Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association.

Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.

Vitamin D and blood pressure control among hypertensive adults: results from NHANES 2001-2014.

OBJECTIVE: Observational evidence supports an inverse association between hypovitaminosis D and blood pressure (BP), but intervention data have failed to demonstrate beneficial effects of vitamin D supplementation on BP. Following the downwards redefinition of hypertension treatment targets and the need to better identify individuals at greater risk for uncontrolled BP, our aim was to test the association of serum vitamin D levels with the definition of uncontrolled BP according to European guidelines in treated hypertensive adults. METHODS: We retrospectively analyzed cross-sectional, nationally representative data from treated hypertensive adults aged at least 18 years with available serum 25 (OH)D measurements. BP was examined as continuous (mmHg) and categorical (at or above treatment goal, as recommended by guidelines) variable; BP means and odds ratios for uncontrolled BP according to vitamin D levels were calculated using progressively adjusted models. RESULTS: Treated hypertensive adults with vitamin D deficiency had higher mean BP (+2.4/3.5 mmHg; P < 0.01) and 25-29% higher risk of uncontrolled BP compared to those with vitamin levels at least 75 nmol/l. These results were confirmed across age, sex, and racial/ethnic strata. Vitamin D insufficiency was associated with higher BP by 0.5/2.4 mmHg, but not with an increased risk of uncontrolled hypertension. CONCLUSIONS: 25 (OH)D levels might indicate host-specific features related to poor BP control. The attempt to use a biomarker of exposure as an indicator of need for treatment risks to be misleading.

Genetic African Ancestry and Markers of Mineral Metabolism in CKD.

BACKGROUND AND OBJECTIVES: Disorders of mineral metabolism are more common in African Americans with CKD than in European Americans with CKD. Previous studies have focused on the differences in mineral metabolism by self-reported race, making it difficult to delineate the importance of environmental compared with biologic factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a cross-sectional analysis of 3013 participants of the Chronic Renal Insufficiency Cohort study with complete data, we compared markers of mineral metabolism (phosphorus, calcium, alkaline phosphatase, parathyroid hormone, fibroblast growth factor 23, and urine calcium and phosphorus excretion) in European Americans versus African Americans and separately, across quartiles of genetic African ancestry in African Americans (n=1490). RESULTS: Compared with European Americans, African Americans had higher blood concentrations of phosphorus, alkaline phosphatase, fibroblast growth factor 23, and parathyroid hormone, lower 24-hour urinary excretion of calcium and phosphorus, and lower urinary fractional excretion of calcium and phosphorus at baseline (P<0.001 for all). Among African Americans, a higher percentage of African ancestry was associated with lower 24-hour urinary excretion of phosphorus (Ptrend<0.01) in unadjusted analyses. In linear regression models adjusted for socio-demographic characteristics, kidney function, serum phosphorus, and dietary phosphorus intake, higher percentage of African ancestry was significantly associated with lower 24-hour urinary phosphorus excretion (each 10% higher African ancestry was associated with 39.6 mg lower 24-hour urinary phosphorus, P<0.001) and fractional excretion of phosphorus (each 10% higher African ancestry was associated with an absolute 1.1% lower fractional excretion of phosphorus, P=0.01). CONCLUSIONS: A higher percentage of African ancestry was independently associated with lower 24-hour urinary phosphorus excretion and lower fractional excretion of phosphorus among African Americans with CKD. These findings suggest that genetic variability might contribute to racial differences in urinary phosphorus excretion in CKD.