Comment

The advancement of women to leadership positions in nephrology lags behind that of men by several metrics. Proactive, intentional approaches, including mentorship and sponsorship, family-friendly policies, career development in hard and soft skills, combatting bias and use of transparent institutional metrics of women’s advancement, are required to address this disparity.

Understanding of the barriers to adequate health care experienced by sexual and gender minority (SGM) people cannot be achieved in the absence of robust and appropriate data. The inclusion of SGM populations in health research and the collection of sexual orientation and gender identity data in research and routine clinical practice is therefore essential to understanding the unique needs of these populations and addressing inequities in health outcomes.

Blockchains enable secure data storage, the verification of data origin and accurate registration of changes in information over time. The widespread adoption of blockchain in nephrology could affect clinical practice and research by enhancing the quality of electronic health records and datasets.

Optimal referral of patients who are at risk of kidney failure to nephrologists could improve their long-term outcomes. Various strategies, including the inclusion of kidney failure risk equations in electronic medical records and the active dissemination of clinical practice guidelines, could help to reduce the gap between optimal referral and what currently happens in clinical practice.

Access to essential medical care can be compromised by social disruptions (such as riots and labour strikes), armed conflict and natural disasters, including extreme weather events. A successful response to such events requires forward planning, preparation and rehearsal with involvement of health-care systems, professionals, patients and their support networks. Following execution of the response, after-action evaluation is required to improve future responses.

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.

Thousands of environmental chemicals are used globally. However, despite clear evidence of their adverse effects on the kidney, substantial knowledge gaps remain. Further studies are needed to better understand the effects of chemical mixtures, windows of physiological susceptibility, vulnerable populations, and the intersection of chemical exposure with health risks associated with climate change and heat stress.

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.

Adequate nutrition is essential for kidney health; however, attempts to improve nutrition and food security have been hindered in recent years by man-made and natural disasters. Approaches to eradicate famine, improve nutritional status and reduce food insecurity are needed to reduce inequities and maintain kidney health in the face of adverse circumstances.

The COVID-19 pandemic exposed flaws in the ability of the nephrology community to efficiently inform clinical decision making. To improve preparedness for the next pandemic, the nephrology community must work more closely together to ensure that research efforts are aligned and put in place a strategy for the effective dissemination of high-quality evidence in real-time.

Long COVID, which refers to post-acute and chronic sequelae of SARS-CoV-2 infection, can affect nearly every organ system and all demographic groups. The high and growing toll of long COVID calls for an urgent need to understand how to prevent and treat it. Governments and health systems must address the care needs of people with long COVID.

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.

Considerable research and investment have focused on the use of electronic patient-reported outcomes (ePROs) in nephrology. However, systematic collection of ePROs to inform the care of patients with chronic kidney disease remains sporadic. A change in culture is needed to encourage their wider adoption in clinical practice.

Kidney disease is an underappreciated medical complication of anorexia nervosa. Further research is needed to clarify the mechanisms that drive kidney disease in patients who restrict caloric intake or engage in purging. Education and awareness are also needed, because kidney disease is often under-recognized by these patients and their clinicians.

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.

Salt substitution — the partial replacement of sodium with potassium in table salt — is emerging as a powerful public health strategy to reduce hypertension and related diseases. Here, we explore whether salt substitution is suitable for people with kidney disease by weighing the potential cardiorenal benefits against the risk of hyperkalaemia.

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.

Advancing kidney health justice for all requires the kidney-care community to embrace gender-affirming care across the life course, including inclusion of gender minority individuals in research, thoughtful attention to sexual-orientation and gender-identity data collection, as well as the promotion of policies and practices that protect and provide comprehensive care to all patients.

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.

People who identify as sexual and/or gender minority individuals face unique and challenging inequities in access to health care. They experience bias, discrimination and underinsurance, which limits their access to high-quality care (including for kidney disease). These inequities must be addressed through the provision of safe and inclusive environments, improved identification of disparities and the creation of a pipeline of equity-focused leaders.