Kidney disease is a leading cause of death in the United States, and it is getting worse. For veterans living in rural areas, a national shortage of nephrologists — along with the reality that the nearest kidney specialist may be hours away — compound the problem.
Rural veterans with chronic kidney disease and refractory hypertension are hospitalized more frequently and die at higher rates than veterans in urban or suburban areas. Many go years with their kidney care managed exclusively by a primary care provider who may not have the training or time to adjust the specialized medications these patients need.
A new VA study published in the Clinical Journal of the American Society of Nephrology shows that the VA’s telenephrology program is closing that gap, and saving lives in the process.
What the Study Found
Researchers studied nearly 12,000 veterans with chronic kidney disease to measure the impact of the VA’s TeleNephrology Enterprise Wide Initiative on veterans living in rural areas. In the program’s hub-and-spoke model, nephrologists at VA medical centers connect remotely with veterans at rural VA clinics through telemedicine, providing specialty kidney care without requiring the veteran to travel to a major facility.
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Veterans whose kidney care was managed by a nephrologist through the telenephrology program had a 15% lower mortality rate than veterans whose kidney care was managed by a primary care provider alone. Veterans in the program were also significantly more likely to be on guideline-directed medications, the drugs that clinical evidence shows slow kidney disease progression and reduce cardiovascular risk. That medication gap is one of the most persistent problems in kidney care nationally. Getting the right drugs prescribed at the right time is often the difference between stable disease and a patient heading toward dialysis.
Why This Matters for Veterans
Nearly 30% of veterans enrolled in VA health care live in rural areas. Many of these veterans manage multiple chronic conditions, including diabetes, hypertension and cardiovascular disease, all of which accelerate kidney damage. Chronic kidney disease is often silent in its early stages. By the time symptoms appear, significant damage has already occurred. Without specialist oversight, the disease can progress to end-stage renal failure, requiring dialysis or a transplant.
The VA’s telenephrology program addresses the core barrier: access. A veteran in rural Maine or eastern Washington who would otherwise see a kidney specialist once or twice a year, if at all, can now have regular telemedicine appointments with a nephrologist who reviews labs, adjusts medications and coordinates care with the local primary care team. Dr. Ramón Bonegio, a nephrologist and director of VA’s TeleNephrology Enterprise Wide Initiative, works out of Boston but currently treats veterans in New Hampshire, Maine and Washington. “Veterans who have kidney disease or Veterans at risk of kidney disease can now reach a specialist through this program,” Bonegio said. “We can help veterans across the country and hopefully change their lives.”
How the Program Works
The hub-and-spoke design pairs nephrologists at larger VA medical centers with rural VA clinics that lack on-site kidney specialists. Veterans attend appointments at their local clinic, where they connect with the nephrologist via VA Video Connect or similar telehealth platforms. The nephrologist reviews bloodwork, urinalysis and imaging results, adjusts medications, and sends recommendations back to the local care team. The veteran does not have to drive hours for a 20-minute appointment. The specialist does not have to be physically present in a rural community that could not support a full-time nephrology practice.
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A separate qualitative study interviewing 44 veterans at five rural VA medical centers found four consistent themes in veterans’ experiences with the program:
- Telenephrology provides timely access to care for rural veterans.
- The clinical partnership between primary care and the nephrologist is critical.
- Veterans value the convenience of not traveling.
- The quality of the telemedicine encounter meets their expectations.
- The findings were published in the American Journal of Nephrology.
What This Means Going Forward
The VA is the largest integrated health care system in the country, and telehealth is one of the areas where it consistently leads the private sector. In fiscal 2025, more than 2.1 million veterans used VA telehealth services across more than 7.7 million care episodes, a 12% year-over-year increase.
The telenephrology results add to a growing body of evidence that specialist telehealth at the VA is not just a convenience. It is producing measurable clinical outcomes that in-person access alone cannot match for geographically isolated patients.
If you are a rural veteran with chronic kidney disease or risk factors like diabetes and high blood pressure, ask your VA primary care provider about telenephrology. The program is available through the VA’s Connected Care office, and your local facility can determine whether you are eligible for a referral.
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