CKM Syndrome Stages 0–4: What Each Stage Means

Cardiovascular-kidney-metabolic (CKM) syndrome is staged according to the combination of metabolic risk factors, kidney disease, cardiovascular risk, and cardiovascular disease a person has. The stages are designed to show where someone currently falls along the CKM health spectrum and to help clinicians match prevention and treatment to the person’s level of risk.

The 2026 AHA/ACC/ADA/ASN CKM syndrome guideline uses Stages 0 through 4. Stage 0 represents ideal CKM health rather than CKM syndrome itself. Stages 1 and 2 identify progressively greater metabolic or kidney-related abnormalities, Stage 3 identifies subclinical cardiovascular disease or an equivalent level of cardiovascular risk, and Stage 4 involves established clinical cardiovascular disease.

The staging criteria can look technical because they incorporate measurements such as blood pressure, blood glucose, kidney function, waist circumference, and cardiovascular risk estimates. This guide explains what each stage means for adults, why someone may qualify for a particular stage, and why CKM staging should not be treated as a prediction that disease will inevitably worsen.

CKM Syndrome Stages at a Glance

The CKM staging model is intended to capture more than one disease. It considers metabolic health, kidney health, cardiovascular findings, and predicted cardiovascular risk together.

For adults, the stages can be summarized as follows:

CKM stage	Main definition	Examples of findings
Stage 0	No CKM risk factors	Normal weight and waist circumference, normal glucose, blood pressure and lipid profile, with no CKD or cardiovascular disease
Stage 1	Excess or dysfunctional adiposity	Overweight or obesity, abdominal obesity, and/or prediabetes without Stage 2 risk factors or CKD
Stage 2	Metabolic risk factors, CKD, or both	Hypertension, high triglycerides, metabolic syndrome, type 2 diabetes, and/or moderate- to high-risk CKD
Stage 3	Subclinical CVD or an equivalent very high level of risk	Subclinical coronary disease, pre-heart failure, very high-risk CKD, or a 10-year PREVENT-CVD risk of at least 20%
Stage 4	Clinical cardiovascular disease with CKM risk	Coronary heart disease, heart failure, stroke, peripheral artery disease, or atrial fibrillation; Stage 4b also includes kidney failure

The guideline recommends CKM staging because two people who appear similar based on body weight or blood glucose alone can have very different cardiovascular and kidney risks. Staging provides a way to place those individual measurements into a broader clinical context.

The 2026 guideline also includes CKM assessment in children and adolescents, but pediatric definitions and thresholds are not identical to adult criteria. The specific numerical criteria discussed below therefore refer to adults.

Stage 0: Ideal CKM Health

Stage 0 represents the healthiest end of the CKM spectrum.

According to the 2026 guideline, an adult in Stage 0 has normal BMI and waist circumference, normal blood glucose, normal blood pressure and a normal lipid profile, with no evidence of chronic kidney disease, subclinical cardiovascular disease, or clinical cardiovascular disease.

An important terminology point is that Stage 0 does not mean someone has an early form of CKM syndrome. It represents the absence of identified CKM risk factors and is used as a benchmark for ideal CKM health.

The emphasis at this stage is prevention: maintaining healthy eating patterns, regular physical activity, healthy sleep, avoidance of nicotine, and appropriate monitoring as health needs change with age and circumstances.

Stage 0 also does not mean a person’s lifetime cardiovascular risk is literally zero. Genetics, family history, aging, pregnancy-related complications, social determinants of health, and other factors can influence future risk even when current measurements are favorable.

Stage 1: Excess or Dysfunctional Adiposity

Stage 1 is the first stage that falls within CKM syndrome. It identifies early metabolic changes before the metabolic risk factors or chronic kidney disease that characterize Stage 2 have developed.

For adults, the guideline places someone in Stage 1 when excess or dysfunctional adipose tissue is present without additional Stage 2 metabolic risk factors or CKD.

Excess Adiposity

Excess adiposity can be identified through either overall body size or abdominal obesity. Adult Stage 1 criteria include:

• BMI of at least 25 kg/m², or at least 23 kg/m² for people of Asian ancestry
• Waist circumference of at least 88 cm for women or 102 cm for men
• For people of Asian ancestry, waist circumference of at least 80 cm for women or 90 cm for men

These measurements are screening tools rather than perfect measures of body composition. BMI, for example, cannot distinguish muscle from fat or show where body fat is stored. Waist circumference adds information about abdominal adiposity, which is particularly relevant to metabolic risk.

Dysfunctional Adipose Tissue and Prediabetes

The guideline also uses prediabetes as evidence of dysfunctional adipose tissue. Adult criteria include a fasting blood glucose of 100–125 mg/dL or an HbA1c of 5.7%–6.4%. Prediabetes can also be identified through impaired glucose tolerance on an oral glucose tolerance test.

The term “dysfunctional adiposity” reflects the fact that adipose tissue is biologically active. Metabolic dysfunction is not determined by body size alone.

Someone can therefore reach Stage 1 through excess weight, increased waist circumference, impaired glucose regulation, or a combination of these findings.

Stage 2: Metabolic Risk Factors, Chronic Kidney Disease, or Both

Stage 2 represents a meaningful increase in CKM risk because additional metabolic abnormalities, chronic kidney disease, or both are present.

The adult guideline identifies several Stage 2 metabolic criteria:

• Hypertension: systolic blood pressure of at least 130 mm Hg, diastolic pressure of at least 80 mm Hg, or use of blood-pressure medication
• Hypertriglyceridemia: fasting triglycerides of at least 150 mg/dL
• Metabolic syndrome
• Type 2 diabetes: including fasting glucose of at least 126 mg/dL or HbA1c of at least 6.5%
• Moderate- to high-risk chronic kidney disease according to KDIGO kidney-risk categories

A person does not need to have all of these conditions. One qualifying Stage 2 condition can be sufficient when more advanced Stage 3 or Stage 4 criteria are absent.

Why Kidney Disease Can Place Someone in Stage 2

CKD classification depends on more than a single kidney filtration number.

Clinicians commonly consider both estimated glomerular filtration rate (eGFR), which estimates how effectively the kidneys filter blood, and urine albumin-to-creatinine ratio (UACR), which can reveal abnormal leakage of albumin into the urine.

The CKM framework uses combinations of kidney filtration and albuminuria to distinguish moderate-to-high CKD risk from very-high CKD risk. Very-high-risk CKD can move someone into Stage 3 even if they have not been diagnosed with clinical cardiovascular disease.

This is one reason a normal-feeling person cannot reliably determine CKM stage from symptoms alone.

Why Stage 2 Is So Broad

Stage 2 can include people with quite different health profiles.

One person might qualify because of hypertension. Another may have type 2 diabetes. Someone else may have CKD without diabetes or obesity. Others may have several metabolic and kidney conditions simultaneously.

That variation is intentional. The CKM framework recognizes that several different pathways can eventually increase cardiovascular risk.

It also means that two people in Stage 2 do not necessarily have the same absolute risk or need the same treatment. Risk prediction and the specific conditions involved still matter.

Stage 3: Subclinical Cardiovascular Disease or Very High Risk

Stage 3 is one of the most important stages to understand because a person does not need to have symptoms or diagnosed clinical cardiovascular disease to qualify.

The guideline describes Stage 3 as a high-risk primary-prevention population. It includes people with subclinical cardiovascular disease in the setting of CKM risk factors, as well as people whose kidney disease or calculated cardiovascular risk is considered equivalent to subclinical cardiovascular disease.

In practical terms, Stage 3 can be reached through three broad pathways.

Subclinical Atherosclerotic Cardiovascular Disease

“Subclinical” means disease is detectable even though it has not yet produced a recognized clinical cardiovascular event or typical symptoms.

One Stage 3 example is coronary artery calcium identified on CT imaging. The adult guideline uses a coronary artery calcium, or CAC, score of at least 100 as one criterion for subclinical coronary atherosclerosis. Certain findings on coronary CT angiography, coronary catheterization, or ankle-brachial index testing can also qualify.

The important point is not that everyone with CKM risk needs these tests. Rather, when clinically appropriate testing has already identified substantial subclinical disease, that finding can affect CKM staging.

Pre-Heart Failure

Stage 3 can also include pre-heart failure, in which structural or functional heart abnormalities, elevated filling pressures, or certain cardiac biomarkers indicate cardiac changes even though clinical heart-failure symptoms are not present.

This is another reason Stage 3 is sometimes described in patient materials as the stage of “silent damage.”

Risk Equivalents

Someone can also qualify for Stage 3 without documented subclinical cardiovascular disease if their risk is sufficiently high.

The 2026 guideline identifies two important risk equivalents:

1. Very-high-risk chronic kidney disease
2. A predicted 10-year total cardiovascular disease risk of at least 20% using the PREVENT-CVD equations

PREVENT stands for Predicting Risk of Cardiovascular Disease EVENTS. The equations integrate cardiovascular, kidney, and metabolic information to estimate future cardiovascular risk.

A more detailed explanation of blood tests, urine testing, eGFR, UACR, PREVENT, and when additional cardiovascular testing may be useful will be covered in our guide to CKM syndrome screening and tests.

Stage 4: Established Cardiovascular Disease

Stage 4 means clinical cardiovascular disease is already present in a person who also has CKM risk factors such as excess or dysfunctional adiposity, metabolic abnormalities, or chronic kidney disease.

Qualifying cardiovascular conditions include:

• Coronary heart disease
• Heart failure
• Stroke
• Peripheral artery disease
• Atrial fibrillation

Stage 4 differs fundamentally from Stage 3. Stage 3 is still considered a primary-prevention stage because a recognized clinical cardiovascular event or disease has not yet occurred. Stage 4 represents established cardiovascular disease, so prevention efforts also include reducing the risk of recurrent or additional cardiovascular events.

Stage 4a and Stage 4b

The 2026 guideline further separates Stage 4 according to kidney failure status.

Stage 4a means clinical cardiovascular disease is present without kidney failure.

Stage 4b means clinical cardiovascular disease is present with kidney failure. The guideline defines kidney failure in this context as an eGFR below 15 mL/min/1.73 m² or the need for chronic kidney replacement therapy.

This subdivision highlights how strongly kidney status affects prognosis and management once cardiovascular disease is established.

It is important not to confuse CKM Stage 4 with Stage 4 chronic kidney disease. They are different classification systems. Someone can have CKM Stage 4 because of clinical cardiovascular disease without having Stage 4 CKD.

What Changes From One CKM Stage to the Next?

The easiest way to understand the stages is to focus on what new level of risk or disease has appeared.

Stage 0 to Stage 1: Early adiposity or glucose-regulation abnormalities appear.

Stage 1 to Stage 2: Additional metabolic disease or clinically meaningful CKD develops.

Stage 2 to Stage 3: Cardiovascular involvement becomes detectable before clinical disease, or kidney/cardiovascular risk becomes extremely high.

Stage 3 to Stage 4: Clinical cardiovascular disease is established.

This progression is conceptually useful, but real people do not necessarily pass neatly through each stage in order.

For example, someone may first come to medical attention after a cardiovascular event and immediately be classified as Stage 4. Another person may have CKD caused by a nonmetabolic condition and enter the CKM framework through kidney disease rather than first progressing through obesity or prediabetes.

The guideline explicitly recognizes that hypertension and CKD can have nonmetabolic causes even though they are included within the CKM framework because of their cardiovascular implications.

Does Everyone Progress From Stage 1 to Stage 4?

No. The stages describe current health and risk, not an inevitable sequence.

The 2026 guideline recommends staging partly to help prevent progression and, where possible, promote movement toward healthier CKM status through lifestyle changes, weight management, and appropriate treatment of metabolic and kidney conditions.

Risk factors such as elevated blood pressure, excess weight, glucose abnormalities, and triglycerides may improve. Kidney and cardiovascular risk may also be reduced through appropriate care.

However, “regression” needs to be interpreted carefully. Some established conditions do not simply disappear when risk factors improve. A history of clinical cardiovascular disease remains medically important even if symptoms, blood pressure, glucose, cholesterol, or other measurements become well controlled.

The purpose of staging is therefore not to chase a lower number. It is to identify the most important risks and apply prevention and treatment at an appropriate intensity.

How Common Is Each CKM Stage?

Because CKM syndrome is a relatively new framework, prevalence studies have had to apply the staging definitions retrospectively to existing population data.

A 2024 JAMA analysis evaluated 10,762 U.S. adults using National Health and Nutrition Examination Survey data collected from 2011 through March 2020. Researchers estimated the following age-adjusted prevalence:

• Stage 0: 10.6%
• Stage 1: 25.9%
• Stage 2: 49.0%
• Stage 3: 5.4%
• Stage 4: 9.2%

Together, approximately 14.6% met criteria for advanced Stage 3 or 4 in that analysis.

These figures should not be interpreted as a direct estimate of the U.S. population in 2026. The data were collected from 2011 to 2020, and the researchers had to adapt CKM staging to the measurements available in NHANES. Some information needed to identify advanced disease—including certain cardiac imaging, biomarkers, atrial fibrillation, and peripheral artery disease—was unavailable, which may have led to underestimation of Stages 3 and 4.

The study nevertheless illustrates an important point: relatively few adults in the analyzed population met the criteria for ideal Stage 0 CKM health.

How Is a CKM Stage Determined?

CKM staging cannot be established from a single measurement.

Depending on the person, assessment can involve:

• Height, weight, BMI, and waist circumference
• Blood pressure
• Fasting glucose and/or HbA1c
• Triglycerides and other blood lipids
• Kidney filtration measured through eGFR
• Urine albumin measured through UACR
• Medical history
• PREVENT cardiovascular risk estimation
• Selected cardiovascular imaging, biomarkers, or other tests when clinically appropriate

The 2026 guideline recommends evaluating metabolic risk factors, kidney function, and cardiovascular disease status together. For adults in CKM Stage 2 and above, it recommends at least annual assessment of blood pressure, glycemia, lipids, eGFR, and UACR, although an individual’s monitoring schedule depends on their specific conditions and care plan.

This is why self-assigning a CKM stage from an online description can be misleading. Some of the distinctions—particularly between Stages 2 and 3—depend on kidney-risk categories, calculated cardiovascular risk, imaging, or clinical findings that require professional interpretation.

Why CKM Staging Matters

The main purpose of CKM staging is not to attach another label to people with common health conditions. It is to help clinicians recognize that cardiovascular, kidney, and metabolic health should be considered together.

At earlier stages, the emphasis is largely on preventing the development of additional risk factors and disease. As risk increases, treatment can become more intensive and more individualized. At advanced stages, management has to account for established cardiovascular disease, kidney function, metabolic conditions, and interactions among treatments.

The 2026 guideline recommends CKM staging across the life course specifically to help prevent stage progression, reduce cardiovascular events and kidney-function loss, tailor therapies to absolute risk, and support healthier CKM status where possible.

Staging also reinforces an important principle: absence of symptoms does not necessarily mean absence of risk. Someone in Stage 2 or even Stage 3 may feel well while clinically important metabolic, kidney, or cardiovascular abnormalities are already present.

What Your CKM Stage Can—and Cannot—Tell You

A CKM stage can provide a useful summary of how far cardiovascular-kidney-metabolic risk or disease has developed. It can help identify whether the priority is maintaining ideal health, addressing early metabolic changes, treating established metabolic or kidney disease, responding to very high cardiovascular risk, or managing clinical cardiovascular disease.

What the stage cannot do is tell the entire story by itself.

Two people in the same stage may differ substantially in age, kidney function, diabetes status, cardiovascular risk, family history, medications, physical fitness, and other health factors. Their appropriate treatment plans may therefore be quite different.

CKM staging works best as a framework for clinical decision-making, not as a stand-alone diagnosis or a score that people should try to interpret without context.

For readers, the practical message is straightforward: knowing the stage can help organize risk, but understanding the individual conditions and measurements that produced that stage is just as important.

This article is for general educational purposes. CKM staging depends on a complete clinical assessment and should not be used to diagnose or stage yourself based on individual measurements.

References

1. Ndumele CE, Rodriguez F, Dixon DL, et al. “2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome.” Circulation and Journal of the American College of Cardiology, 2026.
2. American Heart Association. “2026 Cardiovascular-Kidney-Metabolic Syndrome Guideline: Patient Toolkit.” 2026.
3. American Heart Association. “Top Things to Know: 2026 Guideline for the Prevention, Detection, Evaluation, and Management of CKM Syndrome.” 2026.
4. Aggarwal R, Ostrominski JW, Vaduganathan M. “Prevalence of Cardiovascular-Kidney-Metabolic Syndrome Stages in US Adults, 2011–2020.” JAMA, 2024;331(21):1858–1860.
5. American Heart Association and American College of Cardiology. “Use of Predicted Risk and Expected Benefit to Guide Decision-Making in Cardiovascular-Kidney-Metabolic Syndrome for the Primary Prevention of Cardiovascular Disease.” Journal of the American College of Cardiology, 2026.