A new guideline links care for heart, kidney and metabolic diseases

Some of the most pressing health conditions — including heart disease, kidney disease and diabetes — are best managed as a whole, according to a new clinical guideline.

Published June 9 in Circulation, the guideline lays out a coordinated medical approach to these overlapping conditions and their risk factors, such as obesity and high blood pressure. All fall under the umbrella of cardiovascular-kidney-metabolic, or CKM, syndrome, coined in 2023. The guideline was developed by four major medical societies.

The conditions included in CKM syndrome are widespread in the United States: Nearly 90 percent of adults met criteria for one of the stages of the syndrome as of 2020. Fifteen percent were in an advanced stage. As the syndrome progresses, the risk of heart attacks or other cardiovascular harms, kidney failure or death grows.

It’s rare that heart disease, kidney disease and diabetes happen in isolation, says Chiadi Ndumele, who chaired the guideline writing committee and directs obesity and cardiometabolic research at Johns Hopkins Medicine. Yet the clinical approach has typically been “to think about them in a very siloed fashion.” Because the diseases develop in connection with one another and many therapies help treat several of the diseases at once, the care should be coordinated too, he says.

The guideline also brings a new spotlight to kidney health in routine care. “The impact of kidney disease as a major cause of cardiovascular disease has long been under-appreciated,” says nephrologist Michelle Estrella, executive director of the Kidney Health Research Collaborative at the University of California, San Francisco School of Medicine. The CKM framework brings kidney disease detection and management into primary care visits alongside those for hypertension and diabetes, which are well-established, she says.

Coordinating care under the CKM syndrome banner will involve many providers, including primary care doctors, specialists, social workers and community health workers, as CKM syndrome is driven by social conditions as well as biology. The goal is to streamline care across the syndrome’s many moving parts.

How diseases in CKM syndrome feed each other

The organs and systems in CKM syndrome — such as the heart, kidneys and vascular system — are interrelated “such that abnormality in one part of the system leads to abnormalities in other parts, and improvement in one part helps the other parts,” says Susanne Nicholas, an adult nephrologist at the David Geffen School of Medicine at UCLA.

Those metabolic issues can lead to high blood pressure, which damages blood vessels throughout the body, including in the kidneys, setting the stage for chronic kidney disease. Failing kidneys allow fluid to build up, which can push blood pressure higher and harm the heart.

“Think of CKM syndrome as a bonfire. Obesity lights the match, diabetes fans the flame, and disease in the heart and kidneys keep the flame burning,” Nicholas says. “Without taking appropriate steps to break the cycle, the person can develop kidney failure and heart failure.”

The guideline expands the treatment of the diseases

The new clinical guideline — developed by the American Heart Association, the American College of Cardiology, the American Diabetes Association and the American Society of Nephrology — builds on a four-stage progression first laid out in a 2023 AHA advisory that introduced the syndrome. The guideline “opens the pathway to a holistic, whole-person care approach rather than thinking of each system independently,” Nicholas says.

That recognition extends to choosing therapies that treat more than one disease, such as GLP-1 drugs, which reduce visceral fat, inflammation and cardiovascular risk; SGLT2 inhibitors, which treat type 2 diabetes and benefit those with chronic kidney disease and heart failure; and finerenone, which halts kidney function decline and lowers the risk of kidney and heart failure in those with chronic kidney disease.

The approach “allows us to shift the way we deliver care from being reactive to being proactive,” Nicholas says. “We can now pay closer attention to earlier detection, risk assessment and prevention strategies that can lead to better long-term outcomes.”

Bringing the guideline into practice will take work

Getting patients, providers and systems up to speed will take time. Estrella sees those challenges “as opportunities to fundamentally change how we tackle CKM conditions,” including putting a spotlight on kidney disease.

Inadequate screening for those at risk for chronic kidney disease is largely why “up to 90 percent of people with [the] disease are unaware of their diagnosis,” Nicholas says. The early disease stages have no symptoms. Risk factors include high blood pressure, diabetes, family history, older age and smoking.

Patients may be familiar with the estimated globular filtration rate, which measures how well the kidneys filter blood. That’s usually checked at primary care visits. But another test, the urine albumin-to-creatinine ratio, is called for in certain stages of CKM syndrome. This test “often provides the earliest sign of kidney disease,” Estrella says, even before the filtration rate test is abnormal.

With obesity often the first step of CKM syndrome, approaching weight discussions without judgment is crucial, Ndumele says. “There’s a lot of weight bias and weight stigma in our society and actually also in our clinical environments.”

“Obesity and overweight are impacting over 70 percent of the population” in the United States, he says. “That’s obviously a systemic challenge.” Obesity develops due to “a complex array of social, behavioral and biological factors.” The new guideline points to toolkits for clinicians to be able to discuss weight in health-focused, supportive ways.

The clinical guideline also recognizes that social risk factors — such as housing instability, intimate partner violence, food insecurity — place people “at significantly higher odds of advanced CKM syndrome stages,” Nicholas says.

That’s why screening for social determinants of health is part of the CKM guidelines, Ndumele says, and why community health workers and social workers are key members of the provider team. He cares for patients in Baltimore, including some who can’t afford medications, can’t find healthy foods or have difficult housing situations. Ndumele talks to patients about what’s happening in their lives and has social workers “on speed dial” to help connect people with programs.

Addressing social risks “is certainly a very big challenge,” Ndumele says, “but not one that I think we can afford to ignore.”