@article{b5b41ae3411c4728a40c0d294ecb9891,
title = "Securing the future of kidney transplantation by addressing the challenges of transplant nephrology",
abstract = "Kidney transplant is a life-changing procedure, and transplant nephrologists, as part of a larger transplant team, play an important role in the field by managing the complex medical needs of transplant patients. The subspecialty of transplant nephrology, however, faces structural challenges related to its workforce, reporting structures, compensation, research and innovation, and health care information technology. The position of transplant nephrology at the academic and operational intersection of medicine and surgery may limit its access to critical resources, hinder academic promotion, and contribute to physician burnout. The authors provide an overview of the subspecialty transplant nephrology and propose solutions. Collaborative efforts that fortify the subspecialty of transplant nephrology will ultimately improve the lives of patients suffering from kidney disease.",
keywords = "editorial/personal viewpoint, kidney transplantation/nephrology, patient referral, quality of care/care delivery",
author = "Heher, {Eliot C.} and Hricik, {Donald E.} and Brennan, {Daniel C.}",
note = "Funding Information: The future of kidney transplant will rely on an adequate transplant nephrology work force, supported for success. We suggest the following: Assess the state of the field through data collection. Quantitative data about all nephrologists who care for kidney transplant candidates and recipients is needed. In March 2020, the AST{\textquoteright}s Medical Director Task Force embarked on a survey of transplant nephrologists regarding compensation and job satisfaction, which should yield important results. The planned meeting of medical directors of kidney transplant programs during the 2020 American Transplant Congress would have no doubt yielded valuable insights, though unfortunately it was postponed. Opinions of nephrology leaders regarding transplant nephrology are needed. Address the workforce challenges . The transplant community must ensure an adequate pipeline of transplant nephrologists. Academic investigators or the ASN/AST can use survey data described above to estimate the future workforce needs, accounting for the number and expected growth in transplant recipients, graft survival, practice panel size, and the movement of patients back to general nephrologists. More information is needed regarding the views of nephrology fellows toward transplant nephrology. Would the availability of regular shifts and guaranteed compensation, for example, increase interest among a physicians concerned about work‐life balance? The excellent outcomes enjoyed by most kidney recipients and the availability of novel diagnostics and medications serve as natural advertisements for the field. The AST{\textquoteright}s annual fellows{\textquoteright} symposium is an excellent educational and recruiting event and with additional funding might be expanded to include medical students. Medical school, residency, and fellowship curricula should align with the AAKHI by ensuring that kidney transplant receives as much attention as dialysis. Fund and simplify transplant nephrology fellowship training . Transplant nephrology training should be paid through graduate medical education funds, or the AAKHI. In certain cases, nephrology fellows could fast‐track into transplant nephrology training after 1 year of general nephrology, though fellows must be adequately trained in general nephrology given the importance of this knowledge to their role on the transplant team. Test new payment models to improve compensation. Medicare and other payers should test new payments for transplant nephrology, including billing codes for recipient and donor evaluation or waitlist management. Capitated payments for the care of transplant recipients might evolve based on the AAKHI optional plans to include episodes of care—for example, the treatment of rejection. Address challenges to transplant nephrology within academic medical centers . Departments of medicine should consider creating separate divisions for transplant nephrology, to parallel the organization of abdominal transplant surgery within departments of surgery or should support transplant centers or institutes hiring transplant nephrologists directly. The latter solution works well, based on the authors' experiences and the reports of other transplant nephrologists, particularly when nephrologists have a role in center/institute leadership. Alternatively, divisions of transplant medicine could house nephrologists, hepatologists, cardiologists, infectious disease physicians, and other specialists who work in transplant. Align academic promotion criteria with the requirements of transplant program leadership . Academic promotion committees should consider a track that recognizes the responsibilities transplant physicians have for leading complex programs, just as clinician‐educators are promoted along a separate track. Promotion could be tied to program growth and size, innovation, outcomes, quality improvement activities, and regulatory compliance. Adopt alternative models for delivery of transplant nephrology care . Access to transplant should be ensured independent of transplant nephrology availability. Kidney transplant programs can codify listing criteria so that initial listing requires minimal involvement by transplant nephrologists, who instead can focus on patients who are close to transplant. Kidney transplant programs should fully embrace the efficiency of telehealth, supported by the COVID‐19 era broadening of insurance coverage, to meet the expected increase in referrals from the AAKHI. 16 Expand the role of the transplant nephrologist . Transplant nephrologists can positively impact other types of patients, to the extent they can accommodate additional activities. They can provide valuable insight into the use of immunosuppression for glomerular disease and other nontransplant indications. They can follow patients with failing allografts, to facilitate continuity and repeat transplant. They can increase preemptive transplant through earlier involvement in the chronic kidney disease continuum. Funding Information: The authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation . Dr Heher is the cofounder of Square Knot Health, Inc. This is a new entity with plans to work in the area of chronic kidney disease management. Currently, Dr Heher receives no salary or financial support from Square Knot Health. He owns shares in the company. During the preparation of the manuscript (through April 30, 2020), Dr Heher was the medical director of kidney transplantation at Massachusetts General Hospital. Dr Brennan and Dr Hricik declare no conflict of interest. ",
year = "2021",
month = jan,
doi = "10.1111/ajt.16264",
language = "English (US)",
volume = "21",
pages = "37--43",
journal = "American Journal of Transplantation",
issn = "1600-6135",
publisher = "Wiley-Blackwell",
number = "1",
}