Introduction: Cardiovascular disease (CVD) remains the leading cause of mortality in the US, highlighting the need for novel approaches to its prediction, prevention, and management. Epigenetic age acceleration (EAA), or increased DNA methylation-based age relative to chronological age, is a promising biomarker of disease risk. While previous studies have prospectively linked EAA to CVD, recent work in patients with end-stage kidney disease showed no association between EAA and mortality from CVD, underscoring a need for more research across patient populations. Hypothesis: EAA measures, specifically intrinsic epigenetic age acceleration (IEAA), extrinsic epigenetic age acceleration (EEAA), phenotypic epigenetic age acceleration (PhenoAA), and Grim epigenetic age acceleration (GrimAA), are associated with incident CVD in diabetic kidney disease (DKD). Methods: In a subset of 496 participants from the Chronic Renal Insufficiency Cohort with DKD, selected based on kidney function decline over follow-up (large versus small), we examined four EAA measures: IEAA, EEAA, PhenoAA, and GrimAA. GrimAA is comprised of eight DNA methylation-based biomarkers, including plasminogen activator inhibitor-1 age acceleration (PAI-1 AA ) and tissue inhibitor of matrix metalloproteinase (TIMP-1 AA ), which were also assessed. Primary outcomes were incident CVD, atherosclerotic CVD, and CVD mortality; secondary outcomes included myocardial infarction, congestive heart failure (CHF), cerebrovascular accident, and peripheral artery disease (PAD). Cox proportional models tested associations between the EAA measures and CVD endpoints after adjusting for baseline demographics, clinical center, kidney function decline as a study design feature, lifestyle, and clinical risk factors. Results: Participants were predominantly male (63%), with a median age of 57 years, median eGFR of 44 mL/min/1.73m 2 , and mean hemoglobin A1c of 8.0%. After adjusting for multiple testing, each standard deviation increase in GrimAA was associated with incident CVD (HR=1.27; 95% confidence interval [CI], 1.08-1.50; p=0.012) and PAD (HR=1.65; 95% CI, 1.15-2.37; p=0.006). Likewise, PAI-1 AA was significantly associated with incident CVD (HR=1.24; 95% CI, 1.06-1.44; p=0.006) and PAD (HR=1.46; 95% CI, 1.17-1.81; p=0.001), while TIMP-1 AA was associated with CHF (HR=1.32; 95% CI, 1.09-1.60; p=0.005). Nominally significant associations between IEAA and atherosclerotic CVD were also identified (HR=1.24; 95% CI, 1.00-1.53; p=0.049). Similarly, EEAA was nominally associated with incident CVD (HR 1.22; 95% CI, 1.01-1.47, p=0.039). Conclusion: EAA measures, notably GrimAA, are promising CVD biomarkers in DKD patients. Associations of GrimAA components PAI-1 AA and TIMP-1 AA with incident CVD add to the accumulating evidence of their predictive and therapeutic potential.
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