The rural nephrology workforce shortage is already here

There's a conversation happening in hospitals across rural America that rarely makes it into national headlines. It takes place during morning huddles, in administrator offices, and on the phone between hospitalists and transfer coordinators. It sounds something like this:

"We need a nephrologist. Who do we call?"

And too often, there isn't a good answer.

The nephrology workforce shortage is not a future projection to be addressed at the next strategic planning retreat. It is a present-day operational reality — one that is quietly reshaping what rural hospitals can and cannot do for their patients. Understanding the depth of that reality is the first step toward responding to it.

The numbers tell the story

The fill rate for nephrology fellowship positions has fallen from 94.1 percent in 2010 to 65.8 percent in 2024 — nearly one in three available training positions went unmatched last year. Over the same period, the number of fellowship applicants dropped by more than 37 percent. This is not because training slots disappeared, but because fewer physicians are choosing to enter the field.

HRSA projects a 21 percent shortage of nephrologists by 2037 – but that national figure obscures where the pain is already being felt. Rural areas currently have approximately 30 physicians and specialists per 100,000 residents, while urban areas have 263. The 2025 fellowship match showed a modest 13 percent uptick in candidates — a welcome signal, but far too small to close a gap that has been widening for 15 years.

The structural causes are well documented: complex patient populations, compensation that lags other specialties, and a perception among trainees that nephrology offers cognitive demands without equivalent procedural volume or financial return. The nephrology nursing shortage has also worsened since COVID-19, compounding the challenge for hospitals trying to build or maintain dialysis capacity. These dynamics will not resolve themselves.

What makes this especially consequential for rural communities is the mismatch between need and supply. Patients with chronic kidney disease and end-stage renal disease are disproportionately concentrated in rural America — in communities shaped by higher rates of diabetes, hypertension, and poverty, with limited access to preventive care. Rural Black Americans and Indigenous populations bear particularly high CKD burdens, reflecting decades of inequitable access to primary care and specialty referral pathways. These are the patients who most need nephrology expertise. These are the communities least likely to have it.

What this means for rural hospitals today

For rural hospital leaders, the workforce shortage creates a compounding operational problem that touches clinical outcomes, financial performance, and institutional trust simultaneously.

Patients with acute kidney injury still arrive. Potassium levels still spike dangerously. Fluid overload still compromises respiratory status. The clinical need does not pause because the specialist is unavailable. What changes is how hospitals respond — and responses driven by access constraints rather than clinical judgment are rarely optimal.

Transfers become the default. Observation stays lengthen while teams await guidance. Hospitalists carry uncertainty they shouldn't have to. Length of stay extends. Costs rise. Avoidable transfers carry their own downstream costs — lost revenue, disrupted continuity, and the strain of coordinating across systems under pressure. For prospective payment hospitals already managing tight margins, these inefficiencies compound quickly.

Beyond the acute setting, patients with moderate-to-advanced CKD frequently go without nephrology involvement until their disease has progressed beyond the point where early intervention could have changed the trajectory. By the time many rural patients are referred, the window for meaningful disease modification has narrowed considerably.

Rural hospitals without nephrology access are watching preventable disease progression unfold in front of them — without adequate tools to intervene.

A structural problem requires a structural solution

Recruiting a full-time, on-site nephrologist is not a realistic expectation for most rural hospitals given current workforce dynamics. Even when recruitment succeeds, retention is a persistent challenge. Rural nephrology practice can be professionally isolating, and without adequate subspecialty coverage and administrative support, burnout follows quickly.

This is precisely why tele-nephrology has moved from novelty to necessity.

When integrated thoughtfully into inpatient workflows, tele-nephrology provides real-time nephrology expertise without requiring physical presence. Hospitalists and emergency physicians can access specialty consultation during high-acuity events. Dialysis decisions can be made with expert input rather than institutional default. Length-of-stay variability decreases when specialty guidance arrives early rather than after the fact. That consistency matters — both for patient outcomes and for the operational predictability that hospital leadership depends on.

In outpatient settings, nephrology consultation supports primary care teams managing CKD patients — catching patients earlier, slowing progression, identifying candidates for home dialysis, and allowing patients to prepare for kidney failure rather than face it in crisis. Home dialysis in particular is more viable in rural settings than many clinicians expect, and tele-nephrology is a key enabler of that pathway.

For rural hospital leaders, this is not a stopgap. It is infrastructure. It is the difference between a hospital that can manage kidney disease with confidence and one that cannot.

A call to rural health leadership

The pipeline is insufficient. The geographic maldistribution of nephrology expertise is widening. The patients carrying the greatest burden of kidney disease are too often the ones with the least access to the specialty that could help them most.

Waiting for the workforce to self-correct is not a strategy. Neither is continuing to absorb the cost of inadequate nephrology access — in transfers, readmissions, and preventable disease progression. The communities most affected cannot afford to wait – and neither can the hospitals serving them.

The tools exist to close this gap. Tele-nephrology is not a future possibility. It is a present-day solution delivering real-time specialist support to communities that can no longer afford to wait.

The rural nephrology workforce shortage is already here. The question for health system leaders is whether their hospitals are positioned to respond — or continue absorbing the consequences.

NRHA adapted the above piece from Renasolve, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.
 

Cyril Kuriakose, MD, FASN, is the chief of strategy and innovation at Renasolve Inc. and a board-certified nephrologist with 15 years of clinical and hospital leadership experience. Dr. Kuriakose brings a unique perspective to the intersection of nephrology, systems design, and rural health transformation and is committed to building durable, scalable solutions that expand access to kidney care for the communities that need it most.