As I was nearing graduation from medical school in Bonn, Germany, in May 1991 and preparing to start residency training in a large nephrology center in Nuremberg, Germany, one of my mentors said I should think twice before choosing nephrology as a career because dialysis would soon be obsolete and replaced by implantable or wearable artificial kidneys. Another mentor told me that with the rise of ACE inhibitors and new data showing that these agents can slow kidney disease, there would not be kidney failure in the future. I became a nephrologist anyway, first in Germany, then in the United States.
Now, 30 years later, dialysis has expanded tremendously in the United States and Europe, and its use is expanding exponentially in such emerging economies as India, China, and Brazil. Some medical students and residents recently asked me whether there is any future in nephrology if dialysis would soon dissipate. My response is that dialysis is not likely to become obsolete — despite advances such as SGLT2 inhibitors that have been demonstrated to slow kidney disease progression — and nephrology goes way beyond renal replacement therapy.
Recent trends to avoid or stop dialysis have been heightened by perverse financial incentives to reduce length of hospital stay and prevent 30-day readmissions of patients with kidney problems. Nephrologists may feel pressured to get their dialysis and kidney transplant patients out of needed intensive care unit (ICU) beds via discontinuation of immunosuppression medication or abrupt dialysis withdrawal to expedite hospice transition. Patients and family members may feel coerced by medical teams to choose the end-of-life route portrayed to them as the best option. Other options are available to ameliorate pressure to decrease hospital lengths of stay and prevent readmissions. These include conservative measures that can delay the need for dialysis among patients with chronic kidney disease, such as diet and lifestyle modifications.<sup>1</sup>
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Under a presidential executive order issued in July 2019 (the Advancing American Kidney Health Initiative), the Department of Health and Human Services hopes to achieve a 25% decrease in the incidence of end-stage kidney disease by 2030. It would be against the choice and hope of many patients if this is to be achieved at least in part by steering patients toward palliative and supportive care rather than dialysis.
Each time a patient under my care expresses thoughts to stop therapy to die, I spend extra time to discuss all options. I explain to patients and their families why it may still not be time to give up. I tell my patients that, as long as I am around, you will be, too, if you choose to be.
Kam Kalantar-Zadeh, MD, PhD, MPH Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation UC Irvine School of Medicine, Orange, CA Twitter/Facebook: @KamKalantar
Reference
1. Kalantar-Zadeh K, Wightman A, Liao S. Ensuring choice for people with kidney failure – Dialysis, supportive care, and hope. N Engl J Med. 2020;383:99-101.
