Best Practices in Optimizing Multidisciplinary Care for Patients With Worsening Kidney Function

A preventive cardiologist emphasizes the importance of understanding patients’ health holistically, recognizing that kidney health is closely linked to cardiovascular health. Many patients with chronic kidney disease also have or are at risk for heart disease, and vice versa. Current healthcare tends to treat these diseases late in their course and in isolation, which limits the potential for prevention. Instead, a population health approach that focuses on early identification and prevention across kidney, heart and metabolic health is needed. This requires breaking down silos between specialties and rethinking how care is delivered.

Effective management of these interconnected conditions demands a multidisciplinary team approach rather than relying solely on physicians. Clinical pharmacists, advanced practice providers, community health workers and other care team members can play key roles in evaluating and managing patients with overlapping cardiovascular, kidney and metabolic diseases. Many therapies, including angiotensin-converting enzyme inhibitors, sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists, have benefits across these conditions, making coordinated care even more important. These medications address a range of issues such as diabetes, hypertension, heart failure and obesity, helping slow disease progression and reduce complications.

To truly improve outcomes, healthcare systems need better integration and communication across specialties, potentially through virtual care teams supported by population health programs. Shared electronic health records can help but often aren’t enough on their own. A reorganization of care delivery with a focus on prevention, regular monitoring and timely therapy initiation is critical. By working together and leveraging advances in pharmacotherapy and team-based care, it’s possible to prevent or delay the onset of serious cardiovascular and kidney diseases and improve patient quality of life.