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Abdominal obesity is associated with increased worsening renal function risk in patients with heart failure with preserved ejection fraction

BMC Cardiovascular Disorders volume 24, Article number: 477 (2024) Cite this article

Abstract

Background

Worsening renal function (WRF) is a frequent comorbidity of heart failure with preserved ejection fraction (HFpEF). However, its relationship with abdominal obesity in terms of HFpEF remains unclear. This study aimed to evaluate the value of waist circumference (WC) and body mass index (BMI) in predicting WRF and examine the correlation between abdominal obesity and the risk of WRF in the HFpEF population.

Methods

Data were obtained from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial. Abdominal obesity was defined as WC ≥ 102 cm for men and ≥ 88 cm for women. WRF was defined as doubling of serum creatinine concentration from baseline. Restricted cubic splines and receiver operating characteristic curves were used to evaluate the value of WC and BMI in predicting WRF. Cumulative incidence curves and cox proportional-hazards models were used to compare patients with and without abdominal obesity.

Results

We included 2,806 patients with HFpEF in our study (abdominal obesity, n: 2,065). Although baseline creatinine concentrations did not differ, patients with abdominal obesity had higher concentrations during a median follow-up time of 40.9 months. Unlike BMI, WC exhibited a steady linear association with WRF and was a superior WRF predictor. Patients with abdominal obesity exhibited a higher risk of WRF after multivariable adjustment (hazard ratio: 1.632; 95% confidence interval: 1.015–2.621; P: 0.043).

Conclusions

Abdominal obesity is associated with an increased risk of WRF in the HFpEF population.

Trial registration

URL: https://beta.clinicaltrials.gov. Unique identifier: NCT00094302.

Peer Review reports

Background

Heart failure with preserved ejection fraction (HFpEF) representing over 50% of the total heart failure population, which is continuously increasing in number [1]. Obesity is the most common comorbidity of HFpEF, and over 80% of patients were reported as being overweight or obese in the HFpEF population, which is double the rate observed in the general population [2, 3]. Patients with cardiometabolic phenotype significantly differ from non-affected patients in several ways, including greater plasma volume and epicardial fat tissue, more ventricular remodeling and dysfunction, and lower natriuretic peptide levels [4].

Worsening renal function (WRF) is one of the most clinically important complications of heart failure, occurring in approximately 25% of all cases [5]. It restricts the range of medications available for use in affected patients, complicates volume management, promotes the development of heart failure, and induces a heightened risk of subsequent mortality [5,6,7,8]. Therefore, the early identification of patients at elevated risk of WRF may be important.

As a classic anthropometric indicator, high body mass index (BMI) is correlated with the onset of worsening renal function in the population without kidney failure [9]. However, BMI has limitations in predicting risks in patients with HFpEF due to the challenge of distinguishing between central and subcutaneous fat. [10, 11]. As the importance of body fat distribution becomes more recognized, abdominal obesity, accessed by waist circumference (WC), has received more attention than general obesity. It is reported that abdominal obesity is associated with the elevated risk of all-cause mortality in the HFpEF population [12]. However, the longitudinal relationship between abdominal obesity and WRF in this population is unclear. Therefore, we conducted a study with the aim of reevaluating the anthropometric indicators and assessing their predictive potential for WRF in this population.

Methods

Patient population

Data were obtained from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, which is a randomized, double-blind phase III trial of spironolactone at 233 sites in six countries. The methodology of the trial has been previously described [13]. In short, patients aged ≥ 50 years who had a left ventricular ejection fraction ≥ 45% and a history of hospitalization for heart failure in the previous 12 months or an elevated level of brain natriuretic peptides (BNP) in the 60 days before randomization (BNP ≥ 100 pg/ml or N-terminal pro-BNP ≥ 360 pg/ml), systolic blood pressure < 140 mmHg, and a serum potassium concentration ≤ 5.0 mmol/L were included. Patients with a life expectancy < 3 years, estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, or a serum creatinine concentration ≥ 2.5 mg/dL were excluded [13]. Since TOPCAT trial included patients with an LVEF > 45%, it recruited patients with mildly reduced as well as preserved ejection fraction, so we excluded patients whose LVEF on enrolment below 50%. Furthermore, we excluded patients with missing BMI and WC data in the current study. A WC of ≥ 102 cm for male patients and ≥ 88 cm for female patients was used as the criterion for abdominal obesity [14]. A final total of 2806 patients were suitable for inclusion. This study followed the Helsinki Declaration principles and ethical approval was granted by the Hunan Provincial Hospital ethics committee and all patients provided written informed consent.

Definition of worsening renal function

The optimal definition of WRF has not yet been established. In the TOPCAT trial, WRF was defined as doubling of serum creatinine levels from baseline on two determinations separated by ≥ 28 days and beyond the upper reference limit [15]. Follow-up laboratory tests were performed in weeks 1, 4, and 8, months 4, 8, and 12, and every 6 months thereafter. We used an eGFR-based definition of WRF for the sensitivity analyses, defined as a relative decrease of eGFR of > 25%, between baseline and month 4 [16], the calculation of eGFR during follow-up has been previously described [17].

Statistical analysis

Baseline characteristics are reported as frequencies with corresponding percentages for categorical variables. Continuous variables are presented as mean ± standard deviation for normally distributed data, while for non-normally distributed data, median with interquartile range was used. Normality was assessed using normal quantile-quantile plots. The chi-square test was used to compare categorical variables, whereas Student’s t-test or the Mann–Whitney U test was used to compare normally and non-normally distributed continuous variables, respectively.

Cox proportional hazards regression models and cumulative incidence curves were utilized to explore the correlation between abdominal obesity and the development of WRF. We adjusted for different baseline covariates in two models to reduce the potential bias caused by multicollinearity. Model 1 included age, gender, race, hypertension, diabetes, smoking, drinking per week. Model 2 is adjusted for all variables that were significantly different between the category of interest in Table 1 and the logistic regression predictors of abdominal obesity in the HFpEF population (Supplement Table 1). For the sensitivity analyses, we further tested the effect of abdominal obesity on WRF in 8 subgroups in the univariate cox regression models (age, sex, American region, New York Heart Association functional class, eGFR, hypertension, diabetes, and use of spironolactone) and performed interaction analyses to assess potential interaction effect in these subgroups.

Table 1 Baseline characteristics of patients with and without abdominal obesity
Full size table

A multivariable cox proportional hazards model with restricted cubic splines was used to model the nonlinear correlation between BMI/WC and WRF. The potential of WC and BMI in predicting WRF was evaluated by receiver operating characteristic (ROC) curves and pairwise comparisons of ROC curves were conducted by Delong-test. A P-value < 0.05 was considered statistically significant. All analyses were conducted using R (v4.2.2, www.R-project.org) and IBM SPSS Statistics (v22.0, IBM Corp., Armonk, NY, USA).

Results

Clinical characteristics

Patients with abdominal obesity were more prone to be female and black and to have higher baseline heart rate, systolic blood pressure, BMI, and New York Heart Association functional class than those without abdominal obesity. Patients with abdominal obesity more often had a history of chronic obstructive pulmonary disease, hypertension, diabetes, and dyslipidemia and took ARBs, CCBs, statins and diuretics. A smaller number of patients with abdominal obesity had previously experienced myocardial infarction and angina pectoris, were current smokers (Table 1). Following randomization, patients experienced a short-term elevation in creatinine levels in both spironolactone and placebo arms, but patients with abdominal obesity demonstrated a tendency towards elevated serum creatinine concentration during follow-up visits, despite no significant differences in baseline creatinine concentration (P: 0.200) (Fig. 1).

Fig. 1
figure 1

Serum creatinine concentration at the follow-up visits. During the entire follow-up period, serum creatinine concentration was lower in patients without abdominal obesity than that in those with abdominal obesity. Cr: creatinine

Full size image

Abdominal obesity and the risk of WRF

After a median of 40.9 months’ follow-up period, 205 participants had developed WRF. Abdominal obesity significantly increased the risk of WRF in patients with HFpEF (unadjusted hazard ratio [HR]: 1.967; 95% confidence interval [CI]: 1.355–2.855; P < 0.001) when using the creatinine-based definition (Fig. 2A). Similar outcomes were observed with the eGFR-based definition (unadjusted HR: 1.275; 95% CI: 1.050–1.548; P: 0.014) (Fig. 2B).

Fig. 2
figure 2

Cumulative incidence curves for worsening renal function. Abdominal obesity is associated with higher risk of WRF in patients with HFpEF. Similar results were obtained when using an eGFR-based definition of WRF. eGFR: estimated glomerular filtration rate

Full size image

After adjusting for age, sex, and race, hypertension, diabetes, smoking, drinking per week, patients with abdominal obesity had a 60.1% higher risk of WRF. The increased risk remained significant after adjusting for all other confounding variables, with a 63.2% higher risk (Table 2). The results of subgroup analysis showed in Fig. 3, abdominal obesity was associated with an increased risk of WRF in all subgroups. Although the female subgroup, higher New York Heart Association functional class subgroup, hypertensive subgroup, diabetic subgroup, and both American and non-American subgroup didn’t exhibit statistically significant results, no interaction effects were discovered in any of the 8 subgroups, which enhance the credibility of the result.

Table 2 Risk of worsening renal function in HFpEF with and without abdominal obesity
Full size table
Fig. 3
figure 3

Subgroup analyses for worsening renal function. Abdominal obesity was associated with an increased risk of WRF in all subgroups, no interaction effects were discovered in all 8 subgroups. CI: confidence interval, eGFR: estimated glomerular filtration rate, NYHA: New York Heart Association

Full size image

As illustrated in Fig. 4, BMI exhibited a nonlinear correlation with WRF in univariate model, patients with a mildly elevated BMI faced a lower risk of WRF, while excessively high or low BMIs led to an increased risk of WRF in univariate model, this relationship disappears when multivariable adjusted, while WC and WRF had a linear association in univariate and multivariate model. The ROC curves indicated that WC was superior to BMI for prediction of WRF (Fig. 5; Table 3).

Fig. 4
figure 4

Restricted cubic splines for the relationship between BMI/WC and worsening renal function. Unlike BMI, WC shows a steady linear association with WRF in male and female patients. Full-adjusted model included age, gender, race, hypertension, diabetes, smoking, drinking per week, BMI, HR, SBP, LVEF, myocardial infarction history, angina pectoris history, COPD history, dyslipidemia history, eGFR, serum potassium, hemoglobin, glucose, use of ACEIs, ARBs, CCBs, diuretics, and statins. BMI: body mass index, CI: confidence interval, HR: hazard ratio, WC: waist circumference, WRF: worsening renal function

Full size image
Table 3 Predictive capacity of BMI/WC in worsening renal function in HFpEF
Full size table
Fig. 5
figure 5

Receiver operating characteristic curves for worsening renal function. WC was superior to BMI for prediction of WRF. BMI: body mass index, WC: waist circumference, WRF: worsening renal function. Other factors included age, gender, race, hypertension, diabetes, smoking, drinking per week, BMI, HR, SBP, LVEF, myocardial infarction history, angina pectoris history, COPD history, dyslipidemia history, eGFR, serum potassium, hemoglobin, glucose, use of ACEIs, ARBs, CCBs, diuretics, and statins

Full size image

Discussion

Two main conclusions can be drawn from our study. First, abdominal obesity is associated with the elevated risk of WRF in the HFpEF population. Second, WC exhibited a greater capacity for predicting WRF than BMI.

Following randomization, patients experienced a short-term elevation in creatinine levels in both spironolactone and placebo arms, and those with abdominal obesity maintaining higher levels. However, previous study suggested that the beneficial effect on cardiovascular mortality is pronounced despite the incidence of WRF [16]. Similar results were observed in trials of diuretics and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) [18, 19]. Those results led us to reevaluate the relationship between WRF and clinical outcomes, the prevalence of WRF may be overestimated owing to the phenomenon of “pseudo-WRF”, in this condition, a patient’s clinical status improves or remains constant despite an elevated serum creatinine concentration [20].

The relationship between visceral adipose tissue deposition and poor nephritic outcomes has gained attention in recent years. Studies showed that in obese, overweight, average-weight, and even lean people, a central pattern of fat distribution is an important factor in new-onset renal impairment [21, 22]. Possible reasons for the superiority of abdominal obesity in predicting WRF include the following. First, perirenal and renal sinus fat mechanically compress the thin loop of Henle and vasa recta of the renal medulla, resulting in reduced tubular flow and increased sodium reabsorption, which activates tubular glomerular feedback and exacerbates renal hyperfiltration [23]. Second, epicardial adipose tissue in HFpEF correlates with worsening hemodynamic parameters, which exacerbate the decreased effective renal perfusion pressure [24]. Third, visceral adipose tissue exhibits lower oxygen tension and more abundant macrophages, regulatory and natural killer T cells, and eosinophils, all of which secrete inflammatory cytokines and induce systemic inflammation, [25] together with increased oxidative stress, this type of inflammation causes wide-ranging endothelial dysfunction that eventually results in fibrosis of the heart and kidneys [26, 27].Fourth, lipolysis of visceral adipose tissue contributes 5–10% (normal-weight) and up to 25% (abdominal-obese) to hepatic free fatty acid delivery. This stimulates very-low-density lipoprotein production and ectopic fat accumulation in the kidneys, resulting in glomerulosclerosis, tubular injury, and fibrosis [28].

The subgroup analysis revealed differences in incidence rates across various subgroups, aligning with our expectations that patients with poorer health status and more comorbidities would have a higher incidence of WRF. For example, patients with NYHA class III-IV had a higher incidence of WRF (10.81% vs. 9.18%), and elderly patients also exhibited a higher incidence (7.79% vs. 6.40%). Notably, the results from the American region are significant, with patients in this region experiencing a dramatically higher incidence of WRF. However, neither the American nor the non-American subgroups showed statistically significant results, which may be attributed to the limited sample size of the TOPCAT trial and the substantial differences in baseline characteristics between regions [29]. Although there was no significant interaction effect of regions on the relationship between abdominal obesity and WRF, our findings warrant further confirmation in large-scale studies.

Furthermore, our study confirmed the findings about sex-specific difference, it suggested that males appear to be more susceptible to the impact of central obesity and the development of WRF. Indeed, sex differences in body-fat distribution have garnered attention in recent decades. The findings of the current study suggest that there are variations in the proportion of visceral adipose tissue between sexes, with men accumulating a higher proportion of visceral adipose tissue compared to women [30]. This kind of sex difference in fat distribution leads to a poorer prognosis in men with abdominal obesity compared to women, which is reported in previous studies [31,32,33].

As a modifiable risk factor, reduction of visceral adipose tissue following bariatric surgery, as in the Roux-en-Y gastric bypass, is reported to yield significantly improved left ventricular diastolic function, ventricular remodeling, and pericardial restraint [34,35,36,37]; to reverse tissue fibrosis; and to reduce the incidence of WRF in patients with or without pre-existing kidney disease [38, 39]. The underlying mechanisms may be associated with inhibition of chronic inflammation and improvement of mitochondrial function [40].

While this study presents important findings and has notable strengths, several limitations should be acknowledged. First, more accurate indices for assessing visceral adipose distribution, such as the visceral adiposity index, and for WRF, such as the urinary concentration of Kidney Injury Molecule-1, were identified after the completion of the TOPCAT trial. Second, we cannot rule out the possibility of reverse causality due to changes in WC during the follow-up period. Third, the limited sample size of the TOPCAT trial may have introduced bias in the subgroup analysis. Therefore, our results require further validation in large-scale studies that incorporate these newer indices and include a broader range of patients.

Conclusions

Based on our study’s findings, WC exhibits a steady linear correlation with WRF and is a superior predictor of WRF than BMI in the HFpEF population. Abdominal obesity is associated with the elevated risk of WRF in the HFpEF population. Future research should aim to identify superior indicators for predicting WRF and examine the benefits of weight loss during follow-up in prospective studies.

Data availability

Our study was completed using the TOPCAT data collected by the National Heart, Lung, and Blood Institute (NHLBI) Biologic Specimen and Data Repository Information Coordinating Center. (Trial registration: URL: https://beta.clinicaltrials.gov. Unique identifier: NCT00094302)

Abbreviations

HFpEF:

Heart failure with preserved ejection fraction

BMI:

Body mass index

TOPCAT:

Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist

eGFR:

Estimated glomerular filtration rate

ACEI:

Angiotensin-converting enzyme inhibitor

ARB:

Angiotensin receptor blocker

WC:

Waist circumference

ROC:

Receiver operating characteristic

HR:

Hazard ratio

CI:

Confidence interval

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Acknowledgements

Our study was completed using the TOPCAT data collected by the National Heart, Lung, and Blood Institute (NHLBI) Biologic Specimen and Data Repository Information Coordinating Center. The views expressed by the authors in this article may not align with the perspectives of TOPCAT or NHLBI.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China

    Quan Zhang, Shi Tai & Shenghua Zhou

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Contributions

SZ and ST defined the study themes and methods; QZ and ST analyzed the data; QZ wrote the paper and SZ and ST edited the manuscript. All authors have read and approved the final manuscript.

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Correspondence to Shenghua Zhou.

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This study followed the Helsinki Declaration principles and ethical approval was granted by the Hunan Provincial Hospital ethics committee. All patients provided written informed consent for.

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Zhang, Q., Tai, S. & Zhou, S. Abdominal obesity is associated with increased worsening renal function risk in patients with heart failure with preserved ejection fraction. BMC Cardiovasc Disord 24, 477 (2024). https://doi.org/10.1186/s12872-024-04118-0

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BMC Cardiovascular Disorders

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