ASN's Next Era: Reimagining Legacy Activities, Advocating for the Specialty, and Confronting Existential Risks

These legacy activities are threatened and may not survive this decade let alone the fourth era.

ASN Kidney Week works best as an in-person experience; as an international meeting (approximately 45% of participants come from outside the United States); and with an educational and scientific focus on every aspect of kidney diseases, practice types, and research disciplines. The COVID-19 pandemic accelerated forces against these three goals: online learning is more accepted, resulting in attendees missing the personal interaction among those with whom they have the most in common, and global travel is trickier.

For Kidney Week to survive as the premier nephrology meeting in the world, ASN must consider radical changes. These include, but are not limited to, shortening the presentations to align with how modern content is consumed, expanding Kidney Week material throughout the year (both in-person and online) and across the world, reorganizing the meeting experience to emphasize the many constituencies and micro-communities within nephrology, accentuating the social aspects of the meeting, and considering the need to shorten the entire in-person experience.

ASN's commitment to helping nephrologists certify and recertify must also change. Traditionally, an in-person experience for U.S. participants that occurred in July, the ASN Board Review Course & Update (BRCU) is now a shorter, in-person meeting, valued for its on-demand content and popularity among international participants. Through BRCU, the ASN In-Training Examination for nephrology fellows, the Nephrology Self-Assessment Program (nephSAP), and the Kidney Self-Assessment Program (KSAP), ASN offers a suite of programs to help nephrologists promote clinical excellence.

With the advent of the Longitudinal Knowledge Assessment (LKA) for recertification, however, the American Board of Internal Medicine (ABIM) has broken a longstanding firewall between assessment and education (2). LKA allows nephrologists to maintain their certification by answering regular questions during a 5-year cycle (instead of sitting for a secure examination every 10 years). In fairness, nephrologists and other diplomates requested that ABIM take this step, but it forces ASN to reconsider the role of BRCU, nephSAP, and KSAP in helping nephrologists recertify as well as question whether the society should continue to maintain the firewall.

The future of the publishing industry is also very much uncertain, and it is impossible today to say what JASN, CJASN, Kidney360, and Kidney News will look like in the future. People still value information, but they want it instantly, as easily accessible and usefully brief as possible, highly relevant to their specific interests, and (in scientific publishing at least) peer reviewed. Print media (especially daily newspapers), linear television (like ESPN), and streaming entertainment (like Netflix) are evolving at an even faster pace, and it is hard to imagine ASN's publishing enterprise not following suit.

Until the COVID-19 pandemic escalated in 2020, ASN membership had grown every year. While the society has regained most of the members it lost during the pandemic and will soon surpass 2019's total, generational differences signify imminent struggles. These challenges will affect what future generations want from medical specialty societies like ASN. Beyond Kidney Week, other educational offerings, and publishing, the society is already trying to navigate very different preferences related to policy priorities. For example, nephrology fellows and early career nephrologists are much more interested in existential risks—like climate change—than their predecessors were.

In 2000's Bowling Alone: The Collapse and Revival of American Community, Robert D. Putnam, PhD, explained why medical societies will struggle to attract members in the future: “Much of the decline in civic engagement in America during the last third of the twentieth century is attributable to the replacement of an unusually civic generation by several generations (their children and grandchildren) that are less embedded in community life” (3). Millennials (born 1981–1996), Generation Z (born 1997–2012), and Generation Alpha (born approximately 2013–2025) only accelerated this disengagement for reasons that Dr. Putnam could not have predicted, such as social media, handheld devices (like smartphones), and a global pandemic.

For the past 20 years, ASN championed kidney care, research, and education as well as promoted the nephrology workforce.

In a previous editorial, I used a table as a metaphor for ASN's efforts in these arenas (4). Patient care is the tabletop, “with education (undergraduate/graduate and continuing), research, and advocacy as the supporting legs. Diversity, equity, and inclusion are the joints that lock aprons (health care justice) to the legs, strengthening the table.”

In 2024, ASN will initiate new activities to further advance kidney care, research, education, and advocacy, as well as promote diversity, equity, inclusion, and justice. Besides supporting the society's membership, improving the lives of people with kidney diseases, and benefiting the rest of the kidney community, these efforts will take advantage of opportunities and overcome threats—both seen and unseen today.

Directly or indirectly, these ventures will also help continue the society's efforts to implement the final recommendations from the ASN Task Force on the Future of Nephrology (5):

• Publish kidney health guidance to encourage high-quality, patient-centered care across the spectrum of kidney diseases, covering the patient-care journey from screening and early detection through palliative care.

• Finalize plans for individualized, competency-based education in nephrology training to clarify, expand, and systematize the educational continuum for all types of nephrologists, including subspecialists.

• Pursue accreditation for transplant nephrology fellowship training programs by the Accreditation Council for Graduate Medical Education (ACGME), ideally by working with the American Society of Transplantation.

• Address increasing concerns about the nephrology workforce by trying to partner with other members of the kidney community, such as the American Nephrology Nurses Association and American Nephrologists of Indian Origin.

• Increase nephrology's presence within the American Medical Association (AMA)—including the AMA Specialty Society Relative Value Scale Update Committee (that provides recommendations on physician reimbursement)—by seeking collaboration with the Renal Physicians Association.

• Concentrate on other difficulties in providing high-quality care to people with kidney diseases, such as the U.S. Preventive Services Task Force's need to recognize the value of screening for kidney diseases, structural challenges within the Medicare Advantage program, the Centers for Medicare & Medicaid Services' goal of enrolling all Medicare beneficiaries in accountable care organizations by 2030, and lower compensation for nephrologists when compared with other medical specialties.

• Formalize interactions with integrated kidney care companies to improve kidney health by intervening earlier to prevent, diagnose, coordinate care, and increase awareness of kidney diseases, while working to pursue true value-based care.

• Reevaluate priorities for funding of federal research agencies due to concerns about the government's budget deficit, the politicization of health-related research, the advent of the Advanced Research Projects Agency for Health, and attenuated support for the next generation of “renal researchers.”

• Enhance ASN's commitment to diversity, equity, inclusion, and justice considering the U.S. Supreme Court's recent decision on Affirmative Action as well as improve enrollment in clinical trials focused on kidney diseases of people who identify as racial or ethnic minorities.

• Advocate for establishing the U.S. Department of Health and Human Services Office of Kidney Health and Transplantation to ensure the federal government shifts the emphasis from treating kidney failure to promoting kidney health (6).

In addition to these activities, ASN will continue to support efforts to implement the task force's recommendations. On Monday, July 1, 2024, for example, ACGME is expected to implement new requirements for accredited nephrology fellowship training programs. These new requirements will likely compel more training in home-based therapies, such as home hemodialysis, as recommended by the task force.

At least seven existential risks have important connections to kidney health.

The first four of these forces (see list, 1–4) could lead to human extinction, while the remaining three (5–7) could accelerate the demise of humanity:

1. Climate change and sustainability. A recent article by Aryn Baker in Time declares, “Chronic kidney disease is poised to become the black lung of climate change” (7). Ms. Baker describes chronic kidney disease of non-traditional origin, which “tends to manifest among outdoor laborers who work grueling hours in high heat conditions.” The changing climate also increases the likelihood of natural disasters, causing crush injuries from earthquakes, swamped dialysis facilities from hurricanes, and other emergencies for people, regardless of whether their kidneys are healthy or not.

2. Nuclear war and nuclear winter. Beyond the casualties, a nuclear war would present many of the same challenges to the kidney community as natural disasters (8). A nuclear winter would result in horrific conditions for the survivors, including people who require dialysis (particularly adequate power and nonradioactive water) or are trying to keep a transplanted kidney healthy (9).

3. Public health and pandemics. COVID-19 “disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education,” according to Geetha et al. in 2022 (10). Optimistically, the experience with COVID-19 will result in governments agreeing to work together, support public health, and prepare for future pandemics. Bill Gates (author of How to Prevent the Next Pandemic) is not so hopeful: “When the World Health Organization first described Covid-19 as a pandemic just over three years ago, it marked the culmination of a collective failure to prepare for pandemics, despite many warnings. And I worry that we're making the same mistakes again. The world hasn't done as much to get ready for the next pandemic as I'd hoped” (11).

4. Augmented and artificial intelligence (AI). In May 2023, the Center for AI Safety issued the following statement signed by more than 350 AI experts, including the top executives from OpenAI, Google DeepMind, and Anthropic: “Mitigating the risk of extinction from AI should be a global priority alongside other societal-scale risks such as pandemics and nuclear war” (12). AI can quickly accelerate and exacerbate human-caused error and bias—especially in health care—threatening our well-being. If harnessed, however, AI has the potential to help address other existential threats and improve health care throughout the world. Unfortunately, as the ASN Augmented Intelligence and Digital Health Task Force noted last year, “[N]ephrology trails other fields—such as cardiology, critical care, and radiology—in bringing these tools to clinical care” (13).

5. Autocratic and authoritarian governments. Anne Applebaum (a staff writer at The Atlantic and a senior fellow at the Agora Institute at Johns Hopkins University) explains that “autocracies are run not by one bad guy, but by sophisticated networks composed of kleptocratic financial structures, security services (military, police, paramilitary groups, surveillance), and professional propagandists” (14). According to Ms. Applebaum, “the members of these networks are connected not only within a given country, but among many countries.” For example, “The Chinese Communist Party is teaching African leaders its authoritarian alternative to democracy at its first overseas training school” (15). This approach to government relies on misinformation/disinformation, is anti-science, and devalues education, placing it at odds with the basic tenants of the medical profession. Life expectancy declines in democracies that become autocracies (and kidney diseases test public health throughout the world), so nephrologists and other kidney health professionals need to care about this risk (16).

6. Inequities and disparities. The International Monetary Fund estimates that “Some 10 percent of the world's population owns 76 percent of the wealth, takes in 52 percent of income, and accounts for 48 percent of global carbon emissions” (17). An estimated “252 men have more wealth than all 1 billion women and girls in Africa, Latin America, and the Caribbean, combined” (18). According to the U.S. Department of the Treasury, “Racial inequality in the United States today is rooted in longstanding behaviors, beliefs, and public and private policies that resulted in the appropriation of the physical, financial, labor, and other resources of non-[W]hite people” (19). Of the more than 37 million Americans with kidney diseases, a disproportionate number are Asian American, Black or African American, Hispanic or Latin/o/a/x, Indigenous or Native American, and Native Hawaiian or Other Pacific Islanders. Disproportionately, people with kidney diseases also have lower socioeconomic status.

7. Migration and workforce. The United Nations International Organization for Migration's World Migration Report 2022 estimates that 3.6% of the world's population (or 281 million people) are defined as migrants, moving from one country to another “for reasons related to work, family and study” (20). The United States “remains the primary destination for migrants, at over 51 million international migrants,” and “India has the largest emigrant population” with an estimated “18 million people living abroad.” Of the 11,554 nephrologists practicing in the United States, 51% graduated from international medical schools (21). At this time, 29% of all U.S. physicians were born abroad, but “Competition for healthcare talent is intensifying at the global level, leaving some countries with an edge and others at a disadvantage, including the U.S.” (22).

These existential risks are individually daunting and collectively overwhelming. No one organization can confront any of these threats alone, making it vital that ASN work with other members of the kidney community and beyond to focus on improving the lives of the more than 850 million people with kidney diseases worldwide.

During her ASN President's Address in 2021, Susan E. Quaggin, MD, FASN, charged the audience to:

• Amplify your passion for kidney health.

• Elevate the patient voice and choice.

• Unite. We can solve the most complex problems when we work together.

• Be political and demand change.

• Adopt innovation.

• Don't settle.

• This is our time, our moment, let us stand up to the challenges… (23).

Dr. Quaggin's call to action is the perfect inspiration for each member of the kidney community, including ASN. In 2024 and 2025, the society must determine how best to reimagine legacy activities, advocate for the specialty, and confront existential risks. The decisions made during the next 2 years will determine future success for the specialty, ASN, and—most important—people with kidney diseases.