Renal Physicians Association Annual Meeting offers platform for debate on future of CKD
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I find it valuable to conduct an introspection of our specialty – and ourselves – amid our daily efforts to assess patients with chronic kidney disease and to provide treatment.
That includes reviewing where nephrology has been and where the specialty is going.
When looking back at the major milestones – broadly defined – during the last 2 decades, our profession has had a remarkable ability to keep people with disease processes alive that were uniformly fatal just 60 years ago.
However, nephrology as a profession and as a medical-scientific endeavor in those same 20 years has in many ways been stagnant or even regressed. This has led to what I think is our largest failure: to alleviate the symptomatic burden of kidney disease in the United States. But that may be changing.
Positive signs
There is the potential for an explosion of improvements in how we manage kidney care. The quandary is to know how and when these advances will make it to our patients. Unless we re-think nephrology as a cohesive specialty with contributions from diverse sources, I am concerned we will see little change, even with these new treatments.
Advances I see coming or have recently arrived include the following:
- earlier identification and more accurate diagnosis of CKD and analytics that allow stratification of risk of progression;
- greater understanding of the physiology of CKD and targeted approaches to therapy;
- better understanding of transplant immunology and continued improvement in allograft survival and immunosuppressive complications;
- continued interval improvement in dialysis technology, including vascular access and infection prevention; and
- a shift in health policy that starts to embrace quality and "value-based" care.
Quantum advances are hard to predict and so, therefore, I won't. Continued basic investment in these advances may yield unexpected improvements, including xenotransplantation, gene-therapy, stem-cell therapy, wearable dialysis technology and the artificial kidney.
But this generation of nephrologists should not remain complacent while waiting.
Care delivery
A concern we must address if any of the above can be applied to the care of patients with CKD is how will we deliver this care. Surprisingly, I think CMS may be philosophically ahead of nephrology leadership on this issue. Challenges nephrology must solve include the following:
- concentration of dialysis care and technology under control by just a few companies;
- creating viable economic pathways for innovation in CKD, dialysis and transplantation;
- aligning economic incentives with patient care;
- moving nephrology out of silos and into more collaborative models; and
- the failure of academic nephrology to train nephrologists to meet both the patient care and scientific need.
We still have plenty of questions to ask about the future of nephrology – not only how to improve care but how best to pay for it.
Editor’s Note: Brent Miller, MD, the Michael A. Kraus Professor of Clinical Medicine at Indiana University School of Medicine, will be presenting the talk, "Innovations in kidney disease treatment: What to expect for nephrology practice in the next 10 years," at the Renal Physicians Association Annual Meeting, being held March 24-27 in Dallas, For more information on the program and to register, visit www.renalmd.org.
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