Integrated Care for Patients With Kidney and CV Risks: Roy Mathew, MD

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Establishing best practices for the seamless integration of care from nephrologists, cardiologists, and primary care for patients with coexisting kidney and cardiovascular risks is challenging, said Roy Mathew, MD, associate professor of medicine at the Loma Linda VA Health Care System. He presented on kidney health as a determinant of cardiovascular risk during the 2025 American Heart Association (AHA) Scientific Sessions, held in New Orleans, Louisiana, November 7-10, 2025.

Right now, there is no definitive answer on what the best practices are to integrate care between different specialties for these patients, but there are some models that have been able to do it. He pointed to the Cardiometabolic Center Alliance, which has found a way to incorporate cardiology and endocrinology into the care of patients with high-risk heart failure and diabetes in the chronic kidney disease space.

“We'd bring in pharmacists, nutritionists, [and] social workers, along with the nephrologist,” he said. “But I think that care has to now expand.”

However, he acknowledged that every health system is different, and they don’t all have the same capabilities. In rural areas with limited specialist availability, integration relies on leveraging nonphysician providers, including primary care, nurse practitioners, physician assistants, and community members. For larger health systems, the solution involves structural changes, particularly adjusting payment systems to incentivize collaboration and enable truly patient-centered care.

At University Hospitals in Cleveland, Ohio, the Center for Integrated and Novel Approaches in Vascular-Metabolic Disease, known as CINEMA, is a very patient-centric model that brings all the providers to the patient, Mathew explained. The team-based care model at CINEMA is designed to not only address cardiovascular-kidney-metabolic (CKM) health risks in patients with type 2 diabetes or prediabetes, but it also aims to streamline care through multidisciplinary collaboration.

AHA’s CKM Health initiative is focusing on what models, like CINEMA, work throughout the country. “That will be a good registry of information for people who want to try to implement that [model] into their systems,” Mathew said.