Viewpoint

The theme of World Kidney Day 2024 is “kidney health for all — advancing equitable access to care and optimal medication practice”. To mark this event, Nature Reviews Nephrology invited five researchers from different geographical regions worldwide to discuss the impact of new and emerging therapies for diabetic kidney disease on patient care as well as the barriers that must be overcome to ensure equitable access to these therapies.

Transgender persons can face a number of barriers in accessing primary and specialist care that is equitable, inclusive and appropriate for their needs. In this Viewpoint, commissioned to recognize Pride, five researchers with expertise across different disciplines, including nephrology, endocrinology, public health, psychology and sociology, provide their perspectives on key considerations that are required to achieve optimal primary and nephrology care for transgender individuals, including barriers to care and how these might be overcome to ensure that the provision of care is inclusive and safe.

In this Viewpoint, we asked three individuals who have been affected by kidney failure for their views on the importance of understanding the drivers of kidney disease and, on a personal level, what they hope might be achieved with this information.

Here, four leading researchers discuss key considerations related to women's kidney health, including specific risk factors, the main challenges and barriers to care and policies and systems that could be implemented to improve the kidney health of women and their offspring.

Here, five leading researchers describe changes in the epidemiology of obesity-related kidney disease, advances in current understanding of the mechanisms involved and current approaches to the management of affected patients.

In this Viewpoint, six leading researchers reflect on progress made in their specialist field of paediatric kidney disease. They provide their insight as to the direction research will take in future years, and comment on areas in which additional research or initiatives are required to improve renal outcomes and patient care for the paediatric and neonatal population.

In this Viewpoint, five members of theNature Reviews Nephrologyadvisory board reflect on the progress and frustrations of the past decade in basic and clinical nephrology research. They comment on areas where effort and money should be invested and the challenges that remain to be overcome, as well as give their predictions for progress in the next decade.

In many low-to-middle income countries (LMICs) access to essential medications is limited and the number of clinical trials conducted is small because of regulatory issues and a lack of infrastructure. In this article,Nature Reviews Nephrologyasks three experts their opinions on how to improve drug access and increase the numbers of clinical trials conducted in LMICs.

Lower blood concentrations of protein-bound solutes have been directly linked to better outcomes in patients on dialysis. Studies indicate that clearance of protein-bound solutes is more efficient in patients on hemodialysis than in those on peritoneal dialysis; however, paradoxically, the circulating levels of these solutes are lower in patients on peritoneal dialysis. Vanholder and colleagues consider possible explanations for this discrepancy, such as differences in intestinal generation or metabolism of these molecules.

Studies have shown that rituximab, a chimeric monoclonal antibody that targets the CD20 antigen of B cells, might be a valuable alternative to current therapies for idiopathic membranous nephropathy. In this Viewpoint article, Ruggenenti and colleagues discuss the use of rituximab in idiopathic membranous nephropathy and reason that titrating rituximab therapy to CD20⁺cell counts might be an effective way of limiting patient exposure to rituximab without reducing the efficacy of treatment, and would also substantially reduce treatment costs.

The role of aldosterone in the progression of kidney dysfunction, via its actions on mineralocorticoid receptors, is increasingly recognized. The authors of this Viewpoint outline the beneficial effects that have been seen in animal and human studies of mineralocorticoid receptor blockade in various forms of kidney disease. They predict that low daily doses of the aldosterone blocker spironolactone—an inexpensive, generic medication with few and easily recognizable adverse effects—might one day become the renal equivalent of 'baby' aspirin.

Here, Cohen and Kimmel attempt to counter the arguments presented by Lynda Szczech in the preceding Viewpoint. They point out that HIV-associated kidney disease exists in various forms that have different treatment requirements and that renal biopsy is necessary to establish the exact diagnosis. They argue, furthermore, that the efficacy and safety of highly active antiretroviral therapy against HIV-associated nephropathy is questionable and that such treatment should not, therefore, be initiated empirically.

This Viewpoint attempts to counter the arguments presented by Cravedi et al. in this issue of Nature Clinical Practice Nephrology. Although β-cell islet transplantation is not yet a widely viable treatment for type 1 diabetes, AM James Shapiro argues that the procedure's shortcomings are not insurmountable and that now is not the time for a moratorium on clinical research. Enhancing the mass of the initial islet engraftment, which would alleviate many of the present challenges, could be achieved in ongoing trials, and remarkable progress with xenotransplantation and human embryonic stem cells foreshadows the possibility of a renewable islet cell source.

Should renal biopsy be performed in all patients with both HIV infection and kidney disease? In this Viewpoint, Dr Szczech argues that, given its efficacy against conditions like HIV-associated nephropathy, antiretroviral therapy should be implemented before biopsy is considered. Only when suppression of viral replication fails to improve renal function does the case for biopsy become more compelling. In any event, much as with HIV-negative patients with renal disease, empiric therapy should be implemented before renal biopsy is undertaken.

The enthusiasm for pancreatic β-cell islet transplantation that followed the introduction of the 'Edmonton protocol' in 2000 has been tempered by evidence that the immunosuppressants used in the protocol might be nephrotoxic and that the resultant insulin independence is only short-term in most patients. Cravedi and colleagues analyze the risks and benefits of islet transplantation and argue that it should not be regarded as a general alternative to insulin replacement therapy for patients with type 1 diabetes mellitus.

The development of a wearable device that can replace conventional dialysis in patients needing chronic renal replacement therapy is not as far-fetched as it once was. Ronco et al. describe technological achievements, propose future research directions and discuss the clinical, technical and socioeconomic reasons for continuing the push to realize the wearable artificial kidney.

Various strategies have been considered in attempts to improve the outcomes of dialysis patients. Such strategies include increasing dialysis dose, using alternative depuration methods, changing dialysis schedules and focusing on preventing or treating specific co-morbidities and complications. In this Viewpoint, Andreas Pierratos discusses the first three strategies, and concludes that he believes that a paradigm shift, a disruptive change-in the form of daily home nocturnal hemodialysis-is needed to improve dialysis outcomes.

Lymphocyte depletion has recently been adopted to allow immunosuppression minimization or even to achieve donor-specific tolerance in transplant recipients. The long-term aim of such therapy is to minimize toxic effects associated with standard immunosuppression, but this beneficial effect is offset by the potential toxicity of the global depletion of lymphocytes and, in some cases, monocytes and neutrophils. This Viewpoint summarizes current data on depletion strategies in kidney transplantation, typically in the setting of induction treatment.

Inhibitors of vascular endothelial growth factor, such as bevacizumab, are a promising approach to the treatment of tumors and other angiogenesis-dependent conditions. However, it is becoming increasingly obvious that these drugs can have serious adverse effects including proteinuria, hypertension and thrombotic microangiopathy. This Viewpoint evaluates current evidence to argue that these adverse effects are probably elicited by inhibition of nitric oxide production in the renal vasculature.

Multifactorial approaches to the treatment of type 2 diabetes mellitus have proven more effective than any individual intervention alone in reducing the risk of cardiovascular complications. As the spread of diabetes and obesity accelerates worldwide, unhindered by lifestyle modification approaches, the authors of this Viewpoint propose an aggressive multifactorial strategy for treating patients who have one or more risk factors for the metabolic syndrome in an effort to prevent or delay the onset of diabetes.