Connecting the Pieces for Better Cardiovascular, Kidney, and Metabolic Health
By April Hopcroft
Experts in diabetes care recently shared valuable insights for managing kidney health, lipid levels, glucose, and body weight on a recent diaTribe panel. Panelists emphasized the importance of education and self-advocacy, plus newer treatments like SGLT-2 inhibitors and PCSK9 inhibitors.
The American Heart Association recently coined the phrase cardiovascular-kidney-metabolic (CKM) syndrome – but what does this smorgasbord of words mean for people with diabetes?
The term CKM syndrome describes the strong connections between heart disease, kidney disease, and metabolic conditions like type 2 diabetes and obesity. Having one of these conditions often makes the risk higher risk for the others.
For instance, people with diabetes have an increased risk of heart disease. Studies show that a person with diabetes has the same cardiovascular risk as someone without diabetes who’s experienced a cardiac event (such as a heart attack or stroke).
Likewise, if you have kidney disease, you are also at higher risk of developing heart disease. Many CKM conditions have similar underlying causes, namely, diabetes and high blood pressure.
diaTribe recently hosted a virtual roundtable discussion, "Connecting the Pieces - New Insights on Metabolic, Lipid and Kidney Health," where experts shared practical advice for optimizing metabolic, lipid, and kidney health. Panelists highlighted the importance of screening, proactive treatment, and self-advocacy to address these interconnected conditions.
The panel was moderated by Dr. Diana Isaacs, an endocrine clinical pharmacy specialist and director of education and training in diabetes technology at the Cleveland Clinic, and included:
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Dr. Roopa Mehta, an endocrinologist and researcher in the department of endocrinology and metabolism at the National Institute of Medical Sciences and Nutrition Salvador Zubrian in Mexico City.
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Daniel Newman, type 1 diabetes advocate, chronic kidney disease survivor, and host of The Talking Type1 podcast.
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Dr. Ted Okerson, a specialist in clinical hypertension and senior field physician at AstraZeneca.
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Dr. Robert Eckel, professor of medicine, emeritus, at the University of Colorado Anschutz Medical Campus.
Know your risk for chronic kidney disease
Years of high blood sugar levels can increase the risk of chronic kidney disease (CKD) for people with diabetes. Aging also plays a role, regardless of whether you have diabetes or other health conditions. After age 30 to 40, you begin to lose nephrons, which are the filtering units of the kidney – even if you are otherwise healthy.
“Everyone with diabetes has to pay attention to kidney function and get proper screening tests so they can be treated early,” said Dr. Eckel. 
While anyone with diabetes can develop kidney disease, people with type 1 diabetes have a higher risk compared to those with type 2 diabetes. CKD also progresses more rapidly in type 1 diabetes. There are currently few treatments available for people with type 1 diabetes and CKD, but research is underway to expand treatment options.
As Eckel noted, early detection is key. Everyone with diabetes should receive two screening tests each year to check kidney function:
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Estimated glomerular filtration rate (eGFR): This is a blood test used to calculate how well the kidneys are working.
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Urinary albumin creatinine ratio (uACR): This test uses a urine sample to measure how much protein has leaked from the kidneys. When the kidneys are damaged, they often leak protein into the urine.
While most healthcare providers are familiar with conducting yearly eGFR tests, Eckel acknowledged that sometimes they skip the uACR test.
“Healthcare providers sometimes forget that protein in the urine is an important marker of diabetic kidney disease and can relate to ongoing kidney damage,” he said.
Indeed, recent research by the National Kidney Foundation shows that over half of people with diabetes aren’t receiving these screenings. For these reasons, Dr. Isaacs said it’s important to advocate for yourself if you haven’t received the proper screenings.
SGLT-2 inhibitors are essential for heart and kidney protection
When SGLT-2 inhibitors – such as Jardiance (empagliflozin), Farxiga (dapagliflozin), and Invokana (canagliflozin) – were first approved in 2014, they were primarily used for glycemic control benefits.
Since then, many large trials have documented the heart and kidney benefits of these drugs, leading to their approvals for heart failure and chronic kidney disease in people with and without diabetes.
Dr. Okerson emphasized that SGLT-2 inhibitors have been shown to reduce death from any cause (not just heart disease) in clinical trials. Based on these findings, guidelines now recommend that people with diabetes who have or are at risk for cardiovascular or kidney disease should take an SGLT-2 inhibitor and/or a GLP-1 receptor agonist.
Okerson noted that many people experience a minor drop in eGFR after starting an SGLT-2 inhibitor, but this dip is perfectly normal, often temporary, and generally not a cause for concern.
Another challenge in the use of SGLT-2 inhibitors is their high cost, which is about $600 for a one month supply. In July 2023, the FDA approved a new SGLT-2 inhibitor, Brenzavvy, which is available at a lower cost with no insurance through Cost Plus Drugs. However, there is no cardiovascular or kidney outcome data yet on this SGLT-2 inhibitor.
What are triglycerides and why are high levels harmful?
Beyond heart and kidney disease, it’s also important to consider lipid levels.
Triglycerides are a type of fat that circulate in the blood along with cholesterol; they are also found in high concentrations in fat (adipose) tissue. High blood sugar levels cause more triglycerides to be released from the liver, which can lead to insulin resistance.
While evidence suggests that triglycerides do not directly cause heart disease, Eckel explained that high triglyceride levels are “a clue that something in metabolism has gone awry.” This should alert healthcare providers to find the underlying cause of high triglycerides – whether it’s genetics, excess body weight, elevated blood sugar, or something else.
Typically, someone is considered to have what’s called hypertriglyceridemia when triglyceride levels are above 150 mg/dL. When triglycerides are above 500 mg/dL, this is classified as severe hypertriglyceridemia, which elevates the risk of acute pancreatitis (inflammation of the pancreas).
So, what can you do to lower triglycerides?
1. Weight loss
Typically, when people lose weight, high triglycerides are reduced. Eckel highlighted the importance of maintaining weight loss through physical activity and dietary changes.
He explained that with weight loss and physical activity, body composition changes. Specifically, people typically lose fat and build lean tissue including muscle, which helps with lowering triglycerides. Maintaining weight loss also contributes to overall cardiovascular health.
2. Limit alcohol
The more you drink, the greater the impact on triglyceride metabolism and overall triglyceride levels, Eckel explained. In general, he recommended avoiding alcohol altogether when triglyceride levels are over 500 mg/dL.
If your triglyceride levels are above 300 mg/dL, Eckel suggested limiting yourself to one drink occasionally. If you do choose to drink, be sure to stick to moderate amounts and learn to identify carb-filled drinks ahead of time.
3. Avoid simple sugars and minimize carbohydrates
Nutrition guidelines recommend that people with diabetes should get less than 10% of their calories from simple sugars, which are the most basic form of sugar. Simple sugars are found in foods like soda, candy, cakes, and other baked goods.
According to the American Heart Association, women should limit themselves to no more than 100 calories per day from added sugars and men should have no more than 150 calories per day from added sugars. 
Reducing intake of simple sugars is easier said than done, Dr. Mehta noted. Often, family preferences or cultural norms can influence eating patterns, and it can be hard to make major changes.
Habit stacking can be a good way to link new, healthy eating habits to existing parts of your routine. If you’re still struggling to follow a nutritious diet, your healthcare provider can refer you to a nutritionist or dietitian for further support.
Newer treatment options for managing cholesterol
In addition to triglycerides, it’s important to know your cholesterol levels through an annual lipid panel test.
Cholesterol is another form of fat that circulates in the bloodstream. LDL cholesterol (“bad” cholesterol) is directly linked to heart disease, as it can accumulate on the walls of your blood vessels, blocking the flow of blood, oxygen, and nutrients to the heart and brain, which can lead to a heart attack or stroke.
To reduce the amount of LDL cholesterol, it’s important to avoid foods that are high in saturated or trans fats. Statins are usually the first course of treatment for high cholesterol and are highly effective in reducing cholesterol levels and risk of heart disease, Mehta said.
Beyond statins, there are newer drugs that can help people further reduce their LDL cholesterol. These medications include oral drugs like Zetia (ezetimibe) and Nexletol (bempedoic acid). There are also injectable options, such as the PCSK9 inhibitors like Praluent (alirocumab), Repatha (evolocumab), and a newer medication called Leqvio (inclisiran).
“Lipids are a pillar of diabetes care that need to be managed with diet, statins, and newer drugs coming in with even greater benefit that will help patients better reach their targets,” said Mehta.
Managing diabetes distress, letting go of perfectionism, and self-advocacy are also key
Dan Newman has lived with type 1 diabetes for over 27 years. During that time, he has experienced the ups and downs of diabetes, including being diagnosed with chronic kidney disease and diabetic retinopathy. .png)
As a teenager, Newman struggled with diabetes distress and burnout. At one point, he decided he would only take insulin, but wouldn’t engage in other diabetes management, such as checking his blood glucose levels.
A diagnosis of CKD in his mid-20s provided a much-needed wake-up call. Newman had high levels of albuminuria – meaning his kidneys were leaking protein into his urine – and ultimately received a kidney transplant from a family member in 2018, narrowly avoiding the need for dialysis.
“The transplant has been transformational for me in terms of quality of life. I’m very fortunate to have had a family member who was a match,” Newman said.
Newman stressed the importance of educating and advocating for yourself.
“If you’re a person with diabetes today, learning to advocate for yourself is so important. Also educate yourself on kidney health, what your blood pressure readings are, cholesterol, glucose levels, and the long term impact of diabetes,” he said.
For instance, Newman said that he was unaware that there was so much hidden salt in the African and Caribbean foods he grew up eating.
“I had to really change the type and amount of seasoning I was using, which meant changing my cultural identity too. This is another indirect cost of diabetes,” Newman said.
Despite facing many challenges in his diabetes management, Newman said he stays positive by letting go of perfectionism and the goal of being the “ideal” patient with type 1 diabetes. It’s important to recognize that some days will be better than others, and that’s okay.
Newman said he views small steps toward healthy living as equally important as major goals. For instance, he said any time he spends exercising is worth it for his physical and mental health.
“Don’t be scared of what can happen in the future with diabetes. It’s better to know now and have that knowledge,” he said.
Learn more about kidney, heart, and metabolic health in diabetes here:
