Nephrology: Taking the Lead (President's Address, Kidney Week 2020 Reimagined)

Welcome to ASN Kidney Week Reimagined for 2020! 

On behalf of our society, I thank each one of you for your unwavering commitment to improving kidney health throughout the world. This first-ever Kidney Week Reimagined symbolizes many of the opportunities and challenges nephrology faces. Your participation during these unparalleled and supremely challenging times is so highly valued and greatly appreciated.


Welcome to ASN Kidney Week Reimagined for 2020! 

On behalf of our society, I thank each one of you for your unwavering commitment to improving kidney health throughout the world. This first-ever Kidney Week Reimagined symbolizes many of the opportunities and challenges nephrology faces. Your participation during these unparalleled and supremely challenging times is so highly valued and greatly appreciated.

As we present this Kidney Week, I recognize the two Kidney Week Co-Chairs, Linda Fried and Jon Klein, who led an exceptional Education Committee (Slide 2), all of whom pivoted to a virtual platform. I express my immense gratitude to the ASN staff, specifically Jin Soo Kim and Alex Zapple, for their efficient teamwork that enabled this meeting. (Slide 3)

ASN has greatly benefited from close partnerships with many other kidney societies and patient organizations, in the United States and abroad. (Slide 4) Our joint efforts are clearly having a positive and meaningful impact for nephrology across the globe.

I want to thank the current and past ASN Council members, and in particular, the past president and outgoing councilor, Mark Rosenberg. I extend my sincere gratitude to ASN Executive Vice President Tod Ibrahim, who tirelessly supports the ASN community and is crucial to our success. (Slide 5)

I am grateful to the members of my Division of Nephrology at the University of Alabama at Birmingham (Slide 6), as well as members of my research group (Slide 7). A special thanks to my mentors, Professors K. S. Chugh, Karl Nath, Craig Tisher, and Harry Nick, (Slide 8) who played key roles in shaping my career in academic nephrology. 

Finally, I express my love and gratitude to my family—my wife and a kidney scientist, Lisa Curtis, for her unconditional support and counsel, and our children—Alex and Megan—who at one time assumed that every physician friend I introduced them to was a “kidney doctor.”  (Slide 9)

Just as we reimagined Kidney Week to meet today’s challenges, we must accept the need to change our discipline. Today, nephrology stands at a critical crossroads. The COVID-19 pandemic and sweeping movements to advocate for racial equality have brought into focus the need for us—all of us—to take the lead and shape our future.

The American Association of Kidney Patients has proclaimed the 10 years from 2020 to 2030 “The Decade of the Kidney.” (Slide 10)

Each of us must commit to creating lasting change by 2030.


To do that, we must take the lead in three key areas: (Slide 11)

            Building our workforce;

            Advancing diversity, inclusion, and equity; and

            Expanding innovation and collaboration.


Building Our Workforce

More than three decades ago, Dr. Thomas Ferris (Slide 12)—who was Chair of Medicine at the University of Minnesota when I was a fellow there—asked during his 1988 ASN Presidential Address:  “Why are we having difficulty attracting others into our specialty?”

The problems Dr. Ferris highlighted more than 30 years ago have persisted.

For too long, nephrology has been undervalued compared with other specialties, despite the life-saving contributions of those in our field. This misperception has dampened interest among students thereby reducing the recruitment of talented professionals needed to build on today’s achievements.

The COVID-19 pandemic has dispelled this misperception, and demonstrated the indispensible value of our specialty. A significant increase in inpatient nephrology consultations and dialysis which persisted even after the surge were common occurrences (Slide 13)

As we have taken the lead providing life-saving care to a vulnerable patient population amid this crisis, we must also lead in building our workforce.

To build our future, we must inspire and attract the next generation of students.

Today, we’re honored to have with us participants in our Kidney STARS program (Slide 14): they will build the next generation of transformative change for our patients. How does nephrology attract more people like these gifted students and residents?

I share an inspiring example of how young talent in the pipeline can impact the future of our workforce. Saakshi Thukral, an undergraduate student in the Honors Program at my institution, is raising funds to start a chapter of the Kidney Disease Screening and Awareness Program or KDSAP (Slide 15). She witnessed her father’s struggles with kidney disease, and this experience motivated her call to improving kidney health. This calling can only come to fruition for Saakshi and many others like her, if we – all of us – serve as mentors and create environments that attract, support and inspire them. We, as current members of the kidney community, deliberately and devotedly must reach out to and inspire those on whom the future of nephrology fully rests and who will bring about the needed advances in the treatment of kidney diseases.  

I thus challenge our community to create more local programs like KDSAP, founded by Dr. Li-li Hsiao. I challenge you to take advantage of R25 grant programs for undergraduates and similar programs across the globe. (Slide 16) Students who witness the dedication and commitment you bring to your work, the lives you change, will be inspired by you to pursue nephrology and kidney research.

We must take the lead and reach medical, graduate and undergraduate, and even high school students and spark their interest in our ability to change lives.

We must diversify to build excellence.

How do we build a dynamic and engaged nephrology workforce equipped to meet our patients’ needs? We must recruit -- and value -- professionals of divergent races, ethnicities, experiences, and perspectives.

Later, I will address some of the complex challenges related to building diversity and inclusion into the fabric of our health care system. Each of us must commit to diversity and inclusion. Otherwise, nephrology will not reflect the full range and depth of talent needed to deliver exceptional care, educate the next generation, and transform our patients’ lives through research and innovation.

Without diversity and inclusion, we cannot take the lead.

We must also focus on a key component of the nephrology workforce in the United States—international medical graduates.

These talented physicians have maintained and enhanced excellence in kidney care and research, particularly in an era of declining U.S. medical graduates entering nephrology.

As an international medical graduate myself, I was fortunate to further my clinical and research training in nephrology in the United States. Since that time, the gap between the number of these graduates applying to nephrology programs in comparison to U.S. medical graduates has continued to widen. Today, 49% of the U.S. nephrology workforce are international medical graduates (Slide 17/2017 AAMC data).

Most of these graduates face restrictions on where they can practice. This policy prohibits their taking a shift at a second hospital where they may desperately be needed, something that became quite evident during the COVID-19 pandemic.

We must create avenues for these graduates to achieve permanent residency and citizenship.

ASN is pushing the U.S. Congress to enact change (Slide 18), including the Healthcare Workforce Resilience Act of 2020. This legislation would direct the U.S. government to “recapture” up to 25,000 visas for nurses and 15,000 visas for physicians, and roll back restrictions that disproportionately impact immigrants from countries with higher rates of immigration to the United States.

We must build a fair compensation structure.

Nephrologists provide complex care and 24-hour coverage to a vulnerable patient population, but the pay scale and remuneration for nephrologists do not reflect this complex care. In this regard, the work of the Renal Physicians Association has clearly benefitted nephrologists, but compensation is still more aligned with cognitive specialties that often do not have to provide 24-hour emergency call (Slide 19).

We must reform the current flawed approach to compensation for nephrologists. It discourages interest in our specialty and indeed compromises patient care. This problem leads many talented medical graduates to pursue better compensated careers, that generate salaries needed to pay down their increasingly staggering medical student debt.  

ASN has launched a task force, led by former ASN President Sharon Moe, to help facilitate some of this much-needed change.  (Slide 20)

After 50 years as a board-certified specialty, nephrology should develop structured subspecialties with RVU and compensation benchmarks, such as those on the slide (Slide 21), to address the changes needed to enhance patient care and professional fulfillment.

In addition, ASN is building a survey mechanism to capture and track compensation, productivity, and demographic data across the career trajectory, to provide all ASN members the ability to review and compare detailed data on our profession. (Slide 22)

Building the workforce is not enough. We must support it.

All of us must commit to ensuring work-life balance for our peers, our trainees, and ourselves. We know when we enter health care that we will be called upon in times of crisis. Recently, Beirut, Lebanon, experienced a terrible industrial accident. In describing his 52-hour shift after that explosion, Dr. Bassam Ossam wrote (Slide 23):

In my capacity as a doctor, and in the name of all the doctors I have seen fiercely fighting their own battle yesterday, I tell you, it will take much more than an uprising, economic crises, currency collapse, hyperinflation, corona pandemic and a massive blast to hold us back.

Any of us would do the same as Dr. Ossam and his peers. But, we must distinguish crises from routine life. As nephrologists, we face multiple stressors that disrupt our work-life balance. The COVID-19 pandemic and the tensions we are facing with systemic racism have added to these challenges.

We must support work-life balance, recognize the importance of mental health, and reduce stress and burnout. Only then will we have the resilience to lead nephrology forward to 2030 and beyond. Dr. Tait Shanafelt, Chief Wellness Officer from Stanford University, will address this topic on Friday.

Advancing Diversity, Inclusion, and Equity (Slide 24)

In its fullest expression, diversity includes diversity of age, sex, gender, thought, socioeconomic background, geography, and education. A richness of experiences, skills, perspectives, and insights empowers us to effect meaningful change within the worldwide platform in which we deliver care (

As the CEO of Google said,

“A diverse mix of voices leads to better discussions, decisions, and outcomes for everyone. (Slide 25).

What about inclusion? Without inclusion, diversity has no meaning. Dr. Kirk Campbell cites a metaphor from Verna Myers’ TED talk on overcoming bias: “Diversity is being invited to the party; inclusion is being asked to dance.” (Slide 26)

I believe inclusion means being essential and welcomed members of the group planning the party, choosing the dance music and enjoying the music on the dance floor.

Our specialty must reflect the diversity of the patient population we serve. We know too well that kidney disease disproportionately afflicts racial and ethnic minorities. Health disparities and limited access to care mean many enter the healthcare system with advanced kidney disease. These disparities have become most evident during this COVID-19 pandemic (Slide 27). 

We must commit to taking action and creating positive, measurable change.

We must begin by focusing on diversity and inclusion in our own backyard, within ASN. ASN will advance diversity and inclusion within all our programs and initiatives. Overall, our society has made progress. For the first time at ASN, our eight-member Council includes four women, and all eight of us have diverse racial and ethnic backgrounds (Slide 28). Other initiatives (Slide 29) reflect some of ASN’s efforts to improve diversity and inclusion.

We must also acknowledge when we fall short. ASN received criticism in a paper published after last year’s Kidney Week that addressed representation among our speakers, moderators, and award recipients. That helped us re-focus our efforts to ensure that diversity and inclusion are reflected in all facets of our meeting this year. More than 45% of our speakers and moderators during Kidney Week 2020 are women. (Slide 30)

We must address the failure of U.S. medical schools to increase representation of African Americans, particularly Black men. ASN is proud to launch, in 2021, a loan mitigation program focusing on trainees underrepresented in medicine; that program will include outreach to undergraduates and medical students (Slide 31).

We must diversify all levels of leadership. We must do more to understand and mitigate challenges of diversity and inclusion across the globe.

Diversity and inclusion can only thrive within a framework of equity. The recent movement around the globe to advocate for racial equality and to end systemic racism has crystallized the urgent need for institutions to embrace and value all people. 

How will we take the lead? Last month, ASN’s webinar delineated salient challenges in this regard, and opportunities for all of us to contribute to positive change (Slide 32). ASN’s Diversity and Inclusion Committee is galvanizing change across the landscape.

I promise you ASN will take the lead in building a racially equitable culture in nephrology across the globe. And we will report to you regularly on our progress.

I do not minimize these challenges. But, as kidney professionals, our life’s work embraces complexities and difficulties. Together, we will make 2030 look very different than today.

Expanding Innovation and Collaboration   (Slide 33 )

To lead the way to 2030 and beyond, we must leverage our groundbreaking work and our creative solutions to unresolved public health challenges.

Just as flaws in compensation undermine our efforts to build the workforce pipeline, the perception that nephrology lacks innovation compromises our ability to attract future researchers and scientists to study kidney diseases.

In fact, this is one of the most exciting times in kidney research and innovation.

The ASN KidneyX program recently awarded $3 million in prizes to six winners, highlighting projects focused on transforming dialysis for millions of patients worldwide (Slide 34).  An engineer from Ireland won the Affordable Dialysis Prize with his design of a solar powered machine to prepare peritoneal dialysis fluid using water from any source and costing ~$500 (Slide 35). This kind of positive, concrete change creates a culture of innovation and advances patient care.

However, less than 10% of today’s nephrologists pursue a career in research. Grant applications are diminishing. (Slide 36). We must take advantage of the current higher funding levels for NIH, particularly for new and early stage investigators.

We must support more clinical trials and attract more scientists and researchers into our specialty to drive discoveries of new, life-saving therapies and devices, including efforts such as the ISN Advancing Clinical Trials program (Slide 37).

The recent discovery of SGLT2 inhibitors and endothelin antagonists in slowing the progression of kidney diseease.

Artificial intelligence, if applied responsibly, can improve clinical care in our specialty. We are all encouraged by the potential of using novel agents to target the HIF pathway for anemia of chronic kidney disease. I look forward to learning more about such advances when Nobel prize winner and nephrologist, Sir Peter Ratcliffe presents some of his vital research.

My challenge to anyone who drives innovation and pioneers advances: Tell the story of your work. Share your successes. Find ways to work with and inspire the students and trainees who will build on and expand your achievements. Take the lead.

Extending Collaboration

As we build the path forward to 2030 and beyond, we must leverage all the knowledge and talent needed to provide exceptional patient care and transform the future of our specialty.

The COVID-19 pandemic has facilitated new methods of collaboration among nephrologists worldwide as we confer and exchange information about the impact of the virus on our patients. The power of social media cannot be overstated.

Early in this pandemic, reports from China posted that kidney involvement was not commonly seen in COVID-19 patients. However, as the pandemic hit Europe and the United States, cases of AKI in COVID-19 patients were increasingly reported, first on Twitter, from Italy, New York, and other areas (Slide 39). 

In an article in Nephrology Dialysis Transplantation, Dr. Rajiv Agarwal described the work of two nephrologists – Matthew Sparks and Swapnil Hiremath – in curating a resource for nephrologists. They were among the first to address the question of whether angiotensin receptor blockers should be stopped in COVID-19 patients. Their conclusion—that patients should continue taking these drugs—was later supported by multiple independent publications (Slide 40).  

ASN worked closely with the American Nephrology Nurses Association to assist dialysis nurses in various COVID-19 hotspots around the United States. ASN also assisted the American College of Emergency Physicians to help care for patients in dialysis units, freeing much needed ER space for COVID-19 patients.

Earlier, we referenced the joint NKF/ASN Task Force (Slide 41) committed to ensuring that eGFR provides an unbiased assessment of kidney function: an example of essential collaboration. We cannot take the lead in improving care without collaborating with our patients, understand their perspectives, creating partnerships based on trust and personalized care, and reducing the use of clinical jargon in favor of more commonly used language.

Continued innovation and discovery in our field depends on outside funding. In the United States, Medicare spends $120 billion a year to care for people with kidney diseases, including $36 billion for dialysis alone. But, NIH allocates significantly less money for kidney research than many other diseases, such as cancer, diabetes, HIV, and heart disease.

How do we build this path forward?  

By flooding the gates of all funding agencies and journals with our ideas

By supporting our undergraduate and graduate students to pursue kidney-related research (Slide 42  

By making sure lawmakers understand the need to fund kidney research. (Slide 43)

By collaborating with experts across the globe. (Slide 441)

ASN Kidney Week represents the largest international collaboration in nephrology, as experts around the world listen to and learn from each other. Our scientific sessions, diverse speakers, and exchange of ideas foster continuing education, spark new collaborations, and inspire and mentor the next generation (B-roll from previous meetings).

Here’s my challenge to each one of you.

Before the end of this meeting, Take the Lead by participating actively, and reaching out to as many of your colleagues as possible. Encourage others to submit their work for grant funding and publication. Determine how best you can make a difference.


Workforce, innovation, diversity, collaboration all of these will help create positive, inspiring change by 2030. But this year, of all years, we should recognize fully what we have accomplished.

We must celebrate our landmark achievements—providing innovative care during a pandemic, developing promising new therapies, creating research partnerships that make a difference.

Our focus has never wavered. Our patients will benefit from the skill, determination, and commitment each of you has displayed this year.

The fundamental question I posed at the beginning of this talk is:

            What could nephrology look like in 2030, and what do we need to do to get there?

Together, all of us, must embrace three imperatives:

One: We must improve practice to identify, prevent, slow and ideally stop kidney diseases.

Two: We must advance science and medicine to treat—and ultimately cure—kidney diseases.

Three: We must enrich society by addressing health disparities and social determinants of health.

If we accept these imperatives today, then, in 2030, we will:

Implement systems that value and advance our specialty and our contributions to individual patients and to public health. (Slide 45)

Dismantle systemic racism in nephrology. (Slide 46)

Build a diverse and overflowing pipeline of students and trainees eager to cure kidney diseases. (Slide 47)

Overcome the barriers social determinants of health impose on kidney care. (Slide 48)

Secure the funding that will spur research, discovery, and innovation as well as improve global health. (Slide 49)

Starting today, we must take the lead. (Slide 50)

Nephrology: Taking the Lead (download slides)