Prevention, not just dialysis: an AJKD perspective stakes nephrology's claim in CKM

The argument

Nephrology grew up around organ failure: dialysis, transplant, the slow march toward both. Sridhar and Levin argue that the specialty now has drugs that can slow kidney disease, and should act like it. That means treating prevention and early diagnosis as core work, not an optional extra. The trigger is the cardio-kidney-metabolic (CKM) syndrome, a framework the American Heart Association introduced in 2023 that health systems and industry are now adopting.

Key points

• Referral comes too late by design. Guidance to refer at an eGFR below 30 often becomes the only trigger, and proteinuria or an abnormal sediment gets overlooked. Patients first seen at stage 4 or 5 progress faster, are hospitalized more and more often start dialysis unplanned.
• "Time is nephrons." A near-normal GFR after an injury can hide real nephron loss. That quiet phase may be the best window to act.
• The CKM model has blind spots. It is built around diabetes and obesity, so primary kidney diseases fit poorly. Albuminuria is optional in it, and kidney failure is not counted as an outcome at all. It also folds three specialties into one "CKM specialist", as if their silos and payment models did not exist.
• Success should be redefined. The goal becomes fewer AKI events, slower CKD, fewer cardiovascular events, fewer unplanned dialysis starts and more people who never reach kidney failure.
• Nephrologists should claim specific roles: finding the cause of kidney disease, interpreting GFR and albuminuria, managing drugs in kidney disease, reading tests whose thresholds shift with GFR, and joining or leading shared care in HFpEF, diabetes with albuminuria and resistant hypertension when CKD is present.

Why it matters

The authors' warning is concrete. Without nephrologists, they say, early targeted therapy gets missed in people with lower GFR or albuminuria, as in IgA nephropathy, and the specialty loses its voice in trial design. Training, they note, is still mostly hospital-based, and payment still rewards dialysis over outpatient care. They suggest updating fellowship and perhaps creating "CKM subspecialists."

Caveats

This is an invited opinion piece with no data. It does not test a care model, count the workforce needed or say how payment would change. The research agenda it lists is a set of questions, not answers.

Industry ties: Sridhar reports travel support, speaker fees or advisory fees from Merck Canada, Lexicon, Bayer Canada and Novo Nordisk Canada. Levin reports grants and other support from AstraZeneca, Boehringer Ingelheim and Janssen, plus research support from several companies and public funders.

The source: Sridhar VS, Levin A. A Perspective on the Role of Nephrologists in the Cardio-Kidney-Metabolic Syndrome. Am J Kidney Dis. Published online September 22, 2026 (Articles in Press). Read the original

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