Cardiovascular-kidney-metabolic (CKM) syndrome

What is CKM syndrome?

Cardiovascular-kidney-metabolic (CKM) syndrome is a health condition that affects your heart, kidneys and metabolism (how your body takes food and water and turns them into energy). CKM syndrome can develop over time as risk factors and health conditions begin to affect your heart, kidneys and metabolism. 

Conditions linked to CKM syndrome include:

• Kidney disease
• Cardiovascular (heart) disease
• Type 2 diabetes
• Overweight and obesity

Since these conditions are closely connected, having one can increase your risk of developing another. For example, having diabetes can damage the kidneys, and having kidney disease can increase the risk of heart problems. This important connection helps doctors look at these conditions together instead of treating them as separate health problems. Finding and treating CKM syndrome early may help prevent serious health issues.

What are the symptoms of CKM syndrome?

Many people with CKM syndrome do not have symptoms in the early stages. As CKM syndrome gets worse, signs and symptoms may include:

• Feeling tired or weak (fatigue)
• Swelling in your feet, ankles or legs
• Leg pain while walking
• Shortness of breath
• Chest pain or pressure
• High blood pressure (hypertension)
• Needing to urinate (pee) more or less often
• Changes in appetite 
• Sleep apnea
• Gout
• Unexplained weight gain from fluid buildup in the body

What causes CKM syndrome?

CKM syndrome does not have one single cause. It develops over time when conditions that affect your heart, kidneys and metabolism are connected and affect one another.

Several health conditions can increase your risk of CKM syndrome, including:

• Overweight and obesity: long-term condition where a person has too much body fat
• Prediabetes: Having blood sugar levels that are higher than normal
• Type 2 diabetes: A condition in which blood sugar levels become too high over time because the body doesn't make enough insulin or doesn't use insulin well, leading to high blood sugar
• High blood pressure
• High cholesterol: Having unhealthy levels of fats or cholesterol in the blood
• Chronic kidney disease: Long term condition where the kidneys lose the ability to filter waste and fluid out of the blood
• Heart disease: broad category of diseases that affect the heart and blood vessels

Taking the right steps to care for your heart, kidneys and overall health may help prevent CKM syndrome or slow it from getting worse.

Who is at risk for CKM syndrome?

According to the American Heart Association, 1 in 3 adults in the United States have three or more risk factors for heart disease, diabetes or kidney disease. A risk factor is something that increases your chance of developing a health condition. Having one of the conditions means you're at higher risk of developing 1 or more of the other conditions.

You may be at higher risk for CKM syndrome if you have:

• Kidney disease
• Heart disease
• Prediabetes or type 2 diabetes
• High blood pressure
• High cholesterol 
• Overweight or obesity
• Metabolic dysfunction-associated steatotic (fatty) liver disease (MASLD), also known as Non-alcoholic Fatty liver disease 
• Sleep apnea (a condition that causes breathing problems during sleep)
• A family history of heart disease, kidney disease or diabetes

Some lifestyle factors can also increase your risk, including:

• Not getting enough physical activity
• Smoking or using tobacco products
• Eating patterns high in sodium (salt), added sugars and unhealthy fats
• Poor sleep habits

Talk to your doctor about your risk factors and steps you can take to protect your health

How is CKM syndrome diagnosed?

Your doctor may do several tests and screenings to look at your heart, kidney and metabolic health, including:

• Checking your blood pressure
• Blood tests:
  •  eGFR (estimated glomerular filtration rate) to measure kidney function and how well your kidneys are removing waste from your blood
  • Glucose and HbA1C (or A1C) to measure average blood sugar over the past few months
  • Lipid panel to measure cholesterol levels in your blood including LDL, HDL, triglycerides
  • BNP/NT-proBNP to measure a type of protein which is released when your heart is under stress or working too hard
• Urine test: uACR (urine albumin-to-creatinine ratio) to look for signs of kidney damage checking for albumin in your urine
• Weight and body mass index (BMI)

These tests can help your doctor determine your stage of CKM syndrome and the risk of future heart and kidney problems.

What are the stages of CKM syndrome?

There are 5 stages of CKM syndrome:  

• Stage 0: No CKM syndrome 
• Stage 1: Extra body fat
• Stage 2: Metabolic risk factors present 
• Stage 3: Heart and blood vessel problems begin 
• Stage 4: Heart disease is present

Treatment depends on your stage of CKM syndrome and your overall health. 

People can shift between stages as their health conditions get better or worse.

Stage 0: No CKM syndrome

At this stage, you do not have risk factors for CKM syndrome and should focus on maintaining healthy habits like staying physically active and eating healthy to prevent future health problems.

It's important to have regular checkups with your doctor to monitor your blood pressure, blood sugar and cholesterol to stay healthy and prevent developing CKM syndrome.

Stage 1: Extra body fat

At this stage, you may have: 

• Overweight/obesity (extra body fat, especially around your waist that may increase your risk of health problems) which is measured by waist circumference or BMI
• Prediabetes (blood sugar levels that are higher than normal but have not developed type 2 diabetes yet)

During this stage, the goal is to lower your risk of developing diabetes, kidney disease and heart disease with lifestyle changes and weight loss. 

In stage 1, your doctor may:

• Help you create a plan to reach or maintain a healthy weight
• Recommend you lose at least 5%-10% of your body weight to reduce risk of CKM syndrome
• Recommend lifestyle changes to improve your heart and kidney health
• Monitor your blood sugar levels and screen for conditions such as diabetes, high blood pressure and high cholesterol 

Stage 2: Metabolic risk factors present 

At this stage, you may have one or all of the following metabolic risk factors: Prediabetes or Type 2 diabetes, high blood pressure, high levels of cholesterol called triglycerides and chronic kidney disease (CKD).

During this stage, the goal is to manage conditions that can damage the heart and kidneys.

In stage 2 CKM, your doctor may:

• Prescribe medicines to help manage your high blood pressure, kidney disease, blood sugar or cholesterol
• Monitor your kidney function with regular blood and urine tests, such as eGFR and uACR.
• Recommend specific lifestyle changes, like eating patterns and physical activity.

Stage 3: Heart and blood vessel problems begin 

At this stage, you are at a high risk of heart disease and may start to have heart and blood vessel problems, like high blood pressure, even if you feel fine. In this stage, the focus is on treating heart problems, preventing heart disease and other complications.

In stage 3 CKM, your doctor may:

• Prescribe medicines to help manage your high blood pressure, kidney disease, blood sugar or cholesterol
• Monitor your heart more regularly through blood pressure checks and monitoring kidney health with regular blood and urine tests such as eGFR and uACR.
• Recommend getting your blood pressure, cholesterol and blood sugar checked more often. Talk to your doctor about how often you should get checked.
• Recommend a coronary artery calcium (CAC) test for artery problems to help guide treatment options
• Refer you to a cardiologist (heart doctor) or nephrologist (kidney doctor)

Stage 4: Heart disease is present 

People in Stage 4 have heart disease. They may have had a heart attack, stroke or heart failure. They may also have had any problems from previous stages of CKM. This stage has two substages: 

• Stage 4a: People without kidney failure 
• Stage 4b: People with kidney failure 

In stage 4 CKM, your doctor may:

• Create a treatment plan based on your specific health needs
• Prescribe you medicines to help manage heart disease and other CKM conditions
• Refer you to a cardiologist (heart doctor) or nephrologist (kidney doctor)
• Monitor your heart and kidney function more regularly through blood pressure checks, and regular blood and urine tests such as eGFR and uACR

How do doctors treat CKM Syndrome?

Treatment can depend on your stage of CKM syndrome, medical history and which conditions are affecting your heart, kidneys and metabolism.  If you have kidney disease with type 2 diabetes or albumin (a type of protein) in your urine, your doctor may prescribe certain medicines to help protect your heart and kidneys and lower your risk of complications.

These medicines may include:

• Blood pressure medicines like Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) to lower blood pressure and help protect the kidneys
• Diabetes medicines like metformin to help lower your blood sugar levels
• Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) to help manage blood sugar levels, CKD, diabetes and obesity. These medicines reduce appetite, which can lead to weight loss, helping to lower your risk.
• Sodium-glucose cotransporter-2 (SGLT2) inhibitors to help lower blood sugar and help protect the heart and kidneys
• Non-steroidal mineralocorticoid receptor antagonists (nsMRA): to help slow the damage to the kidneys
• Medicines to help manage weight and in some cases bariatric or weight loss surgery if needed for people with severe obesity
• Other medicines to treat heart disease and kidney disease

Talk with your doctor and healthcare team at each appointment visit to review your medications and doses, how often to monitor your health at home, how often you need to have certain lab tests, and what changes may be needed.

Where can I find help and support?

Managing CKM syndrome can feel overwhelming, but you do not have to do it alone. You are the most important part of your healthcare team. Asking questions can help you make informed decisions about your care.

Take action: Talk with your doctor about CKM syndrome

If you have heart disease, kidney disease, type 2 diabetes or obesity, talk with your doctor about specific ways to protect your health and prevent CKM syndrome.

Here are some questions you can ask your doctor:

• What changes can I make to lower my risk of CKM syndrome?
• What does a health weight look like for me?
• How often should I have my blood pressure, blood sugar and cholesterol checked?
• How often should I have my kidney function checked?
• Do I need any medicines to help protect my heart and kidneys?
• Should I see a kidney doctor?

If something is unclear, ask your doctor to explain it in a different way so that you can understand.

American Kidney Fund (AKF) Resources

• Community Resource Finder: Find local support services and assistance
• Know Your Kidneys: Learn more about kidney disease and prevention
• Know Your Cause:Learn more about the cause and the reasons behind your kidney disease.
• Know Your Plan: Create a plan that empowers you to take charge of your kidney health
• Kidney Kitchen: Recipes, guides and information on kidney-friendly eating for each stage of kidney disease.
• Prescription assistance programs for common kidney medicines: prescription assistance programs and resources that may help lower medicine costs for people living with chronic kidney disease 
• Health Insurance Premium Program (HIPP): financial assistance to help pay your health insurance premiums
• Living Donor Assistance Program (LDAP): Financial support for living kidney donors
• Kidney Education Corner: AKF's hub for online kidney disease education 
• Kidney Health Coach CKM course: interactive community health education online course