XJEK also decreased SCR, BUN, urinary proteins in 24h urine, serum Ang II and TGF-β1 concentrations and the intra-renal TGF-β1 protein expression.

CONCLUSION

XJEK therapy in the 2K1C hypertensive rats affects the rise in blood pressure and ameliorates the severity of kidney injury. The protective effect is most likely due to the ability of XJEK to affect the Renin-Angiotensin-Aldosterone System (RAAS) and the TGF-β systems.

Emerging drug combinations to optimize renovascular protection and blood pressure goals

Hypertension and renal disease are closely related. In fact, there is an inverse linear relationship between renal function and prevalence of hypertension. Hypertensive patients with renal dysfunction exhibit a poor clinical profile, which markedly increases their risk for cardiovascular outcomes. This review considers the available evidence on the best therapeutic approach for optimizing renovascular protection in the hypertensive population. To effectively reduce or at least slow the establishment and progression of renal disease in the hypertensive population it is critical to reach blood pressure targets. Many studies have shown that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prevent or at least delay the development of microalbuminuria in patients with hypertension and type 2 diabetes, reduce the incidence of overt diabetic nephropathy, and are also beneficial in patients with nondiabetic renal disease. Therefore, renin-angiotensin system (RAS) inhibition plays a key role in the prevention of renal outcomes. As the majority of patients with hypertension will need at least two antihypertensive agents to achieve blood pressure goals, the use of RAS inhibitors is a mandatory part of antihypertensive therapy. The question of which antihypertensive agent is the best choice for combining with RAS blockers should be considered. Many studies have shown that diuretics and calcium channel blockers are the best choice. However, more studies are needed to clarify the subgroups of patients who will benefit more from a combination with a diuretic or from a combination with a calcium channel blocker. To date, RAS inhibitors recommended in this context are angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Aliskiren, the first oral direct renin inhibitor available, has shown promising results.