Kidney Care: 5 Reasons for Independent Guidelines in the US

Should clinical and patient care guidelines for our country, particularly in nephrology, continue to rely on international guidelines or be created domestically for American patients, using US-specific data? The global kidney health community, led by organizations like KDIGO (Kidney Disease: Improving Global Outcomes), has made significant contributions to standardizing guidelines worldwide. However, it is becoming increasingly clear that these guidelines may not be fully applicable to the unique challenges of the US healthcare system and patient population. There are several compelling reasons why the US should shift towards developing its own nephrology guidelines.

1. Unique Characteristics of the US Healthcare System

The US healthcare system is distinct in its complexity, structure, and patient demographics. Unlike many European and other nations that have universal healthcare or standardized national policies, the US operates within a privatized, diverse, and often fragmented system despite its Medicare and Medicaid. Consequently, nephrology care must navigate different health providers, hospital systems, dialysis and transplantation services, and regional variations in patient demographics and access to kidney care. These elements are rarely addressed in such international guidelines as KDIGO, which are influenced heavily by European healthcare standards.

2. KDIGO Guidelines & Limitations for American Patients

KDIGO guidelines, while well-intentioned and supported by international experts, often fail to fully account for the specific needs of US patients. For example, these guidelines do not reflect the demographic diversity and high prevalence of chronic kidney disease (CKD) among African Americans, Latinos, and Native Americans in the US. These groups are at higher risk of progressing to end-stage kidney disease (ESKD). The US has unique health disparities that require tailored approaches to kidney care, yet KDIGO’s recommendations are based largely on European data, which does not reflect the complex reality of US nephrology practice. Moreover, European regulatory and healthcare financing structures differ substantially from the US, making many of KDIGO’s recommendations impractical or misaligned with US practice patterns and policies.

3. KDOQI’s Review of KDIGO: A Compromise, Not a Solution

The KDOQI (Kidney Disease Outcomes Quality Initiative), an US-based organization that initially led the development of nephrology guidelines in the US, has increasingly relied on reviewing and endorsing KDIGO guidelines. While KDOQI’s review process is intended to provide a US lens on international guidelines, this process does not equate to the creation of original US-based guidelines. Endorsing KDIGO recommendations still subjects US patients to international influence and compromises the ability to develop truly US-centric standards that consider the economic, social, and healthcare realities unique to the nation.

4. Precision Medicine and US-Centered Guidelines

In the era of precision medicine and patient-centered care, it is essential that guidelines reflect the needs and characteristics of the populations they serve. The US is a global leader in precision medicine, and this approach should extend to nephrology care. Guidelines that are based on international standards overlook the nuances of US patients, such as different comorbidity profiles in Americans with kidney disease. By creating US-based nephrology guidelines, we can ensure that they are tailored to the specific characteristics and socioeconomic factors that affect US patients.

5. A Call for US Independence in Nephrology

At a time when there is political and public discourse around strengthening US independence from international influence, including in healthcare, there is an opportunity to revitalize US-based nephrology guidelines. Just as President Trump has called for reducing reliance on European policies, the US nephrology community should embrace this opportunity to reclaim its guidelines. By developing and maintaining our own set of nephrology care standards, the US can ensure that its patients receive kidney care that is optimized for their specific circumstances, rather than being subjected to globalized guidelines that may not fit.

In conclusion, the US nephrology community should prioritize creating independent guidelines that reflect the realities of American patients and the complexities of the US healthcare system. Whereas international collaboration has its merits, correct patient care is an overarching priority and should be tailored to the populations it serves. By developing US domestic guidelines focused on precision medicine and patient-centeredness, the US can take the lead in advancing kidney care tailored to its unique population, setting an example for other countries to follow.

Kam Kalantar-Zadeh, MD, MPH, PhD, is Chief, Division of Nephrology, Hypertension & Transplantation, Harbor-UCLA and Professor of Medicine and Epidemiology, UCLA David Geffen School of Medicine Los Angeles, California. He is a member of the RUN editorial advisory board.