ASN President's Update: A World without Kidney Diseases

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March is our month! Not only do we celebrate National Kidney Month in the United States, but we also make our brackets to compete in NephMadness and, together with our colleagues across the globe, observe World Kidney Day on Thursday, March 9, 2023.

While you, like me, may think every day is kidney day, World Kidney Day is an annual initiative to raise awareness about the importance of kidneys to our health and the public health challenges of kidney diseases. Started in 2006 as a joint effort by the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations, World Kidney Day is observed on the second Thursday of March and has a different focus each year. The theme for 2023 is “Kidney Health for All: Preparing for the Unexpected, Supporting the Vulnerable!”

There are several important reasons for ASN to advocate for kidney health outside the United States, North America, and the Americas. Despite the society's name, ASN is an international organization. More than 35% of ASN members live outside the United States in 139 countries, approximately 45% of participants at Kidney Week are international, and an estimated 70% of manuscripts submitted to the Journal of the American Society of Nephrology (JASN) come from abroad. We are part of the global kidney community whose effectiveness is synergized, amplified, and heard when we all work collaboratively, rather than in silos. Finally, in its strategic plan, ASN's vision is to “Create a World without Kidney Diseases,” so we have an obligation to consider our field globally (1).

We are part of the global kidney community whose effectiveness is synergized, amplified, and heard when we all work collaboratively.

With this goal in mind, ASN Past President Susan E. Quaggin, MD, FASN; President-Elect Deidra C. Crews, MD, ScM, FASN; Executive Vice President Tod Ibrahim; and I met with our counterparts from the European Renal Association (ERA) and ISN in January in Brussels, Belgium (Table 1). These leaders from ASN, ERA, and ISN discussed issues and initiatives of mutual interest that are important to the more than 850 million people living with kidney diseases worldwide.

Table 1.

ASN-ERA-ISN joint leadership meeting participants

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In addition to reaching agreement several years ago on the number of people worldwide living with kidney diseases (2), the three organizations have worked together to advance several shared goals, including the World Health Organization's recognizing kidney diseases as one of the top noncommunicable diseases driving premature death worldwide, educating the kidney community about ethical challenges confronting nephrologists, and addressing the state of the global nephrology workforce (3).

Disaster relief—both from natural and human causes—was an area of shared interest for which all three societies have experience and expertise. This discussion ranged from earthquakes in Japan, hurricanes in the Caribbean, the COVID-19 pandemic, and multiple global conflicts. Last month's tragic earthquake in Turkey and Syria reinforced the importance of disaster preparedness worldwide as well as how the type of catastrophe varies by geographic location. If you would like to contribute to Direct Relief's efforts to help the people of Turkey and Syria, please visit https://www.asn-online.org/news/item.aspx?ID=341.

Also, February 24, 2023, marked the first anniversary of the war in Ukraine. Lessons learned from addressing the needs of dialysis and transplant patients in Ukraine and other war-ravaged countries were discussed. At last year's World Kidney Day commemoration, ASN, ERA, and ISN appealed “for kidney health for all war victims.” Past President Quaggin stated, “People with kidney failure and kidney transplants urgently need to find alternatives, because wars are destroying dialysis facilities, interrupting energy and water supplies, causing medical staff shortages, and making travel to facilities unsafe.”

ASN, ERA, and ISN also expressed concern for kidney patients and their caregivers who are in harm's way, thanked the companies and organizations that have already contributed aid, commended the countries that have opened their borders to receive people in need, and urged governments to do more. To date, ASN's partnership with Direct Relief has raised nearly $25,000 (4).

Last month, the leaders of ASN, ERA, and ISN also discussed the many ongoing efforts to support sustainability, or “green nephrology,” throughout the world. Each society is committed to addressing this critical issue, but we recognize that to be most effective, we need to work locally, then coordinate and collaborate globally. To this end, the three societies plan to collaborate through a joint working group.

The intersection of the environment and nephrology is increasingly coming to public attention. Ed Kashi—a photojournalist who “uses photography, filmmaking and social media to explore geopolitical and social issues that define our times”—has focused his camera on individuals living with chronic kidney disease of undetermined etiology (or unknown cause [CKDu]), humanizing the problem and increasing awareness of this worldwide epidemic (5). In some of the most compelling photojournalism I have seen, he is bringing attention to this issue in short films and still photographs:

• His 2015 documentary, “Under Cane,” depicts the devastation of kidney diseases in sugar cane workers in Nicaragua.

• “Hidden Under the Indian Sun,” a 2017 documentary, follows individuals with kidney diseases who worked in the rice fields in Southeastern India.

• His 2018 documentary, “With Every Breath,” shares the tragic story of a family and others with kidney diseases in Peru.

• A 2022 documentary, “Too Hot to Work,” follows a group of laborers who traveled from Nepal to Qatar, some of whom became dialysis dependent after working for hours in the heat.

Some experts have attributed CKDu to environmental nephrotoxin exposure in agricultural areas (6). Others have argued that the basis for this disease is occupational heat stress (7). It has also been noted that CKDu is occurring in disadvantaged populations that are at risk for lower nephron mass for several reasons, starting as early as the time of fetal growth and development (8, 9).

Although the causes of CKDu or CKD of nontraditional origin (CKDnt) are unclear, what is clear is that an increasing number of people are experiencing kidney failure as a result, requiring dialysis or a kidney transplant. Affected people are often the breadwinners in their family and are left unable to work. Thus, the impact of their illness has dire consequences not only for the individuals with kidney diseases but also for their families.

Regardless of whether the changing environment is driving incidence of CKDu or CKDnt worldwide, there are signs that repeated exposure to higher temperatures has significant consequences for kidney health. The Washington Post (10) and The New Yorker (11) are among the major media outlets reporting on the connection between a warming planet and kidney health. A recent article in The New Yorker—“A Hotter Planet Takes Another Toll on Human Health”—by American environmentalist Bill McKibben, quoted research by ASN member David S. Goldfarb, MD, FASN, that considers whether the increasing incidence of nephrolithiasis in African Americans in the United States can be, in part, connected to historic discriminatory redlining practices that led to minoritized populations living in neighborhoods that are for all practical purposes “urban heat islands” in which the temperatures are hotter, a situation only being exacerbated by the warming planet (12).

The leaders of ASN, ERA, and ISN also discussed the final report of the National Kidney Foundation (NKF)–ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases. Released in September 2021, the final report provides a new race-free approach to diagnose kidney diseases. NKF and ASN recommended the following: 1) “the adoption of the new eGFR [estimated glomerular filtration rate] 2021 CKD EPI [epidemiology collaboration] creatinine equation that estimates kidney function without a race variable”; 2) “increased use of cystatin C combined with serum (blood) creatinine, as a confirmatory assessment of GFR or kidney function”; and 3) more funding for “research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities” (13).

As NKF and ASN work to implement these three recommendations in the United States, ERA and ISN leaders indicated that country-specific formulas may perform better in other parts of the world. The task force's first two recommendations, which work well for the US population, may not work as well for some other countries. Recognizing the limitations of currently available equations, unacceptable variance will continue to exist until an affordable, non-creatinine-based, universally applicable and available GFR measure exists.

Diversity, equity, and inclusion, along with health care justice, were important topics discussed by the leaders of the three societies. With attention brought to how these efforts are gaining traction in some countries, the discussion focused on how to implement them more broadly. The meeting illustrates the importance of working together to achieve shared goals worldwide.

If I have not convinced you yet that we need to think globally while acting locally, let us examine the US workforce. Nephrologists working in the United States come from all over the world. International Medical Graduates (IMGs) currently comprise 50.5% of the 11,407 practicing nephrologists in this country (14). That percentage is likely to rise as IMGs make up 66% of the current fellows training in US nephrology fellowship programs (15). While some of these professionals will return to their countries of origin or pursue other opportunities abroad, many will stay in the United States.

This migration causes a “brain drain” for the countries from which these nephrologists depart. At the same time, the lives of these nephrologists and their families often benefit, as does the specialty in the United States. Unfortunately, despite our benefiting from IMGs who work here, their ability to stay is challenging because of the onerous visa requirements. Currently, the Conrad 30 waiver program is the only federal mechanism for IMGs to apply for a waiver of the 2-year foreign residence requirement after completion of graduate medical education on a J-1 visa. The Conrad 30 has extremely limited capacity, however, with only 30 spots a year for each state across all physician specialties and subspecialties. We need to make the system less difficult for IMGs who wish to stay and work in the United States, but we must also consider how best to address problems caused by the brain drain throughout the world.

Former ASN President Anupam Agarwal, MD—who was recently named Dean of The University of Alabama at Birmingham Marnix E. Heersink School of Medicine—notes, “IMGs are critical members of the nephrology workforce in both academic and community practice settings in the United States. A significant number of nephrology fellowship trainees are also IMGs who provide important service to our patients in our hospitals and clinics. They often practice in underserved rural areas for years due to requirements to fulfil immigration obligations. As an IMG myself, I have greatly benefited from the training, mentorship, and amazing opportunities offered to me throughout my more than 30 years of being in this country. Given the significant shortages of physicians and the projected numbers in the coming years to be even worse, making pathways for IMGs to continue to work in the United States easier and less cumbersome is critically important.”

As we enjoy March, celebrate National Kidney Month, play NephMadness, and mark World Kidney Day, I want to take a moment to applaud, highlight, and support all efforts to raise awareness and emphasize the importance of kidney diseases throughout the world. We may live in a world divided into 195 countries, but kidney diseases have no citizenship, know no borders, and are clearly a growing public health challenge across the globe.