We've Come Full Circle in Managing Cardio Kideny Metabolic Syndrome

 Have we come full circle? It's been almost 6 months since "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" was published.

We've been here before, or have we?

Metabolic syndrome, which encompasses many pathophysiologic mechanisms, was discussed in the past and made many of us both in primary and secondary care decide on more holistic management of the person living not just with diabetes but other metabolic conditions, such as hypothyroidism, hypertension, and liver dysfunction. What primary care did better than most was to take that holistic view rather than focusing solely on the clinical aspects of the patient. Primary care also presented the view that social determinants of health (SDOH) are vital in managing patients.

No disease state — especially diabetes — exists in isolation, and we already know that as we get older, we generally tend to have more coexisting conditions which have a bearing on the 3 Ms (as I call it): management, morbidity, and mortality. The American Heart Association (AHA) statement acknowledges critical gaps in knowledge related to the mechanisms of disease development, heterogeneity related to phenotype, and the role of SDOH.

Suffice it to say, we have always had a clinical approach to managing any disease; we always seem to see our patients once the horse has bolted, and we are struggling to close the barn door. There are many reasons for this — not least our medical education systems, which pay lip service to SDOH and give more importance to the clinical aspects of disease. It's only now that we are seeing the fallacy of such training, when we are faced with a tsunami of disease and largely metabolic disease.

Getting back to the AHA statement, it is a testament to the growing recognition (and it's about time) of the interconnectedness of the physiologic systems and the need to have a holistic approach to management. Is this any different from the CaReMe strategy which develops therapies to enable interconnected, holistic treatment and improve outcomes for the patient?

The evidence for the interconnectedness has been there long before the development of the AHA statement or the CaReMe strategy, but this document makes us think more holistically and encourages us to have a view beyond the clinical. There is no disputing the evidence — there is a plethora of it, especially in the recent past, with numerous trials and data showing the benefit of early intervention and initiation of appropriate therapies based on evidence and the effects on the outcomes.

The statement also points out the dearth of evidence on early detection and prevention and reducing the risk associated with SDOH, especially those attributed to poverty, ethnicity, and deprivation. it elucidates clearly the interconnectedness and the mechanistics associated with SDOH, which include hyperglycemia and hemodynamic, metabolic, inflammatory, and fibrotic processes.

The statement also provides us with diagnostic criteria, risk stratification, and therapeutic interventions, which are invaluable not only to physicians but also to healthcare systems which are under financial strain and therefore must prioritize care based on risk and need.

What really impressed me as a physician who practices both within the community and a specialist setting is the socioecological framework for CKM syndrome. My belief has always been that we need to prioritize SDOH much earlier — perhaps as far upstream as postnatally and during the school-age years — because as we are seeing now, not investing in SDOH is causing more ill health and also financially bankrupting systems.

In the statement, the AHA authors acknowledge important gaps in our knowledge and research, especially with regard to mechanisms of cardiovascular disease development in CKM, heterogeneity within CKM, the need for longitudinal studies, and understanding of the bidirectional cardiovascular-kidney relationships.

To paraphrase the committee, their review of the current guidelines fell into three categories: lifestyle; pharmacotherapy; and other, including SDOH, interdisciplinary care, and patient-centered approaches. 

The strength of the document rests on the fact that it acknowledges the challenges and gaps in knowledge and limitations in providing such a statement. It also provides us with avenues for future research to guide the trajectory studies in this field.

In conclusion, to the many healthcare professionals who have said "I told you so," the new AHA statement serves as a landmark document in the field of CKM disorders. It has the potential to reshape how healthcare professionals approach the management of CKM syndrome: less silo working, more collaboration, more cross-specialty education and support, and a more patient-centered rather than disease-centered approach, one in which clinicians have a better knowledge of SDOH — ultimately improving outcomes for affected individuals.

To answer my own question: Yes, we have been here before — but last time, we just took a quick glance in. Now we've turned around and come back for an in-depth visit to the city of interconnectedness.

Naresh Kanumilli, MBBS, MRCGP

Consultant, Department of Diabetes, Manchester University Foundation Trust, Manchester, United Kingdom

Disclosure: Naresh Kanumilli, MBBS, MRCGP, has disclosed the following relevant financial relationships:
Serve(d) as a speaker or a member of a speakers bureau for: AstraZeneca; BI; Novartis; Abbott; Viatris 
Received income in an amount equal to or greater than $250 from: AstraZeneca; BI; Novartis; Abbott; Viatris

https://www.medscape.com/viewarticle/weve-come-full-circle-managing-ckm-2024a10007gg