Mallika Mendu

On July 10, the White House announced the signing of an executive order to launch Advancing American Kidney Health, a new initiative to improve the lives of Americans suffering from kidney disease, expand options for American patients and reduce health care costs. The new initiative builds on groundwork laid over the last several decades by many in the nephrology community, including leaders at the Brigham.

In this Q&A, Mallika Mendu, MD, medical director for Quality and Safety at the Brigham, director of Quality for the Brigham Renal Division, associate medical director at Partners Population Health for Specialty Programs and practicing nephrologist at the Brigham, shares her reflections on the initiative and its implications for providers and patients. For the last four years, Mendu has served on the American Society of Nephrology’s (ASN) Quality Committee, which, in collaboration with other nephrology and patient advocacy organizations, offered guidance that helped shape the Health and Human Services proposal leading to the new initiative.

Q: What was your reaction when you heard this executive order was being signed?

MM: I felt a great deal of optimism for our patients with kidney disease that we as a nation are taking a huge leap forward in advancing kidney disease therapies and improving the quality of care delivered. I also feel a tremendous amount of pride as a member of the American Society of Nephrology, Partners Population Health team and Brigham Renal Division — all of which have been championing efforts to transform kidney care delivery to improve outcomes for patients. It’s incredibly exciting to be able to share this news with my patients in clinic: Our government and our nation are paying attention to the need for advances in kidney health, and we have real reforms on the horizon.

Q: Why is a comprehensive kidney health strategy to improve care for patients with chronic kidney disease so important?

MM: In comparison to cardiovascular disease and oncologic disease, there have been very few significant advances in kidney disease therapies for the past five decades. We are relying on technology (namely, dialysis) that was developed decades ago to treat patients with kidney failure. The last major legislative effort to help patients with kidney disease was the Medicare End Stage Renal Disease (ESRD) benefit in 1972. We now have 37 million patients with kidney disease, close to 700,000 with ESRD and Medicare costs over $35 billion a year attributable to the disease. It’s worth noting that ESRD accounts for less than 1 percent of the population, but over 7 percent of the expenditure. Finally, and most importantly, patients with ESRD have high rates of mortality, frequent utilization of care such as emergency department visits and hospitalizations, increased rates of disability and poor quality of life.

The comprehensive kidney health strategy, or Advancing American Kidney Health, facilitates improved patient outcomes, reduced medical expenditure and improved quality of life for patients. It’s a huge win for patients and for society.

Q: What aspects of the announcement excite you most?

MM: I am excited that, for the first time, policy is focused on stemming progression of chronic kidney disease, increasing home dialysis, increasing transplantation and supporting innovation of new therapies. This contrasts with the traditional model of in-center hemodialysis. Many patients have voiced that in-center hemodialysis is taxing physically and emotionally. It’s also expensive for society to pay for the treatment through Medicare.

Q: Can you tell us more about your involvement in the ASN’s Quality and Policy Committees and the team that outlined the population health initiatives?

MM: I have been extremely fortunate to have been given the opportunity when I was a fellow to serve first on ASN’s Public Policy Committee for two years. More recently, I’ve served on the ASN Quality Committee (for the past four years). It has been an absolute privilege and highlight of my career to have a voice on how policy is shaped and implemented. The Quality Committee comprises well-respected nephrologists across the nation who are actively engaged in clinical practice and most of whom are engaged in research efforts related to quality of care delivery for kidney disease patients. I have had the opportunity through ASN to meet with congressional staff on multiple occasions to advocate for kidney health policy and quality issues. Lastly, ASN partners with other kidney health organizations, including patient advocacy groups. Working closely with incredible patient advocates who share their compelling stories with congressional members has been inspiring.

Q: In what other ways has the Brigham been involved in laying the groundwork for the new strategy?

MM: The Brigham has always been at the forefront of kidney health therapies and research. Dr. Joseph Bonventre, chief of the Renal Division, has championed basic science, clinical and translational research to advance the field, and has been incredibly supportive of public policy efforts. Our division has helped shape the national strategy that has resulted in Advancing American Kidney Health.  Dr. Bonventre has greatly encouraged the efforts to enhance awareness of kidney disease and expand resources for improvement of care and finding new therapies and was able to impact the public agenda of the ASN particularly during his time on the ASN Council and as its president. More recently he has chaired the Initiative to create a Technology Roadmap to Innovative Alternatives to Renal Replacement Therapy, which is intended to increase interest, investment and innovation in renal replacement therapy. This effort has contributed to the creation of the Kidney Innovation Accelerator (Kidney X), which is designed to foster innovation in preventing and treating kidney disease.

In addition, we have developed and implemented innovative approaches to care delivery for patients with kidney disease. We developed an Acute Kidney Injury (AKI) Standardized Clinical Assessment and Management Plan that guides providers on appropriate timing of renal replacement initiation for patients with AKI. We also developed a novel ESRD Care Coordination Program that seeks to reduce utilization (ED visits, hospitalizations) and facilitate transplantations for patients with ESRD, very much in the vein of what has been proposed. Finally, we’ve worked on the development of a chronic kidney disease (CKD) registry in concert with other Partners institutions to capture CKD patients across the network, identify key care delivery opportunities and identify patients at highest risk for developing ESRD.

Q: As a physician who treats patients with kidney disease, what does the national attention to kidney health mean to you personally?

MM: In the clinic, I have had the chance to let my patients know about this exciting news. Several mentioned to me that they watched the announcement live and have hope that care delivery improvements are on the horizon. It also means a lot for kidney disease patients to know that their condition is not being ignored, their challenges are being recognized and there is now support for making things better. As a nephrologist who has focused her career on care delivery innovation and improving quality and safety, it’s a huge moment that carries a tremendous amount of promise.

Reflections on a Historic Moment Other Brigham leaders in kidney health and transplantation share their thoughts on the launch of Advancing American Kidney Health.

“End-stage kidney disease leads to greater mortality than breast, prostate or colorectal cancers; it was time for our society and the government to recognize the impact of kidney disease and provide appropriate resources to advance the research and improve these outcomes.”  —  Leonardo Riella, MD, PhD, Associate Medical Director of the Kidney/Pancreas Transplant Program

“The Brigham has played a seminal role in kidney medicine. We were the site of introduction of dialysis with creation of the Kolff-Brigham Artificial Kidney and site of the first successful kidney transplant, as well as the site of many scientific discoveries that have transformed our understanding of kidney health and disease. It is truly exciting that kidney disease will now get the national attention it deserves as we work to prevent it and greatly improve the lives of our patients. While dialysis has prolonged the lives of large numbers of patients, in many cases, the quality of life of the dialysis patient is poor. We at the Brigham Renal Division are working to develop new alternatives to dialysis. Dialysis started at the Brigham. It should end at the Brigham!”  — Joseph Bonventre, MD, PhD, Chief of the Division of Renal Medicine

“Kidney transplantation has long been recognized as the best treatment option for patients with kidney failure. Currently the complex regulations that govern the procurement and use of donor organs can impede transplantation. This new focus on increasing the number of kidney transplants will be welcome by kidney specialists and patients alike.” – Anil Chandraker, MD, FASN, FAST, FRCP, Medical Director of the Kidney and Pancreas Transplantation and Director, Transplantation Research Center