Dr. Chiadi Ndumele: “CKM Syndrome Doesn’t Respect Our Subspecialty Silos”

In honor of National Kidney Month in March, we interviewed Chiadi Ndumele, MD, PhD, MHS, Associate Professor of Medicine and Director of Obesity and Cardiometabolic Research, Division of Cardiology at Johns Hopkins University School of Medicine. He is a national expert on Cardiovascular-Kidney Metabolic (CKM) Syndrome and a participant in NCQA’s recent convenings focused on improving CKM Syndrome care. The results of the NCQA convenings are summarized in our new white paper, Cardiovascular-Kidney Metabolic Syndrome: Improving Quality of Care and Accountability.

Dr. Ndumele shared his perspective on the challenges and opportunities in CKM Syndrome care and why we need to break down silos and work together to address what he refers to as “one of the largest public health issues of our time.”

What inspired you to become a physician?

Growing up, I liked math and science. When I was in high school, my mom took me to a community health program that was occurring in our area. They were doing health screenings and trying to connect people with resources to support them in their health journey. I was amazed by how providing screenings and enhancing people’s awareness of different risk parameters could have such a positive impact. People were coming back to us and telling us how they had made all these positive changes in their lives—just because we had provided that information to them! It was hard for me to believe we were making a difference to that extent in people’s lives, but it was the case, and I was hooked. I ended up going to Johns Hopkins University and then Harvard Medical School. I really loved studying the workings of the cardiovascular system and also appreciated that it was connected to multiple modifiable risk factors, which made it a natural fit with my interest in prevention.

What is the focus of your clinical practice?

I focus a lot of my efforts on cardiovascular disease prevention, but I also see patients with existing cardiovascular disease who are trying to improve their quality of life and reduce the risk of recurrent cardiovascular disease events. What I’ve noticed in my practice over the last 20 years is that people are coming in with higher risk, more complexity and a greater burden of interrelated clinical conditions. We’re seeing more people who have obesity, many of whom also have uncontrolled diabetes, chronic kidney disease, or both additional comorbidities. Usually, patients with diabetes and chronic kidney disease also have hypertension and some dyslipidemia (an abnormal level of fats in the blood), and it’s this interrelated cluster of risk factors that we’re seeing over and over again.

The clusters of risk factors I saw in my clinical practice overlapped with my research on the growing impact of obesity on multiple downstream systemic challenges, including the development of diabetes and chronic kidney disease, with resultant increased risk for cardiovascular disease—and that is what we’re talking about with CKM syndrome.

How did the name CKM Syndrome come about?

The main reason behind the naming of CKM Syndrome is the interrelatedness, or connectivity, among cardiovascular, metabolic and kidney conditions. Many patients feel like they’re just having bad luck, wondering “Why are all these things happening to me at the same time?” without recognizing that their health conditions are interrelated.

The other reason for the name is that there’s a reliable and predictable trajectory that leads to the development of this kind of complex presentation. It typically starts with excess and dysfunctional adipose tissue (body fat), progressing to the emergence of chronic kidney disease and metabolic conditions like diabetes, hypertension and dyslipidemia, leading to the development of subclinical cardiovascular changes and eventual clinical cardiovascular disease. The consequence of progression along this spectrum is a greater risk for premature mortality, most often due to cardiovascular disease.

As a cardiologist, I often see people at a point when these interrelated factors have not been addressed for many years and now they have cardiovascular disease that is difficult to manage because of its severity and the multiple coexisting comorbidities. But I also recognize the opportunity to identify and address the risk much earlier in the process and, hopefully, avoid getting to these really severe and complex stages.

What challenges do people with CKM Syndrome experience when trying to access healthcare?

First, there’s quite a bit of under-recognition. Many of the risk factors aren’t recognized by patients or clinicians, and even if they are recognized, they may not be addressed due to other things that seem more pressing. If a patient has multiple interrelated conditions and is trying to see multiple clinicians from different specialties, it can be hard to navigate. If there is conflicting advice, they are trying to figure out who to listen to. It doesn’t help that clinicians tend to operate in our own silos. The kidney doctor will be focused on protecting the kidneys, the heart doctor will be focusing on what’s good for the heart and the endocrine doctor will focus on what is best for the endocrine system. CKM Syndrome doesn’t respect our subspecialty silos. We need to move beyond that and understand that these conditions are interrelated and make sure that risks are addressed holistically and in a timely fashion.

How can we empower patients to prevent or manage CKM Syndrome?

We need to help people understand that there’s a predictable trajectory that occurs with these interrelated conditions and that these issues are readily addressable, particularly in the earlier stages. The CKM staging concept is really important. It helps patients to identify where they are along the spectrum and learn what they can do to preserve health for as long as possible. There’s no doubt that a healthy lifestyle is at the core of preventing and managing CKM Syndrome. But a healthy lifestyle is not just about behavioral choices—it is about the multi-level social drivers of health that impact a person’s lifestyle. We need to recognize the barriers patients may encounter and do what we can to make it easier for them to make the healthy approach their default approach.

What was your experience participating in NCQA’s CKM Syndrome convenings?

It was a really thoughtful group of individuals that represented a lot of different perspectives, including some people who were coming into this with fresh eyes. I appreciated the shared sense of urgency. There is widespread agreement that this is a shared challenge across disciplines, driving risk for patients and driving worsening mortality trajectories in the population. It’s something we all need to work together to help solve. The framework outlined in the white paper is a great step forward.

What were some of your key takeaways from the expert panel?

One of the really important things we talked about was using measurement as a platform for enhancing CKM Syndrome care. We need to think about cross-cutting measures that incorporate multiple disciplines and focus on recognizing risk in earlier stages, as well as some patient-facing measures that can guide us toward more integrated care. I also enjoyed the discussions about innovations in our approach to activating and supporting clinicians and patients through EMR-based strategies, other health technologies and the use of artificial intelligence.

What would be the most impactful change we could make to have a positive impact on CKM Syndrome care and outcomes?

It’s hard to pick just one. If people had more of an awareness of what CKM syndrome is, then it would be a great starting point for conversations with their clinicians. If clinicians focused more on holistically recognizing and addressing CKM risk—and if that CKM risk profile could be shared across all specialties—then we would all be looking at the same snapshot and we could talk to our patients in the same language. For example, the American Heart Association recently developed a new online risk calculator for cardiovascular diseases, which integrates and quantifies the clinical impact of CKM risk factors, that has been very impactful.

I also believe care coordination is very important for CKM syndrome. If we had a CKM care coordinator working with patients to address lifestyle changes and social determinants of health and coordinating care across all of the specialties, that would be a tremendous help. In the NCQA convening, we also talked about emerging EMR-based and AI-enabled approaches that could support care coordination when we don’t have enough people to play that role.

Basically, we need to make this complexity a little bit more accessible for both patients and clinicians and help us all speak the same language in a way that makes our care more patient-centered and less siloed. Also, identifying and addressing CKM risk earlier will lead to the best clinical outcomes for patients.

Learn More

• Download our white paper, Cardiovascular-Kidney Metabolic Syndrome: Improving Quality of Care and Accountability.
• Get more CKM Syndrome resources from the American Heart Association.
• Learn more about the American Heart Association PREVENT™ risk calculator.