Cardiovascular-Kidney-Metabolic (CKM) syndrome underscores the pathophysiologic interplay among metabolic risk factors, chronic kidney disease (CKD) and the cardiovascular system. This crosstalk precipitates multi-organ dysfunction, increases adverse cardiovascular events, and imposes heavy familial and socioeconomic burdens. Building a health-management platform within research wards is therefore urgent. Such a platform is the pivotal venue for assessment, monitoring, intervention and follow-up in continuous care.
Leveraging the existing health-management system of the Health Screening Center at Peking University Third Hospital, the investigators will develop a comprehensive CKM platform that integrates systemic inflammatory biomarkers, cardiovascular early-warning algorithms, and personalized diet-and-exercise prescriptions. The system will provide cyclic management encompassing evaluation, guidance, monitoring, feedback and longitudinal follow-up.
A randomized controlled trial with two-year prospective follow-up will enroll patients at CKM stages 0-2 to evaluate clinical improvement, quality of life, dietary behavior and physical activity after platform enrollment. The project will enable early identification of high-risk individuals, deliver precision management, maximize data utility, and offer a novel research-ward model that addresses mobile-health pain points and closes the CKM care loop.
CKM stage 0-2 as defined by the American Heart Association CKM diagnostic guidelines
Age 18-75 years
Able to use a smartphone and wearable activity tracker
Willing to sign informed consent and attend scheduled follow-up visits
CKM stage 3-4
Acute or critically ill conditions requiring hospitalization
Malignant tumors or any active cancer under treatment
Parallel
Comprehensive Health Management Platform
BehavioralThe health-management programme comprises: * Screening: collection of demographic data, medical and personal history, physical examination (blood pressure, heart rate, etc.), laboratory tests (inflammatory markers, lipids, glucose, renal and liver function), exercise habits, nutritional status, body-composition analysis, and physical-fitness tests (reaction time, grip strength, vertical jump, one-leg stance with eyes closed, back strength, sit-and-reach, 1-min sit-ups, 1-min push-ups, cardiopulmonary exercise test). * Assessment: CKM risk stratification based on the above. ③ Intervention: individualised exercise, dietary and pharmacological prescriptions. * Follow-up: ongoing monitoring of clinical indices, exercise, diet and medication adherence by a physician-health-manager team.
Post-examination follow-up management
Other interventionPost-examination report interpretation service and telephone follow-up for patients with abnormal findings.
Height
Body height measured in centimeters using a height and weight measuring instrument. Reported as mean value at each assessment time point.
Weight
Body weight measured in kilograms using a height and weight measuring instrument. Reported as mean value at each assessment time point.
Systolic Blood Pressure
Systolic blood pressure measured in millimeters of mercury (mmHg) using an automated sphygmomanometer after 5 minutes of rest. Reported as mean value at each assessment time point.
Diastolic Blood Pressure
Diastolic blood pressure measured in millimeters of mercury (mmHg) using an automated sphygmomanometer after 5 minutes of rest. Reported as mean value at each assessment time point.
White Blood Cell Count
White blood cell count measured in 10\^9 cells per liter (10\^9/L) using automated hematology analyzer. Reported as mean value at each assessment time point.
Red Blood Cell Count
Red blood cell count measured in 10\^12 cells per liter (10\^12/L) using automated hematology analyzer. Reported as mean value at each assessment time point.
Hemoglobin Concentration
Hemoglobin concentration measured in grams per liter (g/L) using cyanmethemoglobin method. Reported as mean value and number of participants with values below lower limit of normal (LLN) at each assessment time point.
Platelet Count
Platelet count measured in 10\^9 cells per liter (10\^9/L) using automated hematology analyzer. Reported as mean value at each assessment time point.
Score on International Physical Activity Questionnaire-Short Form (IPAQ-SF)
Physical activity level assessed using the International Physical Activity Questionnaire-Short Form (IPAQ-SF), a 7-item self-administered questionnaire measuring the frequency and duration of vigorous-intensity activity, moderate-intensity activity, and walking during the past 7 days. Total physical activity is calculated as metabolic equivalent of task (MET)-minutes per week, categorized as low (\<600 MET-min/week), moderate (600-3000 MET-min/week), or high (\>3000 MET-min/week) activity level. Higher MET-minutes indicate higher physical activity level. Reported as mean total MET-minutes per week and number of participants in each activity category at each assessment time point.
Score on 36-Item Short Form Health Survey (SF-36)
Health-related quality of life assessed using the 36-Item Short Form Health Survey (SF-36), a 36-item self-administered questionnaire measuring eight health domains: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). Each domain score ranges from 0 to 100, with higher scores indicating better health status. Two summary component scores are calculated: Physical Component Summary (PCS) and Mental Component Summary (MCS). Reported as mean scores for each domain and summary components at each assessment time point.
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