Volume 18 Issue 2, February 2022

The dramatic increase in advocacy and scholarly work on the impact of structural racism on health inequities that began in 2020 has been sustained in the past year. In response to the call for action on these issues, the nephrology community has developed policy-based mitigation strategies and continues to examine our role in promoting health equity and justice in the care of patients with kidney disease.

In 2021, extreme weather and climate events caused preventable injuries, illnesses and deaths. A clear imperative exists to reduce greenhouse gas emissions and increase the sustainability and climate resilience of health systems. Countries and communities must implement strategies to mitigate climate change and invest in health systems to protect their populations.

We saw impressive progress in our understanding of the genetics of kidney function and disease in 2021. Genome-wide association studies defined key common variants for kidney function and disease, and multi-omics methods, including quantitative trait analyses and single cell studies, illuminated key genes and cell types responsible for disease development.

New DAPA-CKD trial analyses have confirmed the outstanding renoprotective benefits of sodium–glucose co-transporter 2 inhibitors, independently of the presence of diabetes or the stage of kidney disease. Moreover, the non-steroidal mineralocorticoid receptor antagonist finerenone provides renal and cardiovascular protection in diabetic kidney disease when combined with renin–angiotensin–aldosterone system inhibitors.

Patients with kidney disease are particularly vulnerable to COVID-19. In 2021, key studies demonstrated the safety of renin–angiotensin blockade in patients with kidney failure and COVID-19, and provided new data on the therapeutic potential of soluble angiotensin-converting enzyme, COVID-19 vaccine responses and the long-term effects of COVID-19 on kidney function.

Glucocorticoid exposure remains a major contributor to morbidity and mortality in patients with immune-mediated kidney disease. Recent clinical trials have tested novel potential therapies for these patients and showed that glucocorticoid doses can be reduced without compromising efficacy.

Here, the authors discuss how structural racism underlies many of the health disparities that affect individuals from minority racial groups. They also examine how the use of race coefficients in estimated glomerular filtration rate equations might contribute to health inequities in Black patients with kidney disease.

Endothelial cells in the kidney microvasculature have an intrinsic molecular and phenotypic heterogeneity and respond to sepsis-induced acute kidney injury conditions in a segment-specific manner. This Review discusses the roles of these cells and the molecular systems that control endothelial functions in the development of sepsis-induced acute kidney injury.

Pain management in patients with haemodialysis-dependent kidney failure might involve the use of opioids. This Review discusses the safe implementation of opioid therapy in these patients, including specific pharmacological considerations, drug choice and opioid use monitoring.