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Raymond C Harris MD FASN

Nephrologists are leaders in medicine and science, but do we always define ourselves as such?

This “moment” in health care encompasses a huge amount of change, the kind of change nephrologists are incredibly well suited to lead. The skills that make us great nephrologists are the same skills that make us effectively pilot and implement new approaches to health care. Changes in government policies that focus on quality measures and team care, and the rollout of bundled payment mandates mean that clinicians must adjust their practice patterns. Nephrology is already a leader in these areas; we understand how to provide the highest quality care in a bundled payment environment, and we excel at leading medical teams that provide high-quality care for a complex patient population.

Raymond C Harris MD FASN

We are all aware that the landscape for the practice of medicine in the United States is rapidly changing. For Nephrology in particular, how we practice currently will be very different from practice patterns in 20, 10 or even 5 years from now. Three recent developments may have significant effects upon the practice of Nephrology:

1. MACRA. MACRA (legislation approved in 2015) repealed the Medicare SGR physician payment system and replaced it with two tracks for Medicare physician payments, MIPS (Merit-based Incentive Payment System) and APMs (Alternative Payment Models).            

Raymond C Harris MD FASN

When I think back over the time that I have been in nephrology, I am struck by how many advances we have made in our understanding of kidney function and the pathogenesis of kidney disease. In no particular order, a (very) incomplete list includes: the enormous new insights into the biology of the podocyte and its importance as a target of kidney disease, the regulation of the renin-angiotensin system, its role in kidney diseases and the effectiveness of its targeting in slowing progression, the role of inflammatory cells in kidney diseases, insights into the underlying pathophysiology of numerous genetic kidney diseases (eg PKD, Alport’s Syndrome, cystinosis, Bartter’s Syndrome, Liddle’s Syndrome, Gordon’s Syndrome), elucidation of underlying causes of  glomerular diseases (eg IgA nephropathy, membranous nephropathy), the discovery of a genetic predisposition of certain populations to  glomerular disease (ApoL1), spectacular success in developing more effective immunosuppression so that both patient and transplanted kidney survival have significantly improved, and immunotherapy for a variety of glomerular diseases.

Raymond C Harris MD FASN

Nephrologists have always been considered among the best educators in medicine. Our commitment to excellence in patient care and research extends to finding innovative ways to teach students, residents and fellows about some of the most complex (and interesting) issues physicians and scientists face. Nephrologists also provide complete care for a complex patient population in ways that most other specialties do not.

Raymond C Harris MD FASN

In my last column I looked back at nephrology in 1966, the year ASN was founded, and marveled at the advances made in the past 50 years. In this column I’ve described my thoughts of what will be roles and activities of the nephrologist of the future, and the way in which kidney professionals will transform that future.

A Look into the Future

There will be an increasing reliance on “big data” to inform our understanding of underlying mechanisms of kidney pathophysiology, and we will have new and more precise tools to analyze the data so that we can break down barriers between basic and clinical research and between disciplines.

Raymond C Harris MD FASN

Physicians, scientists, and other health professionals are problem solvers. This reality is especially true in nephrology, in which complex diseases and co-existing conditions are often challenging and sometimes daunting. However, this very complexity provides so many of us lifelong career interest and opportunities, and profound satisfaction when we can provide and improve care for our patients with kidney diseases.

Raymond C Harris MD FASN

Evolving from the previous concept of “personalized medicine,” all aspects of medical practice are demonstrating increasing interest in the implementation of “precision medicine.”  The National Research Council defines precision medicine as referring “… to the tailoring of medical treatment to the individual characteristics of each patient. It does not literally mean the creation of drugs or medical devices that are unique to a patient, but rather the ability to classify individuals into subpopulations that differ in their susceptibility to a particular disease, in the biology and/or prognosis of those diseases they may develop, or in their response to a specific treatment. Preventive or therapeutic interventions can then be concentrated on those who will benefit, sparing expense and side effects for those who will not. Although the term ‘Personalized Medicine’ is also used to convey this meaning, that term is sometimes misinterpreted as implying that unique treatments can be designed for each individual. For this reason, the Committee thinks that the term ‘Precision Medicine’ is preferable to ‘Personalized Medicine.’”

Raymond C Harris MD FASN

“Among patients undergoing hemodialysis, hospitalizations for infection have increased 43% since 1993, although the overall hospitalization rate and total hospital days have declined,” they noted. “Mortality due to infection peaks in the second month after starting dialysis, at 43 deaths/1,000 patient-years, and falls to 19.4 deaths/1,000 patient-years after one year...Nonetheless, only half of all patients who start hemodialysis are still living three years later, and infections cause or contribute to many of these deaths.” (1)  

Raymond C Harris MD CoChair of the Kidney Health Initiative and John R Sedor MD Chair of the KidneyX Steering Committee

RRTRoadmapLogo_506x353_Twitter.jpg“We are going to prioritize a truly transformative goal: the development of an artificial kidney." - President Donald J. Trump

Last week, the Department of Health Human Services (HHS) and the White House announced a set of sweeping new policies, initiated by the leadership of HHS Secretary Alex Azar II, intended to improve the lives of the 37,000,000 people in the United States with kidney diseases. This is a nearly unprecedented level of government investment and national attention for kidney diseases. As a result, people with kidney diseases have real reason to hope that treatment options will improve for them and future kidney patients.