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  • 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.

    • Mustafa Arici
  • Comment |

    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.

    • Rachael L. Morton
    •  & Karan K. Shah
  • Comment |

    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.

    • Matthew A. Borg
    •  & Peng Bi
  • Comment |

    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.

    • Vivekanand Jha
    •  & Dwomoa Adu
  • Comment |

    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.

    • Peter J. Blankestijn
  • Comment |

    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.

    • Nanditha Anandakrishnan
    •  & Evren U. Azeloglu
  • Comment |

    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.

    • Edward G. Clark
    • , Swapnil Hiremath
    • , Lauralyn McIntyre
    • , Ron Wald
    • , Gregory L. Hundemer
    •  & Michael Joannidis
  • Comment |

    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.

    • M. R. Moosa
    •  & K. C. Norris
  • Comment |

    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.

    • Yot Teerawattananon
    • , Kriang Tungsanga
    • , Solange Hakiba
    •  & Saudamini Dabak
  • Comment |

    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.

    • Sami Alasfar
    •  & Robin K. Avery
  • Comment |

    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.

    • Katherine R. Tuttle
  • Comment |

    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.

    • Juan Carlos Q. Velez
    • , Tiffany Caza
    •  & Christopher P. Larsen
  • Comment |

    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.

    • Balazs Szamosfalvi
    •  & Lenar Yessayan
  • Comment |

    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.

    • Jonathan Himmelfarb
    •  & Buddy Ratner
  • Comment |

    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.

    • Neil Greenberg
  • Comment |

    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.

    • John W. M. Agar
    •  & Katherine A. Barraclough
  • Comment |

    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.

    • Andreas Kronbichler
    • , Philipp Gauckler
    • , Martin Windpessl
    • , Jae Il Shin
    • , Vivekanand Jha
    • , Brad H. Rovin
    •  & Rainer Oberbauer
  • Comment |

    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.

    • Andrew S. Levey
    • , Kai-Uwe Eckardt
    • , Nijsje M. Dorman
    • , Stacy L. Christiansen
    • , Michael Cheung
    • , Michel Jadoul
    •  & Wolfgang C. Winkelmayer
  • Comment |

    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.

    • Tess V. Dupre
    • , Rick G. Schnellmann
    •  & Gary W. Miller
  • Comment |

    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.

    • Rosalinde Masereeuw
    •  & Marianne C. Verhaar
  • 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.

    • Maya Sabatello
    •  & Hila Milo Rasouly
  • Comment |

    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.

    • Nieltje Gedney
    • , Wim Sipma
    •  & Henning Søndergaard
  • Comment |

    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.

    • Ilaria Geremia
    •  & Dimitrios Stamatialis
  • Comment |

    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.

    • Fokko P. Wieringa
    •  & Jeroen P. Kooman
  • Comment |

    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.

    • Marjorie W. Y. Foo
    •  & Htay Htay
  • Comment |

    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.

    • Claudio Ronco
    •  & Thiago Reis
  • Comment |

    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.

    • Daniel P. Gale
    • , Andrew Mallett
    • , Chirag Patel
    • , Tam P. Sneddon
    • , Heidi L. Rehm
    • , Matthew G. Sampson
    •  & Detlef Bockenhauer
  • Comment |

    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.

    • T. Alp Ikizler
    •  & Alan S. Kliger
  • Comment |

    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.

    • Andrew M. South
    • , Laurie Tomlinson
    • , Daniel Edmonston
    • , Swapnil Hiremath
    •  & Matthew A. Sparks
  • Comment |

    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.

    • Fokko P. Wieringa
    • , Murray I. Sheldon
    •  & Ana Hidalgo-Simon
  • Comment |

    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.

    • Chia-shi Wang
    •  & Elaine Ku
  • Comment |

    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).

    • Kamyar Kalantar-Zadeh
    •  & Philip K.-T. Li
  • Comment |

    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.

    • William H. Fissell
    •  & Shuvo Roy
  • Comment |

    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.

    • Julie K. Hudson
    •  & Billy G. Hudson
  • Comment |

    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.

    • Manfred Hecking
    •  & Trond Jenssen
  • Comment |

    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.

    • Matthew G. Sampson
    •  & Hyun Min Kang
  • Comment |

    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.

    • Jenny E. Blau
    •  & Simeon I. Taylor
  • Comment |

    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.

    • Richard J. Johnson
    •  & Bernardo Rodriguez-Iturbe
  • Comment |

    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.

    • Susie L. Hu
    •  & Robert H. Weiss
  • Comment |

    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.

    • Kai Hahn
    • , A. Ahsan Ejaz
    • , Mehmet Kanbay
    • , Miguel A. Lanaspa
    •  & Richard J. Johnson