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Advancing American Kidney Health—New Opportunities for Collaborative Care

      On July 10, 2019, President Donald Trump announced an executive order launching the Advancing American Kidney Health (AAKH) Initiative, a 3-pronged strategy aimed at improving outcomes for patients living with kidney disease by changing the way that advanced chronic kidney disease is detected, treated, and paid for in the United States.

      The White House. Executive Order on Advancing American Kidney Health. Available at: https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/. Accessed July 29, 2019.

      Not since President Richard Nixon signed into law the landmark Medicare End-Stage Renal Disease Program on July 1, 1973, has kidney disease in the United States received such attention from the federal government. At its core, the new initiative seeks to reduce the use of the most costly form of treatment for chronic kidney failure—conventional in-center hemodialysis—by reducing the number of new kidney failure cases, increasing the number of patients who receive kidney transplants, and encouraging greater use of home dialysis modalities. This tripartite goal is driven by dual objectives to improve the quality of care for patients with kidney disease and also to reduce the financial cost to the US health care system. Care for patients with chronic kidney failure remains extraordinarily expensive, with Medicare expenditures for these patients accounting for more than 7% of all Medicare costs, despite representing only 1% of the Medicare population.
      US Renal Data System
      2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States.
      One of the most ambitious components of the AAKH Initiative is an explicit aim to reduce the number of Americans developing end-stage renal disease by 25% by 2030. Slowing the progression of kidney function decline in patients with chronic kidney disease to the extent necessary to achieve this goal will require an extraordinary effort to maximally implement evidence-based treatments, identify and treat established kidney disease risk factors such as hypertension and diabetes, and improve access to care for those with identified chronic kidney disease. Though access to nephrology care has been associated with better outcomes among patients with advanced kidney disease, fewer than half of patients with stage 4-5 chronic kidney disease and only a small minority of patients with earlier stages of disease report having ever seen a nephrologist.
      • Jurkovitz CT
      • Elliott D
      • Li S
      • et al.
      Physician utilization, risk-factor control, and CKD progression among participants in the Kidney Early Evaluation Program (KEEP).
      Thus, the reality is that improving kidney care and reducing kidney failure incidence will require strengthening partnerships among all providers caring for these patients, including not just nephrologists, but also primary care providers, endocrinologists, pharmacists, and others. Patient-level kidney disease awareness remains unacceptably low, lagging behind awareness of other chronic diseases such as heart disease or diabetes.
      • Tuot DS
      • Plantinga LC
      • Hsu C-Y
      • et al.
      Chronic kidney disease awareness among individuals with clinical markers of kidney dysfunction.
      Improved awareness can trigger lifestyle modifications, improve treatment adherence, and increase patient engagement with the health care system; thus, health care providers have a clear ability to improve care outcomes through targeted kidney disease education during clinical encounters. Though the current armamentarium of pharmacologic agents for reducing kidney disease progression remains limited, major opportunities exist to increase adherence to established evidence-based treatments such as the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptors blockers (ARBs) in albuminuric chronic kidney disease. Furthermore, new research findings, such as the results of recent studies showing improved cardiovascular and kidney outcomes with use of inhibitors of sodium-glucose cotransporter 2 (SGLT2) in patients with diabetic kidney disease, represent opportunities for interventions driven by primary care to decrease the incidence of kidney failure.
      The second key component of the AAKH Initiative is a goal to increase the use of home dialysis modalities among patients with end-stage renal disease. In the United States currently, only 10% of all dialysis patients are treated with peritoneal dialysis at home, and 2% are treated with home hemodialysis. Peritoneal dialysis in particular is associated with dramatically lower per-person per-year costs to the health care system compared with in-center hemodialysis while providing similar health outcomes. The US Department of Health and Human Services (HHS) has stated am aim to have 80% of patients with newly diagnosed end-stage renal disease in 2025 treated with dialysis at home or with a kidney transplant. This is an ambitious target over a short period, would represent a dramatic shift in the current approach to dialysis treatment modalities in this country, and may not be feasible in the near term. However, home dialysis is unquestionably underused in the United States because of myriad factors, including existing in-center dialysis infrastructure, inadequate provider education, and economic incentives historically favoring in-center dialysis with separately billably injectable drugs. Recent expansion in the home dialysis population in the United States has occurred concurrently with declining morbidity and mortality among these patients, supporting that further growth can be achieved safely.
      • Young EW
      • Kapke A
      • Ding Z
      • et al.
      Peritoneal dialysis patient outcomes under the Medicare expanded dialysis prospective payment system.
      Furthermore, there is international precedent for high use of home dialysis, particularly in parts of Southeast Asia, China, and Latin America, where national governmental policies incentivize the use of home modalities.
      • Li PK-T
      • Chow KM
      • Van de Luijtgaarden MWM
      • et al.
      Changes in the worldwide epidemiology of peritoneal dialysis.
      This is not to say that numerous barriers to expansion of home dialysis in the United States do not exist but that such barriers are addressable with sufficient investment of resources and a commitment to patient-centered collaborative kidney care. Importantly, substantial increased use of home dialysis in the United States will affect not only nephrologists but also primary care providers and other subspecialists because these latter providers may lack familiarity with home dialysis and modality-specific health complications such as peritoneal dialysis-associated peritonitis or encapsulating peritoneal sclerosis. Collaborative relationships between nephrologists and primary care providers will also be key to understanding each patient's home environment and to the adequate preparation of patients with advanced kidney disease to successfully initiate dialysis at home.
      Increasing access to kidney transplantation is the third goal of the AAKH Initiative. With the introduction of the new Kidney Allocation System on December 4, 2014, significant progress was made toward reducing disparities in access to kidney transplantation.
      • Stewart DE
      • Kucheryavaya AY
      • Klassen DK
      • Turgeon NA
      • Formica RN
      • Aeder MI
      Changes in deceased donor kidney transplantation one year after KAS implementation.
      However, concurrent with the introduction of the new allocation system, there was an increase in the rate of organ discards, that is, the percentage of kidneys procured from deceased donors that are subsequently not transplanted. Since then, reducing the organ discard rate has become a focus of HHS. Such rates do vary regionally across the United States, and reducing discard rates may incrementally improve access of patients to kidney transplantation. Additionally, numerous research and public policy efforts are currently aimed at investigating how to increase the use of high-risk organs. One high-prolife area of active interest is in the use of hepatitis C virus-positive donor organs in recipients who are hepatitis C negative, facilitated by the now widespread availability of direct-acting antiviral therapy for hepatitis C virus infection.
      • Levitsky J
      • Formica RN
      • Bloom RD
      • et al.
      The American Society of Transplantation Consensus Conference on the use of hepatitis c viremic donors in solid organ transplantation.
      Such efforts involve physicians from multiple subspecialties and will require interdisciplinary collaboration to achieve optimal patient-centered outcomes. Furthermore, HHS plans to explore how to best reduce disincentives and barriers to living kidney donation, including the lack of reimbursement for lost wages and travel expenses for individuals who choose to undergo kidney donation. HHS is exploring mechanisms to expand reimbursement for these financial losses, which amount to a small fraction of what it costs each year to maintain a patient on dialysis therapy.
      Finally, how does the AAKH Initiative intersect with current efforts to encourage innovation in dialysis technologies, including investing in the development of wearable or implantable artificial kidneys? Such devices, when they become available for clinical use, will revolutionize the treatment of kidney failure. However, such new technologies are years away from being meaningfully available for use in clinical practice. Partnerships among providers who care for patients across the kidney disease spectrum are needed to improve outcomes now for these patients by focusing on implementing evidence-based care to reduce progression to kidney failure and by increasing the use of patient-centered renal replacement therapies such as home dialysis and kidney transplantation. We are entering a new era in the management of patients with advanced kidney disease, and successful interdisciplinary collaborative care is and will continue to be essential to ensure the best outcomes for these patients in the 21st century.

      References

      1. The White House. Executive Order on Advancing American Kidney Health. Available at: https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/. Accessed July 29, 2019.

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        • Ding Z
        • et al.
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        • Turgeon NA
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