Association of the triglyceride-glucose index combined with a body shape index with all-cause and cardiovascular mortality in individuals with cardiovascular-kidney-metabolic syndrome stage 0-3: findings from two prospective cohorts

Abstract

Background: The triglyceride-glucose (TyG) index, as a measure of insulin resistance, has been confirmed to be associated with adverse clinical outcomes. The new composite indicator, TyG-A body type index (TyG-ABSI), by integrating the TyG index and the A body type index, has demonstrated superior efficacy in predicting the risk of cardiovascular death in the general population compared to traditional indicators. This study aims to deeply explore the association between TyG-ABSI and all-cause mortality and CVD mortality in the population with cardiovascular kidney-metabolic syndrome (CKM) stages 0-3. The analysis will be conducted from multiple dimensions such as the intensity of indicator correlation and potential influencing mechanisms, in order to comprehensively reveal the relationship between the two.

Results: We analyzed data from 13,480 participants in the NHANES cohort (1999-2018) using Cox proportional hazards models and restricted cubic spline functions. The results indicated that elevated TyG-ABSI values were independently associated with a higher risk of all-cause mortality (HR = 1.226, 95% CI 1.104-1.361) and cardiovascular mortality (HR = 1.377, 95% CI 1.149-1.651). Time-dependent receiver operating characteristic (ROC) curves and concordance index evaluations demonstrated that TyG-ABSI yielded more accurate long-term prognostic performance than other TyG-derived metrics. The area under the curve (AUC) of this indicator reached 0.688-0.708 in the prediction of all-cause mortality risk over 5-15 years, and 0.696-0.739 in the prediction of cardiovascular mortality risk. External validation using CHARLS data confirmed the robustness of these findings in predicting all-cause mortality.

Conclusions: Among individuals with CKM stages 0-3, TyG-ABSI demonstrates a stronger association with mortality risk and superior predictive ability compared with other TyG-derived metrics. Its performance suggests a potential role in capturing variations across diverse clinical subgroups, and informing optimal timing for preventive interventions.

Keywords: A body shape index; Cardiovascular-kidney-metabolic syndrome; Insulin resistance; Mortality; Triglyceride-glucose index.

Fig. 1

Flow chart for eligible participants. CKM Syndrome, cardiovascular-kidney-metabolic syndrome; TyG, triglyceride-glucose; ABSI, a body shape index; NHANES, National Health and Nutrition Examination Survey

Fig. 2

Boruta-based feature importance ridge plot for all-cause mortality in CKM Syndrome. CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval; TyG, triglyceride-glucose; ABSI, a body shape index; BMI, body mass index; WWI, weight-adjusted waist index; WHtR, waist-to-height ratio; WC, waist circumference; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL-C, high-density lipoprotein; LDL-C, low-density lipoprotein

Fig. 3

Restricted cubic spline curve for the association between TyG-ABSI and mortality. Adjusted for age, sex, ethnicity, educational level, marital status, PIR, smoking status, alcohol consumption, HEI-2015, PA, HDL, LDL, HbA1c, eGFR, uACR, uric acid, CKD, liver disease, cancer, hypertension, DM, antihypertensive drug, hypoglycemic therapy, lipid-lowering drug, and CKM syndrome. (A) Association between TyG-ABSI index and all-cause in patients with CKM stage 0–3. (B) Association between TyG-ABSI index and cardiovascular disease mortality in patients with CKM stage 0–3. The solid line and red area represent the estimated values and their corresponding 95% CIs. Abbrevaitons: CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval; TyG, triglyceride-glucose; ABSI, a body shape index; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein

Fig. 4

Time-dependent Receiver Operating Characteristic analysis of TyG-ABSI in predicting mortality. ROC curves and AUC for the assocaitions of TyG-ABSI, other TyG indices with all-cause mortality in patients with CKM syndrome stage 0–3 at 5-year(A), 10-year(B), and 15-year(C). ROC curves and AUC for the assocaitions of TyG-ABSI, other TyG indices with cardiovascular disease mortality in patients with CKM syndrome stage 0–3 at 5-year(D), 10-year(E), and 15-year(F). Adjusted for age, sex, ethnicity, educational level, marital status, PIR, smoking status, alcohol consumption, HEI-2015, PA, HDL, LDL, HbA1c, eGFR, uACR, uric acid, CKD, liver disease, cancer, hypertension, DM, antihypertensive drug, hypoglycemic therapy, lipid-lowering drug, and CKM syndrome. Abbreviations: ROC: receiver operating characteristic, AUC: area under the curve, CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval; TyG, triglyceride-glucose; ABSI, a body shape index; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein

Fig. 5

C-index evaluation for TyG-ABSI in forecasting mortality. (A) C-index variation of different TyG-derived indices over time for all-cause Mortality. (B) C-index variation of different TyG-derived indices over time for cardiocascular disease mortality. Adjusted for age, sex, ethnicity, educational level, marital status, PIR, smoking status, alcohol consumption, HEI-2015, PA, HDL, LDL, HbA1c, eGFR, uACR, uric acid, CKD, liver disease, cancer, hypertension, DM, antihypertensive drug, hypoglycemic therapy, lipid-lowering drug, and CKM syndrome. Abbreviations: C-index: concordance index, TyG: triglyceride–glucose, ABSI, a body shape index; BMI, body mass index; WWI, weight-adjusted waist index; WHtR, waist-to-height ratio; WC, waist circumference; CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval; TyG, triglyceride-glucose; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein

Fig. 6

Relationships of TyG-ABSI with all-cause mortality varying by subgroup. Adjusted for age, sex, ethnicity, educational level, marital status, PIR, smoking status, alcohol consumption, HEI-2015, PA, HDL, LDL, HbA1c, eGFR, uACR, uric acid, CKD, liver disease, cancer, hypertension, DM, antihypertensive drug, hypoglycemic therapy, lipid-lowering drug, and CKM syndrome. HR, hazard ratio; CI, confidence interval; CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval; TyG, triglyceride-glucose; ABSI, a body shape index; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein

Fig. 7

Relationships of TyG-ABSI with CVD mortality varying by subgroup. Adjusted for age, sex, ethnicity, educational level, marital status, PIR, smoking status, alcohol consumption, HEI-2015, PA, HDL, LDL, HbA1c, eGFR, uACR, uric acid, CKD, liver disease, cancer, hypertension, DM, antihypertensive drug, hypoglycemic therapy, lipid-lowering drug, and CKM syndrome. Abbrevaitions: HR, hazard ratio; CI, confidence interval; CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; HR, hazard ratio; CI, confidence interval; TyG, triglyceride-glucose; ABSI, a body shape index; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein

Fig. 8

Path diagram of the mediation analysis of ePWV and SIRI. The graphs in (A–D) represented the mediating role in all-cause mortality (via ePWV, SIRI) and CVD mortality (via ePWV, SIRI), respectively. Adjusted for age, sex, ethnicity, educational level, marital status, PIR, smoking status, alcohol consumption, HEI-2015, PA, HDL, LDL, HbA1c, eGFR, uACR, uric acid, CKD, liver disease, cancer, hypertension, DM, antihypertensive drug, hypoglycemic therapy, lipid-lowering drug, and CKM syndrome. Abbrevaitions: HR, hazard ratio. CI, confidence interval. CKM Syndrome, cardiovascular-kidney-metabolic syndrome; CVD, cardiovascular disease; TyG, triglyceride-glucose; ABSI, a body shape index; uACR, urinary albumin/creatinine ratio; PA, physical activity; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycosylated hemoglobin; HEI-2015, healthy eating index-2015; PIR, poverty income ratio; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein; ePWV, estimated Pulse Wave Velocity; SIRI, systemic inflammation response index