Advances in Chronic Kidney Disease

Of late, fewer residents are choosing nephrology as a career. Contributing factors may include lack of prestige, uncertain potential of future income, and poor work-life balance. Some current nephrologists are considering transitioning to another career for similar reasons. For those who decide that practicing nephrology is no longer appealing, there are many available avenues where they can use their nephrology expertise and still have a successful future. A leadership role in the pharmaceutical industry is a potentially attractive and viable option to nephrologists who are ready to transition to a different career...

The leaders of 20th century kidney failure treatment took chances; 21st century leaders of integrated kidney care must do the same. Some risks are clinical, some are organizational, and some are financial. Decent and constructive leadership entails humility. A working practitioner is a better leader. Effective leaders empower their employees and collaborators to lead and encourage them to work together. Integrated kidney care leadership supports exchange of ideas within and among organizations, uninhibited by competitive considerations...

Women and men tend to take different paths to leadership, with men being more intentional. When women do undertake leadership activities, they tend to be surprised by how much they enjoy it. Women's leadership styles tend to be more collaborative and inclusive. Women are used to multitasking and tend to persist under difficult circumstances. The nephrology manpower crisis affects both men and women, although some of the drivers are different. There is a persistent and well-known pay disparity between men and women physicians that many have tried to address without consistent success...

Mentorship has always been important in medicine. In fact, one can argue that that is how doctors are trained. Moreover, mentorship has been proven to preserve and elevate those who wish to pursue academic medicine. In nephrology, mentorship has become paramount, as interest in the field has declined during this decade. In this article, we will delineate how mentorship impacts physician careers, describe different types of mentors and their characteristics, and summarize responsibilities of mentors and mentees...

As a specialty and profession, nephrology has deep roots in the arenas of advocacy and public policy, with nephrologists playing a significant role in garnering legislative attention on the needs of patients with end-stage renal disease. The depth of experiences and unique perspectives of nephrologists and sharing our positions with legislators, regulators, and decision makers are central to achieving the Triple Aim for patients with kidney disease. Advocacy and public policy are conducted externally as well as internally to the House of Medicine and shape the future of kidney care and nephrology practice...

The responsibilities of a dialysis unit medical director are specified in the ESRD Conditions for Coverage and encompass multiple quality, safety, and educational domains. Many of these responsibilities require leadership skills that are neither intuitive nor acquired as part of the medical director's training. An effective medical director is able to shape the culture of the dialysis facility such that patients and staff feel free to communicate their concerns regarding suboptimal processes without fear of retribution, and there is a continuous iterative process of quality improvement and safety, which values input from all stakeholders...

Private practice is entering an era of diminishing reimbursement and increasing overhead associated with federally mandated payment reforms resulting in a need to move from the traditional fee-for-service to a value-based model, changes that place financial and organizational strain on nephrology practices. In addition, the changing geopolitical scene is one of mergers and consolidation of health care networks, which in turn are developing their own insurance plans or partnering with commercial payers. The new landscape will require the leadership of a private nephrology practice to vigilantly monitor and adapt to these changes for success...

Nephrologists, perhaps more than other physicians, are drawn to health-care leadership positions. In this article, we consider reasons that nephrologists are uniquely suited to serve in these roles. We briefly review key aspects of leadership principles and skills. Finally, we discuss routes to non-nephrology leadership for younger members of the profession.

The early beginning of the end-stage kidney disease program with the introduction of the Medicare Act of 1973 was marked by nephrologist entrepreneurs pioneering dialysis centers to deliver dialysis addressing the clinical needs of patients in a collaborative effort between physicians and nurses. As the number of patients grew, a system reliably providing dialysis treatments for many more patients than was ever anticipated was required to enable the demands of the increased scale. Solutions appropriate to respond to the growing needs of out-patient dialysis centers were developed combining emerging technology, clinical advances, and operational efficiency...

The position of chief of a division of nephrology in an academic medical center is a hands-on job, offering the opportunity to influence the future of the field through the creation of unique clinical, research, and education programs. Today, most academic centers face significant financial challenges, thus the division chief must develop a variety of skills to accomplish his or her goals. Interactions and relationships with the leadership of the academic center, including the hospital executives, can facilitate or impede progress on proposed projects; therefore, aligning the goals of the division with the goals of leadership is an imperative...

The history of chronic dialysis in the United States highlights the impact nephrology leaders have on improving kidney disease care. Belding Scribner and his Seattle team transformed end-stage renal disease from a fatal illness to a treatable condition with use of the first successful Scribner shunt in 1960. Advances in dialysis machines emerged from Les Babb and Richard Drake finding ways to treat more patients. Innovative nephrology leaders foster incremental change leading to the technically complex, life-sustaining treatments that are widely available to end-stage renal disease patients today...

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No abstract text is available yet for this article.

Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart...

Heart failure (HF) is extremely prevalent and for those with end-stage (stage D) disease, 1-year survival is only 25-50%. Several studies have captured the mortality impact of kidney disease on patients with HF, and measures of kidney function are a component of many HF risk stratification scores. The management of advanced HF complicated by cardiorenal syndrome (CRS) is challenging, and irreversible kidney failure often limits patient candidacy for advanced HF therapies, such as transplant or left ventricular assist device therapy...

Acute decompensated heart failure has the highest rate of hospital readmission among all medical conditions and portends a significant financial burden on health care system. Congestion, the hallmark of acute decompensated heart failure, represents the primary reason for hospitalization and the driver of adverse outcomes in these patients. Although diuretic-based medical regimens remain the mainstay of management of acute decompensated heart failure, they often show suboptimal efficacy and safety profiles in this setting...

The leading cause of death worldwide is cardiovascular disease. The heart and the kidneys are functionally interdependent, such that dysfunction in one organ may cause dysfunction in the other. By one estimate, more than 60% of patients with congestive heart failure develop chronic kidney disease. Volume overload and congestion are hallmarks of heart failure, and these findings are associated with severe symptoms and poor outcomes. Given the importance of congestion, diuretics remain a cornerstone of heart failure management...

Although the field of oncology has made significant steps toward individualized precision medicine, cardiology and nephrology still often use a "one size fits all" approach. This applies to the intersection of the heart-kidney interaction and the cardiorenal syndrome as well. Recent studies have shown that the prognostic implications of worsening renal function (WRF) in acute heart failure are variable; thus, there is a need to differentiate the implications of WRF to better guide precise care. This may best be performed with biomarkers that can give the clinician a real-time evaluation of the physiologic state at the time of developing WRF...

The exact significance of kidney function deterioration during acute decompensated heart failure (ADHF) episodes is still under debate. Several studies reported a wide percentage of worsening renal function (WRF) in ADHF patients ranging from 20% to 40%. This is probably because of different populations enrolled with different baseline kidney and cardiac function, varying definition of acute kidney injury (AKI), etiology of kidney dysfunction (KD), and occurrence of transient or permanent KD over the observational period...

Cardiorenal syndrome represents the confluence of intricate hemodynamic, neurohormonal, and inflammatory pathways that initiate and propagate the maladaptive cross talk between the heart and kidneys. Several of these pathophysiological principles were described in older historical experiments. The last decade has witnessed major efforts in streamlining its definition, clinical phenotypes, and classification to improve diagnostic accuracy and deliver optimal goal-directed medical therapies. The ability to characterize the various facets of cardiorenal syndrome based on its pathophysiology is poised in an exciting vantage point, in the backdrop of several advanced diagnostic strategies, notably cardiorenal biomarkers that may help with accurate delineation of clinical phenotype, prognosis, and delivery of optimal medical therapies in future studies...