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The current and future landscape of dialysis

Nature Reviews Nephrology volume 16, pages 573–585 (2020)Cite this article

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Abstract

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Key points

  • The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

  • The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

  • Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

  • Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

  • Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

  • Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

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Fig. 1: Current and projected prevalence of kidney failure requiring kidney replacement therapy.
Fig. 2: Changing the ecosystem of dialysis care and technology to support transformative outcomes.

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Authors and Affiliations

  1. Kidney Research Institute, Seattle, WA, USA

    Jonathan Himmelfarb & Rajnish Mehrotra

  2. Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA

    Jonathan Himmelfarb & Rajnish Mehrotra

  3. Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Ghent, Belgium and European Kidney Health Alliance (EKHA), Brussels, Belgium

    Raymond Vanholder

  4. Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada

    Marcello Tonelli

Authors
  1. Jonathan Himmelfarb
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  2. Raymond Vanholder
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  3. Rajnish Mehrotra
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  4. Marcello Tonelli
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Contributions

The authors contributed equally to all aspects of the article.

Corresponding author

Correspondence to Jonathan Himmelfarb.

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Competing interests

J.H. declares that The Kidney Research Institute and the Center for Dialysis Innovation at the University of Washington, which he directs, has received gift and grant support from the Northwest Kidney Centers, a not-for-profit dialysis provider. The Center for Dialysis Innovation has also received a Phase I prize from KidneyX, and a grant from the Veterans Administration. J.H. is also a founder and holds equity in AKTIV-X Technologies, Inc. R.V. has consulted for Baxter Healthcare, B. Braun and Neokidney. R.M. has received an honorarium from Baxter Healthcare and serves as a member of the Board of Trustees of the Northwest Kidney Centers. M.T. has received a lecture fee from B. Braun, which was donated to charity.

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Nature Reviews Nephrology thanks M. Verhaar, who co-reviewed with M. van Gelder, and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Related links

Affordable Dialysis Prize: https://www.dialysisprize.org/

Dutch Kidney Foundation: https://www.narcis.nl/organisation/RecordID/ORG1238896/Language/en

ESRD Data Standard Project: https://khi.asn-online.org/projects/project.aspx?ID=78

European Kidney Health Alliance: http://ekha.eu/

Kidney Health Initiative: https://khi.asn-online.org/

KidneyX: https://www.kidneyx.org/

Neokidney: https://www.nextkidney.com/

Nephrologists Transforming Hemodialysis Safety: https://www.asn-online.org/ntds/

Nephrology and Public Policy Committee: https://www.era-edta.org/en/nppc/

Nierstichting Nederland: https://nierstichting.nl/

Patient and Family Partnership Council: https://khi.asn-online.org/pages/?ID=1

SONG-HD: https://songinitiative.org/projects/song-hd/

SONG-PD: https://songinitiative.org/projects/song-pd/

Standardizing Outcomes in Nephrology Group (SONG): https://songinitiative.org/

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Himmelfarb, J., Vanholder, R., Mehrotra, R. et al. The current and future landscape of dialysis. Nat Rev Nephrol 16, 573–585 (2020). https://doi.org/10.1038/s41581-020-0315-4

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