HJNO Mar/Apr 2024

CHANGING THE CARE: CKM SYNDROME 30 MAR / APR 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   it to say that moderate risk CKD encompass- es moderately increased albuminuria (30-300 mg/g) and/or eGFR between 45 and 60 mL/ min (yellow areas in heat map), whereas high- risk CKD is comprised of severely elevated al- buminuria (> 300 mg/g) and/or eGFR between 30 and 45 mL/min (orange areas in heat map). There are multiple overlapping pathophysio- logical considerations that link these stages to- gether, with metabolic syndrome predisposing to diabetes and with diabetes and/or hyper- tension predisposing to CKD, with CKD in turn predisposing to hypertension. At this point, the proactive interventions include those indicated in stage 1 along with tight blood pressure con- trol (at least < 130/80 if not the KDIGO recom- mendation of systolic BP < 120), which is eas- ily accomplished through digital hypertension management programs. When blood pressure is controlled very tightly, progressive declines in eGFR are slowed or even reversed and albu- minuria can be reduced. At stage 2, a goal of regression to stage 1 is still conceivable. When albuminuria is detected and moderate- to high-risk CKD is identified, treatment with so- dium glucose transport type 2 inhibitors (SGLT2 inhibitors) may also be indicated. We reviewed this class of medications in part two of this se- ries, where we stated that this class of medica- tions is decent for treating type 2 diabetes but excellent at treating CKD and heart failure. We are moving from an era of risk factor modifica- tion 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 pro- actively design the most effective solutions to overcome those barriers, using the data gener- ated from our interactions to constantly refine our improvement efforts. And we can use up- to-date pharmacotherapeutic agents that are now more appropriately identified as organ protective agents, like the SGLT2 inhibitors. Stage 3 is designated by very high-risk CKD (red areas in the heat map, corresponding to severe albuminuria and/or eGFR < 30 mL/ min) or subclinical CVD overlapping with CKM risk factors. Subclinical CVD can be identified through the coronary artery calcium score where any score > 0 indicates at least the pres- ence of some coronary artery calcifications and therefore at least some atherosclerotic plaque. Again, all the same proactive interventions discussed for stages 1 and 2 remain relevant, including tight blood pressure control with use of angiotensin receptor blockers or angio- tensin-converting enzyme inhibitors as well as the SGLT2 inhibitors. However, now the statins (discussed in part three of this series) become very important for their antioxidant and anti- inflammatory effects, and targeted LDL goals of < 70 will likely become the standard of care. Digital lipid management has likewise already become a reality, so even up into stage 3, con- nected health strategies and digital medicine programs can manage these patients from the convenience of their home though continuous connected relationships. Stage 3 represents the stage where regression to earlier stages is no longer possible but where abundant up- stream emphasis is placed on preventing the first heart attack or stroke rather than reacting to such an event once it has already occurred. Stage 4 indicates the presence of clinical CVD, such as angina, heart attack, TIA, or stroke, be- ing further subdivided into 4a (without CKD) and 4b (with CKD); and while extremely ag- gressive downstream interventions at this stage may clearly be warranted, it also represents a relentless progression to an irreversible stage that I would consider a blatant failure of our current healthcare system. However, the ap- proach outlined for stages 1 through 3 will usher in a new era of accountability for health systems and providers as we can track the num- ber of patients who progress to stage 4 over time to see how often we are failing our mis- sion to improve the health of those we serve. n REFERENCES 1 Ndumele, C.E.; Rangaswami, J.; Chow, S.L.; et al. “Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association.” Circulation 148, issue 20 (Nov. 14 2023): 1606-1635. https://doi.org/10.1161/ CIR.0000000000001184 “Moving away from episodic interactions toward a connected relationship revamps a health system into a proactive care organization with deeply connected relationships that create differentiated levels of retention, loyalty, and advocacy.”