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Zen and the future of nephrology
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Looking toward the next 30 years of treating kidney disease
Editor's note: Nephrology News & Issues is celebrating 30 years of publishing this year. In this series, we are looking to the future. How will treating kidney disease change in the next three decades?
Despite recent trans-corporation of my consciousness into a Google CloudBody, I found myself experiencing happiness (or a reasonable equivalent thereof) on learning that there are no longer any patients receiving long-term hemodialysis in North America. It is with some sense of awe (again—an approximation given my current form) that I am able to add some commentary to this milestone of medical history.
What I saw then…
I was first exposed to dialysis during medical school, sometime around 1999 or so. By that time, the technology and supportive interventions were unpleasant, but tolerated by most patients. The two decades prior to my training were marked by numerous quality-of-life improvements. The perpetual vomiting due to acetate baths and intermittent transfusions in a world without ESAs were the memories of the older nurses and doctors. The battles nephrologists fought at that point in time were largely social, logistic, and administrative. Patient compliance with fluid intake and high-phosphorus foods were the most common subject of dialysis rounds. Planning for, placing, monitoring and maintaining dialysis vascular access in many patients was the largest focus of our dialysis unit.
It is astounding to remember that, back then, before our molecular printers and implantable diffusers, patients most often took medications orally. Our patients were often taking 10-20 different medications, multiple times a day. Worst of all, medications had to be retrieved or delivered from a pharmacy. And the management of all the pills and administration schedules was organized on paper lists. It is amazing we didn’t hurt more people with polypharmacy and the inherent potential confusion of so many pills.
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While transplant was (and is) the most ideal outcome, the supply of kidneys was so constrained that most transplanted kidneys came from deceased donors! Unlike today’s immune-neutral, cultured-cell-on-printed-matrix organs, or even the more crude human HLA animal-grown organs, we spent a lot of time worrying about immunosuppressive medications—dosing, side effects, complications, etc. Back then, I would have never imagined the phrase “premature matrix failure of a lab-grown kidney.”
We are all mired in the perspective of our times. Though a bit unfair, when my career started, medicine often felt like voodoo. Pills were magic potions and my orders were the incantations. To be sure, we alleviated discomfort and prolonged life, but in the early decades of the 21st century, health care was reactive and heavily burdened by logistics, cost, and access. I remember the hours many physicians (and other health care providers) spent advocating for our patients and our specialty as the government slowly but firmly pushed forward a series of payment schemes holding the physicians and the dialysis units accountable for the quality of care we provided. It was during this time that the unintended consequences of these programs materialized—the “brain drain” of early retirement and career shifts of the most experienced frontline health care workers.
…and my place in tomorrow
By the early 2020s, our health care workforce was woefully understaffed due to decreased financial rewards and the difficulties of work-life balance. Concomitant to the pressures on the providers, demand was increasing as well. A generation of patients were living longer and, as a consequence, demanded higher volumes of low-cost care with the latest breakthroughs of the day. Health care was being treated like the bulk food stores—more, more, more for less, less, less. It was the 2024 election that I think broke the cycle that was destroying health care in general and nephrology in particular.
President George Clooney was not the first actor elected to the presidency. He was, however, the first to politically neutralize the “Baby Boomer” generation. Under his eight years of leadership, the key components of the health care workforce strategy fell into place. Called the Healthcare Workforce Continuity Act of 2029, it brought many health care jobs under federal control and creating the Healthcare Security Agency (HSA) and Healthcare for All Citizens law of 2030 broadening Medicare to an all-inclusive model with many former for-profit insurance companies becoming regional third party administrators. ClooneyCare, as these laws came to be collectively known, laid the groundwork for the end of dialysis as we knew it.
As a nephrologist living through those times, I was both amazed and skeptical. Sometime in early 2031, the workforce capacity started equilibrating with demand and care was further enhanced with an array of innovation. Since the early 2030s, with the advent of holographic exam pods with dialysis capability, the five regional dialysis control hubs were able to handle the now dwindling need for dialysis care. Our implantable biomonitoring/biosynthetic drug infusers allow real time feedback loops to keep an array of previously difficult-to-manage diseases (from diabetes to hypertension and other endocrine and autoimmune diseases) in check. Lab-grown organs and limbs became common, but with a new set of problems to monitor and treat. And while there was (and is) an endless need to troubleshoot odd cases and directly care for those not willing to avail themselves of technologic innovation, being a nephrologist became much more focused on the patient, albeit often from afar.
Working in concert with my biotechnologist, the last years of my career were quite fulfilling. Though I was no longer as praised for my diagnostic acumen, my telehealth exams and deep appreciation for the interface between biology and technology kept me engaged beyond my expectations.
Unfortunately, it was still economically unsustainable. These innovations spawned greater demand that could not be matched by our country’s resources. And so, yet again, we looked to technology to bypass a resource limitation.
Body double
Until 2036, people were “stuck” in their bodies. There was no practical distinction between the body and the neuro-electrical patterns we call consciousness. In other words, there was a hard-stop—your consciousness died when your body died. Ironically, and despite a robust understanding of preventative care, many people did not take care of their bodies. It should not be a surprise, however, since the consumers of health care (the patients) were not held fiscally or socially responsible for the increased health care costs of their choices. And there was little political will to change the situation. While many states tried to mitigate state-level costs by taxing food based on the caloric or carbohydrate content, these efforts were largely unsuccessful. For many years, and even after the implementation of ClooneyCare, only hospitals and providers were held accountable for the outcomes and cost of the care provided. But this only lasted so long. When the increasing financial and logistic burden of the US population born in the 1950s and 1960s became more evident, the political forces for change fell into place.
Leaders of the future
I remember how many of us were surprised by how far our neuroscience engineers had come in mapping, uploading, and storing the electrical patterns we understand to be consciousness when the first public announcements were made. It was not a surprise, however, that the egos and money of the Musk and Zuckerberg families fueled this innovation, largely in an effort to prolong the lives of the people bearing these names. While the impact on aphorisms has been disruptive (mind-blowing, out-of-body experience, etc.), the implications for health care (and society at large) have been revolutionary. For the first time in human history, trans-corporation broke open the “existential cage” of the body.
Commercializing trans-corporation took a few years, but the combination of an aging population and the persistent lack of resources to meet the demand for care, aligned technologic innovation with political will. The 2039 No Mind Left Behind law, based on the principles of eminent domain, finally and forcibly held recipients of care responsible for their health. By capping per capita federally-funded medical spending (for those over 18, with an inflation and geographical price adjustment), we have solved the greatest examples of the “tragedy of the commons” brought about over the last 80 years—more demand for publicaly-financed health care in a world of a finite fiscal resources.
It seemed we had finally incentivized the consumers to demand high quality, high value health care by striving to take care of themselves. And when your personal wealth and/or federal medical savings account is depleted, you have the options of death or trans-corporation. Since data storage is so much cheaper than caring for biologic organisms, we had once again found a technologic solution to a resource scarcity problem.
The wave of change
As for this nephrologist, I felt I had seen enough. I retired in 2041 thinking I would enjoy the fruits of my savings and let the field evolve onward without me. There was still work to be done, but dialysis is now largely a bridge to transplant. Kidney diseases needed management, but from regional telehealth centers. The specialty is now predominated by bio-technicians who monitor, troubleshoot, and replace bioengineered organs and devices with real-time monitoring and control.
I had saved wisely and was happy to enjoy what I thought it would be a long and comfortable retirement, even though I means-tested out of the hundreds of thousands of dollars I contributed to our Social Security system.
It was not without some sense of irony that I watched my toilet fill with foamy urine in April 2044. I was not surprised when my socks indicated a 3 cm increase in my ankle diameter along with increased bioimpedance. Over the next few days, when my Apple iWaste™ Health Monitor AI system reported increasing proteinuria with each bathroom visit and a significant probability of a new kidney disease, I thought, “Screening tools pointing to diagnosis within hours of symptom onset. If only I had this kind of stuff in 2010!”
I was at the local branch of our regional health center with an injectable nanoprobe-confirmed diagnosis of a membranous nephropathy and a holographic tele-exam with our regional medical center within five days.
No amount of predictive analytics can account for random variation. I am told that only 1 in 1.4 million people suffer a severe side effect from the latest immune modulating medication for membranous nephropathy. But like winning the lottery in reverse, in mid-May 2045, I woke up in an intensive care pod, still ventilated and now on dialysis. An anaphylactic-like reaction due to an immune cross-reactivity not yet documented by the manufacturer is still a thing of the 2040s, so I learned. Either way, I was too sick to transplant and too obstinate to die.
My Medtronic artificial kidney worked well enough and though I am relatively young by today’s standards, I did not have the capacity to fully recover.
My two years on dialysis were not without bright spots, but in retrospect was wasteful. I had to charge the organ once a week. I had one episode of tubular cell failure in the setting of sepsis. Even in 2040s, caring for weakened biologic bodies is expensive. When my federal health savings account ran out in July 2046, I faced death or trans-corporation. I decided to leave behind the sensations of being a sharp mind trapped in a debilitated body. But for my two years and countless expenses I earned the unique distinction of being the longest-term user of the Medtronic artificial kidney. For a guy living in 2046, my mindset was clearly still stuck in the 2010s.
So you now have the pleasure of reading the first public output from my disembodied intellect. It is surprisingly comfortable in my CloudBody. I have not yet figured out how to manage all of the available settings (I seem to reside in an endless shade of teal at the moment), but I’ve decided to start working again. It turns out that telehealth doesn’t require an embodied physician. -by Adam Weinstein