The CKD Dilemma

About 30 million Americans suffer from some form of kidney disease and it was the nation’s ninth leading cause of death in 2017. When patients reach the final stage of kidney failure, they require either a transplant or frequent dialysis to stay alive. Only about 12 percent start their dialysis treatment at home.

President Trump’s Advancing Kidney Health Executive Order is a welcome move that shone the national spotlight on the immense burden of kidney disease. How it will be implemented is yet to be seen.

“The last 30 years as a country all we’ve done is wait for kidneys to fail and we put people on dialysis,” said Bobby Sepucha, the chief administrative officer at Cricket Health, a kidney care provider.

Bobby Sepucha appears to be an advocate for renal care and kidney patients. I feel this statement is very dismissive and diminishes what physicians have been doing all these years treating and managing CKD.

Nephrologists especially have been waging this battle for decades. Since the advent of Ace inhibitors, and later Angiotensin receptor blockers, we have been able to successfully slow the progression of kidney disease in many cases. The aggressive treatment of diabetes and hypertension, the two major causes of chronic kidney disease, has also helped to delay progression.

This has been shown in trials such as the REENAL, REIN, IDNT and many others. The search for other ways to slow and even stop progression is ongoing. Physicians including Nephrologists are constantly battling the obesity epidemic in our offices as it is another major cause of chronic kidney disease.

CKD clinics around the country are treating associated diseases such as anemia and secondary hyperparathyroidism and managing the increased burden of cardiovascular disease in that population.

All our stage four CKD patients are required to tour the dialysis units and learn about in- center and home dialysis modalities. Many are referred to transplant centers for evaluation. The sad truth is that most do not qualify and there is a dire organ shortage.

The degree of debilitation of the ESRD population in the United States is grossly underestimated and most cannot do home dialysis. The goal of eighty percent home dialysis and transplant is exceedingly lofty at best and almost laughable given the current situation. There will need to be a huge paradigm shift at all levels to enable more successful home dialysis. 

Currently most nursing homes also do not offer the service and do not want to deal with the liability of patients/ spouses performing it themselves. 

As a nephrologist, I am thrilled that there is now a national spotlight on CKD/ESRD. However, please do not diminish what Nephrologists and other primary care physicians have been battling, and have achieved despite all odds. Also tying reimbursement to largely unachievable goals of home dialysis and transplant is going to make Nephrology an even more undesirable specialty for upcoming doctors. And that is the last thing the country currently needs.

Anupama Verma MD

Anupama Verma is a board-certified nephrologist practicing for close to seventeen years in Green Bay, Wisconsin. She graduated from the University of Nigeria and subsequently moved briefly to England. She then moved to the United States where she did her residency in internal medicine at the University of Pennsylvania/ Presbyterian health system. She did her fellowship in Nephrology at Lankenau Hospital in Philadelphia. She has lived and observed the practice of medicine on four continents and thus has unique insights into global healthcare. In addition, she teaches medical students and serves on the pharmaceutical and therapeutics committee at Bellin hospital. She believes strongly in preventive medicine and medical narratives to bring about change and healing. She is a patient and physician advocate and has contributed articles to KevinMD and Doximity among others. She is on Twitter and instagram @anuvmd. 

  5 comments for “The CKD Dilemma

  1. Jerry
    July 25, 2019 at 8:18 am

    Almost all of the CKD that I see in practice is due to HTN or diabetes. Unfortunately other than good control of the disease and the use of ACEI/ ARB’s there is little that we can do to stop the progression of CKD. Now with the obesity epidemic, the explosion of more people with diabetes and HTN, extremely poor compliance of patients with even taking their medicine, and the aging population, I don’t see how we can improve the situation very much,

    • R Stuart
      July 25, 2019 at 12:25 pm

      “I don’t see how we can improve the situation very much”

      Blame the doctors – that always works.

  2. Steve O'
    July 25, 2019 at 12:31 am

    The narrative is depressingly similar to the approach the US Government makes to most things. Failure, no matter the topic, is due to the presence of bad players – who don’t care, who are lazy and selfish and greedy. What Government offers is to bring young people with bright eyes and bright ideas, people from the Best and Brightest who are problem-solvers and innovators.
    I care for some of the hundreds of thousands of burnt-out shells from the horrors of America’s wars in Southeast and Southwest Asia. They are the price of taking the path of the Best and Brightest, those filled with enough arrogance and inexperience to hop from government department to the next, calling their wreckage “innovation,” and blaming the failure on the thousands of those in flyover land.
    So Donald Trump wishes for us to do home dialysis, eh? Someone who knows nothing about sterile technique or renal pathology. All it takes is applying sufficient force, and the lazy and bad doctors who are failing to cure renal disease, will hop to it!
    All we need is a new front in the Global War on Everything, and when we punish the bad people who cause the problem, then good times will be had by all.
    I care for people with all ranges of renal failure. I hand them off when they need a fistula or a shunt. If I get a patient with a creatinine clearance of 30, it’s rare for it to change for my patients over the course of years. Success in management of the renal patient is so subtle, it’s essentially invisible. They live out the rest of their lives without significant progression of disease. Even many of the patients themselves don’t get what I do. It involves tacit concepts, experience and principles, not regulations. In other words, it is the ineffable and indescribable soul of medical care that is fading out of memory, like our wrecked warriors from World War II have almost faded away.
    We have forgotten what the Ardennes meant; so we had island-hopping and Iwo Jima, that too is forgotten; and Pleiku and the Tet Offensive only remembered by few.
    Too much experience brings too much understanding, and with it comes too much humility. We will always have the next generation of Best and Brightest to scar the next generation of their fellows in far-away lands.
    Once humanity can be fully removed from medicine, we will have something modern; and that is called large-animal herd veterinary-style national care. I see no interest in anything else.

  3. Bridget Reidy
    July 24, 2019 at 1:15 pm

    All diseases that are common with advancing age have this problem. Someone assumes the incidence is about healthy people who have no other diseases and the ability to engage in complexities, when in fact those are the minority. Insurance companies, used to only meddling in the care of the nondisabled under 65 crowd, and bureaucrats with no understanding of multimorbidity combined with a strong desire to meddle, need to get a grip before they enter this domain.

    • Pat
      July 26, 2019 at 1:40 am

      Too late.

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