Comment

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.

The coronavirus disease 2019 global pandemic has disrupted every economy in the world. Now, more than ever, universal health coverage is needed to protect the world’s most vulnerable individuals, who are not only at very high risk of virus-related disability or death but also of falling into poverty owing to catastrophic health-care spending.

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.

Progress towards the Sustainable Development Goals depends on population health in all countries. Implementation research is crucial for generating evidence on how to sustainably embed effective clinical interventions in health systems and local delivery mechanisms, thereby improving their likelihood of success, and informing policy change to improve population 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.

The drug development pipeline for kidney diseases is plagued with challenges ranging from an insufficient understanding of disease mechanisms to a lack of robust preclinical models. Bioengineering approaches have the potential to streamline preclinical drug discovery efforts and improve the success of clinical trials for kidney disease.

Interest in the use of haemoperfusion for severe COVID-19 has been spurred by anecdotal reports of its efficacy and expert reviews suggesting theoretical benefits. However, on the basis of the limited current evidence, haemoperfusion remains an experimental therapy that should only be applied within the context of well-designed randomized trials.

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.

Management of kidney transplant recipients requires a sustainable infrastructure that can provide reliable medical care both before and after transplantation. The COVID-19 pandemic has disrupted transplant referral and listing processes, led to decreases in the numbers of transplant procedures and resulted in changes in practice for pre- and post-transplantation management and follow-up.

The COVID-19 pandemic has placed a tremendous strain on sustaining the clinical research enterprise and will also likely affect key study outcomes; these effects must be considered during data analysis and interpretation. Nevertheless, the responses to the pandemic have also introduced innovations that will advance the conduct of clinical research.

Reports of collapsing glomerulopathy in patients of African ancestry and high-risk APOL1 genotype infected with SARS-CoV-2 have emerged during the COVID-19 pandemic. This new entity, which we term COVID-19-associated nephropathy (COVAN), may particularly impact individuals in some regions of the world. Awareness of this potentially ominous complication of COVID-19 must be raised.

Continuous kidney replacement therapy (CKRT) can be a lifesaving intervention for critically ill patients; however, mortality remains high. The adaptation of existing innovations, including anti-clotting measures; cloud-computing for optimized treatment prescribing and therapy monitoring; and real-time sensing of blood and/or filter effluent composition to CKRT devices has the potential to enable personalized care and improve the safety and efficacy of this therapy.

The most common treatment option worldwide for persons with kidney failure is in-centre haemodialysis; however, this treatment has remained largely unchanged over decades owing to a lack of true patient-centred technological innovation. The development of safe and effective wearable forms of dialysis has the potential to transform the lives of these patients.

Health-care workers involved in the response to the COVID-19 pandemic are often required to work in highly challenging conditions and may therefore be at increased risk of experiencing mental health problems. This Comment sets out a practical approach to protecting the mental health of health-care workers based on contemporary evidence.

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.

The coronavirus disease 2019 (COVID-19) pandemic poses important challenges to the care of patients with immune-mediated kidney diseases and to kidney transplant recipients. Here, we discuss the management of immunosuppression for these patients during the pandemic and suggest potential approaches that could be considered in the absence of validated strategies.

An obligation of medical journals is the responsible, professional and expeditious delivery of knowledge from researchers and practitioners to the community. The task of editors, therefore, rests not merely in selecting what to publish, but in judging how it might best be communicated. The challenge of improving descriptions of kidney function and disease in medical publishing was the impetus for a KDIGO consensus conference. The conference goals included standardizing and refining kidney-related nomenclature and developing a glossary to be used by journals.

New exposome-based approaches permit omic-scale characterization of the non-genetic contributors to kidney disease. High-resolution mass spectrometry analysis of plasma and urine samples captures a wide range of exogenous and endogenous metabolites that can be used in combination with genetic risk factors to identify new biomarkers of exposure and therapeutic approaches.

Kidney failure is associated with the retention and subsequent accumulation of uraemic toxins, which have detrimental effects on various physiological processes. The removal of these toxins by current dialysis modalities is inadequate, highlighting the need for innovative approaches to enhance their clearance and/or suppress their generation to improve outcomes for patients with kidney disease.