First-Ever Clinical Guideline Unifies Care for Cardiovascular-Kidney-Metabolic Syndrome
核心洞察
A new joint guideline from the AHA, ACC, ADA, and ASN published in Circulation establishes the first coordinated clinical approach to cardiovascular-kidney-metabolic (CKM) syndrome, retiring the 2013 obesity (搜索) management guideline.
Nearly 90% of U.S. adults met criteria for at least one CKM stage as of 2020, with 15% in an advanced stage facing elevated risks of heart attack, kidney failure, or death.
The guideline recommends GLP-1-based therapies (搜索) for select individuals with obesity (搜索) and/or type 2 diabetes (搜索), alongside SGLT2 inhibitors (搜索) and finerenone for overlapping cardiorenal-metabolic benefits.
A landmark clinical guideline published June 9 in Circulation and the Journal of the American College of Cardiology (搜索) establishes, for the first time, a unified framework for preventing, detecting, and managing cardiovascular-kidney-metabolic (CKM) syndrome — an interrelated condition encompassing heart disease, chronic kidney disease (搜索), type 2 diabetes (搜索), and metabolic risk factors such as obesity (搜索) and hypertension.
The 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (搜索) was developed by the American Heart Association, the American College of Cardiology (搜索), the American Diabetes Association (搜索), and the American Society of Nephrology (搜索). It retires and replaces the 2013 Guideline for the Management of Overweight and Obesity (搜索) in Adults.
"Heart, kidney, and metabolic conditions don't occur in isolation – they are deeply connected," said Chiadi E. Ndumele, MD, PhD, MHS, chair of the guideline writing committee and director of obesity (搜索) and cardiometabolic research at Johns Hopkins Medicine. "This guideline calls for earlier screening and care, focusing on prevention and coordinated action to reduce the risk of cardiovascular disease before serious complications develop or a major cardiac event occurs."
A Syndrome of Interconnected Diseases
CKM syndrome, coined in a 2023 AHA advisory, reflects the biological reality that abnormalities in one organ system cascade into others. Obesity (搜索), diabetes, and hypertension damage blood vessels, including those in the kidneys, setting the stage for chronic kidney disease (搜索). Failing kidneys allow fluid buildup, further elevating blood pressure and straining the heart.
"Think of CKM syndrome as a bonfire. Obesity (搜索) lights the match, diabetes fans the flame, and disease in the heart and kidneys keep the flame burning," said Susanne Nicholas, MD, an adult nephrologist at the David Geffen School of Medicine at UCLA. "Without taking appropriate steps to break the cycle, the person can develop kidney failure and heart failure (搜索)."
The syndrome's reach is vast: nearly 90% of U.S. adults met criteria for one of the four CKM stages as of 2020, with 15% in an advanced stage. As the syndrome progresses, the risk of heart attacks, other cardiovascular harms, kidney failure, or death grows.
Kidney Health Takes Center Stage
The guideline brings new attention to kidney health in routine primary care. Nephrologist Michelle Estrella, MD, executive director of the Kidney Health Research Collaborative at the University of California, San Francisco School of Medicine, noted that "the impact of kidney disease as a major cause of cardiovascular disease has long been under-appreciated."
Inadequate screening contributes to a striking statistic: "up to 90 percent of people with [chronic kidney] disease are unaware of their diagnosis," Nicholas said. The early stages produce no symptoms, and risk factors — including high blood pressure, diabetes, family history, older age, and smoking — often go unaddressed.
The guideline recommends use of both estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) "to characterize CKD and guide the use of kidney-protective agents to confer both cardiovascular and kidney benefits." The UACR test "often provides the earliest sign of kidney disease," Estrella said, even before eGFR becomes abnormal.
Expanded Therapeutic Arsenal
The guideline formally recommends therapies that address multiple conditions simultaneously. For the first time, GLP-1-based therapies (搜索) are recommended for select individuals with obesity (搜索) and/or type 2 diabetes (搜索) and other cardiovascular risk factors. These agents reduce visceral fat, inflammation, and cardiovascular risk. SGLT2 inhibitors (搜索), which treat type 2 diabetes and benefit those with chronic kidney disease (搜索) and heart failure (搜索), and finerenone, which halts kidney function decline and lowers the risk of kidney and heart failure in those with chronic kidney disease, are also highlighted.
The approach "allows us to shift the way we deliver care from being reactive to being proactive," Nicholas said. "We can now pay closer attention to earlier detection, risk assessment and prevention strategies that can lead to better long-term outcomes."
Risk Assessment and Social Determinants
The guideline introduces improved risk assessment using the new PREVENT equations to estimate 10- and 30-year risk for cardiovascular disease. These equations incorporate kidney and metabolic health factors for more comprehensive risk estimation compared with previous tools. A corresponding AHA/ACC Scientific Statement, chaired by Sadiya S. Khan, MD, MSC, FACC, reviews the evidence supporting these recommendations and offers "practical guidance for applying risk assessment as the first step in shared decision-making."
Screening for social drivers of health — including food insecurity, housing instability, intimate partner violence, and financial strain — is now part of the CKM framework. Social risk factors place people "at significantly higher odds of advanced CKM syndrome stages," Nicholas said. The guideline recommends coordinated interdisciplinary care involving a CKM coordination point person, alongside primary care doctors, specialists, social workers, and community health workers.
Implementation Challenges and Future Directions
Ndumele acknowledged the difficulty of addressing social risks but emphasized, "it's certainly a very big challenge, but not one that I think we can afford to ignore." With obesity (搜索) and overweight impacting over 70% of the U.S. population, the guideline points clinicians to toolkits for discussing weight in health-focused, supportive ways, recognizing that "there's a lot of weight bias and weight stigma in our society and actually also in our clinical environments."
The authors note unanswered questions remain, particularly for CKM patients with heart failure (搜索), those with both heart failure and CKD, and individuals with advanced CKD. They also highlight the need to revisit education, training, and structural factors — including automated technology, billing and reimbursement policies, and shared clinical space — to optimally implement guideline recommendations across diverse clinical and geographic settings.