# Evaluating the Whole Patient: Lessons from the Pre-CKM Era Toward Integrated Cardio–Kidney–Liver–Metabolic Care

## TL;DR

This study highlights gaps in diagnosing cardio-kidney-liver-metabolic health in patients with hypertension before the CKM syndrome concept was introduced.

## Contribution

The paper identifies diagnostic blind spots and emphasizes the need for integrated, interdisciplinary screening in hypertension care.

## Key findings

- 39% of patients lacked key heart failure diagnostic tests like NT-proBNP or echocardiography.
- 27% of patients had incomplete liver assessments, missing ultrasound or Fib-4 data.
- Previously undetected conditions included suspected heart failure in 21% and CKD in 6%.

## Abstract

Before the American Heart Association introduced the cardiovascular–kidney–metabolic (CKM) syndrome concept in 2023, clinical care was largely organ-specific. This retrospective study analyzed diagnostic patterns and gaps in 406 patients with hypertension referred to and evaluated at the University Hospital Basel Hypertension Centre in 2017, 2019, or 2022 to identify blind spots in the assessment of cardio–kidney–liver–metabolic health. Electronic health records were used to assess CKM-relevant diagnostics, including lipid profiles, N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography, kidney function (estimated glomerular filtration rate: eGFR, urinary albumin-to-creatinine ratio: uACR), and hepatic assessment (Fib-4 score, abdominal ultrasound). Previously undetected conditions were identified according to contemporary criteria for dyslipidemia, chronic kidney disease (CKD), suspected heart failure (HF), diabetes, and suspected metabolic dysfunction-associated steatotic liver disease (MASLD). Although 94% of participants had laboratory data, key CKM parameters were inconsistently assessed. Of the participants, 39% had neither NT-proBNP measurement nor echocardiography, and 27% lacked hepatic ultrasound or sufficient data for Fib-4 calculation. Previously unrecognized comorbidities were common (suspected HF 21%, CKD 6%, suspected MASLD 3%). Lipoprotein(a) testing increased from 0% in 2017 to 23.7% in 2022, indicating growing awareness. Despite specialized care, diagnostic fragmentation persisted, underlining the need for systematic, interdisciplinary screening and informing the design of prospective registries such as the Swiss CKLM Registry to integrate patient-centered cardio–kidney–liver–metabolic care.