Key takeaways:

• Advanced practice providers help enable a sustainable, patient-centered approach to chronic kidney disease management.
• Nephrology teams must create pathways that support their integration and impact.

As the physician shortage grows, advanced practice providers are redefining what kidney care looks like.

The nephrology workforce is changing, and it is a change we need to embrace. The number of medical students entering the specialty is trending downward while the workforce is aging out. The 2024 nephrology fellowship match data showed an 11% drop in candidates, with one-third of fellowships unfilled last year. We have 240 nephrologists set to retire each year during the next decade. If current trends continue, the field could face a 21% shortage of nephrologists by 2037.

These trends reveal a bigger issue: The number of practicing nephrologists is not keeping pace with the number of patients who need our help. About 35.5 million adults in the U.S. have chronic kidney disease. Demand is outpacing supply, and practices across the country are feeling the strain. If practices wait until they feel the shortage most acutely, it will already be too late.

The solution is not just about finding more doctors. It is about fundamentally rethinking how we deliver care by building strong, collaborative teams. Many nephrology practices are turning to advanced practice providers (APPs), including nurse practitioners and physician assistants, to support clinical efficiency, reduce physician burden and enable more proactive, patient-centered care. Physicians simply cannot do it alone. APPs are essential for creating a sustainable model of care.

APPs becoming a force in kidney care

At Metrolina Nephrology Associates in Charlotte, North Carolina, and in many other nephrology practices across the country, APPs are now an essential component of the provider pool caring for patients across all sites of service. They handle routine follow-ups, reinforce treatment plans and monitor disease progression. They care for patients with CKD, end-stage kidney disease and transplants. One can find them in the nephrology office, dialysis unit and hospital. Wherever patients are, an APP is likely nearby.

That consistency matters. It is how we deliver the best care and keep patients engaged, educated and supported at every step along the kidney disease journey. The presence of APPs greatly amplifies and augments what nephrologists do. APPs are far more than just support staff. Working with physicians, they help create a seamless, team-based approach that addresses both routine and complex patient needs.

Beyond direct clinical work, APPs support administrative functions and drive practice-wide clinical initiatives, such as telehealth, patient education and value-based care. They also serve as key coordinators within multidisciplinary teams, overseeing quality while streamlining communication among primary care providers, cardiologists, endocrinologists and nephrologists. These roles are critical to successfully managing comorbid conditions and preventing avoidable hospitalizations.

APPs help stabilize care across all settings. In the office, they see patients between physician visits to keep the care plan moving forward and catch issues early. In dialysis units, they manage large patient panels — often 100 to 200 patients — and take calls for inpatient and outpatient needs.

This support absorbs the operational pressure that can fragment physician time and allows physicians to focus where they add the most value. It also creates much-needed capacity. Many practices are struggling to meet demand, and APPs help expand access, especially for new referrals, so patients are seen sooner, and care starts when it should.

But this model requires physician support. This complex approach to care only works if there is confidence and trust between physician, APP and patient. The physician must know that the APP is well trained and will reach out when needed. The APP must know the physician is available and willing as backup. And the patient must feel that their care team functions as one.

When this relationship works, it allows physicians to focus on complex cases or tasks only they can perform, like medical director responsibilities. The patient benefits from more engaged and proactive care. It can be a win for everyone.

APPs are also helping build the next generation of the nephrology workforce. Nearly 30% mentor students or new hires and teach kidney education programs. And the APP workforce itself is changing. Roughly 60% of nephrology APPs are aged 30 to 49 years, and many are relatively new to the field. That signals both a pipeline of talent and a need for continued support.

From gap fillers to system changers

Even APPs can help only so much in a system that was not built for chronic care. Fee-for-service medicine was not built for conditions like CKD, where success depends less on a single appointment and more on what happens in between. Fee-for-service models are transactional. They reimburse practices for volume, with no regard for outcomes or continuity. This leaves little room for proactive care, patient education or care coordination — the very steps that help people with CKD avoid hospitalizations and delay the need for dialysis or transplant. Fee-for-service does not work for chronic disease management, and continuing to rely on that model risks widening the gap between patient needs and the system’s ability to meet them.

Value-based care changes the equation. By shifting the focus from volume to outcomes, value-based care models, thoughtfully designed, enable practices to improve access to care and care delivery by investing in resources such as APPs and care coordination technology.

At Metrolina, for example, APPs are central to the practice’s ability to deliver care in a value-based model. Many of the core functions, such as patient education, care coordination, timely follow-up and proactive outreach, fall squarely within the scope of a well-trained APP. Delegating this work to APPs is both operationally and financially efficient. Physicians do not have the capacity to absorb these additional responsibilities while continuing to manage ever-growing patient demand and complexity. In this model, APPs are not filling gaps, they are performing the activities that enable practices to succeed and patients to thrive.

Support, structure and leadership matter

Support is essential. According to the National Kidney Foundation’s Council of Advanced Practice Providers 2024 Salary and Benefits Survey, 31% of APPs said they had no formal training in nephrology. Most (83.9%) said they relied on informal mentorship or on-the-job training when entering the specialty. Practices that invest in onboarding, specialty-specific training and ongoing mentorship will ensure that APPs are empowered to practice at the top of their license and will be better positioned to unlock the full potential of APPs and maintain high-quality care as the system evolves. Fail to train them, and you set up your providers and patients to fail.

Support has to go beyond education. APPs also need a clearly defined role within practice structures that the practice physicians embrace. Because they do not fit neatly into traditional “nursing” or “physician” roles, nephrology teams must create pathways that support their integration and impact. If a practice is serious about successfully integrating APPs, it needs to commit to the infrastructure that supports them. This means more than onboarding or clinical shadowing. It means having real systems in place that APPs can step into and rely on.

It is difficult to train any team member without a clear system. If your practice does not have a defined way to do dialysis rounds or a consistent approach to CKD clinic with clearly delineated roles, the practice risks duplication of efforts at best, missing key patient care milestones altogether, or at worst conflicting care plans. Setting up protocols, creating job expectations and defining what good care looks like gives APPs the tools for success. It reduces variation, improves outcomes and makes training meaningful.

That is why Metrolina built a formal APP training program, including the nationally accredited Ready for Rounds and Cleared for Clinic modules, and protocolized CKD clinic care delivery systems, dialysis rounding models and pathways for mentorship and professional development. This approach empowers APPs, supports their retention and ensures their contributions are central to long-term success in value-based kidney care. APPs have become such a critical part of Metrolina’s care model that the practice now exceeds a 1:1 ratio of APPs to physicians and benefits from their efforts in every site of service.

Looking ahead

The kidney care workforce is evolving, and APPs play a key role in that change. Whether managing complex dialysis populations, coordinating across specialties, mentoring new clinicians or anchoring virtual care models, APPs are helping to redefine who delivers kidney care and how. They are not alone in this effort. Other extended interdisciplinary care team members, including renal care coordinators, dietitians and social workers, also play a vital role in patient education, lifestyle support and addressing social determinants of health. Their work ensures care plans are actionable and practical for patients to follow.

As health care moves from reactive, fragmented systems toward value-based, team-driven models, APPs help enable a scalable, sustainable, patient-centered approach to chronic disease management. In kidney care, where time is precious and continuity is critical, this is not a nice-to-have, it is imperative. Practices that build strong APP teams now will be better positioned to adapt to workforce pressures and build sustainable models for future growth while continuing to provide high-quality care.

The future of nephrology is not about filling gaps. It is about building teams that can truly transform patient care. APPs are already at the heart of that solution, helping practices deliver more consistent, timely and personalized care that improves patients’ lives. Practices that embrace this shift will be better prepared to deliver the kind of care patients expect and deserve in the years ahead.