CKM syndrome affects the majority of American adults, but most people have never heard of it.
The acronym stands for cardiovascular-kidney-metabolic syndrome, a new syndrome defined in an October 2023 American Heart Association presidential advisory as a systemic disorder that reflects the strong links between obesity, Type 2 diabetes, chronic kidney disease and cardiovascular disease. It is estimated that more than 90% of adults fall on the CKM spectrum, driven mainly by record levels of obesity and Type 2 diabetes in adults and children. CKM syndrome increases the risk of heart attacks, stroke, heart failure, kidney failure, and premature death.
“Cardiovascular-kidney-metabolic syndrome is an umbrella term that includes most of the disease we treat in cardiology and in medicine on a whole,” says Eugenia Gianos, M.D., a cardiologist and director of cardiovascular prevention for Northwell Health. “At the core of this syndrome is obesity, with adipose or fat tissue leading to insulin resistance, inflammation, and oxidative stress that then lead to later stages of disease.”
Grouping CKM health into one syndrome reflects the intricate relationships between diabetes, obesity, heart disease, kidney disease, and encourages more holistic treatment for these conditions. It also provides a cohesive framework for screening, education, and prevention.
Notably, the advisory factors in the increased risk for CKM caused by social detriments of health, such as poverty and unequal access to healthcare.
“One of the key highlights is that we need to continue to address the social determinants of health related to this disease, with greater access to healthy foods and medications that will lead to greater health equity overall,” Gianos says.
The advisory recommends specific screenings for CKM risk factors and provides CKM staging from 0 to 4, with recommendations for interventions and preventive measures at each stage. Below are the stages of CKM syndrome:
STAGE 0: NO CKM RISK FACTORS
Individuals at Stage 0 have no known CKM risk factors. They have a normal body mass index (BMI) and waist circumference, normal blood sugar, blood pressure and lipid profiles, and no evidence of kidney disease or cardiovascular disease. As risk factors generally increase with age, youth and young adults are more likely to be in this category than older adults.
The goal at Stage 0 is to prevent CKM syndrome by maintaining good health, including healthy eating, exercise, and sleep habits, avoiding nicotine, and maintaining optimal weight, blood pressure, blood sugar and cholesterol levels, according to the AHA. Screenings are recommended every three to five years for blood pressure, triglycerides, HDL (good) cholesterol and blood sugar.
STAGE 1: EXCESS BODY FAT AND/OR PREDIABETES
Stage 1 applies to people who have excess body fat, with a BMI greater than 25, and/or a lot of fat around the waist, and/or who have impaired glucose tolerance or prediabetes. These individuals should be given support for making healthy lifestyle changes, encouraged to lose at least 5% of their body weight and receive appropriate screenings every two to three years. They should also be treated for glucose intolerance if applicable.
STAGE 2 – METABOLIC RISK FACTORS AND KIDNEY DISEASE
People at Stage 2 may have Type 2 diabetes, high blood pressure, high triglycerides or kidney disease, and are at a higher risk for worsening kidney disease and heart disease. Care at this stage should address the individuals’ particular risk factors to prevent progression to cardiovascular disease and kidney failure. For instance, treatments may include medications to control blood pressure, blood sugar and cholesterol.
The advisory emphasizes certain drugs, including GLP-1 receptor agents such as Wegovy and Ozempic, which help with insulin resistance and weight loss and reduce cardiovascular disease mortality.
“It’s important to remember that this is a very preventable disease state through lifestyle and advanced therapies,” says Gianos.
Screening suggestions for Stage 2 CKM syndrome call for yearly assessment of blood pressure, triglycerides, cholesterol, blood sugar and kidney function, and screening for advanced liver fibrosis every one to two years in individuals with diabetes, prediabetes or two or more metabolic risk factors.
STAGE 3 – EARLY CARDIOVASCULAR DISEASE
Stage 3 refers to individuals with early cardiovascular disease (without symptoms) along with metabolic risk factors or kidney disease, or who are otherwise at high predicted risk for cardiovascular disease. At Stage 3, the goal is to prevent high-risk individuals from progressing to symptomatic cardiovascular disease and kidney failure. Depending on the specifics, this may include increasing, changing, or adding medications and putting additional emphasis on healthier lifestyle choices.
STAGE 4 – SYMPTOMATIC CARDIOVASCULAR DISEASE
Stage 4, which refers to symptomatic cardiovascular disease in combination with excess body fat, metabolic risk factors or kidney disease, is broken out into two substages: (4a) for individuals without kidney failure or (4b) for individuals with kidney failure. In these advanced stages, people may already have heart failure and may have had a heart attack or a stroke. Individuals in this category may also have additional cardiovascular conditions such as peripheral artery disease or atrial fibrillation. The goal of care is individualized treatment for cardiovascular disease and addressing other CKM syndrome issues.
Since the AHA guidance is new, “it’s not yet clear how CKM syndrome will be managed or to what extent it will be embraced across the different specialties,” says Dr. William Lawson, director of preventive cardiology at the Stony Brook Heart Institute. But given the interconnectedness of the conditions, he says, there already is some collaboration across the specialties.
“It has been clear for some time that there is an increased risk for heart disease among patients with diabetes,” Lawson says. “Kidney disease is a risk factor in heart disease whose impact on both likelihood and survival has not been fully appreciated until recently. We now know that certain medications that benefit the kidneys and diabetes also benefit the heart. When kidneys function better or an overweight patient loses weight, it’s better for the heart. It’s all connected.”
