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Observational Study
. 2025 Jul 8;15(1):24346.
doi: 10.1038/s41598-025-04523-1.

Dissecting the relationship between heart failure and diabetic retinopathy severity in patients with diabetes and chronic kidney disease: an observational cohort study

Affiliations
Observational Study

Dissecting the relationship between heart failure and diabetic retinopathy severity in patients with diabetes and chronic kidney disease: an observational cohort study

Yi-Chen Huang et al. Sci Rep. .

Abstract

Diabetic retinopathy (DR) is associated with increased cardiovascular risk, but evidence of its relationship with heart failure (HF) in people with diabetes and chronic kidney disease (CKD) is limited. Therefore, we examined the association between DR severity and concurrent HF status, as well as the risk of subsequent HF hospitalization in this population. A total of 1,503 patients with both diabetes and CKD underwent fundus photography. DR severity was classified into three groups: Group 1 (no apparent DR, mild non-proliferative DR [NPDR], moderate NPDR), group 2 (severe NPDR, very severe NPDR), and group 3 (proliferative DR [PDR], and high-risk PDR). Associations between HF status and DR severity were analyzed using ordinal regression. Cox proportional hazard models examined the association between DR severity and subsequent HF hospitalization. HF was positively associated with worse DR grade (adjusted odds ratio 2.09, 95% confidence interval [CI] 1.37-3.18). In patients without HF at baseline, a higher incidence of acute HF hospitalization over 5 years was identified in group 2 (hazard ratio 1.37, 95% CI 0.83-2.26) and group 3 (hazard ratio 1.86, 95% CI 1.22-2.83) compared to patients with less severe DR. In summary, DR severity is independently associated with both concurrent HF and risks for HF hospitalization over 5 years among those with diabetes and CKD and could aid cardiovascular risk stratification.

Keywords: Chronic kidney disease; Diabetes mellitus; Diabetic retinopathy; Heart failure.

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Conflict of interest statement

Declarations. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Study flowchart illustrating the selection process of 1,503 patients with diabetes and CKD stratified into three groups based on diabetic retinopathy severity.
Fig. 2
Fig. 2
Subgroup analysis of the association between heart failure and severity of diabetic retinopathy stratified by baseline characteristics. The consistent approximately 2-fold increased odds of worse DR with HF across all subgroups demonstrates the robustness of this relationship regardless of age, sex, CKD stage, or hyperlipidemia status.
Fig. 3
Fig. 3
Kaplan-Meier curve of severity of diabetic retinopathy and risk of acute heart failure hospitalization in DM and CKD patients without diagnosis of heart failure. Group 2 (Severe NPDR + Very severe NPDR) and Group 3 (PDR + High-risk PDR) demonstrate significantly higher risk of acute heart failure hospitalization compared to Group 1 (No apparent, Mild NPDR and Moderate NPDR), with Group 3 showing the highest risk (log-rank p < 0.0001).
Fig. 4
Fig. 4
Subgroup analysis of the association between severity of diabetic retinopathy and risk of acute heart failure hospitalization among DM and CKD patients without diagnosis of heart failure stratified by baseline characteristics. Results demonstrate consistent positive associations between DR severity and acute HF risk across all examined subgroups, supporting the robustness of this relationship.

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