Whose role is it to care for this patient? The AHA’s statement on CKM syndrome

Cardiovascular diseases frequently coexist with metabolic disorders (such as obesity and diabetes) and chronic kidney disease (CKD). Multidirectional harmful pathophysiological interactions exist between these disorders.[1,2] As a result, having one condition increases the risk of development, and of progression, of others within the cardiovascular–kidney–metabolic (CKM) spectrum.[3,4] Furthermore, the risk of adverse cardiovascular outcomes associated with each condition multiplies with each additional disorder. Globally, cardiovascular disease, diabetes and CKD together accounted for approximately 38% of all deaths in 2021.[5] The global burden of CKM is expected to rise further owing to the increasing prevalence of obesity and diabetes.[6] Those from low and middle-income countries are already disproportionately affected by these conditions and have amongst the greatest burden of adverse social determinants of health.[5]

It is perhaps unsurprising, given human nature, that until the recent explosion in therapeutic strategies proven to reduce adverse cardiovascular and kidney outcomes for people with metabolic, kidney and/or cardiovascular disorders, insufficient attention was afforded to the clinical and public health implications of the rapidly expanding CKM population. Lack of prioritisation amongst the clinical and scientific communities has resulted in lack of agreement on both the definition and grading of CKM. It has encouraged us to develop and publish guidelines that systematically ignore the cross-talk between metabolic, cardiovascular and kidney pathways. The way we deliver healthcare has, in addition, become increasingly organ-specific, resulting in time-consuming and fragmented care for the CKM population, poor health outcomes and exaggerated healthcare costs.

So what has changed? SGLT2 inhibitors, GLP-1 agonists and non-steroidal MRAs: a new swathe of therapeutic strategies for the CKM population that address metabolic risk factors, delay the progression of kidney disease and reduce the associated cardiovascular risk. With new power, comes new responsibility to address the clinical and public health priority that CKM syndrome increasingly represents. Our ability to define CKM, identify those at risk and effectively and equitably deliver care to this high-risk population, however, still lags. We need consistent terminology, not only to identify those at risk, but to facilitate communication between the clinical and research communities and prioritise this group with respect to healthcare policy and funding. The benefits and risks of screening require re-evaluation and, crucially, we must develop cross-specialty guidelines and models of healthcare delivery that provide cost-effective, equitable and holistic care to this population.

The recently published scientific statement on CKM by the American Heart Association (AHA) was designed to address many of these issues.[7] Twenty-eight experts from nephrology, cardiology, endocrinology, primary care and paediatrics were asked to develop a consensus statement on the definition, identification and management of CKM. Using a combination of literature review, appraisal of current US and European guidelines, and expert knowledge, their aim was to bring the clinical and research communities up to date with rapidly emerging evidence in this field. The statement summarises not only what we know (regarding pathophysiology, risk factors for CKM progression and optimal management), but also highlights areas that require further research, and the development of appropriate clinical resources. For example, the authors highlight areas in which major guidelines require harmonisation, and the need for novel risk calculators able to predict adverse CKM outcomes and the net benefits afforded by pharmacological options. The associated Presidential Advisory outlines novel value- and volume-based healthcare models, which have the potential to overcome current barriers to holistic and patient-centred care experienced by this population.[8] 

Where does this leave us? The existence and burden of the CKM syndrome, its staggering associated morbidity and mortality, and resultant healthcare costs is irrefutable. Current models of specialised, siloed healthcare result in fragmented care for this high-risk population and, as a result, further amplify associated costs, drive inequities in access to care, and lower compliance with lifestyle and pharmacological interventions.[9] The AHA’s suggested model of “value-based care”, in the form of interdisciplinary multiprofessional clinics, may be appropriate for people with the most complex CKM. Such models are already being trialled in isolated centres in Canada, Sweden and the UK.[10–12] These are likely to offer cost savings and non-inferior or improved outcomes when compared to multi-specialty care but will, however, only ever cover the very tip of the CKM population iceberg. Use of electronic health records to identify patients and offer virtual advice (“volume-based care”) may cover another few per cent. 

Whose duty, therefore, is it to care for the vast remainder of individuals with CKM who lie beneath the waterline? Should we continue to focus on screening for and treatment of disease within the single organ-system to which we attach our specialty name? Or have we a duty to expand our knowledge and responsibilities such that we provide holistic care for the person in front of us at each interaction, simultaneously reducing the demands on the patient, our colleagues and our healthcare systems as a whole?

A digest of the study can be read here.

References

1. Amdur RL, Feldman HI, Dominic EA et al; CRIC Study Investigators (2019) Use of measures of inflammation and kidney function for prediction of atherosclerotic vascular disease events and death in patients with CKD: Findings from the CRIC Study. Am J Kidney Dis 73: 344–53
2. Neeland IJ, Ross R, Després JP et al; IAS; ICCR Working Group (2019) Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement. Lancet Diabetes Endocrinol 7: 715–25
3. Wilson PW, D'Agostino RB, Parise H, Sullivan L, Meigs JB (2005) Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus. Circulation 112: 3066–72
4. van der Velde M, Matsushita K, Coresh J et al (2011) Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts. Kidney Int 79: 1341–52
5. World Health Organization (2011) Fact Sheets. Available at: https://www.who.int/news-room/fact-sheets (accessed 30.11.23)
6. GBD 2021 Diabetes Collaborators (2023) Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 402: 203–34
7. Ndumele CE, Neeland IJ, Tuttle KR et al; AHA (2023) A synopsis of the evidence for the science and clinical management of cardiovascular-kidney-metabolic (CKM) syndrome: A scientific statement from the American Heart Association. Circulation148: 1636–64
8. Ndumele CE, Rangaswami J, Chow SL et al; AHA (2023) Cardiovascular-kidney-metabolic health: A presidential advisory from the American Heart Association. Circulation148: 1606–35
9. Joo JY (2023) Fragmented care and chronic illness patient outcomes: A systematic review. Nurs Open 10: 3460–73
10. Al-Chalabi S, Alderson H, Garratt N et al (2023) Improving outpatient clinic experience: the future of chronic kidney disease care and associated multimorbidity. BMJ Open Qual 12: e002188
11.  Spaak J (2017) Novel combined management approaches to patients with diabetes, chronic kidney disease and cardiovascular disease. J R Coll Physicians Edinb47: 83–7
12. Dubrofsky L, Lee JF, Hajimirzarahimshirazi P et al (2022) A unique multi- and interdisciplinary cardiology-renal-endocrine clinic: a description and assessment of outcomes. Can J Kidney Health Dis 9: 20543581221081207