This 40% reduction of worsening renal function/need for dialysis seen in the SGLT2i trials (which included pts with Diabetes Type 2, except DAPA-HF/EMPEROR) has some rather implications for the business models of dialysis & transplant and the nephrology workforce

For the remainder, I will use data and figures from
https://jasn.asnjournals.org/content/30/1/127
(this is a key paper - need differential equations to do properly, but I will use back of envelope calculations.
Please vote if you want to see the math hardcore version with differential equations

This is the projected incidence of ESRD in that paper. I will round the overall incidence to 370 cases per million population. A 40% reduction irrespective of the presence of diabetes (likely result of DAPA-CKD), drops this to 222 ie turns the clock back to the early 1990s

Dialysis companies make money by dialyzing ALL people, not just the patients with new onset renal failure. This is the prevalence, not the incidence.
Basic epi:
Prevalence = Incidence x Mean Duration of Disease or
P = I x T

T determined by time to death or transplant

Let's make a simplifying assumption: nothing changes in T (will revisit this below), as the incidence declines, so is the prevalence. Hence once the system equilibrates, the dialysis industry will have 40% LESS business in a few years if ALL pts who needed SGLT2i, could get them

Right now there are significant barriers in obtaining SGLT2is (copays) which are not going to go away until @CMSGov decides to do something about access. They could save money on dialysis by using their monopsony power to have an convo and cut a fair deal with the SGLT2i pharma

If it were up to me, I'd just hand 1-2B over to make an exclusive contract with *any* SGLT2i pharma and make the drug available for minimal (or even zero) copays. I'd expect to shave > 10B off the Medicare budget. This is FAR greater than any ESCO/ACO/PPS fantasy entertained

Of course this is unlikely to happen because of the failure to actually think out of the box. In any case, a scenario between 1990s and 2015 is more likely. For the dialysis companies this means a reduction in revenues by 0-40% when the system equilibrates (likely by 2025)

Nephrology income will also go down as a result; dialysis revenues (= medical directorships and dialysis professional fees) make up most the Neph revenues.
Let's look at a business case
https://www.healio.com/news/nephrology/20180227/survival-guide-for-the-independent-nephrologist
About 50% of revenue derives from dialysis, & 40% x 50% = -20%

Many small existing practices are unlikely to survive a 20% hit. So I'd expect further consolidation and sellouts to bigger or hospital based practices.
The flip side, is that individual nephs may survive by staying solo, or joining multispecialty practices as IM/Nephro

In other words, if you are fellow who is graduating or someone who is not ready to sell your practice and retire, do re-invest on your IM skills: you will most likely than not need them to stay in independent business. Or start looking for an employer to hire you on a salary

I suspect these changes will be more dramatic in big cities than rural areas, so if you live in a densely populated area you may want to look carefully at the landscape ACROSS the USA.

Let's look at workforce issues

Nephrology grew primarily because of the need to take care dialysis patients. So anything that affects the number of dialysis patients, e.g. SGLT2i, will reduce the need for nephrologists. Hence the demand for our services is likely to decline *unless* we take ownership of ....

…. early CKD. However if anyone can (and should!) start SGLT2i, then you can only differentiate yourself is by providing Primary + Specialty Care. This has been the model for HIV management since the first convenient and effective HAART in the late 90s, early 00s.

So Internal Medicine yet again!
The corollary is that @ASNKidney should stop worrying about workforce issues and expend resources on maximizing quality over quantity.
Same thing for fellowships: offer education on things that the graduating fellows can use to market themselves

Let's go back to the basic epidemiological formula and the business of dialysis. I will use joint epi/business notation

P(=$) = I (=new $) x T ( = long lasting relationships with customers)

Let this formula sink in...

As I(=new $) will decrease, the only way to maintain P(=$) is to increase T. This means:
a) you have to treat your patients with respect (pretty soon there will be capacity for them to move around, if you don't)
b) increase survival on dialysis
c) reduce transplants

@CMSGov and the @ESRDNetworks must figure out how to prevent c) from happening. And forget the fantasy about cutting a small pct if a certain % of patients are not listed. Such measures are mistargeted & are VERY unlikely to be major deterents to reduced transplants anyways

Let's examine (b). First, my background: I hold a neph license in both US and a European country. My first job as a doctor was at my med school's Renal Department back in 1998, while over the years I have practiced in both academics & private practice.
And now my vent ….

The care provided by Nephrologists in the dialysis units SUCKS across the globe. There is very little time (and interest) to manage things that matter (e.g. volume) and too much attention on trivialities (like Kt/V which have been rendered irrelevant by membrane tech)

Primary care ( @mikejohansenmd) for these patients also sucks since no one takes ownership or assumes responsibility. Diabetes management for example stops once one ends up on dialysis because the A1c looks good, vascular dz remains an elusive goal (well we ask pt to take binders)

palliative care and symptom management is not done (I am guilty about this particular one too) and everyone relies on corporate protocols. There is too LITTLE individualization of the treatment regimen or the medications, as ppl carry out meaningless rounds (=care plans).

One can argue that we need more resources for those, so hopefully @CMSGov will take the clue and spend some of the SGLT2i savings on raising the dialysis procedural and professional fees (this could be a good carrot).

In any case increasing the T, without reducing transplants

requires we increase survival on dialysis. This would have been my personal goal if I were running a LDO, refocusing quality initiatives so that they don't report meaningless observational findings from the big data analytics factories, but spinning them off to trials.

I personally think that volume is the final frontier of dialysis with important modifying effects to be played by the large cutoff dialysers and/or online hemodiafiltration (please note that this is a personal opinion - studies are actually needed)

What about transplants then?
Kidney transplants have been increasing recently, so let's assume a rate of 24,000 per year for my scenarios.
Universal adoption of SGLT2i will cut the ESRD incidence to 222 pmp ie about 73,260 per year.

There is no way transplantation can keep up with this, but the average time on the waiting list will decrease, quite likely to levels of the 90s. Of course I don't expect universal adoption of SGLT2i, so waiting times will probably decrease to levels of the early 00s

Furthermore, as a result of the broad CV benefit of SGLT2i it is likely that people reaching dialysis will have a healthier CV system. This in turn means that the chances of outcomes for which transplant centers are penalized for, under the quality metrics we use will decline.

If the metrics don't change, then programs may be inclined to take riskier organs which are currently discarded and thus overall number of kidney transplants *may* increase.

This means that transplant will become again something more tangible and thus will be brought up by pts

So to sum up, SGLT2is will:
a) decrease incidence of ESKD thus
b) affecting dialysis chain (and nephro) revenues thus
c) driving further consolidation and
d) diversification of practices to include Internal Medicine/Primary Care
e) reducing waiting time for kidney transplants

f) to the extent that @CMSGov is after true innovation, they should look for ways to cover SGLT2i without copays, expecting LARGE reduction in health care expenditures, h) part of which should be reinvested to increase the quality of care for dialysis pts by increasing fees