Predialysis Nephrology Care Improves Dialysis Outcomes

Abstract

“Knowing is not enough; we must apply. Willing is not enough; we must do.“ — Goethe Bradbury and associates utilized the Dialysis Outcomes and Practice Patterns Study (DOPPS) database to identify predictors of early mortality among recent US incident hemodialysis patients (1). This editorial addresses the implications of those findings within the context of numerous other observations supporting that notion. This is not a new or contentious position (2). Perhaps a randomized controlled trial might settle the question of the efficacy of predialysis care, but surely we understand that rationale and have wiser ways to use limited resources. Maybe we are asking the wrong question. Why has progress toward implementing predialysis care been so slow, ineffective, inefficient, and inadequate? The first of the two subtitles of this editorial suggests a cynical “Now what?” We’ve had a pretty clear picture for more than two decades as to what we need to do, but we have failed to implement what we know to be the best practices and to provide the direction as to how to do it. This lack of success is not restricted to the US. Perhaps our systems are so broken and incentives so misaligned that, for all practical purposes, well-demonstrated benefits of predialysis nephrology care are lost. Or, ever the optimist, are there some potential solutions? We have been attempting to fix this problem for more than 20 years with minimal success. We could continue to take small, ineffective steps, and see no real progress until those of us reading this editorial are long retired. Alternatively, we can attempt bold initiatives that use the available evidence and our experiences to do what needs to be done. The alternative subtitle to this editorial is “Chapter Two,” implying a new start; let’s move on. Let’s figure out a way to …