When new guidelines came out last month emphasizing cohesive management of cardiovascular, kidney, and metabolic health, reactions were mixed.

“I was a little shocked at the pushback,” said Brian Rifkin, MD, a nephrologist at the Hattiesburg Clinic in Hattiesburg, Mississippi. “People called it a fake condition. They thought it was weak messaging, confusing staging. People were asking why we’re being asked to do more preventive cardiology, and is there going to be some kind of designation or certificate that’s completely meaningless?”

But those complaints and concerns are overblown, experts told Medscape Medical News.

Clinical Need

The multisociety recommendations, led by the American Heart Association (AHA) and American College of Cardiology (ACC) as a replacement for their obesity guidelines, are the first to focus on cardiovascular-kidney-metabolic (CKM) syndrome. While the framework was first proposed in 2023 by the AHA, the concept has been developing for decades.

“There’s a history here that one can’t ignore, and it’s driven by obesity,” said Robert Eckel, MD, an endocrinologist at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, who has played a key role in past cardiovascular disease prevention guidelines.

The metabolic syndrome began to be defined in the mid-1990s. Cardiorenal syndrome followed in the early 2000s, and then diabetes was brought into the interconnected construct. SGLT2 inhibitor trials over the last decade proving benefit for both kidney and cardiovascular outcomes and then GLP-1 and glucose-dependent insulinotropic polypeptide agonist data further consolidated the idea of looking at CKM outcomes together, said Rajiv Saran, MBBS, a nephrologist at the University of Michigan in Ann Arbor, Michigan, and long-time investigator with the National Kidney Disease Surveillance System.

“This new entity is really old wine in new bottles, in my view,” but there’s a need for that “new bottle,” he said.

“There’s too many guidelines in particular for primary care physicians to consume. Each specialty has their own guideline,” Saran said. “I think the framework is a good one for generalists but also will encourage us specialists to think holistically because we tend to get siloed in our field and we don’t necessarily think of our responsibility for the other subspecialties’ framework.”

The CKM guideline urges that all adults be routinely assessed for metabolic risk factors and kidney function and then emphasizes lifestyle management, SGLT2 inhibitors, and weight-loss medication to manage those at elevated risk.

“When people look at these guidelines and say we already do this stuff — well, you kind of do and kind of don’t,” Rifkin said. “Because we know for even something simple like ACE inhibitors or ARBs [angiotensin II receptor blockers] — very cheap medication, very few side effects, and yet only about 50%-60% of people for whom it’s indicated are actually taking these medicines.”

If the guideline sounded like everyone was being asked to do some preventive cardiology, that’s true, Rifkin noted.

“Yes, at some level, we are all cardiologists. We all have to prevent cardiovascular disease because that is the number one killer,” he said.

Even if outside of one’s clinical comfort zone, “you should at least consider them,” he added. “And if you’re not going to do it, then you need to get them somebody who will do it.”

Stage Fright

The new guideline also offers a staging system for CKM syndrome. Stage 1 encompasses overweight/obesity or prediabetes without other metabolic, kidney, or cardiovascular disease manifestations or risk factors. Stage 2 adds metabolic risk factors like hypertension and type 2 diabetes and chronic kidney disease (CKD) to the mix without overt cardiovascular disease. Stage 3 escalates to subclinical disease, high cardiovascular disease risk, or very-high kidney disease risk. Stage 4 involves diagnosed cardiovascular disease with overweight/obesity, kidney disease, or other metabolic risk factors.

These stages mimic the nomenclature most familiar to the public in the cancer setting. And that does pose some risk for unnecessary anxiety for patients, said Rifkin.

“I’m not a great fan of staging,” he said. In CKD, “it definitely confuses the heck out of patients. It makes them panic more. They say, ‘I got CKD-4, my doctor sent me here. I’m dying, right? No.”

Saran, however, said it can be a tool to get people’s attention and an opportunity for more patient education and health literacy. “If you just throw information without explanation, then yes, it’ll be scary.”

Mainly though, staging is useful for billing purposes, Rifkin said. Saran predicted International Classification of Diseases, 10th Revision codes would soon be in the works for the various stages of CKM.

If so, it could be used to further support access to incretin-based therapy prescriptions, Saran suggested. “It will increase the likelihood that if the drug is considered and prescribed, that there’s more likely to be coverage,” he said.

Risk of Overmedicalization

CKM syndrome has sufficient consensus as a real disease entity, Saran said, but the staging system puts almost all American adults on its spectrum.

“There is a danger of medicalization,” Saran said. “What worries me more is that more and more medications will be used to manage perhaps too early and lifestyle will still get short shrift.” Even if the guidelines tout lifestyle intervention as the foundation of management, its importance often pales against the option of medication in practice, he said.

Rifkin argued against there being a risk from including so many people in CKM stage 1, when the treatment for them would be healthy lifestyle. Pushing screening is worth it to get more people into treatment earlier, when it can be more effective, he said.

“I think that the pendulum is way too far to the left right now, that we’re not looking at these patients nearly enough. And we’re trying to force it a little bit to the opposite side where we do screening in a much larger population,” Rifkin said.

Eckel agreed but without the worry about increasing the number of people on weight-loss medication. “To a large extent we’re not very effective in modifying behavior in individuals, families, populations, and clearly globally enough to take care of the obesity problem worldwide,” he said.

“The drug trials now are sufficient in number with various pharmaceuticals to show that pharmaceutical consideration really is mandatory once you get past stage 1 and maybe even in stage 1 where weight gain may be an initial target for therapeutic intervention,” said Eckel, who was part of The Lancet Commission team that redefined clinical obesity in 2025.

Implementation Concerns

Industry stands to benefit from increased medicalization, but patients and society do too.

“Even if we only get a couple more people [in a given health system] to start screening and looking earlier, that makes a big difference in a population when you’re trying to move the needle on cardiovascular disease and kidney disease,” Rifkin said.

Saran predicted a slow path to community awareness of even CKM as an entity much less implementation of the guidelines.

The guidelines emphasize interdisciplinary care models for overlap among type 2 diabetes, CKD, and cardiovascular disease and having a care-coordination point person — aspects that present a challenge for infrastructure in many centers.

Health systems will need to buy in to the concept, Eckel suggested.

“For the complicated advanced stage 3 or very complicated stage 4 patient with existing disease, we need a comprehensive healthcare system that approaches this with a single clinic visit that has multiple subspecialists and multiple healthcare providers that are capable of meeting the needs of a very much more complicated patient,” he said, although economic feasibility is an open question.

The paradigm of care coordinators already exists in blood pressure management, kidney disease, and other settings, Saran said. Existing personnel likely can absorb this role in many centers, or the diabetes coordinator and other somewhat siloed coordinators will have to come together as a team, he said.

For the overwhelming number of earlier stage patients, no extensive training should be needed, Eckel said. “We just need to have good primary care docs, including internists and family docs, who can do a better job.”

Primary care can’t shoulder the whole burden, though, Saran said. “They’re also overworked. They will need help,” he said. “But there is the potential for care coordination to be more successful if the will is there to do it first of all.”

However, rather than leading to more burnout, it could lead to less, Rifkin said.

“At the end of the day, I’m happier when my patients do better and I can keep them off dialysis and keep them from dying from heart disease,” he said. “That’s much more stressful from my standpoint. I spend a lot of administrative time getting people prepared for dialysis. If I can get them further away from that point, where they don’t ever need dialysis, that’s better for me.”

Saran disclosed being an advisor to the National Committee for Quality Assurance and participating in Kidney Disease: Improving Global Outcomes meetings.

Rifkin reported having no relevant conflicts of interest.

Eckel disclosed consulting or advisory board activity with Amgen, Arrowhead, 89bio, Ionis, Lilly, Madrigal, New Amsterdam, Novo Nordisk, Precision Biosciences, Regeneron, The Healthy Aging Co., Tolmar, UpToDate, and Viatris.

Crystal Phend is an award-winning medical journalist with decades of experience reporting on clinical research and healthcare developments across specialties. When not walking the halls at a medical conference, she can be found at a keyboard in upstate New York.