Several factors for chronic kidney disease (CKD), including diabetes, hypertension, and obesity, are described consistently in the literature; studies describing modifiable lifestyle factors, includin

The gap

Consensus across the literature

Supporting evidence — 3 representative gaps

• Glycemic status, adiposity indices and cardiovascular risk in chronic kidney disease: Core findings from a nationwide cohort study (2026) · doi

  Lack of dynamic data on body composition, failure to consider gender differences, and it was an observational study that could not draw causal relationships CKD: Chronic kidney disease; IFG: Impaired fasting glucose; DM: Diabetes mellitus; BMI: Body mass index; WC: Waist circumference; CVD: Cardiovascular disease; HR: Hazard ratio. Open in New Tab Full Size Table The large sample size and rigorous study design provide important clinical evidence for personalized cardiovascular risk stratification and intervention strategies in CKD patients, highlighting significant academic value and practical implications. However, as with any landmark study, it raises several critical questions that merit further exploration. By synthesizing recent literature, including landmark trials such as Flow Research on Renal Outcomes with Semaglutide, Dapagliflozin in Patients with CKD, and Empagliflozin in Patients with CKD, alongside emerging data on novel obesity metrics and muscle atrophy, we present a forward-looking perspective designed to advance cardiovascular risk management within this heterogeneous population. THE COMPLEX INTERPLAY BETWEEN GLYCEMIC STATUS AND ADIPOSITY IN CKD The findings of Bae et al[1] underscore the intricate interplay between body composition, glycemic status, and cardiovascular outcomes in CKD. The observation that underweight diabetic patients exhibit the highest risk of CVD is consistent with the well- documented “obesity paradox” in CKD, where a higher BMI is often associated with better survival[2,3]. However, this paradox ⌃ may be attributed to the limitation of BMI in distinguishing between fat mass and lean mass. Within the context of CKD, malnutrition[4], sarcopenia[5], and underweight[6] are prevalent conditions that are independently associated with adverse  outcomes. Muscle loss may promote insulin resistance and systemic inflammation, which in turn exacerbates cardiovascular risk[7,8]. In contrast, the finding that central obesity elevates CVD risk among normoglycemic individuals highlights the critical role of fat distribution. Visceral adiposity is metabolically active and contributes to inflammation, endothelial dysfunction, and insulin resistance[9,10]. Recent research indicates that measures such as the body roundness index (BRI)[11] and visceral adiposity index[12] may more accurately reflect this risk than BMI alone[13]. Large-scale studies have further demonstrated that BRI surpasses BMI in predicting both all-cause and cardiovascular mortality in general and CKD populations[14,15]. Consequently, a key remaining challenge is determining how to incorporate advanced body composition metrics into risk stratification protocols for patients with CKD. UNRESOLVED ISSUES AND FUTURE DIRECTIONS In this opinion review, we seek to build upon the findings of Bae et al[1] by discussing unresolved issues and proposing future directions. Specifically, we address five key areas: (1) The limitations of traditional adiposity indices; (2) The need for CKD stage- specific risk stratification; (3) The role of long-term glycemic control; (4) The translation of risk stratification into targeted interventions; and (5) The ethnic considerations in generalizing findings. We respectfully offer a few additional reflections, hoping to provide a reference for subsequent research and clinical translation in the related fields, as summarized in Table 2. Table 2  Summary of limitations and optimization suggestions.

  Keywords: risk cardiovascular body patients stratification adiposity composition mass index outcomes obesity glycemic disease size large
• The Association among Smoking, Heavy Drinking, and Chronic Kidney Disease (2006) · doi

  Several factors for chronic kidney disease (CKD), including diabetes, hypertension, and obesity, are described consistently in the literature; studies describing modifiable lifestyle factors, including smoking and consumption of alcohol, are sparse, sometimes contradictory.

  Keywords: factors including several chronic kidney disease diabetes hypertension obesity described consistently literature describing modifiable lifestyle
• Comparison of Risk Prediction Using the CKD-EPI Equation and the MDRD Study Equation for Estimated Glomerular Filtration Rate (2012) · doi

  CONTEXT: The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation more accurately estimates glomerular filtration rate (GFR) than the Modification of Diet in Renal Disease (MDRD) Study equation using the same variables, especially at higher GFR, but definitive evidence of its risk implications in diverse settings is lacking.

  Keywords: disease equation context chronic kidney epidemiology collaboration accurately estimates glomerular filtration rate modification diet renal