CKM syndrome is catching on — it now has guidelines and everything. But the transition to routine care requires clinicians to overcome old habits.

Last week, the American Heart Association (AHA) and American College of Cardiology issued the first guidelines for CKM (cardiovascular-kidney-metabolic) syndrome, marking a major milestone for the framework first introduced in 2023.

Designed to break down clinical silos, the concept replaces fragmented care with an integrated, stage-based scoring system (from stage 0 to stage 4). Reframing three disorders as one means a risk factor in one area triggers testing for the others — emphasizing their interrelatedness and pushing for aggressive early intervention.

“In the old world of thought, each of these conditions is a siloed problem,” said Jen Manne-Goehler, MD, ScD, cardiometabolic disease researcher and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. 

In the new world, here are five common mistakes to avoid.

Mistake #1: You Skip uACR Testing.

An analysis of 192,000 adults found that only 17.5% of patients with hypertension or diabetes received a urine albumin-to-creatinine ratio (uACR) test.But according to the new guidelines,albuminuria testing is recommended for any patient with hypertriglyceridemia, hypertension, metabolic syndrome, or type 2 diabetes. Failing to screen could be a missed opportunity for early intervention: New therapy combinations have been shown to reduce uACR so dramatically that they cut the risk of chronic kidney disease progression by 27%. There’s a continuous relationship between increasing uACR levels and all-cause and cardiovascular mortality, said nephrologist Yelena Drexler, MD, MS, an associate professor of clinical medicine at the University of Miami Miller School of Medicine, Miami, and author of a recent review of the latest advances for CKM risk prediction and treatment. That rising risk starts as early as when albuminaria levels are below 30 mg/g.

What to do: Check your electronic medical record system for a CKM lab panel or workflow that includes uACR. If there isn’t one, request that it be added. Automating the option makes it less likely to be overlooked.

Mistake #2: You Ignore Stage 0.

About 1 in 10 adults (mostly younger ones) have no CKM risk factors — described as “stage 0.” The fact that the vast majority of adults — 90% — are in stages 1-4 shows how critical it is to take action at this point, before patients cross the threshold into stage 1, Drexler said. Even at stage 0, people have the same 15-year cumulative incidence of cardiovascular mortality as people in stage 1 (around 5%), according to a recent analysis. It rises to 9% at stage 3 and 15% at stage 4.

What to do: Introduce young patients to Life’s Essential 8, the AHA’s checklist for disease prevention. “At every stage, there’s a window for intervention before clinical CVD [cardiovascular disease] and kidney disease develops,” Drexler said. Stage 0 is also the time to start education and raising awareness about CKM, since the risk for progression to CKM is high.

Mistake #3: You Revert to Siloed Treatment Considerations.

“To me, this is where CKM offers something new and a potential improvement,” said Manne-Goehler. Instead of managing each condition in a clinical silo, the framework allows clinicians to use a unified mental model. This makes it easier to prescribe multitargeted therapies — like GLP-1s or SGLT2 inhibitors — that concurrently address cardiovascular, metabolic, and renal risk. “It’s not just the rebranding,” she said. “It’s also about making providers comfortable with treatments that are multipotent — treating multiple problems at the same time.”

What to do: Consult this table of treatment options from the new guidelines. Your first considerations should be GLP-1s and/or SGLT2 inhibitors, Manne-Goehler said. Drexler also suggested considering a nonsteroidal mineralocorticoid receptor antagonist. The CONFIDENCE trial showed that it is safe and effective to simultaneously start empagliflozin and finerenone in people with chronic kidney disease and type 2 diabetes, she said.

Mistake #4: You Assume Patients Can’t Afford GLP-1s.

“A lot of doctors and medical providers are still thinking about GLPs like they’re a Hollywood drug,” said Manne-Goehler, who was the technical writer of the World Health Organization’s GLP-1 guideline. But access is opening up.

What to do: Keep GLP-1s top of mind and seek out affordable options. (Eli Lilly and Novo Nordisk both offer direct-purchase discounts.) “It is a powerful, transformative cardiometabolic risk reduction tool. We’re underusing it,” Mann-Goehler said.

Mistake #5: You Let a Denial Deter You.

The indications for GLP-1s continue to expand, and coverage is changing regularly. 

What to do: See if a different multicondition cluster will trigger an approval, such as trying MASLD (metabolic dysfunction-associated steatotic liver disease) or kidney disease with diabetes, Manne-Goehler said. Keep tabs on which plans are covering them for which patients and which conditions. “It’s hard because insurance is all over the place right now, but you need to ask for your patients,” Mann-Goehler said. “You need to ask insurance: Can I get it for this person? And don’t back down.”

Manne-Goehler is a consultant to the World Health Organization on GLP-1s. Drexler cited no disclosures.