Abstract
Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one. The so-called scientific model is built around kidney transplantation and care of glomerulonephritis and immunologic diseases, which probably pose the most important challenges in our discipline, but do not mirror the most common clinical problems. Conversely, the pragmatic one is built around dialysis (the most expensive and frequent mode of renal replacement therapy) and pre-dialysis treatment, focusing attention on the most common diseases, the holistic, or comprehensive, model comprehends both, and is integrated by several subspecialties, such as interventional nephrology, obstetric nephrology, and the ideal-utopic one is based upon prevention, and early care of common diseases. Each model has strength and weakness, which are commented to enhance discussion on the crucial issue of the philosophy of care behind its practical organization. Increased reflection and research on models of nephrology care is urgently needed if we wish to rise to the challenge of providing earlier and better care for older and more complex kidney patients with acute and chronic kidney diseases, with reduced budgets.
Highlights
Nephrology is the mother of all battles, at least in the eyes of nephrologists
Complex, multifaceted discipline offering, which is usually in exchange for long hours of hard work, the opportunity to practice in a hospital ward and witness the advances of organ transplantation, the challenges of internal medicine and the complexity of dialysis, the only “organ replacement therapy” that enables patients to live for decades on machine support
We hope that our reflection, which is mainly based upon Italian and French examples, on the account of the direct experience of the authors, will highlight the strengths and weaknesses of different approaches to the organisation of care, which we tried to synthetize into four different models and help in identifying what road nephrologists should be taking
Summary
Nephrology is the mother of all battles, at least in the eyes of nephrologists It is a rich, complex, multifaceted discipline offering, which is usually in exchange for long hours of hard work, the opportunity to practice in a hospital ward and witness the advances of organ transplantation, the challenges of internal medicine and the complexity of dialysis, the only “organ replacement therapy” that enables patients to live for decades on machine support. At least in Europe, cost constraints on the one hand, and competition with internal medicine and other specialties on the other, are obliging us to consider what the actual core of our specialty is In this setting, we hope that our reflection, which is mainly based upon Italian and French examples, on the account of the direct experience of the authors, will highlight the strengths and weaknesses of different approaches to the organisation of care, which we tried to synthetize into four different models and help in identifying what road nephrologists should be taking
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