What Role Should Nephrologists Play in the Care of Patients With Kidney Diseases?

Patients with advanced kidney diseases usually see their nephrologists far more often than the other members of their care team. This has worked well for nephrologists in a fee-for-service environment, for whom these patients represent a reliable income stream for the practice due to their frequent visits. However, when patients are shifted to value-based care (VBC) models, financial success is uncoupled from visit volume and instead comes from reduction in care costs, especially hospitalizations. A particular focus of VBC efforts includes patients with multiple comorbid illnesses, since they are hospitalized frequently and are at high risk for care gaps because they are seen by multiple specialists. Nephrologists risk being sidelined in the care of patients with kidney diseases if they do not embrace updated clinical guidelines, polychronic care, and efforts to address care fragmentation.

Cardiovascular-kidney-metabolic (CKM) syndrome is common in the population of patients living with chronic kidney disease (CKD). Therapies for CKM syndrome, including angiotensin-converting enzyme inhibitors (ACEis), sodium-glucose cotransporter-2 inhibitors (SGLT2is), and glucagon-like peptide-1 receptor agonists (GLP-1RAs), now have multiple indications and can be reasonably prescribed by primary care physicians, cardiologists, endocrinologists, and nephrologists. The prevalence of CKM syndrome and the high cost of care inspired St. Luke's Mid America Heart Institute to create the Cardiometabolic Center Alliance, a network of clinical centers of excellence. Most of the founding clinics are run by cardiologists, with scant representation from nephrologists. Earlier this year, the alliance published its results in improving use of guideline-directed medical therapy (1). The rate of SGLT2i use in patients with diabetes and CKD improved from 33.3% to 82.3% over 6 months. This is substantially better than the 13% reported nationwide in patients with diabetic kidney disease (2).

The Advancing American Kidney Health Initiative VBC programs focus on patients with stages 4–5 CKD and kidney failure. Many of the companies that partner with nephrologists in these programs are choosing to hire their own clinical staff to implement their interventions. One company describes the fragmented care that patients can experience and notes, “Nephrologists are focused on dialysis and care within their centers.” They tout their “multispecialty teams of employed physicians and nurse practitioners” to provide complex, coordinated care (3). Another company lists the tasks its nurse practitioners perform, including “deliver[ing] the best care” and “break[ing] communication [silos]” (4).

Where, then, are the nephrologists in the care of these patients with kidney diseases? For now, they may be happy that someone else is taking on the load. Gaining experience with new medications such as GLP-1RAs takes effort, and fee-for-service visits pay the same, whether or not updated standards of care are applied. Coordinating care with other physicians is time consuming and poorly reimbursed. However, the Centers for Medicare & Medicaid Services has a stated goal of 100% of Medicare beneficiaries to be in a VBC arrangement by 2030 (5). If nephrologists remain focused on dialysis rounds and defer the implementation of new therapies to the primary care physicians and cardiologists, they will find themselves on the outside of newer care models and clinics.

As we head into 2025, it should be just as unthinkable for a nephrologist to defer treatment of heart failure with an SGLT2i or obesity with a GLP1-RA as it would be to pass on prescribing an ACEi for hypertension. Nephrologists should be actively involved in treating all aspects of CKM syndrome. Practices should be building analytic capabilities to monitor their performance and embracing partnerships that rely on their active participation in improving outcomes. By doing so, they will help ensure that our specialty remains centered in the care of patients with kidney diseases.