As a former ICU registered nurse and clinical director of a Pritikin Intensive Cardiac Rehab (ICR) program, I have spent years recognizing and educating patients about risk factors that lead to the development of cardiovascular disease (CVD). The most rewarding part was educating my patients on how to slow the disease progression by adopting healthier lifestyle choices.  Many of my previous cardiac rehab patients came to the program unknowingly suffering from metabolic syndrome. This disorder involves a combination of risk factors such as elevated blood sugar, triglycerides, and blood pressure, along with low levels of HDL (the “good” cholesterol) and an above-average waist circumference.

However, that is only one piece of a much larger puzzle of associated health conditions. The direct relationship between the health of our heart and kidneys (cardiorenal syndrome) is well-documented. But recently, this confluence of metabolic and kidney conditions and their elevated risk of mortality from cardiovascular disease has captured healthcare’s attention.

On Monday, October 9th, the American Heart Association (AHA) published a Presidential Advisory on Cardiovascular Kidney Metabolic Health (CKM). CKM syndrome identifies links between a patient’s metabolic risk factors. These links can predict one’s probability of developing serious kidney and cardiovascular conditions. The new term also reflects new guidance for screening and treatment.

What is CKM Syndrome?

According to AHA’s CKM Health initiative co-chairs, Dr. Janani Rangaswami, a nephrologist, and Dr. Chiadi Ndumele, a cardiologist, CKM Syndrome is a systemic condition derived from a cluster of metabolic risk factors such as obesity, diabetes, hypertension, chronic kidney disease (CKD), and cardiovascular disease. When combined, they can have a detrimental effect on multiple organs of the body and result in increased mortality from cardiovascular disease. Unfortunately, at least one-third of American adults already have three or more of the components that can lead to the high mortality risk associated with CKM Syndrome. Individually, obesity, diabetes, and hypertension, in and of themselves, can put a person at risk for cardiovascular disease.  Layer on kidney disease and this risk is multiplied significantly. According to Dr. Rangaswami, 90% of people with CKD are completely unaware they have the disease.

In this video, Dr. Janani Rangaswami and Dr. Chiadi Ndumele explain CKM Syndrome in more detail.

How do we identify CKM Syndrome?

Unlike metabolic or cardiorenal syndromes, the presidential advisory explains that CKM syndrome includes the time before the onset of any symptoms, stressing the importance of screening for metabolic factors at an early age. This includes not only looking at the biological issues at play but also the social determinants of health (SDOH) that affect clinical outcomes. These can include financial hardships and environmental, social, and psychological factors that can put a person at an increased health risk. To help assess risk for CKM, the AHA has created the staging system outlined below. The goal in all stages is to prevent progression to the next stage and, especially, to the diagnosis of CVD or CKD.

Stages of CKM syndrome. The cardiovascular-kidney-metabolic (CKM) staging construct reflects the progressive pathophysiology and increasing absolute cardiovascular disease (CVD) risk along the spectrum of CKM syndrome. Stage 0 CKM includes individuals with normal weight, normal glucose, normal blood pressure, normal lipids, normal kidney function, and no evidence of subclinical or clinical CVD; the focus in stage 0 CKM is primordial prevention and preserving cardiovascular health. Stage 1 CKM includes individuals with excess adipose tissue, dysfunctional adipose tissue, or both. Excess adiposity is identified by either weight or abdominal obesity, and dysfunctional adipose tissue is reflected by impaired glucose tolerance and hyperglycemia. Stage 2 includes individuals with metabolic risk factors (hypertriglyceridemia, hypertension, metabolic syndrome, or type 2 diabetes), moderate- to high-risk chronic kidney disease (CKD), or both. Although hypertension and CKD are usually downstream of metabolic risk factors, the curved arrows represent individuals with nonmetabolic causes of these conditions; the risk implications and treatment approaches are similar. Stage 3 includes individuals with subclinical CVD with overlapping CKM risk factors (excess/dysfunctional adipose tissue, metabolic risk factors, or CKD) or those with the risk equivalents of very high-risk CKD or high predicted risk using the forthcoming CKM risk calculator. Stage 4 includes individuals with clinical CVD (coronary heart disease, HF, stroke, peripheral artery disease, or atrial fibrillation) overlapping with CKM risk factors. Afib indicates atrial fibrillation; ASCVD, atherosclerotic cardiovascular disease; CHD, coronary heart disease; HF, heart failure; KDIGO, Kidney Disease Improving Global Outcomes; and PAD, peripheral artery disease.
The 0-4 stages outlined in this graphic can be used in both children and adults. | This image is shared from the linked AHA Journal article, "Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association"
  • Stage 0: No Risk Factors
    • In this stage, individuals are typically young, asymptomatic with normal weight, no metabolic risk factors, or diagnoses of CKD or CVD.
    • These individuals would benefit from early preventative screenings for biological metabolic factors and SDOH. They should be encouraged to adopt heart-healthy lifestyle behaviors in order to maintain a low risk of developing CVD.
  • Stage 1: Excess/Dysfunctional Adipose Tissue
    • In this stage, individuals typically have increased body fat, abdominal obesity, and/or prediabetes without any other metabolic risk factors or any diagnoses of CKD or CHD
    • These individuals would benefit from adopting a heart-healthy lifestyle with an emphasis on weight loss along with screenings every 2-3 years for hypertension as well as abnormal cholesterol and glucose levels.
  • Stage 2: Metabolic Risk Factors and CKD
    • In this stage, individuals will have developed additional metabolic risk factors such as hypertension, Type 2 diabetes, metabolic syndrome, elevated cholesterol levels, or CKD
    • These individuals would benefit from intensive lifestyle modification to address individual risk factors, appropriate pharmacotherapy, and additional screenings for CKD.
  • Stage 3: Subclinical CVD in CKM Syndrome
    • In this stage, individuals have metabolic risk factors from the earlier stages, may have symptoms, and will test positive for subclinical diagnoses of heart disease, heart failure (HF), or peripheral artery disease (PAD).
    • These individuals would benefit from aggressive lifestyle modification, guideline-directed medical therapy, and additional screenings including, but not limited to, cardiac calcium scores, angiograms, and lab tests including BNP or NT pro-BNP as well as cardiac enzymes.
  • Stage 4: Clinical CVD in CKM Syndrome
    • In this stage, individuals have cardiovascular disease, ischemic stroke, clinical HF, PAD, and/or an irregular heart rate like atrial fibrillation.
    • These individuals would benefit from individualized treatment options such as guideline-directed medical therapy based on their level of metabolic involvement and clinical severity. Continued aggressive lifestyle modifications, screenings for SDOH, and a well-connected interdisciplinary care team are crucial.

Call to Action

To improve CKM health in the general population, the AHA recommends several interventions:

  1. Communities need to improve access to healthy lifestyle opportunities and improve overall health education.
  2. The multidisciplinary treatment team should maintain open lines of communication regarding individualized treatment and a patient-centered approach.
  3. SDOH need to be recognized for how they can affect one’s health and level of care.
  4. Guideline-directed medical therapies should be utilized to their fullest potential to alleviate risk.

What can you do?

You do not have to be in the healthcare field to recognize the early signs of CKM Syndrome.  I guarantee we all know someone very close to us that might be at risk. Please advocate for yourself or for your patients, friends, or family members by encouraging healthy lifestyle choices, regular physician checkups, and proper screenings.

Further Reading...

Redefining CVD Risk: CV-Kidney-Metabolic (CKM) Syndrome
A new formal definition of CKM syndrome from the American Heart Association reflects the strong interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system.
Cardiovascular-kidney-metabolic (CKM) syndrome
Learn about cardiovascular-kidney-metabolic (CKM) syndrome, its risk factors and the connection between heart disease, kidney disease, type 2 diabetes and obesity.
Heart disease risk, prevention and management redefined
Advisory Highlights: A new American Heart Association presidential advisory identifies the strong connections among cardiovascular disease (CVD), kidney disease, Type 2 diabetes and obesity, and suggests redefining CVD risk, prevention and management. ...