With their ownership stakes in brick-and-mortar facilities and facing a stagnant Medicare reimbursement rate, nephrologists embraced cost-containment in unexpected ways. A ‘one-size-fits-all’ mentality became the norm for dialysis care. Virtually no one foresaw that most nephrologists would utilize the cheapest, fast, and often iatrogenic dialysis treatment for nearly all their patients. Kt/V (or urea kinetic modeling) was widely embraced as the gold standard of care, providing patients with minimal hemodialysis treatments based on two outcomes: ‘not dead’ and ‘not in the hospital.’ Two hemodialysis treatment shifts were made to fit into one 8-hour staff shift. Only a small percentage of clinics provided treatment times that began after 5 pm. Ownership stakes in brick-and-mortar dialysis facilities by nephrologists also effectively killed the development of breakthrough technologies for dialysis. Advances in dialysis care had to fit within the brick-and-mortar facility model, both physically and financially. While smaller, portable, wearable, and easy-to-operate dialysis devices would have greatly benefitted working-age patients, these technology breakthroughs would have been financially devastating for nephrologist owners and the dialysis corporations. Stagnant technology sustained the wealth generation pathway for nephrologists for decades. Promising technology, such as the small, portable REDY machine that utilized sorbent technology developed by NASA, disappeared from the U.S. market. Hemodiafiltration, an advanced renal replacement therapy that appears to offer many advantages over standard dialysis treatments, is widely utilized in Europe and Japan. It is virtually unknown in the U.S. Few would foresee that many nephrologists would not refer patients for home training or for transplantation in order to keep chairs filled in their dialysis facilities.
One of the reasons for the slow development of better treatment options is that the keystone development requirements have not occurred until recently. Enhanced filteres have made implantable artificial kidneys possible. New methods of collagen frame work makes cloning a viable option. New nanotube methodology means even better filters. We are on the cusp of major changes.