CKM Guideline Aims to Break Down Specialty Silos: Keith Bellovich, DO

The first formal clinical practice guideline built on the 4-stage cardiovascular-kidney-metabolic (CKM) syndrome framework is pushing nephrology, cardiology, endocrinology, and internal medicine toward a shared, patient-centered care plan rather than fragmented, specialty-by-specialty treatment, according to Keith Bellovich, DO, MBA, chief nephrologist at Strive Health.

The CKM staging framework has existed since 2023, but this June marked the release of the first guideline built around it with graded recommendations, published jointly by the American Heart Association, American College of Cardiology, American Diabetes Association, and American Society of Nephrology.¹ Bellovich, speaking in an interview with The American Journal of Managed Care^®, said the update matters because it formally brought multiple specialty societies to the table.

Guideline Elevates a Historically Siloed Field

“What historically had been the case is a siloization of the care across the different subspecialties of medicine,” Bellovich said. “These patients carry a lot of comorbidity that overlaps multiple specialties, and what was critical about this most recent guideline was the importance of elevating it to include multiple specialty societies from multiple areas of expertise: cardiology, nephrology, and endocrinology, and internal medicine.”

That collaboration, he said, gives clinicians a common reference point. “We all had a reasonable expectation of what everyone was going to deliver, but now it’s a single patient-centered approach with a single flag planted that we’re all striving to then attain,” Bellovich said.

He noted that from a value-based care standpoint, ownership of specific tasks matters less to payers than results: “The payers really don’t care who’s delivering the care and who’s responsible for which aspect of the care. What they want is to see a reduction in the total cost of care and enhanced outcomes, ie, the definition of value.”

Vascular Risk Signals Guide When to Loop in Specialists

Asked what should trigger a nephrologist to bring in a cardiologist or endocrinologist rather than manage a patient alone, Bellovich pointed to vascular risk broadly rather than a single lab value.

“The key factor here is where were these vessels at risk, whether that be in the myocardial bed, the cranium, or the kidney, or the peripheral vascular system,” he said.

He added that proteinuria, captured through the glomerulus, helps quantify vascular stress, while cardiac function—specifically whether a patient has preserved or reduced ejection fraction—signals when cardiology should be engaged.

“The second leading referral source to nephrologists is the cardiologist outside of the primary care world,” he said, describing a “very close, collaborative practice” between the 2 specialties.

Interoperability and Communication Remain the Biggest Barriers

On the structural obstacles to coordinated CKM care, Bellovich named interoperability first but said it is not the whole story.

“It isn’t necessary, a requirement that everyone work off the same electronic platform, although it certainly helps,” he said, pointing to artificial intelligence tools and the ACCESS model as efforts to incentivize integrated chronic disease management.

Still, he said, “communication, good old-fashioned communication still serves as the greatest reward in terms of delivering multifaceted, multispecialty, interdisciplinary care.”

Equitable Screening Called an “Untapped Frontier”

CKM syndrome’s advanced stages disproportionately affect Black adults, older adults, and men.² Bellovich said building equitable screening for patients without easy specialist access remains unresolved.

“That’s really the untapped frontier. How do we identify and screen the right populations for disease?” he said, noting that additional at-risk groups beyond those most discussed also carry CKM risk.

He pointed to metabolomic, proteomic, and genomic indicators, alongside routine serology and laboratory data, as areas of ongoing research to improve targeting. Bellovich also flagged endocrinology’s growing role, particularly around diabetes and obesity management.

“We’re watching how the management of obesity is also relatively an open field,” he said, describing its shift “from a surgical disorder into more of a medical management condition” that depends on collaboration among primary care, general internal medicine, endocrinology, cardiology, and nephrology.

References

1. Ndumele C, Rodriguez F, Dixon D, et al. 2026 AHA/ACC/ADA/ASN guideline for the prevention, detection, evaluation, and management of cardiovascular-kidney-metabolic syndrome: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. 2026;87(suppl 22):e1889-e2007. doi:10.1016/j.jacc.2026.03.056
2. Aggarwal R, Ostrominski JW, Vaduganathan M, et al. Prevalence of cardiovascular-kidney-metabolic syndrome stages in US adults, 2011-2020. JAMA. Published online November 8, 2024. doi:10.1001/jama.2024.20516