Boston Specialists Debate How to Operationalize Cardio-Kidney-Metabolic Care

Cardiologists, nephrologists, endocrinologists, and pharmacists from Boston's major health systems gathered for a Population Health Roundtable hosted by The American Journal of Managed Care^® to discuss how cardio-kidney-metabolic (CKM) syndrome is being—and should be—managed at the population level. The conversation came days after the American College of Cardiology, American Heart Association, American Diabetes Association, and American Society of Nephrology issued a joint guideline on CKM screening and management.

Despite the new guidance, participants agreed that significant gaps remain in how clinicians screen for, refer, and treat patients whose disease spans the heart, kidneys, and metabolic system and that these gaps will require structural change, not just education, to close.

Is CKM a Term Clinicians Will Actually Use?

Moderator Muthiah Vaduganathan, MD, MPH, a cardiologist at Brigham and Women's Hospital, opened by asking whether the CKM framework, which was introduced in the literature only within the past 5 years, will resonate clinically or remain mainly useful to academics and drug developers. Ralph Riello, PharmD, BCPS, a clinical pharmacy specialist in cardiorenal metabolic disorders at Yale New Haven Health, said he was initially skeptical but now believes the term is "here to stay," noting that the American Heart Association has absorbed the Cardiometabolic Alliance into its CKM framework. Others noted there is still no billing code for CKM, so reimbursement continues to flow through single-organ diagnoses.

Lee Kaplan, MD, PhD, a hepatologist and professor emeritus at Harvard Medical School, compared the moment to immunology's shift from organ-based to disease-based thinking and predicted CKM will eventually be reorganized around shared mechanisms. However, he notes that he remains skeptical a durable "CKM specialist" will emerge, since specialties have historically formed around organs, not pathophysiology. Varsha Tanguturi, MD, cardiologist and medical director of population health services for Mass General Brigham, said that despite the unfamiliar vocabulary, the underlying logic resonates as she builds clinical programs, since therapies developed for one condition routinely benefit the others.

Why Aren't More Clinicians Ordering UACR?

Much of the discussion centered on urine albumin-to-creatinine ratio (UACR) testing, which panelists called one of the most underused, highest-value screening tools in CKM care. Riello said cardiology colleagues have been surprised to learn UACR predicts cardiovascular events in some populations, as well as N-terminal pro-B-type natriuretic peptide, yet Vaduganathan acknowledged that even within his own health system, it remains rare for a cardiologist to order the test.

Workflow, not knowledge, emerged as the larger obstacle. One pharmacist described clinic-collect urine programs that let medical assistants hand patients a specimen cup at check-in, improving screening rates in primary care but not yet replicated across every department. Kaplan argued that education alone won't close the gap but rather automation is what will get screening done at scale.

How Should the 4 Pillars of GDMT Be Sequenced?

Participants agreed the 4 pillars of guideline-directed medical therapy, which include renin-angiotensin system (RAS) inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, mineralocorticoid receptor antagonists (MRAs), and glucagon-like peptide-1 (GLP-1)–based therapies, offer overlapping, multiorgan benefit regardless of which comorbidity predominates, though no single sequencing strategy emerged as consensus. Riello argued against maximizing 1 pillar before adding the next, since starting an SGLT2 inhibitor upstream can improve tolerability of subsequent therapies. A nephrologist also part of the roundtable described prioritizing RAS inhibition and SGLT2 inhibitors first, with earlier MRA use when hyperaldosteronism is present and earlier GLP-1 use when obesity predominates. Cost, more than awareness, was the dominant barrier cited. Riello noted that out-of-pocket costs for all 4 pillars in heart failure with reduced ejection fraction have fallen to roughly $1 per day under a recent affordability initiative, but prior-authorization burden still causes clinicians to defer starting therapy. Om Ganda, MD, MACE, senior physician and consultant at Harvard Medical School, estimated that more than 60% of patients discontinue GLP-1 therapy within the first year, largely because of cost.

Who Should Coordinate Care for Patients With Overlapping Disease?

Fragmentation surfaced repeatedly as a structural problem. An endocrinologist described patients at Boston Medical Center seeing 3 or 4 different endocrinology subspecialists within a few months, driven by time-constrained visits that incentivize narrow, single-disease focus. Several participants pointed to e-consults as a scalable middle ground, and Emily Persson, PharmD, a clinical ambulatory pharmacist in cardiology at Boston Medical Center, described a model that lets one point of contact manage refills and titration without requiring patients to see multiple subspecialists. Kaplan favored cross-training generalists and expanding pharmacist and advanced-practice roles over creating a new CKM subspecialty, which he argued would lack a durable reimbursement pathway.

What's Next

The speakers agreed that a near-term goal is adding UACR to existing collaborative pharmacy practice agreements, building automated electronic health record nudges for omitted CKM-related labs and therapies, and breaking down disease-specific silos that prevent patients from moving between programs as risk evolves. Persson said the discussion underscored the need to pair any new screening initiative with affordability for underserved patients, who may struggle to cover co-pays for established therapies even as attention shifts to newer, costlier ones.