Prospective Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Diabetes. Apr 15, 2024; 15(4): 712-723
Published online Apr 15, 2024. doi: 10.4239/wjd.v15.i4.712
Associations between remnant cholesterol levels and mortality in patients with diabetes
Deng Pan, Lin Xu, Li-Xiao Zhang, Da-Zhuo Shi, Ming Guo
Deng Pan, Li-Xiao Zhang, Da-Zhuo Shi, Ming Guo, Department of Cardiovascular, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, China
Deng Pan, Graduate School, Beijing University of Chinese Medicine, Beijing 100020, China
Deng Pan, Li-Xiao Zhang, Da-Zhuo Shi, Ming Guo, National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, China
Lin Xu, Gynecological Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing 100020, China
Co-first authors: Deng Pan and Lin Xu.
Co-corresponding authors: Da-Zhuo Shi and Ming Guo.
Author contributions: Pan D and Xu L performed statistical analysis; Xu L and Zhang LX retrieved raw data from NHANES; Pan D, Shi DZ designed the study. Pan D, Shi DZ and Guo M wrote the manuscript; Xu L and Guo M acquired the fundings supporting the article. The reasons for designating Xu L and Pan D as co-first authors are as follows: First, the research was performed as a collaborative effort, the effort to retrieve raw data is necessary, and statistical analysis is also essential to finish the article. Second, the two authors cooperated together, Pan D designed the study and Xu L made effort to acquire data. Additionally, Pan D wrote the draft, and two authors managed post-submission matters. We think it is necessary for the article and the two authors contributed with equal importance. Shi DZ and Guo M were co-corresponding authors, the reasons were as follows. Shi DZ inspired the study design and checked the data from NHANES, and confirm the accuracy of the data. Moreover, Shi DZ wrote the draft for the manuscript. Guo M also wrote the draft, and responsible for the revision of the article. In addition, Guo M acquired the fundings and also maintained the raw data. Guo M and Shi DZ are responsible for the data. Hence, we thought Guo M and Shi DZ as co-corresponding authors.
Supported by Project of National Natural Science Foundation of China, No. 82274345 and No. 82104907; and Fundamental Research Funds for the Central public welfare research institutes Grant, No. ZZ13-YQ-016 and No. ZZ13-YQ-016-C1.
Institutional review board statement: The NHANES study was reviewed and approved by the NCHS Research Ethics Review Board.
Clinical trial registration statement: This is a cohort study based on National Health and Nutrition Examination Survey (NHANES) without any intervention and does not require a registration.
Informed consent statement: This is a cohort study based on National Health and Nutrition Examination Survey (NHANES) without any intervention. All participants have provided the consent forms according to NHANES official.
Conflict-of-interest statement: The authors declare they have no conflict of interest.
Data sharing statement: The datasets generated and/or analyzed during the current study are available from https://www.cdc.gov/nchs/nhanes/.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ming Guo, PhD, Deputy Director, Department of Cardiovascular, Xiyuan Hospital of China Academy of Chinese Medical Sciences, No. 1 Xiyuan Cao Chang, Qinglongqiao Street, Haidian District, Beijing 100091, China. mguo@xycacms.ac.cn
Received: December 30, 2023
Peer-review started: December 30, 2023
First decision: January 17, 2024
Revised: January 29, 2024
Accepted: March 7, 2024
Article in press: March 7, 2024
Published online: April 15, 2024
Processing time: 103 Days and 10.5 Hours
Abstract
BACKGROUND

Dyslipidemia is frequently present in patients with diabetes. The associations of remnant cholesterol and mortality remains unclear in patients with diabetes.

AIM

To explore the associations of remnant cholesterol with all-cause and cardiovascular mortality in patients with diabetes.

METHODS

This prospective cohort study included 4740 patients with diabetes who participated in the National Health and Nutrition Examination Survey from 1999 through 2018. Remnant cholesterol was used as the exposure variable, and all-cause and cardiovascular mortality were considered outcome events. Outcome data were obtained from the National Death Index, and all participants were followed from the interview date until death or December 31, 2019. Multivariate proportional Cox regression models were used to explore the associations between exposure and outcomes, in which remnant cholesterol was modeled as both a categorical and a continuous variable. Restricted cubic splines (RCSs) were calculated to assess the nonlinearity of associations. Subgroup (stratified by sex, age, body mass index, and duration of diabetes) and a series of sensitivity analyses were performed to evaluate the robustness of the associations.

RESULTS

During a median follow-up duration of 83 months, 1370 all-cause deaths and 389 cardiovascular deaths were documented. Patients with remnant cholesterol levels in the third quartile had a reduced risk of all-cause mortality [hazard ratio (HR) 95% confidence interval (CI): 0.66 (0.52-0.85)]; however, when remnant cholesterol was modeled as a continuous variable, it was associated with increased risks of all-cause [HR (95%CI): 1.12 (1.02-1.21) per SD] and cardiovascular [HR (95%CI): 1.16 (1.01-1.32), per SD] mortality. The RCS demonstrated nonlinear associations of remnant cholesterol with all-cause and cardiovascular mortality. Subgroup and sensitivity analyses did not reveal significant differences from the above results.

CONCLUSION

In patients with diabetes, higher remnant cholesterol was associated with increased risks of all-cause and cardiovascular mortality, and diabetes patients with slightly higher remnant cholesterol (0.68-1.04 mmol/L) had a lower risk of all-cause mortality.

Keywords: Diabetes; Remnant cholesterol; Mortality; Cardiovascular; National Health and Nutrition Examination Survey

Core Tip: This cohort study of 4740 patients with diabetes from the National Health and Nutrition Examination Survey was aimed at evaluating the associations of remnant cholesterol with all-cause and cardiovascular mortality. Diabetes patients with remnant cholesterol levels in the third quartile (0.68-1.04 mmol/L) had a lower risk of all-cause mortality than did nondiabetic patients with remnant cholesterol levels in the other quartiles, and the associations of remnant cholesterol with all-cause and cardiovascular mortality were U-shaped. A per standard deviation increase in remnant cholesterol was associated with a greater risk of all-cause and cardiovascular mortality. A focus should be placed on the level of remnant cholesterol in patients with diabetes.