Humanitarian challenges in Nephrology

The prohibitive costs of new pharmacological agents, particularly biologicals, have largely limited their use to high-income countries, resulting in widening of health disparities. Urgent action from the pharmaceutical industry, governments and healthcare organizations is needed to improve access to treatment and address these inequities.

The inclusion of individuals with disabilities and patients as partners in biomedical research is critical for driving innovation. Equally important are patient–researchers, who are instrumental in identifying key research problems and driving research towards areas of direct benefit. We call for institutions to actively work towards accommodating patient–researchers.

Awareness of chronic kidney disease (CKD) and uptake of evidence-based interventions (EBIs) that increase awareness and/or slow progression to kidney failure remain alarmingly low. The global rise in immigration might exacerbate CKD prevalence among minoritized groups, which underscores the need for the nephrology community to acknowledge the diverse contexts that influence EBI implementation and to integrate health equity approaches.

A growing burden of diabetic kidney disease in Fiji threatens to overwhelm newly established nephrology services. Greater attention to early detection and intervention, incorporation of kidney health into national strategic plans, and international support to prioritize chronic kidney disease as a global priority is imperative.

Kidney disease disproportionately affects American Indian and Alaska Native (AI/AN) communities, largely owing to adverse social drivers of health that stem from systemic issues including colonization, structural racism and historical trauma. Kidney health equity for AI/AN communities requires systemic and multilevel interventions across the CKD spectrum and life course.

Chronic kidney disease (CKD) satisfies established criteria for screening. Although the economic burden of screening is substantial, many countries have adopted screening initiatives into their existing national programmes. Recognition of CKD as a major non-communicable disease by international bodies will help to improve global kidney care overall.

For women with kidney disease of childbearing age, kidney care should feature discussions of pregnancy, including informed counseling and support. Health disparities between regions with different levels of income are undeniable, but special care programs aimed at the early identification and management of patients at risk can greatly decrease the magnitude of the problem.

American Indian and Alaska Native peoples have low life expectancy and a disproportionate disease burden (including of chronic kidney disease), owing to inadequate education, poverty, discrimination and underfunding in the delivery of health services, and healthcare institutions’ lack of appreciation for cultural differences. These broad quality-of-life issues are rooted in economic adversity and poor social conditions.

Kidney disease is strongly linked with cardiovascular diseases, hypertension, diabetes, infections and other health conditions, as well as social determinants of health and climate change. Consequently, a holistic approach to promote well-being, protect individual health and improve access to quality primary care will support kidney health.

Chronic kidney disease is a life-changing diagnosis for millions of people worldwide, as the risk of disease progression and kidney failure creates unbearable uncertainty and limits lifestyle. The devastating impact of advanced kidney disease must be acknowledged in the public health agenda to pave way for improved outcomes for patients at all stages of disease.

Addressing the burden of non-communicable diseases is a global public health priority. In this joint Consensus Statement, the American Society of Nephrology, the European Renal Association and the International Society of Nephrology highlight the need to recognize kidney disease as a key driver of premature mortality, in addition to other non-communicable diseases already prioritized by the World Health Organization.

The prevalence of kidney disease and its associated morbidity and mortality continue to rise. This crisis cannot be tackled unless kidney disease is made a global public health priority.

Global inequities and inequalities, human and health-care crises, transplantation successes in the face of limited organ availability, and desperate donors and recipients underlie the backstory of organ trafficking, namely the exploitation of the most vulnerable. Despite the framework set out by the Declaration of Istanbul for the ethical donation and transplantation of organs, organ trafficking remains a global challenge.

The availability of antiretroviral therapy has led to a transformation in the spectrum of kidney diseases associated with HIV infection. This Review describes the changing pattern of kidney diseases associated with HIV infection, their risk factors, methods of evaluating kidney function in patients with HIV and current therapeutic approaches.

First Nations peoples in Australia face systemic inequities in access to kidney transplantation. The National Indigenous Kidney Transplant Taskforce was established to address these. It has provided support to clinicians to implement and evaluate innovative practices and developed strategies to address biases in the structures and models of care that create barriers to wait-listing.

Digital transformation offers unprecedented opportunities for advancing healthcare, but also raises complex ethical and legal challenges. Emerging drivers of health disparity termed ‘digital determinants of health’ call for purposeful, equity-focused strategies to ensure that technological innovation benefits all without exacerbating disparities.

The diagnosis of glomerular disease relies largely on meticulous histological and laboratory investigations that continue to improve with technological advances. However, low-income countries such as Uganda lack this investigatory armamentarium and patients are often treated on the basis of suboptimal evidence.

Among global destabilizing events, natural disasters often receive widespread attention whereas protracted conflicts and economic crises fade into the background. Low- and middle-income countries bear the brunt of this indifference, resulting in severely weakened health systems. People who require dialysis are particularly vulnerable, necessitating urgent collaboration to ensure equitable and sustainable care during such crises.

Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of the disease. The authors of this Review describe the different inequities that affect kidney health and care worldwide, and consider potential solutions to help to mitigate these.

Racial and ethnic minoritized populations are underrepresented in clinical trials in nephrology, but overrepresented in adverse kidney disease outcomes. Targeted enrolment, revision of problematic policies, inclusion of minoritized populations in trial planning, and language-, race- and ethnicity-concordant investigative teams can improve representation in clinical trials.

Acute kidney injury (AKI) is a global concern that affects patient outcomes and resource utilization. An effective educational programme aimed at improving early AKI identification, triaging and treatment, using risk scores and care bundles coupled with access to point-of-care diagnostics, can help to prevent AKI-related deaths in regions with limited resources.

During disasters, the morbidity and mortality of patients with kidney disease far exceeds that of the general population. Here, the authors discuss the medical and logistical problems that are faced by these patients and their care-givers during mass disasters and suggest pragmatic approaches to improve patient outcomes.

In the wake of the Supreme Court’s decision to abolish the right of American women to a pregnancy termination, the most vulnerable women, including those with chronic kidney disease, require heightened care and attention. Nephrologists need to urgently evolve expertise in reproductive care to ensure their health and well-being.

Indigenous Māori experience inequitably high rates of kidney failure and lower rates of kidney transplant, pre-emptive procedures and home dialysis when compared to the New Zealand population as a whole. Prevention strategies in primary care, cultural safety training and routine clinical audit for renal practitioners alongside Indigenous people in governance, management and the clinical workforce would greatly improve Māori outcomes.

The devastating effects of war are far-reaching and particularly affect people with kidney disease. The Ukrainian conflict has highlighted problems encountered in the provision of support for this vulnerable group. On the basis of these and previous experiences in massive disasters, we propose a sustainable action plan to prepare for similar logistical challenges in future conflicts.

People with chronic diseases are at high risk of becoming innocent victims of the Russian–Ukrainian war, owing to interruption of their health care. More than 10 million Ukrainian people have left their homes and almost 5 million have left the country. Provision of kidney care for these refugees is an emerging challenge.

Here, the authors discuss how structural racism underlies many of the health disparities that affect individuals from minority racial groups. They also examine how the use of race coefficients in estimated glomerular filtration rate equations might contribute to health inequities in Black patients with kidney disease.

To quote Nelson Mandela, “education is the most powerful weapon which you can use to change the world”. Education and training have changed the world of nephrology in Africa for many patients and their physicians, but most low- and middle-income countries still lack access to affordable therapies for kidney disease.

Interruptions to dialysis services in resource-limited settings, like India, amidst the COVID-19 pandemic has highlighted our ill-preparedness. We need alternative plans to safeguard the provision of this life-sustaining treatment and protect our vulnerable patients.

As witnesses to the health consequences of social discrimination, clinicians are uniquely positioned to build coalitions of stakeholders to address inequities and drive change. Such civic engagement is needed to ensure that all populations are given the opportunity to thrive.

Ameliorating the inequitable burden of kidney disease that is experienced by Aboriginal and Torres Strait Islander peoples is an achievable goal. Genuine and committed partnerships between the Australian government, health-care providers and Aboriginal and Torres Strait Islander peoples are imperative to maximize the success of health equity initiatives.

Rationing of scarce health-care resources is distressing. Clinicians therefore require clear guidance, which should be developed systematically and transparently through multi-stakeholder engagement. Rationing is seldom required in high-income settings but is often necessary in low-income settings. Global solidarity and health system strengthening are required to reduce the need for rationing.

Venezuela is going through a humanitarian crisis that has severely impacted all programmes of kidney replacement therapy — dialysis coverage has decreased markedly, particularly in small towns and rural areas, and almost all peritoneal dialysis and deceased donor organ procurement for kidney transplantation have been discontinued.

The COVID-19 pandemic and the Movement for Black Lives have focused attention on racial disparities in kidney health outcomes. In 2020, kidney professionals highlighted threats posed by racism and other negative social drivers of kidney health, and proposed solutions to address these issues through scholarship and advocacy for social justice.

The nephrology community is increasingly being confronted with the challenge of caring for refugees with kidney disease. An urgent need exists for a global registry of these patients as well as consistent guidance for financial, cultural and ethical issues in order to ensure that they receive sustainable and equitable care.

Millions of people in under-privileged regions of the world continue to drink heavily polluted water and die from diarrhoea-related acute kidney injury whilst world super-powers continue to offer military aid to these regions. This gun aid must convert into water aid.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.

Many children die from preventable and/or treatable kidney disease in low-resource settings. Here, the authors examine strategies to improve the care of these children, including the need to invest in disease prevention and early detection, promote disease awareness and education, and adapt treatments to expand provision.

Chronic kidney disease (CKD) is a rapidly growing public health problem, especially in disadvantaged populations. Major political interventions are required to mitigate the social and socioeconomic inequities that contribute to the development and progression of CKD and its disproportionate impact on low and middle-income countries.

Public policy for kidney replacement therapy eludes most low- and middle-income countries owing to the seemingly low number of cases and high cost. Countries such as Thailand have shown that public health authorities can effectively provide treatment and elevate health care for populations by overcoming some common challenges.

A critical need exists for innovations in education that increase the recruitment of high school students from diverse backgrounds into the biomedical research workforce. Aspirnaut is one model that addresses this challenge.

Peritoneal dialysis has many advantages over haemodialysis in the treatment of acute kidney injury (AKI) in low-resource settings. One limitation, however, is the availability of commercial dialysis fluid. Following the International Society of Peritoneal Dialysis AKI guidelines, a frontline hospital in Cameroon now shows that locally prepared fluids are safe and effective.

Haemodialysis options for undocumented immigrants with end-stage renal disease range from standard of care thrice-weekly treatments to emergency-only haemodialysis. This latter approach is associated with poor patient outcomes and high costs. The time has come for the nephrology community to demand an end to the practice of emergency-only haemodialysis.

People with kidney disease are particularly vulnerable to the impacts of natural disasters and extreme weather events. As climate change is increasing the frequency and severity of these events, a robust response is needed to improve disaster preparedness and increase the resilience of these patients.

Climate change is increasing global temperatures and causing more frequent and severe extreme heat events. The resulting additional disease burden is inequitably distributed. Strategies that reduce inequities in heat exposure and vulnerability to heat-related illness, as well as health protections at multiple levels (from individual to regional), are urgently needed to contain the looming crisis.

In 2021, extreme weather and climate events caused preventable injuries, illnesses and deaths. A clear imperative exists to reduce greenhouse gas emissions and increase the sustainability and climate resilience of health systems. Countries and communities must implement strategies to mitigate climate change and invest in health systems to protect their populations.

The incidence of kidney diseases from communicable and non-communicable causes is expected to increase globally — especially in low and middle-income countries — as a consequence of global warming. As this increase could lead to overburdening of health-care systems, action is crucial to minimize the negative impacts of climate change on kidney health.

Health-care professionals in general and nephrologists in particular can and should make clear contributions towards achieving the Sustainable Development Goals. This commitment will require changes in patient care, research and education, which should be carried out in collaboration with relevant stakeholders, such as health-care industries.

Current dialysis technologies require vast quantities of pure water; however, water is a finite resource and water scarcity is increasing globally. For dialysis to be sustainable, a critical need exists for innovative approaches that address the consumption and wastage of water by dialysis.

Here, the authors outline the relationship between environmental change and kidney diseases and discuss the environmental impact of kidney care delivery, focusing on dialysis. They highlight existing opportunities to reduce the carbon footprint of nephrology, as well as areas for future research.

Exposure to environmental pollutants is a major cause of kidney injury and disease worldwide and is a particular problem in the developing world. In this Review, the authors discuss the different environmental pollutants that affect the kidney, and our understanding of the pathogenic mechanisms of environmental pollutants in kidney injury and disease.