Cardio-Renal What? Time to Speak the Same Language

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this special introductory episode of For Kidneys’ Sake, nephrologists Prof Jeremy Levy and Dr Andrew Frankel open a new series on Cardio-Renal Metabolic (CRM) disease, a complex syndrome where kidney disease, cardiovascular disease, and metabolic dysfunction intertwine. With obesity, diabetes, and hypertension on the rise, CRM is becoming a leading cause of kidney disease and an urgent challenge for integrated care delivery.

The conversation touches on how albuminuria and declining GFR are early signs of vascular damage, even in asymptomatic patients, and why abdominal fat is now viewed as metabolically active tissue that contributes to systemic inflammation. Jeremy and Andrew call for a shift from specialist-led care to a patient-focused model that unifies treatment strategies across kidney, heart, and metabolic health. This episode sets the stage for an enlightening series aimed at primary care clinicians and healthcare teams working with complex, multimorbid patients.

Key Takeaways: 

1. Cardio-Renal Metabolic (CRM) disease represents a unified condition, not just overlapping risk factors. 

2. Obesity-driven inflammation is a major contributor to both CKD and cardiovascular damage. 

3. Albuminuria and mild GFR decline often signal early systemic disease — even without symptoms. 

4. Healthcare must shift from fragmented, specialty-based care to integrated, patient-centric pathways. 5. Early intervention, education, and service redesign are key to managing CRM effectively.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub

Chapters

• 0:29 Introduction to CRM and why it matters
• 2:06 Kidney Disease & Cardiovascular Risk
• 5:43 Rising Burden of Metabolic Disease
• 7:49 Problems in Healthcare Structure
• 11:04 Preventative & Unified Care
• 11:48 Key Takeaways

Transcript

Jeremy Levy
So hello, I'm Jeremy Levy. I'm a consultant nephrologist at Imperial Healthcare NHS Trust.

Andrew Frankel
And hello, I'm Andrew Frankel, a colleague of Jeremy's at Imperial College Healthcare NHS Trust. And we have another episode in our series of podcasts For Kidney’s Sake. Avid listeners will have been aware that we produced a series of podcasts that focuses on kidney disease. However, listeners would also be aware that we frequently consider issues that relate to cardiac disease and metabolic disease where these are associated with kidney disease.

In fact, the combination of kidney disease, cardiac disease and metabolic disease, which is referred by a variety of names, but I'm going to call it cardiorenal metabolic disorders, is increasingly being recognised as a distinct disorder and indeed is one of the commonest reasons why people develop kidney disease in the UK.

There is a sea change occurring in relation to how we manage people with cardiorenal metabolic disease and that is going to accelerate in the coming years. We are moving to try and build care around these individuals rather than delivering care in this siloed manner focusing on kidneys, hearts and metabolic syndrome individually.

The hope is that we will have better integrated care, fewer visits to healthcare teams for patients and better oversight of multi-morbid patients and provision of advice. So we're going to now start a series of podcasts within the For Kidneys Sake series focusing on cardiorenal metabolic disease. And today we really just want to introduce the topic. So Jeremy, we've always known that kidney disease and cardiovascular disease have a close relationship between the two.

Jeremy Levy
So that's absolutely right, Andrew. You're absolutely right. There's been a sea change in the way we think about things, but none of this is really new. And we've known for really quite a few years that once you develop any form of kidney disease, and that's whether you've lost kidney function, so your GFR is dropping, or you've preserved your GFR, but you've developed albumin in your urine, proteinuria, both of those reflecting, of course, some kidney damage, your increased risk of cardiovascular disease.

Overall be that a sudden cardiac death, heart failure, stroke, coronary artery disease, arrhythmias — any form of cardiovascular disease. And this has been known for at least 40 years with really good data emerging in the early 2000s about this.

The risk of all cardiovascular outcomes — morbidity and mortality — increases as your GFR declines, so worse outcomes with worse GFR, but also that risk increases as your albuminuria increases. Worse risks with higher proteinuria. And many of you will be familiar with that sort of CKD, so-called KDIGO heat map, that grid. The top left-hand corner has got better GFRs, lower proteinuria. And the bottom right-hand corner, the ones that are dark red, has got worse GFR, higher proteinuria. And all those cardiovascular risks get worse as you go down to the bottom right-hand corner.

Andrew Frankel
So Jeremy, and I'm going to repeat this because I think it's so important, that risk involves all forms of cardiovascular disease, whether it be ischemic heart disease, heart failure, stroke or peripheral vascular disease. And also we see this increased risk in association with all forms of kidney disease, don't we? But can I ask you, Jeremy, is that risk greater in people with metabolic diseases such as diabetes and obesity?

Jeremy Levy
I'm going to agree and disagree with you on this one, Andrew. Yes, of course that's true that we are seeing an increased risk of cardiovascular disease irrespective of the nature of the kidney disease, but it does seem to be worse in people with diabetes or metabolic syndrome over people who don't have those problems. And as you know, we're seeing more and more people with diabetes, obesity, metabolic disease and therefore having CKD in association with that, both of those leading to increased recognition of the problem.

So, for example, to make this a bit clear: if you had a 35-year-old patient with preserved GFR, GFR more than 90, but with small amounts of blood and protein in their urine, they'd had a renal biopsy because of that and it showed IgA nephropathy, common cause of blood and protein in the urine, but their GFR is more than 90 and their urine ACR is let's say 10 and they're otherwise fit and well.

They've got a much lower risk of cardiovascular disease and bad outcomes than say your same 35-year-old patient but with a BMI of 40, type 2 diabetes, preserved GFR of let's say 80 and an ACR of 30 that's slowly increasing. That last person has got much higher risk of cardiovascular disease and worsening metabolic syndromes.

The place I'm going to slightly disagree is that there are this battery of rarer causes of kidney disease which are inflammatory — vasculitis, lupus for example — and those actually have just as much cardiovascular disease as your diabetic who's got metabolic syndrome. But that's a small minority. Overall, yes, you're right. CKD with diabetes and metabolic syndrome: much worse outcomes than other causes of CKD.

Andrew Frankel
So Jeremy, I apologise for my constant fixation on metabolic disease and diabetes and kidney disease. And I suspect it relates to my rather long career in nephrology, which dates back even further than yours. And I am sure that primary care clinicians are really aware of the phenomenon that I've seen, which is that more and more people are developing kidney disease on the background of diabetes, obesity and metabolic disease.

And this is a really marked phenomenon, not just in the UK, but internationally, and absolutely is likely to be driven by the increasing incidence of obesity and the change in our eating habits that's occurred over that 40 years. And that is something that primary care really are facing at the moment — this significant increase in metabolic disease, diabetes associated with obesity.

Jeremy Levy
You're actually right and I completely agree with that. I don't get back anywhere near as far. I was so much younger than you are, Andrew. Now that's clearly not true at all. I think it's about two years difference. But as you say, it's always actually linked really we think now to obesity and weight gain. And that's partly because of the inflammatory effects of obesity, which seems to be a key driver. And that's really, really important and seems to be one of the really important factors in both CKD and metabolic syndromes.

And that's only been recognised really very recently in the last few years. Fat is not just a wobbly bit of white flabby tissue sitting on our plates doing nothing that we would normally throw away. Inside us, particularly in our abdomens, all this story about abdominal fat — fat is active. It produces hormones, it secretes inflammatory cytokines. It responds to the body's metabolic state. It is not benign tissue. It's really active and it contributes to kidney damage and cardiovascular damage.

That inflammatory state — people who are fatter have worse inflammation — drives lots of end organ damage and for us that's kidneys and cardiovascular. And that's becoming really, really apparent. And so that's why these things are now all linked.

Andrew Frankel
Well, I hope primary care get the message that if you can really get good weight management and manage obesity, you're probably going to be doing more in the long term for preventing kidney disease than all of us nephrologists working at the Imperial College Kidney and Transplant Centre.

We have though, I think you'd agree Jeremy, structured our medical services in a very, I would call it doctor-centric manner, where we build our services around the different specialty areas. And I think, and indeed it's now recognised, that this causes significant inefficiencies and it also causes confusion for patients who actually then have to see many clinicians.

Jeremy Levy
I think that's a really important point. We've sort of fixated on our skills and rather the impact for the patient. And there is a problem there because we all have to learn more about some other areas we may be less confident in.

And this whole change, the fact that we really want to link cardiac disease, renal disease, metabolic syndrome, weight gain, are going to have to change how we manage things to help patients. And it's not just the seeking medical advice from lots of different sources, is it? Because actually individuals, for example, cardiologists, will get worried if somebody's got kidney disease about what medicines, and they say to the patient: I'm not sure what to do.

So this is an educational issue for us as clinicians, whether it be primary care or secondary care. But it's also an issue about the boring bit, the commissioning of services. How does the system pay for it? How do we deliver it? Do we get the right education and the right people in the right place?

And I know that you've tried to deal with some of these system-wide issues, which you can tell us about in a second, because actually that's part of the issue, isn't it? How you can bring these things together to help manage patients and to help patients manage themselves.

Andrew Frankel
Yes, Jeremy, and in fact, we're to be devoting a number of podcasts on different aspects of the work that's being done to better manage cardiorenal metabolic disease. And I know that we'll be inviting Dr. Khaldir Johal to talk to us next time around early CRM disease and obesity.

However, I want to really reiterate for the audience that they appreciate that once a person has evidence of CRM from a kidney perspective — that's albuminuria or an impaired GFR — they need to understand that that individual, even though it may not yet be apparent, has already got ongoing cardiological and vascular damage. And we shouldn't be waiting for people to develop more advanced disease, such as stage G3 CKD or a cardiac event or heart failure, but we should be thinking about how we prevent this early on.

Jeremy Levy
I think that's really important, Andrew, and we're now talking about diseases that haven't yet manifest symptomatically as well, which also makes it very hard as we discuss and explain to patients, doesn’t it? They're not getting symptoms, and that little bit of albuminuria, ACRs of 10–20 — so low level they're not going to be causing any symptoms — are telling us that blood vessels and hearts and kidneys are all unhappy in combination.

So we hope that our series of podcasts are going to help clinicians to upskill themselves in relation to CRM, Cardiorenal Metabolic Medicine, so that they can talk to patients about early management to prevent these diseases becoming more manifest. We hope that our audience will recognise the importance of this.

And for me, it's not just moving to a more preventative approach to health care. But this unified advice, I think, is really, really important. Historically, colleagues have often said, "This isn't my area, I don't know what to do." For example, high-dose statins for somebody with early heart disease and CKD.

We want to upskill clinicians so that they can bring these three things together and actually talk about prevention of strokes and cardiovascular disease and diet and exercise and the kidney disease and the weight gain and the weight loss treatment, because they're all intimately linked.

Andrew Frankel
So let's now, Jeremy, think about the three key takeaways that we can get from this to introduce the whole subject of cardiorenal metabolic disease.

The first is that we've highlighted the association between kidney disease and cardiac and metabolic disease is more than an association and in many individuals defines a specific pathological condition that requires a holistic management plan. Remember that often one of this triad — e.g. heart failure or a cardiac event — may not yet have become clinically manifest, but the patient still has a CRM syndrome.

Secondly, I think everyone should reflect, whether they're in primary care — of course, which is where we're aiming this series of podcasts — but also in secondary care, particularly, because in fact, primary care clinicians are generalists. We need to reflect on the skills that we need to best manage the people who we care for and not just pick and choose elements of the disorder the person is presenting with.

And then we need to look at the structure of our services so we build those around the person's needs rather than around our individual interests.

So Jeremy, I'm looking forward to discussing these issues with you and guests in the coming weeks and really exploring cardiorenal metabolic disease together with a range of experts who can help us understand how best to deliver care for these individuals.

Jeremy Levy
I'm very excited, Andrew. I'm looking forward to learning some things myself — and talking all these issues with you. Bye for now.

Andrew Frankel
Bye for now.