We Can Actually do Something and Finally Move to a Proactive Culture in Nephrology

Andrew Kowalski, MD, FASN

Nephrology has historically centered on the management of advanced CKD, dialysis, and transplantation. It does dabble in other issues, but I would consider these 3 to be the foundation of our speciality. CKD affects nearly 10% of the global population and is a leading contributor to morbidity, mortality, and health care costs.

Guess what?

The numbers are going up and the number of doctors are dropping! So, what do we doe now???

Traditionally, calling on a nephrologist for help/advice has been delayed until there have been significant declines in kidney function, or in other words, when opportunities to slow progression are long and gone.

I have recently been a (very) LOUD (and specifically annoying) advocate that our field needs to transition from being a REACTIVE speciality (addressing CKD once the damage has been done) to becoming a PROACTIVE field, where early treatment and intervention can work and PREVENT the speedy decline of kidney function.

In the field of medicine, and specifically nephrology, we now have the ability to ACTUALLY DO SOMETHING to slow and even STOP CKD progression, if we are asked about or even see the patient early enough.

Historically, and unfortunately even now, nephrologists largely focus on managing complications, preparing for renal replacement therapy, and optimizing dialysis or transplantation outcomes. This reactive paradigm overlooks opportunities for prevention and early intervention and stands in contrast with other specialties, although other specialities are slowly beginning to move in a preventative direction. If nephrology remains tethered to advanced disease management, it risks losing relevance in an evolving landscape of preventive medicine.

So without any commitment or bias, I decided to play with AI and see if I can create a senario that would show that a preventative approach would not be favorable, or even wasteful, in our field. With all the models that I could come up with (please take with a grain of salt, as I do not consider myself an expert in AI or an athority in prompt creation) a preventative approach, on average, showed that for every dollar spent on prevention in nephrology the burden on medcial care among these patients would see a $14 increase, as opposed to remaining reactive and focusing on dialysis, which would lead to a loss in all aspects...meaning an increase in tax dollars and an increase in our medical costs overall.

The late-stage orientation of nephrology presents several challenges.

1. The delay in specialist involvement results in missed opportunities to preserve renal reserve, since interventions have reduced efficacy once significant nephron loss has occurred.

2. Resource allocation is skewed toward dialysis and transplant services, which are not only costly, but also associated with substantial morbidity and mortality. (This pertains to remaining on dialysis long term. Any patient who is able to receive a transplant, regardless, has a much better overall outlook in overall health).

3. The identity of nephrology remains tethered to renal replacement therapy rather than proactive, preventive care. Emerging evidence, however, now supports a reorientation of nephrology toward proactive engagement with primary care, earlier initiation of renoprotective pharmacotherapies, and structured lifestyle interventions.

The past decade has introduced therapies that extend beyond symptom control to genuine renal protection. Sodium–glucose cotransporter 2 (SGLT2) inhibitors and non-steroidal mineralocorticoid receptor antagonists, including finerenone, have shown efficacy in reducing albuminuria, preserving kidney function, and delaying progression to kidney failure even in patients without advanced CKD. The data underscore the potential benefits of earlier intervention. Screening for albuminuria and monitoring for subtle eGFR decline are low-cost, high-yield strategies, and KDIGO has emphasized the importance of early detection and risk-based interventions as critical for modifying disease trajectory.

Lifestyle strategies, including dietary sodium restriction, plant-predominant diets, regular physical activity, smoking cessation, and weight management, have demonstrated beneficial effects on blood pressure, metabolic control, and kidney health. While their impact may be less dramatic than pharmacologic therapies, lifestyle interventions are central to long-term CKD prevention. To take it a step further, implementing these lifestyle changes early on can have a larger impact on kidney health earlier on than any medication availabel to us now.

Beyond these clinical benefits, preventing progression to dialysis and transplantation reduces healthcare expenditures and morbidity. Moreover, because CKD is tightly linked with cardiovascular disease, early kidney-directed interventions confer cardiovascular benefits. This literature is growing by the minute and will be addressed further in a alter post.

Despite the compelling evidence, several challenges impede a shift toward prevention.

1. Primary care knowledge gaps persist, with albuminuria being under-screened and renoprotective therapies underprescribed.

2. The nephrology workforce is insufficient to directly manage all patients with early CKD or risk factors, and current reimbursement structures incentivize dialysis and transplantation services over preventive care

3. Clinical inertia, driven by concerns regarding side effects and ambiguous guideline recommendations, delays initiation of therapy in earlier stages

4. Sustained adherence to lifestyle changes requires structured support and resources not widely available.

A reorientation of nephrology toward prevention will require cultural, clinical, and structural change. Earlier thresholds for nephrology involvement, such as persistent albuminuria ≥30 mg/g or rapid eGFR decline, should prompt specialist input. Collaboration with primary care through shared protocols, electronic health record, decision support, and e-consults can extend nephrology expertise upstream. Standardized approaches to initiating SGLT2 inhibitors, renin–angiotensin system blockers, and finerenone in high-risk patients will reduce therapeutic inertia.

Unfortunately, this will not have any meaningfull impact of what insurance decides to pay for, but that is another rant at a later time.

Embedding dieticians, exercise physiologists, and behavioral support within nephrology practices can improve adherence to lifestyle interventions. Monitoring early referral rates, albuminuria screening, uptake of renoprotective therapies, and eGFR decline slopes will align clinical practice with preventive goals. Finally, fellowship programs and continuing medical education should emphasize CKD prevention and population-level kidney health to reshape the identity of the specialty.

The prevailing model of nephrology as a late-stage specialty is grossly insufficient for contemporary practice. Effective therapies now exist that can delay or prevent CKD progression if applied earlier, supported by risk stratification, structured lifestyle interventions, and stronger collaboration with primary care. A cultural shift toward proactive nephrology is essential to improve patient outcomes, reduce healthcare costs, and position the specialty within the broader framework of preventive medicine.

Without such transformation, nephrology risks being defined solely by dialysis and transplantation, which is a grave injustice to the patient and the medical system itself.

References

1. Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446. doi:10.1056/NEJMoa2024816

2. Bakris GL, Agarwal R, Anker SD, et al. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-2229. doi:10.1056/NEJMoa2025845

3. Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference on early CKD identification and intervention. Kidney Int. 2020;98(2):294-309. doi:10.1016/j.kint.2020.04.019

4. Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107. doi:10.1053/j.ajkd.2020.05.006

5. Herrington WG, Preiss D, Haynes R, et al. The potential for improving cardio-renal outcomes by early intervention in CKD. Kidney Int. 2022;101(1):20-34. doi:10.1016/j.kint.2021.09.026

6. Hahn A, Zheng S, Chen X, et al. Effect of an EHR-integrated population health management intervention for CKD: a cluster randomized trial. JAMA Intern Med. 2024;184(4):343-351. doi:10.1001/jamainternmed.2023.7815