Reformulating the integrated care concept for the new millennium.

The concept of integrated care advocates a planned approach to predialysis care. Its components include timely referral to a renal care team, timely preparation for dialysis, and timely initiation of dialysis, with peritoneal dialysis (PD) as the initial therapy for suitable patients. This initial therapy may then be followed by timely transfer to hemodialysis (HD) when residual renal function declines or when other PD-related problems occur. We argue that at least three problems exist with the integrated care approach as it is currently being articulated. They are (1) an under emphasis on slowing the rate of progression of chronic kidney disease, aggressive management of cardiovascular risk factors and other comorbidities, and pre-emptive live donor transplantation; (2) a lack of consideration of home HD as an alternate initial therapy; and (3) a lack of discussion about patient choice. We propose a modified version of integrated care that we believe will optimize modality distribution and patient outcomes, while reducing the relative costs per patient treated, compared to the current situation in most countries.