Comment

Growing genomic knowledge has provided immense insight into the aetiology and mechanisms of kidney diseases but raises ethical issues that risk the successful implementation of genomic medicine. We highlight such issues in two contexts: the return of individual genetic results from nephrology research and preimplantation genetic diagnosis for heritable kidney diseases.

The need for innovation in dialysis is long overdue. As past and present users of dialysis we are fully aware of the limitations of current dialysis modalities. The time for complacency is over — developers must engage with dialysors to ensure that our needs are met so that we can live the best life possible. Let us share our dream for devices that will enable us to enjoy life.

Haemodialysis is a life-saving therapy. However, in comparison with the healthy kidney, it removes only a small fraction of the uraemic toxins produced, does not function continuously and cannot replicate biological kidney functions. Innovations in membrane design hold promise to overcome these limitations with potential to improve patient outcomes.

Peritoneal dialysis and haemodialysis are lifesaving but intrusive treatments that are associated with high morbidity and mortality. Despite the considerable time patients with kidney failure spend tied to their life-saving therapies, relatively few vital signs are monitored. Smart, unobtrusive approaches to track clinical parameters could help to individualize treatments and improve patient outcomes.

Peritoneal dialysis (PD) is the dialysis modality of choice for many regions. The application of innovative technology has led to the development of new PD devices that reduce the environmental and economic costs of the therapy, as well as miniaturized devices that provide greater freedom for patients.

The prevalence of direct kidney involvement in novel coronavirus disease (COVID-19) is low, but such involvement is a marker of multiple organ dysfunction and severe disease. Here, we explore potential pathways of kidney damage and discuss the rationale for extracorporeal support with various blood purification strategies in patients who are critically ill with COVID-19.

The increasing availability of sequencing has accelerated the discovery of genetic causes of kidney disease, with clear benefits for patients. However, insufficient or contradictory evidence exists for numerous variants that were previously reported to be pathogenic, calling into question some proposed gene–disease associations. Rigorous re-appraisal of evidence is needed to ensure diagnostic accuracy.

Patients on haemodialysis or peritoneal dialysis are likely to be at increased risk of novel coronavirus disease (COVID-19). Preventive strategies must be implemented to minimize the risk of disease transmission in dialysis facilities, including education of staff and patients, screening for COVID-19 and separation of infected or symptomatic and non-infected patients.

The current COVID-19 pandemic is associated with unprecedented morbidity and mortality. Early reports suggested an association between disease severity and hypertension but did not account for sources of confounding. However, the responsible virus — SARS-CoV-2 — gains entry to host cells via angiotensin-converting enzyme 2 (ACE2), highlighting the need to understand the relationship between the virus and the renin–angiotensin system (RAS) and how this might be affected by RAS inhibitors.

Regulations for market access and reimbursement of medical devices vary across jurisdictions, complicating the development of innovative technologies for world-wide use; however, several converging regulatory principles are now emerging. Here we discuss approaches by which regulatory and related agencies can promote innovation and boost the effectiveness of regulatory processes to expedite patient access to innovative technologies, including renal replacement therapies.

eHealth is gaining momentum in nephrology, although evidence for its efficacy remains unclear and challenges to its widespread adoption persist. Successful integration of eHealth into kidney care will require patient engagement to develop effective interventions and issues such as data validity, regulation, oversight and adequate infrastructure to be addressed.

The 2020 World Kidney Day campaign highlights the importance of prevention of chronic kidney disease. Various strategies and therapies are available to prevent disease before its onset (primary prevention), during early disease stages (secondary prevention) and for effective management of established disease to prevent dialysis (tertiary prevention).

Kidney disease is one of the leading causes of death and its prevalence continues to increase worldwide. However, the pace at which new treatments have become available has been excruciatingly slow over the past 30 years. A new White House directive promises to focus the spotlight on accelerating innovations for patients with kidney disease.

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.

Sodium–glucose cotransporter 2 inhibitors (SGLT2i) have been recommended for the treatment of patients with type 2 diabetes mellitus and cardiovascular disease, heart failure or chronic kidney disease. Findings from recent efficacy and safety trials of empagliflozin in kidney transplant recipients with post-transplantation diabetes are timely, given the elevated cardiovascular risk associated with solid organ transplantation.

To advance kidney discovery, our community is driven to maximize the utility of genomic data that we all generate. We can best accomplish this through excellence in appropriately incorporating publicly available genomic data into our research efforts and by enthusiastically embracing widespread data sharing in a manner that facilitates its broad use.

Sodium–glucose cotransporter 2 (SGLT2) inhibitors provide metabolic and cardiorenal benefits for patients with type 2 diabetes but are associated with a number of safety issues. Here, we discuss evidence suggesting that indirect activation of the FGF23–1,25-dihydroxyvitamin D–parathyroid hormone axis by SGLT2 inhibition might contribute to adverse effects on bone health.

Although most nephrologists spend their days managing patients with acute and chronic kidney disease (CKD), it is useful to occasionally consider the landscape of our current treatment approach. Here, we present the hypothesis that the major mechanisms that drive CKD are changing and will necessitate new approaches to manage this disease.

Renal cell carcinoma (RCC) is the most common malignancy seen in the nephrology clinic, yet most nephrologists have inadequate knowledge of current treatment options. Here we discuss RCC presentation and therapies, including potential renal adverse effects, and highlight the need for involvement of nephrologists in the multidisciplinary management of this disease.

SGLT2 inhibitors have shown great promise in the management of diabetes mellitus and the prevention of cardiovascular complications, but increasing evidence suggests that their use can be associated with an increased risk of acute kidney injury. Insights into the mechanisms involved might help to identify individuals who are at risk of renal injury.