Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline

Abstract

Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one. The so-called scientific model is built around kidney transplantation and care of glomerulonephritis and immunologic diseases, which probably pose the most important challenges in our discipline, but do not mirror the most common clinical problems. Conversely, the pragmatic one is built around dialysis (the most expensive and frequent mode of renal replacement therapy) and pre-dialysis treatment, focusing attention on the most common diseases, the holistic, or comprehensive, model comprehends both, and is integrated by several subspecialties, such as interventional nephrology, obstetric nephrology, and the ideal-utopic one is based upon prevention, and early care of common diseases. Each model has strength and weakness, which are commented to enhance discussion on the crucial issue of the philosophy of care behind its practical organization. Increased reflection and research on models of nephrology care is urgently needed if we wish to rise to the challenge of providing earlier and better care for older and more complex kidney patients with acute and chronic kidney diseases, with reduced budgets.

Unraveling Cardiovascular Risk in Renal Patients: A New Take on Old Tale

“…This phenomenon is partly related to the increase, in developing Countries, of risk factors that can accelerate CV disease development, such as the aging of the population and the change in dietary habit toward high caloric and fatty foods compared to still limited prevention and treatment strategies (Barquera et al, 2015). All these evidences confirm the burden of CV disease in CKD patients and reinforce the need to improve and better understanding how to reduce CV risk in these frailty patients (Piccoli et al, 2018) as well as to ameliorate health care access and infrastructure in developing countries (Perico et al, 2005). Moreover, these findings also encourage incorporating CV disease in the evaluation of the benefits of CKD screening worldwide.…”

Holistic vision of the patient with chronic kidney disease in a universalistic healthcare system

“…The definition of clinical goals is an important process to achieve quality care outcomes. The study from Piccoli et al 50 discusses about different clinical approaches, not mutually exclusive, the scientific, the pragmatic, the holistic, and the utopic model. The scientific model takes place in the university setting, and it concerns with treatable kidney disease and kidney transplantation.…”

Promises of Big Data and Artificial Intelligence in Nephrology and Transplantation

“…CKD is linked with a higher danger of argumentative outcomes, like cardiovascular complications, death, decreased quality of life, and substantial healthcare resource utilization [7][8][9][10][11], and it has been assessed that around 850 million individuals suffer different types of kidney diseases globally [12,13]. If left untreated, CKD may evolve into end-stage kidney disease (ESKD), which is associated with high mortality [14][15][16]. It is well-known that kidney diseases are very much multifactorial, with overlapping and complex clinical phenotypes, as well as morphologies [17].…”

“…The general capacity for undertaking cohort studies that involve a large sample size or Rapid Control trial is very much present across various parts of the globe, and has thereby resulted in the absence of research evidence within nephrology. In addition, limited activity in kidney research has impacted the evidence base for the treatment of kidney diseases, resulting in a lack of useful surrogate end-points for progression from the early stages of kidney disease-hindered trials [14,15]. On the same note, a great amount of cohort data could also be applied in generating relevant hypotheses and provide major insights into the etiology, pathogenesis, and prognosis of kidney diseases [23,24].…”