President Richard Nixon signed into law the Social Security Amendments of 1972, which included creation of the National End-Stage Renal Disease (ESRD) Program. This legislation authorized Medicare entitlement for dialysis therapy coverage under Parts A and B of Medicare without the age requirement of 65 years or older. Some consider the ESRD program the first and last socialist medicine initiative in the country. With subsequent legislation, dialysis therapy has emerged as one of the most statutorily regulated Medicare programs, with designated ESRD Network Organizations acting as the federal government’s oversight bodies to ensure quality and safety of the delivery of ESRD services.
Along with the resultant growth of the dialysis industry, medical organizations issued practice guidelines in the late 1990’s recommending earlier rather than later dialysis transition (when the estimated glomerular filtration rate [eGFR] reaches 15 mL/min/1.73 m2 or lower). During the first 2 decades of the 21st century, however, there has been a trend toward increasingly earlier dialysis transition, with almost a quarter of patients now having an eGFR value above 15 mL/min/1.73 m2 on dialysis therapy initiation.
In July 2019, the US Presidential Executive Order known as the “Advancing American Kidney Health Initiative” was issued. One of its goals is a 25% reduction in the ESRD rate by 2030, a target to be achieved by adding strong financial incentives for health care providers to manage the care of patients with advanced chronic kidney disease (CKD) as well as ESRD. The idea is to encourage clinicians to provide care that delays the need for dialysis and perform more preemptive kidney transplants. These so-called value-based models are being operationalized as of 2022 and include the “Kidney Care First” and “Comprehensive Kidney Care Contracting” initiatives.
At this writing, it is not clear how dialysis initiation should be delayed in patients with CKD. The most likely scenarios include more effective nutritional management of CKD using low protein and plant dominant diets, along with adjunct pharmacotherapy for fluid management, anemia, acidosis, potassium and phosphorus load, and symptom management such as pruritus. Just how effective such an integrated multimodal approach can be in delaying dialysis is unknown. And when dialysis becomes necessary, clinicians might want to consider a more conservative approach, such as increasing the frequency of dialysis incrementally or using dialysis only as needed.
Going forward, nephrologists and dietitians will be eager to apply and enhance their knowledge in their attempt to improve kidney care so patients can avoid or delay dialysis.
Kam Kalantar-Zadeh, MD, PhD, MPH, is Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation at UC Irvine School of Medicine, Orange, CA