Run the List: Cardiovascular-Kidney-Metabolic (CKM) Syndrome

Date: May 19, 2025
Hosts: Walker Redd (B)
Guest: Dr. Ryan Bonner, Nephrologist (C)
Theme: Understanding and Managing Cardiovascular-Kidney-Metabolic Syndrome (CKM) in Chronic Kidney Disease (CKD) Patients

Episode Overview

This episode dives into the intricate overlap between cardiovascular, kidney, and metabolic disease, now formalized in the concept of Cardiovascular-Kidney-Metabolic (CKM) syndrome. Host Walker Redd and returning guest Dr. Ryan Bonner discuss practical approaches for trainees and practitioners on how to assess and manage patients with multiple interrelated chronic conditions, using the CKM framework to guide prevention and treatment.

Key Discussion Points & Insights

1. Defining CKM Syndrome and Its Importance

• Timestamp: 02:26
• Dr. Bonner frames CKM as a dense network of interconnected diseases, including cardiovascular (ASCVD, heart failure, arrhythmias), chronic kidney disease, and metabolic syndrome (type 2 diabetes, obesity, hypertension).
• Emphasis on the pathophysiologic links now well-evidenced in the literature, beyond just epidemiologic overlap:

  “There is a link between all of them pathophysiologically...these patients are at super high risk of premature cardiac death and progression of each of these comorbidities.” (C, 02:55)

• Practitioners must move beyond siloed problem lists and see the synergistic risk these conditions pose.

2. Risk Stratification for Atherosclerotic Cardiovascular Disease (ASCVD)

• Timestamp: 04:16
• ASCVD in CKM includes not just coronary disease but strokes and peripheral arterial disease; the risk is especially high.
• New AHA “PREVENT” risk calculator assesses 10- and 30-year risk for ASCVD and heart failure, integrating CKM factors like eGFR, albumin-creatinine ratio, and classic cardiovascular risk markers.
• For younger patients, 30-year risk calculations highlight the cumulative impact of risk factors over time.
• Dr. Bonner underscores using this deeper risk understanding to guide patient conversations and decision-making regarding modifiable risks:

  “The value is not just in understanding the 10 year risk of ASCVD...but also this 30 year risk and understanding again, that cumulative nature of how these comorbidities compound on each other.” (C, 05:20)

3. Obesity Management in CKM / CKD Patients

• Timestamp: 06:43
• Lifestyle adjustment (diet and exercise) is foundational but often inadequate alone.
• GLP-1 receptor agonists are preferred pharmacologic agents given their multidimensional benefits (cardiac, metabolic, and renal protection demonstrated in trials like FLOW).
• Where non-pharmacologic and medical management are insufficient, bariatric/metabolic surgery is highly effective though not without increased risks in CKD; collaborative, multidisciplinary management is key:

  “GLP1 receptor agonists really hit a variety of different components of CKM and are really, really valuable… Surgical management, bariatric or metabolic surgery is highly effective, not without risk, especially in patients with kidney disease.” (C, 07:15)

• ASN guidance (Nov 2024) on CKD-specific obesity management was highlighted as a highly recommended read.

4. Hypertension Management: Aggressive but Individualized

• Timestamp: 09:10
• Guideline target: Aim for <120/80 mmHg if safe and practical, acknowledging that patients will often fall below <130/80, which aligns with other guidelines.
• Reliable home BP monitoring and patient education are critical.
• Special attention needed for older or frail patients, as too aggressive BP lowering can induce orthostasis and increase fall risk:

  “I do tend to aim to keep people less than 120 over 80 if at all possible. Certainly there are folks where the risk of being that aggressive may outweigh the benefits...So at each visit, checking in on patients to make sure that they're taking steps to avoid those symptoms.” (C, 10:07)

• Caveat: Expect serum creatinine to rise when lowering BP aggressively, reflecting a beneficial drop in glomerular hyperfiltration rather than injury.

5. Heart Failure Management: Continuous Collaboration

• Timestamp: 12:26
• ACE inhibitors/ARBs, mineralocorticoid receptor antagonists, and SGLT2 inhibitors are principal therapies—especially SGLT2s, which benefit both heart and kidneys (including heart failure with preserved EF).
• Practical focus: Not just on initiating but maintaining evidence-based therapies, being attentive to side effects and contraindications.
• Cross-specialty collaboration (nephrology, cardiology, primary care) is crucial for continuity and optimizing comorbidity management:

  “There’s a lot that goes into not just starting people on these medicines, but keeping them on...” (C, 12:50)

Memorable Quotes

• On CKM’s Clinical Relevance:

  “CKM is made up of so many different components that contribute to excess mortality…a key piece of being someone who takes care of one of these different components is being aware of and somewhat facile with the others.” (C, 14:52)

• ASCVD Risk Stratification:

  “The value is not just in understanding the 10 year risk of ASCVD...but also this 30 year risk and understanding again, that cumulative nature of how these comorbidities compound on each other.” (C, 05:20)

• GLP-1 Agonists as a Gamechanger:

  “GLP1 receptor agonists really hit a variety of different components of CKM and are really, really valuable…” (C, 07:15)

• Personalizing BP Targets:

  “I do tend to aim to keep people less than 120 over 80 if at all possible. Certainly there are folks where the risk of being that aggressive may outweigh the benefits...” (C, 10:07)

Timestamps for Key Segments

• CKM Overview and Pathophysiology – 02:26–03:27
• ASCVD Risk and Risk Calculator – 04:16–06:15
• Obesity and Weight Management in CKM – 06:43–08:35
• Hypertension in CKM/CKD – 09:10–11:24
• Heart Failure Management in CKM – 12:26–14:21
• Episode Takeaways/Clinical Pearls – 14:52–16:01

Clinical Pearls & Takeaways

• Think of CKM as a syndrome, not isolated problems—manage holistically.
• Use risk calculators (like the PREVENT tool) for both 10- and 30-year risk to drive prevention strategies, even in younger patients.
• GLP-1 receptor agonists and SGLT2 inhibitors are central to multi-system benefit; know their expanding roles.
• Strive for aggressive blood pressure targets when safe—patient education and individualized risk assessment are vital.
• Multidisciplinary care is essential—nephrologists, cardiologists, endocrinologists, and primary care must partner on CKM patients.
• “Be aware of and somewhat facile with” all components of CKM—even outside your specialty.

This episode is a vital listen for generalists and specialists seeking an organized, practical approach to the growing burden of closely intertwined chronic diseases seen in CKM syndrome.