As the extent of the global explosion in chronic kidney disease becomes ever more apparent, attention is increasingly turning to the question of how to ensure that enough skilled clinicians are available to care for the growing load of patients.

Even in Western developed countries, nephrologists are frequently in short supply. Trainee physicians are often reluctant to pursue a career in nephrology as the field is scientifically and clinically demanding, our patients present challenging and sometimes intractable long-term problems, and remuneration rates are less than those for other specialties. The situation in the developing world is even worse. Many such countries have poorly developed health-care systems, very few or even no fully trained consultants practising nephrology, and limited capacity to provide even basic medical services, let alone expensive life-sustaining treatments such as dialysis.

The International Society of Nephrology (ISN) has been actively searching for possible solutions to this dilemma, and in April 2007 it convened a workshop on the training of nephrologists, as part of the World Congress of Nephrology held in Rio de Janeiro. Two broad lines of thinking and action emerged from these discussions.

...the quality of care delivered to renal patients is directly determined by the quality of the education and experience provided to trainees...

First, where resources permit, it is important that well-structured programs for the training of nephrologists are established, on the premise that the quality of care delivered to renal patients is directly determined by the quality of the education and experience provided to trainees in this field. Towards this end, the Education Advisory Committee of the ISN's Commission for the Global Advancement of Nephrology (COMGAN) has developed a set of flexible recommendations as well as a Core Curriculum for Postgraduate Training in Nephrology, both of which are available on the ISN website (http://www.nature.com/isn/society/programs/isn_20062.html) for consultation or adoption by any interested national nephrology society or health body. COMGAN has also been involved for over a decade in the organization and delivery of an extensive program of continuing medical education courses in developing regions of the world. These courses stimulate the interest of many trainees in pursuing a career in nephrology and help these individuals form personal and professional contacts with international experts. The ISN also has a fellowship program that gives promising young nephrologists in developing countries the opportunity to undertake a period of training in a Western center. Furthermore, the Society has a Renal Sister Center program that links renal departments in the developed world with those in the developing world.

Second, it is not realistic to expect Western models of specialist renal care to be developed in resource-poor regions overnight. An alternative approach that has been proposed for these countries is to offer a more limited form of training to selected medical graduates interested in nephrology. These doctors, who could be called 'emerging' nephrologists, would be equipped to carry out the basic medical care of patients who present with evidence of renal disease, and, in close collaboration with non-medical community health workers, they would guide the development and implementation of programs for the detection and prevention of renal disease in their communities. Emerging nephrologists would also have the potential to become fully trained nephrologists, ideally by furthering their training in a regional nephrology school.

The world faces a human and financial crisis as a consequence of the burden posed by chronic kidney disease, and multiple approaches to the provision of a suitably trained nephrology workforce must be explored as a matter of urgency.