More than half of adults are overweight/obese and one in 10 has chronic kidney disease (CKD). These patients are at high risk of cardiovascular morbidity and mortality. This review discusses the pathophysiology, epidemiology, therapeutic principles and challenges of obesity management in adults with non-dialysis-dependent CKD. Inflammation, metabolic dysfunction and neurohormonal changes are central processes in the development of obesity-associated kidney disease. Obesity with metabolic syndrome is a risk factor for de novo CKD, progression to end-stage kidney disease and cardiovascular death. Treatment options to address obesity and related sequelae include lifestyle interventions, such as dietary modification and exercise therapy, drug treatment, such as glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter inhibitors, and metabolic surgery, such as vertical sleeve gastrectomy, Roux-en-Y gastric bypass or gastric banding. Challenges of management include fragmented care, limited evidence and the obesogenic environment. Cardiologists and nephrologists should work collaboratively to proactively screen for and manage cardiorenal risk in obese adults with CKD to mitigate avoidable harm.

Anti-cancer tyrosine kinase inhibitors are less selective than usually believed and may cause cardiovascular off-target effects. Ibrutinib, a first-in-class covalent inhibitor of Bruton tyrosine kinase, is a pillar of treatment of chronic lymphocytic leukaemia (CLL) and other B-cell malignancies yet is associated with risks of hypertension, AF and, less frequently, heart failure or ventricular tachyarrhythmias, which may lead to sudden death. The GLOW trial of ibrutinib plus the Bcl-2 inhibitor venetoclax as the first-line, fixed-duration treatment of CLL in elderly patients reported a number of cardiac and sudden deaths; these have been cited by many to downplay the otherwise unprecedented efficacy of this treatment. This article demonstrates that deaths in GLOW were mistakenly attributed to ibrutinib and should have been interpreted in the light of a complex composite of patient characteristics and the dynamics of cardiovascular events. Critical analysis of deaths in GLOW should serve as a lesson to improve clinicians’ appraisal of the risk:benefit ratio of using one cancer drug or another.

Cardiac regeneration remains a major challenge in clinical medicine. Following MI, up to 25% of cardiomyocytes in the left ventricle can be lost, a key factor contributing to heart failure. In adults, this loss is not compensated by new cardiomyocyte formation. However, in neonatal mammals and some other species, such as fish and amphibians, heart regeneration occurs naturally through the proliferation of the surviving cardiomyocytes. Over the past two decades, substantial progress has been made in understanding the molecular pathways that regulate cardiomyocyte proliferation during development, early neonatal life and in other species. Notably, several human microRNAs, identified through extensive screening for their ability to stimulate cell proliferation, have emerged as potent inducers of cardiomyocyte proliferation and cardiac regeneration when administered therapeutically. This review highlights the gene targets and regenerative effects of the most effective of these microRNAs, including the miR-17-92 and miR-302-367 clusters, miR-199a, miR-1825, miR-590 and miR-33b, and discusses their potential for clinical application in treating MI and heart failure.

Meta-analysis and meta-regression are feasible and reliable statistical tools to assess the joint effect of divergent studies and studies that were underpowered or in uncertain areas. Meta-analysis should be performed accurately and have a clear objective. Conclusions of meta-analyses should not rely on small numbers of events and should not tell what is already known or obscure what should be remembered; similarly, those that rely on indirect comparison should be cautiously interpreted. New aspects of meta-analyses include analysis of subgroups, multivariate adjustment, assessment of bias or network meta-analyses. Meta-regression can elucidate the effect on variables predicted according to the results of previously available studies and can be adjusted for one or more explanatory variables that might influence the size of intervention effect. This has also been used for the estimation of the effect of novel therapies. This review summarises current knowledge related to metaanalysis and meta-regression with published examples.

Cardiovascular disease is a major cause of morbidity and mortality in individuals with kidney disease. In recent years, biomarkers such as cardiac troponins have become indispensable to the diagnosis and prognosis of cardiac disease, such as MI and heart failure. However, these biomarkers behave differently in the general population compared with people with kidney disease, who may have higher baseline levels and reactions to acute disturbance due to a combination of reduced renal clearance of biomarker molecules and increased production due to concurrent cardiovascular disease and cardiorenal syndrome. Three decades of research into cardiac biomarkers have produced a range of literature investigating their applications in different patient groups and healthcare settings. This review explores the evidence surrounding measurement and interpretation of cardiac troponin levels in people who have chronic kidney disease, and have had dialysis and/or kidney transplantation, with reference to baseline levels and changes over time, their relationship to incident cardiovascular morbidity and mortality, and their application in acute settings.

This review explores the use of point-of-care (POC) monitoring of direct oral anticoagulants (DOACs) in patients with non-valvular AF globally and in Malaysia. As patent protection measures for innovative medicines come to an end, and generic alternatives become available, we expect a greater uptake of DOACs than warfarin by patients due to cost advantages. However, the anticoagulation effect of DOACs has been shown to vary from patient to patient and is associated with thrombotic and bleeding risks. Despite the availability of laboratory technology, including at POC, that can monitor the pharmacological effects of DOACs, it has not achieved any substantial traction in clinical use to date. Future efforts should focus on establishing the therapeutic window or ‘sweet spot’ of DOAC therapy for the POC assays and ensuring adherence before implementation of POC monitoring. This is crucial for the tailoring of anticoagulation therapy, potentially reducing overall healthcare costs and improving patient health outcomes.