Patients With CRM Disease Are Outgrowing the Silos Built to Treat Them

Patients with overlapping heart failure, chronic kidney disease (CKD), diabetes, and obesity—often described as cardiorenal-metabolic (CRM) disease and formalized by the American Heart Association (AHA) as cardiovascular-kidney-metabolic (CKM) syndrome—are becoming a defining clinical and financial challenge for health systems, according to Sheng Fu, MD, a cardiologist at Baptist Health Miami Cardiac & Vascular Institute, part of Baptist Health Heart & Vascular Care, in an interview with The American Journal of Managed Care^®. Fu described a growing patient population whose overlapping cardiometabolic and renal conditions can complicate traditional disease-specific treatment approaches and challenge existing care delivery models.

When Traditional Heart Failure Management Falls Short

Fu's clinical definition of the patient within the CRM landscape describes someone who appears volume overloaded and seems to need diuretics but whose kidney function worsens once diuresis begins. Layer in CKD, diabetic nephropathy, obesity, and obstructive sleep apnea, and standard heart failure management may not produce the expected clinical response.

"This patient is not behaving like the book, and the book probably needs to be rewritten from that perspective," said Fu.

In 2023, the AHA issued a presidential advisory formally defining CKM syndrome and introducing a 5-stage framework, from no risk factors to established cardiovascular disease (CVD), to capture how adiposity, metabolic dysfunction, kidney disease, and CVD interact rather than progress in isolation. Notably, the advisory emphasizes coordinated, multidisciplinary care involving primary care, cardiology, nephrology, endocrinology, nursing, and pharmacy for patients with CKM syndrome, particularly those with multiple overlapping conditions.¹

That mismatch between guideline-based treatment and real-world comorbidity clusters is expensive. A retrospective analysis of more than 387,000 Kaiser Permanente Northwest members found that the onset of a new CRM condition was associated with sharp cost increases. Total costs rose 130% with incident CKD, 84% with type 2 diabetes, 304% with atherosclerotic CVD, and 475% with incident heart failure. The study found that onset of any new CRM condition drove a substantial cost increase, with heart failure and atherosclerotic disease typically requiring hospitalization and, in heart failure's case, costly readmissions.²

Where Coordination Breaks Down

Fu pointed not to a knowledge gap but a transition-of-care scenario: diuretic regimens that change during hospitalization and don't translate cleanly to the outpatient setting. A patient discharged on a different dose than they started on, followed by a clinician who isn't their usual outpatient physician, in a system with fragmented electronic medical records, can lose track of something as basic as their own medication regimen.

"It can be just enormously confusing for patients and patients' family members," said Fu, calling this med-reconciliation gap "low-hanging fruit" that remains "such an enormous barrier to overcome."

The result, in his experience, is a steady stream of readmissions that may be related to medication confusion and breakdowns in care transitions: patients unsure what to take who simply stop taking anything and then return to the clinic severely volume overloaded.

Should CRM Become Its Own Subspecialty?

Fu is skeptical that formalizing CRM as an accredited subspecialty is the right fix. Cardiology fellowships fill at a 100% match rate annually, he noted, while nephrology and endocrinology have struggled for years to fill their own slots—making a brand-new niche specialty unlikely to draw enough trainees to move the needle on a population-wide basis. He sees more promise in adding CRM-focused training to internal medicine or existing preventive cardiology fellowships, paired with systems-level "disease centers" rather than a new credential.

Whatever the structure, Fu was direct about why health systems can't ignore the problem.

"These patients get readmitted very frequently, and they drive a significant portion of health care costs,” he explained.

No Clear "Quarterback," and a Case for Pharmacists

Without an established referral pathway, Fu said the clinician managing a patient with CRM is often simply whoever sees them first, with cardiology frequently taking the lead given its familiarity with agents like sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists. But he was emphatic that the most undervalued team member is the pharmacist, citing their role navigating prior authorizations, managing complex dosing, and tracking patients longitudinally, a concrete, fundable lever for health systems building CRM programs.

For managed care organizations, Fu's account suggests the highest-yield interventions may not require new specialists: stronger discharge medication reconciliation, clearer outpatient hand-offs, and pharmacist-led longitudinal monitoring, delivered through coordinated programs rather than separate fee-for-service visits with separate specialists.

References

1. Ndumele CE, Rangaswami J, Chow SL, et al. AHA. cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. Circulation. 2023;148(20):1606-1635. doi:10.1161/CIR.0000000000001184
2. Nichols GA, Amitay EL, Chatterjee S, et al. Health care costs associated with the development and combination of cardio-renal-metabolic diseases. Kidney360. 2023;4(10):1382-1388. doi:10.34067/KID.0000000000000212