Advancing American Kidney Health

Abstract

CKD is a unique character on the stage of noncommunicable diseases in the United States: high prevalence (.20% in adults), significant expense to public payers ($114 billion among Medicare fee-for-service enrollees), and relatively little investment in research ($29 per patient in National Institutes of Health spending). Although CKD risk factors, including diabetes and hypertension, have garnered justifiable attention, CKD itself has not attracted the same level of attention as heart disease or cancer. The Executive Order (EO) on Advancing American Kidney Health presents a unique opportunity to focus attention on CKD and reset expectations about health care delivery and clinical outcomes in the later stages of CKD. The EO includes three aims: (1) by 2030, to decrease by 25% the number of new patients with ESKD; (2) by 2025, to have 80% of new patients with ESKD undergo either home dialysis or a pre-emptive transplant; and (3) by 2030, to double the number of organs available for kidney transplant. From a clinical perspective, these are very ambitious goals; meeting them will require creativity and investment from the entire kidney care community, including patients, nephrologists, dialysis providers, transplant providers, and the Centers for Medicare & Medicaid Services (CMS). The first EO goal-to reduce the number of new patients with ESKD by 25%-should be placed in perspective. The US Renal Data System reported 125,000 new patients with ESKD in each of 2015 and 2016 (1). McCullough et al. (2) forecasted a 15% increase in the incidence of ESKD between 2015 and 2030. With projected growth of the United States population to 355 million in 2030, around 157,000 new patients with ESKD can be expected. Thus, the first goal of the EO translates to only 118,000 new patients in 2030. How can this be accomplished? Pharmacologic therapy continues to hold promise. Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are used by only 36% of patients with diagnosed CKD, despite strong evidence of ESKD risk reduction in CKD with diabetes and/or proteinuria (3). Canagliflozin, a sodium-glucose cotransporter 2 inhibitor, was recently shown to reduce ESKD risk by 32% in CKD stages 2 and 3 with albuminuria (4). In CKD stages 4 and 5, the prevalence of anemia, acidosis, hyperphosphatemia, and hyperparathyroidism is markedly higher (5). Intensive medical management of these abnormalities, control of BP, and avoidance of nephrotoxic

Keys to Driving Implementation of the New Kidney Care Models

“…Successful implementation of the models within the AAKH initiative requires a coordinated effort from multiple, engaged stakeholders and, ideally, adequate health care and community resources to address social determinants of health challenges. Dialysis clinics with home therapy capacity do not exist in many communities (59). Centers for transplantation may be far from dialysis clinics (44) and may not have the capacity to handle a surge of referrals.…”