ASN President's Update: The Art of Nephrology

Susan E. Quaggin Susan E. Quaggin, MD, FASN, is with the Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, and is ASN President.

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Built on innovation, nephrology is a specialty of many firsts: from developing organ replacement therapies to advocating successfully for government support of lifesaving dialysis to removing race from a commonly used clinical algorithm. If asked in 2019, I would have declared nephrology the epitome of visionary leadership: determined to solve the most complex medical and social justice issues globally and inspired by a passion for patients.

Today, I view things somewhat differently. During the past 2 years, our specialty has demonstrated some of the most effective crisis leadership in medicine. When this column publishes, we may be past the worst of the surge caused by the Omicron variant. Yet, as I write today, we are in the midst of local, regional, national, and global emergencies, facing critical shortages of dialysis staff, resources, and supplies, as well as exhaustion across the entire spectrum of our workforce and most of all, an overwhelming shared concern for our patients who are among the most vulnerable.

Different than the previous COVID-19 surges, we—the kidney community—are acutely aware of the excess burden of loss of life of patients with kidney diseases and kidney failure, who at least one media outlet called “the pandemic's perfect victims” (1); of the blunted immune responses of our transplant and dialysis populations to vaccines (2); and of the shared experience of working the frontlines at a time when supplies—particularly personal protective equipment (PPE)—were non-existent or scarce, when there were no vaccines, and when rationing treatments was required.

We have witnessed firsthand the major impact of the acute infection and long-term complications from COVID-19 on kidney health (2). We also understand the increased kidney disease burden that the world will surely face in the coming years.

Approaching the third year of this pandemic, we face unprecedented numbers of infections throughout the world and increased infections in our own colleagues and family members. And, just as we did in early 2020 and 2021, we are demonstrating exemplary, effective, and resolute rapid-response leadership.

It is this flexibility—meeting the needs of our patients wherever and however we can—that is so remarkable. We continue to work tirelessly in the face of critical clinical demand, and yet, despite the ever-increasing needs, we still innovate, speak up, and lead for health and social justice, as well as continue to develop new therapies to slow and ultimately cure kidney diseases (3).

Our short-term responses to this crisis are helping inform the long-term transformation of our specialty. This is the art of nephrology.

Since the first reported SARS-CoV-2 case in November 2019 (4), many positive clinical trials have occurred in our field (3), bringing new hope for the more than 1.2 billion people worldwide with kidney diseases and diabetes (5, 6). There have also been several treatment approvals by the US Food and Drug and Administration (FDA) for orphan (7) and common (8) kidney diseases, reports of major advances to make xenotransplantation a reality (9), and tangible changes that demonstrate our commitment to include health justice in each and every activity we pursue. For example, I am thrilled that ASN has offered loan mitigation to six nephrology fellows (scheduled to start July 1, 2022) who identify as underrepresented in medicine.

Previously, I felt that visionary leadership was all that was needed to continue to transform our specialty and to accelerate our wins. Today, I am struck that, in fact, we are a specialty in perfect balance, demonstrating both visionary and responsive leadership, as well as successfully and rapidly adapting in the face of adversity, guided by a core principle: patients first, always. Throughout this crisis, we have responded to life-threatening, often unexpected, challenges that have sustained and even improved care.

All pandemics end. Although there will be far too many deaths, lifelong illnesses, and battle scars, I am confident that our specialty will emerge different and stronger.

As we contemplate a post-pandemic world, we must capitalize on our experiences of bringing the art of nephrology to bear even in a crisis. We must use what we have learned to truly transform our specialty for the better.

Our community is building toward a new future in at least two ways:

Nephrology is defined by kidney health, not kidney failure.

When millions of Americans with kidney diseases (10)—end-stage and chronic kidney disease—were at much higher risk of severe infection from SARS-CoV-2, our community raised the alarm, advocating for improved safety measures, PPE, and vaccines in dialysis units; promoting telehealth and increased access to home therapies; and reporting, in real time, the increased risk of death and serious outcomes for patients with kidney diseases.

The kidney community's rapid action saved lives and raised awareness of the burden of kidney diseases throughout the world. Now is the time to pivot and bring our shared vision of dramatically reducing the burden of kidney diseases by ensuring all patients who need powerful new therapies—such as the “flozins” and non-steroidal mineralocorticoid antagonists—receive them.

How can you help?

We must end crash-starts on dialysis. In the United States, one-third of all Americans are at risk for kidney diseases (10), and 90% of people with kidney diseases are unaware they are affected with the disease (10). The US Preventive Services Task Force recommendations, published in 2012 (the same year ASN and FDA established the Kidney Health Initiative), do not recommend screening, citing inadequate evidence that early intervention of chronic kidney disease is beneficial (11). Because these decade-old recommendations have “sunsetted,” we require new ones, and we must raise awareness that the 33% of Americans at risk for kidney diseases (12) deserve to know.

ASN, patient organizations (such as the National Kidney Foundation and the American Association of Kidney Patients), and other stakeholders worldwide are working on this issue, and we need your voice to amplify these requests. Overwhelming evidence exists that these powerful therapies can prevent kidney diseases, kidney failure, and death. We must identify people at risk for kidney diseases, so they receive the benefit of these new therapies.

Learn how to prescribe these new treatments, participate in webinars or use resources (such as the ASN Diabetic Kidney Disease education module), empower your patients and become their health allies to demand access to these lifesaving interventions, partner with your colleagues in primary care and related specialties (such as cardiology and endocrinology) to amplify your excitement for these advances, promote interdisciplinary clinical teams and new training programs (such as nephro-cardiology), and bring the excitement of these new therapies to trainees, informing them that we are a specialty “on the move” with the power to change the course of kidney diseases. Demand access to these therapies for all patients who need them, and help change payer restrictions and policies that discriminate and cause harm to the people who need these therapies most.

Science and medicine are leading us out of the pandemic, and they are changing our specialty. Nephrology is no longer overshadowed by kidney failure but defined by kidney health. We cannot stop until everyone is aware: kidney diseases matter, nephrology matters, the 850 million people with kidney diseases matter (13).

Nephrology is committed to health care justice and access for all.

The disproportionate impact of COVID-19 on communities of color and disadvantaged populations throughout the world, including in the United States, demands that society acknowledge the horrific truth of health and social injustice. Having long raised awareness about the disproportionate burden of kidney diseases, leaders in the kidney community are addressing the pervasive and negative impact of systemic racism and the impact of social determinants of health on kidney disease prevalence and outcomes.

The publicized condemnation of race in clinical algorithms and media coverage of our community's patient-centered approach to remove race from the kidney function estimating formula (i.e., estimated glomerular filtration rate [eGFR]) provide us a new visibility and leadership. Even as we continue to battle the pandemic, we must build on our rapid response and unwavering commitment by demanding more on behalf of our patients, so that they are able to access and receive the best care. It is unacceptable that Black Americans are three times more likely to have kidney failure (10). It is time to intervene and eliminate these disparities.

As a result of our efforts in this arena, kidney issues have been discussed and broadly disseminated by The New York Times, ProPublica, and “Grey's Anatomy,” to name but a few. We must continue to lead this charge by demanding that politicians, policymakers, the media, health care institutions, and industry honor their commitments to support justice, equity, diversity, and inclusion. They must now turn their expressed intentions into actions.

Begin by demanding accountability each and every day—from ourselves, our colleagues, and others. Why does the National Institutes of Health spend $18 per patient for kidney research compared with $305 per patient for cancer (14)? Advocate for change. At academic institutions, demand changes to student admission and tenure criteria, or serve on tenure or admission committees. Get involved with community outreach programs, amplify the efforts of others on social media or through sponsorship, or provide aid or donate to local charities to grow communities of opportunity, as David R. Williams, PhD, MPH, urged in his State-of-the-Art Lecture during ASN Kidney Week 2021.

In my address at last year's Kidney Week, I asked you to “remember who we are”—we are remarkable! The kidney community has come together, collaborating and reacting at record speed to the global crisis, advocating successfully for our patients and for needed resources, and continuing to innovate. Let us continue to leverage these advances and build on what we’ve learned during the past 2 years.

Responding successfully to major crises and being visionary at our core: these efforts represent the art of nephrology.