National strategies for addressing chronic kidney disease (CKD) are crucial to improving kidney health. We sought to describe country-level variations in non-communicable disease (NCD) strategies and CKD-specific policies across different regions and income levels worldwide. The International Society of Nephrology Global Kidney Health Atlas (GKHA) was a multinational cross-sectional survey conducted between July and October 2018. Responses from key opinion leaders in each country regarding national NCD strategies, the presence and scope of CKD-specific policies, and government recognition of CKD as a health priority were described overall and according to region and income level. 160 countries participated in the GKHA survey, comprising 97.8% of the world’s population. Seventy-four (47%) countries had an established national NCD strategy, and 53 (34%) countries reported the existence of CKD-specific policies, with substantial variation across regions and income levels. Where CKD-specific policies existed, non-dialysis CKD care was variably addressed. 79 (51%) countries identified government recognition of CKD as a health priority. Low- and low-middle income countries were less likely to have strategies and policies for addressing CKD and have governments which recognise it as a health priority. The existence of CKD-specific policies, and a national NCD strategy more broadly, varied substantially across different regions around the world but was overall suboptimal, with major discrepancies between the burden of CKD in many countries and governmental recognition of CKD as a health priority. Greater recognition of CKD within national health policy is critical to improving kidney healthcare globally.

Each generation produces a few individuals who by dint of their efforts, opportunities, and talents rise above all of the rest. For the discipline of nephrology, Stewart Cameron was one of these rare persons—larger than life and full of joy, energy, and boundless enthusiasm, mixed with a bit of playful mischievousness. He had a keen and wide-ranging intellect, he had a broad understanding of history, and he was a master of clinical medicine, with unparalleled skills in both written and verbal communication. He managed to amalgamate a deep sense of the value of teamwork and a common sense approach to clinical research in ways that brought much success to those who had the good fortune to be his colleagues or mentees. These attributes, along with his comprehensive knowledge of the field of kidney disease and his leadership qualities, fostered the development of an internationally recognized center of excellence at Guy’s Hospital in London, UK, where he served as the successor to one of his personal heroes, Richard Bright—the 19th century founding father of the clinical study of kidney disease. Stewart Cameron’s passing, at the age of 89 years, on July 30, 2023, leaves a formidable void that will now be filled by his enormous legacy of contributions to the field, by his pupils, and by the memories of his unforgettable persona. John Stewart Cameron was born in Aberdeen, Scotland, on July 5, 1934, the son of a master mariner and a secretary. His father was a skilled draughtsman and artist, and Stewart, with similar gifts, considered following in his footsteps. But his desire to remain deeply connected to people and a passionate interest in science drew him irrevocably to a medical career. He was by now living in London but considered going back to Aberdeen to study medicine. However, fate had a different idea, and he was accepted at Guy’s Hospital Medical School in 1953. He remained firmly attached to that institution for the remainder of his life—70 years in total. He received first-class honors for a BSc degree in physiology in 1956, and graduated MBBS (with distinction) in 1959, by which time he was married with 2 children (an unusual circumstance in those days). During his early house officer days, he was unsure which branch of medicine to pursue, but influenced by his interest in physiology and his careful reading of Homer Smith’s “green” book of 1951 (The Kidney: Structure and Function in Health and Disease), he began to gravitate toward a career in clinical investigation. His work in diabetes with John Butterfield (professor of experimental medicine at Guy’s Hospital and later regius professor of physics in Cambridge) crystallized his views on a career in medical research and gave him exposure to “teamwork,” which would become one of the mantras of his life in medicine. Nephrology did not yet exist as an independent discipline, but Professor Butterfield recognized the nascent talent embedded in Stewart and also wanted to develop a kidney research group at Guy’s Hospital. So, Stewart was directed to spend time with the group led by Professors E. Lovell (“stretch”) Becker and Robert F. Pitts at Cornell School of Medicine in New York City starting in 1962—where he performed research on the permselectivity of proteinuria in kidney disease and also learned about dialysis, kidney biopsy, and other “nuts and bolts” of clinical nephrology. In 1963, he returned to Guy’s Hospital as a lecturer in the Department of Medicine and began to develop the core elements of a dedicated renal unit, along with his first true colleague, John Trounce, a clinical pharmacologist at Guy’s Hospital with a companion interest in renal medicine. At that time, chronic dialysis was in a rudimentary stage of development in the United Kingdom, having been first started by Stanley Shaldon (Royal Free Hospital) and David Kerr (Newcastle). Kidney transplantation was also in its early phase, but a talented surgeon, Frank Ellis, joined Stewart in developing a transplant program at Guy’s Hospital. In 1966, Chisholm Ogg joined the burgeoning group, first as a registrar and then as a consultant, and added greatly to the growing luster of the nascent renal unit. Stewart and Chisholm became the closest of colleagues and lifelong friends. The coalescence of a renal unit devoted to an integration of dialysis and transplantation at Guy’s Hospital gave Stewart the opportunity to put into action the principles of teamwork he learned from Professor Butterfield. A pivotal step in this process was that Guy’s Hospital was selected by the UK government to receive a grant to establish a chronic dialysis facility. His interest in glomerulonephritis also grew exponentially, and in due time, the Guy’s Hospital Renal Unit and Stewart became widely known as among the world leaders in this branch of kidney diseases. The clinical investigative work of Stewart and the Guy’s Hospital unit in glomerulonephritis was truly pioneering, and the published articles describing these efforts are still cited today. Soon Stewart became an ubiquitous presence at national and international meetings devoted to this topic. A meeting on glomerulonephritis without Stewart on the program was seldom encountered, and without him such meetings generated less energy and enthusiasm. Not unexpectedly, the reputation for excellence of the renal unit at Guy’s Hospital with Stewart as its leader soon had him involved in many organizations. He became president of the European Society of Pediatric Nephrology (ESPN, 1975), the European Dialysis and Transplant Association (EDTA, 1984–1987), and the International Society of Nephrology (ISN, 1993–1995). He held the presidency of the UK Renal Association and the ISN simultaneously—a formidable challenge indeed. He helped to create the journal of the European Dialysis and Transplant Association (Nephrology Dialysis Transplantation). All during these encounters with international nephrology, he retained his Scottish identity, even to the point of wearing the Cameron kilt and sgain dubh at the opening ceremony of the International Congress of Nephrology in London in 1987. His academic credentials correspondently notched progressively upward. He was appointed as professor of renal medicine in 1974 and as director of the clinical sciences laboratories at Guy’s Hospital in 1974, both positions he retained until his retirement in 1996. He received numerous awards and named lectureships, including a Commander of the British Empire (CBE) in 1998, the Jean Hamburger Award of the ISN in 2003, and the David Hume Award of the National Kidney Foundation in 2004. He became a Fellow of the Royal College of Physicians in 1971, and at the College, he gave the Goulstonian Lecture in 1972, the Lumleian Lecture in 1987, and the Fitzpatrick Lecture in 1998. He and his colleagues made many seminal contributions to the field of glomerular diseases, autoimmunity, and lupus nephritis, including their therapy, in both children and adults. He authored hundreds of original publications in prestigious journals, a dozen books, over a hundred book chapters, and many clinical trials. He also made many important contributions to the field of urate and purine metabolism, spurred on by his personal experience with gouty arthritis. He had strong connections to pediatric nephrology, aided by his excellent collaborators and steadfast friends Chisholm Ogg, Richard White, and Cyril Chantler. Throughout his long and distinguished career, Stewart was an avid student of the history of kidney disease, dialysis, and transplantation. This was fitting for his position at Guy’s Hospital—a splendid place of discovery and healing that played such a central role, through Richard Bright, in the development of nephrology as a distinct discipline. His writings on the history of nephrology can be read and reread with much joy and appreciation of his encyclopedic knowledge of the subject. From the beginning of his medical career, Stewart never lost sight of his implicit contract with his patients—to do his best at all times in a wise and compassionate way, even if it meant breaking some rules in response to common sense and exposing himself to the tearful personal reflections that come when those efforts fail. He and others in his “renal family,” including nurses, put themselves at risk of harm—most notably, during the hepatitis B epidemic in the Guy’s Hospital Renal Unit in 1969. Stewart became seriously ill with hepatitis B—so much so that his career was threatened for a time. His compassion and uncompromising dedication to the welfare of his and others’ patients are testimony to his egalitarian beliefs. But Stewart was not “just” a complete physician or academician. He was multilingual and read literature voraciously. Many of his friends commented that he was a “walking British library” long before the advent of Google. A conversation with Stewart was an intense experience, full of magnificent opportunities to learn new things at the foot of a master. As mentioned earlier, he married young and his wife, Margot, became an essential partner in his career in medicine. The two of them together verified the old adage that “the sum is greater than the individual parts.” After his retirement, in 1996, Margot and Stewart relocated to a renovated farmhouse among the hills of Cumbria in northern England. The location was pastoral and the community was small, but the views were beautiful and soothing; and from his study there, Stewart continued to pursue his writing and his interest in history. Unfortunately, Margot developed progressive dementia, requiring the devotion to her care that Stewart provided with great love and compassion until her death. He later rekindled a happy relationship with a former Guy’s Hospital renal nurse, Alison Russell, with whom he had coauthored a book on nursing aspects of kidney disease, dialysis, and transplantation (first published in 1968); they were married in 2018 and were happy together. A son, Ewen, passed away in 2013; and Stewart is survived by Alison; a daughter, Sheena; a granddaughter, Laura; 3 step granddaughters; and 8 step great grandchildren. Of course, he also leaves behind droves of students, mentees, friends, colleagues, and grateful patients who had the good fortune of knowing this remarkable man. In sum, Stewart had a big compassionate heart and an enormous intellect in a diminutive, sometimes weakened, body. His humility, vigor (despite his personal health challenges), integrity, compassion, joie de vivre, and encyclopedic knowledge stand out as characteristics that inspired admiration and deep, lasting relationships among the many who knew him—be they close friends or brief acquaintances. His impact on the field of nephrology was prodigious, lasting, and of international scope. His legacy can be measured and will be continued by his countless intellectual successors. These are the hallmarks of greatness. What more can one ask of a life well-lived? Gabhadh e fois ann an sith! (Rest in peace, our dear friend!) The authors gratefully acknowledge the help and support of Alison Cameron, Sheena Cameron, Laura Levy Cameron, and Barry M. Brenner, MD, during prepartion of this tribute.

Access to care for children with kidney disease is limited in less well-resourced regions of the world and paediatric nephrology (PN) workforce development with good practical skills is critical. Retrospective review of a PN training program and trainee feedback from 1999 to 2021, based at Red Cross War Memorial Children’s Hospital (RCWMCH), University of Cape Town. A regionally appropriate 1–2-year training program enrolled 38 fellows with an initial 100

Introduction: Glomerular Research And Clinical Experiments-IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South Asian IgA nephropathy (IgAN) cohort with prespecified objectives, protocolized longitudinal follow-up, and extensive biosample collection. The baseline risk scores predicted high risk of kidney disease progression. Methods: A total of 195 of 201 patients (97%) completed 3-year follow-up in September 2020. All patients received optimized supportive care, and those at high risk of progression were offered systemic corticosteroids. Results: A total of 76 patients (76 of 193, 39.4%) had rapid progression in 3 years (>= 5 ml/min per 1.73 m(2) decline in estimated glomerular filtration rate [eGFR] per year). A total of 72 patients (72 of 195, 36.9%) experienced the composite outcome (CO), defined as >= 50% fall in eGFR, eGFR < 15 ml/min per 1.73 m(2), commenced kidney replacement therapy or death, in 3 years. At each scheduled follow-up, achievement of proteinuria level < 1 g/d significantly delayed the time to the CO. The receiver operating characteristic curve of average annual decline in eGFR >= 5 ml/min per 1.73 m(2) had 86% sensitivity and 89% specificity for CO in 3 years and had good discrimination from 1 year onwards (area under the curve 0.8, SE 0.04, 95% CI 0.7-0.9, P < 0.0001). The significant predictors of CO by Cox proportional-hazards model were as follows: baseline MEST-T2 score (hazard ratio [HR] 3.3, 95% CI 1.7-6.5, P < 0.001), along with 24-hour urine protein level >= 1 g/d (HR 2.1, 95% CI 1.1-3.9, P = 0.02), eGFR < 60 ml/min per 1.73 m(2) (HR 2.9, 95% CI 1.1-7.6, P = 0.03), and rate of eGFR decline >= 5 ml/min per 1.73 m(2)/yr (HR 2.7, 95% CI 1.6-4.8, P < 0.001) all measured at 6 months. Mortality was 11 of 195 (5.6%). Conclusion: We identified longitudinal clinical variables measured at 6 months and >= 5 ml/min per 1.73 m(2) annual fall in eGFR after kidney biopsy as important predictors for composite outcome in addition to baseline histology.

Background. Health information systems (HIS) are fundamental tools for the surveillance of health services, estimation of disease burden and prioritization of health resources. Several gaps in the availability of HIS for kidney disease were highlighted by the first iteration of the Global Kidney Health Atlas. Methods. As part of its second iteration, the International Society of Nephrology conducted a cross-sectional global survey between July and October 2018 to explore the coverage and scope of HIS for kidney disease, with a focus on kidney replacement therapy (KRT). Results. Out of a total of 182 invited countries, 154 countries responded to questions on HIS (85% response rate). KRT registries were available in almost all high-income countries, but few low-income countries, while registries for non-dialysis chronic kidney disease (CKD) or acute kidney injury (AKI) were rare. Registries in high-income countries tended to be national, in contrast to registries in low-income countries, which often operated at local or regional levels. Although cause of end-stage kidney disease, modality of KRT and source of kidney transplant donors were frequently reported, few countries collected data on patient-reported outcome measures and only half of low-income countries recorded process-based measures. Almost no countries had programs to detect AKI and practices to identify CKD-targeted individuals with diabetes, hypertension and cardiovascular disease, rather than members of high-risk ethnic groups. Conclusions. These findings confirm significant heterogeneity in the global availability of HIS for kidney disease and highlight important gaps in their coverage and scope, especially in low-income countries and across the domains of AKI, non-dialysis CKD, patient-reported outcomes, process-based measures and quality indicators for KRT service delivery.

Importance:The effect of glucocorticoids on major kidney outcomes and adverse events in IgA nephropathy has been uncertain.Objective:To evaluate the efficacy and adverse effects of methylprednisolone in patients with IgA nephropathy at high risk of kidney function decline.Design, Setting, and Participants:An international, multicenter, double-blind, randomized clinical trial that enrolled 503 participants with IgA nephropathy, proteinuria greater than or equal to 1 g per day, and estimated glomerular filtration rate (eGFR) of 20 to 120 mL/min/1.73 m2 after at least 3 months of optimized background care from 67 centers in Australia, Canada, China, India, and Malaysia between May 2012 and November 2019, with follow-up until June 2021.Interventions:Participants were randomized in a 1:1 ratio to receive oral methylprednisolone (initially 0.6-0.8 mg/kg/d, maximum 48 mg/d, weaning by 8 mg/d/mo; n = 136) or placebo (n = 126). After 262 participants were randomized, an excess of serious infections was identified, leading to dose reduction (0.4 mg/kg/d, maximum 32 mg/d, weaning by 4 mg/d/mo) and addition of antibiotic prophylaxis for pneumocystis pneumonia for subsequent participants (121 in the oral methylprednisolone group and 120 in the placebo group).Main Outcomes And Measures:The primary end point was a composite of 40% decline in eGFR, kidney failure (dialysis, transplant), or death due to kidney disease. There were 11 secondary outcomes, including kidney failure.Results:Among 503 randomized patients (mean age, 38 years; 198 [39%] women; mean eGFR, 61.5 mL/min/1.73 m2; mean proteinuria, 2.46 g/d), 493 (98%) completed the trial. Over a mean of 4.2 years of follow-up, the primary outcome occurred in 74 participants (28.8%) in the methylprednisolone group compared with 106 (43.1%) in the placebo group (hazard ratio [HR], 0.53 [95% CI, 0.39-0.72]; P < .001; absolute annual event rate difference, -4.8% per year [95% CI, -8.0% to -1.6%]). The effect on the primary outcome was seen across each dose compared with the relevant participants in the placebo group recruited to each regimen (P for heterogeneity = .11): full-dose HR, 0.58 (95% CI, 0.41-0.81); reduced-dose HR, 0.27 (95% CI, 0.11-0.65). Of the 11 prespecified secondary end points, 9 showed significant differences in favor of the intervention, including kidney failure (50 [19.5%] vs 67 [27.2%]; HR, 0.59 [95% CI, 0.40-0.87]; P = .008; annual event rate difference, -2.9% per year [95% CI, -5.4% to -0.3%]). Serious adverse events were more frequent with methylprednisolone vs placebo (28 [10.9%] vs 7 [2.8%] patients with serious adverse events), primarily with full-dose therapy compared with its matching placebo (22 [16.2%] vs 4 [3.2%]).Conclusions and Relevance:Among patients with IgA nephropathy at high risk of progression, treatment with oral methylprednisolone for 6 to 9 months, compared with placebo, significantly reduced the risk of the composite outcome of kidney function decline, kidney failure, or death due to kidney disease. However, the incidence of serious adverse events was increased with oral methylprednisolone, mainly with high-dose therapy.Trial Registration:ClinicalTrials.gov Identifier: NCT01560052.

Background Acute kidney injury (AKI) is increasingly encountered in community settings and contributes to morbidity, mortality, and increased resource utilization worldwide. In low-resource settings, lack of awareness of and limited access to diagnostic and therapeutic interventions likely influence patient management. We evaluated the feasibility of the use of point-of-care (POC) serum creatinine and urine dipstick testing with an education and training program to optimize the identification and management of AKI in the community in 3 low-resource countries. Methods and findings Patients presenting to healthcare centers (HCCs) from 1 October 2016 to 29 September 2017 in the cities Cochabamba, Bolivia; Dharan, Nepal; and Blantyre, Malawi, were assessed utilizing a symptom-based risk score to identify patients at moderate to high AKI risk. POC testing for serum creatinine and urine dipstick at enrollment were utilized to classify these patients as having chronic kidney disease (CKD), acute kidney disease (AKD), or no kidney disease (NKD). Patients were followed for a maximum of 6 months with repeat POC testing. AKI development was assessed at 7 days, kidney recovery at 1 month, and progression to CKD and mortality at 3 and 6 months. Following an observation phase to establish baseline data, care providers and physicians in the HCCs were trained with a standardized protocol utilizing POC tests to evaluate and manage patients, guided by physicians in referral hospitals connected via mobile digital technology. We evaluated 3,577 patients, and 2,101 were enrolled: 978 in the observation phase and 1,123 in the intervention phase. Due to the high number of patients attending the centers daily, it was not feasible to screen all patients to assess the actual incidence of AKI. Of enrolled patients, 1,825/2,101 (87%) were adults, 1,117/2,101 (53%) were females, 399/2,101 (19%) were from Bolivia, 813/2,101 (39%) were from Malawi, and 889/2,101 (42%) were from Nepal. The age of enrolled patients ranged from 1 month to 96 years, with a mean of 43 years (SD 21) and a median of 43 years (IQR 27–62). Hypertension was the most common comorbidity (418/2,101; 20%). At enrollment, 197/2,101 (9.4%) had CKD, and 1,199/2,101 (57%) had AKD. AKI developed in 30% within 7 days. By 1 month, 268/978 (27%) patients in the observation phase and 203/1,123 (18%) in the intervention phase were lost to follow-up. In the intervention phase, more patients received fluids (observation 714/978 [73%] versus intervention 874/1,123 [78%]; 95% CI 0.63, 0.94; p = 0.012), hospitalization was reduced (observation 578/978 [59%] versus intervention 548/1,123 [49%]; 95% CI 0.55, 0.79; p < 0.001), and admitted patients with severe AKI did not show a significantly lower mortality during follow-up (observation 27/135 [20%] versus intervention 21/178 [11.8%]; 95% CI 0.98, 3.52; p = 0.057). Of 504 patients with kidney function assessed during the 6-month follow-up, de novo CKD arose in 79/484 (16.3%), with no difference between the observation and intervention phase (95% CI 0.91, 2.47; p = 0.101). Overall mortality was 273/2,101 (13%) and was highest in those who had CKD (24/106; 23%), followed by those with AKD (128/760; 17%), AKI (85/628; 14%), and NKD (36/607; 6%). The main limitation of our study was the inability to determine the actual incidence of kidney dysfunction in the health centers as it was not feasible to screen all the patients due to the high numbers seen daily. Conclusions This multicenter, non-randomized feasibility study in low-resource settings demonstrates that it is feasible to implement a comprehensive program utilizing POC testing and protocol-based management to improve the recognition and management of AKI and AKD in high-risk patients in primary care.

Introduction: Despite optimal current care, up to 30% of individuals suffering from immunoglobulin A nephropathy (IgAN) will develop kidney failure requiring dialysis or kidney transplantation. The Therapeutic Evaluation of STeroids in IgA Nephropathy Global (TESTING) study was designed to assess the benefits and risks of steroids in people with IgAN. We report the trial design as well as the baseline characteristics of study participants. Methods: It is an investigator-initiated, multicenter, double-blind, placebo-controlled, randomized trial of individuals with kidney biopsy-confirmed IgAN, proteinuria ≥1 g/day, and an estimated GFR of 20–120 mL/min/1.73 m2, following at least 3 months of standard of care including maximum labelled (or tolerated) dose of renin-angiotensin system blockade. The original study design randomized participants 1:1 to oral methylprednisolone (0.6–0.8 mg/kg/day, maximum 48 mg/day) for 2 months, with subsequent weaning by 8 mg/day/month over 6–8 months, or matching placebo. The intervention was modified in 2016 (due to an excess of serious infection) to low-dose methylprednisolone (0.4 mg/kg/day, maximum 32 mg/day) for 2 months, followed by weaning by 4 mg/day/month over 6–9 months, or matching placebo. Participants recruited after 2016 also received prophylaxis against Pneumocystis jirovecii pneumonia during the first 12 weeks of treatment. Results: The study recruitment period extended from May 2012 to November 2019. By the time the excess of serious infections was observed, 262 participants had been randomized to the original full-dose treatment algorithm, and an interim analysis was reported in 2016. Subsequently, 241 additional participants were randomized to a revised low-dose protocol, for a total of 503 participants from China (373), India (78), Canada (24), Australia (18), and Malaysia (10). The mean age of randomized participants was 38, 39% were female, mean eGFR at randomization was 62.7 mL/min/1.73 m2, and mean 24-h urine protein 2.54 g. The primary endpoint is a composite of 40% eGFR decline from baseline or kidney failure (dialysis, transplantation, or death due to kidney disease), and participants will be followed until the primary outcome has been observed in at least 160 randomized participants. Analyses will also be made across predefined subgroups. Effects on eGFR slope and albuminuria will also be assessed overall, as well as by the steroid dosing regimen. Conclusions: The TESTING study (combined full and low dose) will define the benefits of corticosteroid use on major kidney outcomes, as well as the risks of therapy, and provide data on the relative effects of different doses, in individuals with high-risk IgAN.

IntroductionGlomerular Research And Clinical Experiments–IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South Asian IgAN cohort with protocolized follow-up and extensive biosample collection. Here we report the baseline clinical, biochemical, and histopathologic characteristics of GRACE IgANI and calculate baseline risk of progression for the cohort.Methods201 incident adults with kidney biopsy–proven primary IgAN were recruited into GRACE-IgANI between March 2015 and September 2017. As of April 30, 2020, the cohort had completed a median follow-up of 30 months (interquartile range [IQR] 16-39).ResultsThe commonest clinical presentation in GRACE IgANI was hypertension, with or without proteinuria, and nephrotic-range proteinuria was present in 34%, despite <10 months of lead time to kidney biopsy. The GRACE-IgANI kidney biopsy data demonstrated a disproportionate absence of active glomerular lesions and overrepresentation of segmental sclerosing lesions and tubulointerstitial fibrosis at presentation, often coexistent with relatively well-preserved estimated glomerular filtration rate (eGFR) and low levels of proteinuria, especially in males. Baseline risk of progression was calculated for each evaluable patient using 2 different risk prediction tools. The median 5-year absolute risk of end-stage kidney disease (ESKD) was 19.8% (IQR 2.7–57.4) and median 5-year risk of progression to the combined endpoint of 50% decline in eGFR or ESKD was 35.5% using the 2 tools.ConclusionsThe predicted risk of progression in this cohort was considerable. Over the next 5 years, we will dissect the pathogenic pathways that underlie this severe South Asian IgAN phenotype.

Donal O’Donoghue died on January 3, 2021 from coronavirus infection. A fine clinical leader, and a passionate advocate on behalf of people with kidney disease, has been taken from us suddenly at the height of his powers. He had done so much good over the last 30 years, in which he became a leading advocate for the development of effective nephrology services in the United Kingdom and beyond, and there would surely have been many more opportunities for him to turn his gifts and energy to the causes about which he cared so much. Donal O’Donoghue was born in 1956 in Manchester, UK, his father a head teacher and his mother devoted to the upbringing of their 2 sons. Apart from brief spells working elsewhere in the United Kingdom and Europe during his nephrology training, Manchester remained Donal’s home and the center of his professional work. He qualified from the University of Manchester in 1980 with First Class Honors in Physiology and Honors in Medicine. He trained in internal medicine and nephrology in Nottingham, Manchester, and Edinburgh. His early research work was in immune mechanisms in glomerular disease, particularly IgA nephropathy, Henoch-Schönlein purpura, and anti–neutrophilic cytoplasmic autoantibody vasculitis, first in Manchester, and then in 1987 as a Medical Research Council Traveling fellow at Necker Hospital in Paris, France. In 1992, he was appointed as consultant nephrologist at Hope Hospital in Salford on the west side of Greater Manchester, later to be renamed Salford Royal Hospital. This was the only tenured position he ever held, and he was still in clinical practice there at the time of his death. When he came to Hope Hospital, the renal unit was small, understaffed, and overstretched. He became clinical director, and with his colleagues set to work modernizing and transforming the service, developing the multiprofessional team approach and a patient-focused culture that became the hallmarks of all his future local, national, and international work. The unit’s practice became evidence based and subject to continuous quality improvement by audit, peer review, and multiprofessional research. Such approaches now seem routine, but 30 years ago were innovative, and not always understood or valued. There had also been a lack of coordinated service development and long-term underinvestment in renal services across Greater Manchester, illustrated by the situation that 50% of those starting renal replacement therapy were receiving peritoneal dialysis for lack of hemodialysis facilities; patients could be given no choice. A radical review was necessary and, despite his youthful lack of experience in medical politics, Donal was appointed to chair a group that produced a successful plan for future provision of renal services through hub and spoke development across Greater Manchester. From 1998 to 2001, he directed the implementation of this complex plan through change management, with service design, information technology, human resources, education, research, and finances all considered; crucially, patients and carers were involved in all phases. This became the Greater Manchester Renal Managed Clinical Network, which Donal chaired, the first of its kind in the United Kingdom. Donal had found his métier in clinical and organizational leadership, and national opportunities soon followed. In the late 1990s, the UK government had proposed a National Service Framework for Renal Services, a description of an optimal service against which existing services could be judged and resources sought; Donal led the National Service Framework through some rocky issues to a successful completion in 2005, and the following year was appointed to a new position of National Clinical Director for Kidney Care, which he held until 2013. As the inaugural National Clinical Director, he advised the government on the development of kidney care in a resource-limited National Health Service, and provided a much needed interface between government and clinical leadership. His tenure was marked by a major expansion in the UK’s renal replacement therapy services and the nephrology workforce. He advocated energetically for kidney disease, ensuring it was properly understood across the health community as a major noncommunicable disease. He was an opportunist; with other enthusiasts, he grasped at a chance to mandate UK clinical laboratories to routinely report estimated glomerular filtration rate alongside serum creatinine values. He rode the criticism that this would be misunderstood and drive unnecessary referral to nephrologists, especially among older people with chronic kidney disease, and he committed himself to the education programs, especially among primary care practitioners, that were needed to make this work. A transient surge of referrals soon settled, and there was evidence of reduction in the high rates of emergency presentation of undiagnosed end-stage kidney disease. He then led an effort to ensure that emerging evidence of suboptimal clinical care for people with acute kidney injury was used to drive the introduction of mandatory real-time reporting to clinicians of suspected acute kidney injury among inpatients through serum creatinine values, and championed the extensive education needed across the health community to drive improvements in acute kidney injury care. Donal’s skills and gifts were ideally suited to the role of National Clinical Director. He had the intellect and clarity of thought to analyze the issues and provide rational solutions, as well as the charm, humanity, and unstinting determination to make the case and build consensus among clinical leaders, health managers, and politicians. He was realistic enough to understand that he could not be popular with all the people all the time and bore criticism with equanimity and patience. His natural gift of friendship and his freedom from self-importance were always apparent. He ensured that the voice of patients would always be heard when kidney care was being planned and implemented. These attitudes underpinned his success as a mentor to a whole generation of UK nephrologists. His research interests developed in parallel with his interests in clinical care and service development. In recent years, he published on the prevalence and management of chronic kidney disease and acute kidney injury in the United Kingdom and worldwide, on the growing importance of supportive care for end-stage kidney disease, on taking opportunities to advocating for kidney disease, and on the importance of patient-orientated outcomes in clinical research. He became Honorary Professor of Renal Medicine at the University of Manchester. He was President of the Renal Association (the UK’s professional body of nephrologists and renal scientists) from 2016–2018, having been President of the British Renal Society (representing the multiprofessional renal team) from 2000–2003. He later became chair of the patient support charity Kidney Care UK. In 2018, in the Queens Honors List, he received the Order of the British Empire for his services to kidney patients. His skills and experience were increasingly valued in UK medicine beyond nephrology, and he was Registrar of the Royal College of Physicians of London from 2018 until his death. His reputation grew beyond the United Kingdom, and his advice on the development of nephrology services was sought by other health care jurisdictions. The National Health Service initiatives to improve kidney care that he had driven were soon respected worldwide. He always recognized that the initiatives had been designed for the unique circumstances of the United Kingdom, but that their principles and the education and advocacy needed to drive through change were universal. He was a member of the expert group of the International Society of Nephrology Summit on Chronic Kidney Disease in 2017, and went on to represent International Society of Nephrology at a number of World Health Organization meetings, which were crucial in bringing kidney disease closer to the center of the noncommunicable disease agenda. In 2018, he became chair of the International Society of Nephrology Advocacy Working Group, a task ideally matched to his unique experience of interaction with governments and health system managers, his determination to ensure the patient voice remains at the center of health professional work, and his passion for advancing global kidney health in every setting. He always emphasized the importance of data (e.g., in the International Society of Nephrology Global Kidney Health Atlas, in building the advocacy case); and the unique value of digital communications, including social media, in spreading the message. Donal’s energy seemed boundless, and his love and commitment for his work and his family all-consuming. But there was a little left, which he reserved for his beloved Manchester United football club. He followed them with one-eyed enthusiasm, even inviting their famous manager Sir Alex Ferguson to open a new dialysis unit in Salford, and, engaged by Donal’s charm, he became its supporter. In 2014, the British Medical Journal published an interview with Donal that is revealing of his principles and priorities.1O’Donoghue Donal being a doctor is “a ball.”.BMJ. 2014; 349: g5497Crossref PubMed Scopus (0) Google Scholar In it, he says that being a physician is “a ball.” He was continuing to “have a ball” in nephrology right up until his sudden final illness. Many young physicians were inspired by his example, energy, mentorship, and friendship to follow him into nephrology, and found that he was correct in loving every minute of it. The lives of those with kidney disease in many parts of the world are immeasurably better for his unrelenting work on their behalf. He is survived by his wife, Marie; their 3 children, Daniel, Kathryn, and James; 4 grandchildren, whom he also adored; and his close colleagues and many friends worldwide, who will miss his warmth and generosity of spirit. We miss him not only because of what he gave us all, but because there might have been so much more. All the authors declared no competing interest.

Objectives The Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide. Setting A cross-sectional global survey. Participants Key stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included. Primary outcomes Primary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries. Results 160 countries (covering 98% of the world’s population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries. Conclusion Significant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

In 2020, the International Society of Nephrology (ISN) celebrates 60 years since its founding and first congress in 1960. The history of its development until 2010 has been well-documented.1Robinson R.R. Richet G. International Society of Nephrology: a forty year history. 1960-2000.Kidney Int Suppl. 2001; 79: S1-S100Abstract Full Text Full Text PDF PubMed Google Scholar,2Barsoum R. A mission in evolution: the International Society of Nephrology in the past 10 years—2001-2010.Kidney Int. 2011; 79: 935-943Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Since then, in the decade 2011–2020, the ISN's activities around the world have had increasing range and impact, enabling the ISN to maintain its unique role as the leading professional organization in global nephrology. The ISN's Vision and Mission, redrafted in 2018, reflect its global role in nephrology (Table 1). In the decade 2011–2020, the ISN has sought to expand its efforts in low- and middle-income countries (LMICs) while maintaining its responsibility to provide valuable benefits for all its members, including those in high-income countries.Table 1International Society of Nephrology (ISN) vision and mission from 2018VisionA future where all people have equitable access to sustainable kidney healthMissionThe ISN is a philanthropic organization dedicated to advancing worldwide kidney health. We do this for all our stakeholders by:•BRIDGING THE GAPS of available care through advocacy and collaborations with our global partners;•BUILDING CAPACITY in health care professionals via granting programs, education, and research; and•CONNNECTING OUR COMMUNITY to develop a stronger understanding of the management of kidney disease. Open table in a new tab In 2011, the ISN was supported by the Brussels-based association management company Interel. Luca Segantini was ISN Executive Director from 2009 until 2018, and in 2010, there were 8 employed staff members. In 2011, the ISN became self-managing, reducing costs and improving efficiency. The ISN has continued to be served by a highly committed, young, multilingual staff, which has grown as the ISN's activities and infrastructure relentlessly increased; currently, in 2020, the ISN has 36 staff members. Charu Malik succeeded as Executive Director in 2019. In 2011, the ISN Council had 32 elected counselors, determined using geographical boundaries little changed for 30 years. In 2016, regional boards in each of the 10 world regions were established with the goal that they be the "eyes and ears" of the ISN in each region—ensuring dissemination of key information, advising about regional contexts for new proposals, and helping to plan regional implementation. This development was followed in 2018 by a revision of the council structure; there are now only 20 counselors, the chairs and deputy chairs of each regional board. The day-to-day leadership of the ISN has devolved to be the executive committee chaired by the ISN president, and includes past-president, president-elect, secretary-general, treasurer, and executive director, with up to 4 other ISN members selected by the president. In 2017, the role of secretary-general was discontinued, since those administrative responsibilities were taken over by headquarters staff. During the decade 2011–2020, the ISN was served by 5 presidents (Figure 1), 3 secretary-generals (Adeera Levin [Canada], Ricardo Correa-Rotter [Mexico], and Robyn Langham [Australia]), and 3 treasurers (Victor Schuster, Thomas Coffman, and Stuart Shankland [all USA]). The ISN made other governance changes during the decade, including broadening membership to include allied health professionals, as well as more effective implementation of policies for equity, diversity, and inclusion. ISN membership numbers were maintained through the decade; currently in 2020, there are more than 8500 members, with an encouraging shift in the age distribution to a younger membership. Nephrologists still in training are now given free ISN membership for the first year, followed by a reduced fee until they complete training. Those in lower-middle-income countries are offered group ISN membership (2 to 5 members for 1 fee). Membership is free to all in low-income countries. A unique strength of the ISN is its network of more than 100 affiliated national and regional nephrology societies. Some of these societies sign up a proportion of their members and become Collective ISN Members at a special annual rate. In 2020, these include the nephrology societies of Australia and New Zealand, Brazil, Colombia, Canada, Netherlands, Estonia, Hong Kong, Iran, Israel, Jordan, the Philippines, Panama, Paraguay, South Africa, Spain, and Switzerland. The transforming effects of the digital era have influenced the ISN's approach to communications. The website remains a primary source of information. Regular ISN communications with the membership are focused into a fortnightly "e-blast" known as ISN Insight, keeping additional e-mail communications to a minimum for greater impact. The ISN has steadily increased its presence on social media, coordinated by the ISN's Social Media Task Force (Twitter: @ISNKidneyCare, @ISNEducation, and @worldkidneyday). The decade has seen expansion in the range and depth of ISN global efforts in education, advocacy, and research. Many ISN activities involve more than 1 of these elements, but for convenience, they are described here under these headings. The ISN is uniquely placed to have global impact in nephrology, but it does so more effectively when sharing complementary expertise and resources. The ISN has continued to partner extensively with other global and regional nephrology organizations to deliver its programs. The World Congress of Nephrology (WCN) was held in alternate years throughout the decade, moving to different regions of the world by rotation. WCN was held in Vancouver (2011), Hong Kong (2013), Cape Town (2015), Mexico City (2017), and Melbourne (2019) (Table 2). It was agreed that WCN would become an annual meeting from 2020 onward—the chosen cities so far being Abu Dhabi (2020; unfortunately cancelled because of the coronavirus pandemic), Montreal (2021), and Kuala Lumpur (2022).Table 2World Congresses of Nephrology, 2011–2019DateCityPartner societiesChair, Scientific Program CommitteeChair, Local Organizing CommitteeRegistrations2011VancouverCSNRichard Johnson (US)Adeera Levin (Canada)43002013Hong KongAPSNHKSNCarol Pollock (Australia)Philip Li (Hong Kong)58992015Cape TownAFRANSARSPierre Ronco (France)Charles Swanepoel (South Africa)36002017Mexico CitySLANHKai-Uwe Eckardt (Germany)Ricardo Correa-Rotter (Mexico)40002019MelbourneANZSNAPSNMasaomi Nangaku (Japan)Peter Kerr (Australia)3580AFRAN, African Association of Nephrology; ANZSN, Australia and New Zealand Society of Nephrology; APSN, Asian Pacific Society of Nephrology; CSN, Canadian Society of Nephrology; HKSN, Hong Kong Society of Nephrology; SARS, South African Renal Society; SLANH, Latin American Society of Nephrology and Hypertension. Open table in a new tab AFRAN, African Association of Nephrology; ANZSN, Australia and New Zealand Society of Nephrology; APSN, Asian Pacific Society of Nephrology; CSN, Canadian Society of Nephrology; HKSN, Hong Kong Society of Nephrology; SARS, South African Renal Society; SLANH, Latin American Society of Nephrology and Hypertension. Increasing emphasis at WCN is being given to the sustainability of logistics and organization; the 2019 WCN at Melbourne was completely paper-free. The proportion of registrations from within the region where WCN is being held is increasing. The WCN scientific program continues to cover most aspects of nephrology, but it has increasingly provided a focus on issues specific to the region: for example, HIV-related kidney disease and fetal–maternal kidney health issues in Cape Town in 2015, and diabetic kidney disease in Mexico City in 2017. The WCN educational program offers a solid diet of core nephrology teaching, including a renal pathology course, and there are hands-on interventional nephrology workshops. The ISN's many other activities in education, research, and advocacy, such as ISN Programs and World Kidney Day, are now showcased at WCN more clearly than they were in the past. ISN awards are presented during plenary sessions, which also include a number of ISN lectures named in honor of past ISN leaders. From 2013, the ISN instituted Pioneer Awards, given to "unsung heroes" from LMICs who have made outstanding contributions to nephrology in their own country or region (Table 3).Table 3International Society of Nephrology Pioneer Awards, 2013–2019Region2013201520172019AfricaYackoob Seedat (South Africa)Rashad Barsoum (Egypt)Hasan Abu-Aisha (Sudan)Oladipo Olujimi Akinkugbe (Nigeria)Central and Eastern EuropeMomir Polenakovic (FYR Macedonia)Vytautas Kuzminskis (Lithuania)Ayla San (Turkey)Halima Resic (Bosnia and Herzegovina)Latin AmericaNelson Mazzuchi (Uruguay)José Luis Peña (Mexico)Nestor Schor (Brazil)Edgar Sanclemente (Colombia)Middle EastTareq Suhaimat (Jordan)Berhooz Broumand (Iran)Riyad Said (Jordan)No awardaPioneer Awards were not made in 3 regions in 2019 because there were no suitable nominations.Russia and NISNatalia Tomalina (Russia)Maya Ignatova (Russia)Assiya Kanatbayeva (Kazakhstan)Valery Pilotovich (Belarus)North and East AsiaHaiyan Wang (China)Shan-yan Lin (China)Wu-Chang Yang (Taiwan)No awardaPioneer Awards were not made in 3 regions in 2019 because there were no suitable nominations.OSEAVisith Sitprija (Thailand)Zaki Morad (Malaysia)Wiguno Prodjosudjadi (Indonesia)Supat Vanichkarn (Thailand)South AsiaVidya Acharya (India)Adibul Hasan Rizvi (Pakistan)Harun-Ur-Rashid (Bangladesh)No awardaPioneer Awards were not made in 3 regions in 2019 because there were no suitable nominations.FYR, former Yugoslav Republic; NIS, newly independent states; OSEA, Oceania and South East Asia.a Pioneer Awards were not made in 3 regions in 2019 because there were no suitable nominations. Open table in a new tab FYR, former Yugoslav Republic; NIS, newly independent states; OSEA, Oceania and South East Asia. The ISN's Forefronts meetings were focused on topics typically of most interest to laboratory researchers. Seven Forefronts meetings were held during the decade (Table 4). The ISN was a net investor to ensure the scientific success of each Forefronts meeting, which typically did not draw in substantial external financial sponsorship.Table 4International Society of Nephrology Nexus, Forefronts, and Frontiers Meetings, 2011–2020Meeting and yearTopicVenueRegistrationsNexus September 2012Bone and the kidneyCopenhagen, Denmark678 April 2014New era of drug discovery and clinical trials in kidney diseaseBergamo, Italy316 September 2014Hypertension and the kidneyBrisbane, Australia143 April 2016Translational immunology in kidney diseaseBerlin, Germany213Forefronts June 2012Systems biology and the kidneyAnn Arbor, USA119 October 2012Tubulointerstitial disease in diabetic nephropathyMelbourne, Australia126 September 2013Stem cells and regeneration in the kidneyFlorence, Italy92 March 2014Intrinsic regulation of kidney functionCharleston, USA78 September 2014Genetic basis of renal diseaseBoston, USA106 October 2015Immunomodulation of cardio-renal functionShenzhen, China181 September 2016The metabolome and microbiome in kidney diseaseSan Diego, USA99Frontiers February 2018Kidney disease and cardiovascular diseaseTokyo, Japan1584 October 2020Complement-related kidney diseases: classification, genetics, and treatmentBergamo, ItalyIn preparation Open table in a new tab Nexus meetings focused on topics with an established bench-to-bedside spectrum of work, to provide a "nexus" for interaction between laboratory and clinical investigators and clinicians in a series of meetings characterized by plenary discussion across the whole gamut from disease mechanisms to clinical care and therapeutics. Four Nexus meetings were held during the decade (Table 4). As time passed, the distinction between topics suitable for Nexus or Forefronts blurred, and beginning in 2016, they were amalgamated into a new meeting series, ISN Frontiers (Table 4). During this decade, Kidney International (KI) remained ISN's flagship journal. Editors-in-chief were Qais Al-Aqwati (2005–2011), Detlef Schlöndorff (2011–2018), and Pierre Ronco (2018–). The editorial office for KI remained at Washington University, St. Louis, Missouri, USA, under Executive Editor Pat Morrissey. KI's impact factor grew from 6.5 in 2010, and in 2018, its 5-year impact factor was 8.6, placing it third among nephrology journals. KI Supplements provide a parallel opportunity for focused publications, such as Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines or meeting proceedings, sometimes with publication costs met by commercial sponsorship. A decade-long contract for KI with Nature Publishing Group expired in 2015, and a new 10-year contract was signed with Elsevier. An open-access, exclusively online journal, KI Reports, was launched in 2016 with Jai Radhakrishnan (USA) as Editor-in-Chief, and Radha McLean as Executive Editor. KI Reports publishes original research and educational content related to kidney disease, and it encourages submission of original research from LMICs. The ISN developed an online educational offering launched in 2011 as ISN Education and known from 2017 as ISN Academy.3International Society of NephrologyISN Academy.https://www.theisn.org/education-external/isn-academyDate accessed: April 16, 2020Google Scholar There has been a rapid accumulation of varied content, including talks streamed from ISN meetings, podcasts, cases and images, guidelines, and webinars. ISN Academy is distinctive in containing much material that is particularly relevant to emerging nephrology in LMICs. Currently in 2020, the ISN Academy contains some 8000 hours of educational content in 7 languages, attracting around 1000 visitors each month. The ISN's unique capacity-building programs fill important gaps in places with the greatest need and bring global recognition and respect to the society. The 5 programs available only to applicants from LMICs are Fellowships, Continuing Medical Education, Sister Renal Centers, Educational Ambassadors, and Clinical Research (including the ISN Scientific Writing Course).4International Society of NephrologyPrograms: education, training & research.https://www.theisn.org/programsDate accessed: April 16, 2020Google Scholar These were known since 2009 as ISN-GO (Global Outreach), and since 2014 as ISN Programs. Through the collective effort of these capacity-building programs, the ISN has contributed to the growth of kidney care services in large parts of sub-Saharan Africa and South and South East Asia and helped establish long-term partnerships that have endured beyond the term of ISN support. Qualitative feedback about the programs is strongly positive, and efforts continue to quantify their impact.5Feehally J. Brusselmans A. Finkelstein F.O. et al.Improving global health: measuring the success of capacity building programs: a view from the International Society of Nephrology.Kidney Int Suppl. 2016; 6: 42-51Abstract Full Text Full Text PDF Scopus (29) Google Scholar In recent years, some 40% of ISN fellowships have been awarded for training within the recipient's region, rather than in host centers in a developed country. Such in-region training ensures relevant clinical experience, minimizes language and cultural disparities, and has reduced the concern that fellows who go to high-income countries will find attractive career opportunities there and never return home. For example, since 2010, more than 90% of fellows from sub-Saharan Africa, who have trained in centers in South Africa, have returned home. One reason for the change in emphasis toward supporting fellowship training within region is the increasing number of centers in LMICs with the expertise and capacity to provide such training, several of which have graduated from the Sister Renal Center Program. Since 2016, ISN has recognized the best of these, 9 throughout the world, as ISN Regional Training Centers (Table 5).Table 5International Society of Nephrology Regional Training Centers from 2016RegionCenterAfricaRed Cross Children's Hospital, Cape Town, South AfricaGroot Schuur Hospital, Cape Town, South AfricaEastern and Central EuropeNephrology Department, Hospital of Lithuanian University of Health Sciences, Kaunas, LithuaniaLatin AmericaDepartment of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, MexicoFundacion Valle de Lili, Cali, ColombiaNewly Independent States and RussiaNational Center of Nephrology and Renal Replacement Therapy, Minsk, BelarusNorth and East AsiaInstitute of Nephrology, Peking University, Beijing, ChinaDivision of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, ChinaNational Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing, ChinaSouth AsiaDepartment of Pediatric Nephrology, St. John's Medical College Hospital, Bangalore, India Open table in a new tab A recent feature of the Sister Renal Center Program is "trios"—center pairs that have "graduated" and in turn support another emerging center. A Sister Transplant Center Program was also established in 2013 in partnership with The Transplantation Society. Among many notable successes, one Sister Transplant Center has successfully established a kidney transplant program in Palestine, West Bank. The ISN supports speakers to attend continuing medical education meetings in LMICs for which the program has been developed to meet local needs. These programs increasingly include practical skills training (e.g., in interventional nephrology). Local organizers provide opportunities for visits to hospitals and teaching ward rounds and meetings with local health leaders. Support is also being given to larger regional meetings, which affords opportunities for not only education but also strategic discussions among nephrology leaders in the region. The first of these were held in West Africa and East Africa in 2018. In the Educational Ambassador Program, experts undertake short visits to an emerging center to support development of an aspect of clinical care (e.g., renal pathology or vascular access care). The expert can be accompanied by supporting personnel (e.g., a nurse or technician). Many of these visits lead to longer-term mentorship. Some of the investigators who receive funding through the Clinical Research Program are now offered training in critical evaluation, data analysis, and writing through the residential ISN Scientific Writing Course, first held in Bangalore, India in 2018 and 2019 (where it was co-funded by the ISN and the American Nephrologists of Indian Origin) and now being given in other regions. The ISN's Renal Disaster Relief Task Force works in partnership with Médecins Sans Frontières (Doctors Without Borders) to rapidly deploy clinical teams that can institute measures to prevent acute kidney injury (AKI), facilitate acute dialysis, and support those already on chronic dialysis. The last major earthquake requiring Renal Disaster Relief Task Force deployment was in Port au Prince, Haiti in 2011. Local nephrology services within the affected country or its regional neighbors increasingly have capacity to handle such crises, and the Renal Disaster Relief Task Force is shifting its emphasis toward supporting local and national disaster preparedness plans. Recognizing the lack of data on patients with kidney disease in LMICs, the ISN SharE-RR (SHARing Expertise to support the set-up of Renal Registries) was established in 2017 to develop resources to support the development of renal registries in LMICs. Starting in 2012, the Saving Young Lives Program—a partnership of the ISN, the International Pediatric Nephrology Association, the International Society for Peritoneal Dialysis, and EuroPD—established "proof of principle" that sustainable acute peritoneal dialysis programs treating adults and children with AKI can be developed and maintained in very-low-resource settings through education, training, and mentorship.6Smoyer W.E. Finkelstein F.O. McCulloch M.I. et al."Saving Young Lives" with acute kidney injury: the challenge of acute dialysis in low-resource settings.Kidney Int. 2016; 89: 254-256Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar The clinical approach is based on the International Society for Peritoneal Dialysis clinical practice guideline for acute peritoneal dialysis,7Cullis B. Abdelraheem M. Abrahams G. et al.Peritoneal dialysis for acute kidney injury.Perit Dial Int. 2014; 34: 494-517Crossref PubMed Scopus (178) Google Scholar which emphasizes when necessary the utility of locally produced, low-cost peritoneal dialysis fluid and improvised peritoneal dialysis catheters. In 2013, ISN President Giuseppe Remuzzi launched the 0by25 initiative with the goal of reducing avoidable deaths from AKI to zero by 2025.8Mehta R.L. Cerdá J. Burdmann E.A. et al.International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology.Lancet. 2015; 385: 2616-2643Abstract Full Text Full Text PDF PubMed Scopus (754) Google Scholar Projects were developed to increase knowledge and awareness of AKI9Mehta R.L. Burdmann E.A. Cerdá J. et al.Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study.Lancet. 2016; 387: 2017-2025Abstract Full Text Full Text PDF PubMed Scopus (281) Google Scholar and develop practical interventions for low-resource settings. Starting in 2017, an 0by25 project (Macedo EM, Sharma SK, Hemmila U, et al. Risk factors and definition of kidney dysfunction in the community setting: The ISN 0BY25 Initiative [abstract]. Kidney Int Rep. 2019;4:S79) evaluated the feasibility of improving AKI detection and management of AKI in the community in LMICs using a symptom-based risk score and point-of-care serum creatinine testing, supported by education and training. Its generalizability into routine practice in LMICs is now being evaluated. As the year 2025 approaches, the ISN is focused on showing measurable progress toward the original 0by25 challenge of zero avoidable deaths, even though this will not be fully achieved by 2025. During the presidency of Adeera Levin (2015–2017), she developed an additional emphasis on the growing challenge of CKD as a noncommunicable disease that is increasingly prevalent but of which there is variable awareness among health policymakers. Country-by-country information about expertise and access to care, as well as relevant health policy, is now available in the ISN Global Kidney Health Atlas, first published in 2017, with a second edition in 2019 that collected data from 160 countries.10International Society of NephrologyGlobal Kidney Health Atlas.https://www.theisn.org/all-articles/665-global-kidney-health-atlasDate accessed: April 16, 2020Google Scholar Sequential information can now be used to monitor progress, and where necessary, provide challenge to health systems that lag in delivering care. The ISN's first global health summit to review these issues was held in Vancouver in 2016, leading to a "road map" providing recommendations on closing gaps in care, research, and policy.11Levin A. Tonelli M. Bonventre J. et al.Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy.Lancet. 2017; 390: 1888-1917Abstract Full Text Full Text PDF PubMed Scopus (644) Google Scholar During the presidency of David Harris (2017–2019), he led an effort to provide additional emphasis on the worldwide challenges of end-stage kidney disease care. Few countries, even high-income countries, have truly integrated end-stage kidney disease care, including renal replacement therapy by dialysis and transplantation, and conservative care. To address these disparities, the ISN held its second global health summit in Sharjah, United Arab Emirates in 2018, which produced an action plan for progress.12Harris D.C.H. Davies S.J. Finkelstein F.O. et al.Increasing access to integrated ESKD care as part of universal health coverage.Kidney Int. 2019; 95: S1-S33Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar The ISN does not have the resources to be a major research funder, but in this decade, it has developed projects through which the ISN's global networks and influence can best be used to support renal research worldwide. ISN—Advancing Clinical Trials works to improve the clinical trials capacity of the global nephrology community through networking and training, and by standardizing high-quality trial conduct. This group provides a monthly inventory of important clinical trials, which is published on the ISN Academy website. The ISN—International Network of CKD Cohort Studies has built a network of existing CKD cohort studies from across the world; the network currently contains more than 20 cohorts from 6 continents, and it has already published 2 meta-analyses. The ISN has developed the International Consortium of CKDu Collaborators (i3C), bringing together many voices to promote better understanding of the epidemics of CKD of uncertain origin (CKDu), which are occurring in poor agricultural communities in equatorial LMICs, such as Sri Lanka and countries in Central America. In 2011, the ISN led advocacy efforts to ensure that the political declaration that emerged from the United Nations and World Health Organization High-Level Meeting on Noncommunicable Disease recognized the impact of kidney disease on worsening health outcomes. In 2012, the ISN came into "official relations" with the World Health Organization and now provides regular input into its policy discussions on kidney disease and health. The World Health Organization has commissioned the ISN to develop guidance on establishing chronic dialysis programs in low-resource settings. The ISN has established regional policy forums held during WCN, first in Mexico City in 2017, then in Melbourne in 2019. Representatives of health professionals, patients, and policymakers assemble to address issues related to kidney health in the region and seek commitments from health ministers to policy change and investment to address gaps in care. The first 2 forums produced substantial statements of intent, including a set of 12 recommendations to improve kidney health.13International Society of NephrologyGlobal Kidney Policy Forum Series: Focus on Latin America.https://www.theisn.org/images/Policy_Forum_8_pager_DEF_26072017_interactive_jh_aug_9.pdfDate accessed: June 21, 2020Google Scholar,14International Society of NephrologyGlobal Kidney Policy Forum Series: Focus on South East Asia and Oceania.https://www.theisn.org/advocacy#policy-papers-publicationsGoogle Scholar The ISN played a key role in partnership with The Transplantation Society in the 2008 Declaration of Istanbul against organ trafficking and transplant tourism and for the promotion of ethical transplant practices. A joint ISN and The Transplantation Society Declaration of Istanbul Custodian Group continues to challenge, through local professional societies and governments, any re-emergence of unacceptable transplant practices. World Kidney Day was throughout the decade a successful advocacy opportunity. It continued to be a partnership between the ISN and the International Federation of Kidney Foundations. Various aspects of kidney health were chosen as themes year by year. In 2020, there were World Kidney Day events in 99 countries worldwide, and the web and social media visibility of World Kidney Day continues to increase. The ISN's range and depth of work has grown remarkably in this decade. The ISN has maintained its relevance for kidney professionals worldwide with a special focus on LMICs.

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes — many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.

Immunosuppression in IgA nephropathy (IgAN) should be reserved for patients at high-risk of disease progression, which KDIGO guidelines determine based solely on proteinuria 1g or more/day. To investigate if treatment decisions can be more accurately accomplished using individualized risk from the International IgAN Prediction Tool, we simulated allocation of a hypothetical immunosuppression therapy in an international cohort of adults with IgAN. Two decision rules for treatment were applied based on proteinuria of 1g or more/day or predicted risk from the Prediction Tool above a threshold probability. An appropriate decision was defined as immunosuppression allocated to patients experiencing the primary outcome (50% decline in eGFR or ESKD) and withheld otherwise. The net benefit and net reduction in treatment are the proportion of patients appropriately allocated to receive or withhold immunosuppression, adjusted for the harm from inappropriate decisions, calculated for all threshold probabilities from 0-100%. Of 3299 patients followed for 5.1 years, 522 (15.8%) experienced the primary outcome. Treatment allocation based solely on proteinuria of 1g or more/day had a negative net benefit (was harmful) because immunosuppression was increasingly allocated to patients without progressive disease. Compared to using proteinuria, treatment allocation using the Prediction Tool had a larger net benefit up to 23.4% (95% confidence interval 21.5-25.2%) and a larger net reduction in treatment up to 35.1% (32.3-37.8%). Thus, allocation of immunosuppression to high-risk patients with IgAN can be substantially improved using the Prediction Tool compared to using proteinuria.

Substantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. The implementation and oversight of basic standards of care requires sufficient infrastructure and appropriate workforce and financial resources to support the basic levels of care and safety practices. It is important to understand how these standards then can be reasonably adapted and applied in low- and lower-middle-income countries.

A large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one-half to three-quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that >3 million people in the world died each year because they could not access KRT. This review discusses the reasons for the differences in treated and untreated ESKD and KRT modalities and outcomes and presents strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes.

Chronic kidney disease (CKD) affects approximately 11% to 13% of people worldwide and is associated with catastrophic economic expenditure. 1 Hill N.R. Fatoba S.T. Oke J.L. et al. Global prevalence of chronic kidney disease: a systematic review and meta-analysis. PLoS One. 2016; 11: e0158765 Crossref PubMed Scopus (2216) Google Scholar Although global variations in the burden of kidney disease, related care practices, and their health outcomes have been reported in adults, 2 Crews D.C. Bello A.K. Saadi G. Burden, access, and disparities in kidney disease. Arch Argent Pediatr. 2019; 117: e243-e251 Google Scholar data describing the global capacity to deliver kidney replacement therapies (KRT), dialysis, and kidney transplantation) for children have never previously been described, to our knowledge. The present study reports current disparities in ESKD care between children and adults around the world, along with the barriers to achieving equity for children, based on the findings of the 2018 International Society of Nephrology Global Kidney Health Atlas (GKHA) survey. 3 Bello A.K. Levin A. Lunney M. et al. Global Kidney Health Atlas: A report by the International Society of Nephrology on the global burden of end-stage kidney disease and capacity for kidney replacement therapy and conservative care across world countries and regions. International Society of Nephrology, Brussels, Belgium2019 Google Scholar