Abstract
Background:
The benefits of ideal cardiovascular-health metrics (ICVHMs) in patients with renal insufficiency remain unclear. This study aimed to investigate the associations between ICVHM and prognosis in a renal insufficiency population.
Methods:
The trial enrolled 29,682 participants from the US National Health and Nutrition Examination Survey (NHANES), 2007–2018, with mortality follow-up through December 31, 2019. Participants were divided into three groups based on estimated glomerular filtration rates. Cardiovascular health was assessed using new “Life’s Essential 8” metrics. Cox regression analyses based on NHANES data were used to determine the associations between ICVHMs and cardiovascular mortality in patients with renal insufficiency.
Results:
During a mean follow-up of 6.58 years, ideal cardiovascular health (hazard ratio [HR] = 0.42; 95% confidence interval [CI]; 0.25–0.70) and ideal health behavior (HR = 0.53; 95% CI; 0.39–0.73) reduced cardiovascular mortality in participants with renal insufficiency. For each one ICVHM increment, a 25% reduction in cardiovascular mortality was recorded (95% CI; 0.69–0.82). When compared with participants with normal renal function, for those with mild renal insufficiency, the HR for cardiovascular mortality gradually decreased from 1.47 (95% CI; 0.85–2.52) in those who had ≤1 ICVHMs to 0.30 (95% CI; 0.12–0.77) in participants who had >6 ICVHMs.
Conclusions:
From an ICVHM perspective, enhanced cardiovascular benefits were observed in individuals with renal insufficiency, coupled with a reduced risk of all-cause mortality. Furthermore, when compared with individuals with normal renal function, increased ICVHMs can mitigate adverse risks associated with renal impairment.
Keywords: Cardiovascular health, Cardiovascular mortality, NHANES, Prognosis, Renal insufficiency, Life’s Essential 8
Introduction
Incidences of renal insufficiency are increasing and mortality remains unacceptably high.[1–5] Notably, the risk of cardiovascular disease (CVD) is significantly increased in individuals with renal insufficiency and is increased by twofold to fourfold when combined with impaired kidney function.[6] Potential non-pharmacological interventions can help to reduce the cardiovascular burden in renal insufficiency cohorts.[7–9]
Cardiovascular health (CVH) was previously defined and has become an important factor in reducing the substantial CVD burden and other chronic health conditions in the past decade.[10,11] Recently, the American Heart Association (AHA) published an updated algorithm for quantifying CVH scores and redefining CVH—Life’s Essential 8.[11] Many studies have reported that individuals with a more ideal CVH have markedly lower risks for CVD events and end-stage renal disease (ESRD).[12,13] A recent study reported that participants with pre-diabetes or diabetes who achieved at least five ideal cardiovascular health metrics (ICVHMs) decreased their risk of cardiovascular events when compared with normal individuals.[14] It was also reported that the coronary risks conferred by chronic kidney disease (CKD) surpassed those conferred by diabetes.[15,16] However, as an important subpopulation with high CVD incidence and mortality, CVH status in renal insufficient populations is not ideal, and similarly, the benefits of updated CVH metrics in this population remain unclear.
Therefore, we investigated ICVHM benefits in populations with renal insufficiency. Additionally, we explored whether a higher number of ICVHMs, when compared with the general population, could mitigate cardiovascular damage caused by renal dysfunction.
Methods
Study design and participants
The National Health and Nutrition Examination Survey (NHANES) is a continuously monitored health system based on a typical sampling of the American civilian non-medical population. Available data, materials, and guidelines on methods are publicly accessible from the National Center for Health Statistics of the Centers for Disease Control and Prevention (https://www.cdc.gov/nchs/nhanes/index.htm).
Our study was limited to adult participants from the 2007–2018 NHANES survey who were 20 years or older in the US community, and whose estimated glomerular filtration rate (eGFR) values were calculated using CKD Epidemiology Collaborative equation formula.[17] According to Supplementary Figure 1 and Supplementary Materials, http://links.lww.com/CM9/C291, NHANES participants in the US community, who were 20 years or older (n = 35,922), were included. We excluded those with missing CVH data (n = 6087) and eGFR data (n = 107). Also, 46 potential participants were lost to follow-up. Thus, 29,682 individuals (17,297 with normal renal function, 9502 with mild renal insufficiency, and 2883 with moderate to severe renal insufficiency) were eventually enrolled in the study.
Patient and public involvement statement
The project was authorized by the National Center for Health Statistics Research Ethics Review Board (Protocol #2005-06, Protocol #2011-17, and Protocol #2018-01). Written informed consent was obtained from all participants.
CVH measurements and classification
The CVH concept was updated in the latest 2022 AHA recommendations, Life’s Essential 8.[11] Currently, four health behaviors (diet, physical activity, nicotine exposure, and sleep) and four health factors (body mass index [BMI], cholesterol, blood glucose, and blood pressure) have been identified. CVH measurement details are shown in Supplementary Table 1, http://links.lww.com/CM9/C291. The total CVH score was the average of the eight health index scores, and the range was 0–100. An individual with CVH score of <50 was poor; while 50–79 and ≥80 scores were intermediate and ideal, respectively.
Defining variables of interest
Age, sex, race, education level, alcohol use, and CVD history (congestive heart failure, coronary heart disease, stroke, heart attack, and angina), as well as family histories of CVD and diabetes, were self-reported. We performed analyses using eGFR values, which were calculated using the CKD Epidemiology Collaborative equation.[17] We divided participants into three eGFR categories:[18] (1) normal renal function with eGFR ≥90 mL·min−1·m−2; (2) mild renal insufficiency with eGFR 60–89 mL·min−1·m−2; and (3) moderate to severe renal insufficiency with eGFR <60 mL·min−1·m−2.
Mortality outcomes
Mortality information was collected by the National Center for Health Statistics and was based on several population surveys and death certificate records from the National Death Index. The primary study outcome was cardiovascular mortality. Cause of death was categorized using the International Classification of Diseases 10th edition (ICD-10) codes I00–I078. The secondary study outcome was all-cause mortality. Mortality follow-up data for NHANES participants from 2007 to 2018 were available as of December 31, 2019.
Statistical analysis
Analyses were performed using NHANES-recommended weights. Continuous variables were expressed as the mean ± standard error (SE) and statistically analyzed using one-way analysis of variance tests. Categorical variables were expressed as percentages and tested using the chi-squared method.
Cox proportional hazard models after recommended weighting were used to calculate hazard ratios (HRs) and 95% confidence intervals (CI) for cardiovascular or all-cause mortality, with multivariable adjustments for age, sex, race, alcohol consumption, education, CVD, family history of diabetes and CVD. Cardiovascular and all-cause mortality risks were assessed based on individual ICVHMs, combined health behaviors, combined health indicators, and combined CVH scores in participants with renal insufficiency. By analyzing the associations between ICVHMs components and cardiovascular and all-cause mortality, we adjusted for all other cardiovascular indicators. Additional analyses on the number of ideal health behaviors, ideal health indicators, and ICVHMs were performed to assess cardiovascular risk and all-cause mortality. We also conducted the subgroup analyses. Moreover, restricted cubic spline plots were used to explore health behavior, health scores, and CVH score associations with cardiovascular risk and all-cause mortality.
In supplementary analyses, we also analyzed cardiovascular risk and all-cause mortality according to combined health behaviors, combined health factors, combined CVH scores, individual ICVHMs, the number of health behaviors, health factors, and combined ICVHMs in participants with mild or moderate to severe renal insufficiency vs. individuals with normal renal function. Participants were stratified into subgroups according to age and sex; associations between health behaviors, health factors, and combined CVH scores, and cardiovascular or all-cause mortality in participants with mild renal insufficiency or moderate to severe renal insufficiency were examined and compared to participants with normal renal function in each age or sex subgroup. CVH distribution and trend levels in patients with renal insufficiency (from 2007 to 2018) were explored. A two-sided P-value <0.05 indicated statistically significant difference. The data analyses were performed using R software (version 4.2.0; R Foundation for Statistical Computing, Vienna, Austria).
Results
Of 29,682 participants, 17,297 (weighted rate, 59.0%) had normal renal function, 9502 (weighted rate, 33.3%) had mild renal insufficiency, and 2883 (weighted rate, 7.6%) had moderate to severe renal insufficiency. The mean age ranged from 40.2 ± 0.2 years to 71.6 ± 0.4 years. Baseline characteristics of study participants according to renal function status are shown in Table 1. When compared to participants with normal renal function, those with mild renal insufficiency had the highest percentages of males, while the moderate to severe category had the lowest education levels. Participants with mild or moderate to severe renal insufficiency were older, had lower health factor scores, lower CVH scores, and fewer ICVHMs.
Table 1.
Baseline characteristics of participants with normal renal function, mild renal insufficiency, and moderate to severe renal insufficiency (n = 29,682)*.
| Baseline characteristics | Normal renal function | Mild renal insufficiency | Moderate to severe renal insufficiency | P-values |
|---|---|---|---|---|
| Participants | 17,297 (59.0†) | 9502 (33.3) | 2883 (7.6) | – |
| Age (years) | 40.2 ± 0.2 | 57.8 ± 0.3 | 71.6 ± 0.4 | <0.001 |
| Men | 8113 (47.6) | 5043 (51.4) | 1394 (43.2) | <0.001 |
| Race | <0.001 | |||
| Mexican American | 3357 (11.8) | 998 (4.3) | 230 (3.4) | |
| Non-Hispanic Black | 3671 (12.2) | 1832 (8.2) | 647 (10.8) | |
| Non-Hispanic White | 5965 (59.6) | 4898 (77.4) | 1644 (78.4) | |
| Other Hispanic | 2024 (7.2) | 911 (3.9) | 197 (2.9) | |
| Other race | 2280 (9.2) | 863 (6.2) | 165 (4.5) | |
| Education level | 0.013 | |||
| <12 grades | 4194 (16.0) | 2196 (13.7) | 860 (20.9) | |
| 12 grades | 3895 (23.2) | 2159 (22.5) | 733 (26.3) | |
| >12 grades | 9201 (60.8) | 5135 (63.8) | 1287 (52.8) | |
| Drinking status | <0.001 | |||
| Non-drinker | 4184 (20.9) | 2989 (25.9) | 1313 (43.7) | |
| Low to moderate drinker | 4863 (32.1) | 3482 (44. 6) | 935 (41.3) | |
| Heavy drinker | 6943 (46.9) | 2315 (29.6) | 355 (15.1) | |
| Self-reported CVD | 905 (4.4) | 1657 (13.9) | 1132 (35.7) | <0.001 |
| Family history of CVD | 1966 (11.6) | 1328 (14.9) | 451 (15.8) | |
| Family history of diabetes | 7599 (41.2) | 4139 (40.1) | 1382 (44.0) | 0.102 |
| Healthy diet | 4056 (23.8) | 2810 (29.8) | 789 (27.9) | <0.001 |
| PA at goal | 12,226 (74.6) | 6045 (69.9) | 1255 (48.6) | <0.001 |
| Smoking status at goal | 10,033 (56.2) | 4991 (54.5) | 1432 (51.3) | <0.001 |
| Sleeping at goal | 10,388 (63.5) | 5922 (66.6) | 1749 (64.1) | <0.001 |
| BMI (kg/m2) | 29.2 ± 0.1 | 29.3 ± 0.1 | 30.7 ± 0.2 | <0.001 |
| Non-high cholesterol (mg/dL) | 139.1 ± 0.7 | 142.4 ± 0.8 | 132.1 ± 1.4 | 0.371 |
| Systolic BP (mm Hg) | 119.4 ± 0.2 | 125.2 ± 0.3 | 132.1 ± 0.8 | <0.001 |
| Diastolic BP (mm Hg) | 71.1 ± 0.2 | 71.3 ± 0.2 | 64.9 ± 0.5 | <0.001 |
| Glycated HbA1c (%) | 5.6 ± 0.0 | 5.8 ± 0.0 | 6.3 ± 0.0 | <0.001 |
| CVH sore | 69.6 ± 0.3 | 67.1 ± 0.3 | 60.5 ± 0.5 | <0.001 |
| Health behavior score | 67.1 ± 0.4 | 69.0 ± 0.4 | 64.0 ± 0.6 | 0.852 |
| Health factor score | 72.1 ± 0.3 | 65.1 ± 0.4 | 56.9 ± 0.6 | <0.001 |
| ICVHMs | <0.001 | |||
| ≤1 | 989 (5.0) | 855 (7.0) | 343 (10.2) | |
| 2 | 2212 (11.1) | 1654 (14.2) | 667 (21.6) | |
| 3 | 3549 (18.4) | 2351 (22.8) | 862 (29.5) | |
| 4 | 3913 (23.3) | 2212 (23.8) | 579 (19. 9) | |
| 5 | 3262 (20.0) | 1419 (17.2) | 291 (11.5) | |
| 6 | 2127 (13.4) | 702 (9.7) | 115 (6.0) | |
| ≥7 | 1245 (8.7) | 309 (5.3) | 26 (1.3) |
Values were shown as mean ± SE or n (%). *All estimates accounted for complex survey designs. †All the rates in Table 1 indicate the weighted rates. BP: Blood pressure; BMI: Body mass index; CVD: Cardiovascular disease; CVH: Cardiovascular health; HbA1c: Hemoglobin A1c; HEI-2015: Healthy Eating Index 2015; ICVHMs: Ideal cardiovascular health metrics; PA: Physical activity; SE: Standard error; –: Not applicable.
Overall, the ideal CVH status, ideal health behaviors, and health factors were observed in a lower proportion of participants with renal insufficiency [Supplementary Figure 2, http://links.lww.com/CM9/C291]. Moreover, the overall trend in individual or combined ICVHMs from 2007 to 2018 was different. The ideal status proportion was an increasing trend in glucose level and smoking level, and was a downward trend in BMI level [Supplementary Figure 3, http://links.lww.com/CM9/C291]. However, both individual and combined ICVHMs remained mostly stable.
As indicated in Table 2, the associations were identified between each ICVHM component and cardiovascular mortality and all-cause mortality. During a mean follow-up of 6.58 years, an ideal CVH and ideal health behaviors reduced cardiovascular mortality (ideal CVH: HR = 0.42; 95% CI: 0.25–0.70; ideal health behaviors: HR = 0.53; 95% CI: 0.39–0.73), and all-cause mortality (ideal CVH: HR = 0.58; 95% CI: 0.45–0.76; ideal health behaviors: HR = 0.55; 95% CI: 0.46–0.65) in participants with renal insufficiency. When compared with participants who had one ideal metric or none, for participants who had two to five and at least six ideal metrics, the cardiovascular mortality HR was 0.83 (95% CI: 0.51–1.35), 0.56 (95% CI: 0.36–0.86), 0.43 (95% CI: 0.29–0.62), 0.44 (95% CI: 0.27–0.70), and 0.25 (95% CI: 0.13–0.50), respectively [Table 3]. For each one ICVHM increment, a 25% reduction in cardiovascular mortality (95% CI: 0.69–0.82) was recorded. A similar HR pattern was observed for desirable health behavior metrics in participants with renal insufficiency; each increment in health behavior was associated with an HR = 0.68 (95% CI: 0.61–0.77) for cardiovascular mortality. The result of all-cause mortality was similar to cardiovascular mortality. In subgroup analyses, cardiovascular and all-cause mortality continued to decrease as each ICVHM, ideal health behavior, and ideal health factor increased [Figure 1]. Moreover, restricted cubic spline analyses showed that relationships between CVH, health behavior, and health factor scores, and all-cause mortality appeared to be non-linear (All P for non-linear <0.001; Supplementary Figure 4A, http://links.lww.com/CM9/C291). However, the relationship between CVH scores and cardiovascular mortality appeared to be linear (P for non-linear = 0.071; Supplementary Figure 4B, http://links.lww.com/CM9/C291).
Table 2.
HR (95% CI) of all-cause mortality and cardiovascular mortality according to individual ICVHMs among participants with renal insufficiency*.
| Categories | All-cause mortality† | Cardiovascular mortality† | ||||
|---|---|---|---|---|---|---|
| Person-years | No. of cases | HR (95% CI) | Person-years | No. of cases | HR (95% CI) | |
| Diet | ||||||
| Non-ideal | 56,276 | 1760 | 1 [Reference] | 56,276 | 476 | 1 [Reference] |
| Ideal | 24,026 | 617 | 0.91 (0.78–1.07) | 24,026 | 165 | 0.86 (0.61–1.22) |
| PA | ||||||
| Non-ideal | 31,753 | 1390 | 1 [Reference] | 31,753 | 392 | 1 [Reference] |
| Ideal | 48,549 | 897 | 0.60 (0.52–0.69) | 48,549 | 249 | 0.54 (0.41–0.70) |
| Smoking | ||||||
| Non-ideal | 38,271 | 1349 | 1 [Reference] | 38,271 | 343 | 1 [Reference] |
| Ideal | 42,031 | 938 | 0.63 (0.56–0.72) | 42,031 | 298 | 0.79 (0.60–1.04) |
| Sleeping | ||||||
| Non-ideal | 31,089 | 942 | 1 [Reference] | 31,089 | 272 | 1 [Reference] |
| Ideal | 49,214 | 1345 | 0.78 (0.70–0.88) | 49,214 | 369 | 0.75 (0.61–0.92) |
| BMI | ||||||
| Non-ideal | 62,015 | 1669 | 1 [Reference] | 62,015 | 492 | 1 [Reference] |
| Ideal | 18,287 | 618 | 1.33 (1.15–1.54) | 18,287 | 149 | 1.16 (0.91–1.48) |
| Total cholesterol | ||||||
| Non-ideal | 45,641 | 1044 | 1 [Reference] | 45,641 | 287 | 1 [Reference] |
| Ideal | 34,661 | 1243 | 1.13 (0.98–1.31) | 34,661 | 354 | 0.99 (0.77–1.27) |
| Glycated HbA1c | ||||||
| Non-ideal | 46,957 | 1677 | 1 [Reference] | 46,957 | 487 | 1 [Reference] |
| Ideal | 33,346 | 610 | 0.83 (0.71–0.97) | 33,346 | 154 | 0.76 (0.57–1.02) |
| BP | ||||||
| Non-ideal | 11,973 | 763 | 1 [Reference] | 11,973 | 239 | 1 [Reference] |
| Ideal | 4,727 | 263 | 0.85 (0.66–1.09) | 4727 | 75 | 0.75 (0.45–1.26) |
| Health behavior score | ||||||
| Non-ideal | 55,562 | 1881 | 1 [Reference] | 55,562 | 528 | 1 [Reference] |
| Ideal | 24,740 | 406 | 0.55 (0.46–0.65) | 24,740 | 113 | 0.53 (0.39–0.73) |
| Health factor score | ||||||
| Non-ideal | 66,371 | 2032 | 1 [Reference] | 66,371 | 581 | 1 [Reference] |
| Ideal | 13,932 | 255 | 0.94 (0.79–1.12) | 13,932 | 60 | 0.72 (0.51–1.03) |
| CVH score | ||||||
| Non-ideal | 69,433 | 2146 | 1 [Reference] | 69,433 | 608 | 1 [Reference] |
| Ideal | 10,869 | 141 | 0.58 (0.45–0.76) | 10,869 | 33 | 0.42 (0.25–0.70) |
*12,385 participants (9502 with mild renal insufficiency, and 2883 with moderate to severe renal insufficiency) were included in the analysis. †All analysis adjusted for age, sex, race, education level, alcohol drinking, family history of diabetes (yes or no), family history of CVD (yes or no) and self-reported CVD (congestive heart failure, coronary heart disease, stroke, heart attack, and angina). Individual CVH metrics were mutually adjusted. BP: Blood pressure; BMI: Body mass index; CI: Confidence interval; CVD: Cardiovascular disease; CVH: Cardiovascular health; HbA1c: Hemoglobin A1c; HR: Hazard ratio; ICVHMs: Ideal cardiovascular health metrics; PA: Physical activity.
Table 3.
HR (95% CI) of all-cause mortality and cardiovascular mortality according to the number of combined ICVHMs in participants with renal insufficiency.
| Categories | All-cause mortality† | Cardiovascular mortality† | ||||
|---|---|---|---|---|---|---|
| Person-years | No. of cases | HR (95% CI) | Person-years | No. of cases | HR (95% CI) | |
| No. of ICVHMs | ||||||
| ≤1 | 7587 | 315 | 1 [Reference] | 7587 | 99 | 1 [Reference] |
| 2 | 14,639 | 671 | 0.87 (0.68–1.12) | 14,639 | 157 | 0.83 (0.51–1.35) |
| 3 | 20,644 | 619 | 0.69 (0.53–0.90) | 20,644 | 169 | 0.56 (0.36–0.86) |
| 4 | 18,191 | 437 | 0.64 (0.49–0.82) | 18,191 | 121 | 0.43 (0.29–0.62) |
| 5 | 11,321 | 248 | 0.53 (0.41–0.70) | 11,321 | 73 | 0.44 (0.27–0.70) |
| ≥6 | 7921 | 97 | 0.38 (0.27–0.53) | 7921 | 22 | 0.25 (0.13–0.50) |
| No. of health behaviors | ||||||
| ≤1 | 24,879 | 1050 | 1 [Reference] | 24,879 | 288 | 1 [Reference] |
| 2 | 28,639 | 759 | 0.68 (0.59–0.79) | 28,639 | 220 | 0.70 (0.56–0.88) |
| 3 | 20,427 | 402 | 0.53 (0.46–0.62) | 20,427 | 109 | 0.46 (0.33–0.63) |
| 4 | 6367 | 76 | 0.26 (0.19–0.37) | 6367 | 24 | 0.32 (0.19–0.53) |
| No. of health factors | ||||||
| ≤1 | 30,417 | 909 | 1 [Reference] | 30,417 | 274 | 1 [Reference] |
| 2 | 22,430 | 685 | 0.98 (0.83–1.16) | 22,430 | 181 | 0.78 (0.61–0.98) |
| 3 | 9275 | 207 | 0.93 (0.74–1.16) | 9275 | 49 | 0.65 (0.43–0.99) |
| 4 | 2554 | 37 | 1.54 (0.92–2.59) | 2554 | 5 | 0.47 (0.16–1.35) |
| Each 1-number increment in ideal health behaviors | NA | NA | 0.70 (0.65–0.74) | NA | NA | 0.68 (0.61–0.77) |
| Each 1-number increment in ideal health factors | NA | NA | 1.02 (0.92–1.12) | NA | NA | 0.79 (0.67–0.94) |
| Each 1-number increment in ICVHMs | NA | NA | 0.83 (0.79–0.87) | NA | NA | 0.75 (0.69–0.82) |
*12,385 participants (9502 with mild renal insufficiency, and 2883 with moderate to severe renal insufficiency) were included. †All analyses were adjusted for age, sex, race, education level, alcohol consumption, family history of diabetes (yes or no), family history of CVD (yes or no), and self-reported CVD (congestive heart failure, coronary heart disease, stroke, heart attack, and angina. CI: Confidence interval; CVD: Cardiovascular disease; HR: Hazard ratio; ICVHMs: Ideal cardiovascular health metrics; NA: Not applicable.
Figure 1.
HR (95% CI) of all-cause mortality and cardiovascular mortality according to each 1-number increment in combined ICVHMs in participants with renal insufficiency, according to age and sex categories. CI: Confidence interval; HR: Hazard ratio; ICVHMs: Ideal cardiovascular health metrics.
As shown in Table 4, when compared to participants with normal renal function, participants with mild renal insufficiency who had ideal CVH reduced cardiovascular mortality (HR = 0.34; 95% CI: 0.14–0.81). In participants with moderate to severe renal insufficiency, the HR for cardiovascular mortality decreased gradually from 8.41 (95% CI: 3.35–21.12) for poor CVH to 2.10 (95% CI: 0.81–5.43) for an ideal CVH (P for trend <0.001). Similar results were observed in health behavior and all-cause mortality scores. In participants with mild renal insufficiency and younger than 75 years, an ideal CVH significantly reduced cardiovascular and all-cause mortality. In men and women participants, an ideal CVH or ideal health behaviors significantly reduced cardiovascular mortality [Supplementary Figure 5A, http://links.lww.com/CM9/C291]. A similar association was not observed in participants with moderate to severe renal insufficiency [Supplementary Figure 5B, http://links.lww.com/CM9/C291]. However, the HR for cardiovascular or all-cause mortality was not increased when compared to participants with normal renal function.
Table 4.
HR (95% CI) of all-cause mortality and cardiovascular mortality according to individual and combined ICVHMs in participants with mild renal insufficiency or moderate to severe renal insufficiency when compared to participants with normal renal function*.
| Categories | All-cause mortality | Cardiovascular mortality | ||||||
|---|---|---|---|---|---|---|---|---|
| Person-years | No. of cases | HR (95% CI)† | P for trend | Person-years | No. of cases | HR (95% CI)† | P for trend | |
| Normal renal function | 121,909 | 366 | 1 [Reference] | 121,909 | 84 | 1 [Reference] | ||
| Mild renal insufficiency | ||||||||
| Healthy diet | 19,074 | 352 | 0.94 (0.73–1.21) | 19,074 | 84 | 1.01 (0.64–1.59) | ||
| PA at goal | 40,963 | 591 | 0.73 (0.59–0.90) | 40,963 | 151 | 0.87 (0.53–1.43) | ||
| Ideal smoking | 33,520 | 490 | 0.63 (0.49–0.81) | 33,520 | 146 | 0.98 (0.58–1.64) | ||
| Sleeping at goal | 38,941 | 738 | 0.77 (0.63–0.96) | 38,941 | 178 | 0.90 (0.55–1.46) | ||
| Ideal BMI | 15,120 | 367 | 1.11 (0.84–1.47) | 15,120 | 79 | 1.08 (0.62–1.90) | ||
| Ideal blood cholesterol | 25,936 | 668 | 1.05 (0.84–1.32) | 25,936 | 160 | 1.05 (0.65–1.69) | ||
| Idea blood glucose | 29,159 | 395 | 0.73 (0.56–0.94) | 29,159 | 90 | 0.91 (0.55–1.51) | ||
| Ideal BP | 22,297 | 314 | 0.84 (0.66–1.07) | 22,297 | 71 | 0.87 (0.53–1.43) | ||
| Health behaviors score | <0.001 | 0.010 | ||||||
| Poor | 12,026 | 381 | 1.29 (1.02–1.63) | 12,026 | 211 | 1.47 (0.92–2.36) | ||
| Intermediate | 30,684 | 603 | 0.69 (0.57–0.84) | 30,684 | 87 | 0.86 (0.52–1.41) | ||
| Ideal | 20,892 | 277 | 0.52 (0.40–0.69) | 20,892 | 29 | 0.77 (0.44–1.36) | ||
| Health factors score | 0.440 | 0.080 | ||||||
| Poor | 15,018 | 317 | 0.73 (0.59–0.91) | 15,018 | 94 | 1.10 (0.68–1.79) | ||
| Intermediate | 36,062 | 770 | 0.75 (0.60–0.93) | 36,062 | 201 | 0.98 (0.59–1.61) | ||
| Ideal | 12,522 | 174 | 0.75 (0.57–0.99) | 12,522 | 32 | 0.60 (0.31–1.15) | ||
| CVH score | <0.001 | <0.001 | ||||||
| Poor | 9489 | 300 | 1.16 (0.93–1.46) | 9489 | 89 | 1.70 (1.01–2.85) | ||
| Intermediate | 44,350 | 858 | 0.70 (0.57–0.86) | 44,350 | 220 | 0.88 (0.55–1.40) | ||
| Ideal | 9763 | 103 | 0.47 (0.33–0.69) | 9763 | 18 | 0.34 (0.14–0.81) | ||
| Moderate to severe renal insufficiency | ||||||||
| Healthy diet | 4952 | 265 | 1.87 (1.19–2.93) | 4952 | 81 | 4.14 (1.10–15.51) | ||
| PA at goal | 7586 | 306 | 1.31 (0.96–1.77) | 7586 | 98 | 2.41 (1.23–4.72) | ||
| Ideal smoking | 8511 | 448 | 1.38 (0.99–1.92) | 8511 | 152 | 2.49 (1.39–4.48) | ||
| Sleeping at goal | 10,273 | 607 | 1.69 (1.24–2.31) | 10,273 | 191 | 3.80 (1.57–9.19) | ||
| Ideal BMI | 3167 | 251 | 2.30 (1.57–3.38) | 3167 | 70 | 3.78 (2.02–7.09) | ||
| Ideal blood cholesterol | 8725 | 575 | 1.87 (1.43–2.46) | 8725 | 194 | 3.23 (1.86–5.60) | ||
| Idea blood glucose | 4187 | 215 | 1.51 (1.13–2.02) | 4187 | 64 | 3.33 (1.84–6.03) | ||
| Ideal BP | 4727 | 263 | 1.54 (1.15–2.06) | 4727 | 75 | 2.42 (1.28–4.57) | ||
| Health behaviors score | <0.001 | <0.001 | ||||||
| Poor | 4061 | 354 | 2.86 (2.11–3.87) | 4061 | 103 | 7.45 (3.42–16.24) | ||
| Intermediate | 8791 | 549 | 1.71 (1.24–2.36) | 8791 | 169 | 3.90 (1.64–9.26) | ||
| Ideal | 3849 | 129 | 0.91 (0.61–1.35) | 3849 | 42 | 1.56 (0.68–3.59) | ||
| Health factors score | 0.040 | 0.080 | ||||||
| Poor | 5995 | 386 | 2.09 (1.50–2.92) | 5995 | 125 | 5.62 (2.27–13.95) | ||
| Intermediate | 9296 | 559 | 1.58 (1.19–2.11) | 9296 | 161 | 3.16 (1.50–6.65) | ||
| Ideal | 1410 | 81 | 1.43 (0.98–2.09) | 1410 | 28 | 3.90 (1.71–8.91) | ||
| CVH score | ||||||||
| Poor | 4044 | 319 | 2.79 (1.97–3.95) | <0.001 | 4044 | 107 | 8.41 (3.35–21.12) | <0.001 |
| Intermediate | 11,551 | 669 | 1.53 (1.14–2.04) | 11,551 | 192 | 2.76 (1.32–5.74) | ||
| Ideal | 1106 | 38 | 0.85 (0.54–1.32) | 1106 | 15 | 2.10 (0.81–5.43) | ||
*29,682 participants (17,297 with normal renal function, 9502 with mild renal insufficiency, and 2883 with moderate to severe renal insufficiency) were included. †All analyses were adjusted for age, sex, race, education level, alcohol consumption, family history of diabetes (yes or no), family history of CVD (yes or no), and self-reported CVD (congestive heart failure, coronary heart disease, stroke, heart attack, and angina). Individual CVH metrics were mutually adjusted. BP: Blood pressure; BMI: Body mass index; CI: Confidence interval; CVD: Cardiovascular disease; CVH: Cardiovascular health; HR: Hazard ratio; ICVHMs: Ideal cardiovascular health metrics; PA: Physical activity.
Furthermore, when compared to participants with normal renal function, in participants with mild renal insufficiency, the HR for cardiovascular mortality gradually decreased from 1.47 (95% CI: 0.85–2.52) in those who had ≤1 ICVHMs to 0.30 (95% CI: 0.12–0.77) in participants who had >6 ICVHMs [Supplementary Table 2, http://links.lww.com/CM9/C291]. All-cause mortality and cardiovascular mortality decreased with increasing ICVHMs. Similar trends were observed in participants with increased ICVHMs or increased healthy behaviors in participants with mild and moderate to severe renal insufficiency. The magnitude of incremental risks for cardiovascular mortality associated with fewer ICVHMs was greatest among participants who were younger than 75 years (≥6 ICVHMs: HR = 0.02; 95% CI: 0.00–0.16; ≤1 ICVHMs: HR = 1.75; 95% CI: 0.87–3.53; Supplementary Figure 6A, http://links.lww.com/CM9/C291) and greatest in female participants (≥6 ICVHMs: HR = 0.87; 95% CI: 0.30–2.51; ≤1 ICVHMs: HR = 3.67; 95% CI: 1.69–7.98). Similar healthy behavior and health factor results were also observed in participants with mild renal insufficiency. In participants with moderate to severe renal insufficiency, similar correlations between ICVHMs, health factors, and health behaviors with age and sex were observed [Supplementary Figure 6B, http://links.lww.com/CM9/C291].
Discussion
In this retrospective cohort study, ideal CVH ratios in participants with renal insufficiency were <20% over 10 years. For each ICVHM increment, cardiovascular mortality risk in renal insufficiency populations decreased by >20%. Furthermore, when compared with individuals with normal renal function, increased ICVHMs mitigated adverse risks associated with renal impairment.
Evidence for a relationship between renal dysfunction and adverse cardiovascular events was first recognized in dialysis populations; approximately 50% of individuals with ESRD die from a cardiovascular event.[19,20] Many studies have reported that relationships between renal impairment and increased CVD morbidity and mortality extend across the renal insufficiency spectrum, including the mildest degrees of renal impairment.[21,22] However, approximately half of individuals with severely reduced renal function and most individuals with renal damage or mildly reduced renal function were unaware of having CKD—this situation leads to a lack of treatment and partly explains the severe adverse outcomes due to renal impairment.[23] Additionally, kidney disease usually degenerates over time, and in some patients, the disease progresses to kidney failure even with proper treatment.[23] Therefore, in addition to monitoring and treatment strategies, controllable risk prevention and intervention approaches are highly advantageous when managing individuals with renal insufficiency. A retrospective cohort study of 837 Chinese individuals reported that positive changes in ICVHMs exerted favorable effects on renal function.[24] However, few further trials investigating ideal CVH benefits in reducing poor prognoses during renal impairment have been conducted, especially in the field of cardiovascular. Our results suggest that individuals with renal insufficiency should continuously strive for ideal AHA CVH metrics to improve cardiovascular event outcomes. Furthermore, maintaining the highest possible CVH metric levels will generate the best outcomes; however, if more than one metric is suboptimal or trending badly, they do not all need to be addressed simultaneously as the AHA suggested.[11] Our study emphasized that individuals with renal insufficiency should maintain more healthy behaviors than healthy factors, and that improving health factors alone does not provide ideal benefits.
In 2020, the AHA released their 2030 Impact Goals, which was to achieve CVH for all.[25] However, in 2020, <1% of US adults had all ideal metric levels and only 13% had five metrics in the ideal range.[26] Recent studies also highlighted the need to focus on ICVHMs in specific groups.[14] In a renal insufficiency cohort, analyses indicated that only the ratios of ideal smoking status and glycated hemoglobin A1c are over 50%. Meanwhile, the prevalence of individual ICVHMs did not have a significant increasing tendency during our study period. Our data should encourage the AHA to meet the 2030 goals in their drive to achieve CVH for all and help renal insufficiency and other chronic disease advocacy groups refine CVH definitions and reduce the global CVD burden in the future. It is important to adopt this approach when formulating future public policies and implementing effective population-based prevention and management strategies.
Using newly updated CVH information, we analyzed cardiovascular risk factor profiles to ascertain the cardiovascular benefit of CVH in a population with renal insufficiency. Importantly, regardless of gender, age, and renal function severity, the cardiovascular benefits of ideal CVH were extremely high in renal insufficiency populations. Additionally, we observed that participants with mild renal insufficiency, who had a greater number of ICVHMs, appeared to have a lower risk of cardiovascular mortality risk, and this counteracted the adverse risk of renal impairment in patients with moderate to severe renal function insufficiency when compared with the overall population with normal renal function. Our study also had several limitations. Firstly, as a retrospective cohort study, robust causal inferences were difficult to establish. Secondly, individual CVH’s were self-reported and subjected to misclassification and recall bias and may have led to an over- or under-estimation of our results. Thirdly, when investigating whether ICVHMs could offset the risks posed by renal insufficiency, we did not consider the CVH status of the reference population. However, factoring in the CVH of the general population for analysis would be both complex and challenging. Finally, the competing risk of cardiovascular mortality was not accounted for in our models. Using NHANES and weighting, it was difficult to balance them at the same time, therefore, we performed all-cause mortality analyses to support cardiovascular mortality results.
In conclusion, with a redefined CVH, we observed that benefits, especially cardiovascular, increased with ICVHMs in all patients with renal insufficiency, and an increased number of ICVHMs counteracted renal impairment harm when compared with the normal population. Our observations showed that effective CVH interventions in populations with renal insufficiency may promote higher CVH levels, help formulate public health policies, and reduce the burden of cardiovascular illness in this population.
Acknowledgements
The authors thank the participants and staff of the NHANES database for their valuable contributions.
Funding
This work was partially supported by the Leading Talents Plan, Beijing Municipal Health Commission (No. LJRC20240306).
Conflicts of interest
None.
Supplementary Material
Footnotes
How to cite this article: Chen WH, Xiao GT, Ding S, Shi SS, Pan YX, Tu JB, Zhang YB, Liao Y, Chen LL, Chen KH, Huang RC. Life’s Essential 8 metrics and prognosis in patients with renal insufficiency: Results from the National Health and Nutrition Examination Survey, 2007–2018. Chin Med J 2025;138:2824–2831. doi: 10.1097/CM9.0000000000003461
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