Broadening Our Perspectives: CKD Care and the Dialysis Transition
Authors: Thomas Hostetter, Josie P. Briggs
Journal: Journal of the American Society of Nephrology (2018)

The new editorial team at the Journal of the American Society of Nephrology (JASN) is working to strengthen our Perspectives section. Our goal is to bring to you, our readers, timely, useful, and stimulating commentaries on a broad range of topics important to nephrology research and practice. In recent issues, we have offered Perspectives on the application of innovative methods, such as single-cell sequencing or protein mass spectroscopy, to renal research as well as articles on tough clinical issues, including the effect of bariatric surgery on the kidney and the effect of dialysis on cognition. These articles are, in the judgment of the editors, interesting and address new findings, and we hope that you agree. However, we recognize that they deal with topics that our readers are accustomed to seeing in these pages. In this issue, we are moving into new territory for JASN with two Perspectives on health care policy and care delivery. Fact-based discussion of health care delivery is important for our specialty, and rigorous research is possible. These essays address the tough problem of care delivery for patients with advanced CKD that is approaching ESRD,1,2 proposing redesign of care delivery to this vulnerable group and change in payment structures. Both articles consider substantial problems in the care that we are currently providing for people with CKD who are not yet on dialysis, and they envision improvements in outcomes and potential cost savings resulting from offering more thorough support and expanded care teams. Importantly, they suggest a number of research questions. The nephrology research community is actively pursuing the next big steps in caring for patients with renal disease, such as the evolving interventions to slow CKD progression. We believe that this next generation of interventions will have an effect as significant as that achieved with transplantation and chronic dialysis. Nevertheless, there are important questions that need to be addressed about how we deliver currently available therapies. Changes in care delivery should be evidence based, and both observational studies and practical experiments, such as pragmatic trials, are needed to contribute to this evidence base. We recognize that there will be no simple answers: payment and administrative rearrangements are not easy to achieve and may encounter opposition. Changes also may have unanticipated consequences. However, we think that the JASN can serve our discipline and our patients as a forum for dialog about needed changes and as a place where research questions are raised and studies that explore how to improve care are published. We hope to encourage in our Perspectives section further thoughtful discussions on health care delivery and policy related to kidney disease. These discussions deserve a place beside the clinical and basic science that will propel major therapeutic advances. We welcome your thoughts. We are open to Letters to the Editor about these Perspectives as well as further submissions, both opinions and research studies, on health care policy and delivery. Disclosures None.