The cardio-renal-metabolic connection: a review of the evidence

Abstract

Type 2 diabetes (T2D), cardiovascular disease (CVD) and chronic kidney disease (CKD), are recognized among the most disruptive public health issues of the current century. A large body of evidence from epidemiological and clinical research supports the existence of a strong interconnection between these conditions, such that the unifying term cardio-metabolic-renal (CMR) disease has been defined. This coexistence has remarkable epidemiological, pathophysiologic, and prognostic implications. The mechanisms of hyperglycemia-induced damage to the cardio-renal system are well validated, as are those that tie cardiac and renal disease together. Yet, it remains controversial how and to what extent CVD and CKD can promote metabolic dysregulation. The aim of this review is to recapitulate the epidemiology of the CMR connections; to discuss the well-established, as well as the putative and emerging mechanisms implicated in the interplay among these three entities; and to provide a pathophysiological background for an integrated therapeutic intervention aiming at interrupting this vicious crosstalks.

Keywords: Cardiometabolic; Cardiorenal; Comorbidities; Epidemiology; Metabolic syndrome; Pathophysiology.

Fig. 1

Cardio-metabolic-renal interconnections and therapeutic options. SNS, sympathetic nervous system; RAAS, renin–angiotensin–aldosterone system; NPs, natriuretic peptides; SGLT2i: sodium-glucose cotransporter 2 inhibitors; GLP1- RA: glucagon-like peptide 1 receptor agonists

Fig. 2

Cardio-renal interplay in the context of T2D. The figure illustrates some of the mechanisms that sustain the bidirectional relationships between kidney disease and cardiac remodeling leading to heart failure in the context of type 2 diabetes. SNS, sympathetic nervous system; RAAS, renin-angiotensin-aldosterone system; eGFR: estimated glomerular filtration rate CKD, chronic kidney disease; ESKD: end-stage kidney disease