Comment

Clinical trial data suggest that thiazides and thiazide-like drugs could be beneficial for blood-pressure lowering in patients with severe chronic kidney disease. However, prolonged exposure to these photosensitizing drugs could translate into increased risk of squamous cell carcinoma and post-transplant diabetes in the already extremely vulnerable kidney transplant population.

Kidney registries are essential to understanding the burden of kidney disease and facilitating the development of sustainable and effective programs for kidney disease prevention and care. Key barriers to implementation of registries at a global scale include funding and data quality. These issues warrant the attention of the global nephrology community.

Haemodialyser technology has not advanced much in decades, despite its unresolved shortcomings. Sophisticated new computational tools such as high-fidelity surrogate in silico dialyser models could reduce the time and expense of exploring alternative designs, dialysis dose and operating conditions compared with the current gold standard in vitro studies.

Global inequities and inequalities, human and health-care crises, transplantation successes in the face of limited organ availability, and desperate donors and recipients underlie the backstory of organ trafficking, namely the exploitation of the most vulnerable. Despite the framework set out by the Declaration of Istanbul for the ethical donation and transplantation of organs, organ trafficking remains a global challenge.

All patients with kidney disease have the right to have a say in their own clinical care, the provision of health services and research into kidney disease. Patient empowerment and advocacy, especially for those whose views are seldom heard, can be enhanced by working together in communities.

Treatment of chronic kidney disease requires a comprehensive approach including universal access to early diagnosis and to medications that can slow disease progression. Such equitable access is not only an ethical requirement but can also reduce the financial and human costs of advancing kidney and cardiovascular disease.

Overcoming barriers to deliver high-quality care requires an assessment of the contribution of each barrier within a local context. Tools to identify early disease, knowledge of best therapies, access to care providers and medications, and an accountable and integrated health-care system are essential elements of quality care. Education of patients, providers and policy makers in conjunction with advocacy efforts and national policy frameworks are required to deliver high-quality care worldwide.

Many countries worldwide, particularly those with low or lower-middle incomes, do not have enough nephrologists to provide health services for patients with kidney disease. Increasing training opportunities, improving job satisfaction and using new technologies and advances in artificial intelligence could help to increase the nephrology workforce and improve patient outcomes.

The current nomenclature for cardiorenal syndrome is problematic owing to its chronological approach and the systemic nature of some of the subtypes. We suggest adoption of a new concept, chronic cardiovascular–kidney disorder, that better reflects the contributions of common risk factors and shared pathophysiological mechanisms.

First Nations peoples in Australia face systemic inequities in access to kidney transplantation. The National Indigenous Kidney Transplant Taskforce was established to address these. It has provided support to clinicians to implement and evaluate innovative practices and developed strategies to address biases in the structures and models of care that create barriers to wait-listing.

Digital transformation offers unprecedented opportunities for advancing healthcare, but also raises complex ethical and legal challenges. Emerging drivers of health disparity termed ‘digital determinants of health’ call for purposeful, equity-focused strategies to ensure that technological innovation benefits all without exacerbating disparities.

Among global destabilizing events, natural disasters often receive widespread attention whereas protracted conflicts and economic crises fade into the background. Low- and middle-income countries bear the brunt of this indifference, resulting in severely weakened health systems. People who require dialysis are particularly vulnerable, necessitating urgent collaboration to ensure equitable and sustainable care during such crises.

A lack of federal access to health-care resources for undocumented immigrants in the USA has led to variability in access to health care — including dialysis — across states. Transforming dialysis care for these individuals is justified both on humanitarian and economic grounds, but requires a roadmap for advocacy and stakeholder engagement.

Individuals who are members of multiple marginalized populations experience multiple axes of oppression and discrimination. Such intersectional discrimination can have interactive, negative effects on all aspects of life, including health. To achieve health equity, intersectional-discrimination-induced kidney harms must be examined, measured and mitigated.

Chronic kidney disease (CKD) is highly prevalent in women in perimenopause and menopause. Both CKD and menopause affect several important pathologies, such as cardiovascular disease (CVD) and bone mineral disease. More research is needed to better understand the relationships between menopause, CKD, CVD and bone disease.

The importance of incorporating factors related to sex and gender in all aspects of research is increasingly recognized. Kidney disease pathophysiology, presentation, response to therapy and outcomes differ by sex and gender, but these factors are often not considered in basic and clinical studies. It is time for nephrology to catch up.

Specific policies embedded in organ and tissue donation and transplantation systems discriminate against sexual orientation- and gender identity-diverse populations, restricting or excluding the use of donated organs and tissues. Revision of these policies is needed to promote equity and increase the supply of high-quality organs and tissues for those who need them.

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.