April 12, 2021

Dear Colleague:

Nephrology, more than any other specialty in medicine, was built on innovation. The artificial kidney--imagined, invented, and implemented by pioneers in our field--is nothing short of miraculous. In 1972, the US Congress changed federal policy to guarantee renal replacement therapy to anyone with kidney failure. With this change, dialysis "death panels" were disbanded.

Almost 50 years after the dialysis law was enacted, nephrology has taken the lead once again.

In the earliest days of the COVID-19 pandemic, the medical community witnessed astonishing rates of kidney damage and kidney failure. Facing national and global shortages of dialysis equipment and supplies, the international kidney community banded together, sharing experiences and rapidly developing safe protocols for acutely ill hospitalized patients and for patients who had to travel to dialysis units. As supplies ran out, international shipments were arranged.

Our community's critical leadership in a time of crisis engendered new respect amongst our medical colleagues, trainees, and leaders of hospitals and health systems as well as the public, many of whom had never considered lack of dialysis resources as a preventable cause of death.

Beyond the case count and rates of kidney diseases, wide-ranging health disparities were laid bare by the pandemic. The murder of George Floyd and continuing attacks against people who are of Asian or Pacific Islander descent placed social justice reform at the center of the global stage--exactly where it belongs. Calls to dismantle systemic racism in health care reverberated throughout our institutions, practices, and the world.

Among many calls for change, one that garnered widespread attention is the removal of race from the kidney function estimating equations. Because race is a social and not a biologic construct, it has no place in clinical algorithms, including eGFR. Leading the way for other disciplines to follow, the work of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Estimating Kidney Diseases will inform a national approach for an equitable, raceless replacement.

However, we know race modifiers in clinical algorithms are but "the tip of the iceberg" of kidney health inequities, which are pervasive, and heavily influenced by racial, ethnic, and sexual identity biases and socioeconomic injustices around the world.

Stark statistics remind us that there is urgency for more change:

An estimated 850 million people worldwide and 37 million people in the United States have kidney diseases, and an astounding 90% of Americans with kidney diseases are unaware of their diagnosis. Globally, immense inequities in access to kidney care and preventable deaths are commonplace. The current national and international emphasis on removing inequities, ending disparities, and dismantling racism provides us with time-sensitive opportunities.

I wonder if you ever ask the same questions as I do?

• If the clinical training enterprise--including undergraduate and graduate medical education, the organizations that accredit them, and the organizations that certified and recertify physicians--are truly interested in ending health inequities and disparities, why isn't nephrology a mandatory core competency for all trainees, particularly internal medicine residents?
• Why has there been so little innovation in the delivery of dialysis in the United States during the past several decades? Is it because more than one-half the people who fill dialysis chairs are members of minoritized communities? Would the current system stand if most of our patients were White?
• Public and private funding agencies have announced they will focus on funding research to reduce health disparities. Will we see the historical funding gaps reversed? Increased resources must be provided to fund fundamental basic kidney research and follow through to implementation to end health inequities and disparities.

In a year consumed by COVID-19 and civil unrest, we have also witnessed phenomenal successes in our field. Trials testing a new class of kidney-targeted therapies, the SGLT2 inhibitors, which were first developed by nephrologists, signaled the end of a 30-year drought in new treatments for our patients. These powerful therapies prevent death and reduce kidney failure. If implemented effectively, we will save millions of lives and protect millions of kidneys throughout the world, with the biggest impact seen in communities overburdened by kidney diseases and diabetes.

I am an optimist.

I am as passionate about our discipline today as I was on my first day as an intern when I chose nephrology. However, it is easy to become disheartened by reports that bemoan the lack of clinical trials, research funding, and career interest in our field--a field that led the way in the past and is starting to lead the way again now.

The promise of new therapies to reduce kidney failure is breathtaking. Let us hold up this opportunity as an exemplar of health justice for public and private organizations locally, regionally, nationally, and globally that must commit to bring these treatments equitably into the clinic and into the communities where they are urgently needed.

Let us do what we do best--lead through a crisis, come together to find the solutions that others cannot, and take effective action boldly. Let us leverage this moment in time and demonstrate the value of nephrology.

If we keep the pressure continuous and strong, I fully believe the rest of medicine, policymakers, and other decision makers will make the right choices. The time for accepting the status quo is over. It is time for us to recognize our worth and act. Let us stand together, all in, and demand change.

Sincerely,

Susan E. Quaggin, MD, FASN, President