Cardiovascular-Kidney-Metabolic Syndrome

A graphic depiction of a mesh anatomically correct heart. Below, is a blue line with two peak areas and then a flat line. The Background is a dark blue.
  • April 12, 2024

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.

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  October 9, 2023 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.



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.

A graphic image illustrating the stages of Cardiovascular-Kidney-Metabolic Syndrome. Stage 0 shows a graphic image of a healthy woman jogging and the logo for the AHA's Life's Essential 8 calculator, which focuses on primordial prevention and preserving cardiovascular health. From that starting point, a white arrow points into a yellow zone for Stage 1: Excess/Dysfuntional Adipose Tissue, which shows a cutout of an overweight/obese figure, a microscopic view of dysfunctional adipose tissue, and feet on a scale over the caption: Overweight/obesity, Abdominal obeisty, Impared glucose tolerance. From there, a light yellow arrow points into a darker yellow zone for Stage 2: Metabolic Risk Factors and CKD showing an illustration of the interactions between hypertension (blood pressure cuff), metabolic syndrome (cell slide), moderate to high-risk CKD (kidneys), type 2 diabetes (blood sugar reading), and hypertriglyuceridemia (molecular sugars). From there, a dark yellow arrow points into an orange zone for Stage 3: Subclinical CVD in CK Syndrome illustrated with scans showing evidence of subclinical ASCVD and subclinical HF. The orange zone further describs risk equivalents of subclinical CVD in CKM Stage 3: 1) Very high-risk CKD (G stage 4 and 5 CKD or by KDIGO heat map) and 2) High predicted risk for CVD using risk calculator. Finally, an orange arrow points into the red zone for Stage 4: Clinical CVD in CKM Syndrome showing five medical images representing CHD (injured heart), HF (enlarged heart), PAD (blocked arteries in the leg), Stroke (injured brain), and Afib (arrhhythmia reading).

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...,as%20well%20as%20they%20should.


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