Comment

Decades of research have revealed that nephron number is a crucial determinant of kidney health. However, a lack of appropriate tools has limited these studies to ex vivo analyses. For the first time, techniques are emerging that might enable the use of functional nephron number as a biomarker in living humans.

Dominant narratives that describe the power of individual-level resilience underplay the long-lasting consequences of structural violence and perpetuate harms to historically marginalized patients and communities. It is time to update our approaches and narratives by addressing the root causes of inequities through redress and collective resistance to create the equitable conditions needed for communities to thrive.

Increased awareness of chronic kidney disease among the general public is required to facilitate action to improve kidney health. An integrated approach involving mass media campaigns, primary health-care interventions and advocacy is needed to draw attention to chronic kidney disease and shift the focus from kidney failure to achieve a public health perspective on this disease.

Living with chronic kidney disease (CKD) is not easy, and patients must adopt lifestyle changes that can be difficult. Owing to the complexities of the disease, patients must be supported to improve their understanding of CKD and to enable them to make informed decisions about the management of their disease.

Growing patient empowerment and the deluge of health information and misinformation have highlighted the importance of health literacy. Unfortunately, public information and literacy programmes often fail to counter the effect of misinformation. Successfully countering misinformation presents distinctive challenges beyond patient education, and may require trust built on collaborative patient–clinician relationships.

Chronic kidney disease is a major public health problem that is associated with excessive morbidity, mortality and healthcare costs. However, limited clinician awareness of chronic kidney disease is universally identified as a key barrier to care. A concerted effort is urgently needed to address the knowledge gaps of primary care providers.

Quality geriatric kidney care extends beyond traditional therapy to care that balances the impact of both disease and treatment around how individuals manage their daily routines. In this Comment, we discuss clinical and policy changes that could benefit older people with advanced kidney disease.

Vaccination against SARS-CoV-2 seems to be safe in patients with immunity-mediated kidney disease, although their immunological responses to vaccination are impaired. Further strategies, including the administration of additional vaccine doses and passive immunization with long-acting monoclonal antibodies, might increase protection in this vulnerable patient group.

Patients receiving dialysis are at high risk of contracting SARS-CoV-2 and developing severe COVID-19. Established SARS-CoV-2 vaccination schemes might lack efficacy in these patients and a personalized approach is therefore necessary. Importantly, given the enhanced infection risks associated with dialysis, current vaccines do not replace non-pharmacological measures to prevent infection.

Kidney transplant recipients receive therapeutic immunosuppression that impairs their immune responses to the COVID-19 mRNA vaccine. For this reason, this vulnerable patient population is insufficiently protected by the standard two-dose COVID-19 vaccination programme and requires a specific follow-up to guide personalization of an intensified vaccination approach.

Kidney involvement is common in patients with acute SARS-CoV-2 infection, and subclinical inflammation and injury may persist for many months, resulting in a progressive decline in kidney function that leads to chronic kidney disease. Continued research is imperative to understand these long-term sequelae and identify interventions to mitigate them.

Preparation for health-care transition from paediatric to adult-focused care must continue in young adulthood and requires coordination and an inter-disciplinary approach; however, the implementation of available tools and interventions remains challenging worldwide. Current practices fail to address issues related to patient safety, mental health, respect and equity, even in resource-rich societies.

Key differences exist between clinical and research genomics. As genomic testing is adopted in nephrology clinical care, we propose focusing on clinical genomics approaches to obtain genetic diagnoses in order to ensure optimal use of resources and maximum patient benefit.

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.

Living donor kidney transplantation benefits the recipient. However, kidney failure can occur in a small fraction of donors — the risk is not uniform but varies according to donor characteristics. Studies to date have failed to match on important factors, such as era, environment or family history. Long-term studies with well-matched healthy controls are therefore needed.

Patients with kidney diseases should be prioritized for COVID-19 vaccination and the available data suggest that replication-defective viral-vectored vaccines and mRNA vaccines are safe to use. As vaccine responses are likely to be lower in patients with kidney diseases than in the general population, highly potent vaccines should be preferred.

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.

Insomnia is common among patients on maintenance haemodialysis and may be exacerbated by the challenges of the COVID pandemic. However, data on the efficacy of insomnia interventions in this population are limited. Efforts are needed to address this important problem and increase access to insomnia interventions for patients on haemodialysis.

Regular physical activity can help people to live well with kidney disease, yet the promotion, funding, level of interest, and general support of physical activity remains poor. Novel high-quality approaches to increase physical activity must be considered, and practical means of scaling up effective interventions at the population level are required.

Older adults receiving dialysis commonly experience poor quality of life. A cyclical process of quality of life assessment, needs assessment and individualized care plans should be implemented to integrate quality of life into care planning. Improvements in health-care delivery and interpersonal communication are needed to prioritize quality of life.