ASN President's Update: Nephrology: A Commitment to Courage

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As we move into the second half of 2022, almost 29 months since a pandemic changed the world, the time to reflect on how nephrology and our field have evolved seems fitting. My pledge to run 850 miles each year to raise awareness for the 850 million people living with kidney diseases provides me ample time for reflection. This weekend, as I hit mile 3, a single word formed in my mind—courage. This word defines our approach to one of the most complex—and rewarding—areas in medicine.

Courage has many definitions. The one I like the best is “mental and moral strength to venture, persevere, and withstand danger, fear, or difficulty” (1). In our specialty's infancy, courage impelled nephrologists to advocate for care where none existed. Today, it enables us to transform our field even as we struggle with unimaginable external stresses.

Trainees who choose nephrology opt to overcome and to manage understandable fears. Recalling my first month as an intern rotating on the nephrology service, I am reminded of some experiences: using emergent dialysis for pulmonary-renal syndrome and a methanol poisoning, calling in patients in the middle of the night to receive a cadaveric transplant and managing them from recovery room to discharge, managing a potassium of 8.5 and a sine wave rhythm, and managing a sodium as low as 109 or as high as 165. These examples define baptism by fire!

Like countless other trainees, I fell in love with the specialty, inspired by the patients. Each year during fellowship interviews, trainees describe their passion for acute management of complex, life-threatening problems and emphasize the privilege to develop long-term patient relationships in the ambulatory setting. The ability to handle—and to embrace—the diversity and complexity of conditions that span emergent and long-term care, to step in where others may not, requires fortitude and fearlessness.

Before the end of training, kidney professionals learn to excel in emergency management of diverse conditions, line placements, immunology, and acid-base disorders. As recently told to me by Jane O. Schell, MD, an Associate Professor of Medicine at the University of Pittsburgh School of Medicine, we must recognize our ability and responsibility to walk beside a patient during his or her journey. Truly remarkable advice that clearly demonstrates how much we gain from stepping up to the challenges and joys of our profession.

Of course, it is not hard to call on inner strength and courage when we partner with patients who continually inspire us with their personal story, individual strength, and unique bravery, guiding the profession and using their powerful voices so that the urgent issues surrounding kidney health and kidney diseases are heard by the public, by policymakers, by media, and by other health professionals.

Then there's physical courage and bravery, clearly not unique to nephrology. Physicians are often called on to put their own lives at risk—most recently with the SARS-CoV-2 pandemic. However, during the Ebola outbreak in several countries and SARs outbreak in Toronto, Canada, nephrologists were called on and answered without question. When personal protective equipment was not available, members of the kidney care team—dealing with the incredible burden of acute kidney failure—did not hesitate to provide lifesaving treatments, often requiring prolonged exposure to patients who were not intubated, placing nurses and physicians in harm's way.

We all know colleagues and team members who contracted SARS or SARS-CoV-2 before the vaccinations or treatments, including many who we tragically lost. As a division chief, I am always struck that there is never a shortage of faculty members who immediately volunteer to provide coverage, place lines, or sleep at the hospital—colleagues who are always stepping up during times of crisis. When protests erupted in Chicago, IL, following the murder of George Floyd, nephrologists transported patients when hospital staff could not access the hospital. No job was left unfilled.

In recent events in Ukraine—and over the years in other war-torn countries or during natural disasters, such as hurricanes and earthquakes—nephrologists have again chosen responsibility over fear. Serhan Tuglular, MD, a European Renal Association (ERA) councillor and ERA Renal Disaster Relief Task Force General Coordinator and a nephrologist at the Marmara University School of Medicine in Istanbul, Turkey, led ERA's recent response in Ukraine with support from ASN, the International Society of Nephrology (ISN), and other societies (2), ensuring medications for transplant patients and dialysis options were available.

In 2017, during the devastating hurricanes in the Caribbean, Zaheeb Choudhry, MD, a nephrologist from Aruba and member of the ASN Emergency Partnership Initiative, received a distress call from the medical director of a dialysis unit in St Maarten, which was directly in the path of Hurricane Maria. Unwilling to put patients’ lives at risk, Dr. Choudhry coordinated with a friend in the Aruba military to bring him to the island to transport patients to safety. Just minutes before winds would have prohibited their takeoff, they departed and accompanied patients to life-saving treatments in Aruba.

And we are not afraid to disrupt the status quo, to lead where others are reluctant. The call to remove race—a social and not a biologic construct—from clinical algorithms created sometimes heated opposition and online pressure. The members of the National Kidney Foundation-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases maintained their focus on ensuring that patients were managed equitably and in September 2020, released and started to implement a new recommendation for a race-free assessment of kidney function (3). ASN, ERA, and ISN are now working together to tackle the issue of kidney function estimates globally where diet and location may impact measurements.

Perhaps the greatest example of courage in our discipline is the tenacity and stamina we have always shown when the patient-physician relationship is threatened. Nephrologists speak up even in the face of opposition and even in times when we are warned to step back. This is not new in our field. Members of the kidney community have always been social and health care justice activists. We have always been courageous. The fight and commitment to advance care for patients, when no care existed, have been exemplified by the pioneers in our field who innovated and created methods to replace kidney function, refining and improving systems, undaunted by monumental obstacles, and resolute to ensure that care reached the greatest number of those in need.

There are many notable giants in our field, whose names we recognize throughout the world. In addition, there are countless unsung heroes who we all know locally, who have made tremendous contributions to our field. When I arrived in Chicago, Peter Ivanovich, MD, an incredibly kind and gentle nephrologist, adored by nurses and still seeing his patients at the Jesse Brown Department of Veterans Affairs Medical Center at the age of 86 years, had been recruited by Belding Scribner, MD, when he was a research trainee. Dr. Ivanovich, who helped solve issues of calcium homeostasis seen in patients on dialysis, would later travel back and forth behind the Iron Curtain, bridging the gap between European and American advances in renal replacement care that catalyzed innovations in treatment.

In the United States, advocacy from giants and unsung heroes, like Dr. Ivanovich, resulted in a law providing access to dialysis for all people with kidney failure through the Medicare program. Medicare itself became law in 1965, just 7 years before the program was expanded to include every American with kidney failure.

In India, home to 17% of the world's population with kidney diseases, the community advocated successfully to launch the Pradhan Mantri National Dialysis Programme (4), providing needed resources for patients in India requiring dialysis. Still, costs of providing kidney replacement therapy are astronomical. As a global community, we are now seizing the moment to be “United 4 Kidney Health” (5) and to advocate for policies, initiatives, and therapies that:

1. INTERVENE EARLIER to prevent, diagnose, coordinate care, and educate.

2. TRANSFORM TRANSPLANT and increase access to donor kidneys.

3. ACCELERATE INNOVATION and expand patient choice.

4. ACHIEVE EQUITY and eliminate disparities.

Nephrologists’ activism is aligned with our approach to care: We have always been precision and data driven. When we see evidence of a negative impact on our patients, we act with courage. This is why we have always led as health care justice activists, providing and fighting for optimal care for all patients (6). Since 1983, ASN has bestowed the John P. Peters Award, which celebrates Dr. Peters’ “urging that public funds support medical care for the indigent, medical research, and the improvement of medical education, and that federal health and medical activities be consolidated into a separate department” (7).

In the same week that the U.S. Supreme Court ruled to overturn Roe v. Wade, it also ruled in favor of the Marietta Memorial Hospital Employee Health Benefit Plan in its lawsuit with DaVita (8, 9). The court decided that a health plan can refuse to pay for lifesaving dialysis for its insured patients with kidney failure. In so ruling, the court has likely forced patients prematurely off their health plan onto Medicare, potentially leaving other family members, who do not qualify for Medicare, uninsured and resulting in additional financial burden for kidney patients (10). In her dissent, Justice Elena Kagan asserted, “Now Congress will have to fix a statute this Court has broken” (8).

The entire kidney community is banding together to ensure Congress fixes what the court has broken. “The insurer practice at issue—shifting patients prematurely to Medicare—will exacerbate inequalities in access and quality care for an already vulnerable population,” said John P. Butler, chair of Kidney Care Partners (KCP), a coalition of which ASN is a member. “Despite this ruling, KCP remains steadfast in our commitment to ensuring equitable, affordable access to quality care for the millions of individuals living with or at risk for kidney disease,” Mr. Butler added (11).

As I wrote to the kidney community earlier this year (12), we will bring our values with us to the first in-person Kidney Week since 2019. ASN Kidney Week 2022 is taking place in Orlando, FL, and we will stand up to legislative actions that threaten our colleagues and patients (13).

Few other specialties require such skill and knowledge, art and creativity, and bravery and resolve in making rapid, “on your feet” decisions and displaying such iron-willed determination to improve and transform a global chronic disease. We are always on the frontlines—leading during times of turbulence and peace. We stand up and lead when it is convenient and when it is not. We do not stand silently by when actions might harm our patients or our field. We commit to excellence in care and accept all the burden that promise requires.

Courage—by any definition—is nephrology.