HJNO Mar/Apr 2024

CHANGING THE CARE: CKM SYNDROME 28 MAR / APR 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   tions that are most impactful at preserving and restoring health. It opens the door toward a fu- ture where regression away from an unhealthy state and toward a state of better health be- comes the future standard of care. I can think of no better example than what is now being called cardiovascular-kidney-metabolic syn- drome, an updated framework building on the older concept of metabolic syndrome. FromMetabolic Syndrome to CKM Syndrome Metabolic syndrome is probably best de- scribed as a “pre-chronic” condition com- prised of multiple elements: overweight (with excess or dysfunctional adiposity), insulin resis- tance, prediabetes or impaired glucose toler- ance or impaired fasting glucose, metabolic dysfunction-associated steatotic liver disease (MASLD, discussed in the last issue of this journal), and hypertriglyceridemia. Its primary significance is that it can be an “upstream” harbinger of the “downstream” problems to come. Overweight can lead to obesity with all its disease-associated complications. Insulin re- sistance or glucose perturbations can progress to diabetes mellitus with its micro- and macro- vascular complications; MASLD can progress to metabolic dysfunction-associated steatohepa- titis and then eventually liver failure; and hy- pertriglyceridemia can contribute to the risk of pancreatitis or cardiovascular disease. In each case, the downstream treatments for the com- plications are expensive and consume a grow- ing proportion of limited healthcare resources — time, effort, and money. The good news is that there is reason for hope and optimism for each of these precursors to chronic condition development. That is because each of them is reversible. Indeed, modern thinking would put all of these conditions — even the ones that have progressed to the chronic state — along a spectrum that can either worsen or improve depending on the effectiveness of our up- stream solutions and proactive interventions. In the November 2023 issue of the journal Circulation , a presidential advisory commission from the American Heart Association published an extensive review article that outlines an ap- proach to what will now be called cardiovascu- lar-kidney-metabolic syndrome (or CKM syn- drome). The advisory first seeks to define this “We are moving from an era of risk factor modification where patients are expected to “comply” with recommendations to move more and eat healthier, to a future where we gather enough data to understand their barriers, challenges, and obstacles to doing so. Then we can proactively design the most effective solutions to overcome those barriers, using the data generated from our interactions to constantly refine our improvement efforts.” new entity with a formal definition as follows: “CKM syndrome is a systemic disorder char- acterized by pathophysiological interactions among metabolic risk factors, CKD [chronic kidney disease], and the cardiovascular system leading to multiorgan dysfunction and a high rate of adverse cardiovascular outcomes. CKM syndrome includes both individuals at risk for CVD [cardiovascular disease] due to the pres- ence of metabolic risk factors, CKD, or both and individuals with existing CVD that is potentially related to or complicates metabolic risk factors or CKD. The increased likelihood of CKM syn- drome and its adverse outcomes is further in- fluenced by unfavorable conditions for lifestyle and self-care resulting from policies, econom- ics and the environment.” The simpler, patient- facing definition is that “CKM syndrome is a health disorder due to connections among heart disease, kidney disease, diabetes and obesity leading to poor health outcomes.” 1 More important than a definition, however, was the creation of a staging framework that calls attention to the idea that this syndrome can begin early in life and progress over time due to the interaction of biological, social, and environmental factors. As we’ve been discussing over the past few issues of this journal, the accumulation of excess and dys- functional adipose or “fatty” tissue can result in inflammation, oxidative stress, and insulin resistance that is harmful to multiple organs. As progression ensues, confluent comorbidi- ties can result in the development of subclini- cal coronary atherosclerosis, for which stents and bypass surgery are most certainly not the answer, as well as declines in kidney function, metabolic liver disease, and metabolic syn- drome — hence the designation cardiovas- cular-kidney-metabolic syndrome. Staging al- lows us to prospectively identify the windows of opportunity to intervene early and often before damage becomes irreversible and is depicted along a spectrum where not only progression can occur but improvement and regression to earlier stages can occur as well. Stages of CKM Syndrome Stage 0 is when no CKM risk factors are pres- ent and can be assessed at baseline by measur- ing height and weight to calculate body mass index along with waist circumference to detect