In short: CKM (cardiovascular–kidney–metabolic) staging places a patient on a 0–4 continuum that reflects how far the linked disease process has advanced — from no risk factors (Stage 0), through excess or dysfunctional body fat (Stage 1) and metabolic risk factors or chronic kidney disease (Stage 2), to subclinical or high-risk disease (Stage 3) and established clinical cardiovascular disease (Stage 4). The stage guides how aggressively to screen and treat.
What CKM syndrome is
Cardiovascular–kidney–metabolic (CKM) syndrome is the term for the way heart disease, kidney disease, and metabolic risk factors such as obesity and type 2 diabetes drive one another rather than occurring in isolation. The American Heart Association defined the syndrome and its staging in a 2023 Presidential Advisory; in 2026 the AHA, American College of Cardiology, American Diabetes Association, and American Society of Nephrology issued the first joint clinical guideline. The central practical shift is that the kidney is treated as an early driver of cardiovascular risk, not a late complication.
The five CKM stages
| Stage | Defining features | Emphasis of care |
|---|---|---|
| 0 | Normoglycaemia, normotension, normal lipids, no excess or dysfunctional adiposity, and no CKD. | Primordial prevention; periodic CKM reassessment. |
| 1 | Excess or dysfunctional adiposity — overweight/obesity (BMI ≥25 kg/m², or ≥23 in adults of Asian ancestry) or increased waist circumference — with normoglycaemia to prediabetes and no other metabolic criteria or CKD. | Weight-centric lifestyle, with pharmacotherapy where indicated. |
| 2 | Metabolic risk factors (hypertriglyceridaemia ≥135 mg/dL, hypertension, the metabolic syndrome, or type 2 diabetes) and/or moderate- to high-risk CKD on the KDIGO grid. | Guideline-directed control of each axis plus organ-protective therapy per indication. |
| 3 | Subclinical atherosclerosis or subclinical heart failure, or a risk equivalent such as very-high-risk CKD or a high predicted 10-year cardiovascular risk (≥20% by PREVENT, per the 2026 guideline). | Intensified preventive pharmacotherapy. |
| 4 | Established clinical cardiovascular disease within CKM syndrome. 4a = no kidney failure; 4b = kidney failure present. | Secondary prevention; kidney function modifies prognosis, drug choice, and dosing. |
Why the stage changes management
Staging is useful because it re-frames when to act. A patient can sit at Stage 2 — and therefore warrant organ-protective therapy — on the strength of kidney findings alone, before any heart disease is clinically apparent. Consider a 46-year-old with obesity and type 2 diabetes, an eGFR of 52 mL/min/1.73m², and a urine albumin-to-creatinine ratio of 120 mg/g, with no known heart disease. The metabolic risk factors together with moderate-to-high-risk CKD place her at Stage 2 even in the absence of clinical cardiovascular disease — which is precisely the point at which early, organ-protective treatment has the most to offer.
See CKM staging interactivelyMove a patient along the 0–4 continuum and watch the risk and therapy change in the CKM Explorer.Open the CKM Explorer →Frequently asked questions
What are the CKM stages 0 to 4?
Stage 0 is no CKM risk factors; Stage 1 is excess or dysfunctional adiposity alone; Stage 2 is metabolic risk factors and/or moderate-to-high-risk chronic kidney disease; Stage 3 is subclinical cardiovascular disease or a high-risk equivalent; and Stage 4 is established clinical cardiovascular disease (4a without kidney failure, 4b with kidney failure).
Who defined CKM syndrome and its staging?
The American Heart Association defined cardiovascular–kidney–metabolic syndrome and its staging in a 2023 Presidential Advisory. In 2026 the AHA, ACC, ADA, and ASN issued the first joint clinical practice guideline.
Can a patient be at CKM Stage 2 without heart disease?
Yes. Metabolic risk factors or moderate-to-high-risk chronic kidney disease each define Stage 2 on their own, so a patient can be Stage 2 on kidney or metabolic findings alone, before any clinical cardiovascular disease is present.
What is the difference between CKM Stage 4a and 4b?
Both mean established clinical cardiovascular disease within CKM syndrome. Stage 4a is without kidney failure; Stage 4b is with kidney failure. Kidney function is separated out because it directly modifies prognosis, drug selection, and dosing.
References
- Ndumele CE, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation. 2023. doi:10.1161/CIR.0000000000001184
- 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome. J Am Coll Cardiol. 2026. doi:10.1016/j.jacc.2026.03.056
- Khan SS, et al. Development and Validation of the American Heart Association’s PREVENT Equations. Circulation. 2024. doi:10.1161/CIRCULATIONAHA.123.067626
- KDIGO CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024. doi:10.1016/j.kint.2023.10.018
Educational use only. This page explains concepts for health professionals, trainees, and students. It is not medical advice and does not calculate an individual patient’s risk.