• CV, metabolic and kidney risks should be routinely assessed by nephrologists.
• Sequential or combination therapies should be considered.
• Lifestyle modifications should be encouraged in CKM syndrome management.

The American Society of Nephrology issued new kidney health guidance on cardiovascular-kidney-metabolic syndrome, highlighting the specific role of the kidneys in the disease’s treatment paradigm.

Nisha Bansal, MD, MS, professor of medicine and nephrology at the University of Washington School of Medicine, and Alexander R. Chang, MD, MS, professor in the departments of nephrology and population health sciences at Geisinger Medical Center, lead authors on the kidney health guidance, said the recommendations were developed to be “complementary rather than contradictory” to the recent American Heart Association, American College of Cardiology, American Diabetes Association and ASN guideline on cardiovascular-kidney-metabolic (CKM) syndrome.

“We felt it was important to translate [the CKM syndrome] framework specifically for nephrologists and highlight the central role of kidney disease across the CKM spectrum,” Bansal and Chang told Healio. “In particular, we wanted to address how cardiovascular risk assessment and treatment may need to be approached differently in people with kidney disease, who are at particularly high risk but are often underrepresented in clinical trials.”

ASN’s guidance and executive summary, both published in the Journal of the American Society of Nephrology, highlight chronic kidney disease-specific recommendations for nephrologists to consider.

In routine care, nephrologists should conduct eGFR, urine albumin-creatinine ratio, blood pressure, BMI and/or waist circumference, HbA1c and lipid profile tests, according to the workgroup.

“We don’t think CKM assessment needs to become another checklist or another clinic visit — it should largely be integrated into what nephrologists are already doing,” Bansal and Chang said. “We use information collected at routine visits to identify treatment gaps and prioritize interventions.”

In addition, the workgroup recommends use of the CVD PREVENT equation and Kidney Failure Risk Equations for use alongside routine kidney assessments.

“CKD itself should be viewed as a major CKM risk factor, so cardiovascular and kidney risk should be assessed together rather than separately,” Bansal and Chang said.

The workgroup highlighted the use of foundational CKD therapies, including renin-angiotensin system (RAS) inhibitors and SGLT2 inhibitors, for treating patients at risk for CKM syndrome.

GLP-1 receptor agonists should be considered for patients with CKD who have overweight or obesity or for patients with type 2 diabetes on RAS inhibitors and SGLT2 inhibitors, the workgroup wrote. Nonsteroidal mineralocorticoid receptor antagonists may also slow kidney disease progression and improve CV outcomes for patients with CKD, they wrote.

Initiation of these therapies can begin either simultaneously or in rapid sequence for high-risk patients depending on a patient’s tolerance, treatment preferences and affordability, according to the guidance. Initial eGFR dips should be expected when beginning treatment with an SGLT2 inhibitor and should not lead to treatment discontinuation, they wrote.

For patients with nondialysis dependent-CKD stages 3 to 5 and atherosclerotic CVD, lipid-lowering therapies should be considered primary and secondary treatment options, according to the workgroup.

As part of CKM syndrome management, lifestyle modifications, including physical activity, healthy diet and sleep patterns, and tobacco avoidance should also be encouraged, the workgroup wrote. Resistance or strength training and adequate protein intake are encouraged to minimize risk for sarcopenia and preserve lean muscle mass, they wrote.

The workgroup called for more research in populations underrepresented in CKM syndrome trials, including kidney transplant recipients, patients on dialysis, children, older adults and patients with glomerular diseases.

“Treatment in these populations needs to be individualized around prognosis, symptoms, treatment burden and patient goals,” Bansal and Chang said. “Clinicians should not assume that the absence of trial data means the absence of benefit, but rather carefully consider extrapolated evidence, competing risks, immunosuppression and the unique priorities of each patient.”

Nephrologists should also consult with cardiologists, endocrinologists, liver specialists and dietitians depending on a patient’s symptoms, the workgroup wrote.

Overall, physicians should be treating CVD, kidney disease, diabetes and obesity as “interconnected manifestations of the same underlying biology,” Bansal and Chang said.

“Ultimately, we would like to see earlier identification of risk; more coordinated care across specialties; better evidence for patients with advanced CKD, kidney failure and transplant; and treatment strategies that are truly centered on outcomes that matter to patients,” Bansal and Chang said.

Nisha Bansal, MD, MS, can be reached at nbansal@uw.edu.

Alexander R. Chang, MD, MS, can be reached at achang@geisinger.edu.