The roads less traveled? Diverging research and clinical priorities for dialysis patients and those with less severe CKD.

Over the last 4 decades, there has been tremendous growth in the number of long-term hemodialysis patients and kidney transplantation has been identified as the renal replacement modality of choice. These developments have been accompanied by substantial increases in the age and comorbid conditions of the typical dialysis patient, a general failure to identify treatments that prevent hard clinical outcomes in dialysis populations, and the recognition that patients and their physicians often have very different perspectives about which outcomes matter most. In parallel with this, the global epidemic of noncommunicable chronic diseases has led to unprecedented numbers of people worldwide who have or are at risk for CKD, many of whom do not have access to renal replacement therapies. These observations suggest that future clinical and research priorities should differ substantially for dialysis patients compared with those for individuals with less severe CKD. For dialysis populations, clinical and research efforts should be refocused to better align with the preferences and priorities of patients. In those with less severe CKD, new methods of health service delivery are needed to address the tremendous burden of illness at a population level, especially in lower income settings. This article describes how this divergence of priorities could be approached.