Your curated list of high priority open roles across the kidneyverse, delivered straight to your inbox every two weeks. This week features senior roles across biotech, value-based care, and kidney care operations, with multiple openings at Akebia, Travere, and Vertex as kidney disease pipelines continue to grow.

Subscribe now

At A Glance

• Chief of Staff, Research (Biogen)

• Director, Procurement & Sourcing (Akebia Therapeutics)

• Manager, Strategic Initiatives (Monogram Health)

• Associate Director, EHS (Vantive)

• Senior Research Associate (Renasant Bio)

• Market Research Associate Director (Travere Therapeutics)

• Transplant Financial Coordinator (Renown Health)

• Clinical Account Manager (Travere)

• Senior Director, Technical Operations – Biologics (Akebia)

• Epic Professional Billing Analyst (Interwell Health)
  
  

  Browse all jobs

Open Roles

• Biogen is hiring a Chief of Staff, Research (Cambridge, MA, On-site) to serve as a strategic thought partner and operational anchor for the Head of Research at one of the world’s leading biotechs. This role advises at the EVP/C-suite level, synthesizes complex decisions across a matrixed organization, and requires deep experience across biotech, pharma, or top-tier consulting. Apply here.

• Akebia Therapeutics is hiring a Director, Procurement & Sourcing (Cambridge, MA, On-site) to lead all sourcing, contracting, and requisition-to-pay operations for a commercial-stage kidney disease biotech. Reporting to the CFO, the role spans clinical trial supply, commercial product support, and vendor negotiations across MSAs, SOWs, and NDAs. Ten-plus years of life science procurement experience required. Apply here.

• Monogram Health is hiring a Manager, Strategic Initiatives (Brentwood, TN, On-site) to partner with the Chief of Staff on high-priority enterprise initiatives, owning discrete workstreams and driving structure and execution across the organization. The role is designed for candidates with a background in top-tier consulting or investment banking who are comfortable operating with limited oversight in a fast-moving healthcare environment. Apply here.

• Vantive is hiring an Associate Director, Environmental Health & Safety (Dublin, Ireland, Remote) to shape and lead global EHS strategy across sites in Europe, the U.S., LATAM, and Asia. A senior leadership role for a kidney care medtech company building out its global operational foundation following its separation from Baxter. Apply here.

• Renasant Bio is hiring a Senior Research Associate (Berkeley, CA, On-site) to execute high-resolution protein and nucleic acid analyses supporting a kidney disease pipeline built around novel small molecule programs. The role requires hands-on biochemistry expertise and prior biotech industry experience. Apply here.

• Vertex Pharmaceuticals is hiring a Market Research Associate Director (Boston, MA, Hybrid) to generate commercial insights shaping strategy and launch readiness for its genetic kidney disease portfolio, including programs targeting APOL1-mediated kidney disease. The role sits within the North America Forecasting, Analytics & Insights team and requires 8-plus years in biopharma market research or analytics. Apply here.

• Renown Health is hiring a Transplant Financial Coordinator (Reno, NV, On-site) to serve as a financial advocate for transplant patients and families, managing insurance benefits, authorizations, and billing coordination across the full transplant continuum of care. Apply here.

• Travere Therapeutics is hiring a Clinical Account Manager (Manchester, NH, Remote) to bring Filspari to nephrologists treating rare glomerular disease across a New England territory. The role requires 8-plus years of specialty pharma or biotech sales experience and deep comfort calling on prescribers of high-value, complex products. Apply here.

• Akebia Therapeutics is hiring a Senior Director, Technical Operations – Biologics (Cambridge, MA, On-site) to lead end-to-end CMC strategy for AKB-097 from clinical development through commercialization, building and managing Akebia’s external biologics manufacturing network. Requires 12-plus years of progressive biologics experience and a track record advancing programs through late-stage trials and BLA submission. Apply here.

• Interwell Health is hiring an Epic Professional Billing Analyst (Remote) to own configuration and operational integrity of Epic’s professional billing workflows for a leading kidney care management company. Requires Epic Resolute PB and Charge Router certifications and deep hands-on experience in revenue cycle workflows at scale. Apply here.

Every one of these roles is a chance to move the needle on kidney health. We hope you find yours. More roles added weekly at jobs.signalsfs.com.

Share

Are you hiring? Post a role on Signals Jobs. Looking for your next opportunity? Browse the full board. We believe great talent is everywhere, and that the right people in the right roles get us closer to a world without kidney disease.

In Part One of this series, Bill Fitzsimmons and Kevin Fowler helped define the moment and unmet need in transplant medicine. We talked about why progress has stalled and how changes in regulatory pathways could unlock new investment and treatment options for patients. This conversation builds on that foundation.

Q&A

Let’s start with introductions. What is your background and connection to this space?

I’m Deirdre Sawinski, an associate professor of medicine and transplant nephrologist at Weill Cornell. I’m also a researcher, epidemiologist, and clinical trialist. What drew me to this field, and what’s kept me here, is really the people. I care deeply about the patients I serve. What I love about research is that I can go to clinic, see something I don’t fully understand, and then go back to the data to try to answer it. Why didn’t that kidney last? What could we have done differently? That loop between patient care and discovery is what keeps me going.

I’m Sejal Patel. I’m a physician by training and now work in renal therapeutics in industry. I’ve also lived this personally. I had a kidney and pancreas transplant 17 years ago, and then a second kidney five years ago. That second graft failed due to nephrotoxicity. That experience has really shaped how I think about the gap between innovation and long-term outcomes. Living on both sides, clinical and patient, you see things very differently. There’s so much opportunity to improve outcomes, but there’s also a real disconnect between what we measure and what patients actually go through.

I’m Steve Rizk, Senior Vice President of Medical Affairs at Veloxis. I’ve been in the industry for about 24 years, much of that in transplantation. Drug development in transplant is not for the faint of heart. Short-term outcomes are very strong, but long-term outcomes have remained relatively stagnant. A lot of my work has focused on trying to change that trajectory, whether that’s aligning on endpoints, working with regulators, or making the case internally to continue investing in this space.

What are we missing when we talk about outcomes in transplant?

Patel: From a patient perspective, we’re missing a lot. Yes, short-term outcomes are strong. But long term, patients are dealing with infections, malignancies, cardiovascular issues, and the side effects of immunosuppression. Those things don’t always show up cleanly in clinical endpoints, but they shape daily life in a major way. Something like diarrhea might not sound like a big deal clinically, but I’ve seen patients who can’t leave their house because of it. That leads to dehydration, hospitalizations, and ultimately impacts the graft itself.

For me personally, the toxicity was very real. I had severe bone loss. I broke my ankle and my knee multiple times. I’ve had joint replacements. These are life-altering complications, even if they don’t show up as primary endpoints in trials. There’s a real gap between the science and the lived experience.

Sawinski: I think that’s exactly right. And to build on that, we’ve been using essentially the same regimen, tacrolimus and mycophenolate, for over two decades.2 We don’t treat cancer in 2026 the same way we did in 2001. We don’t treat heart disease or diabetes the same way. So why should transplant be different? At some point, “good enough” becomes a barrier.

Rizk: And the data supports what you’re describing. In a recent survey of over 10,000 transplant recipients, 92% reported experiencing adverse side effects on a regular basis. One quarter of those patients skipped doses due to side effects. That’s a clear signal that what we have today isn’t enough.

Figure: Side effect frequency (left panel) and overall burden (right panel)3

Why has transplant lagged behind other areas of kidney disease?

Sawinski: A big part of the challenge is regulatory. If you want to bring a new drug to market, you still have to compare it against the current standard using endpoints like acute rejection and one-year graft survival. The problem is those outcomes are already very good—greater than 95% graft survival at one year. That means you need thousands of patients to show a difference, which makes trials incredibly difficult and expensive. In many cases, innovation gets stalled before it even starts.

Rizk: From a development standpoint, you need two things: a regulatory pathway and a treatable population. The population is there. The challenge is the pathway. Without agreement on endpoints like iBox or other surrogate markers, it’s very difficult to design feasible trials. And without that, companies hesitate to invest.

Patel: There’s also a mindset component. There’s a perception that we already have something that works, so why take the risk of changing it. And in transplant, that risk feels higher because patients have been given this life-saving organ. That makes people cautious about testing new approaches, even when long-term outcomes clearly need improvement.

How should we be thinking differently about endpoints and success?

Sawinski: If we’re going to incorporate patient-reported outcomes (PROs), we have to do it rigorously. That means validated instruments and agreement across the field. But beyond that, we need to rethink what success actually means. Are we willing to accept a 10% increase in acute rejection if it leads to a 50% improvement in quality of life? Are we willing to accept a 5% reduction in GFR for a 25% improvement in symptoms or tolerability? Those are real tradeoffs. And I think sometimes, from a clinical or regulatory perspective, we default to objective measures like creatinine or rejection rates.

But patients may value those tradeoffs very differently. Some patients might say, “I’m okay living a slightly shorter time if I can live better during that time.” And that’s not a crazy perspective. That’s a real human decision.4

Patel: I completely agree with that. I think the key is involving patients earlier in the process so they can help define what success looks like. Not just as an afterthought, but from the beginning. When you start prioritizing things like tolerability, long-term toxicity, and quality of life, you begin to acknowledge that one size doesn’t fit all. That’s where personalization really starts to matter.

Rizk: And from a development perspective, those endpoints have to be measurable and attributable to the therapy. That’s the challenge. But we’ve seen this work in other areas. IgA nephropathy is a great example, where proteinuria was accepted as a surrogate endpoint. That opened the door for innovation. We need something similar in transplant. It doesn’t have to be perfect, but it has to be good enough to move the field forward.

Figure: Patient-Reported Outcomes in the Regulatory Balance

Subscribe now

What would meaningful innovation actually look like?

Patel: For patients, I think it’s really about choice. If you look at oncology, there are multiple therapies and approaches. Patients and physicians can choose what fits best. In transplant, we don’t really have that. We have a few options, and they’re often used in very specific scenarios rather than tailored to the individual.

For example, we’re using nephrotoxic drugs in patients who already have a transplanted kidney. Patients ask about that, and it’s a fair question. We just don’t have enough alternatives.

Sawinski: Yes, I get that question all the time. Patients ask, “Why are you giving me something that’s toxic to my new kidney?” And the honest answer is that this is the best we have right now. But in other areas of medicine, we’re moving toward precision. In cancer, we genotype tumors and target therapy. That’s where transplant needs to go.

Rizk: And part of the challenge is that even years after transplant, many patients don’t have their regimen adjusted. In that same survey, about one in four patients reported never having their therapy changed six and a half years after transplant, despite most experiencing side effects. That’s not because clinicians don’t want to change therapy. It’s because there aren’t enough viable alternatives.

Share

How do we make clinical trials more accessible and relevant to patients?

Patel: Trust is a big factor. Patients trust their physicians, but they also trust other patients. Hearing from someone who has actually participated in a trial can make a huge difference. Patient advocates, testimonials, even short videos explaining the experience, those things help. There are also practical barriers. People are busy. They have jobs, families, and other responsibilities. Making trials more accessible through virtual visits or remote monitoring could go a long way.

Sawinski: We also have to acknowledge that trial participants don’t always reflect the broader population. There’s historical mistrust, there are time constraints, and for many people, transplant is just one part of their life, not something they want to center everything around again. We need to design trials that fit into people’s lives.

Rizk: There are definitely more opportunities for remote participation than we sometimes assume. The pandemic forced us to think differently, and there are lessons there that we haven’t fully carried forward. We’re starting to incorporate patient feedback earlier in protocol design, which helps, but there’s still more we can do.

Final thoughts: what needs to happen next?

Rizk: I’ll highlight three things. First, Amy Silverstein’s work.5 She made it very clear that while organ donation is miraculous, transplant medicine still has a long way to go. Second, the “gratitude paradox.” Patients are understandably grateful for their transplant, but that gratitude can make it harder to speak up about ongoing challenges and unmet needs. Third is advocacy. That’s how we move forward. We need to carry the voices of patients, whether that’s individuals like Dr. Patel or the 10,000 patients who participated in the survey, and make sure they’re heard by regulators, clinicians, and industry.

Sawinski: I think that’s exactly right. Patients should speak up, to their physicians, to policymakers, to anyone who will listen. That’s how unmet needs become visible. And from our side, we need to keep those conversations front and center. That’s how we push for change.

Patel: What gives me optimism is that all of these perspectives are starting to come together. The science, the clinical need, and the patient voice are finally converging. That wasn’t happening even a few years ago. We’re starting to build momentum. And if patients, clinicians, and industry continue to work together, that’s where real change will come from.

###

If this conversation resonates, we’d love to hear from you. Join the discussion in the comments and share your perspective, questions, or experience.

Leave a comment

Share

Continue learning

• Too Grateful to Complain? A guest essay by Karin Hehenberger MD, PhD on why organ transplantation lags behind oncology in innovation and public voice.

• Life on Immunosuppression. The largest survey of its kind reveals the daily toll of transplant drugs, and the case for rewriting the playbook through advocacy, policy, and innovation.

• Unboxing the next frontier in transplant medicine. A Signals brief on the novel iBox score; how it works; and why it might change the course of decision-making and drug development in kidney transplantation.

• Mapping the Xeno Immune Response With PITOR’s Erwan Morgand and Alessia Giarraputo. How researchers from Paris Transplant Group, NYU, and MGH are using multimodal diagnostics to uncover the earliest immune response signatures in pig-to-human xenotransplantation.

• Signals KOLs with Dr. Ben Hippen, a conversation about IOTA, incentives, and how to build a transplant-inclusive kidney care model.

Refer a friend

Last week I attended the two-day AI in Nephrology meeting at UC San Diego. One session in particular stuck with me, Dr. Rupesh Raina’s talk on pediatric nephrology.1 It sent me down a bit of a rabbit hole this weekend. The more I read and the more I listened, the clearer something became. Pediatric kidney disease is fundamentally different from what we spend most of our time discussing in adult nephrology. It rarely shows up in the broader kidney care conversation, but it should.

In this brief, we take a closer look at what we know today, where the gaps are, what’s starting to change, and what comes next.

It starts differently

From the outside, it is easy to miss how different kidney disease looks in children. The dominant drivers are congenital and genetic. Congenital anomalies of the kidney and urinary tract (CAKUT), hereditary nephropathies, nephrotic syndrome, and rare glomerular diseases shape the landscape early in life. These conditions follow patients for decades, but the systems around them were largely built with adult disease in mind.

As one clinician told me:

As patients age, the specificity that defines pediatric care often gives way to broader CKD labels, even though the underlying biology and risk profiles remain distinct. A highly classified system early in life becomes more generalized at the point where long-term risk is accelerating.

CAKUT alone is the leading cause of CKD and kidney failure in patients under 30. That should anchor how we think about this population.2

Where the system falls short

The gaps show up most clearly at the point where discovery is supposed to translate into care. In adult CKD, therapies like SGLT2 inhibitors have quickly become foundational, supported by large trials showing meaningful renal and cardiovascular benefit. In children, that same progress has been slower to take hold. Pediatric populations were excluded from early studies, and the underlying disease looks different enough that results cannot simply be carried over.3

Most pediatric CKD is driven by congenital and non-glomerular disease.4 Progression is more variable, proteinuria is less consistent, and traditional endpoints are harder to apply. Safety considerations also shift: what looks manageable in adults raises different questions in children, from hydration to growth and development. The result is a familiar pattern. By the time therapies reach clinical practice, the evidence base in children is thinner, and access follows more slowly.

A July 2023 workshop convened by Kidney Health Initiative and NephCure on pediatric CKD and SGLT2 development offers a window into how the field is working through this transition in practice. The questions raised are simple, but they map directly to the challenges of extrapolation, trial design, and feasibility.

Subscribe now

This is starting to show up in real trials. The EMPA-KIDNEY Kids trial is now underway, designed to evaluate empagliflozin in children with CKD across safety, dosing, and early efficacy signals. It is a major step forward, and it also highlights how much coordination, infrastructure, and time are required to bring therapies to this population.

The same pattern shows up beyond therapeutics. In dialysis, equipment is still not consistently designed for children, despite well-known differences in physiology and scale. In acute care, pediatric AKI remains an area of active study, a core focus of Dr. Raina’s work and presentation, with growing use of predictive models and biomarkers but fewer standardized approaches to early intervention.5 Across settings, the underlying issue is consistent. The science is advancing, but the systems needed to deliver it are still catching up.

That gap is now getting more deliberate attention across research, policy, and clinical development. It requires bringing the right groups together to align on data, endpoints, and how to move therapies forward.

What is starting to change

Earlier this month, KidneyFuture convened a summit at the FDA on congenital kidney disease and trial readiness. It brought together patients, parents, clinicians, researchers, industry, and regulators around a practical question: how to ensure children born with CAKUT benefit from both the scientific progress and therapeutic wave already underway in CKD.6

As pediatric nephrologist and trialist Dr. Jennifer McKenzie shared, the challenge is not a lack of need, but a lack of fit. Children with congenital kidney disease do not map cleanly to adult populations. There is no clear analogue for extrapolation, disease trajectories vary widely, and it remains uncertain which endpoints best reflect long-term benefit.

One of the clearest takeaways was a growing alignment around underlying biology. Despite differences in presentation, CAKUT appears to converge on a common pathway. Reduced nephron number leads to compensatory hyperfiltration, where the remaining nephrons work harder to make up for fewer filters. Over time, this drives progression along familiar CKD pathways. That framing matters because it creates a bridge to therapies that already exist or are being developed in adjacent populations.

From there, the discussion moved into application. Several therapeutic pathways already being explored in adult CKD and rare kidney diseases may be relevant in congenital populations. The challenge is less about whether these therapies could work and more about building the conditions to test them.

That is where the focus of the summit landed. Defining target populations, developing inclusion and exclusion criteria, identifying meaningful surrogate endpoints, and assembling the data and infrastructure needed to support trials. A substantial body of data already exists in CAKUT, but it has not yet been organized through a drug development lens. In many cases, these patients are present in broader CKD datasets but not identified as a distinct, high-risk subgroup.

Share

Efforts like the TRACK Consortium (Therapeutic and Regulatory Science Advancement in Congenital Kidney Disease) are starting to take shape around this work. Convened by KidneyFuture, TRACK brings together patients and families, clinicians, researchers, registries, industry, and regulators to clarify natural history, distinguish evidence from uncertainty, and develop shared, trial-ready frameworks in a pre-competitive setting.

That urgency is also reflected in how KidneyFuture itself was built. As founder Vincent Ko shared recently, the organization emerged from lived experience, shaped by the isolation and uncertainty families face and a desire to move from waiting to acting. The goal is straightforward. Connect patients, care, and science in a way that accelerates progress.

A recent commentary in Pediatrics offers a useful lens on how the field has evolved. Early work in the mid-20th century focused on describing disease and managing complications, often with limited effective therapies and high mortality. Over time, tools like the Schwartz equation made it possible to identify CKD early and follow progression, and later guidelines brought more structure to how pediatric CKD is identified and managed.7 What stands out is how much of pediatric nephrology has been built around observation, measurement, and standardization. The next phase is about connecting that foundation to mechanism and intervention.

In parallel, the science is starting to resolve what has long been treated as a black box. In idiopathic nephrotic syndrome, the most common glomerular disorder in children, attention is shifting toward the kidney’s filtration barrier.8 The podocyte and its key structural protein, nephrin, are becoming central to how we understand disease.

Figure: A closer look at the podocyte filtration barrier, where nephrin maintains structure and disruption leads to protein leakage. 9

Emerging evidence suggests that in some patients, antibodies target nephrin and disrupt this barrier. That disruption leads to the protein leakage that defines the disease. Seeing it this way starts to connect structure, mechanism, and outcome in a more direct way.

That shift is beginning to show up in treatment. Therapies like rituximab and obinutuzumab are targeting the immune pathways involved, and early work on plasma cell–targeting approaches (e.g. CD38) suggests there is still room to refine how these patients are treated.

What the field says it needs

What clinicians and researchers say they need reflects both ambition and constraint. In the Kidney Health Initiative’s recent pediatric research priorities survey, SGLT2 inhibitors rose to the top, driven by the momentum these therapies have created in adult CKD. Hemodialysis equipment ranked near the top of the list, a reminder that foundational infrastructure remains an active challenge as well.10

Subscribe now

Dr. Raina’s work on pediatric AKI fits into this same dynamic. The vision is clear: predictive models embedded in clinical workflows that identify risk earlier and guide intervention. Early results are encouraging, including models that can predict steroid-resistant nephrotic syndrome at disease onset with high accuracy.11 The limiting factor is less about model performance and more about the surrounding system. Small datasets, variation across centers, and limited validation cohorts continue to constrain how quickly these tools can move into practice.

The through line

Children with kidney disease grow into adults living with the long-term consequences of those early conditions. The decisions made in pediatric care shape trajectories that extend across decades. That connection creates an opportunity to intervene earlier, with more clarity around biology and risk than is often possible later in life.

At the same time, there is a clear imbalance in attention and resources. One parent shared that while pediatric nephrology remains underrepresented in drug development, the clinicians in the field are among the most engaged and committed they have encountered. The limiting factor is less about effort and more about funding and focus. With more support, the path to new therapies may be shorter than many assume.

What stood out this week is a field that is starting to align around that opportunity. The pieces are there: data, biology, early signals from new therapies, and a growing push to make trials feasible. The next phase will depend on how well those pieces come together.

If this resonates, share it and weigh in. Where do you think pediatric nephrology is being overlooked, and what needs to change?

Leave a comment

Share

I want to thank everyone who reached out to share their perspective while I was working on this piece. The work happening across this field to advance care and give children a voice is clear. Thank you all for what you do.

Subscribe now

In Part One, we argued that kidney disease is medicine’s earliest warning system, one the system has spent decades ignoring in favor of treating its most expensive consequences. The natural question that follows is where structural change will actually occur. These gaps persist because the system rewards what happens later, not earlier. That structure has held for decades and produced durable businesses built around kidney failure as the endpoint. Changing it requires shifting where value accrues.

The opportunity sits beyond the current silos. Science has advanced significantly over the past decade. Therapies now exist that can slow or stop disease progression. Yet only a small share of eligible high-risk patients are on inexpensive therapies with proven renal and cardiovascular benefits, and two thirds of new kidney failure cases are driven by diabetes and hypertension, conditions that are detectable and manageable long before kidney function declines.

The gap between what we know and what we do is a systems problem, and systems problems have a specific architecture. They live at the handoffs between domains, where information, clinical judgment, treatment, and accountability must transfer from one part of the system to the next. Those handoffs are where the kidney care system breaks down, consistently and predictably, because it was never designed to make those transfers work.

Mapping the Handoffs

We think of the chronic care system as a circle rather than a pipeline. Signal becomes decision, decision becomes action, action should produce accountability, and accountability in a well-designed system feeds back into better signal. Each stage depends on the one before it, and each transition between them is a place where something can go wrong. In kidney and cardiometabolic care, things go wrong at all four.

Figure: The Four Bridges of the CKM Care System

Keen eyes will notice payment sits outside our four stages. We treat it as the terrain every stage operates within. Today that terrain is fragmented, misaligned, and constraining. As financial models evolve, solutions that account for that terrain will endure. The companies worth watching are building bridges that can stand within it and, over time, begin to reshape it.

The companies closing these gaps rarely fit neatly into “kidney” care, but their impact will be felt here. Some of the strongest proof points come from cardiovascular and metabolic care, where this kind of infrastructure is already in place and delivering results. Kidney care is building its own, and the pace is accelerating.

Subscribe now

Bridge One: Signal to Decision

The kidney is medicine’s earliest warning system, which makes the first bridge the most fundamental one. A creatinine that ticks upward, protein spilling into urine, a potassium level drifting toward a dangerous threshold. These signals precede catastrophic cardiovascular events by years, sometimes decades, and they are measurable with tools that already exist. The problem is more than detection. It is what happens after detection occurs, which in most cases is still too little.

Basic kidney screenings recommended for high-risk patients are ordered less than half the time in primary care. When results arrive, they enter workflows already crowded with data, leaving little time for interpretation. A risk score sitting unread in an inbox never becomes a clinical signal. The challenge is building infrastructure that makes data actionable at the point of care.

Datavant has demonstrated what that connective infrastructure can look like at scale, linking fragmented patient-level data across disconnected systems, including labs, pharmacy records, claims, and EHR data, into a coherent picture that would otherwise be impossible to assemble.1 For kidney and cardiometabolic populations, where a single patient’s relevant signals are distributed across nephrology, cardiology, endocrinology, primary care, and pharmacy records that were never designed to talk to each other, that kind of interoperability is a prerequisite for individualized care. A new generation of companies is building toward that gap in kidney and cardiometabolic care specifically. Some are applying AI to standard lab data to generate earlier and clearer grounds to act, giving clinicians a reason to intervene before the window closes.2 Others are combining population-level screening with predictive analytics to identify patients before disease advances to the stage where the system finally pays attention.3 Still others are developing continuous monitoring tools that capture signals currently invisible between clinic visits, signals that carry serious cardiovascular risk when they go undetected and that no current standard of care is designed to track.4

Share

Bridge Two: Decision to Action

The evidence base for treating kidney and cardiometabolic disease earlier is stronger than ever. RAAS and SGLT2 inhibitors, along with GLP-1 receptor agonists, are supported by some of the most robust trial data in modern medicine, and the guidelines reflecting that evidence are widely available to clinicians. Only fifteen percent of eligible high-risk patients are currently on SGLT2 inhibitors.5 The gap sits between clinical decision and delivered intervention. That distance remains wide, and much of the system underestimates it.

Fragmentation is the structural cause. Nephrology, cardiology, and endocrinology evolved as separate disciplines, each organized around its own workflows, its own incentives, and its own answer to the question of whose patient this is. No single part of the system owns the full trajectory of risk, which means decisions made in one setting routinely get lost before they reach the patient in another. The prescription that never gets filled, the referral that never gets followed up, the treatment plan that made clinical sense but ran into a formulary barrier no one had time to navigate. These are routine care gaps for kidney patients moving through a fragmented system.

Specialty-specific care infrastructure has already attracted billions in capital, as investors recognized that building around a single high-cost population, with the right clinical model and payment alignment, could drive meaningful outcomes at scale.6 Value-based kidney care has been one of the clearest expressions of that thesis, with a generation of companies demonstrating that coordinating care around a defined population can work clinically and operationally. What that capital built is a layer of infrastructure that now exists across the kidney ecosystem and is beginning to expand its reach to a majority of diagnosed CKD patients. Kidney entities are incorporating cardiac and metabolic populations. Cardiovascular platforms are recognizing kidney disease as a comorbidity they can no longer manage around. Large payers are asking these entities to take on more risk for more complex patient populations. The category has matured into the operating environment within which the next generation of companies will need to build, partner, and compete. Understanding that environment—its players, contracts, and constraints—is a prerequisite to investing in this space.7

Bridge Three: Action to Accountability

Systems of care are made up of a vast web of possible actions: delivering treatments, writing prescriptions, and appointment reminders to name a few. But what almost never follows is a retrospective accounting of whether any of it worked as planned. The system produces documentation in abundance, but documentation alone is a far cry from accountability. Accountability means the answer changes what gets funded, what gets contracted, and what gets done differently next time. In practice that means a payer or practice renewing a contract with a partner that demonstrably reduced hospitalizations, or a health system redirecting resources toward an intervention that the data showed actually worked, or a nephrologist changing prescribing behavior because the outcomes of the last hundred patients told them something their training did not. That connection, between what was done and whether it mattered, is precisely what fee-for-service medicine was never designed to make.

Simply put, the current payment architecture has little structural need to make that connection. Volume is the metric that matters, and whether the action produced the intended result is, by design, someone else’s concern. The people delivering care within that system are often doing exceptional work, but the system itself was never built to follow-up or follow-through.

Turquoise Health has built a model in adjacent parts of the system that illustrates what accountability through transparency can accomplish, making hospital pricing and contract data visible in ways that create genuine pressure toward better performance.8 The dialysis contracting market is among the least transparent in American healthcare, and the gap between what that market costs and what it delivers in outcomes is one of the most visible disconnects in the downstream CKM system. Arbital Health represents the archetype that Bridge Three needs most in kidney care specifically: outcomes infrastructure whose business model is only viable if the clinical action produced the intended result, and that therefore has a durable structural reason to care whether it did.9 That alignment of financial and clinical consequence is precisely what fee-for-service was never designed to produce, and what value-based care has promised for years.

Bridge Four: Accountability to Signal

This bridge determines whether the other three add up to a system or remain a collection of parallel interventions.

A learning system measures outcomes and feeds them back into earlier detection, more effective intervention, and smarter allocation of resources. It is a reporting system, and the distinction matters enormously for a disease like kidney failure, where the window for intervention is long but the system has historically been structured to act only after that window has closed. Fee-for-service medicine was never designed to close this loop because there was no incentive to ask whether last year’s intervention changed this year’s trajectory. Value-based care creates that incentive in principle, but the infrastructure to act on it remains largely unbuilt across most of the CKM system.

Truveta demonstrates how outcomes data from real clinical practice can feed back into evidence that shapes guidelines, prescribing behavior, and resource deployment across a health system. Drawing on more than five years of patient history across hundreds of hospitals, it generates real-world evidence at a depth and scale beyond traditional research. An equivalent layer of infrastructure for CKM populations remains incomplete. Relevant data sits across nephrology practices, dialysis centers, primary care offices, and cardiology clinics, each operating in separate systems. Bringing that data into a unified picture of what is working, for whom, and under what conditions remains a core opportunity.

Century Health is building toward that real-world evidence layer for kidney and cardiometabolic populations specifically, translating clinical data into the kind of evidence that can change practice at scale rather than sit in a research paper that takes years to influence a guideline.

This bridge closes the circle. It allows the system to learn from its own outcomes and apply those lessons to earlier decisions. Without it, the system repeats the same failures at the same moments. Improvements at the other three bridges stay local, fragile, and unable to compound into system-level learning.

A Field in Motion

Capital is beginning to follow the same realization that reshaped cardiovascular care: that the highest-leverage opportunities sit upstream, where risk can still be identified, managed, and changed. The four bridges are where that opportunity lives today.

The capital flowing into this space tells two distinct stories. The first is validation. Over the past two years, more than twenty billion dollars in kidney-related mergers and acquisitions – largely pharma consolidating therapeutic assets in rare kidney diseases – confirmed that the underlying science has matured and that the market is paying attention. These are late-stage affirmations of mechanisms and evidence that took decades to develop.

The second story is where our opportunity lives. Alongside those exits, more than three billion dollars has flowed into early-stage companies working across care delivery, diagnostics, software, and data infrastructure, building the connective tissue that links the system together and extends beyond what pharma exits can provide. Through Signals, we’re tracking more than one hundred fifty companies across the kidney and cardiometabolic ecosystem. That landscape points to a field at a genuine inflection point: new platforms and tools taking shape, and established players reorienting around upstream intervention and the integrated care models the CKM era demands.10

While exits validate the market, early-stage capital reinforces our belief the work is far from done. What remains largely unbuilt is the layer that connects them, the bridges that turn therapeutic breakthroughs into demonstrable outcomes for the patients who need them most. That is the work of this decade, and it is still early.

The Bright Frontier

In 1827, a physician named Richard Bright published a series of case studies from Guy’s Hospital in London that changed the course of medicine. Through careful observation of patients with edema, he identified albuminuria as a defining marker of kidney disease and described a connection between kidney failure and cardiac enlargement. He is remembered as the “father of nephrology,” but he was also describing the cardio-kidney continuum nearly two centuries before the field gave it a name.

The frontier he opened is still being mapped. Gene therapies designed to halt progression, bioengineered kidney tissue as an alternative to a transplant waitlist that will never be long enough, RNA medicines targeting the underlying biology of cardiometabolic disease, and xenotransplantation moving into early human trials. Across each of these frontiers, early-stage companies are doing the work that will define what kidney and cardiometabolic medicine looks like a decade from now.

The companies creating and capturing value in this space are building at the intersections. They turn fragmented signals into clinical decisions, coordinate care across specialties, and make outcomes meaningful across the system. That is where capital accelerates innovation, and where deep ecosystem knowledge and clinical expertise become a durable advantage. From early detection to organ failure and every point in between, a new category of companies will redefine care across the CKM continuum. This is where the next system will be built.

A Call for Collaboration

What this moment requires is not more validation that the problem is real, but coordinated effort to build the infrastructure that connects what we know to what we do. Across data, diagnostics, care delivery, and biology, the work ahead sits at the intersections.

At Bright Frontier, we are building an investment and convening platform to back the companies working across these bridges, and to bring together the operators, clinicians, patients, and policymakers needed to make those connections hold. The goal is to support the systems that allow insight to move, decisions to translate, care to reach patients, and outcomes to feed back into the system.

Signals Group is what makes that work possible. It provides a real-time map of where the system is breaking and where it is beginning to come together, informed by a community of more than 15,000 readers across 65 countries. That perspective shapes how we identify opportunities, test assumptions, and build our thesis. The work of closing these gaps and building these bridges will define the next phase of kidney and cardiometabolic care. We are building Bright Frontier to catalyze that future.

Where are the most important gaps? Which bridges matter most to you? The work is already underway. Our goal is to learn from the people doing it and to help accelerate what works.

Leave a comment

This series will continue with deeper looks at each bridge, perspectives from the people building them, and the science shaping what comes next. If you are working in these spaces, we want to hear from you.

We covered what the program is, why it matters, and how its mentor model helped them reach their personal goals as physicians. For a field navigating reimbursement pressure and shifting care models, understanding this side of nephrology is becoming just as important as practicing within it. Thanks for being here with us.

Subscribe now

Q&A

Let’s start with quick introductions. Tell us a bit about you and your practice.

Kinjel: I’m a private practice nephrologist outside Detroit. I trained in Michigan and stayed there. I’m about five years in and just made partner, so I’m right at that transition point where you start thinking more about the business and long-term direction of the practice. We’re a larger group. About 25 physicians, 15 APPs, and we cover over 1,300 dialysis patients. For me, the timing of this program was huge. I was going through partnership while also getting exposure to leadership and advocacy.

Aman: I’m in Southern Oregon. This is my first job out of fellowship, and I’m about four years into practice. We’re a smaller group. Six full-time nephrologists, a few part-time, covering around 400 ESRD patients across five dialysis units. We’re also the only nephrology group in this part of the state, so that was a big driver for me. I wanted to meet other nephrologists, compare experiences, and understand what’s happening nationally, especially on the policy side.

Romin: I’m in Durham, North Carolina, in a smaller private practice. Five full-time, one part-time nephrologist, plus APPs. We cover multiple dialysis units and a couple hospitals. We’re also in the backyard of a major academic system. That creates a different kind of pressure. You’re constantly thinking about how to stay independent and relevant. I’d had some exposure to RPA through my group, but this was my first time really being inside it. And honestly, probably got more out of it because of that.

What is the RPA Leadership Development Program?

Aman: At a high level, it’s about exposure. Exposure to policy. Exposure to advocacy. Exposure to how RPA operates. The idea is if you introduce nephrologists early in their careers to how these systems work, they’re more likely to stay engaged long term. And that ultimately helps both patients and practices.

Kinjel: We were paired with a mentor from RPA leadership right away. That part is underrated. You sit down early and say: what do I actually want out of this? Not just what RPA wants from me. Then there are three main touchpoints between the annual meeting in April, advocacy weekend in October, and board level meetings in the summer. And the board meetings are a big deal. Most physicians never see that side of things, and you’re sitting in the room where real decisions are actually being discussed.

Why did you apply? What were you hoping to get out of it?

Kinjel: For me, it was advocacy. During training, especially with COVID, we lost a lot of exposure. You’re just trying to survive clinically. Then you get into practice, and it’s the same thing. You’re grinding. Covering hospital, clinic, dialysis. You don’t stop to think about the system around you.

But that system is what determines whether your patients can access care. Telehealth is a perfect example. If coverage changes, my patients who live four to six hours away are suddenly impacted. I wanted to understand that layer better.

Romin: My motivation was a little more existential. Independent practices are getting squeezed. In our area, a lot of specialties have already been absorbed into large systems like Duke. We’re still independent, but for how long? So I wanted to learn how to think about innovation, strategy, and advocacy in a way that helps us stay competitive and continue to exist.

Aman: For me, it started with the business side. Once I became partner, I started seeing the numbers more clearly. Costs are rising every year. Staffing, operations, everything. Reimbursement hasn’t kept up. So effectively, margins are shrinking. That made me step back and ask: what are other groups doing? What’s happening at a national level? Are there levers we’re not pulling? And then there was also just a personal interest in policy. Being able to go to D.C., meet representatives, and see how decisions get made - that is a great experience and was definitely a draw.

What surprised you most about the experience?

Kinjel: That you can actually make a difference. It sounds simple, but I didn’t believe it before. You hear “advocate for your patients,” but it feels abstract. Then you’re in D.C., talking to staffers, discussing real legislation, and you see how things move. Then you realize, okay, this isn’t just symbolic. This actually matters.

Romin: I was struck by how few physicians get this experience. Most people are just too busy, which is understandable. But it means a small group ends up shaping a lot of the conversation.

How much do most nephrologists understand about policy today?

Kinjel: Honestly, not much. There were people who didn’t even realize telehealth coverage had changed.1 They’re just busy practicing, which is part of the challenge. These decisions are happening in D.C. that affect our patients and practices, whether we’re paying attention or not.

Romin: I agree, I think it’s limited to people actively involved in organizations like RPA. Otherwise, it’s not part of the day-to-day.

How does this tie back to the reality of running a private practice?

Aman: The economics are probably the biggest pressure. Over the last 20–25 years, reimbursement hasn’t kept pace with inflation. Meanwhile, costs keep rising, so you’re constantly trying to do more with less. And unless you understand policy and broader trends, you’re reacting instead of planning.2

Romin: And in some markets, you’re also competing with large systems that have very different resources. So the question becomes: how do you stay viable? How do you differentiate? That’s where this kind of exposure helps.

Kinjel: The biggest thing is mindset. It’s very easy to just grind. See patients, go home, repeat. But if that’s all you do, you’re not building anything, you’re just maintaining. Programs like this force you to zoom out. To think about your role not just as a clinician, but as part of a system. And the people who don’t adapt are going to struggle.

What would you say to early-career nephrologists considering this program?

Romin: Do it. Even if you’re unsure. You’ll learn something valuable, no matter what your long-term goals are. And you’ll meet people who genuinely want to help you grow.

Kinjel: I agree, it makes you better. As a physician, as a leader, and as an advocate for your patients.

What about residents or trainees thinking about pursuing nephrology?

Aman: Explore it properly. Most people don’t get enough exposure. And what they do see is often skewed to acute dialysis.

Kinjel: Exactly. In training, you mostly see the sickest patients. The ones who keep getting admitted. That’s not the full picture. If you really want to understand nephrology, you have to go outpatient. See a CKD clinic and home dialysis unit. See transplant patients. That’s where you understand the upside and true relationships with patients.

Romin: And at a minimum, every internist should have a strong nephrology foundation. It’s core to patient care.3

Final takeaways

What stood out from this conversation is how much of the future of nephrology sits outside the clinic, and how few early-career physicians get real exposure to it. The fellowship gives participants a window into the policy, economic, and organizational forces that shape how care is delivered, not just how it is practiced. For a field navigating reimbursement pressure and shifting care and payment models, that perspective is increasingly important. The clinicians who take the time to understand and engage with these dynamics will be better positioned to build sustainable practices, advocate effectively for their patients, and contribute to how the field evolves over time.

These same themes were on display at last year’s RPA Advocacy and Innovation Weekend, where conversations around policy, practice, and emerging technologies are increasingly overlapping. The AI Summit explored how these tools are beginning to influence clinical and operational decision-making, and I look forward to continuing that discussion in Atlanta later this week. If you’ll be there and want to connect, let me know.

Leave a comment

###

If you’re a nephrologist or practice leader attending RPA, we’re hosting a small dinner on 4/18 from 6–8pm ET with Confido Health to bring together ~20 peers to talk about what’s top of mind in growing and operating practices today. If you’d like to join us, please reach out below.

Dinner RSVP

Your curated list of high priority open roles across the kidneyverse, delivered straight to your inbox every two weeks. You can opt in or out anytime. Thanks for being here.

Subscribe now

At A Glance

• Principal Engineer, AI Products & Platform (Aledade)

• Manager, Reporting & Analytics (Evergreen Nephrology)

• Executive Director, Scientific Communications (Travere)

• Sr. Principal Engineer, Device Innovation (Edwards Lifesciences)

• Kidney Nurse Navigator (Conviva Senior Primary Care)

• Transplant Hepatologist (University of Rochester)

• Director, U.S. Market Access Marketing (AstraZeneca)

• Deputy Director, Nephrology (The Royal Melbourne Hospital)

• Business Coordinator, Intelligent Care (UC San Diego Health)

• Lead Analyst, Risk Adjustment Analytics (Strive Health)

• Senior Manager, Clinical Project Manager (Akebia)

• Senior Buyer (Diality)
  
  

  Browse all jobs

Open Roles

• UC San Diego Health is hiring a Business Coordinator, Intelligent Care (San Diego, CA, On-site) to support the CMO’s office and the West Health Accelerator, a partnership focused on advancing technology-enabled care for older adults. UC San Diego Health is one of the country’s leading academic health systems, and this role sits at the center of several high-priority strategic initiatives. The ideal candidate brings 7+ years of related experience in executive administration, project management, or business coordination, with strong analytical skills and the ability to manage competing priorities in a complex environment. Apply here!

• Aledade is hiring a Principal Engineer, AI Products & Platform (Remote) to shape the technical foundation of one of value-based care’s most recognized companies. Aledade partners with independent primary care practices across the country to help them succeed in value-based contracts, and is now building the next generation of AI-powered tools to support that mission at scale. This is a senior technical leadership role reporting to the SVP of Engineering, with scope to influence dozens of engineering teams and architect systems from the ground up. The ideal candidate brings 10+ years of production engineering experience, deep expertise in distributed systems, and a track record of technical decision-making at scale. Apply here!

• Evergreen Nephrology is hiring a Manager, Reporting & Analytics (Remote) to lead a small analytics team building the data infrastructure that drives clinical outcomes and business performance across their value-based nephrology practice. Evergreen is one of the fastest-growing kidney care companies in the country, partnering with nephrologists to deliver coordinated, value-based care to patients with chronic kidney disease. The ideal candidate brings 5+ years of experience in healthcare analytics, strong SQL skills, and hands-on experience with Power BI or Tableau. Python experience is a plus. This role reports to the VP of Analytics and comes with real room to grow. Apply here!

• Travere Therapeutics is hiring an Executive Director, Scientific Comms (San Diego, CA, Hybrid) to lead portfolio-wide scientific communications strategy as a senior member of the Global Medical Affairs leadership team. Travere is a biopharmaceutical company focused on rare kidney and liver diseases, with an approved therapy for IgA nephropathy and an active pipeline. This is a portfolio-level leadership role spanning publications, medical education, and congress strategy across multiple assets. The ideal candidate holds a PharmD, PhD, or MD and brings 12+ years of experience in scientific communications or medical affairs, ideally with rare disease or nephrology experience. Apply here!

• Edwards Lifesciences is hiring a Senior Principal Engineer, Device Innovation (Irvine, CA, On-site) to join a hand-picked incubation team tackling the hardest unsolved problems in structural heart disease. Edwards is one of the most respected names in cardiovascular medtech, known for its leadership in heart valve therapies and hemodynamic monitoring. This team is starting with a blank canvas and the mandate to potentially define an entirely new business vertical for the company. The ideal candidate brings a strong entrepreneurial background, cardiovascular medical device or diagnostics experience, and at least a decade of engineering experience. Apply here!

• Conviva Senior Primary Care is hiring a Kidney Nurse Navigator (Coconut Creek, FL, On-site) to support patients with chronic kidney disease, dialysis, and transplant care within a senior-focused primary care setting. Conviva is a CenterWell company and one of the largest senior primary care providers in the country, built around value-based care for Medicare patients. This is a care coordination role for an experienced RN who can guide patients through complex care pathways and collaborate across multidisciplinary teams. Nephrology nursing certification and experience in value-based care or population health are strongly preferred. Apply here!

• University of Rochester Medical Center is hiring a Transplant Hepatologist (Rochester, NY, On-site) to join a collaborative team of transplant surgeons and hepatologists managing end-stage liver disease across the full continuum of care. URMC is one of the leading academic medical centers in the Northeast, with a robust transplant program and strong ties to the University of Rochester School of Medicine and Dentistry. Candidates should be board-certified or board-eligible in Transplant Hepatology, eligible for New York State medical licensure, and at a level commensurate with appointment at the Associate Professor level. Apply here!

• AstraZeneca is hiring a Director, U.S. Market Access Marketing (Boston, MA, On-site) to lead payer and provider marketing strategy for Alexion's rare disease portfolio. Alexion, an AstraZeneca company, is the global leader in complement biology and rare disease therapeutics, with a portfolio that includes treatments relevant to kidney and hematologic disease. This role sits at the intersection of brand marketing, health economics, and access strategy, building campaigns across payers, specialty pharmacies, and channel partners. The ideal candidate brings 5-7 years of U.S. managed care or pharmaceutical marketing experience and a working knowledge of medical and pharmacy benefit reimbursement. Apply here!

• The Royal Melbourne Hospital is hiring a Deputy Director of Nephrology (Melbourne, Australia, On-site, Part-Time) in a senior clinical leadership appointment designed for a nephrologist who excels in operational strategy and systemic improvement. The Royal Melbourne is one of Australia's premier academic health systems, with a renal service that spans inpatient, outpatient, and community-based care. This role balances administrative and governance responsibilities with dedicated clinical commitments. Candidates must hold FRACP (Nephrology), a PhD, and be registered or eligible for registration with the Medical Board of Australia. Apply here!

• Strive Health is hiring a Lead Analyst, Risk Adjustment Analytics (Denver, CO, On-site) to drive financial performance and clinical strategy across one of the most prominent kidney care companies in the value-based care space. Strive partners with health plans and health systems to manage high-risk kidney disease patients in value-based arrangements, and this role sits at the core of how they evaluate and optimize that performance. The ideal candidate brings 4+ years of risk adjustment analytics experience, deep familiarity with MMR, MOR, and MAO-004 data, strong SQL and Excel skills, and at least 3 actuarial exams passed. Apply here!

• Akebia Therapeutics is hiring a Senior Manager, Clinical Project Manager (Cambridge, MA, On-site) to oversee the full lifecycle of clinical trials at a nephrology-focused biotech with an approved therapy for anemia in chronic kidney disease. Akebia is one of the few companies with deep, dedicated focus on the biology of kidney-related anemia, and this role is central to how they advance their pipeline. The ideal candidate brings 5+ years of clinical research operations experience, including at least 3 years managing Phase 1-4 studies directly, with a strong track record of running trials in-house with limited CRO support. Apply here!

• Diality is hiring a Senior Buyer (Irvine, CA, On-site) to optimize procurement and supply chain operations for a medical device company developing a portable home hemodialysis machine. Diality is building technology designed to give kidney disease patients more freedom and flexibility in how they manage dialysis, and this role supports the operational backbone of that mission. The ideal candidate brings 5-8 years of supply chain experience in an FDA-regulated medical device environment, with strengths in supplier relationship management, new product introduction, and life cycle management. CPIM or CPM certification and Six Sigma experience are a plus. Apply here!

Every one of these roles is a chance to move the needle on kidney health. We hope you find yours. More roles added weekly at jobs.signalsfs.com.

Share

Are you hiring? Post a role on Signals Jobs. Looking for your next opportunity? Browse the full board. We believe great talent is everywhere, and that the right people in the right roles get us closer to a world without kidney disease.

Subscribe now

Every four minutes, someone in the United States reaches kidney failure. That is more than 130,000 people each year crossing into the most advanced and costly stage of disease. Most never get there. They die first, most often from cardiovascular complications, before the system ever registers them as a kidney patient.1

Thirty-seven million Americans have chronic kidney disease, and ninety percent do not know it. The United States spends more than $150 billion per year managing the consequences and over $50 billion on dialysis alone.2 Against that, the NIH invests just $19 per patient annually in understanding how to treat and prevent it.3 The system is not ignoring kidney disease, it is paying for it at the worst possible moment.

Kidney disease is one of the most common, expensive, and invisible chronic conditions in modern medicine. It sits in plain sight, shaping outcomes across cardiovascular disease, diabetes, and metabolic health, yet remains largely undiagnosed until its latest stages. This is not a niche problem confined to nephrology. If you develop drugs for cardiometabolic disease, manage risk in a payer organization, operate a primary care network, or build diagnostics and data infrastructure, you are already positioned at the center of one of healthcare's most significant market shifts in decades. The only question is whether you are seeing it clearly enough to act on it.

The Signal Nobody’s Reading

Two simple and widely available tests, eGFR from a blood draw and albuminuria from a urine sample, can detect kidney damage years before symptoms appear. These markers often signal risk earlier than cholesterol, blood sugar, or body mass index, capturing decline before it becomes visible in more familiar ways.4 In that sense, kidney function does not just track disease, it anticipates it.

Figure: The kidney sits at the center of the cardiometabolic system

Heart disease, metabolic disease, and kidney disease are deeply interconnected. They share biology and reinforce each other over time. Kidney function is often where that shared decline surfaces first, making it one of the clearest indicators of where a patient is heading.5

Miners carried canaries because they needed a signal sensitive enough to detect danger before humans could. The kidney serves a similar role in medicine today, offering an early warning that something in the broader cardiometabolic system is beginning to fail. The difference is that we have built a system that consistently ignores the warning.

Subscribe now

A System Designed Around the Wrong Endpoint

The reason this signal goes unaddressed is not scientific, it is structural. In 1972, Congress established a Medicare entitlement for end-stage renal disease, making it the only conditions in U.S. history to receive guaranteed coverage regardless of age.6 The decision was grounded in compassion for patients facing certain death, and it fundamentally reshaped the economics of kidney care for the next fifty years.

When payment is guaranteed at the point of failure, the system organizes around that endpoint. Dialysis infrastructure expanded rapidly. Clinical training focused on late-stage disease. Research investment followed areas with clear reimbursement pathways. Over time, the system became highly effective at sustaining life once kidney failure occurs, but far less capable of preventing patients from reaching that point in the first place. For patients, this means the first time they hear ‘kidney disease’ is often when there’s only one option in front of them.

Figure: A 50-fold increase in dialysis patients since the Medicare ESRD entitlement

The dialysis chair is a life-saving intervention for more than 550,000 Americans. It is also the endpoint toward which decades of incentives have been aligned. Outcomes on dialysis remain sobering, five-year mortality exceeds 50%, worse than many common cancers, yet the system continues to optimize around it. The same incentive structure that built the dialysis industry has made it difficult to expand alternatives. While nine in ten nephrologists report they would choose home dialysis for themselves, fewer than 15% of patients receive dialysis at home.7 Annual kidney transplants reach only a fraction of those who need them.8

This dynamic was reinforced by specialization. Nephrology, cardiology, and endocrinology evolved in parallel, often managing the same patients through disconnected care models. No single part of the system owned the full trajectory of risk. Earlier stages of disease, where intervention could slow or prevent progression, received far less attention.

Share

Science, Data, & Policy

The science has advanced in a meaningful way. Therapies now exist that can slow kidney disease progression, which means finding patients earlier is no longer just a diagnostic exercise, it is an actionable one. SGLT2 inhibitors and GLP-1 receptor agonists have demonstrated consistent benefits across both cardiovascular and kidney outcomes. At the same time, new therapies targeting conditions such as IgA nephropathy and APOL1-mediated disease are establishing new paths for precision medicine in nephrology. Kidney endpoints are becoming central to how therapies are developed, evaluated, and commercialized.910

The data environment is shifting, but not in the way the technology optimists usually describe it. The bottleneck was never the absence of data. Across the operators, payers, diagnostic companies, and policymakers we have spoken with over the past year, the same problem surfaces in different language: the signal exists, can be detected, and is routinely generated by tests that cost less than a co-pay. What doesn’t exist is the infrastructure to keep that signal alive as a patient moves through the healthcare system. A risk flag created under one employer’s insurance plan disappears when that patient changes jobs. A lab result sits in one system while the treating physician works in another. A kidney decline visible in the data years before a crisis arrives triggers no intervention because no one in the care chain is accountable for connecting the signal to a response. This is fragmentation, and it is not a technology problem. It is a coordination and incentive problem, which means solving it requires more than better software. It requires someone to own the patient’s trajectory across the gaps the current system leaves open.

Policy is the most powerful lever in this system, and the hardest one to move quickly. The people working on it are not the problem. The structure is. Payment model design runs on multi-year cycles by necessity: build a model, run it, wait for the data, analyze it, and iterate. The Kidney Care Choices model, the federal government’s most ambitious experiment in rewarding earlier kidney intervention, just reported that participating care entities generated $311 million in gross savings in its most recent performance year. That is a real signal, produced by real operators doing real work. But that result took years to generate, and the model itself sunsets in 2027. Meanwhile, leadership priorities shift every four years. What the field actually needs, and what we do not yet have, is a policy infrastructure capable of learning and adjusting in closer to real time: one that treats early intervention as a reimbursable act rather than an act of goodwill.

The Canary for the System

Kidney disease is not just a clinical problem. It is a diagnostic for how the healthcare system behaves. It reveals how early signals can be present and measurable, yet fail to drive action. It shows how payment structures shape behavior more consistently than clinical evidence. It highlights how preventable progression becomes normalized when incentives are misaligned.

These dynamics extend far beyond kidney care. They are simply easier to observe here because the signal appears earlier and the consequences are well defined. If these patterns can be addressed in kidney disease, they can be addressed elsewhere. If not, they will continue to repeat across other chronic conditions.

Figure: Cardiovascular costs are projected to reach $1.4 trillion by 205011

Kidney disease rarely appears in isolation. It sits at the center of cardiovascular disease, diabetes, and metabolic health, conditions that together represent some of the largest and fastest-growing cost categories in American medicine. That is precisely why kidney disease remains undercounted and underprioritized. The costs are visible, but they are attributed elsewhere. The signal is present, but no single part of the system owns it.

This is where the canary analogy earns its weight. The kidney is not just another downstream consequence of diabetes and hypertension. It is the earliest measurable indicator that those conditions are winning. Finding and managing kidney disease earlier does not just change the kidney trajectory. It changes the cardiovascular trajectory, the metabolic trajectory, and ultimately the cost trajectory for the entire system. The burden of these conditions is already large and growing fast, with direct costs projected to reach $1.4 trillion by 2050. If we want to bend that curve, we should be looking more closely at the kidneys. That is where the earliest signals emerge, where disease pathways converge, and where the opportunity to intervene still exists.

Why This Moment Matters

The United States spends more than five trillion dollars annually on healthcare, yet outcomes across chronic disease continue to lag behind peer nations.12 This gap is not due to a lack of scientific capability or clinical expertise. It reflects a system built to respond to late-stage illness rather than act on early signals.

Figure: Treating kidney disease at the wrong stage costs ten times more

The cost curve is not an abstraction. A patient identified at Stage 2 costs the system roughly $15,000 per year. The same patient at end-stage kidney disease costs nearly eight times that, driven by dialysis and hospitalizations that earlier intervention could have prevented. The system is not failing to spend money on kidney disease. It is spending it at precisely the wrong moments. In 2024, the NIH invested just one half of one percent of what Medicare spends managing the disease each year. The payment system rewards the crisis, not the prevention.

The Value Capture Problem

The economics of kidney care have never been broken, they have been working exactly as designed. A system built around guaranteed payment at the point of failure created a fifty-year business model for managing end-stage disease. What it has not done is create returns for the organizations willing to invest upstream, where the actual prevention happens.

That dislocation is what this series is about. Value is being created across the cardio-kidney-metabolic (CKM) continuum by drug developers, diagnostics companies, data platforms, and care delivery innovators doing the hard work of finding patients earlier, getting them on the right therapies, and keeping them out of the most expensive and least effective stages of disease. But the financial architecture still routes disproportionate returns toward late-stage intervention.

The science has moved. The payment models are beginning to move. The data infrastructure is being built. What has not moved fast enough is capital; specifically, the capital willing to fund companies working upstream, before the crisis, in the spaces the current reimbursement system does not yet adequately reward. The window between when the science is proven and when the payment system fully catches up is where the best returns in health innovation have historically been built. That window is open right now in kidney and CKM care, but it will not stay open indefinitely. The question is who will be positioned to lead it when it does.

In Part Two, we map where the gaps are largest and where a new generation of companies is beginning to close them.

We want to hear from you. If you are building, investing, or working in kidney or cardiometabolic care, leave a comment below.

Leave a comment

What Happened in PY24

PY24 was supposed to be the KCC Model at full stride. Both cohorts were operational, the provider network had grown to over 9,200 participants, and aligned beneficiaries reached 282,335, the largest patient panel the model had covered to date. The full incentive structure was in place: the CKD Quarterly Capitation Payment, the $15,000 Kidney Transplant Bonus, and shared savings available across all risk tracks.

Figure: KCC model participation and beneficiary alignment, PY22–PY26

Then, after the May termination date, twenty entities exited based on participant lists provided by CMS in subsequent years.1 Effective participation dropped to 103 KCEs and 186,948 aligned beneficiaries. What makes this significant is the timing: it happened before CMS announced any changes to the model’s incentive structure. Whatever drove that decision, it was a judgment about the economics of the program and selected risk tracks for those participants.

What makes PY24 worth examining closely is that we now have entity-level reconciliation data for it. Combined with comparable PY22 data, we have a before-and-after picture of 116 unique entities operating under the model’s original financial architecture. Signals assembled this dataset from publicly available CMS reconciliation files. It is the most granular look we will have at how the model performed when fully funded and incented, and we think it warrants synthesis, analysis, and discussion.

Reading between the lines

The headline most people know is that the KCC Model cost Medicare roughly $304 million in net losses in PY23. That number is important, but it’s only part of the larger story, as I've shared before. The breakdown of where that $304.8M actually went tells a different story than the headline suggests. When you look beneath it at what individual entities actually did: how they performed against their benchmarks, how quality scores moved, how the cohorts compared, the picture is far more complete and compelling.

Table: How Medicare calculates net KCC spend (PY23)

Subscribe now

Let’s start with the math behind that $304M figure. The Lewin Group’s PY23 evaluation showed that more than 60% of that loss came from the incentive payments themselves - that’s the QCP, shared savings distributions, transplant bonuses, and high performers pool. These weren’t wasteful spending, they were what CMS deliberately designed to change behavior, and they did. The gross Part A&B claims impact was $115.6M. Significant, yes, but a different story than the net headline. Most of the “losses” in the headline number were planned incentives from CMS, not overspending by providers. In other words, CMS paid providers to change behavior, and those payments show up as “losses” in the program-level accounting.

The chart below shows how those components stack up across PY22, PY23, and PY24. In PY23, the hatched green bar drops below zero, that is the claims impact, not a savings figure. In PY22 and PY24, the solid green bars represent gross savings generated by entities against their benchmarks.

Figure: KCC model financial performance, PY22–PY24

The PY24 reconciliation data adds another layer. The 80 KCEs active in PY24 generated $311 million in gross savings against their risk-adjusted benchmarks, nearly five times the $63 million generated by 55 KCEs in PY22, and a ~3x jump in gross savings rate from 1.2% to 3.6% of benchmark. That trajectory matters, and it may be one of the clearest signals this model is working as intended.2

At the entity level, 67 of 80 KCEs generated positive net savings in PY24. That’s 84% of the shared-risk entities in the model, at a mean savings rate of 1.9% of benchmark. The Cohort 1 entities, two full years in, averaged 2.0% with 40 of 45 in positive territory. The Cohort 2 entities, in just their second year, averaged 1.8% with 27 of 35 positive. A gap of less than a quarter point between experienced and newer participants is not a steep learning curve. It suggests the model's financial logic is fairly accessible once the infrastructure is in place.

Performance varied by affiliated organization in ways that are worth examining closely, both for what improved and for what the patterns might suggest about different approaches to building sustainable kidney VBC infrastructure. Here is where things stood for Cohort 1 entities with data in both years:

Table: Top 10 Entities by Gross Savings ($) and Net Savings (%)

A few observations stand out. Interwell entered PY24 with the strongest quality scores and held them. DaVita showed meaningful improvement on both quality and savings. DCI improved substantially on quality scores across all three of its entities, with one achieving a perfect score by PY24 and earning recognition in the high performers pool. US Renal Care had the highest net savings rate in PY24, a trajectory of improvement that raises good questions about what changed operationally and what others can learn from it. In my view, these are the kinds of patterns worth tracking as PY25 data eventually becomes available. Behind these numbers are hard won lessons from delivering care locally.

Among top performers clearing 3.6% of benchmark in PY24, DaVita accounted for four entries, with Evergreen and US Renal Care each contributing two. On quality, Interwell led with five entities scoring in the top decile. The two measures don’t always travel together, and that gap is worth watching as the field matures. One exception is worth calling out. The green-highlighted entity appearing in both tables operates across Iowa, Kansas, and Nebraska. With roughly 2,000 aligned beneficiaries, a quality score of 85%, $10 million in gross savings, and a net savings rate of 4.4% of benchmark, it was among the model's top performers on both dimensions in PY24. And it did so in its second year of participation.

Taken together, these patterns suggest there isn’t a single path to success in kidney VBC. Some organizations are winning through care infrastructure and consistency. Others are improving through their scale and iteration cycles. And a few appear to be unlocking step-changes in performance that aren’t yet fully understood. As more data becomes available, the key question won’t just be who performed best, but which of these approaches proves most durable under changing incentives.

One thing worth dwelling on before we move to the policy picture: kidney care VBC is uniquely challenging compared to many other risk-bearing models, especially those further upstream where patient panels are large and risk tends to average out. These specialty ACO entities are managing populations defined by advanced, multimorbid disease. A single patient progressing from CKD Stage 5 to ESRD mid-year, or a cluster of high-cost hospitalizations in one quarter, can move a small entity’s financials materially. Risk adjustment helps, but those swings matter for KCEs and the patients they serve. Comparing a 500-beneficiary independent practice in rural Mississippi to a 3,000-beneficiary entity in metropolitan Texas on a single savings percentage misses most of what is actually happening. I’m consistently impressed by what these practices are doing on the ground: managing extraordinarily complex patients in a new payment paradigm while still generating measurable savings. That context is important to keep in mind when reading these numbers.

We need to talk about hospitalizations

There is one metric worth addressing honestly: hospitalizations. Reducing those costs is a central quality mandate of the model, and it is a downstream outcome that would most clearly validate the long-term investment thesis, alongside reducing total cost of care and increasing optimal starts.3 We don’t have claims data here. What we do have is the Lewin Group’s PY23 evaluation, which found no statistically significant impact on hospitalizations, readmissions, or emergency department visits.

That finding deserves context rather than alarm. The clinical investments the model drove upstream are exactly the kind of interventions that should reduce acute care events over time.4 We saw a 31% increase in optimal ESRD starts, 10% more home dialysis use, a 69% jump in preemptive transplants, and 29% fewer hemodialysis catheters. Each of these is significant on its own, and together they’re a strong positive signal. The PY24 financial data suggests those investments are beginning to translate into measurable cost management, even before seeing hospitalization trends. The open question is whether reducing the QCP and eliminating the transplant bonus will slow the clinical progress that was supposed to produce those reductions in the first place. You cannot cut the upstream investment and expect the downstream savings to show up on schedule, if at all.

Subscribe now

Why this timing matters

In May 2025, CMS announced a set of changes to the KCC Model effective in 2026. These included a 50% cut to the CKD QCP and elimination of the Kidney Transplant Bonus. Benchmark discounts of 1% were added for both the Professional and Global tracks. The KCF option was terminated a year early. The CKCC options were extended through 2027, but under this restructured design. Everything is a balancing act: CMS needs to experiment with model incentives to find sustainable ways to drive down costs, while model participants need incentives to finance and scale care models that deliver better outcomes. That is why the CMS innovation center exists, and it’s also why more than $2 billion in private capital has flowed into value-based kidney care models in recent years.

PY24 and PY25 were the last two years in which the model operated under its original incentive architecture. Since PY25 entity data is not yet public, PY24 is the last complete picture we have of what the model looked like when fully funded under this incentive design structure. The participation trajectory makes this sharper: from 130 entities at peak in PY23 to 74 in PY26, a 43% decline over three years, all happening while clinical outcomes were improving. The entities that remain built infrastructure and scale needed to continue growing. With over 1.5 million lives and nearly $40 billion in medical spend under management, the kidney VBC entities have grown well beyond the ~237,000 beneficiaries currently aligned to the KCC model. The question most operators are sitting with now is this: how do we plan for what comes next, and how do we sustain what we've built until we know?

What we’re watching now

July 2026 marks roughly 18 months from the model’s current end date. That is historically the window in which CMS signals what comes next, whether that means a successor model, a certification pathway, or a sunset.

Figure: KCC incentive payment components, PY22–PY245

Here is what we will be watching:

1. What will a full PY24 evaluation show? The reconciliation data tells us what entities recorded. A Lewin-style evaluation would tell us what the model actually caused, including whether hospitalizations finally moved and whether the savings are there. That distinction matters enormously for what CMS decides to do next.

2. Can entities sustain care coordination infrastructure under reduced incentives? The QCP funded the coordinators, navigators, and modality educators that drove quality gains. A 50% cut is steep, so time will tell whether clinical progress holds or erodes.

3. What happens to transplant access in future innovation center models? The KTB is gone and the IOTA model shifts focus to transplant hospitals rather than the nephrologists who identify and navigate transplant-eligible patients. It’s hard to run a controlled experiment in the “real” world, so keep an eye on both models.

4. How does MA growth change the calculus? Several organizations in KCC are running parallel MA-based kidney care strategies. For many, it’s their primary growth strategy. While federal APMs set the tone for private payer alignment, MA operates under different constraints. How organizations navigate those tradeoffs while chasing what remains a large pool of unmanaged spend will be worth watching.

5. What does consolidation look like from here? The model has an end date. Capital raised by kidney VBC organizations over the past several years is maturing, investment timelines are tightening, and the public markets are watching what companies like Omada, Hinge, and Virta demonstrate about the tech-enabled path to scale and profitability.6 I’d wager the dozen or so organizations operating in this space will look a bit different in 18 to 24 months.

Final thoughts

We are still working through the details, and a full PY24 evaluation will add important context if and when it arrives. We don’t yet know whether CMS plans a KCC 2.0, a certification pathway, or something else entirely. We expect the second half of this year to tell us a great deal. In the meantime, PY24 is the most complete picture available of what this model produced under the conditions it was designed for.

Based on the information we have, PY24 suggests the model can work. The question now is whether the system has what it needs to continue funding the next generation of accountable care.

We’d like to hear what you’re seeing. If you’re operating in this model, what are we getting right, what are we missing, and what should others know as they interpret these results?

Leave a comment

###

Signals Advisory built a full entity-level year-over-year tracker covering PY22 and PY24 KCC reconciliation data: 116 unique entities, 35 metrics, and the financial and quality trends underlying the findings in this brief. It is part of our broader value-based kidney care research offering, which tracks more than 1.5 million lives and nearly $40 billion in medical spend under management across the kidney VBC landscape. Available to operators, startups, industry, investors, and those looking to go deeper on these topics.

Learn more

By popular demand, we're bringing a curated list of high priority open roles to your inbox every two weeks. The range of companies and positions reflects the full breadth of this ecosystem, from the lab to the bedside, and everyone building in between. You can opt in or out anytime. Thanks for being part of Signals.

Subscribe now

At A Glance

• Sr. Laboratory Auditor, Quality Assurance GLP (Travere)

• Associate Director, Tax Operations (Natera)

• Program Manager (Vantive)

• Advanced Account Manager (Mozarc Medical)

• Associate Director, Environmental Health & Safety (ProKidney)

• National Business Director, Thymoglobulin West (Sanofi)

• Sales and Account Representative (RenalEdge GPO)

• AI Innovator in Residence (PRINE Health)

• Clinical Registry Research Coordinator (GlomCon Foundation)
  
  

  Browse all jobs

Open Roles

• Travere is hiring a Sr. Laboratory Auditor, Quality Assurance GLP (remote, San Diego) to lead execution of GLP quality audits and support the integrity of data generated across preclinical and clinical development programs. The ideal candidate brings 6+ years in drug or biologics development, at least 5 years of GLP/QA experience, and deep knowledge of global regulatory frameworks including FDA, EMA, and OECD guidelines. Travere is a rare disease biotech with a focused kidney and metabolic disease portfolio. Apply here!

• Natera is hiring an Associate Director, Tax Operations (remote) to lead multi-state tax strategy, governance, and execution for a publicly traded genomics company. The ideal candidate brings 10–15+ years of experience in state and local taxation, payroll tax, and equity compensation, with a background in Big 4 or large multinational environments and hands-on SOX compliance experience. Natera is a leading genetic testing and diagnostics company with a significant and growing presence in kidney health through its Renasight gene panel and Prospera transplant monitoring portfolio. Apply here!

• PRINE Health is hiring an AI Innovator in Residence (hybrid, New York) to own and execute their AI and digital transformation strategy, building and deploying solutions across clinical operations, revenue cycle, and patient workflows. The ideal candidate is early to mid-career with a CS, data science, or health informatics background, someone who has shipped real things in production and moves fast without waiting for permission. PRINE Health is a physician-owned and led nephrology supergroup that has expanded into a unique independent multispecialty network spanning primary care, care management, and a range of specialties, all built around a value-based kidney care model. Simon Prince, PRINE’s founder, wrote a great piece for us last year on what makes their model different. It’s worth a read if you want to understand the vision behind this role. Apply here!

• Sanofi is hiring a National Business Director, Thymoglobulin West (remote) to serve as the medical policy and product expert across kidney transplant centers, health systems, and IDNs, driving access and adoption of Thymoglobulin in the transplant setting. The ideal candidate brings 6+ years of field-based pharma or biotech experience with a background in solid organ transplant, payer strategy, and health system engagement. Thymoglobulin is a cornerstone immunosuppressive therapy used in kidney transplantation, and this is a high-visibility commercial role on a team we know well. Adam and Todd are building something special here. Reach out if you think you’re a fit and want an intro. Apply here!

• Vantive is hiring a Program Manager (onsite, Plymouth MN) to lead project execution across product development initiatives, owning timelines, budgets, and cross-functional coordination from identification through implementation. The ideal candidate brings 10+ years of product lifecycle experience, 5+ years of project management in medical devices, and PMP certification. Vantive is a kidney-focused medical device company spun out of Baxter last year, specializing in peritoneal dialysis, hemodialysis, and acute renal therapies. Apply here!

• Mozarc Medical is hiring an Advanced Account Manager (hybrid, San Francisco) to drive sales growth across a vascular and dialysis access portfolio, building relationships with interventional radiologists, nephrologists, and vascular surgeons. The ideal candidate brings 4+ years of B2B or healthcare sales experience and a background in medical devices. Mozarc Medical is a kidney-focused med tech company formed from equal investments by DaVita and Medtronic, focused on reimagining holistic kidney health technology. Apply here!

• ProKidney is hiring an Associate Director, Environmental Health & Safety (onsite, Winston-Salem NC) to lead EHS programs across all company sites, ensuring regulatory compliance and a culture of safety across manufacturing, quality, and laboratory operations. The ideal candidate brings 7–10+ years of EHS experience in biotech or pharma manufacturing, with a background in GMP environments and multi-site operations. ProKidney is a clinical-stage biotechnology company developing an autologous cell therapy designed to slow the progression of chronic kidney disease. Apply here!

• RenalEdge GPO is hiring a Sales and Account Representative (remote) to educate members on GPO partnerships and drive engagement across a growing renal-focused group purchasing organization. The ideal candidate brings 5+ years of medical sales experience, with GPO and renal sales experience strongly preferred. RenalEdge serves independent dialysis providers and health system members, helping them access better pricing and services across the renal care supply chain. Reach out if you think you're a fit and want an intro, who wouldn’t want to work with Glenn Davis?! Apply here!

• GlomCon Foundation is hiring a Clinical Registry Research Coordinator (remote) to support the day-to-day operations of a global clinical data registry and real-world evidence studies focused on rare kidney disease. The ideal candidate brings 2–4 years of clinical research coordination experience, with a background in registry-based or observational studies preferred. GlomCon is a global nephrology education and research platform dedicated to advancing the understanding and treatment of glomerular diseases. Apply here!

Every one of these roles is a chance to move the needle on kidney health. We hope you find yours. More roles added weekly at jobs.signalsfs.com.

Share

Are you hiring? Post a role on Signals Jobs. Looking for your next opportunity? Browse the full board. We believe great talent is everywhere, and that the right people in the right roles get us closer to a world without kidney disease.

Refer a friend

In this conversation, we discuss the stagnant state of transplant therapeutics, what patients still face after transplant, the promise of surrogate endpoints like iBox, and why stronger alignment across patients, clinicians, industry, and regulators could help unlock a new era of innovation.

Subscribe now

This is the first in a series of conversations exploring the transplant therapeutics landscape and what it will take to unlock a new era of innovation in the field.

Q&A

Let’s start with introductions. What is your background and connection to this space?

BF: I spent most of my career in the pharmaceutical industry, focused on drug development and regulatory affairs. I started working on the development of tacrolimus for transplant immunosuppression in 1990. Since retiring from industry, I’ve been active on the executive committee of the Transplant Therapeutics Consortium, a public-private partnership working to advance tools and processes that can help bring more innovation into transplantation.

KF: I spent more than 25 years in the pharmaceutical industry, and Bill and I crossed paths during our time at Astellas. In 2014, I started my own consulting business, where I work with pharma companies on earlier intervention in kidney disease and better treatments in transplant. I’ve also been living with a kidney transplant since August 2004, so this is both professional and deeply personal for me.

Bill, how do you see the current state of transplant therapeutics and innovation?

BF: Unfortunately, innovation in transplant therapeutics has been fairly stagnant. There are drugs in development, but very few have made it across the goal line and into clinical use. The last novel immunosuppressant approved by the FDA was in 2011. So we have gone roughly 15 years without a truly new immunosuppressant reaching the field.

Figure: FDA Drug Approvals by Year and Therapy Area, 2000-22

Our current standard of care, tacrolimus in combination with mycophenolate mofetil, has been around for more than 30 years and is still used in 80% to 90% of new transplants globally.1 So while there has been scientific activity, there has not been much innovation that has actually reached patients over the last decade, or really the last three decades.

Kidney more broadly has seen progress in recent years. Why has transplant lagged behind?

BF: One of the main reasons is that the current regimen performs well in the short term. We have low acute rejection rates and strong patient and graft survival at one year. That creates a high bar for showing superiority over standard of care in a traditional trial design.

But the long-term picture is still not where it needs to be. Kidney graft survival at 10 years is only about 50% to 60%, and patients still carry a heavy burden from side effects and tolerability issues related to chronic immunosuppression.2

Compare that with IgA nephropathy. In 2017, there were no approved therapies for IgAN. But through close engagement among FDA, sponsors, researchers, and patients, a more workable development pathway emerged, including the use of proteinuria as a surrogate endpoint for accelerated approval. That changed the field. Since 2021, five new drugs have been approved for IgAN, and several more are in late-stage development. It is a strong example of how regulatory partnership can unlock investment and therapeutic development in kidney disease.3

Figure: Landscape of IgAN clinical trials over the last 3 decades (2022)4

So the challenge is not just scientific or clinical. It is also regulatory?

BF: Exactly. The short-term outcomes are good enough that the field has been stuck. That is a good problem in one sense, but it also becomes a barrier if it keeps us from improving long-term outcomes and quality of life.

There is a real opportunity for transplant to follow a model similar to what happened in IgAN and other areas like HIV, oncology, and liver disease. Those fields benefited when regulators and stakeholders aligned around tools that made development more feasible. Transplant has not yet been able to do that in the same way.

Kevin, where do you see the patient voice in this landscape today?

KF: There has been progress, and I think it is important to acknowledge that. CMS is now working on a patient-reported outcome measure, which is a big step. The American Society of Transplant Surgeons has also launched a patient voice initiative to better educate and engage patients on legislative issues and public policy.

That said, I still think there is a major opportunity to more directly engage the patient community with the FDA around the issues Bill is describing. I served on the Kidney Health Initiative for more than a decade and saw firsthand what can happen when patients, clinicians, industry, and regulators are all at the table together.

I would love to see a listening session between the FDA and the transplant patient community this year so we can have an honest conversation about what life after transplant is really like and what patients still need.

What are some of the biggest misconceptions about life after transplant?

KF: One of the biggest misconceptions is that transplant is a cure. It is not. As Bill said, long-term outcomes remain a major problem. If 50% to 60% of grafts fail within 10 years, that is not a cure.

The other issue is quality of life. Even for people doing relatively well, transplant can still come with a heavy treatment burden. My experience is not the norm.

There is also something I have written about called the “gratitude paradox.” Many transplant recipients are understandably grateful to be alive and to have received an organ. I feel that too. But that gratitude can sometimes make it harder to speak openly about ongoing burdens, side effects, fear of loss, and the reality that life after transplant is still medically complex.

And the broader public often does not understand the full picture. A recent Office of Inspector General report showed how hard it is even to get onto the waitlist, let alone get transplanted.5 If you are one of the few who makes it through years of dialysis and then receives a kidney, you may not feel like complaining, even if the system still has major shortcomings.

March 2026 OIG Report

Bill, what are some of the realities patients face after transplant that the field still has not solved?

BF: One major issue is that we still do not have enough tools to individualize treatment. Most patients get essentially the same drugs, but not everyone will tolerate the same regimen equally well.

Current immunosuppressive regimens bring significant toxicities. New-onset diabetes after transplant, for example, occurs in more than 30% of recipients on current regimens.6 These are not minor side effects. They affect both quality of life and long-term graft and patient outcomes.

That is why we have focused so much on finding better tools. We need ways to predict what will happen long term without waiting five or ten years to find out.

Have there been real developments on that front?

BF: Yes. That is where the concept of a surrogate endpoint comes in. The goal is to measure something at one year post-transplant that is both prognostic and predictive of what will happen to the graft over five years and beyond.

That is what iBox is designed to do. It combines commonly measured lab tests for kidney function, immunologic response to the graft, and biopsy histology into a single score. That score can then help predict long-term graft function and survival. In practical terms, it gives you a number at one year that tells you a great deal about what is likely to happen over time.

KF: I would add that surrogate endpoints were not universally embraced in nephrology when these conversations started. I was part of National Kidney Foundation discussions on this back in 2018. But many of us came to support their use because we felt the potential upside for patients and innovation was worth it. The process was transparent, and patients had a chance to be part of that discussion.

What would broader use of iBox make possible?

KF: From the patient side, the biggest thing it provides is hope. I lose friends every year to premature graft loss. So when I think back to those early discussions about surrogate endpoints, what stayed with me was the possibility that things could actually change.

A clear regulatory pathway matters because companies need confidence before they invest. If there is a real pathway, more companies are going to take transplant seriously. That is what patients need. The unmet need is there.

BF: From the development side, iBox could help companies show superiority over current standard of care using an earlier, validated endpoint. That would make it possible to use expedited FDA pathways, including Accelerated Approval.7

There are innovative immunosuppressants out there, but many have been developed for autoimmune diseases rather than for transplant. We want to make it easier for companies and investors to bring those therapies into transplantation. If they can see a feasible path, that changes the equation.

Walk us through the development and qualification process for iBox.

BF: The original iBox model was developed by the Paris Transplant Group as a prognostic tool for individual patients, and it was published in 2019. They used data from roughly 4,000 kidney transplant recipients to build the model.

Through the Transplant Therapeutics Consortium, we took that patient-level prognostic model and adapted it into a trial endpoint. Then we brought it into the regulatory qualification process.8

Figure: iBox Regulatory Timeline with FDA and EMA (2023)9

With the European Medicines Agency, that process moved relatively quickly. iBox was qualified through the EMA in 2022, so it can already be used in kidney transplant development in Europe.10

With the FDA, we made our first submission in 2019 and are still in the process. There are three major steps in the qualification pathway, and we are now in the third. A big part of the work has been validation. We had to show that what was seen in the Paris dataset could also be replicated in other settings, including single-center datasets like Mayo Clinic and Helsinki, and randomized trials such as BENEFIT and BENEFIT-EXT. The answer has been yes, and that body of validation is central to what we submitted.

KF: I attended the 2018 FDA meeting where Alexandre Loupy presented the iBox concept, and I came away feeling hopeful that there was finally a path forward. It has been a long process. From my perspective as an advocate, one challenge is that the process has not always felt very clear from the outside. That is a contrast with some of the nephrology work, where patient participation in the discussion felt more visible.

What are the possible outcomes of the FDA’s current review?

BF: The best-case outcome is that iBox is qualified by the FDA as a reasonably likely surrogate endpoint that can be used in the Accelerated Approval pathway. That is the goal.

The FDA could also reject it outright and decide not to qualify it at all. Or they could say it is acceptable as a secondary endpoint, but not as a surrogate endpoint for accelerated approval.

Figure: Regular vs. Accelerated FDA Approval

Why would a secondary endpoint designation fall short?

BF: Because it would not accomplish what the field really needs. It would not create an expedited pathway, and it would not give companies the ability to promote superiority in the way that a validated surrogate endpoint could.

It would be better than nothing, of course. But it would not send the signal we need. What we are really trying to establish is that the FDA is partnering with the field to help jumpstart innovation in transplant. A secondary endpoint does not do that.

Kevin, where do you see the unmet need most clearly?

KF: It is everywhere. There is unmet need in BK virus, in antibody-mediated rejection (AMR), in highly sensitized patients still waiting on dialysis, and across the broader challenge of chronic nephrotoxicity from current standard of care.11

The fact that standard of care has barely changed in 30 years should tell us something. I struggle to think of another field where that would be considered acceptable.

And again, this is personal. I have had friends lose kidneys prematurely because of the toxicities of current treatment. Then they go back to dialysis and hope they survive long enough to get another transplant. That is real human suffering. We need better tools for physicians and better options for patients.

What should the transplant community be watching over the next few months?

BF: The FDA decision is obviously central. But just as important will be how the community responds to that decision.

If iBox is accepted as a reasonably likely surrogate endpoint, that would be a sign that the FDA is willing to partner with the community to move the field forward. Then the question becomes what happens next over the next five to ten years as companies, investors, and researchers respond.

If the decision falls short, then the community has to decide whether it is willing to accept the status quo. I do not think we should be. Transplant carries a unique moral obligation because every functioning graft represents a donated organ, whether from a living or deceased donor. We owe it to donors and recipients to do everything we can to preserve those gifts and improve long-term outcomes.

KF: What has happened in nephrology over the last decade has been remarkable. I honestly never thought I would see this level of change in my lifetime. That is why this moment matters.

However this turns out, I will not be quiet. If the outcome is positive, I will be celebrating it loudly. If it is not what the community hopes for, I will have a lot of questions. That is how I approach this. I keep coming back to the friends I have lost. That is what drives me.

Is there still an opportunity for people to speak up before a decision is made?

BF: From the TTC side, we are continuing to engage decision-makers at the FDA. We want to make sure there is awareness of the issue at every level of the organization. Beyond that, this is something patients and stakeholders can raise with their representatives. If this matters to them, they should say so. That is how public priorities are communicated through government.

Find Your Legislators

Any final thoughts to leave people with?

BF: Kidney transplant patients deserve safer, newer, better therapies, just like patients in any other serious and life-threatening condition. In fact, I would argue the obligation is even greater here because these therapies are meant to protect a donated organ. We are not asking anyone to lower the bar for safety or efficacy. We are asking the field to raise the bar for long-term outcomes.

KF: Success depends on partnership. Patients, industry, physicians, and the FDA all need to be working in the same direction, with trust and open communication. That is how nephrology started to change. We need the same kind of honest alignment in transplant if we want to see real progress.

###

If this conversation resonates, we’d love to hear from you. Join the discussion in the comments and share your perspective, questions, or experience.

Leave a comment

Share

Continue learning

• Too Grateful to Complain? A guest essay by Karin Hehenberger MD, PhD on why organ transplantation lags behind oncology in innovation and public voice.

• Life on Immunosuppression. The largest survey of its kind reveals the daily toll of transplant drugs, and the case for rewriting the playbook through advocacy, policy, and innovation.

• Unboxing the next frontier in transplant medicine. A Signals brief on the novel iBox score; how it works; and why it might change the course of decision-making and drug development in kidney transplantation.

• Mapping the Xeno Immune Response With PITOR’s Erwan Morgand and Alessia Giarraputo. How researchers from Paris Transplant Group, NYU, and MGH are using multimodal diagnostics to uncover the earliest immune response signatures in pig-to-human xenotransplantation.

• Signals KOLs with Dr. Ben Hippen, a conversation about IOTA, incentives, and how to build a transplant-inclusive kidney care model.

Refer a friend

Earlier this week, Alexa Mikhail wrote in Second Opinion that if you want to understand how AI will change medicine, look at cardiology. She’s right. Cardiology is out front. But nephrology is rarely far behind, and often already in the room. Thirty to sixty percent of patients with heart failure also have chronic kidney disease. More than half of patients with CKD ultimately die from cardiovascular causes. The cardio-renal link is structural. If AI reshapes one field, the other will feel it.123

Kidney care, however, has its own dynamics. Much of it lives in primary care before it is labeled, if it is labeled at all. It is deeply data-driven yet historically underdiagnosed. Signals accumulate across years and settings before anyone connects them. Most people think of dialysis or transplant when they think of kidney economics, but tens of millions sit upstream of that decision

That combination makes nephrology uniquely dependent on longitudinal pattern recognition. The specialty runs on data; AI simply makes that dependence explicit. What we are seeing across research and commercialization is not a single narrative, but convergence around a handful of clinical and economic realities.

After dozens of conversations with nephrologists, dialysis leaders, startups, payers, and policy experts, and a review of the emerging evidence, I see five recurring themes. They are less about technological novelty and more about economic alignment.

Five Observations

1. Make hidden risk visible

2. Align with payment pathways

3. Prevent high-cost events

4. Move upstream, early

5. Improve the human experience
   

Subscribe now

Observation #1: AI is most believable in kidney care when it makes hidden risk visible early enough to change payment, utilization, or modality.

Kidney disease is expensive long before it is obvious. Chronic kidney disease is frequently underdiagnosed and under-coded, especially in its earlier stages. Much of it lives in primary care, cardiology, and endocrinology before a nephrologist ever sees the patient. By the time someone reaches advanced CKD or dialysis, years of risk accumulation have already passed through the system with little recognition.

That invisibility has consequences, and now shows up in newer payment models. Risk scores can become understated, benchmarks drift, and shared savings opportunities shrink. Effective therapies do exist, but more often than not they’re stuck on the sidelines without adequate guideline-directed treatment plans in place. Patients progress without anyone fully appreciating how fast they are moving. That is the story we all know, and the one we all agree must end.

Figure: Distribution of U.S. adults by eGFR and albuminuria category (USRDS)4

This is where AI’s most credible early contribution lies: not in replacing clinical reasoning, but in surfacing what is already there.

Machine learning models have demonstrated strong performance in predicting CKD progression, identifying rapid eGFR decline, forecasting dialysis initiation, and flagging hospitalization risk. Commercial tools now embed these capabilities directly into longitudinal records to surface undocumented stages and high-risk phenotypes in real time.5

We have seen similar arcs in cardiology and oncology. AI gained traction in heart failure not because it was novel, but because it helped identify decompensation risk before readmission. In oncology, predictive tools became economically meaningful when they influenced protocol adherence and outcomes tied to payment models.

As specialty-based total cost of care models expand, nephrology is increasingly evaluated not just on dialysis volume, but on risk-adjusted performance across the disease continuum (including non-nephrology spend, see below).

Figure: Potential savings from managing high-cost specialties in value-based payment models6

Kidney care is structurally suited to this kind of visibility. It spans long time horizons. It relies on repeated lab measurements. It generates dense data streams across years. The signals are there; they are just scattered. When AI consolidates those signals into actionable risk visibility, it changes three things at once: how patients are categorized, how clinicians intervene, and how payment models interpret performance.

That is why risk visibility is the most believable entry point for AI in nephrology today. It does not require reinvention of care delivery. It requires clearer recognition of what is already unfolding, and alignment with systems that increasingly reward accuracy in documenting and managing that risk. The harder problem is not the AI model itself, it is behavior: awareness, workflow integration, and clinical buy-in.

Observation #2: Durable kidney AI companies will align with existing payment pathways before trying to invent new ones.

The AI applications that have endured in other specialties embedded themselves within existing reimbursement systems rather than attempting to reshape them. Radiology tools improved detection inside established imaging payment models. Diabetes technology scaled once it aligned with covered device and pharmacy benefits. In cardiology, remote monitoring gained traction when reimbursement codes and risk arrangements supported managing heart failure outside the hospital. Then insurers stepped in to pay for more of these devices and scans. In each case, alignment, not novelty, drove adoption.

Figure: Calculator inputs, KPIs, and outputs for the return on investment (ROI) calculator for [Radiology AI App]

Nephrology looks similar in some cases. Kidney care sits within a layered and often fragmented payment landscape that includes traditional Medicare, Medicare Advantage, commercial contracts, bundled dialysis payments, shared savings arrangements, and kidney-specific value-based models. It is not a “clean” system, and it is not likely to become one in the near term. The AI tools most likely to endure are not those attempting to bypass that complexity, but those that work within it. Technologies that integrate into reimbursed diagnostics, improve risk adjustment accuracy under Medicare Advantage, strengthen performance in shared savings arrangements, or measurably influence quality metrics tied to payment are structurally advantaged. Novel algorithms alone are insufficient; clinical performance must intersect with economic relevance.

This is particularly important in nephrology because so much of revenue remains concentrated in advanced disease and dialysis. Any upstream or longitudinal AI solution must demonstrate how it connects back to that downstream financial structure, whether by delaying progression, improving contract performance, or reducing costly acute events. Alignment may not be the most glamorous strategy, but I believe it is the most durable. The companies that recognize this early and build for the system that exists, rather than the one they hope will emerge, are the ones most likely to last.

Observation #3: Preventing expensive events in advanced CKD and dialysis is the most immediate ROI case for kidney AI.

If there is a single area in nephrology where the economic case for AI is most straightforward, it is in preventing expensive acute events among patients with advanced CKD and end-stage kidney disease.

Hospitalizations drive cost in kidney care. Admissions for fluid overload, access complications, infections, cardiovascular events, and missed dialysis sessions are frequent and financially consequential.7 They influence total cost of care under risk contracts, shape shared savings performance, and materially affect margins for providers and payers alike. Unlike some upstream interventions that require long time horizons to demonstrate impact, hospitalization avoidance produces measurable economic effects almost immediately.

Figure: Mean annual per patient health care costs covered by commercial payers and Medicare, stratified by eGFR and UACR (Dark Blue = Hospitalization)8

The literature reflects this focus. Machine learning models have been developed to predict hospitalization risk, intradialytic hypotension, rapid hemoglobin shifts, and other destabilizing events in dialysis populations. Some interdisciplinary programs that incorporate predictive analytics into dialysis workflows have reported reductions in hospitalization rates and shortened hospital stays. AI-supported anemia management has been associated with more efficient ESA utilization and fewer adverse events.9 These findings are still evolving, but the direction is consistent: when predictive insight is embedded into care delivery, trajectories can change.

Other specialties moved here first. Cardiology embraced predictive monitoring in heart failure because readmissions were costly and highly visible under reimbursement reforms. The logic is simple: detect deterioration earlier, intervene sooner, avoid costly admissions. Pulmonary programs adopted remote monitoring when COPD exacerbations proved financially punishing. In both cases, the ROI equation was simple: prevent a costly admission, and the technology begins to pay for itself.

Figure: Remote monitoring (RM) technologies and the potential value of remote management throughout the natural history of heart failure (HF)10

Nephrology shares that clarity. A single avoided hospitalization in a dialysis patient can offset significant operational investment (see above chart). In a risk-bearing environment, reductions in admission frequency or length of stay translate directly into contract performance. Even in fee-for-service settings, fewer destabilizing events reduce downstream complications and improve quality metrics that increasingly influence payment.

This does not mean every predictive model will deliver durable savings. Evidence generation, workflow integration, clinician trust, and operational follow-through remain critical. But of all the domains where AI is appearing in kidney care today, preventing high-cost events in advanced CKD and dialysis presents the cleanest economic logic. It is where clinical risk and financial risk overlap most visibly, and where near-term sustainability is most likely to take hold.

Observation #4: Upstream kidney care is becoming economically viable because of advances in predictive analytics and AI.

For decades, the financial center of gravity in kidney care sat at dialysis. Upstream CKD mattered clinically, but economically it was harder to see. That appears to be shifting, slowly but meaningfully.

Measures like KED (Kidney Health Evaluation for Patients with Diabetes) illustrate the change.11 Albuminuria testing in diabetes is now embedded in Medicare Advantage performance frameworks, making early kidney risk visible in ways that influence plan ratings and incentives. Proteinuria often precedes significant GFR decline. When detected and treated earlier, progression slows and cardiovascular risk falls. The cardio-renal connection is structural: early kidney management affects heart failure outcomes and downstream cost.

Figure: Use of CKD tests by health insurer12

That shift creates a new economic surface for AI. Tools that close albuminuria testing gaps, flag rising risk in diabetic populations, or identify patients eligible for guideline-directed therapies are no longer purely preventive aids. They increasingly intersect with measurable incentives. Earlier recognition affects quality scores, risk adjustment, and long-term cost trajectories under value-based arrangements.

Other specialties followed a similar path. Diabetes platforms scaled once prevention translated into measurable cost reduction.13 Musculoskeletal programs expanded when delaying surgery produced employer savings.14 Prevention became durable once it became financially legible.

Kidney care is entering this phase. Tens of millions of patients sit upstream of dialysis, and their risk is increasingly visible to payers and health systems. AI does not create that shift, policy and evidence do. But AI may make it feasible to build these upstream models at scale.

The open question is leadership. Chronic care management platforms are expanding across cardiometabolic, MSK, heart failure, and diabetes. The writing is on the wall: kidney will not remain siloed indefinitely. Whether the next wave is led by nephrology, primary care, health plans, or diversified chronic care platforms remains unclear. Early signals from ACCESS and similar initiatives may help clarify the direction.15

Observation #5: Administrative AI brings real human benefits, but its financial impact in nephrology remains uneven and its governance questions are just beginning.

Ambient documentation and administrative AI are among the most visible applications of AI in medicine today. Early peer-reviewed evidence supports meaningful clinician benefit, including a recent multicenter quality improvement study in JAMA Network Open that showed a ~14% reduction in burnout and ~6% reduction in severe burnout after adoption of an ambient AI scribe. Clinicians described lower cognitive load and greater ability to focus on patients.

Time savings, however, appear modest. Peak reductions in daily EHR time have reached roughly 20 minutes in some evaluations, while after-hours documentation improvements have been small. The primary benefit may be cognitive relief and patient experience rather than dramatic workflow compression, a theme echoed at last fall’s RPA AI Summit and captured well in Season Two of The Pitt.

In nephrology, the financial implications remain variable. Documentation gains can improve risk adjustment and coding accuracy, but their impact depends heavily on payer mix, contract structure, and whether margin is driven by E&M or bundled dialysis revenue. Administrative AI improves the human experience of care. Its economic durability is more context-dependent.

Figure: Challenges in AI Implementation

At the same time, governance is moving to the foreground. A recent Kidney News editorial highlights growing concerns about algorithm transparency, bias, training data provenance, and the risk of automation without specialty oversight. The American Society of Nephrology’s Responsible AI roadmap underscores this point, calling for clinician involvement in model development, validation in kidney-specific populations, post-deployment monitoring, and guardrails around equity and safety.

This is an important distinction. Administrative AI may improve how nephrologists work. But how kidney AI is governed, validated, and aligned with specialty standards will determine whether it strengthens the field or simply layers new tools onto fragile systems.

Closing thoughts

Kidney care has always been a specialty defined by complex physiology, data-driven decision making, and long time horizons. AI does not change that. What it does is expose where risk is hiding, where incentives are misaligned, and where behavior still slows progress even when evidence is clear. The early signals suggest that durability will not come from novelty alone, but from economic alignment, governance, and clinical trust. To me the question is which use cases will earn the right to stick around.

If you’re building, deploying, using or evaluating AI in kidney care, I’d like to hear from you. Where is it working? Where is it stalling? Where do we go next?

Leave a comment

Share

This month’s news begs a bigger question: what was our kidney care system made for? In the Barbie film, Billie Eilish’s “What Was I Made For?” becomes a quiet reckoning about purpose. The title feels like a fitting frame now. Was this system built to manage late-stage failure, or to intervene earlier? To reward volume, or to align around outcomes? To operate in silos, or to treat cardiovascular, kidney, and metabolic disease as the connected reality they are?

Let’s get into it.

Thank you all for being part of Signals. Please take a few minutes to share what you’d like to see from us in 2026 in our annual reader survey.1

Subscribe now

What’s Inside

• News: ACCESS model details, OPTN modernization update, DCD expansion, HHD innovation, major industry bets, Ivenix recall;

• Research: Finerenone Phase 3 data, precision transplant tools, AI in workflow, upstream CKD screening gains

• Community: RPA preview, AI-ready practices, dialysis innovation debate, CKM unification voices, transplant stories

• Events: World Congress of Nephrology, Renal Physicians Association, NKF Spring Clinical Meetings, ANNA National Symposium, Columbia CKM, and more

• Jobs: Ardelyx, Travere, Strive, Monogram, Takeda, Boehringer, Vertex, Revalia, Trestle, CVS Health, Getinge, Natera + dozens more on jobs.signalsfs.com…

  Subscribe now

2026 Reader Survey!

Help shape the future of Signals. We’re expanding across research, data, community, and new tools for the kidney and CKM space. Take 5 minutes to share what would be most valuable to you here. Ten people will receive a $50 digital gift card as a thank you.2

Take the survey

News

POLICY & REGULATORY

• CMMI’s new ACCESS model introduces outcome-aligned payments for early CKM care. The 10-year voluntary model allows organizations to participate in four tracks, including early cardio-kidney-metabolic (eCKM) and CKM (CKD stage 3a or 3b), shifting Medicare FFS reimbursement from volume to outcome-aligned payments (OAPs). For the CKM track, participants can receive $420 per beneficiary in the initial 12-month period and $210 in follow-on years, with an additional $15 rural adjustment. Payments are tied to clinical improvement thresholds and reduced duplicative services, with semiannual reconciliation and potential downward adjustments if fewer than 50% of patients meet outcome targets. CMS will also introduce a co-management payment (~$30 per beneficiary, quarterly) for care coordination. Advocates say the model signals a serious federal push to fund technology-enabled, accountable upstream CKM management rather than waiting until dialysis. Author’s note: I’ll be writing about this in more depth soon, with performance scenarios tailored for both neph practices and tech vendor partners focused on e/CKM. As a reminder, to be considered for the model’s first performance period beginning July 5, 2026, applications must be submitted via the Participant Portal by April 1, 2026. Applications received after this date will be considered for a January 1, 2027 start.

• HRSA’s February update outlines continued modernization of the OPTN, focused on governance reform, technology infrastructure, transparency, and oversight across the transplant system. Key developments include launch of a new OPTN 411 call line (handling 300+ calls in its first month), expanded financial assistance for living donors with income limits removed, addition of 144 new volunteers to OPTN policy committees, rollout of a government-managed Transplant Data Services (TDS) platform, a new Ventilated Patient Form to improve OPO referral visibility, and forthcoming quarterly public reports on transplant center registration fees. The modernization effort signals continued federal pressure to realign transplant infrastructure with current clinical and public health realities.

• Fresenius Kabi recalled certain Ivenix large volume infusion pumps after a software issue that can delay or interrupt therapy and misreport battery life, prompting the FDA to classify the action as Class I, its highest risk level. The issue has been linked to two serious injuries, and the company is directing providers to update to the latest software version. The recall follows multiple prior safety actions and a 2024 FDA warning letter related to the Ivenix platform, which Fresenius acquired in 2022 for $240 million.

• Healthy People 2030 is calling renewed attention to dialysis vascular access, as central venous catheter use rises and mortality worsens. Despite arteriovenous fistulas (AVFs) being the gold standard, nearly 85% of new dialysis patients start with a catheter, which carries a fourfold higher mortality risk. USRDS data show catheter rates climbing post-pandemic, alongside Medicare reimbursement pressures and Medicare Advantage policies that may delay timely access creation. Advocates argue that reaching catheter reduction goals will require payment reform, stronger support for vascular access centers, and renewed focus on infection prevention. (Healio, H/t Terry Litchfield)

INDUSTRY MOVES

• DaVita announced a strategic investment in Elara Caring to co-develop a kidney-specific home-based care model, signaling a push beyond the dialysis clinic and into coordinated in-home support. The partnership pairs DaVita’s risk-based care arm (IKC), which turned profitable in 2025 and now manages roughly $5.6B in annualized medical spend, with Elara’s multistate home health platform. The goal: reduce preventable hospitalizations and lower total cost of care by building the operating layer around kidney patients at home. It’s a bet that value-based economics can fund the next phase of at-home kidney care. Read my full analysis here.

  

• CareDx announced VANTx™, a cloud-native, AI-powered clinical data and analytics platform built on its large-scale longitudinal transplant datasets, unveiled at the 2026 Precision Medicine World Conference. The platform enables secure cohort analysis across patient timelines to support clinical research, real-world evidence generation, and transplant program insights, integrating de-identified molecular, clinical trial, EMR, and remote monitoring data. Built on Databricks and leveraging Llama 3 and proprietary predictive models (KOAR, SHORE, ALAMO, MAPLE), VANTx is designed to help transplant centers and pharma partners generate actionable insights across kidney, heart, lung, and liver transplantation. (H/t Jenny Sato, Hal Gibson)

• SeaStar Medical reported post-approval data showing its selective cytopheretic device (Quelimmune) was safe and may benefit children with life-threatening sepsis-associated AKI requiring kidney replacement therapy. In the first 21 pediatric patients treated under its FDA humanitarian device exemption, 90-day survival was 71%, with no device-related adverse events reported. The device, which works alongside CRRT to modulate hyper-inflammation, is currently the only FDA-approved therapy for this critically ill pediatric population, with additional studies ongoing in both children and adults. (H/t Kevin Chung)

• Cedars-Sinai performed its first fully robotic kidney transplant, joining a small group of U.S. centers offering robot-assisted implantation for recipients. The minimally invasive approach uses smaller incisions, which may reduce pain, infection risk, and recovery time, particularly for patients with higher BMI who face greater wound complication risk. The program aims to expand robotic procedures to as many as 40% of kidney transplants over the next 3–5 years, while emphasizing that patient selection remains individualized.

• Digital health M&A wave gains momentum in 2026. MedCity News reports a sharp uptick in targeted acquisitions, including Sword Health’s $285M purchase of Kaia Health and OpenAI’s $60M acquisition of Torch, as digital health companies seek scale, AI capabilities, and stronger payer leverage. Investors expect continued consolidation, particularly in primary care, post-acute care, ancillary services, revenue cycle management, imaging/radiology, robotics, and consumer health. With IPO markets uncertain, M&A may become the dominant exit path this year.

DATA & INFRASTRUCTURE

• Springer Nature and GlomCon launch Rare Kidney Diseases journal. Springer Nature will publish Rare Kidney Diseases, a fully open access journal from the GlomCon Foundation dedicated to research and innovation in rare and complex kidney disorders. Submissions are expected to open in early 2026, with a focus spanning clinical insights, pathology, and AI applications.

• AST pushes for iBox biomarker qualification at Congressional briefing. The American Society of Transplantation hosted a Capitol Hill briefing focused on patient-centered innovation in transplant immunosuppression, highlighting the burden of current therapies and the need for safer options. A key priority was FDA qualification of the iBox composite biomarker, developed through the Transplant Therapeutics Consortium, as a reasonably likely surrogate endpoint for long-term kidney graft survival. If qualified under the accelerated approval pathway, iBox could modernize transplant trial design and speed access to new therapies while maintaining scientific rigor. Watch it here. (H/t Kevin Fowler)

• Eledon’s Tegoprubart pilot study in islet transplantation completed enrollment (N=12), with 7 patients achieving sustained insulin independence and the earliest participant remaining insulin-free for up to 18 months. The tacrolimus-free immunosuppression regimen has been well tolerated with no observed toxicity, and a related study in patients with type 1 diabetes and chronic kidney disease is expected to open soon (LinkedIn, h/t Piotr Witkowski)

• Dr. Adebowale Adebiyi at the University of Missouri received a $2.8 million NIH grant to study a newly identified contributor to acute kidney injury in premature infants. His research suggests overactivation of voltage-gated sodium (NaV) channels in kidney blood vessels may restrict oxygen delivery during injury, worsening organ dysfunction. The project will explore how nitric oxide interacts with these channels and whether targeting this pathway could restore blood flow and protect kidney function in vulnerable NICU patients.
  

  Subscribe now

Research

THERAPEUTICS

• Finerenone shows first positive Phase 3 data in Type 1 diabetes and CKD since 1993. In a Phase 3 trial published in NEJM, finerenone reduced UACR by 34% over six months in adults with Type 1 diabetes and CKD, compared to a 12% reduction with placebo — a 25% greater reduction overall (P<0.001). eGFR declined modestly at 6 months (–5.6 vs –2.7 ml/min/1.73m²), but values approached baseline after washout, suggesting a hemodynamic effect. Hyperkalemia occurred in 10.1% of finerenone patients vs 3.3% with placebo. This is the first positive Phase 3 trial in this population since the Captopril trial in 1993, and it uses a bridging-biomarker approach to extrapolate albuminuria reductions to long-term outcomes based on prior Type 2 diabetes data. (H/t Robert Lawatscheck, MD, PhD)

• Finerenone reduces heart failure hospitalizations within months, with kidney benefits accruing over time. A participant-level analysis of FIDELITY and FINEARTS-HF published in JACC found that heart failure hospitalization was the earliest event prevented with finerenone. In FIDELITY, sustained statistical significance for HF hospitalization emerged at ~6 months, compared with ~10 months for the composite kidney outcome. In FINEARTS-HF, HF hospitalization reached significance as early as 0.9 months. The findings suggest that finerenone delivers near-term cardiovascular risk reduction, while kidney protection becomes more apparent with longer follow-up, reinforcing the case for earlier implementation in high-risk CKM patients. (H/t Brendon Neuen)

PRECISION MEDICINE

• KPMP biopsy data reveal diagnostic blind spots in diabetic CKD. In a preprint from the Kidney Precision Medicine Project, only 56% of participants enrolled as diabetic kidney disease (DKD) had biopsy-confirmed diabetic nephropathy, underscoring substantial diagnostic heterogeneity. Molecular profiling showed immune and inflammatory pathway upregulation and oxidative phosphorylation downregulation in confirmed diabetic nephropathy, alongside more severe fibrosis and tubular injury. A clinical-biomarker model (age, HbA1c, UACR, KIM-1, sTNFR1) predicted biopsy-confirmed diabetic nephropathy with an AUC of 0.82 and was associated with CKD progression in CRIC (HR 1.48 per 10% higher predicted probability). The findings strengthen the case for precision diagnostics beyond clinical labels alone.

• iBox accurately predicts graft loss in African American transplant recipients. In a multicenter North American preprint study of 3,588 kidney transplant recipients, including 866 African American patients, the iBox prognostication system showed similar discrimination for graft loss across groups (C-index 0.81 vs 0.83; p=0.25) with no significant interaction by race. Although African American recipients had higher baseline risk and a greater 7-year hazard of graft loss (HR 2.14; p<0.001), calibration and overall performance remained robust up to 7 years post-evaluation. The findings support iBox as a relevant surrogate endpoint across diverse transplant populations. (H/t Amanda Klein)

• Microvascular inflammation extends beyond classic antibody-mediated rejection. A review by Alexander Loupy and colleagues highlights that microvascular inflammation (MVI) includes DSA-negative and C4d-negative forms now recognized in updated Banff criteria and linked to worse graft outcomes. Donor-derived cell-free DNA is emerging as a leading noninvasive marker of active injury, and therapies such as CD38-directed agents are under study. The authors call for integrating histology, molecular diagnostics, and AI tools to better classify and treat alloimmune injury. (H/t Alex Loupy)

• A new review in Kidney News outlines rapid automation and design advances across seven FDA-approved home hemodialysis (HHD) machines, highlighting features such as on-demand dialysate production, cloud-based monitoring, automated saline flushes, and enhanced needle dislodgement detection. Despite rapid device innovation, only 0.4% of incident kidney failure patients initiate HHD in the U.S., underscoring that technology alone hasn’t shifted modality adoption.. (H/t Osama El Shamy)

Figure: Comparison of conventional HD with the low dialysate volume approach

AI & REAL-WORLD EVIDENCE

• Clinical Kidney Journal lays out a roadmap for AI integration in nephrology.
  A new state-of-the-art review outlines how AI is moving from pilot projects to clinical integration across AKI, CKD, dialysis, and transplantation. Predictive AKI models, CKD risk stratification tools, AI-enabled dialysis management, and transplant platforms such as iBox are highlighted as leading use cases, though workflow integration and real-world validation remain uneven. The authors flag data bias, interpretability, and regulatory uncertainty as key barriers, and point toward multimodal data integration, reinforcement learning, and digital twins as the next frontier in precision nephrology. (H/t Davide Garrisi)

• A new preprint shows that simple EHR design changes dramatically improved albuminuria screening in patients with hypertension. At Geisinger, UACR testing rose from ~3% in 2020–2021 to 9.7% in 2022 and 17.5% in 2023 after implementing two clinical decision support tools, compared to only ~3% in control health systems. An initial advisory increased testing roughly 3-fold, while a redesigned health maintenance prompt drove ~6-fold improvement from baseline. The findings suggest that thoughtful CDS design, not just guideline awareness, can meaningfully close upstream CKD screening gaps. (H/t Alex Chang)

• AI-triggered interventions reduced short-term hospitalizations in ESKD. A Medicare- and EMR-linked analysis in NEJM Catalyst evaluated AI models that flagged dialysis patients at risk of hospitalization within 7 days for fluid or infection-related events. Among 10,294 patients and 83,928 risk scores, AI-triggered case reviews were associated with an 8% reduction in the odds of hospitalization. The effect was strongest in patients with moderate-to-high risk scores and not significant in the highest-risk group. The findings suggest targeted, workflow-integrated AI may help bend near-term admission risk in value-based kidney care settings.

EPIDEMIOLOGY

• Oral disease tracks closely with CKD progression and systemic inflammation.
  A BMC Nephrology narrative review synthesizing observational studies and trials finds that periodontal disease severity rises alongside CKD stage, with higher DMFT scores and clinical attachment loss correlating with lower eGFR and elevated CRP and IL-6. Non-surgical periodontal therapy modestly improves inflammatory markers, though renal outcomes remain mixed. The authors argue oral health is a measurable, modifiable contributor to CKD progression and call for integrating dental assessments into routine nephrology care, particularly in low-resource settings where fragmentation is most pronounced. (H/t Prakash Gudsoorkar)

• A review in Nature Reviews Nephrology highlights how social determinants of health (SDoH) shape acute kidney injury (AKI) risk and outcomes worldwide. Factors such as socioeconomic status, race, education, environmental exposure, climate change, and conflict influence AKI incidence, recognition, access to care, and long-term outcomes, with disparities widening in low-resource settings. Pediatric populations face unique vulnerabilities, and gaps in data further limit targeted intervention. The authors argue that reducing AKI burden will require policy reform, interdisciplinary strategies, and alignment with broader public health and Sustainable Development Goals to address structural inequities driving disease risk. (H/t Rolando Claure Del Granado)

• A large study in Nature Communications Medicine found that COVID-19 infection is associated with significantly higher kidney risk compared to influenza. In more than 3 million working-age adults, COVID-19 was linked to increased rates of acute kidney injury, chronic kidney disease, end-stage kidney disease, and glomerular disease, while influenza showed no significant association with CKD or ESRD. AKI risk was highest in the short term, while CKD risk persisted over time. The findings support closer kidney monitoring after SARS-CoV-2 infection.

TRANSPLANT TRENDS

• Global transplants hit record high in 2024, but access gaps persist. The Global Observatory on Donation and Transplantation reports 173,727 solid organ transplants worldwide in 2024, a 2% increase from 2023 and the highest number ever recorded. Growth was largely driven by deceased donation, with donations after circulatory determination of death accounting for 28% of all deceased donor activity (47,180 total deceased donations). Despite progress, major geographic disparities and ongoing organ shortages remain central global challenges.

• DCD donation continues to expand in the U.S. A research letter in JAMA reports growing use of donation after circulatory death (DCD) as transplant programs respond to persistent organ shortages. Although DCD organs carry higher risks of dysfunction and require more complex recovery logistics than donation after brain death, technological advances and mounting demand have driven increased adoption. The findings highlight DCD as a key lever for expanding the deceased donor pool in the U.S.

• A companion JAMA perspective piece traces the broader evolution of deceased organ donation, from the 1968 Uniform Anatomical Gift Act to the modern transplant system — offering historical context for how today’s DCD expansion fits into decades of policy and infrastructure development. (H/t Aleah Brubaker & Gabe Schnickel)

• A prospective study in American Journal of Transplantation found that eliminating allocation out of sequence (AOOS) for 30 days increased kidney nonuse. When one OPO (New England Donor Services) strictly followed the national match-run without rescue pathways, nonuse rose from 29.1% to 43.2%, particularly among higher KDPI (more medically complex) kidneys. An estimated 13 additional kidneys might have been transplanted during the study month if prior utilization rates had held. The findings suggest that removing AOOS without a standardized national rescue alternative may increase organ wastage and highlight the need for transparent, policy-driven solutions for hard-to-place kidneys. (H/t Alex Glazier)

• Patients favor flexibility in automated peritoneal dialysis prescriptions. In a national survey of 203 people on automated peritoneal dialysis (APD), most respondents reported starting PD at 7 days per week (73%), yet preferences leaned toward more flexible, incremental approaches that reduce treatment burden. Incremental APD options such as fewer weekly sessions, shorter cycler time, or eliminating daytime dwells were ranked based on perceived impact on quality of life. The findings reinforce that incremental PD is not just clinically viable but aligned with patient-centered care, emphasizing life participation alongside adequacy metrics. (H/t Michael Spigler)

Community

INNOVATION MILESTONES

• Roivios enrolls first European patient in GRADIENT pivotal study. The GRADIENT trial (NCT07017933) evaluating the JuxtaFlow® Renal Assist Device has enrolled its first patient in Europe, marking a key milestone for the company and its partners at American Heart of Poland. The study is testing whether perioperative use of the device can help sustain or enhance kidney function during high-risk procedures. Congrats, team!

• ARPA-H launched ADVOCATE, a new “agentic AI” program aimed at delivering autonomous specialty heart failure care to address clinician shortages, with 46% of U.S. counties lacking a cardiologist. The initiative seeks FDA-authorized AI systems that can provide direct patient care, prescribe medications, integrate with EHRs and wearables, and operate under a novel supervisory AI oversight model. If successful, ADVOCATE could create a regulatory and deployment blueprint for AI-enabled specialty care beyond cardiology, with projected savings of $50B annually. (H/t Haider Warraich)

• Blake Madden spotlights Arbital Health’s “Actuarial AI” for VBC. In a new Hospitalogy deep dive, Blake Madden highlights how Arbital Health is building a real-time actuarial operating system for risk-bearing organizations. Its Merlin AI assistant integrates contract logic, claims data, and predictive models into auditable next-best actions built for actuaries and finance leaders. The argument: VBC struggles less from vision and more from missing infrastructure. I think that’s a message many of my VBC readers can relate to (see our recent report here).

• A Q&A in Healio highlights the University of Washington’s inpatient “Kidney-Heart” service, a specialized cardio-nephrology model for patients with complex cardiovascular-kidney-metabolic disease. In its first 2.5 years, patients treated under the service had lower rates of AKI dialysis (36.7% vs. 42%) and mortality (16.5% vs. 25%) compared to a prior general nephrology cohort. The program embeds nephrologists with cardiac expertise directly into cardiology and cardiac surgery teams to improve early diuretic management and interdisciplinary coordination. Leaders say the model is feasible with sufficient patient volume and institutional support, and are now expanding into a multidisciplinary outpatient clinic.

PROFESSIONAL DEVELOPMENT

• Katie Kwon outlines what to expect at this year’s RPA Annual Meeting (April 16–19, Atlanta), including a new AI-Ready Nephrology Practice certificate, clinical research programming for private practices, and policy discussions with MedPAC Chair Dr. Michael Chernew. The agenda blends practical clinical updates with candid conversations on payment, workforce, and practice management. Will I see you there? Register here.

• ASN launches AI-focused podcast for nephrology leaders. The American Society of Nephrology has introduced Rewired: Navigating AI’s Role in Kidney Health, hosted by Karandeep Singh and Navdeep Tangri. The first episode explores generative and agentic AI and how these technologies are beginning to shape nephrology practice.

• NephMadness 2026 is officially underway! The free, CME-granting, evidence-based tournament (inspired by March Madness) pits top nephrology topics against each other, from IgA nephropathy (B-cell targets vs complement inhibitors) to AI (computational pathology vs NLP) and transplantation (BK vs CMV). This year features eight regions with two subtopics each, blending serious science with creative flair. Brackets are due by March 31 at 3pm ET. Submit your picks here. (H/t Kenar Jhaveri)

  

ADVOCACY / SYSTEM VOICES

• In Health Affairs, Dr. Suzanne Watnick argues that U.S. dialysis has become an “innovation desert” despite being uniquely positioned for research. Nearly 500,000 patients receive highly standardized, data-rich care, yet core treatment protocols have changed little since the 1980s, shaped in part by Medicare’s bundled payment system and industry consolidation, with two for-profit companies controlling ~80% of the market. Although kidney disease costs the federal government more than $150 billion annually, it receives less than 2% of NIH funding, limiting transformative research. She calls for congressional and CMS action to realign incentives, including broader value-based payment models across CKD and transplant, financial incentives for research participation, regulatory support for pragmatic trials, modernization of dialysis IT infrastructure, and reimbursement pathways that explicitly reward innovation rather than cost neutrality.

• ASN’s #LoveYourKidneys campaign ramps up national media push. ASN President Samir Parikh and the ASN team recently wrapped a 17-interview satellite media tour spanning local and national outlets, including CBS News Radio, CNN Newsource, and iHeartRadio, to promote kidney health awareness ahead of National Kidney Month. The campaign bridges the transition from American Heart Month and aims to elevate public understanding of kidney disease risk, prevention, and early detection. Great work Samir, Christine, Tony and Zach— let us know if you’ve seen the message in your local area!

• ASSENT launches push to validate surrogate endpoints in Alport syndrome.
  The Alport Syndrome Foundation’s ASSENT Initiative (Alport Syndrome Surrogate Endpoint Network) is building an international effort to establish evidence-based surrogate endpoints to accelerate clinical trials in rare kidney diseases. Led by a multidisciplinary steering committee, including Committee Co-Chair Dr. Alex Chang, ASSENT brings together patients, regulators, nephrologists, statisticians, and global datasets to evaluate markers such as proteinuria and eGFR as trial endpoints. With multiple rare kidney trials underway across Alport syndrome, ADPKD, IgA nephropathy, AMKD, FSGS, and C3G, now is the time to shorten timelines and strengthen the path to approval for targeted therapies!

• Viet Le calls for unified CKM care, not siloed disease management. In his recent LinkedIn perspective, Viet Le shares that cardiovascular-kidney-metabolic (CKM) syndrome now affects ~90% of U.S. adults, yet we continue to treat A1c, eGFR, and LDL-C in isolation. He lays out a practical framework for staging CKM 0–4, aligning therapy early, and using cross-organ pillars including RAS inhibition, SGLT2 inhibitors, nonsteroidal MRAs, and GLP-1 therapies. The core message: CKM is a shared disease state, and fragmented care is the real risk factor.

TRANSPLANT STORIES

• Former Bengals All-Pro Willie Anderson underwent a successful kidney transplant this month, with his longtime girlfriend serving as his living donor.

• Alex Berrios received a kidney transplant in New York City this month and is now recovering post-surgery (post). After years on dialysis, he shared updates from the hospital and thanked his family for supporting him through the first days of recovery.

• Ben Street, a kidney advocate and OPO leader in San Diego, is seeking a living kidney donor as his kidney function declines to 9% (post). Ben works with UCSD’s Lifesharing and serves as a National Kidney Foundation Region 9 leader, and is asking the community to share his story to help find the right donor match. Apply to be Ben’s donor here.
  

Share

Events Calendar

• Kidney Cancer Patient Summit, March 15 / San Diego, CA

• CKD Drug Development Summit, March 16-18 / Boston, MA

• LSI USA ‘26, March 16-20 / Dana Point, CA

• WCN, Mar 28-31 / Yokohama, Japan

• RPA Annual Meeting, Apr 16-19 / Atlanta, GA

• ANNA National Symposium, April 25-28 / New Orleans

• Columbia CKM: Evolving Frontiers May 1 / Virtual

• NKF Spring Clinical Meetings, May 6-10 / New Orleans

• NephCure Support Groups (Ongoing)
  

  Subscribe now

Jobs

• Nephrologist (Miami, FL) — Kaüna (Say hello!)

• Manager, State Government Affairs — Takeda

• Director, Partner Success — Strive Health

• Sr Analyst, Medical Economics — Monogram Health

• Senior Product Manager, Clinical AI — CVS Health

• Director, Alliance Management — Ardelyx

• Organ Health Specialist (Albany) — Natera

• Sr. Medical Director (Nephrology) — Travere

• Director, Donor Recovery — Donor Network of AZ

• Early Pipeline Forecasting — Vertex

• Analytics Technical Product Manager — Aledade

• Health AI Product Manager — UC San Diego Health

• Director of People — Avo

• Director, Transplant Services (Norfolk, VA) — Sentara

• Globalization Product Manager — Getinge

• …plus hundreds more at jobs.signalsfs.com

Find your next role

Work with us

Signals Group is expanding to support the growth of this community. Whether you’re looking to increase awareness for your work, prepare for your next milestone, or looking to enter a new market, we’d love to hear from you. We support mission-aligned organizations advancing kidney health.

1. Learn — Discover hundreds of articles & interviews in our Data Room

2. Share — See how Signals can help you reach your next milestones

3. Sponsor — Apply to share your mission with a kidney-focused audience
   

   Apply to Sponsor

If something in this month’s recap sparked a thought, question, or you just want to learn more, hit reply. We read every note. Thanks for being here.

Leave a comment

Share

Eight months ago, I published Five Charts That Explain the Current State of Kidney Care. It was an attempt to paint a clear picture of where the kidney world stood at that moment. As you may remember, the story was mixed. Real progress in some areas, stubborn inertia in others, especially early screening, home dialysis, and living donation.

Today kicks off Kidney Month. The burden of kidney disease remains enormous, and hundreds of millions of people still do not know they have it. But as I look across therapeutics, value-based care, primary care integration, and federal payment policy, the center of gravity feels different. The dialysis-centric story is no longer the only one shaping the conversation. Kidney care is being pulled upstream, earlier in the disease journey, and more tightly into cardiometabolic strategy. It’s early, but the signs are there.

We see it in prescribing patterns. We see it in risk-bearing contracts. We see it in how health systems and primary care groups are beginning to think about CKM populations as a risk profile rather than a collection of siloed diagnoses scattered across the medical record. Yes, it’s early innings, but the question is no longer whether kidney disease matters to the broader system. It is shifting to how quickly the system can reorganize around that reality, and who will lead the charge.

So this Kidney Month, I want to highlight four areas that give me reason for optimism. Not because the story is finished. It is not. But because the step-by-step direction of travel from here is already clearer than it was this time last year.

What’s Inside

1. Kidney moves upstream into CKM strategy

2. Risk-bearing care scales beyond nephrology

3. Primary care becomes the leverage point

4. Federal models continue to iterate

Share

#1

First, the kidney is now at the center of cardio-metabolic care. For years, chronic kidney disease sat as an afterthought, downstream of diabetes, heart disease, and obesity. That dynamic has shifted considerably, with recent examples from the Super Bowl and the American Heart Association’s CKM Initiative reinforcing the message. But the shift is most visible in medication management. Considering most adults with CKD stages 3 to 5 are still more likely to die than progress to kidney failure, any movement toward earlier detection and treatment is meaningful.1

The 2025 USRDS Annual Data Report shows how prescribing patterns have evolved over the last decade.2 While traditional diabetes drugs have steadily declined, SGLT2 inhibitors and GLP-1 receptor agonists have accelerated since 2018. Nearly one in five Medicare beneficiaries with CKD and diabetes were receiving an SGLT2 inhibitor in 2023, and uptake was even higher among those who also had heart failure. GLP-1 use has followed a similar upward trajectory. Even among patients with stage 4 and 5 CKD, these newer classes are increasingly part of the treatment mix.

Figure: Percentage of older adult Medicare FFS beneficiaries with CKD and type 2 diabetes receiving diabetes medications, 2013-2023

These trends reflect more than incremental changes in diabetes care. They track closely with major cardiovascular and renal outcomes trials that established SGLT2 inhibitors and GLP-1 receptor agonists as organ-protective therapies.3 Clinical guidelines have incorporated those findings across specialties. The ADA and KDIGO emphasize early use in high-risk populations. The AHA now includes kidney function in its updated cardiovascular risk algorithm. Kidney endpoints are embedded in cardiovascular trials, and cardiovascular outcomes are central to renal studies. The therapeutic goal has shifted from glucose control alone to preservation of heart and kidney function across a connected cardio-kidney-metabolic axis.4

But who is actually writing these prescriptions? National prescribing data show that cardiology, primary care, and endocrinology account for the vast majority of SGLT2 and GLP-1 use, with nephrology representing only a small fraction of overall volume (see below).5 The inflection in prescribing aligns closely with major outcome trials and subsequent label expansions (here, here, and here). Kidney protection is being absorbed into mainstream cardiometabolic practice rather than remaining siloed within nephrology.6

Figure: (A) SGLT2 and (B) GLP‐1 use across clinician specialties

Subscribe now

Adoption remains uneven. Patients with CKD who do not also carry diagnoses of diabetes or heart failure still have very low exposure to these agents. That’s important because many adults with advanced CKD do not see a kidney doctor. In 2023, only 41% of adults with Stage 5 CKD had a nephrology visit. But the direction is clear. Kidney preservation is no longer confined to specialty clinics. It is increasingly part of routine risk management in primary care and cardiology.

When cardiologists, endocrinologists, and primary care physicians are actively prescribing therapies that slow kidney decline, responsibility for CKD no longer sits with one specialty. That shared ownership is foundational to the integrated risk models now expanding across the country, especially as models differ in terms of who ultimately manages the outcomes and costs of that care.

#2

Second, integrated care is scaling through a specialty lens. The growth in kidney value-based care over the past several years is significant. In our latest review of the landscape, ten leading kidney-focused value-based organizations collectively manage more than 1.5 million patient lives and nearly 40 billion dollars in annual managed medical spend. That figure has roughly doubled from prior updates and now represents about 20 percent of fee-for-service Medicare spending across CKD and ESRD populations.

By our count, the number of lives under management has grown by nearly 50 percent in just the past year. Today, close to one-third of kidney disease patients are cared for within some form of value-based arrangement. Contract design varies greatly, but the scale alone is notable. Kidney care, long viewed as fragmented and reactive, is increasingly being managed under structures that hold organizations accountable for total cost of care. The financial risk is shifting from public to private payers; and further, from larger payers to specialized risk managers in the form of these VB kidney care entities (and not just in nephrology).

Figure: Ten companies manage ~1.5M patients and $37B in annualized medical spend across value-based nephrology models

Share

Equally important is how these organizations are evolving. The largest players, including Somatus at roughly 500,000 lives, Panoramic at 330,000, Monogram at 200,000, and both Strive and Interwell at approximately 145,000 each, are no longer operating as kidney-only entities. Several have expanded aggressively into cardiology and broader multi-chronic populations. The top three now account for roughly two-thirds of total lives under management, and the mix increasingly reflects patients with overlapping heart failure and metabolic disease.

The financial layer reinforces this integration. Among providers reporting this data, estimated managed spend per patient ranges from roughly $15,000 to $75,000 annually, with an average near $33,000. That range reflects differences in acuity and contract structure, but it also illustrates the economic surface area under management. When tens of billions of dollars in annual spend sit inside risk-bearing arrangements for a population that historically represents one-quarter of Medicare spend, the importance of care coordination cannot be overstated.

The story is not simply that value-based care is growing. It is that kidney value-based care is integrating outward and aligning with cardiology and primary care in the process. The unit of accountability is shifting from the dialysis chair to the whole patient. But that shift raises a natural question. Is it happening in the other direction, and if so, what is driving it?

#3

Third, primary care remains best positioned to stop kidney disease in its tracks. If CKD is going to be detected earlier and managed differently, primary care has to be center stage. It is where most patients with diabetes, hypertension, and cardiovascular disease already receive care, and where early-stage kidney risk is most likely to surface. Yet despite clear guidelines, the gap persists. The recommended tests, estimated GFR and urine albumin-to-creatinine ratio, are inexpensive, widely available, and embedded in most lab panels. They are guideline recommended for high-risk populations. Still, fewer than half of people with diabetes receive both tests, and albuminuria testing among patients with hypertension alone remains strikingly low. The tests are cheap, available, guideline recommended, and still not happening.

Figure: Proportion of people with chronic kidney disease (CKD) who are aware of their diagnosis and are receiving appropriate guideline-recommended care

Subscribe now

Even when labs are ordered, CKD often remains invisible inside the medical record. Prior analyses suggest that nearly 80 percent of patients with moderate CKD lack a formal diagnosis in their chart. Risk is present but unmanaged, and referrals are inconsistent. The result is predictable: sixty percent of patients still initiate dialysis through an unplanned hospitalization, a moment that is clinically destabilizing and financially expensive.

Figure: Average Medicare spending on patients initiating dialysis, 2017-2018

The economic consequences are clear. Data from Kidney Medicine show a sharp spike in inpatient hospital spending in the first 30 days of dialysis initiation, with per patient monthly costs far exceeding later periods. Federal spending on kidney failure now exceeds $50 billion annually.7 Hospitals often lose money on Medicare dialysis patients, and care remains fragmented across dialysis clinics, transplant centers, vascular access programs, and primary care. No single provider has holistic responsibility. Perhaps health systems should.

The question is whether the surrounding model makes prevention rational. In fee-for-service environments, screening and coordination can feel like friction. When a health system or primary care organization assumes responsibility for total cost of care, the equation changes. Avoiding unplanned starts, reducing hospitalizations, and coordinating specialty care move from being aspirational goals to economic imperatives. Models like ChenMed and Intermountain demonstrate how aligned incentives, embedded specialty access, and kidney-focused navigation can translate early detection into smoother transitions and fewer crisis-driven dialysis starts.

Primary care can anchor this shift, but only if it operates inside an integrated model that aligns clinical responsibility with financial accountability. That is where policy and payment design begin to matter most.

#4

Federal payment models are increasingly aligned with the clinical reality of kidney and cardiometabolic diseases. For more than a decade, CMMI has tested ways to move kidney care away from reactive dialysis spending and toward earlier, coordinated intervention. The pattern is not random. It reflects a steady recognition that late-stage payment structures produce late-stage care. If prevention is the goal, accountability has to move upstream to intervene earlier in the disease progression.8

Figure: Annual CKD Costs By Stage (2007-2012)

The ESRD Treatment Choices model focused on home dialysis and transplant incentives. Kidney Care Choices pushed further by bringing advanced CKD and transplant populations into risk-based arrangements. The model was extended through 2027, giving participants additional runway to translate infrastructure investments into measurable results. In its second performance year, 15 of 21 outcomes moved in a favorable direction (see below), with roughly half of eligible patients, about 225,000 people, aligned to KCC. The lesson was not that transformation is easy. It was that building care coordination, analytics, and staffing capacity requires upfront capital before downstream savings appear.9

Figure: KCC Model Outcomes, Second Performance Year (2023)

At the same time, kidney policy has been embedded inside broader accountable care structures. Chronic disease management cannot be isolated from primary care, cardiology, and population health systems. When kidney risk sits inside total cost of care arrangements, the incentives shift. Hospitalizations, unplanned dialysis starts, and transplant delays are no longer siloed specialty problems. They become financial events for the entire organization.

The next generation of models continues that evolution. ACCESS builds on kidney-specific coordination lessons by extending tech-enabled accountability earlier into CKM risk (CKD stages 3a and 3b), while LEAD introduces a ten-year accountable care pathway with improved benchmarking, population-based payments, and a focus on high-needs and dually eligible patients. A longer runway changes behavior. Organizations are more likely to invest in prevention when the contract horizon matches the biology of chronic disease. Digital tools and outcomes-aligned payments may make earlier, lower-touch interventions economically viable at scale.

Taken together, these models show that CKM is not only a clinical framework. It is becoming embedded in payment architecture. Public models often set the direction for how private payers structure risk, including Medicare Advantage and commercial plans. This broader coordination across payers is often referred to as multi-payer alignment, and it matters. When Medicare, Medicaid, and private insurers align around common measures, payment approaches, and data-sharing standards, it becomes easier for providers to invest in prevention and integrated care. When federal policy begins to price prevention, integration, and long-term accountability, the broader market tends to follow. Over time, the financial system begins to reflect the biology of chronic disease rather than react to its complications.

Note: I’m working on a piece for participants in the ACCESS model, with a few modeled scenarios for the e/CKM tracks. Please reach out if you’d like to share any insights, comments, or questions.

Forward, March

This Kidney Month, I am encouraged by how far the system has moved in the short time I’ve been paying attention.

And yet, real gaps remain. Data still struggles to move cleanly across the ecosystem: primary care, cardiology, nephrology, dialysis, and transplant. Attribution models can blur responsibility rather than clarify it. Many practices lack the physician-level tools, analytics, and care team support needed to manage CKM risk in real time. Incentives may be aligning, but operational capacity is still uneven.

These are not reasons for skepticism. They show us where to focus next. I am hopeful we will get there because of the hard work of so many of you across this ecosystem. Thank you for what you do and for helping move this progress forward.

I’d love to hear from you. What is making you optimistic right now, and what are you celebrating this Kidney Month?

Leave a comment

Share

Subscribe now

RPA’s Annual Meeting brings together practicing nephrologists, APPs, practice managers, and industry, with a focus on networking, peer learning, and the delivery of practical information that is immediately actionable. The audience has grown every year since returning from covid, and the participants and content make this a must-attend event. Here are some of the highlights for the upcoming meeting, which takes place in Atlanta April 16^th through 19^th.

There are two pre-meeting programs that are new this year. The first is given in collaboration with the International Society of Glomerular Disease. This half-day program explains how to set up a clinical research program. The focus is on private practices who are new to the clinical research space, and covers the business case, necessary resources, and potential partnership opportunities. This in-person session takes place on April 16^th, the day before the start of the Annual Meeting. The second offering is a course in artificial intelligence use in nephrology. The program starts with two hours of virtual learning to be completed before the meeting. There will then be a closed 90-minute session with hands-on teaching, delivered in person during the meeting. The program awards a first-of-its-kind certificate -the AI-Ready Nephrology Practice Professional. Both programs are open for registration now; an additional registration fee is required.

Big Picture Talks help attendees understand the complexities of US healthcare delivery and policy. This year we will hear about the ongoing evolution of electronic healthcare records as they incorporate AI and population management tools. The chair of MedPAC (CMS’s payment advisory committee), Dr. Michael Chernew, will do a fireside chat about physician payment and the ongoing shift to value-based care. We will also hear talks about the payor’s perspective and priorities, and how pharmacy benefits managers (PBMs) work. Big Picture Talks are a signature feature of the RPA Annual Meeting and a terrific way to further understanding of the market forces at work on medical practice.

Last year saw the introduction of Round Robin sessions. Participants in the Round Robin sit in groups and discuss their real-life practice management challenges. An RPA staff member at each table captures insights generated from the discussion. Over the course of the session, tables trade their questions, so that the entire group gets a chance to offer solutions. This innovative format returns this year. Imitated but not duplicated, the secret sauce of the Round Robin is the participants. RPA brings together experienced private practice nephrologists and expert practice administrators, leading to deep discussions and innovative problem-solving.

The small size of the meeting lends itself to workshops, designed to facilitate discussion. Workshops this year cover a range of relevant challenges: practice succession planning, disaster preparation, and APP leadership development. For those not ready for the full AI certificate course, there will be a hands-on workshop on AI prompt writing; participants should be sure to bring their laptops for this interactive instructional session.

Sunday remains focused on clinical updates, but this year the content has been reimagined to enhance active learning and audience participation. The focus is on two emerging areas in nephrology: new therapies for glomerular diseases, and hemodiafiltration. The clinical sessions are grounded in practical information that can be used immediately. Staying through the Sunday session is highly recommended so as not to miss this useful content.

Work-life balance and wellness are critical, and one of the stated goals of the meeting is to come away feeling refreshed and recharged, rather than exhausted and depleted. Committee meetings remain in their new position on Thursday evening. This allows for a gentler start in the mornings, with morning wellness sessions for everyone to enjoy. The Pecha Kucha professional development opportunity allows participants to improve their public speaking skills and moves this year from the exhibit floor to its own workshop session. Evening social events include the opening reception and the PAC reception. Finally, donors to the Dale Singer Educational Foundation are invited to an exclusive “Flavor Tripping” experience using all-natural “miracle berries,” which make sour things taste sweet.

Registration for the Annual Meeting and the pre-meeting workshops is open now: https://www.renalmd.org/page/rpaannualmeeting26. The RPA looks forward to welcoming everyone to Atlanta!

Register here

###

Dr. Katie Kwon is a partner at Lake Michigan Nephrology and Vice President of Clinical Affairs at Panoramic Health. She serves on the Board of Directors of the Renal Physicians Association, and contributes to the American Society of Nephrology through its Kidney News editorial board.

If you’re planning to attend the RPA Annual Meeting, let us know! If not, which topics or sessions would you like us to cover while we’re on the ground?

Leave a comment

Share

Today I want to spend some time summarizing what we learned this week, better understanding the deal rationale based on what we know about dialysis footprints and economics, and anticipating where it leads next.

Subscribe now

What happened

On the same day DaVita reported its Q4 2025 results, it also announced a strategic investment in Elara Caring alongside Ares (private equity), and the intent is clear: DaVita and Elara plan to co-develop a kidney-specific home-based care model designed to reduce preventable hospitalizations and lower total cost of care.

The announcement is careful about what it promises. It doesn’t claim a finished product or a national rollout. Instead, it frames this as a model-building effort that will combine Elara’s existing in-home clinical platform with DaVita’s kidney expertise, which is exactly what you would expect if the goal is to move from a strategic thesis (“home is the future”) to something operational (“here’s how we’ll do it”).

As a key focus of the investment, DaVita and Elara intend to co‑develop a kidney‑specific home‑based care model. This new model will build upon Elara’s existing clinical capabilities and apply DaVita’s advanced clinical insights to meet the unique needs of patients with kidney disease, seeking to reduce preventable hospitalizations, and helping to lower the total cost of care. The program will seek to offer patients a new pathway to receive high‑quality, tailored support in the comfort of their own homes, and empower providers with a vital resource to ensure high-touch, continuity of care.

Why Elara

Elara’s scale is part of the rationale. The company describes a footprint across 18 states, supported by roughly 26,000 caregivers and 200 offices, serving over 60,000 patients and their families every day. If DaVita wants to expand its home footprint in a way that goes beyond home dialysis modality, it needs a platform that already knows how to staff, coordinate, and deliver care in the home for complex populations. Building that from scratch is possible, and DaVita has been growing home dialysis for years, but broader uptake has been slow, operationally heavy, and full of headwinds. Partnering may be faster and make financial sense, but only if the incentives, workflows, and accountability are designed to work together. That part takes time, capital, and know-how. Fortunately, this partnership brings all three.

The IKC operating layer

At the same time, DaVita’s latest earnings offer a useful lens on why this partnership is showing up now. IKC is the part of DaVita built for risk: it is designed to manage outcomes and total cost, not just deliver treatments. DaVita also signaled that IKC reached its first profitable year in 2025, with momentum improving in the back half of the year. That shift helps explain why “home-based care” might get a lift here.

Table 1. IKC key metrics: implied PMPM spend and revenue1

The nuance I’m working through is that IKC can look small or big depending on where you’re standing. On the income statement, IKC is still a modest slice of DaVita’s overall business at ~$540 million, less than 5% of total company revenue. But it is moving. IKC revenue doubled quarter over quarter, rising from $94M in Q3 to $190M in Q4. On the patient side, it already touches a much more meaningful share of the population DaVita serves: 75,000+ lives across risk-based and other integrated care arrangements. Set against DaVita’s reported ~295,000 dialysis patients globally, that’s roughly ~26% of the company’s total patient base (with the caveat that these populations can overlap and aren’t perfectly comparable). In other words, IKC is still relatively small as a reported revenue line, while already sizable in terms of lives managed and strategic surface area.

That mismatch matters because the “bigger number” in IKC isn’t its revenue necessarily, it’s the spend it sits on top of. DaVita’s $5.6B in annualized medical spend is not money IKC books as revenue; it’s the total cost of care under management in its risk-based arrangements. That’s the growing pool of at-risk capital that an at-home model could influence, and it’s what makes investments in wraparound home support investable in a way fee-for-service rarely sustains.

Author’s note: For more context on the current landscape and economics of risk-based kidney care, see our recent series here.

Learn more

How it works

What remains unclear, and what I think will define whether this becomes a meaningful new leg of DaVita’s business, is the operating model. The announcement is light on details. For example, whether DaVita will enroll its IKC kidney patients into Elara-delivered home services, whether Elara’s existing patients include a meaningful kidney cohort that DaVita will wrap with kidney-specific programs, or whether the first version is a jointly managed population that starts narrow in a few markets and expands where it’s needed.

It’s also not yet clear how the investment capital will be deployed in practice: whether it supports workforce buildout, technology and coordination infrastructure, payer contracting and risk-sharing mechanics, or a mix of all three. Those are not small details, but they are certainly top of mind for other value-based entities operating home-based care models in this space.

This is a DaVita-specific lens. We’re applying its 2024 setting-level revenue mix to its 2025 blended revenue to estimate an implied split by setting (in-center, home, vs. hospital). It’s not a universal model for home dialysis economics. Smaller home-first providers will have different overhead, staffing ratios, supply costs, and referral dynamics. Some advantages, some challenges.

Table 2. Implied Dialysis Revenue Mix

Assumptions

The key clue in DaVita’s prior reporting is simple: home dialysis is a smaller share of treatments, but a bigger share of dialysis revenue. In 2024, home was ~16% of treatments and ~19% of dialysis patient service revenues. That implies home treatments are about 27% more revenue-dense than in-center treatments.

If we apply that same relationship to DaVita’s reported Q4 2025 blended revenue per treatment ($422.60), we can back into a rough split: ~$396 per in-center treatment vs. ~$501 per home treatment. It’s directional, not precise. Mix changes year to year. But it helps explain why DaVita keeps leaning into “home” even when modality share moves slowly. Home doesn’t need to become the majority to matter. It just needs to scale enough to shift incentives, staffing, and how care gets delivered.

Closing

Mozarc is worth recalling here because it shows DaVita’s long arc. In 2022, DaVita and Medtronic announced Mozarc as a 50/50 kidney technology venture, funded with $200 million each, built around the idea that at-home innovation would require both devices and care delivery know-how. I imagine the Elara partnership reads like the next iteration of that same ambition; less about inventing a new machine, and more about building the operating layer that actually makes home-based kidney care work.

Still, the direction of travel is visible. DaVita is effectively saying that the next home footprint in kidney care will not be measured by modality mix or machine. It will be measured by whether coordinated care can reach patients where they live, keep them stable, and do it in a way that is economically durable under risk. Dialysis economics still pay the bills, but IKC becomes a lever that funds the operating layer around the patient beyond the outpatient network. The Elara partnership is a bet on the care integrations required to do that. IKC’s performance is the early evidence that the economic layer may finally be catching up.

I’d love to hear what you think. Leave a comment below and let us know what questions we should be asking or where you think this leads next.

Leave a comment

Share

Share

By Iqra Aftab

She was 21 years old. A young Black woman with unexplained fatigue, migratory joint pain, and a rash no one could name.

She was my first lupus patient, and she taught me a visceral lesson: In kidney disease, delay is not neutral. Delay is damage.

The silent stakes of lupus nephritis1

Systemic lupus erythematosus (SLE) disproportionately affects young women of color. Black women are diagnosed two to three times more often than white women, develop the disease at a younger age, and experience more severe manifestations, including higher mortality at young ages.2 Among the most consequential manifestations is lupus nephritis, an immune-mediated kidney inflammation that occurs in approximately 40–60% of lupus patients, often within the first few years of diagnosis.3

What makes lupus nephritis uniquely unforgiving is that the kidneys rarely announce their distress loudly. Proteinuria may smolder for months, and serum creatinine can remain deceptively normal. By the time laboratory abnormalities appear alarming, irreversible scarring may already be established. In lupus nephritis, treatment decisions are made not by symptoms alone, but by what the kidney tissue itself shows.

The only reliable way to distinguish reversible inflammatory injury from permanent chronic damage is a kidney biopsy. In lupus nephritis, biopsy findings determine disease class, prognosis, and treatment intensity. The biopsy is therefore not merely confirmatory, it is decisional. It tells us whether we are treating active inflammation or managing the consequences of injury already sustained.

For my patient, getting that biopsy became an uphill battle.

Three delays

Subscribe now

The first delay was diagnosis itself. Her symptoms: fatigue, joint pain, intermittent swelling, were diffuse and easy to dismiss. Like many young women of color with lupus, she did not fit a pattern that triggered immediate recognition, let alone urgency or timely escalation. Studies show that Black and Hispanic patients experience longer delays from symptom onset to lupus diagnosis and longer delays to subspecialty rheumatology care compared with white patients.4

By the time I met her, lupus had been active for months.

The second delay was the biopsy. I practice in South Jersey, a region that appears suburban on a map but functions like rural America when it comes to specialty access. Nephrology referral took weeks. Once nephrology agreed a biopsy was indicated, coordination with interventional radiology took additional weeks. Insurance authorization. Scheduling. Pre-procedure clearance. Each step was reasonable in isolation. Together, they created a delay the disease did not respect.

From the system’s perspective, this was a non-emergent procedure. From the patient’s perspective, it was not.

The third delay came with treatment escalation. When the biopsy was finally performed, it showed active inflammatory disease layered on chronic damage. The window for optimal intervention had narrowed. We initiated aggressive immunosuppression, but her proteinuria proved difficult to control. Second-line therapy. Third-line therapy. Prior authorizations. Toxicity monitoring. Each escalation introduced additional friction. Each step introduced delay not because options were unavailable, but because access to them was gated.

From the outside, it looked like her disease wasn’t responding to treatment. In reality, it was responding to treatment that came too late.

Subscribe now

Delay is not distributed equally

This story is not an outlier. It is a pattern, and it falls hardest on those with the least margin for delay. These outcomes are not surprising; they are the predictable result of unequal access layered onto a time-sensitive disease.

Black patients with lupus are up to four times more likely to develop lupus nephritis than white patients and are more likely to present with high-risk histologic features on kidney biopsy.5 They experience faster progression to end-stage renal disease and lower rates of remission on standard therapies.6 Hispanic and Asian patients face similarly elevated risks of severe renal involvement and poorer outcomes.7

These disparities are not fully explained by genetics or baseline disease severity. They emerge where time-sensitive care meets fragmented access. Access plays a major role. In rural and underserved areas, nephrology care is limited; up to 40% of patients with advanced kidney disease meet a nephrologist for the first time within four months of initiating dialysis.8 In lupus nephritis, where biopsy findings directly determine treatment intensity, delayed access to nephrology and biopsy translates directly into delayed appropriate therapy.

Time-to-biopsy is not a scheduling metric. It is a prognostic one. Delays do not just slow care, they change the outcome.

Share

What this means for kidney care stakeholders

For clinicians, this means recognition is the first intervention, not just screening. Lupus nephritis rarely presents dramatically. Mild proteinuria, intermittent hematuria, or subtle serologic changes may precede severe Class III or IV disease. Waiting for creatinine to rise is waiting too long. High-risk patients, particularly young women of color with lupus, require routine urine surveillance, early nephrology involvement, and a low threshold for biopsy. In kidney disease, vigilance is not defensive medicine; it is disease-modifying care.

For biotech, pharma, and diagnostics, this means drug efficacy is capped by timing. No immunosuppressive therapy can reverse kidney fibrosis that accumulates while patients wait for diagnosis or biopsy. When effective therapies appear to underperform, the problem is often not the molecule, but late deployment. Therapies cannot reach the patients who stand to benefit most if identification, referral, and biopsy remain slow or fragmented. Diagnostics, risk stratification tools, and faster biopsy pathways are prerequisites to therapeutic value, not adjuncts.

For health systems and payers, this means coordination and access are not administrative details; they shape outcomes. Delayed biopsy leads to more advanced disease, more expensive therapies, higher hospitalization rates, and earlier progression to chronic kidney disease and end-stage renal disease. Value-based models that focus narrowly on the cost of procedures fail to capture the far larger downstream costs of delay. Time-to-biopsy should be measured, tracked, and incentivized in the same way time-to-reperfusion is in cardiology or time-to-antibiotics is in sepsis.

For patient advocates, this means delay remains invisible unless someone names it. Lupus patients, especially young women of color, need to understand that kidney involvement is common, often silent, and time-sensitive. Routine urine testing is not optional. Worsening proteinuria is not something to “just watch.” Informed patients can push against system inertia, advocate for earlier referral, and demand urgency when their kidneys are at risk.

What kidneys remember

My patient eventually stabilized. Her disease came under better control. But her kidneys carry the record of every week we lost, written in fibrosis, diminished reserve, and heightened vulnerability to future flares.

She did not fail treatment. The system failed her timeline. Some organs forgive delay. Kidneys do not. They remember it. And once that story is written, no medication can unwrite it.

When it comes to kidney disease, time is tissue; and too many patients are running out of time.

###

Iqra Aftab, MD is a practicing rheumatologist in South Jersey who cares for patients with lupus and other autoimmune diseases. She is also a community builder with Docs in Tech and an expert reviewer for BMC Digital Health & AI, with a focus on connecting clinical care, technology, and patient advocacy to improve outcomes in complex diseases.

Leave a comment

Share

You can see it in plain sight. Kidneys are showing up in places they rarely did before. A New York Times deep dive on metabolic health. Cardio–kidney–metabolic disease becoming a core pillar of CMS’ actions and innovation models. Other specialties increasingly looking to the kidney for answers to their own hardest problems.

The era of overlooking kidneys is ending. Now comes the work of showing why this elegant, underestimated organ is worth understanding, investing in, and fighting for.

That work won’t resolve overnight. It will take years. But our role is simple: make sure the right people are in the room when the future of kidney health is being shaped. If we do that well, the downstream impact will touch hundreds of millions of lives.

Days like this remind me why I started writing Signals in the first place. To cut through the noise. To connect people and ideas that actually move the field forward. And to help make progress in this “space” feel a little more concrete.

You’re a bigger part of that future than you might think. Thanks for being here.

We also released three new pieces this month, including Part 3 of our kidney value-based care landscape series, our list of 26 signals shaping the space this year, and a powerful guest essay by Jeff Parke on the hidden costs of care burden.

Have tips or feedback? Hit reply or drop us a note here.1

Reading time: 35 minutes

Subscribe now

What’s Inside

• News: CKM screening goes mainstream, AI platforms move into healthcare infrastructure, gene therapy momentum in rare kidney disease, transplant system scrutiny intensifies, CMS and FDA signal faster paths for health tech

• Research: Kidney–heart cross-talk via extracellular vesicles, social determinants reshaping global kidney disease, disease-modifying signals in Alport syndrome, metabolic dysfunction as a root driver of CKD and CVD

• Community: ACCESS model readiness and next steps, record-setting transplant volumes at Emory, in-home value-based care outcomes, new playbooks for tech-enabled kidney care, resources for builders and operators

• Events: ASTS Winter Symposium, Mayo Clinic Clinician Update, AHIP: AI In Kidney Care, World Congress of Nephrology, RPA, and more

• Jobs: State of Maine, Harvard, Vertex, Ardelyx, Travere, MediBeacon, Vantive, Primary Venture Partners, GEHA Health + dozens more on jobs.signalsfs.com…

  Subscribe now

This issue is made possible by Renalytix. Renalytix is an artificial intelligence-enabled in vitro diagnostics company, focused on optimizing clinical management of kidney disease to drive improved patient outcomes. Renalytix has received FDA approval and Medicare reimbursement for kidneyintelX.dkd which is offered commercially in the United States. Learn more about the test below, and watch my recent interview with Chief Medical Officer and Lab Director, Michael Donovan.

Learn more

News

EARLY SCREENING & TX

• Nina Agrawal’s recent piece in the New York Times unpacks how poor metabolic health, driven largely by excess visceral fat and insulin resistance, fuels cardiovascular disease, chronic kidney disease, diabetes, and even cancer. With the American Heart Association estimating that ~90% of U.S. adults have some degree of cardio-kidney-metabolic syndrome, the article underscores why early screening, prevention, and sustained lifestyle and medical interventions matter long before organ damage becomes irreversible.

• Boehringer Ingelheim and CommonSpirit Health launched the CARES program, a community-led initiative to improve cardio-kidney-metabolic (CKM) screening and diagnosis in vulnerable populations, beginning in Chattanooga, TN and Omaha, NE. The collaboration focuses on increasing adherence to evidence-based guidelines through clinician training and locally co-created solutions that reflect community needs. CARES targets early identification of CKM conditions such as chronic kidney disease, diabetes, and cardiovascular disease, where under-screening and delayed diagnosis remain persistent challenges, particularly for Black and Hispanic/Latino communities. The partners describe the program as a scalable blueprint for health systems seeking sustainable, equity-driven approaches to CKM care. (Press release)

• Carna Health raised $8M to scale global CKD screening following a strategic partnership with Siemens Healthineers. Together with NeoDocs, the group screened 35,000 people in Cameroon, showing how large-scale, low-cost detection can surface silent disease. Early CKD identification remains a top priority globally, and scalable screening models are finally moving from pilots to population impact. (H/t Salvatore Viscomi)

NEW THERAPIES / R&D

• ENYO Pharma reported encouraging Phase 2 results for vonafexor in people with Alport syndrome, a rare genetic kidney disease with few treatment options. In their Alpestria-1 study, the drug reversed the typical decline in kidney function, shifting patients from a historical loss of kidney function to an average improvement while on treatment. Notably, most patients maintained lower protein levels in their urine even 3 months after stopping the drug, suggesting a potential disease-modifying effect rather than short-term symptom control. Based on these results, ENYO plans to move vonafexor into Phase 3 trials.

• SonoThera launched a $125M Series B to move multiple genetic medicine programs toward first-in-human trials, including kidney diseases like ADPKD and X-linked Alport syndrome. The company’s nonviral RIPPLE™ ultrasound-based delivery platform has shown efficient delivery of DNA payloads to key kidney cell types, including tubular epithelial cells and podocytes, in non-human primate studies. The technology is designed to deliver large genetic payloads safely, repeatedly, and with targeted distribution across organs. SonoThera plans to begin Phase 1 human trials as early as 2027, marking a transition from preclinical development to clinical execution.

AI IN HEALTHCARE

• Anthropic launched Claude for Healthcare, a HIPAA-ready suite of AI tools for providers, payers, life sciences teams, and patients, building on its latest Opus 4.5 model with stronger medical and scientific performance. The offering supports use cases like prior authorization, care coordination, regulatory submissions, and clinical trial operations, with connectors to CMS coverage databases, ICD-10, NPI registries, and major research platforms. U.S. Claude Pro and Max users can also opt in to connect personal health records to summarize data and explain results, with explicit privacy controls and no training use. The launch comes days after OpenAI announced ChatGPT Health. The race to define AI-native healthcare infrastructure is well underway.

• OpenAI launched ChatGPT Health in the U.S., allowing users to upload medical records and health app data to receive more personalized health-related explanations and insights. OpenAI says health conversations are stored separately, won’t be used to train models, and are intended to support (not replace) medical care. Privacy advocates welcomed the potential benefits but warned that health data is highly sensitive and requires airtight safeguards, especially as AI companies push toward deeper personalization and new business models like advertising. The feature is rolling out to a small group of U.S. users and is not yet available in the UK or EU. (Press release, BBC News)

• OpenAI acquired Torch, a four-person health records startup, in an acqui-hire reportedly valued at around $100 million in equity. Torch was building a way to unify medical records, labs, wearables, and consumer health data into a “medical memory for AI”. The team formerly worked together at Forward Health (former member here, I do miss it), and will now join OpenAI’s newly announced ChatGPT Health initiative. (TechCrunch, Axios)

  Author’s note: if you are interested in the topic of care navigation, you might enjoy my recent deep dive on what kidney can learn from cancer care here, or my recent conversations with Intermountain and ChenMed on their kidney navigation service models.

POLICY / REGULATORY

• ARPA-H launched ADVOCATE, a new program to develop FDA-authorized agentic AI systems capable of delivering specialty cardiovascular care in regions with severe clinician shortages, where 46% of U.S. counties lack a cardiologist. The initiative aims to fund full-stack AI solutions that can autonomously manage advanced heart disease care, alongside supervisory AI systems to monitor safety and performance after deployment, and partnerships with health systems to ensure real-world adoption. ARPA-H positions ADVOCATE as a potential blueprint for addressing clinician shortages across chronic diseases, with an independent analysis estimating more than $50 billion in annual savings from improved heart failure care alone. (STAT News, h/t Haider Warraich)

• The FDA issued a Request for Information exploring a new contracting model designed to work more directly with venture-backed companies developing innovative technologies. The agency is seeking input from venture capital firms on a structure that would allow qualified funds’ portfolio companies to compete for FDA task orders, bypassing traditional intermediaries that often favor labor-based contracts over scalable products. FDA leadership framed the move as a way to accelerate access to innovation across areas like AI, biotech, medical devices, and regulatory technology, while addressing long-standing barriers for early-stage companies. Responses to the RFI were due January 18, 2026 (FDA.gov, h/t Sandeep Patel)

• The FDA announced major changes to its oversight of wearables and AI-enabled digital health tools, easing regulation for certain clinical decision support software. Speaking at CES, FDA Commissioner Marty Makary said the agency wants to move at “Silicon Valley speed” and create a more investor-friendly environment, allowing some AI tools to enter clinical workflows without prior FDA review if they meet exemption criteria. (STAT, Latham, h/t Sina Fateh)

• The U.S. Government Accountability Office released a new report calling for urgent action to fix persistent weaknesses in the U.S. organ transplant system. The January 22 report finds that U.S. Department of Health and Human Services has identified major risks in organ allocation, oversight, and IT reliability but has not yet laid out a detailed, time-bound plan to implement reforms under its OPTN modernization initiative. GAO also raised concerns about the system’s longtime contractor offering optional supplemental services to transplant programs, generating $9.6 million in fees in FY2024, without HHS formally assessing the risks or transparency of those arrangements. The watchdog recommended that HHS define clear milestones for modernization, evaluate contractor conflicts, and strengthen interagency coordination; HHS agreed with all three recommendations, signaling that significant changes to transplant governance may now be imminent.

• CMS selected Nevada Donor Network to take over organ procurement services in South Florida after decertifying the University of Miami–affiliated Life Alliance Organ Recovery Agency for failing to meet federal performance standards. The transition will be overseen by CMS to ensure uninterrupted donation and transplant services for a region serving roughly 7 million people. This reflects intensified federal pressure to improve accountability across the transplant system. The move comes as deceased kidney donation declined for the first time in more than a decade, following heightened scrutiny and reports that have led some Americans to remove themselves from donor registries.
  

  Subscribe now

  

Research

ARTIFICIAL INTELLIGENCE

• A state-of-the-art review in Clinical Kidney Journal outlines how artificial intelligence is beginning to reshape nephrology across AKI, CKD, dialysis, and transplantation. The authors highlight promising use cases, from early AKI prediction and CKD risk stratification to dialysis optimization and transplant tools like the iBox system, which has already gained regulatory recognition. The roadmap emphasizes that the next frontier is not autonomous care, but clinically integrated, workflow-aware decision support that pairs strong validation with thoughtful implementation to deliver more precise and equitable kidney care. (H/t Wisit Cheungpasitporn, Joe Ix)

• A feature in the latest issue of Kidney News argues that artificial intelligence has moved from experimentation to core infrastructure in kidney care, influencing clinical decisions, workflows, and patient engagement. The article highlights a new statement from the American Society of Nephrology AI Workgroup outlining principles for responsible AI use, including patient benefit, clinician oversight, and transparency. Paired with priorities from the KDIGO Controversies Conference, the piece frames the next phase of nephrology AI as a shift from building algorithms to integrating them responsibly at scale to support precision, trust, and equity in kidney care. (H/t Wisit Cheungpasitporn)

Figure: AI Scribe Adoption Over 1-Year Period

• An editorial in NEJM AI takes a clear-eyed look at the current limits of AI scribes, arguing they are not yet the productivity breakthrough many hope for. Drawing on two randomized trials, the authors show modest reductions in documentation time and mixed effects on burnout, with real-world gains often amounting to less than a minute per visit. The piece argues that meaningful productivity gains will likely come only as AI scribes expand beyond note-taking into downstream tasks like orders, prior authorizations, and billing. Until then, AI scribes may help at the margins, but they are not yet a transformative fix for clinician workload. (H/t Karandeep Singh)

• A narrative review in Journal of General Internal Medicine critiques the rapid growth of wellness testing, arguing that direct to consumer genomics, broad lab panels, wearables, and whole body imaging have far outpaced the evidence. The authors estimate these low value diagnostics drive more than $100B in annual downstream U.S. healthcare costs while exposing patients to false positives, anxiety, and bias. Instead, they propose a three tier precision health framework that uses AI to guide high sensitivity screening, targeted confirmation, and precision interventions based on pre test probability, with the goal of reducing waste and refocusing prevention on proven care. (H/t Pranav Rajpurkar)

• An editorial in Nephrology Dialysis Transplantation discusses emerging preclinical evidence that CAR T-cell therapy could directly target kidney fibrosis, a core driver of CKD progression. Building on work by Zhao et al., the authors highlight a PDGFRβ-targeted CAR T approach that reduced fibrosis and preserved GFR in animal models, including a novel in vivo strategy using lipid nanoparticle–delivered mRNA to generate transient CAR T cells. If translated to humans, this off-the-shelf, non-oncologic CAR T platform could challenge the long-held view of CKD as only slowly modifiable and open the door to fibrosis-directed therapies alongside existing nephroprotective drugs. (H/t Lars Koch)

CLINICAL RESEARCH

• A review in Nature Reviews Nephrology argues that forces like urbanization, climate change, pollution, and shifting lifestyles are increasingly driving CKD and AKI risk, particularly in low- and middle-income countries where health systems are least equipped to respond. The authors call for integrating social determinants into kidney research, policy, and care models to better predict disease trends and reduce global inequities. (H/t Augusto Cesar)

• A new call to action in The American Journal of Preventive Cardiology urges routine CKD screening as a core strategy to reduce cardiovascular risk and improve outcomes. The paper emphasizes dual screening with eGFR and UACR, noting that most people with CKD remain undiagnosed and are more likely to die from cardiovascular disease than progress to kidney failure. While this message is well established in nephrology, the authors argue that cardiologists and primary care clinicians must now take a leading role in early detection and implementation of guideline-directed therapies. The piece marks an important shift, signaling growing recognition within cardiology that kidney disease is central to cardiovascular prevention, not peripheral. (H/t Erin Michos)

• A synopsis in Annals of Internal Medicine outlines the updated 2025 joint CKD guideline from the U.S. Department of Veterans Affairs and the U.S. Department of Defense, signaling a continued shift of CKD care into primary care. The guidance emphasizes earlier diagnosis, team-based management, clearer referral pathways, and broader use of evidence-based therapies to reduce cardiovascular risk, slow progression, and improve survival. The update reflects how rapidly CKD management has evolved and reinforces the central role of primary care in delivering modern kidney care.

• A new study in Circulation shows that diseased kidneys release circulating extracellular vesicles carrying toxic microRNAs that travel to the heart and impair cardiac function, offering a mechanistic explanation for why cardiovascular disease drives mortality in CKD. In animal models, blocking these vesicles improved heart function, pointing to new opportunities for biomarkers and targeted therapies to identify and protect high-risk patients earlier.

• An expanding wave of phase 3 trial data is rapidly reshaping IgA nephropathy care, with multiple immunosuppressive and non-immunosuppressive therapies showing meaningful proteinuria reduction across different mechanisms. Evidence suggests additive benefits when combining RAAS, SGLT2, endothelin blockade, and newer agents such as APRIL/BAFF inhibitors, but key questions remain around optimal sequencing, upfront combination therapy, and treatment of high-risk groups excluded from trials. Future progress will depend on coordinated trials, real-world data, and better phenotyping to match patients to the right therapies earlier. (Kidney News, h/t Ayman Al Jurdi)

Figure: SleepFM Study: Performance across clinically relevant diseases evaluated on Stanford data (n=5019)

• A paper in Nature Medicine introduces SleepFM, a large multimodal AI model trained on more than 585,000 hours of polysomnography data from 65,000 people to predict future disease risk from a single night of sleep. The model accurately predicted 130 conditions years before diagnosis, including chronic kidney disease, heart failure, stroke, dementia, and all-cause mortality, outperforming traditional demographic risk factors. By learning a unified representation of brain, heart, muscle, and breathing signals, the study positions sleep as a powerful and underused biomarker for early disease detection, including kidney disease, at population scale. (H/t James Zou)

• A study in Kidney International used data from the Mass General Brigham Biobank to better understand the genetic causes of nephrotic syndrome in adults. The researchers found that 17% of patients had a clear genetic form of disease, even though many were labeled as having “secondary FSGS,” a diagnosis that often leads clinicians to skip genetic testing. The study also identified variants in the MEFV gene as a previously underrecognized risk factor for FSGS, even in patients without classic signs of Familial Mediterranean Fever. Overall, the work supports broader genetic testing in adult kidney disease and points to more personalized treatment approaches. (H/t Matt Sampson)

• A behind-the-paper look in Communications Biology explains why kidney scarring in diabetes is so difficult to reverse, even with good glucose control. The authors describe how a small regulatory RNA, miR-299a-5p, becomes elevated in diabetic kidneys and suppresses the organ’s natural antifibrotic defenses, driving ongoing scar formation. In animal models, blocking this microRNA restored protective pathways and improved kidney function, suggesting that durable RNA-level changes may lock diabetic kidney disease into a self-perpetuating course. (H/t Kennedy Nmecha)

• A recent case report highlights side effects with obinutuzumab, a newer anti CD20 therapy increasingly used for difficult to treat immune mediated glomerular diseases. While the drug offers deeper and more durable B cell depletion than rituximab, the authors describe three patients who developed severe hematologic toxicities, including grade 4 neutropenia and persistent anemia, even when used as monotherapy. The findings underscore the need for careful patient selection, close monitoring, and a clearer understanding of risk tradeoffs as newer immune therapies move into routine kidney care.

MARKET TRENDS

• The 2025 HSBC Venture Healthcare Report finds that U.S. healthcare venture capital began to recover from the recent downturn, with investment rebounding late in the year, driven largely by AI-enabled technology rounds and increased M&A activity. While overall deal volume remained constrained, capital concentrated into larger, later-stage financings, particularly mega rounds in biopharma and outsized raises in medtech and healthtech. Looking ahead, HSBC projects modest growth in 2026, with total healthcare venture investment reaching $65–70B, supported by renewed IPO activity, stronger M&A, and growing participation from crossover investors and corporates. The report suggests the next cycle will favor scale, capital efficiency, and platforms that combine clinical impact with durable business models. (H/t Jon Norris)

• Carta data shared by Peter Walker shows that Q4 2025 was the most active quarter for startup M&A on record, with 232 acquisitions, up 60% from Q4 2023. Nearly half of deals involved pre-seed and seed-stage companies, reflecting a surge in acquihires and competition for AI talent, while a record number of acquired companies had raised more than $50M. More than 40% of acquisitions involved AI startups, highlighting how quickly AI-native capabilities are becoming core to corporate strategy, even as many deals fail to generate returns for common shareholders.

• A new report from Hospitalogy offers a detailed look at the current and emerging state of U.S. health systems heading into 2026. The report examines macro trends shaping hospital strategy, including automation and AI adoption, physician employment pressures, specialty drug economics, and shifting nonprofit and for profit performance benchmarks. It also includes health system case studies, financial tear sheets, and analysis of where AI can meaningfully drive margin expansion in areas like prior authorization, denials management, and revenue cycle operations. (H/t Blake Madden)

• Caroline Pearson of the Peterson Health Technology Institute argues that more than $50B invested in digital health has delivered mixed results, highlighting the need for stronger evidence and accountability. After reviewing dozens of tools across healthcare, PHTI finds that technology works best when it scales proven care models, replaces existing services instead of adding cost, and targets the right patients at the right time, while many behavior-change apps have fallen short. I believe this piece reinforces a clear through line from the growing cardio-kidney-metabolic care paradigm: the next phase of health tech must be defined by measurable outcomes, real-world validation, and performance-based adoption, not hype. (H/t Caroline Pearson)

Community

• In his first editorial as president of the American Society of Nephrology, Samir Parikh frames Hope in Nephrology as both a personal reflection and a call to action, alongside ASN’s new 2026–2027 Strategic Plan (see below). He highlights progress made in 2025 across research funding, prevention, transplant policy, and workforce support, while emphasizing that hope must translate into execution, equity, and fair compensation for nephrologists. The piece positions optimism not as sentiment, but as a responsibility to patients, trainees, and the future of kidney care. (H/t Samir Parikh)

• A webinar hosted by HMA and Leavitt Partners breaks down the decade-long, voluntary ACCESS model, which creates a new Medicare payment pathway for digital health, remote monitoring, behavioral support, and co-managed chronic care. For technology companies and value-based care operators, this is one of the clearest signals yet of how CMS plans to operationalize innovation at scale and what applicants should be doing now to prepare for the upcoming RFA (H/t Ryan Howells and Kate de Lisle).

• National Kidney Foundation highlights 5 FDA approvals in 2025 targeting specific kidney disease pathways, from diabetes-related CKD to rare immune-driven disorders like IgAN and C3G. Newly approved therapies span GLP-1s, complement inhibitors, monoclonal antibodies, and endothelin receptor antagonists. It shows kidney care is finally moving beyond one-size-fits-all treatment toward precision therapies (NKF).

• A major milestone for pediatric kidney care: the first patient has been enrolled in the first global prospective pediatric CKD trial evaluating SGLT2 inhibitors. The study builds on a 2023 convening led by the Kidney Health Initiative and NephCure to address trial design, safety, and regulatory gaps. The launch marks a concrete step toward evidence-based therapies for children with CKD and shows how coordinated leadership can translate long-standing needs into action. (H/t Barbara Gillespie, Fortrea)

• An article by Rob Blaser and Rebecca Schmidt in Healio argues that kidney policy advocacy is more important than ever as payment models and care delivery continue to shift. It highlights the long-standing role of the Renal Physicians Association in shaping kidney reimbursement and representing nephrology within the AMA, with a 2026 agenda focused on payment reform, value-based care, living donation, prior authorization, and telehealth. The piece makes the case that sustained advocacy is essential to protect patients and enable modern kidney care as the system evolves. (H/t Rob Blaser)

• Emory Healthcare set a new U.S. record in 2025 with 591 adult kidney transplants, the most ever by a single program in one year. Emory led the nation in both living and deceased donor transplants and performed more kidney transplants in African American patients than any other center, expanding access despite a national decline in organ donation.

• AbsoluteCare appointed Alice Wei as Nephrology Medical Director as it launches a statewide Medicaid CKD initiative in Ohio. Beginning in 2026, the program will deliver whole-person, wraparound kidney care to nearly 10,000 high-need members across urban and rural communities. AbsoluteCare reported a 40% reduction in hospital dialysis starts and higher use of guideline-directed CKD meds. Congrats Alice!

• A new Kidney International editorial describes how a Fiji-led collaboration helped catalyze kidney supportive care in a resource-limited setting, where dialysis access is constrained and symptom burden is high. The piece lays out culturally grounded principles, workforce realities, and a phased pathway to embed supportive and conservative kidney care into routine practice, emphasizing nonabandonment, community engagement, and pragmatic capacity building across the Pacific. (H/t Shilpa Jesudason)

• Venova Medical announced successful initial patient enrollments in the VENOS-3 Pivotal Study evaluating its Velocity® pAVF System, led by Dr. Rishi Razdan and the team at Azura Vascular Care in Jacksonville, Florida. The milestone marks early progress in Venova’s effort to advance percutaneous AV fistula creation as a less invasive option for hemodialysis vascular access.

• In an op-ed in MedPage Today, Macey Levan argues that U.S. transplantation has outgrown its current federal governance and needs a dedicated bureau focused solely on transplant policy and oversight. She warns that limited transparency and stakeholder engagement in OPTN modernization risks weakening a system that depends on clinician and patient participation. She believes a standalone transplant bureau would strengthen accountability, modernize infrastructure, and keep patients and professionals at the center of reform.

• In an internal analysis, Monogram Health reports that its multispecialty, home-based model for polychronic patients is associated with 44% fewer hospital admissions, 52% fewer ED visits, and $160M in partner cost savings in 2024, rising to $375M in 2025. The results reinforce growing evidence that coordinated, whole-person care—especially for kidney and cardio-metabolic populations—can improve outcomes while materially bending the cost curve. (H/t Shammi Gupta)

• Bobby Lawson wrote a great post about how care delivery often breaks at the contract level. A sharp take on why payer–provider agreements fail not in negotiation, but in design: built on assumptions about workflows, incentives, and economics that don’t hold up in real-world care delivery, leading to margin pressure, operational drag, and patient access friction.

We’d love to hear from you. What questions and comments do you have from this month’s recap? What stood out to you, and what else should we know?

Leave a comment

Events Calendar

• ASTS Winter Symposium (Jan 22-25, Phoenix, AZ)

• Mayo Clinic Clinician Update (Feb 13-15, Scottsdale, AZ)

• AHIP: AI In Kidney Care (Feb 26 at 12pm ET)

• WCN (Mar 28-31, Yokohama, Japan)

• RPA Annual Meeting (Apr 16-19, Atlanta, GA)

• Columbia CKM: Evolving Frontiers (May 1, Virtual)

• NephCure Support Groups (Ongoing)
  

  Subscribe now

Jobs

• Nephrologist (Miami, FL) — Kaüna (Say hello!)

• Comp. Biologist Post-Doc — Harvard Med

• Director, Rural Health Program — State of Maine

• Assoc. Director, Patient Marketing — Vertex

• Associate, Healthcare Incubations — Primary VP

• Lead Director, Pop Health — CVS Health

• Analyst, Clinical Transformation — DaVita

• Data Fellow — Rock Health

• VP, Managing Director — GEHA Health Ventures

• Clinical Field Specialist — MediBeacon

• Director, Network Strategy — Strive Health

• …plus hundreds more at jobs.signalsfs.com
  

Find your next role

Work with us

Signals Group is expanding to support the growth of this community. Whether you’re looking to increase awareness for your work, prepare for your next milestone, or looking to enter a new market, we’d love to hear from you. We support mission-aligned organizations advancing kidney health.

1. Learn — Discover hundreds of articles & interviews in our Data Room

2. Share — See how Signals can help you reach your next milestones

3. Sponsor — See why our 2026 sponsorships are filling up fast
   

   See 2026 Sponsor Plans

Share

Recall that in Part 1 of our series we highlighted some of the early, but impactful data that VBCs are sharing. These included increases in dialysis optimal start rates ranging from 62% to 400% and reductions in hospitalizations between 20% and 50%. Part 2 focused on the growth of and investment in VBC models and how they are collected managing about 1.5 million patients and $40 billion in spend while expanding beyond kidney disease.

In Part 3 below, we highlight the approaches and technologies VBCs are using to drive both their own growth and outcomes for patients. While we have collected over 150 new data points in the last few weeks, the analysis below is less about specific numbers and more about highlighting the combination of capabilities VBCs are deploying in the following areas:

1. Patient Support: the suite of services and supports that VBCs offer to patients to help them optimize their outcomes through the stages of kidney disease.

2. Provider Enablement: how VBCs both enable nephrologists, PCPs and other providers deliver care to patients as well as help them optimize their own practices.

3. Technology (both patient and provider oriented): the products and technologies that can be implemented to engage with patients, support clinical decisions, and improve practice operations.

These three categories of capabilities are being used in concert by VBCs to delay disease progression, increase optimal starts, reduce hospitalizations and total cost of care for patients with advanced kidney disease and related comorbidities. However, both the depth and breadth of capabilities varies significantly across the industry, and, as we describe at the end of this article, is dependent on the business model of each competitor.

Patient Support

As shown in the chart below, the hallmark of the VBC business model is Care Coordination: creating an individualized care plan, enabling access to a multidisciplinary care team, and helping to ensure compliance with appointments and adherence to those treatment plans. Every VBC provides a version of this and many also specifically call out their ability to coordinate care with patients’ physicians who are outside of the VBC relationship.

Figure. Number of Leading VBCs Offering Selected Patient Support Services

Share

Across leading kidney VBCs, dedicated teams provide structured medical care, medication management, nutrition, and social support designed to address both chronic disease management and acute care needs outside of traditional visits. These teams are typically physician- or NP-led and interdisciplinary, combining nursing, care coordination, pharmacy, nutrition, and social work to function as an extension of the nephrologist across settings including PCP and nephrology offices, hospitals, and patients’ homes. Strive Health refers to this model as its “Kidney Heroes,” emphasizing deep patient engagement, but similar care team configurations and patient-facing support models are now standard across most scaled kidney VBC platforms.

Moving to the center and right side of the chart, we identified a handful of VBCs offering specialized services to help patients with kidney failure (ESKD) transition out of the hospital (and avoid being re-admitted), pursue transplantation as an alternative to dialysis, and address the day-to-day challenges of being a patient with ESKD. Most of the VBCs likely offer these or similar services, but it has not yet been a priority to highlight them in their public or patient facing materials, so the bars likely underrepresent capabilities. Notably, though, even REACH, one of the smaller VBCs included in our analysis in terms of team size and lives served, highlighted its ability to help patients who receive a new kidney to sustain their transplant over time.

Provider Enablement

Fewer of the VBCs highlight their ability to enable providers relative to supporting patients, but this should not be interpreted as an indication that services provided for physicians and their practices are relatively less important. Rather, it’s likely that the B2B aspect of their business models are not as prominently displayed, and require more nuance to convey than, say, being able to offer kidney-friendly recipes to patients.

Figure. Number of Leading VBCs Offering Selected Provider Enablement Services

That being said, the majority of the VBCs do offer care resources as extensions of physician care teams to help deliver care coordination, medical support, and other of the key services described above to patients. In many cases, these are “boots on the ground” resources in local markets. Somatus, Monogram, and Strive Health in particular highlight how their clinicians can act as physical and in-home extensions of practices by, for example ‘visit[ing] your patients in their homes, serving as your “eyes and ears”’ as highlighted by Monogram. Interwell and Kidneylink even discuss their ability to embed themselves in practices.1

Aside from augmenting staff, several of the VBCs focus on how they can help their partner practices optimize their business and drive growth. Sometimes these services are offered in the form of an upfront business assessment, but often VBCs can deploy a suite of ongoing support services and technologies (discussed in the next section) to help streamline back office functions, train staff, optimize contracts, and even provide financing. Panoramic, Interwell and DaVita highlighted the greatest set of capabilities in these areas, although the latter likely reflects overlaps with dialysis clinic operations and management.

The VBCs who offer these provider enablement services typically frame them as a way for physicians to focus on patients and alleviate the burdens of day-to-day operations without giving up control of either their practice or patient care. To that end, it’s common for VBCs to also highlight how participating physicians can play a role in the overall VBC care delivery model through, for example, Panoramic’s Physician Executive Body (PEB).

Technology (Patient & Provider)

While technology is integral to both supporting patients and enabling providers, one headline takeaway from the chart below is the relatively greater deployment of key systems and platforms to help physicians care for patients versus patients directly leveraging technology. While it’s encouraging that at least half of the VBCs do have a digital (online or app-based) interface for patients, care delivery is still heavily focused on meeting kidney patients where they are, which is often in-practice, in-home, or via phone / telehealth, rather than with a sophisticated technology platform.

Figure. Number of Leading VBCs Offering Selected Technologies to Patients (Blue) and Providers (Green)

Subscribe now

In addition to digital interfaces, VBCs like Interwell, Healthmap, and DaVita utilize their patient-facing websites to deliver extensive patient education materials to patients. Interwell Learning, formerly Raenali, offers providers a reimbursable kidney disease education (KDE) option that includes one-on-one sessions with clinical educators.2 Healthmap’s proprietary Compass platform and recent acquisition of Carium give providers end-to-end kidney population management capabilities. Meanwhile, the mySomatus app offers an online social community for patients, and is just one of five core product elements from its broader RenalIQ platform. A handful of companies suggest that they offer remote patient monitoring (RPM), yet the specifics of these solutions are not described and monitoring the key indicators of kidney disease typically requires lab tests. Of the three VBCs that indicate RPM offerings, Panoramic’s and Monogram’s may reflect their expansion into heart failure and other chronic diseases.

In terms of provider enablement, virtually every VBC highlights two key features of their technology. First, is their patient management platform, which enables the core care delivery capabilities of VBCs that we highlighted in the beginning of this article. These systems help both partner physicians and VBC care teams identify what interventions patients require, when they are needed, and who should deliver them.

Complementing (and often integrating with) these patient management systems are predictive analytics technologies that leverage patient data to identify and analyze the risk of patients progressing through stages of CKD or needing interventions to prevent hospitalizations in the ESKD population. Predictive analytics can also be used from population health perspective and on the “front-end” of a payor or provider relationship to understand the extent of a patient community that may benefit from a value-based care model. Notably, six of the eight competitors indicated that their analytics capabilities were AI or ML driven.

At least half of the VBCs offer electronic health and medical record (EMR / EHR) platforms or the ability to integrate their systems with existing EMRs. DaVita highlights a customized version of Epic, Interwell integrates with Epic via its Acumen platform that it acquired from Fresenius in 2022, while others like Monogram and Strive offer a purpose-built platform combining care management and EHR functionality.

VBC Capabilities Summary

Our research so far highlights the importance most VBCs place on directly supporting patients, enabling providers, and leveraging technology, primarily to maximize the effectiveness of patient touchpoints. The heatmap below distills the data in different way that hints at how various competitors are shaping their offerings to support their business models: Panoramic focused on practice enablement, Somatus both patient and provider oriented, Interwell and DaVita with extensive business optimization from their roots in clinic management while also being experienced in supporting ESKD patients, Healthmap emphasizing its technology, and Strive with its patient forward Kidney Heroes model.

Figure. VBC Capabilities Heatmap

That said, this capabilities review should be interpreted as an initial, high-level perspective on how the VBCs present themselves to patients, providers, and payors via their public facing websites, press releases, and similar materials. Some of the boxes in this heatmap are likely darker in reality, and very light boxes should be viewed more as a “TBD” than an absence of functionality. Signals continues to dig into capabilities, growth, outcomes, strategies, and financial performance of the VBCs to update our database and periodically share the important progress these companies are making on improving the lives of kidney patients.

Subscribe now

Series Conclusion & Next Steps

Across this three-part series, we examined value-based kidney care from outcomes, scale, and capabilities. Taken together, the data show that kidney VBC has moved from pilot-stage experimentation to a more mature, concentrated, multi-billion-dollar segment managing meaningful clinical risk at scale. As we pointed out in Part 2, a small number of platforms now sit at the center of this ecosystem, differentiated less by the mechanics of value-based care and more by how they contract, deliver care, and deploy technology to augment their capabilities.

Underlying this work is a Signals research database designed to support those building, growing, and partnering with value-based kidney care organizations. The database aggregates publicly disclosed and derived data across outcomes, lives managed, financial scale, care models, and product capabilities, with the goal of providing a clearer and more consistent view of how this market is evolving.

We are making this database available to select operators, payers, investors, and partners who are actively working in or adjacent to kidney value-based care and are looking to better understand the competitive landscape, operating models, and areas of differentiation. We plan to update the database regularly as the kidney VBC market continues to evolve.

If you’re interested in learning more about the database or discussing how it may be relevant for your work, please complete the form below.

Request Access

Share

___

About Us

Paul Grill is the Co-Lead of Signals Advisory and a career management consultant, M&A advisor, and venture investor. His most recent role was as Launch Director for the National Kidney Foundation’s Innovation Fund, where he led investments in startups bringing new treatments to kidney patients. Paul is also a living kidney donor and former NKF Board Member who is passionate about improving the lives of kidney patients.

Tim Fitzpatrick is the founder of Signals Group, a media and research platform exploring innovation, investment, and ideas shaping the future of kidney health. Through Signals, he has helped connect thousands of clinicians, entrepreneurs, and investors driving progress across kidney care. Tim previously co-founded IKONA, a learning company using immersive technology to improve patient education and frontline training in kidney care.

Together, Paul and Tim combine deep industry, investment, and advisory experience. From market research and landscape analysis to investment support, financial modeling, and expert feedback, they deliver insights that help companies make confident decisions and accelerate impact in kidney care. Learn more at signalsfs.com

Signals Group

Each year, I try to step back from the onslaught of headlines and ask a simpler question: what actually changed? Not what was announced or debated, but what truly shifted the underlying terrain.

In past years, I’ve used the image of a stream: headlines as stones, with policy and capital shaping how the water flows around them. This year, that metaphor no longer feels sufficient. What’s changing in kidney health isn’t just the placement of stones downstream; it’s the infrastructure being built far upstream. The systems, incentives, and platforms taking shape now will determine where care can flow, who it reaches, and how durable that progress will be over the next decade.

Across cardio-kidney-metabolic (CKM) health, we’re seeing foundational work take hold: new policy frameworks, sustained capital allocation, AI-native data architecture, and care models moving from pilot to scale. These shifts are slower and harder to spot than incremental wins, but in my view they will be far more consequential. They resemble large-scale public works like dams, roads, bridges — projects that quietly reshape what’s possible long after the work is done.

Two years ago, I identified 16 such signals. Last year, it was 25. This year, the list grew again to 26—not because more things are happening, but because more of them are sticking. (“26 in 2026” also has a nice ring to it.) New payment models are coming into focus. Value-based kidney care is maturing. Transplant oversight is tightening. A therapeutic “renaissance” is entering full swing. And data infrastructure is no longer separable from care delivery itself.

Rather than walk through each signal one by one, this piece focuses on the themes that emerge when you view them together. The table below is the reference point. The sections that follow are the lens.

Open Interactive PDF

A. Policy & Regulation Take The Driver’s Seat

Kidney care has long been a testing ground for innovative payment and service delivery models, but 2026 marks a shift from experimentation to durability. CMS is no longer asking whether accountable kidney care can work; it is deciding how long these models should run, who they are built for, and how much risk participants must carry. The extension of Kidney Care Choices (KCC) through 2027, the launch of LEAD as a 10-year successor to ACO REACH, and the introduction of ACCESS together signal a strong commitment to tech-enabled, value-based kidney care. In fact, cardio-kidney-metabolic health is a core pillar these new models aim to address.

What stands out this year is not just continuity, but tightening. KCC’s updated economics introduce benchmark discounts, reduce CKD quality payments, and eliminate the transplant bonus. LEAD offers improved benchmarking and flexibility, but over a longer time horizon that favors organizations built for scale and downside risk. ACCESS tests outcome-aligned payments in Original Medicare, enabling clinicians to offer innovative technology-supported care that emphasizes outcomes over activities. Participation remains voluntary, but the economics are increasingly clarifying who can realistically stay in the game. Updated guidance on clinical decision support and digital health devices aim to give providers and vendors clearer operating boundaries as these models mature.

At the same time, policy uncertainty remains. The fate of enhanced ACA premium subsidies, currently in the Senate, could materially affect coverage continuity for people with kidney disease. Cuts or expiration would disproportionately impact low-income and rural patients already facing access barriers. In parallel, CMS has begun awarding the first payments under its Rural Health Transformation Program, marking a concrete step toward testing whether targeted capital and flexibility can support care delivery in underserved regions across America.

Why this matters: Clearer policy signals and longer timelines give providers and innovators a shared direction for building durable kidney care models, echoing the intent of AAKH without the early ambiguity. But that clarity comes alongside real headwinds—tighter economics, potential coverage cuts, and constrained public spending—raising the bar for what can scale and endure.

B. Care Pathways Converge

The question of whether value-based kidney care can improve outcomes is largely settled. Evidence continues to accumulate showing slowed disease progression, better coordination, and improved patient experience across CKD populations. The more telling signals in 2026 are about scale.

Leading kidney-focused VBC organizations now cover millions of lives, manage tens of billions in medical spend, and attract billions in late-stage capital to expand partnerships, technology, and clinical reach. Importantly, these models increasingly sit at the intersection of kidney, cardiovascular, and metabolic disease—reflecting how patients actually present, rather than how care has historically been organized.

Why this matters: Integrated CKM care is the connective tissue between payment reform and everything that follows. New therapies, technology, and R&D only work if systems and workflows are organized to deploy them effectively. As kidney patients increasingly present with overlapping cardiac and metabolic diseases, coordinated models move from “nice to have” to essential system infrastructure.

C. Transplant Tightens

Transplant remains the gold standard treatment for kidney failure, but 2026 makes clear that access and outcomes depend as much on trust and governance as on innovation and discovery. Federal modernization of the OPTN, an unprecedented closing of an underperforming OPOs, and continued consolidation across the procurement landscape signal a system in transition. This also comes at a time when deceased donor volume has meaningfully decreased for the first time in at least a decade, much of which can be explained by decreases in drug-related deaths.

At the same time, transplantation itself is re-entering an era of experimentation. Gene-edited pig kidneys from companies like eGenesis and United Therapeutics have now supported human life for months, backed by FDA-cleared INDs and early clinical trials. While rejection ultimately ended some of these transplants, their durability represents a step change and underscores a parallel truth surfaced this year by AST survey data: lifelong immunosuppression remains a major clinical and financial burden, with limited innovation over the past decade. Whether for human or xenogeneic organs, progress in transplantation is increasingly constrained not by surgery, but by better understanding and regulating the human immune response.

Why this matters: The transplant field is evolving at both the system and biological levels. Oversight is tightening to restore trust, while advances in organ engineering and immunology are reopening questions about who can be transplanted, with what organs, and under what long-term tradeoffs. Beneath both runs a familiar policy thread: transplantation now has its own payment model experiment in IOTA, with public comments due by February 9, 2026—an important reminder that scientific breakthroughs alone are not enough to bring new solutions to patients.

D. New Therapeutics & Modalities

For decades, progress in kidney therapeutics was slow and episodic, with few options that meaningfully altered disease course. That pattern is now breaking. Recent approvals and late-stage data across rare complement-driven diseases, genetic kidney disorders, and cardio-kidney-metabolic conditions point to a broader and more durable pipeline taking shape. Large-scale evidence reinforcing the kidney-protective effects of SGLT2 inhibitors (here and here) further signals a shift from isolated advances toward therapies that can be deployed at population scale.

This momentum extends beyond drugs alone. Advances in dialysis modalities, such as high-volume hemodiafiltration (HDF) enabled by next-generation systems, reflect renewed attention to improving outcomes within existing care settings, not just replacing them. These approaches are not novel, but their emergence in the U.S. signals shifting clinical and commercial priorities that may lead to meaningful benefits for patients needing dialysis and those awaiting transplant.

Why this matters: As disease-modifying therapies become foundational rather than exceptional, integrated care models are increasingly necessary to deploy them effectively. The value of these advances depends less on individual breakthroughs and more on systems that can identify patients early, coordinate care, and sustain benefits over time. As with much of kidney care today, the limiting factor remains early detection and screening.

Subscribe now

E. Data Infrastructure & AI

AI is not new to kidney care, but 2026 marks an inflection point in how it is adopted and governed. Professional guidance on responsible AI use, clearer FDA boundaries around clinical decision support, expanded CPT codes for AI-enabled and digital health services, and opportunities for enhanced remote and non-invasive monitoring together reduce long-standing friction around payer adoption. (Counter-examples include “downcoding” and the WISeR model.) The result is not a green light for automation, but a clearer set of rules for how AI can be embedded into clinical workflows with physicians firmly in the loop.

At the same time, demand is accelerating from the opposite direction. Consumer-facing platforms like OpenAI are operating at unprecedented scale, with forty million people asking health-related questions daily (and ~800 million on a weekly basis). That pressure is beginning to intersect with clinical care, especially at the seems where access challenges persist. Upstream, companies like Revalia point to where this is headed next: human-first data that has the potential to reshape how therapies are developed, validated, and translated, years before they ever reach patients.

Why this matters: kidney care is laying guardrails before accelerating. With clearer reimbursement, oversight, and infrastructure in place, the field is signaling a preference for clinically embedded, accountable AI. From what we’ve seen and heard across these other areas, I believe trust, integration, and equity will ultimately determine impact.

Closing thoughts

Taken together, these 26 signals point to something more structural than a typical year of progress. Kidney care is entering a phase where the hard work is less about discovering what might work and more about building the systems required to make those advances durable, scalable, and equitable. Payment models are lengthening their time horizons. Care delivery is integrating across chronic conditions. Transplant oversight is tightening as science pushes boundaries. Therapeutics are moving upstream. Data and AI are being constrained before they are accelerated.

As most of you know, this is hard work. It is slow, expensive, and messy. But once built, it has the potential to quietly determine what flows, who benefits, and how resilient these systems become under strain. The challenges ahead are not a lack of innovation. It is whether we can align policy, capital, care models, and trust well enough to ensure these foundations actually hold. The signals are there. What matters next is the follow through.

I’d love to hear from you. What signals do you see shaping kidney and cardiometabolic health in 2026, and where do you think builders, clinicians, and policymakers should focus next?

Leave a comment

Share

Share

No one ever asked how much of myself I could give before I disappeared.

When transplant became the plan, it was as if the room silently agreed that “care” would be there, on demand, without limit. It was treated like gravity: assumed, invisible, powerful enough to hold everything on solid ground. The charts listed my labs and my medications. They never listed the hours my partner spent on hold with insurance, the miles driven before dawn, or the number of nights one of us lay awake, listening for a sound that meant something was wrong.

From the patient side, transplant is a strange kind of second birth: you wake up in a body that has been opened and repaired, but nothing around you feels familiar. You are suddenly dependent on routines that did not exist before—timed pills, forbidden foods, temperature checks, infection rules. The world shrinks to numbers on a screen and instructions taped to the fridge. You feel both grateful and trapped. Philosophers call this a “liminal” state: no longer who you were, not yet someone who feels whole. Life becomes a hallway you aren’t sure you ever get to leave.

In that hallway, love slowly turns into labor.

Life after transplant

Our days were carved into small, precise pieces. Alarms dictated when I swallowed one pill and waited for another. The kitchen counter became a landscape of bottles and boxes. The calendar began to look less like a month and more like a puzzle: lab days, clinic days, refill deadlines, all fitted together around the hope that something resembling normal life could still exist in the cracks. The house looked quiet from the outside. Inside, it felt like a control room.

Psychologically, we were running two operating systems at once. One tried to process what had happened: the violence of surgery, the miracle of a working organ, the guilt of knowing that my survival was tied to someone else’s loss and my partner’s constant watching. The other tried to keep the machine running: Did we order the refills? Did we write down the new dose? Did we reschedule that appointment we had to move? It is hard to feel like a person when your mind is permanently in “task manager” mode.

Care is often described as compassion, but what it felt like, most days, was project management with a beating heart at the center.

What we know about caregiver burden

The psychology of this is not a mystery. Long before my surgery, studies were already describing “caregiver burden” in transplant: the way spouses and family members develop anxiety, depression, sleep problems, and health issues of their own under constant strain.1 Reviews of caregivers across solid organ transplant find the same patterns: chronic hyper‑vigilance, feeling “always on,” and little time or space to process what any of it means.2 None of this was news to us, because we were living the footnotes.

Figure: Domains of Caregiver Burden

Subscribe now

What the research calls “burden,” I would describe as an erosion of boundaries. There was no clear line between where my illness ended and my partner’s life began. My fear leaked into her sleep. Her exhaustion leaked into my guilt. Our shared future was being rewritten by lab slips and appointment times, but the system spoke to us as if we were two separate entries: patient, caregiver. It did not account for the way our minds and nervous systems were braided together.

That is the existential toll: feeling your own life narrowing down to survival tasks, while watching someone you love lose pieces of themselves in the process.

What we fail to measure

And still, in many conversations, transplant success is mostly translated into numbers: one‑year graft survival, hospitalization rates, cost curves.3 The new narrative some are calling for—one that centers what life actually feels like after kidney transplant—rarely makes it into how success is measured and valued. As Kevin Fowler writes:

…A [post-transplant] pilot model that offers physical rehabilitation, psychological counseling, mentorship, etc. would be a step forward in validating the patient experience while aligning with national policy… The full value of a kidney transplant will not be achieved without rehabilitation support. It is analogous to buying an expensive automobile without routine service.4

Table: Est. Number of Family Caregivers, 2015-2025

Unpaid caregiving is one of the biggest hidden subsidies in this system. A 2025 report from AARP estimates that family caregivers in the United States provide roughly $600 billion dollars’ worth of unpaid care each year—more than the total annual spending on Medicaid. A separate analysis from Otsuka and the National Alliance for Caregiving puts that figure even higher, at nearly $874 billion dollars in unpaid labor. Those costs are felt by bodies like ours: backs that hurt, nerves that fray, savings that drain, jobs that bend or break under the weight of “just helping.”

But on paper, that labor is free. In fancy dashboards, it doesn’t get counted.

Given what we know about the mental and physical toll of caregiving, it is not hard to imagine how sustained strain could ripple outward. Missed medications, delayed follow-ups, or preventable hospitalizations can emerge long before anyone recognizes there’s a problem. Yet most transplant centers still lack structured support for caregivers, with no routine way to ask, “How much do you have left?” before something gives.5 It is as if we designed a state-of-the-art bridge, watched the support beams crack, then blamed gravity.

For us, care felt less like a gentle virtue and more like a bank account we were never allowed to replenish. Every appointment, every 3 a.m. check, every argument with insurance was a withdrawal. The “deposits” were rare: a friend who offered a ride without being asked, a clinician who actually paused and asked my partner how she was coping, a day when nothing urgent happened and we could remember what it felt like to laugh about something unrelated to kidneys. Over time, the balance dropped. We still showed up. We still said, “We’re managing.” But the margin for error got thinner and thinner.

The psychological tools we had, coping strategies, humor, and compartmentalization, started to feel like worn-out instruments. We could still use them, but not forever. Resilience is often described as bouncing back. That metaphor fails here. Sometimes resilience is just the ability to keep walking with a cracked foundation because there is no place to sit down. Eventually, the crack spreads.

This is where metaphors do better than metrics: our life after transplant felt like pushing a loaded cart with three wheels across a long, uneven road. Medicine gave us the cart and one very good wheel—the new organ. It did not account for the missing wheel, the broken one, or the people straining behind the handle.

Subscribe now

Systems that care by design

So, what would it mean to take care seriously as a finite resource?

It would mean that when transplant teams talk about “access” and “equity,” they include the capacity of real households, not just the availability of OR time. It would mean caregiver training that isn’t rushed through in a single discharge session, but revisited and reinforced over time. It would mean routine mental‑health check‑ins for both patients and partners as part of standard follow‑up, not as an emergency add‑on.6 It would mean that payers and policymakers stop pretending unpaid care is free and start building respite, paid leave, and community‑based support into what “value” actually means.

And it would mean listening differently—to stories like ours, and to the patterns that show up when you put those stories side by side.

Figure: Types of Support Programs Offered By Transplant Centers

A 2018 systematic review titled “Who Cares?” describes caregivers who report feeling “taken for granted,” “constantly on duty,” and “guilty for wanting time for themselves.”7 Those phrases could have been pulled from our kitchen table. They are not isolated sentiments. They are the emotional signatures of a system that consumes more care than it ever admits.

Care is what keeps patients like me alive. That is the hopeful truth. And yet, unsupported care wears down the very people who make our survival possible. This is the part of our current system of care that we have not yet learned to count.

This isn’t a problem of individual willpower, resources, or family values. It is a design problem. We built transplant pathways that assume an endless human safety net and then look away when that net starts to fray. If we are brave enough to name that, we can be brave enough to change it, shifting from a model that silently spends caregivers’ lives to one that treats their wellbeing as central to the work of keeping people like me here, not as a footnote to a “successful” surgery.

We’d love to hear from you. Leave a comment if this essay resonated or share this story with a friend or colleague. How can we improve post-transplant care?

Leave a comment

Share

From the Editor

My thanks to Jeff for sharing his voice with all of us. Our most recent guest posts featured Jeanmarie Ferguson on finding her voice in the New York Times, and Dr. Karin Hehenberger on why organ transplantation still lags behind oncology in innovation and public awareness. If you want to explore more on these themes, you might enjoy our recent pieces on life on immunosuppression, the iBox score, and Michelle Yeboah’s transplant journey. Thank you for being here with us.

Subscribe now