Features

Presidential Address Kidney Week 2019

Winning the War on Kidney Diseases: The Time Is Now

Mark E. Rosenberg
CJASN August 2020, 15 (8) 1213-1219; DOI: https://doi.org/10.2215/CJN.15011219

Abstract

The American Society of Nephrology Presidential Address was delivered by Mark Rosenberg at Kidney Week 2019 on November 7, 2019 in Washington, DC. The Address describes a remarkable alignment—a syzygy of policy, science, innovation accelerators, clinical trials, clinical care delivery, and activated patients—that exists today in the kidney space. As a community, we must ensure that the strategies developed to take advantage of this alignment, such as Advancing American Kidney Health, succeed. We must overcome our current challenges to thrive as a meaningful specialty. We have an incredible opportunity to come together as a kidney community to ensure success that realigns the priorities and incentives in kidney medicine to better achieve kidney health for all people throughout the world. The time is now to act.

Introduction

Welcome to ASN Kidney Week 2019. On behalf of the American Society of Nephrology, thank you for being here and for leading the fight against kidney diseases throughout the world.

This year, ASN Kidney Week returns to the city that was once its annual home—Washington, DC—for the first time since 1990. In this, the year a transformative Executive Order for Advancing American Kidney Health brings new hope for our patients, it is a fitting coincidence that we gather in the capital of the United States.

Although ASN’s annual meeting started in 1967, it wasn’t until 1988 that the Presidential Address was established. That year, it was delivered by Thomas Ferris in San Antonio, Texas (1). I was a first-year faculty member at the University of Minnesota, and Dr. Ferris was my Chair of Medicine. He had accepted me from the University of Manitoba in Winnipeg, Canada, into the internal medicine residency program at Minnesota, and was instrumental in my decision to become a nephrologist. Unfortunately, Dr. Ferris passed away this year after a long life and an inspirational career (2). As I take this opportunity to thank you for the honor of serving as ASN President, I dedicate this Presidential Address to Dr. Ferris.

As ASN Kidney Week 2019 unfolds, I have overwhelming gratitude for the two Kidney Week cochairs, Don Kohan and Mitch Rosner, who led a distinguished and talented ASN Kidney Week Education Committee. Thank you to members of the committee for your tireless work, expertise, and collaboration. A special thanks to the ASN staff, especially Jin Soo Kim, Cele Fogarty, and their excellent teams for their magical way of making Kidney Week come to life.

Yet my greatest thanks are to you, the members of the kidney community. While nephrology’s many facets keep us engaged—from patient care to research to education and beyond—the special bond enriching these is the sense of community we experience and value, amplifying the joy in the work we do. As Helen Keller noted, “Alone, we can do so little; together, we can do so much.”

As ASN President, I met with many of you in my home state of Minnesota, at ASN’s new headquarters here in Washington, DC, and across the United States. I also had the great privilege to travel the world over the past year, visiting with many of you in Australia, Canada, Germany, Hong Kong, Hungary, and Italy. Thank you for your hospitality, ongoing support, and commitment to improve the lives of millions of people with kidney diseases.

ASN supports more than 21,000 members of this community from over 130 countries. We benefit from our close partnerships with many other kidney societies and patient groups, in the United States and abroad. Key among these partnerships are the collaborative efforts between ASN and our colleagues from European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and International Society of Nephrology (ISN). This joint effort is magnifying nephrology’s reach as we speak with one voice across the globe to demand the best for people with kidney diseases no matter where they live (3).

ASN Kidney Week is the best example of the ASN community. This gathering of dedicated professionals provides a forum for scientific, clinical, and educational exchange, but it is much more than that. Through Kidney Week, ASN reconnects friends and colleagues, fosters mentoring and collaboration, and inspires and reinvigorates all those committed to transforming kidney medicine and improving kidney health.

I am especially proud of the newest members of our kidney community, the Kidney STARS (Figure 1). The students and residents who are here as part of the STARS program represent the future of our specialty, and I am so glad they join us in experiencing the wonders of kidney research, patient care, and education.

Figure 1.
Figure 1.

Kidney STARS participants are from varied educational programs with stable numbers over the past 2 years. The students and residents who are here as part of the STARS program represent the future of nephrology. DNP, Doctor of Nursing Practice; PA, Physician Assistant; STARS, students and residents.

Many ASN members support and extend our community by sharing their time and skills to work on committees, task forces, and other panels; serve on the editorial boards of our journals and self-assessment programs; interact on ASN communities; and engage in social media.

The Time Is Now

Please take a moment to look around the room. If everyone here suffered from kidney failure, one in five of us would not be alive to attend Kidney Week next year, and half of us would be dead in 5 years. The mortality from kidney diseases exceeds that from most cancers. We can and we must do better.

At this moment, a remarkable alignment exists among patients, researchers, clinicians, health care organizations, and policy makers. Building on a hunger for innovation in the kidney space, this syzygy has created unparalleled momentum and hope for the future. Today, now, is the moment for nephrology and for people with kidney diseases. We must seize this opportunity.

The theme for this year’s Kidney Week, “Bringing discovery to people with kidney diseases,” conveys the importance of innovation, discovery, and research in nephrology, and the goal that drives all of us: delivering these advancements to patients. The time is now for accomplishing this goal based on exciting developments in six key areas (Figure 2).

Figure 2.
Figure 2.

Syzygy in kidney medicine. A syzygy of policy, science, innovation accelerators, clinical trials, clinical care delivery, and activated patients exists today in the kidney space.

Policy

In 1962, Life magazine highlighted the dilemma of limited dialysis options for people with kidney failure that led to agonizing decisions over who would, and would not, receive this life-sustaining therapy (4). On October 30, 1972, US President Nixon signed Public Law 92–603 authorizing the ESKD Program under Medicare, a program that provided health insurance coverage for people with kidney failure. This program saved the lives of millions of people, but 46 years later the specialty faces roadblocks obstructing advances in care and innovation. A profession built on producing miracles for people with tremendously complex, often deadly, medical challenges still lacks appropriate recognition and sense of urgency.

Compounding a lack of public awareness and resolve are other significant challenges to a profession charged with advancing care for 850 million people worldwide (3). The cost of providing dialysis care here in the United States and in many other countries is unsustainable (Figure 3). Kidney research is underfunded by governments and the private sector, leading to a dearth of innovation. And too often nephrology is defined by kidney failure and nephrologists are undervalued compared with their enormous contributions to healthcare. These and other factors are limiting interest among those who are needed to build the future of kidney medicine.

Figure 3.
Figure 3.

Challenges facing the nephrology community. NIH, National Institutes of Health.

Our community must overcome these challenges to thrive as a meaningful specialty and to extend the lives, and improve quality of life, for millions who continue to die prematurely and unnecessarily.

Committing the US government to create a system that “pays for kidney health, rather than kidney sickness,” US President Trump signed the “Executive Order on Advancing American Kidney Health” on July 10, 2019 (5). The nation’s first kidney health strategy aims to reduce the number of Americans with kidney failure by 25% over the next decade, to double the number of kidneys available for transplant, and to provide a greater emphasis on transplantation, home dialysis, and new therapies, such as the artificial kidney (6).

We are proud to recognize Department of Health and Human Services Secretary Alex Azar and his team with the ASN President’s Medal for their partnership and leadership in establishing these goals. ASN’s policy experts, led by Crystal Gadegbeku, Scott Bieber, and Rachel Meyer, have long advocated for these initiatives that will transform the lives of people with kidney diseases as have patient organizations, such as the National Kidney Foundation and the American Association of Kidney Patients; and other health professional organizations, such as the Renal Physicians Association, the American Society of Pediatric Nephrology, and the American Society of Transplantation.

Advancing American Kidney Health ushers in a “War on Kidney Diseases.” Bold goals, clear objectives, and sustained support from the government will define a new era in kidney health. The time is now to transform nephrology by accelerating kidney research and discovery, unleashing innovation and product development, piloting new models of delivering care, and increasing access to transplantation.

Kidney Science

Nephrology has come a long way since the initial description by Richard Bright characterizing the features and consequences of kidney diseases. He described the association of dropsy, and a hypertrophied heart with scarred and shrunken kidneys. Fast forward to today: instead of examining just the gross anatomic features of a diseased kidney, we can now examine single-cell genomics. Instead of just case reports, we can now analyze data from vast clinical databases using the tools of machine learning and artificial intelligence. Techniques drive science. Breakthrough scientific advances have occurred that drive the progress of kidney research.

New imaging techniques and advanced computational processing are leading to novel insights into the physiology and pathophysiology of the kidney (7–⇓9). Detailed morphologic reconstructions of the kidney are being developed using multiple imaging modalities. Intravital multiphoton microscopy of the same kidney over days is now possible, and can be used to perform cell-fate tracing under normal and disease conditions (10).

Advances in gene editing have occurred using CRISPR/Cas9 technology (11). These techniques are being applied to the kidney to investigate and target kidney fibrosis and treat experimental kidney diseases (12,13).

Techniques such as kidney-on-a-chip and use of human kidney organoids are being utilized to model and recapitulate the kidney (14–⇓16).

Systems biology approaches such as single-cell and single-nucleus RNA sequencing of individual kidney cells can be performed in normal and diseased kidneys, enabling precise molecular characterization of cell types and states (17–⇓19). Combining mRNA sequencing, proteomics, and bioinformatics is leading to the development of detailed maps of cells, such as the podocyte, to identify new signaling pathways and potentially new therapeutic targets (20).

This is also the year that a nephrologist, Sir Peter Ratcliffe, was one of three scientists to be awarded the Nobel Prize in Physiology and Medicine for their work on discovering how cells sense and adapt to oxygen availability (21). This work has paved the way for new strategies to fight anemia in people with kidney diseases.

These are just some of the many examples where novel techniques and approaches are being employed to enhance our understanding of the normal kidney and to identify new therapeutic targets for people with kidney diseases. The time is now for developing new therapies based on these groundbreaking discoveries.

Clinical Trials

When compared with other specialties, the kidney space has had historically fewer clinical trials, and many of these trials have failed to yield new therapeutic advancements (22). But, this spring, clinical trials identified new and effective treatments for diabetic nephropathy, including endothelin antagonists and sodium-glucose cotransporter 2 inhibitors (23,24). Other trials in kidney diseases are underway examining the effects of SGLT2 inhibitors in non-diabetic kidney diseases, novel mineralocorticoid antagonists, inhibitors of fibrosis, and innovative treatments for GN.

New therapeutic targets in AKI have been identified leading to a clinical trial demonstrating niacinamide is protective against AKI following cardiac surgery in humans (25). As John Kellum and Dana Fuhrman stated in their 2019 Nature Reviews Nephrology article, “The handwriting is on the wall: there will soon be a drug for AKI” (26).

We are harnessing big data, machine learning, and artificial intelligence. A goal of this work is to develop predictive algorithms based on a patient’s unique characteristics to forecast outcomes, guide clinical decision making, and identify specific patients for clinical trials. An example of this approach is the collaboration between Google, DeepMind, and the VA HealthCare System to apply artificial intelligence to the prediction of AKI (27). The modeling used in this study involved more than 700,000 patient records and 6 billion independent data elements.

The time is now to leverage these new clinical trial outcomes including the defining of surrogate outcomes (28) and the power of big data to accelerate the delivery of personalized medicine and new treatments to people with kidney diseases.

Innovation Accelerators

To bring new therapies to life, we are accelerating the pace of discovery and innovation through KidneyX and the Kidney Health Initiative. KidneyX, a partnership between the Department of Health and Human Services and ASN, will accelerate innovation in prevention, diagnosis, and treatment by fostering product development across the spectrum of kidney care. The first KidneyX competition focused on redesigning dialysis. The 15 prize winners were chosen from 160 submitted ideas and were presented at the first KidneyX Summit in April 2019 (29). The second competition, supported by the National Kidney Foundation, will advance the best ideas from patient innovators.

The Kidney Health Initiative (KHI), is a partnership between the Food and Drug Administration, ASN, patients, industry, and other stakeholders to optimize kidney health and the evaluation of drugs, devices, biologics, and food products. For example, the KHI Technology Roadmap for Innovative Approaches to RRT fosters a new, multidisciplinary approach that can improve the lives of people with kidney failure (30). These and other programs in collaboration with the Food and Drug Administration and the Centers for Medicare & Medicaid Services will help bring discovery to people with kidney diseases.

The new war on kidney diseases strengthens these efforts and sends a clear message that the “doors are open” to researchers, inventors, and industry. But capital markets must also hear this message. So must legislators, who set funding levels for research. These efforts will help our community embody an “on-study” culture to better support clinical trials and increase funding and training for clinical trialists.

The time is now to accentuate and galvanize kidney research; develop disruptive approaches to kidney care; and produce new medical products leading to solutions that will improve the lives of the millions of people worldwide affected by kidney diseases.

Patient Care Delivery

People with kidney diseases are the most complex patients. This was demonstrated in a study by Tonelli et al. (31) examining nine markers of patient complexity including number of comorbidities, number of prescribed medications, and rate of hospitalization (Figure 4). Caring for people with kidney diseases requires a team of highly skilled clinicians. Effective and innovative care delivery models must advance to reduce disparities in access to care and to ensure high-quality care across the continuum of kidney diseases.

Figure 4.
Figure 4.

Complexity of patients in different specialties. People with kidney diseases are the most complex patients. Adapted from reference (31), with permission.

Nephrologists Transforming Dialysis Safety (NTDS), a partnership between the Centers for Disease Control and Prevention and ASN, was initially designed to help transform infection prevention in dialysis facilities (32). NTDS has expanded to include human factors engineering to help transform care. More recently, NTDS has become a model for establishing new initiatives to improve care in other areas, such as AKI, diabetic kidney disease, and disaster relief. This approach to complex clinical care problems has enormous potential to transform kidney care in the United States and abroad.

Innovative models of value-based care across the continuum of kidney diseases and kidney failure are being developed in both the private and public sectors. The private sector and the federal government are committing resources to improving care coordination and patient education and to transforming treatment paradigms. The Center for Medicare & Medicaid Innovation is introducing new value-based payment models that align health care provider incentives with patient preferences to improve quality of life for people with kidney diseases.

These care models are facilitated by advances in health technology capable of monitoring and reporting an assortment of physiologic measurements to both the patient and care team. The personal digital revolution that has transformed other industries, such as entertainment, is now poised to improve healthcare throughout the world. The time is now to harness these new models of kidney care delivery and reimbursement to improve care.

Patient Activation

In all these endeavors, the patient voice, patient-reported outcomes, and patient-directed care have progressively intensified during the past decade. Patients want to be and must be informed of their treatment options. They must be empowered to make the choices that best fit with what is most important to them and to their families. Today, an unprecedented level of patient activism and influence exists in our community through individual patients, their families, and the organizations that represent them.

The time is now to engage our patients, energize them, and continue to develop partnerships with them to promote the highest quality of patient-directed care and to advocate for more investment in kidney research.

What Must We Do?

What I have just described is a remarkable alignment—a syzygy of policy, science, clinical trials, innovation accelerators, clinical care delivery, and activated patients—that exists today in the kidney space (Figure 2). As a community, we must ensure that the strategies developed to take advantage of this alignment, such as Advancing American Kidney Health, succeed. Again, we must ensure that these strategies flourish. Kidney health finally became a national priority in the United States in 2019.

We must recognize this is the moment that kidney diseases have ascended to the same level as cancer as a national priority. The time is now. We must work cohesively and with purpose. We must overcome our current challenges to thrive as a meaningful specialty. If we succeed, we will provide people with kidney diseases the future they deserve—a future in which kidney health, not kidney failure, defines care.

We must harness technology to discover new therapies and accelerate bringing these therapies to people with kidney diseases. We must advocate for aggressive funding for kidney diseases research to ensure that projects that improve care and result in new therapies are successful. We must address upstream risk factors and raise awareness among at-risk populations to ensure people in early stages of kidney disease are identified and receive high-quality care to slow, delay, or stop progression of kidney diseases.

We must reinvigorate the nephrology educational continuum. For the next generation of nephrologists, this shift must result in more exposure to kidney medicine in medical schools and residency training; a greater emphasis on home dialysis, transplantation, and new therapies during nephrology fellowships; and the need to align initial certification and recertification with the reality of nephrology practice.

We must ignite all the changes that will transform care, accelerate innovation, and improve lives. We must take ownership of our specialty and emphasize the essential components of nephrology that advance high-quality care and make nephrology and its subspecialties appealing as a future career.

We have an incredible opportunity to come together as a kidney community to ensure success realigns the priorities and incentives in kidney medicine to better achieve kidney health for all people throughout the world. The time is now to act.

Disclosures

Dr. Rosenberg reports honorarium support from Wolters Kluwer that is unrelated to this article.

Funding

None.

Acknowledgments

I would like to thank the American Society of Nephrology (ASN) Council for their tireless leadership, camaraderie, and dedication. A special thanks to ASN Executive Vice President Tod Ibrahim for his leadership and assistance in preparation of this address. I would also like to thank Crystal Anderson for her help in preparing the graphics for this article. I am grateful to my University of Minnesota community for their support and understanding, their impact on my career, and their inspirational leadership. A special thanks to Tom Hostetter and Karl Nath for their mentorship and friendship. Finally, I am forever grateful to my three children, Jack, Maddy, and Joel, and to my wife Monica, for their undying support over the years.

Footnotes

  • Published online ahead of print. Publication date available at www.cjasn.org.

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Presidential Address Kidney Week 2019
Mark E. Rosenberg
CJASN Aug 2020, 15 (8) 1213-1219; DOI: 10.2215/CJN.15011219
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