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Nine kidney disease research breakthroughs from 2023.

2023 was a big year for the nephrology (kidney) research field. From developments in organ transplant options to a new understanding of kidney disease risk, it can be challenging to keep up with it all. Fortunately, the American Kidney Fund (AKF) has been keeping tabs on these headlines for you. 

Here are nine of the biggest headlines from the nephrology research field from 2023.

Breakthrough #1: New atlas of human kidney cells to help unlock kidney disease research | National Institutes of Health (NIH)

In July, the National Institutes of Health (NIH) announced it had created a "comprehensive atlas of the human kidney." By comparing cells from healthy kidneys to those from diseased or injured kidneys, researchers created a "map" or model of the human kidney. This model was created as part of the Kidney Precision Medicine Project (KPMP) with support from NIH's National Institute of Diabetes and Digestive and Kidney Disease. The goal of precision medicine — and the kidney model — is to create new drugs and treatments that target the specific cause of a disease. Not all kidney diseases or acute kidney injuries affect the kidneys in the same way and this model will help scientists to better treat or prevent different types of kidney disease. 

Breakthrough #2: Report redefines overlapping risks of heart and kidney diseases | American Heart Association

The American Heart Association (AHA) submitted a presidential advisory defining and officially declaring  cardiovascular-kidney-metabolic (CKM) syndrome as a specific health condition. This condition acknowledges the overlap between cardiovascular (heart) disease, kidney disease, type 2 diabetes and obesity, breaking the condition into different stages with prevention and treatment guidelines for each stage. Find out more about what experts describe as a paradigm change in this AKF blog post .

Breakthrough #3: Feasibility of an implantable bioreactor for renal cell therapy using silicon nanopore membranes | Nature Communications

The Kidney Project — a national research project led by the University of California San Fransisco to create a bioartificial kidney — announced progress this year. The plan for the implantable device includes two key parts: (1) a bioreactor and (2) a hemofilter. The hemofilter will filter the blood to remove waste and toxins. However, the kidney performs other important functions for the body, too, including managing the level of certain hormones and reabsorbing water and other needed nutrients after the blood has been filtered. The bioreactor will perform these critical jobs, using a combination of kidney cells and silicone membranes. In August, the Kidney Project researchers published their findings that they had successfully implanted the bioreactor in healthy pigs. The next step would be FDA trials, first in animals and eventually in humans.

Breakthrough #4: Pig kidney works a record 2 months in donated body, raising hope for animal-human transplants | AP News

The University of Alabama at Birmingham (UAB) successfully transplanted a genetically modified pig kidney for the first time in August 2023 , which functioned as a healthy human kidney would for the seven days of the study. The New York University (NYU) Langone Health hospital also transplanted a pig kidney into the body of a brain-dead man, Maurice "Mo" Miller, which survived for two months . This is the longest a pig kidney has functioned in a human body to date and scientists are hopeful this may mean they can eventually begin trials to transplant one into a living human.

Breakthrough #5: Global Coalition on Aging Finds Chronic Kidney Disease A Troubling Blind Spot Among Chronic Diseases in the US - Global Coalition On Aging

The Global Coalition on Aging (GCOA), the World's Leading Business Voice on Aging, conducted a survey of 1,000 Americans 18 years and older and discovered a surprising lack of awareness and understanding about chronic kidney disease. Despite the growing rate of kidney disease in U.S., over half of the participants (58%) had no awareness of the disease at all. Even respondents who regularly saw doctors did not have an awareness of the disease. GCOA recommended several steps to increase awareness, some of which AKF has already undertaken — including bringing stakeholders together to discuss concerns within the kidney community .

Breakthrough #6: Millions of lives and billions of dollars: the need for earlier intervention in chronic kidney disease (medicaleconomics.com)

As part of the Patient Access Initiative (PAI), AKF published a white paper called "Reimagining Kidney Care: From Crisis to Opportunity," that examines the dire kidney disease trends in the U.S. The paper also highlights the potential benefits of creating policies that prioritize "upstream care." Upstream care is an approach to health care that puts an emphasis on addressing the root of a medical problem rather than the symptoms. It focuses on earlier detection and intervention of a disease rather than treating it once it has become more advanced. The paper shows how this approach could have benefits for Americans' health and its economy.  Find out more in this AKF blog post . 

Breakthrough #7: New Non-Invasive Test Uses AI and Retinal Scans To Accurately Predict Risk of Chronic Kidney Disease | AP News

A new noninvasive retinal scan that uses an artificial intelligence (AI) deep learning algorithm called Reti-CKD "showed superior prediction of future CKD risk compared to the conventional [estimated glomerular filtration rate (eGFR)] or urine test." The test can accurately predict kidney disease risk because the kidneys and retina (the light-sensitive layer of eye tissue innermost in the eye and is an extension of the brain) have similar micro blood vessels. Concerns about the micro blood vessels in the retina, therefore, can be predictive of possible problems with the micro blood vessels in the kidneys, putting the person at greater risk for kidney disease. 

Breakthrough #8: Risk Calculator for Early-Stage CKD May Soon Enter US Market (medscape.com)

Dr. Naveep Tangri, a nephrologist and professor at the University of Manitoba, is the founder of Klinrisk, Inc., a company that is developing and commercializing a new predictive tool for kidney disease called the  Klinrisk model . Using 20 lab-measured variables from routinely ordered tests, it can predict the risk of an adult with early-stage CKD developing either a 40% or greater drop in eGFR or kidney failure. Since the Klinrisk model uses information from tests a primary care doctor may already give, Dr. Tangri says it is ready for any health system, insurance company or clinic to implement.

Breakthrough #9: Exercise during hemodialysis improved physical function of patients with kidney failure

A study  found that, after 12 months, patients who participated in endurance and resistance exercises during their hemodialysis treatments had improved physical function compared to those receiving standard treatment. The study included 917 patients and found that those who did the exercises during dialysis also reported an improved quality of life and had fewer hospitalizations.

While there is no cure for kidney disease, there are ways to manage or treat it and 2023 had several exciting new developments in the advancement of drugs to treat kidney disease. These developments include FDA approvals for: 

• A  drug to slow down the decline of eGFR in people with kidney disease
• A  phosphate absorption inhibitor drug
• The  first fully-FDA-approved treatment for a rare kidney disease called IgA nephropathy  

Furthermore, a study showed overwhelmingly positive results that the active ingredient in a diabetes treatment and a weight loss drug did not further damage the heart or kidneys . Advancements like these are critical to helping the millions of people living with kidney disease manage or slow down the progression of the disease, and hopefully avoid reaching kidney failure.

You can find more headlines from throughout the year on our Renal news round up page .

We hope to see even more progress in the kidney disease research and treatment space in 2024!

Filed under

• Kidney disease
• Kidney failure
• Kidney transplant

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Publication

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• Even Low Levels of Albumin in Urine Tied to Worsened Kidney Disease JAMA News April 19, 2024 Reproductive Health Full Text | pdf link PDF free

This cohort study examines the association of incident use of tumor necrosis factor (TNF) inhibitors with subsequent decline in kidney function and risk of all-cause mortality among patients with new-onset inflammatory bowel disease (IBD).

This cluster randomized clinical trial examines the effectiveness of an electronic health record–based population health management intervention vs usual care for reducing chronic kidney disease progression.

This review summarizes current evidence regarding the diagnosis, treatment, and prognosis of systemic lupus erythematosus.

This prognostic study investigates if models that incorporate routinely collected clinical and laboratory information can predict morbidity and mortality in patients with heart failure and preserved ejection fraction.

This Review discusses the selection, creation, and maintenance of arteriovenous access for hemodialysis for patients with kidney failure.

This randomized clinical trial evaluates a computerized clinical decision support system for the management of uncontrolled hypertension in patients with chronic kidney disease.

This cross-sectional study calculates deceased kidney donation rates in the US using deaths compatible with donation as the metric’s denominator.

This cohort study examines the association of facility-level patient care technician staffing with outcomes among patients receiving in-center hemodialysis.

This cohort study examines the association of kidney function and acute kidney disease severity with adverse outcomes in patients with dialysis-requiring acute kidney injury.

• Dialysis-Dependent Acute Kidney Injury—A Risk Factor for Adverse Outcomes JAMA Network Open Opinion March 8, 2024 Critical Care Medicine Reproductive Health Renal Replacement Acute Kidney Injury Full Text | pdf link PDF open access

This systematic review describes representation of adults with chronic kidney disease (CKD) in randomized clinical trials for antithrombotic, antihypertension, glucose-lowering, and cholesterol-lowering drugs from 2000 to 2021.

This Viewpoint discusses whether select patient populations may benefit from de-escalation rather than escalation of systemic therapy for kidney cancer.

• Better Outcomes When Kidney Damage Is From COVID-19 JAMA News March 6, 2024 Coronavirus (COVID-19) Reproductive Health Full Text | pdf link PDF

This systematic review and meta-analysis assesses bias and accuracy in glomerular filtration rate estimating equations across various adult populations in the US.

This cohort study compares anemia incidence between sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among patients with type 2 diabetes and chronic kidney disease (CKD) stages 1 to 3 in Taiwan.

This cohort study examines the occurrence of limb loss and mortality in patients with diabetic foot ulcers who are undergoing dialysis who have vs have not received preventive care by podiatrists.

This cohort study investigates the association of income-based disparity with impaired kidney function among a working population in a country with universal health care.

This qualitative study examines the transplant experience among kidney transplant recipients of undocumented immigration status who previously relied on emergency hemodialysis and their family caregivers.

• Learning From the Experiences of Undocumented Immigrant Kidney Transplant Recipients—From Exceptional Individuals to Equitable Systems JAMA Network Open Opinion February 29, 2024 Surgery Transplantation Health Policy Health Inequities Equity, Diversity, and Inclusion Full Text | pdf link PDF open access

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ACUTE AND CHRONIC KIDNEY DISEASE

APOL1 variant reduces risk of kidney disease in individuals with high-risk APOL1 genotypes (October 2023)

Two different polymorphisms in the apolipoprotein L1 (APOL1) gene, termed G1 and G2, are common in individuals of West African descent and confer a high risk of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) when inherited in an autosomal recessive fashion (ie, G1/G1, G1/G2, or G2/G2). In a study of over 150,000 individuals of African ancestry in one primary and two replication cohorts, the increased risk of CKD and ESKD associated with high-risk APOL1 genotypes was completely abrogated in those who also had a different APOL1 mutation, p.N264k [ 1 ] . In addition, in vitro functional studies in cell models showed that APOL1 p.N264k reduced toxicity of high-risk APOL1 genotypes. These data contribute to our understanding of the epidemiology of kidney disease and support ongoing research into novel drugs that mimic the activity of APOL1 p.N264k. (See "Epidemiology of chronic kidney disease", section on 'Apolipoprotein L1 in African Americans' .)

Prior abdominal surgery and successful peritoneal dialysis (March 2024)

Many patients with end-stage kidney disease and a history of abdominal surgery are not viewed as candidates for peritoneal dialysis (PD) because postoperative peritoneal adhesions may prevent successful PD. In a retrospective cohort study of over 850 patients undergoing their first PD catheter insertion who were followed for a median of 12 months, patients with a history of abdominal surgery had a similar incidence of complications leading to abandonment of the catheter, or to interruption or termination of PD, as that of patients without such a history (22 and 18 percent, respectively) [ 2 ]. These and other data suggest that prior abdominal surgery should not be considered a contraindication to PD and support our individualized approach to PD in such patients. (See "Evaluating patients for chronic peritoneal dialysis and selection of modality", section on 'Peritoneal scarring' .)

Increasing advance care planning for patients on dialysis (February 2024)

Although patients on dialysis have high morbidity and mortality, advance care planning (ACP) is often not well integrated into the care of this population. In a cluster randomized trial conducted in 42 dialysis clinics that included nearly 430 patients on dialysis paired with a surrogate decision-maker, patient-surrogate pairs received either a 45- to 60-minute ACP discussion led by a dialysis clinic health care worker (eg, registered nurse or social worker) or usual care [ 3 ]. After two weeks, patient-surrogate pairs in the ACP group had greater congruence on end-of-life care goals and lower patient decisional conflict compared with those in the usual care group. Strategies that involve patient caregivers and dialysis unit staff can increase uptake of ACP among patients on dialysis. (See "Kidney palliative care: Principles, benefits, and core components", section on 'Advance care planning' .)

Lack of efficacy of insomnia therapies for patients on dialysis (February 2024)

Although insomnia may affect nearly half of patients on dialysis, relatively few studies have evaluated the efficacy of commonly used insomnia therapies in this population. In a trial in which over 120 patients on hemodialysis with insomnia were randomly assigned to treatment with cognitive behavior therapy for insomnia (CBT-I), trazodone , or placebo for six weeks, there were no significant differences in the change in Insomnia Severity Index scores from baseline among the three groups after 7 or 25 weeks, but serious cardiovascular events were more frequent in the trazodone group [ 4 ]. The inclusion of patients with obstructive sleep apnea and other factors may have masked a potential benefit of CBT-I. Based on these data and previous studies reporting associations between the use of hypnotic medications and adverse outcomes in patients on dialysis, we prefer nonpharmacologic therapy for the treatment of insomnia in patients with end-stage kidney disease; more studies are needed to delineate the role of CBT-I in these patients. (See "Sleep disorders in end-stage kidney disease", section on 'Treatment' .)

Severe hypocalcemia with denosumab therapy in dialysis-treated patients (February 2024)

Denosumab use is not restricted in individuals with osteoporosis who have advanced kidney disease. However, concerns remain regarding the risk of severe hypocalcemia in such patients. In a cohort study of 2804 female patients (aged ≥65 years) with osteoporosis and undergoing dialysis, severe hypocalcemia (serum calcium <7.5 mg/dL [1.9 mmol/L] or hypocalcemia requiring emergency care) occurred in a higher proportion of patients who initiated denosumab compared with those who initiated an oral bisphosphonate (12-week weighted cumulative incidence 41.1 versus 2 percent, respectively) [ 5 ]. Denosumab also was associated with a higher incidence of very severe hypocalcemia (serum calcium <6.5 mg/dL [1.6 mmol/L]). A boxed warning about risk of severe hypocalcemia in individuals with advanced kidney disease, especially patients on dialysis, has been added for brand name denosumab (Prolia) [ 6 ], underscoring the need for greater caution and increased monitoring during treatment. (See "Denosumab for osteoporosis", section on 'Hypocalcemia' .)

Taurolidine catheter locks for the prevention of hemodialysis catheter-related bloodstream infections (December 2023)

Catheter-related bloodstream infections (CRBSIs) are an important cause of morbidity and mortality in patients on hemodialysis. In a randomized trial of nearly 800 patients on maintenance hemodialysis via a tunneled central venous catheter, a catheter lock solution containing taurolidine, an antimicrobial agent, plus heparin reduced the incidence of CRBSI compared with a heparin control lock solution (2 versus 8 percent) over a mean of 200 days [ 7 ]. No trial participants used chlorhexidine-coated catheter caps, which are commonly used to reduce the risk of CRBSI. Based on these results, taurolidine lock solutions are a reasonable alternative to chlorhexidine-coated catheter caps to help prevent CRBSIs in select patients. (See "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention", section on 'Methods we use' .)

Tenapanor for refractory hyperphosphatemia in patients on dialysis (November 2023)

Despite adequate dialysis, dietary restriction, treatment of hyperparathyroidism, and phosphate binders (PBs), hyperphosphatemia is common among patients on dialysis and associated with adverse outcomes. In a trial in which nearly 170 patients on hemodialysis with hyperphosphatemia despite PB therapy were randomly assigned to PBs plus either tenapanor (an inhibitor of intestinal sodium/hydrogen exchanger 3) or placebo for eight weeks, serum phosphorus levels were 1.76 mg/dL lower in the tenapanor group [ 8 ]. Diarrhea was more frequent among patients receiving tenapanor but was mild or moderate in all cases. These data, in conjunction with prior trial data, support our approach of using tenapanor as add-on therapy in patients on dialysis who have an inadequate response to PBs. (See "Management of hyperphosphatemia in adults with chronic kidney disease", section on 'Refractory hyperphosphatemia' .)

FLUID, ELECTROLYTES, AND ACID-BASE BALANCE

Veverimer and chronic kidney disease progression in patients with metabolic acidosis (March 2024)

In patients with chronic kidney disease (CKD) and metabolic acidosis, alkali therapy may slow the decline in kidney function. In a trial in which nearly 1500 patients with CKD and metabolic acidosis were randomly assigned to veverimer (an investigational gastrointestinal acid binder that increases serum bicarbonate) or placebo, 20 percent of patients in each group had CKD progression at two years, defined as a ≥40 percent decline in estimated glomerular filtration rate (eGFR), kidney failure, or death from kidney disease [ 9 ]. However, because of an unexpected increase in serum bicarbonate in the placebo arm, the separation in serum bicarbonate concentration between the two groups during the trial was minimal (approximately 1 mEq/L), and therefore this trial could not address whether correction of metabolic acidosis delays progression of CKD. We continue to suggest alkali therapy in patients with CKD and metabolic acidosis. (See "Pathogenesis, consequences, and treatment of metabolic acidosis in chronic kidney disease", section on 'Choice of therapy' .)

Diagnosis of arginine vasopressin deficiency (central diabetes insipidus) versus primary polydipsia (February 2024)

It can be difficult to distinguish arginine vasopressin deficiency (AVP-D) from primary polydipsia in patients who present with polyuria and polydipsia; if reliable plasma copeptin measurements are available, these two disorders can be differentiated by measuring plasma copeptin after hypertonic saline infusion (to induce hypernatremia) or after intravenous arginine infusion. In a trial that compared both approaches, the diagnostic accuracy was higher when combining copeptin measurement with hypertonic saline infusion as compared with arginine infusion (96 versus 74 percent) [ 10 ]. Despite the superior accuracy of hypertonic saline infusion, the response to arginine infusion can be used as the initial test because it is easier to perform, generally preferred by patients, and highly accurate if the postarginine copeptin level remains below 3 pmol/L (which is specific for AVP-D) or rises above 5.2 pmol/L (which is highly specific for primary polydipsia). If the postarginine copeptin level is intermediate, then hypertonic saline infusion can be performed. (See "Evaluation of patients with polyuria", section on 'If water restriction is nondiagnostic' .)

GLOMERULAR DISEASE AND VASCULITIS

Sibeprenlimab for IgA nephropathy (December 2023)

A Proliferation-Inducing Ligand (APRIL) is critical for mucosal B cell survival, maturation, and proliferation and has been implicated in the pathogenesis of IgA nephropathy (IgAN). The efficacy and safety of sibeprenlimab, an investigational monoclonal antibody against APRIL, were evaluated in a phase II trial in which over 150 patients with IgAN and persistent proteinuria despite optimized supportive care were randomly assigned to intravenous sibeprenlimab (2, 4, or 8 mg/kg body weight) or placebo once monthly for 12 months [ 11 ]. At 12 months, patients receiving sibeprenlimab had a greater, dose-dependent reduction in proteinuria; rates of serious adverse events were similar among the treatment groups. A larger phase III trial is in progress. (See "IgA nephropathy: Treatment and prognosis", section on 'Investigational agents' .)

Sparsentan in patients with IgA nephropathy (December 2023)

Patients with IgA nephropathy (IgAN) generally receive a renin-angiotensin system (RAS) inhibitor to reduce proteinuria, but proteinuria may persist despite maximally tolerated therapy. The efficacy and safety of sparsentan , a dual angiotensin II receptor and endothelin-1 receptor antagonist, were evaluated in a phase 3 trial in which over 400 adults with IgAN and persistent proteinuria despite three months of optimized supportive care were randomly assigned to sparsentan or irbesartan once daily [ 12,13 ]. At week 110, patients receiving sparsentan had a greater reduction in proteinuria and a smaller decline in two-year estimated glomerular filtration rate (eGFR) chronic slope; while rates of serious adverse events were similar between the groups, hypotension, dizziness, and acute kidney injury were more frequent with sparsentan. We consider sparsentan as an alternative option to reduce proteinuria in patients with IgAN and persistent proteinuria ≥1 g/day despite optimal treatment with an RAS inhibitor and a sodium-glucose cotransporter 2 (SGLT2) inhibitor for at least three to six months. (See "IgA nephropathy: Treatment and prognosis", section on 'Dual endothelin angiotensin receptor antagonists' .)

Trial of sparsentan in focal segmental glomerulosclerosis (December 2023)

Patients with focal segmental glomerulosclerosis (FSGS) are commonly treated with renin-angiotensin system (RAS) inhibitors to reduce proteinuria and stabilize kidney function. In a phase 3 trial in which over 370 patients with an FSGS lesion on kidney biopsy or a genetic variant associated with FSGS were randomly assigned to sparsentan , a dual endothelin receptor and angiotensin II receptor antagonist, or to the angiotensin II receptor antagonist irbesartan , sparsentan-treated patients had a greater reduction in proteinuria at 36 and 108 weeks, but there was no significant difference between the groups in estimated glomerular filtration rate (eGFR) slope at 108 weeks [ 14 ]. The discrepancy between sparsentan's effects on proteinuria and eGFR may reflect the enrollment of a heterogeneous mix of patients with primary, secondary, and genetic FSGS, who have a fundamentally different pathogenesis and disease course. Based on these findings, we do not use sparsentan in patients with an FSGS lesion. (See "Focal segmental glomerulosclerosis: Treatment and prognosis", section on 'Investigational therapies' .)

HYPERTENSION

Monitoring after negative confirmatory testing for primary aldosteronism (February 2024)

After a positive screening test for primary aldosteronism, confirmatory testing is required for diagnosis. In individuals with a positive screening test but negative confirmatory testing, the optimal monitoring strategy is uncertain. In a study that prospectively followed 184 individuals with a positive screening test for primary aldosteronism but negative confirmatory testing, a screening test was repeated after at least two years of follow-up [ 15 ]. If positive, confirmatory testing was performed again. Over a mean follow-up of five years, 20 percent of participants were diagnosed with primary aldosteronism. Those who developed primary aldosteronism exhibited higher blood pressure between initial and repeat testing despite similarly aggressive antihypertensive therapy. These findings support repeat testing for primary aldosteronism in individuals with initially negative confirmatory testing, particularly in those with progressively treatment-refractory blood pressure. (See "Diagnosis of primary aldosteronism", section on 'Negative confirmatory testing' .)

NEPHROLITHIASIS

Tranexamic acid to reduce bleeding after percutaneous nephrolithotomy (December 2023)

Postoperative bleeding can occur after percutaneous nephrolithotomy (PNL) for kidney stone removal; most bleeding is venous in origin and can be managed with conservative measures. A recent meta-analysis of 10 randomized trials found that use of tranexamic acid (TXA), an antifibrinolytic agent used to reduce bleeding in other clinical settings, may reduce the risk of blood transfusion after PNL [ 16 ]. Most trials were conducted in low- to middle-income settings in populations that were younger than those in higher-income settings; whether these findings are generalizable to practice in higher-income settings is uncertain. Pending additional data, we do not routinely use TXA after PNL. (See "Kidney stones in adults: Surgical management of kidney and ureteral stones", section on 'Bleeding' .)

PEDIATRIC NEPHROLOGY

Association between obesity in adolescence and development of chronic kidney disease (April 2024)

Observational studies have suggested that adolescents with obesity are at increased risk for impaired kidney function. In a new study of 630,000 adolescents in Israel, high body mass index (BMI) in late adolescence was associated with development of chronic kidney disease in early adulthood, as measured by albuminuria [ 17 ]. For severe obesity, the adjusted hazard ratio for early chronic kidney disease was 9.4 for males and 4.3 for females. These findings support our suggestion to screen for impaired kidney function in patients with risk factors for chronic kidney disease, including severe obesity, hypertension, or type 2 diabetes. Screening consists of measuring urine albumin-to-creatinine ratio. (See "Overview of the health consequences of obesity in children and adolescents", section on 'Kidney' .)

Serial amnioinfusions for bilateral renal agenesis (January 2024)

Bilateral renal agenesis (BRA) is incompatible with extrauterine life because prolonged oligohydramnios results in pulmonary hypoplasia, leading to postnatal respiratory failure. A prospective study (RAFT) assessed use of serial amnioinfusions to treat 18 cases of BRA diagnosed at <26 weeks of gestation [ 18 ]. Of the 17 live births, 14 survived ≥14 days and had placement of dialysis access, but only 6 survived to hospital discharge. Of the 4 children alive at 9 to 24 months of age, 3 had experienced a stroke and none had undergone transplant. These findings show that serial amnioinfusions for BRA mitigates pulmonary hypoplasia and increases short-term survival and access to dialysis; however, long-term outcome remains poor with no survival to transplantation. Serial amnioinfusions remain investigational and should be offered only as institutional review board-approved research. (See "Renal agenesis: Prenatal diagnosis", section on 'Investigative role of therapeutic amnioinfusion' .)

TRANSPLANTATION

First transplant of a genetically edited pig kidney into a living human (March 2024)

For patients with end-stage kidney disease (ESKD), kidney transplantation is generally preferred over dialysis but is limited by the severe shortage of donated human organs. On March 16, 2024, the first ever transplantation of a genetically modified pig kidney into a living patient with ESKD was performed under a US Food and Drug Administration expanded access protocol (ie, compassionate use) [ 19 ]. The recipient was treated with tegoprubart (an anti-CD40 ligand antibody) and ravulizumab (an anti-complement C5 monoclonal antibody); the xenograft was reported to be functioning well one week after surgery. While this initial report is encouraging, further details on the function and safety of this procedure await full publication of the findings. (See "Kidney transplantation in adults: Xenotransplantation", section on 'Clinical studies in humans' .)

• Hung AM, Assimon VA, Chen HC, et al. Genetic Inhibition of APOL1 Pore-Forming Function Prevents APOL1-Mediated Kidney Disease. J Am Soc Nephrol 2023; 34:1889.
• Khan WA, Oliver M, Crabtree JH, et al. Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry. Am J Kidney Dis 2024.
• Song MK, Manatunga A, Plantinga L, et al. Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2351511.
• Mehrotra R, Cukor D, McCurry SM, et al. Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial. Ann Intern Med 2024; 177:177.
• Bird ST, Smith ER, Gelperin K, et al. Severe Hypocalcemia With Denosumab Among Older Female Dialysis-Dependent Patients. JAMA 2024; 331:491.
• FDA drug safety communication for Prolia. Available at: https://www.fda.gov/media/175509/download?attachment (Accessed on January 22, 2024).
• Agarwal AK, Roy-Chaudhury P, Mounts P, et al. Taurolidine/Heparin Lock Solution and Catheter-Related Bloodstream Infection in Hemodialysis: A Randomized, Double-Blind, Active-Control, Phase 3 Study. Clin J Am Soc Nephrol 2023; 18:1446.
• Nitta K, Itoyama S, Ikejiri K, et al. Randomized Study of Tenapanor Added to Phosphate Binders for Patients With Refractory Hyperphosphatemia. Kidney Int Rep 2023; 8:2243.
• Tangri N, Mathur VS, Bushinsky DA, et al. VALOR-CKD: A Multicenter, Randomized, Double-Blind Placebo-Controlled Trial Evaluating Veverimer in Slowing Progression of CKD in Patients with Metabolic Acidosis. J Am Soc Nephrol 2024; 35:311.
• Refardt J, Atila C, Chifu I, et al. Arginine or Hypertonic Saline-Stimulated Copeptin to Diagnose AVP Deficiency. N Engl J Med 2023; 389:1877.
• Mathur M, Barratt J, Chacko B, et al. A Phase 2 Trial of Sibeprenlimab in Patients with IgA Nephropathy. N Engl J Med 2024; 390:20.
• Heerspink HJL, Radhakrishnan J, Alpers CE, et al. Sparsentan in patients with IgA nephropathy: a prespecified interim analysis from a randomised, double-blind, active-controlled clinical trial. Lancet 2023; 401:1584.
• Rovin BH, Barratt J, Heerspink HJL, et al. Efficacy and safety of sparsentan versus irbesartan in patients with IgA nephropathy (PROTECT): 2-year results from a randomised, active-controlled, phase 3 trial. Lancet 2023; 402:2077.
• Rheault MN, Alpers CE, Barratt J, et al. Sparsentan versus Irbesartan in Focal Segmental Glomerulosclerosis. N Engl J Med 2023; 389:2436.
• Buffolo F, Pecori A, Reincke M, et al. Long-Term Follow-Up of Patients With Elevated Aldosterone-to-Renin Ratio but Negative Confirmatory Test: The Progression of Primary Aldosteronism Phenotypes. Hypertension 2024; 81:340.
• Cleveland B, Norling B, Wang H, et al. Tranexamic acid for percutaneous nephrolithotomy. Cochrane Database Syst Rev 2023; 10:CD015122.
• Tsur AM, Akavian I, Landau R, et al. Adolescent Body Mass Index and Early Chronic Kidney Disease in Young Adulthood. JAMA Pediatr 2024; 178:142.
• Miller JL, Baschat AA, Rosner M, et al. Neonatal Survival After Serial Amnioinfusions for Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial. JAMA 2023; 330:2096.
• Press release. Massachusetts General Hospital. https://www.massgeneral.org/news/press-release/worlds-first-genetically-edited-pig-kidney-transplant-into-living-recipient (Accessed on March 21, 2024).

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Editorial: Artificial intelligence in nephrology

Francesco bellocchio.

1 Clinical Advanced Analytics - International Data Science, Fresenius Medical Care, Bad Homburg, Germany

Hanjie Zhang

2 Computational Statistics & Artificial Intelligence, Renal Research Institute, New York, NY, United States

Artificial Intelligence (AI) has emerged as a revolutionary technology with vast potential to transform various sectors, and healthcare is no exception. In the realm of nephrology, AI presents unprecedented opportunities to enhance patient care, improve diagnostics, streamline workflows, and facilitate more precise treatment decisions. The Research Topic of Artificial Intelligence in Nephrology aims to explore the transformative impact of AI on nephrology, discussing its applications in diagnosis, risk prediction, treatment optimization, and patient monitoring. While acknowledging the challenges and ethical considerations associated with AI implementation, this Research Topic emphasizes the immense potential of AI in revolutionizing nephrology and paving the way for a more efficient and personalized approach to patients with kidney diseases.

The five papers published in this Research Topic provided a glimpse of the many ways in which AI is being used in nephrology today.

A first important aspect covered by the papers regards the use of AI for enhancing diagnosis and prognosis. Both these medical tasks are crucial for effective management and treatment. AI algorithms can assist nephrologists in making timely and accurate diagnoses and prognosis, ultimately leading to improved patient outcomes. Machine learning models can analyze vast amounts of patient data, including laboratory results, medical imaging, and clinical notes, to identify patterns and detect anomalies that may indicate kidney related disorders. These algorithms can aid in the early detection of conditions such as chronic kidney disease (CKD), arteriovenous fistula problems, and cardiovascular complications.

The first paper presents a prognosis tool for cardiovascular events for non-dialysis-dependent CKD ( Neri et al. ). This tool has the potential to improve the identification of patients at high risk for cardiovascular events and could lead to earlier intervention and better outcomes. For the diagnosis task, the second paper discusses the use of AI to automate the diagnosis of kidney diseases from kidney biopsies ( Basso et al. ). This approach could help to reduce the time and cost of kidney biopsy interpretation and could also improve the accuracy of diagnosis.

The prediction ability of AI solutions, created on large amount of data, can be leveraged also in critical and unexpected situations like coronavirus disease 2019 (COVID-19) pandemic. The fifth paper is an example of such application ( Duan et al. ). It describes the development of a machine learning model to predict SARS-CoV-2 infection in dialysis patients. Considering the higher impact of COVID-19 among this fragile population, this model could be used to identify patients at high risk for COVID-19 and could help to prevent the spread of the virus within dialysis clinics.

In general, these models can integrate patient-specific data, including demographics, medical history, genetics, and lifestyle factors, to generate personalized risk scores and treatment recommendations. The personalization of the risk scores can aid in optimizing treatment protocols and devoting healthcare resources where more needed. Furthermore, by analyzing patient characteristics, response to treatment, and data from clinical trials, AI algorithms can assist in identifying the most effective interventions and tailoring treatment plans to individual patients. This personalized approach can improve therapeutic outcomes, minimize adverse events, and enhance patient satisfaction.

Another class of tools to facilitate personalized healthcare is represented by AI-powered monitoring systems. They offer real-time insights into patients’ overall health. Continuous monitoring of vital signs, laboratory results, and wearable device data can provide a comprehensive overview of a patient’s condition, allowing for early detection of complications or changes that require intervention. These AI-driven monitoring systems can significantly improve patient care by enabling timely adjustments to treatment plans and reducing the risk of adverse events. The fourth paper explores specifically this topic ( Canaud et al. ). It discusses the importance of closely monitor CVD in CKD5D patients and intervene early. Recently, home-used, self-operated, connected medical devices have emerged, providing convenient and automated monitoring during the interdialytic period. These sensor devices, equipped with Wi Fi or Bluetooth, analyze data and upload results to secure servers. Patients can access data through smartphone applications, while health care professionals can view it through web interfaces. The use of wearable sensors offers a multidimensional assessment of CKD5D patients, enabling the detection of unexpected disorders and aiding physicians in evaluating treatment responses. As the technology becomes more accessible and affordable, it has the potential to enhance personalized CKD5D patient management, ultimately improving their quality of life and survival.

AI methods can also be exploited to investigate the risk factors of specific disease and acute event. This is the case of the study of the third paper ( Nong et al. ). The aim of the study was to identify risk factors for severe acute kidney injury (AKI) in patients with acute myocardial infarction (AMI). The researchers analyzed data from 2022 patients in the Medical Information Mart for Intensive Care. Patients with severe AKI had higher in-hospital mortality and longer intensive care stays compared to those without AKI. The study found that several factors independently increased the risk of severe AKI in patients with AMI. These findings highlight the importance of monitoring these factors to identify patients at higher risk for severe AKI and improve prognosis following AMI.

While the potential of AI in nephrology is immense, its implementation comes with challenges and ethical considerations. Privacy and data security are paramount, as AI relies on vast amounts of patient data. Ensuring appropriate data anonymization, consent, and adherence to regulatory frameworks is crucial to maintain patient trust and protect sensitive information.

Additionally, transparency and interpretability of AI algorithms are essential to build confidence among healthcare professionals. Nephrologists must understand how AI arrives at its recommendations to effectively incorporate them into clinical decision-making processes.

In conclusion, this Research Topic highlights five different examples how Artificial Intelligence holds transformative potential in nephrology, revolutionizing diagnosis, risk prediction, treatment optimization, and patient monitoring. By leveraging AI technologies, nephrologists can provide more accurate diagnoses, identify high-risk patients, optimize treatment plans, and enhance patient monitoring. However, challenges such as data privacy, algorithm transparency, and ethical considerations must be addressed to ensure the responsible and beneficial integration of AI in nephrology. Embracing the power of AI in nephrology can unlock new possibilities and lead to improved patient outcomes, ultimately shaping a future where kidney care is more efficient, personalized, and effective.

Author contributions

FB: Writing – original draft, Writing – review & editing. HZ: Writing – original draft, Writing – review & editing.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. FB is a full time employee at Fresenius Medical Care.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

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Research Themes and Trends in Ten Top-Ranked Nephrology Journals: A Text Mining Analysis

Affiliations.

• 1 Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, Alabama, USA, [email protected].
• 2 School of Engineering, Center for Integrated Systems, The University of Alabama at Birmingham, Birmingham, Alabama, USA, [email protected].
• 3 Division of Nephrology and Hypertension, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
• 4 Veterans Affairs Medical Center, Birmingham, Alabama, USA.
• 5 Department of Management Science and Information Systems, Spears School of Business, Oklahoma State University, Stillwater, Oklahoma, USA.
• 6 Center for Health Systems Innovation, Department of Management Science and Information Systems, Spears School of Business, Oklahoma State University, Stillwater, Oklahoma, USA.
• 7 Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
• 8 Acute, Chronic, and Continuing Care, School of Nursing, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
• 9 School of Finance, Operations Management and International Business, Collins College of Business, The University of Tulsa, Tulsa, Oklahoma, USA.
• PMID: 31838480
• DOI: 10.1159/000504871

Background: Nephrology research is expanding, and harnessing the much-needed information and data for the practice of evidence-based medicine is becoming more challenging. In this study, we used the natural language processing and text mining approach to mitigate some of these challenges.

Methods: We analyzed 17,412 abstracts from the top-10 nephrology journals over 10 years (2007-2017) by using latent semantic analysis and topic analysis.

Results: The analyses revealed 10 distinct topics (T) for nephrology research ranging from basic science studies, using animal modeling (T-1), to dialysis vascular access-related issues -(T-10). The trend analyses indicated that while the majority of topics stayed relatively stable, some of the research topics experienced increasing popularity over time such as studies focusing on mortality and survival (T-4) and Patient-related Outcomes and Perspectives of Clinicians (T-5). However, some research topics such as studies focusing on animal modeling (T-1), predictors of acute kidney injury, and dialysis access (T-10) exhibited a downward trend.

Conclusion: Stakeholders of nephrology research may use these trends further to develop priorities and enrich the research agenda for the future.

Keywords: Kidney; Nephrology; Text mining; Themes; Trends.

© 2019 S. Karger AG, Basel.

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• Review Article
• Published: 30 July 2020

The current and future landscape of dialysis

• Jonathan Himmelfarb   ORCID: orcid.org/0000-0002-3319-1224 1 , 2 ,
• Raymond Vanholder   ORCID: orcid.org/0000-0003-2633-1636 3 ,
• Rajnish Mehrotra   ORCID: orcid.org/0000-0003-2833-067X 1 , 2 &
• Marcello Tonelli   ORCID: orcid.org/0000-0002-0846-3187 4  

Nature Reviews Nephrology volume  16 ,  pages 573–585 ( 2020 ) Cite this article

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• Haemodialysis
• Health care economics
• Health services
• Medical ethics

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

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Epidemiology of haemodialysis outcomes

Aminu K. Bello, Ikechi G. Okpechi, … David W. Johnson

Epidemiology of peritoneal dialysis outcomes

Kidney disease trials for the 21st century: innovations in design and conduct

William G. Herrington, Natalie Staplin & Richard Haynes

Introduction

Haemodialysis as a treatment for irreversible kidney failure arose from the pioneering efforts of Willem Kolff and Belding Scribner, who together received the 2002 Albert Lasker Clinical Medical Research Award for this accomplishment. Kolff treated his first patient with an artificial kidney in 1943 — a young woman who was dialysed 12 times successfully but ultimately died because of vascular access failure. By 1945, Kolff had dialysed 15 more patients who did not survive, when Sofia Schafstadt — a 67-year-old woman who had developed acute kidney injury — recovered, becoming the first long-term survivor after receipt of dialysis. In 1960, Belding Scribner, Wayne Quinton and colleagues at the University of Washington, WA, USA, designed shunted cannulas, which prevented the destruction of blood vessels and enabled repeated haemodialysis sessions. The first patient who received long-term treatment (named Clyde Shields) lived a further 11 years on haemodialysis. In their writings, both Kolff and Scribner eloquently described being motivated by their perception of helplessness as physicians who had little to offer for the care of young patients who were dying of uraemia and stated that the goal of dialysis was to achieve full rehabilitation to an enjoyable life 1 .

The potential to scale the use of dialysis to treat large numbers of patients with kidney failure created great excitement. At the 1960 meeting of the American Society for Artificial Internal Organs (ASAIO), Scribner introduced Clyde Shields to physicians interested in dialysis, and Quinton demonstrated fabrication of the shunt. The following decade saw rapid gains in our understanding of kidney failure, including the discovery of uraemia-associated atherogenesis and metabolic bone disease, and in virtually every aspect of haemodialysis, including improvements in dialyser technology, dialysate composition, materials for haemocompatibility and water purification systems. The Scribner–Quinton shunt rapidly became an historical artefact once Brescia and colleagues developed the endogenous arteriovenous fistula in 1966 (ref. 2 ), and prosthetic subcutaneous interpositional ‘bridge’ grafts were developed shortly thereafter. Concomitant with these pioneering efforts, in 1959, peritoneal dialysis (PD) was first used successfully to sustain life for 6 months. Within 2 years a long-term PD programme was established in Seattle, WA, USA, and within 3 years the first automated PD cycler was developed 3 .

In 1964, Scribner’s presidential address to the ASAIO described emerging ethical issues related to dialysis, including considerations for patient selection, patient self-termination of treatment as a form of suicide, approaches to ensure death with dignity and selection criteria for transplantation 4 . Indeed, the process of selecting who would receive dialysis contributed to the emergence of the field of bioethics. The early success of dialysis paradoxically created social tensions, as access to this life-sustaining therapy was rationed by its availability and the ‘suitability’ of patients. In the early 1970s, haemodialysis remained a highly specialized therapy, available to ~10,000 individuals, almost exclusively in North America and Europe, with a high frequency of patients on home haemodialysis. In a portentous moment, Shep Glazer, an unemployed salesman, was dialysed in a live demonstration in front of the US Congress House Ways and Means Committee. Soon thereafter, in October 1972, an amendment to the Social Security Act creating Medicare entitlement for end-stage renal disease (now known as kidney failure), for both dialysis and kidney transplantation, was passed by Congress and signed into law by President Nixon.

The resulting expansion of dialysis, previously described as “from miracle to mainstream” 5 , set in motion dramatic changes 6 , including the development of a for-profit outpatient dialysis provider industry; relaxation of stringent patient selection for dialysis eligibility in most HICs; a move away from home towards in-centre dialysis; efforts on the part of single payors such as Medicare in the USA to restrain per-patient costs through the introduction of bundled payments and the setting of composite rates; the development of quality indicators — such as adequate urea clearance per treatment — that were readily achievable but are primarily process rather than outcome measures; consolidation of the dialysis industry, particularly in the USA owing to economies of scale, eventually resulting in a duopoly of dialysis providers; the development of joint ventures and other forms of partnerships between dialysis providers and nephrologists; the globalization of dialysis, which is now available, albeit not necessarily accessible or affordable in many low-income and middle-income countries (LMICs); and finally, a dramatic slowing in the rate of true patient-centred innovation, with incremental gains in dialysis safety and efficiency replacing the pioneering spirit of the early innovators.

The population of patients receiving dialysis continues to grow rapidly, especially in LMICs, as a result of an increase in the availability of dialysis, population ageing, increased prevalence of hypertension and diabetes mellitus, and toxic environmental exposures. However, despite the global expansion of dialysis, notable regional differences exist in the prevalence of different dialysis modalities and in its accessibility. Worldwide, a substantial number of people do not have access to kidney replacement therapy (KRT), resulting in millions of deaths from kidney failure each year. Among populations with access to dialysis, mortality remains high and outcomes suboptimal, with high rates of comorbidities and poor health-related quality of life. These shortcomings highlight the urgent need for innovations in the dialysis space to increase accessibility and improve outcomes, with a focus on those that are a priority to patients. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and provides examples of initiatives that are aimed at stimulating innovations in dialysis and transform the field to one that supports high-quality, high-value care.

Epidemiology of dialysis

Kidney failure is defined by a glomerular filtration rate <15 ml/min/1.73 m 2 (ref. 7 ) and may be treated using KRT (which refers to either dialysis or transplantation) or with supportive care 8 . The global prevalence of kidney failure is uncertain, but was estimated to be 0.07%, or approximately 5.3 million people in 2017 (ref. 9 ), with other estimates ranging as high as 9.7 million. Worldwide, millions of people die of kidney failure each year owing to a lack of access to KRT 10 , often without supportive care. Haemodialysis is costly, and current recommendations therefore suggest that haemodialysis should be the lowest priority for LMICs seeking to establish kidney care programmes. Rather, these programmes should prioritize other approaches, including treatments to prevent or delay kidney failure, conservative care, living donor kidney transplantation and PD 11 . Nonetheless, haemodialysis is the most commonly offered form of KRT in LMICs, as well as in high-income countries (HICs) 12 , and continued increases in the uptake of haemodialysis are expected worldwide in the coming decades. Here, we review the basic epidemiology of kidney failure treated with long-term dialysis and discuss some of the key epidemiological challenges of the future (Fig.  1a ).

Growth is continuously outpacing the capacity of kidney replacement therapy (KRT), defined as maintenance dialysis or kidney transplant, especially in low-income and middle-income countries. a | Global prevalence of chronic dialysis. b | Estimated worldwide need and projected capacity for KRT by 2030. pmp, per million population. Adapted with permission from the ISN Global Kidney Health Atlas 2019.

Prevalence of dialysis use

Prevalence of haemodialysis.

Worldwide, approximately 89% of patients on dialysis receive haemodialysis; the majority (>90%) of patients on haemodialysis live in HICs or the so-called upper middle-income countries such as Brazil and South Africa 12 , 13 . The apparent prevalence of long-term dialysis varies widely by region but correlates strongly with national income 14 . This variation in prevalence in part reflects true differences in dialysis use 12 , 15 but also reflects the fact that wealthier countries are more likely than lower income countries to have comprehensive dialysis registries. Of note, the prevalence of haemodialysis is increasing more rapidly in Latin America (at a rate of ~4% per year) than in Europe or the USA (both ~2% per year), although considerable variation between territories exists in all three of these regions, which again correlates primarily (but not exclusively) with wealth 16 , 17 . The prevalence of haemodialysis varies widely across South Asia, with relatively high prevalence (and rapid growth) in India and lower prevalence in Afghanistan and Bangladesh 18 . Limited data are available on the prevalence of dialysis therapies in sub-Saharan Africa 19 . A 2017 report suggests that haemodialysis services were available in at least 34 African countries as of 2017, although haemodialysis was not affordable or accessible to the large majority of resident candidates 13 .

Prevalence of peritoneal dialysis

Worldwide, PD is less widely available than haemodialysis. In a 2017 survey of 125 countries, PD was reportedly available in 75% of countries whereas haemodialysis was available in 96% 20 . In 2018, an estimated 11% of patients receiving long-term dialysis worldwide were treated with PD; a little over half of these patients were living in China, Mexico, the USA and Thailand 21 .

Large variation exists between territories in the relative use of PD for treating kidney failure; in Hong Kong for example, >80% of patients on dialysis receive PD, whereas in Japan this proportion is <5% 22 . This variation is, in part, determined by governmental policies and the density of haemodialysis facilities 23 . In some countries such as the USA, rates of PD utilization also vary by ethnicity with African Americans and Hispanics being much less likely than white Americans to receive PD 24 . Disparate secular trends in PD use are also evident, with rapid growth in the use of PD in some regions such as the USA, China and Thailand and declining or unchanging levels of PD use in other regions, for example, within Western Europe 22 . As for haemodialysis, access to PD is poor in many LMICs for a variety of reasons, as comprehensively discussed elsewhere 25 .

Incidence of dialysis use

Following a rapid increase in dialysis use over a period of approximately two decades, the incidence of dialysis initiation in most HICs reached a peak in the early 2000s and has remained stable or slightly decreased since then 22 , 26 , 27 . Extrapolation of prevalence data from LMICs suggests that the incidence of dialysis initiation seems to be steadily increasing in LMICs 10 , 28 , 29 , 30 , with further increases expected over the coming decades. However, incidence data in LMICs are less robust than prevalence data, although neither reflect the true demand for KRT given the lack of reporting.

Of note, the incidence of dialysis initiation in HICs is consistently 1.2-fold to 1.4-fold higher for men than for women, despite an apparently higher risk of chronic kidney disease (CKD) in women 31 . Whether this finding reflects physician or health system bias, different preferences with regard to KRT, disparities in the competing risk of death, variation in rates of kidney function loss in women versus men, or other reasons is unknown and requires further study. Few data describe the incidence of haemodialysis by sex in LMICs.

Dialysis outcomes

Mortality is very high among patients on dialysis, especially in the first 3 months following initiation of haemodialysis treatment. Approximately one-quarter of patients on haemodialysis die within a year of initiating therapy in HICs, and this proportion is even higher in LMICs 32 , 33 , 34 . Over the past two decades, reductions in the relative and absolute risk of mortality have seemingly been achieved for patients on haemodialysis. Data suggest that relative gains in survival may be greater for younger than for older individuals; however, absolute gains seem to be similar across age groups 35 . Although controversial, improvements in mortality risk seem to have been more rapid among patients on dialysis than for the general population 36 , suggesting that better care of patients receiving dialysis treatments rather than overall health gains might be at least partially responsible for these secular trends. The factors responsible for these apparent trends have not been confirmed, but could include better management of comorbidities, improvements in the prevention or treatment of dialysis-related complications such as infection, and/or better care prior to the initiation of dialysis (which may translate into better health following dialysis initiation). Historically, although short-term mortality was lower for patients treated with PD than for those treated with haemodialysis, the long-term mortality risk was higher with PD 37 , 38 . In the past two decades, the reduction in mortality risk has been greater for patients treated with PD than with haemodialysis, such that in most regions the long-term survival of patients treated with PD and haemodialysis are now similar 39 , 40 , 41 .

Despite these improvements, mortality remains unacceptably high among patients on dialysis and is driven by cardiovascular events and infection. For example, a 2019 study showed that cardiovascular mortality among young adults aged 22–29 years with incident kidney failure was 143–500-fold higher than that of otherwise comparable individuals without kidney failure, owing to a very high burden of cardiovascular risk factors 42 . The risk of infection is also markedly greater among patients on dialysis than in the general population, in part driven by access-related infections in patients on haemodialysis with central venous catheters and peritonitis-related infections in patients on PD 43 , 44 , 45 , 46 , 47 . Hence, strategies to reduce the risk of infection associated with dialysis access should continue to be a high clinical priority.

The risk of mortality among patients on dialysis seems to be influenced by race. In the USA, adjusted mortality is lower for African American patients than for white patients on dialysis, although there is a significant interaction with age such that this observation held only among older adults, and the converse is actually true among younger African American patients aged 18 to 30 years 48 . A similar survival advantage is observed among Black patients compared with white patients or patients of Asian heritage on haemodialysis in the Netherlands 49 . In Canada, dialysis patients of indigenous descent have higher adjusted mortality, and patients of South Asian or East Asian ethnicity have lower adjusted mortality than that of white patients. In addition, between-region comparisons indicate that mortality among incident dialysis patients is substantially lower for Japan than for other HICs. Whether this difference is due to ethnic origin, differences in health system practices, a combination of these factors or other, unrelated factors is unknown 30 . No consistent evidence exists to suggest that mortality among incident adult dialysis patients varies significantly by sex 50 , 51 , 52 .

Other outcomes

Hospitalization, inability to work and loss of independent living are all markedly more common among patients on dialysis than in the general population 53 , 54 , 55 . In contrast to the modest secular improvements in mortality achieved for patients on dialysis, health-related quality of life has remained unchanged for the past two decades and is substantially lower than that of the general population, due in part to high symptom burden 56 , 57 , 58 , 59 . Depression is also frequent among patients on dialysis 60 , and factors such as high pill burden 61 , the need to travel to dialysis sessions and pain associated with vascular access puncture all affect quality of life 62 .

Future epidemiological challenges

The changing epidemiology of kidney failure is likely to present several challenges for the optimal management of these patients. For example, the ageing global population together with continuing increases in the prevalence of key risk factors for the development of kidney disease, such as diabetes mellitus and hypertension, mean that the incidence, prevalence and costs of kidney failure will continue to rise for the foreseeable future. This increased demand for KRT will undoubtedly lead to an increase in the uptake of haemodialysis, which will pose substantial economic challenges for health systems worldwide. Moreover, as growth in demand seems to be outpacing increases in KRT capacity, the number of deaths as a result of kidney failure is expected to rise dramatically (Fig.  1b ).

The same risk factors that drive the development of kidney disease will also increase the prevalence of multimorbidities within the dialysis population. These comorbidities will in turn require effective management in addition to the management of kidney failure per se 63 and will require technical innovations of dialysis procedures, as well as better evidence to guide the management of comorbidities in the dialysis population.

Finally, the particularly rapid increases in the incidence and prevalence of kidney failure among populations in LMICs will place considerable strain on the health systems of these countries. The associated increases in mortality resulting from a lack of access to KRT will create difficult choices for decision makers. Although LMIC should prioritize forms of KRT other than haemodialysis, some haemodialysis capacity will be required 11 , for example, to manage patients with hypercatabolic acute kidney injury or refractory PD-associated peritonitis, which, once available, will inevitably increase the use of this modality.

Health economy-related considerations

The cost of dialysis (especially in-centre or in-hospital dialysis) is high 64 , and the cost per quality-adjusted life-year associated with haemodialysis treatment is often considered to be the threshold value that differentiates whether a particular medical intervention is cost-effective or not 65 . Total dialysis costs across the population will probably continue to rise, owing to increases in life expectancy of the general population and the availability of improved therapeutics for causes of kidney failure such as diabetes mellitus, which have increased the lifespan of these patients and probably will also increase their lifespan on dialysis. KRT absorbs up to 5–7% of total health-care budgets, despite the fact that kidney failure affects only 0.1–0.2% of the general population in most regions 66 . Although societal costs for out-of-centre dialysis (for example, home or self-care haemodialysis, or PD) are in general lower than that of in-centre haemodialysis in many HICs, these options are often underutilized 67 , adding to the rising costs of dialysis.

Reimbursement for haemodialysis correlates with the economic strength of each region 68 , but in part also reflects willingness to pay . In most regions, the correlation curve for PD or reimbursement with respect to gross domestic product projects below that of in-centre haemodialysis, which in part reflects the lower labour costs associated with PD 68 . Unfortunately, little clarity exists with regard to the aggregated cost of single items that are required to produce dialysis equipment for both PD and haemodialysis and the labour costs involved in delivering haemodialysis 69 , which makes it difficult for governments to reimburse the real costs of haemodialysis.

Although increasing reimbursement of home dialysis strategies would seem to be an appropriate strategy to stimulate uptake of these modalities, evidence from regions that offer high reimbursement rates for PD suggests that the success of this strategy is variable 23 , 68 . However, financial incentives may work. In the USA, reimbursement for in-centre and home dialysis (PD or home haemodialysis) has for a long time been identical. The introduction of the expanded prospective payment system in 2011 further enhanced the financial incentives for PD for dialysis providers, which led to a doubling in both the absolute number of patients and the proportion of patients with kidney failure treated with PD 70 , 71 , 72 , 73 .

Although in countries with a low gross domestic product, dialysis consumes less in absolute amounts, it absorbs a higher fraction of the global health budget 68 , likely at the expense of other, potentially more cost-effective interventions, such as prevention or transplantation. Although society carries most of the costs associated with KRT in most HICs, some costs such as co-payment for drugs or consultations are borne by the individual, and these often increase as CKD progresses. In other regions, costs are covered largely or entirely by the patient’s family, leading to premature death when resources are exhausted 74 . In addition, costs are not limited to KRT but also include the costs of medication, hospitalizations and interventions linked to kidney disease or its complications (that is, indirect costs), as well as non-health-care-related costs such as those linked to transportation or loss of productivity.

Dialysis also has an intrinsic economic impact. Patients on dialysis are often unemployed. In the USA, >75% of patients are unemployed at the start of dialysis, compared with <20% in the general population 53 . Unemployment affects purchasing power but also lifestyle, self-image and mental health. Moreover, loss of productivity owing to unemployment and/or the premature death of workers with kidney failure also has economic consequences for society 75 . Therefore, continued efforts to prevent kidney failure and develop KRT strategies that are less time consuming for the patient and allow more flexibility should be an urgent priority. Concomitantly, employers must also provide the resources needed to support employees with kidney failure.

Hence, a pressing need exists to rethink the current economic model of dialysis and the policies that direct the choice of different treatment options. The cost of dialysis (especially that of in-centre haemodialysis) is considerable and will continue to rise as the dialysis population increases. Maintaining the status quo will prevent timely access to optimal treatment for many patients, especially for those living in extreme poverty and with a low level of education and for patients living in LMICs.

Ethical aspects

A 2020 review by a panel of nephrologists and ethicists appointed by three large nephrology societies outlined the main ethical concerns associated with kidney care 76 . With regard to management of kidney failure (Box  1 ), equitable access to appropriate treatment is probably the most important ethical issue and is relevant not only in the context of haemodialysis but also for the other modalities of kidney care (including transplantation, PD and comprehensive conservative care) 76 . Of note, conservative care is not equivalent to the withdrawal of treatment, but rather implies active management excluding KRT.

As mentioned previously, access to such care is limited in many countries 10 , 77 . Inequities in access to dialysis at the individual level are largely dependent on factors such as health literacy, education and socio-economic status, but also on the wealth and organization of the region in which the individual lives. Even when dialysis itself is reimbursed, a lack of individual financial resources can limit access to care. Moreover, elements such as gender, race or ethnicity and citizenship status 78 , 79 can influence an individual’s ability to access dialysis 80 . These factors impose a risk that patients who are most vulnerable are subject to further discrimination. In addition, without necessarily being perceived as such, dialysis delivery may be biased by the financial interests of dialysis providers or nephrologists, for example, by influencing whether a patient receives in-centre versus home dialysis, or resulting in the non-referral of patients on dialysis for transplantation or conservative care 81 , 82 .

A potential reason for the high utilization of in-centre haemodialysis worldwide is a lack of patient awareness regarding the alternatives. When surveyed, a considerable proportion of patients with kidney failure reported that information about options for KRT was inadequate 83 , 84 . Patient education and decision support could be strengthened and its quality benchmarked, with specific attention to low health literacy, which is frequent among patients on dialysis 85 . Inadequate patient education might result from a lack of familiarity with home dialysis (including PD) and candidacy bias among treating physicians and nurses. Appropriate education and training of medical professionals could help to solve this problem. However, the first step to increase uptake of home dialysis modalities is likely policy action undertaken by administrations, but stimulated by advocacy by patients and the nephrology community, as suggested by the higher prevalence of PD at a lower societal cost of regions that already have a PD-first policy in place 68 .

Although the provision of appropriate dialysis at the lowest possible cost to the individual is essential if access is to be improved 86 , approaches that unduly compromise the quality of care should be minimized or avoided. General frameworks to deal with this challenge can be provided by the nephrology community, but trade-offs between cost and quality may be necessary and will require consultation between authorities, medical professionals and patient representatives. Consideration must also be given to whether the societal and individual impact of providing dialysis would be greater than managing other societal health priorities (for example, malaria or tuberculosis) or investing in other sectors to improve health (for example, access to clean drinking water or improving road safety).

The most favourable approach in deciding the most appropriate course of action for an individual is shared decision-making 87 , which provides evidence-based information to patients and families about all available therapeutic options in the context of the local situation. Providing accurate and unbiased information to support such decision-making is especially relevant for conservative care, to avoid the perception that this approach is being recommended to save resources rather than to pursue optimal patient comfort. Properly done, shared decision-making should avoid coercion, manipulation, conflicts of interest and the provision of ‘futile dialysis’ to a patient for whom the harm outweighs the benefits, life expectancy is low or the financial burden is high 88 . However, the views of care providers do not always necessarily align with those of patients and their families, especially in multicultural environments 89 . Medical professionals are often not well prepared for shared decision-making, and thus proper training is essential 90 . Policy action is also required to create the proper ethical consensus and evidence-based frameworks at institutional and government levels 91 to guide decision-making in the context of dialysis care that can be adapted to meet local needs.

Box 1 Main ethical issues in dialysis

Equity in access to long-term dialysis

Inequities in the ability to access kidney replacement therapy exist worldwide; however, if dialysis is available, the ability to transition between different dialysis modalities should be facilitated as much as possible. Specific attention should be paid to the factors that most prominently influence access to dialysis, such as gender, ethnicity, citizenship status and socio-economic status

Impact of financial interests on dialysis delivery

Financial interests of dialysis providers or nephrologists should in no way influence the choice of dialysis modality and/or result in the non-referral of patients for transplantation or conservative care

Cost considerations

Local adaptations are needed to ensure that the costs of dialysis provision are as low as possible without compromising quality of care

The high cost of dialysis means that consideration must be given to whether the benefits obtained by dialysis outweigh those obtained by addressing other health-care priorities, such as malaria or tuberculosis

Shared decision-making

Shared decision-making, involving the patient and their family, is recommended as an approach to allow an informed choice of the most appropriate course to follow

Approaches to shared decision-making must be evidence based and adapted to local circumstances

Futile dialysis should be avoided

Proper training is required to prepare physicians for shared decision-making

Clinical outcomes to measure progress

Over the past six decades, the availability of long-term dialysis has prolonged the lives of millions of people worldwide, often by serving as a bridge to kidney transplantation. Yet, patients on dialysis continue to bear a high burden of disease, both from multimorbidity and owing to the fact that current dialysis modalities only partially replace the function of the native kidney, resulting in continued uraemia and its consequences. Thus, although dialysis prevents death from kidney failure, life expectancy is often poor, hospitalizations (particularly for cardiovascular events and infection) are frequent, symptom burden is high and health-related quality of life is low 22 , 92 , 93 .

Given the multitude of health challenges faced by patients on dialysis, it is necessary to develop a priority list of issues. For much of the past three decades, most of this prioritization was performed by nephrology researchers with the most effort to date focusing on approaches to reducing all-cause mortality and the risk of fatal and non-fatal cardiovascular events. However, despite the many interventions that have been tested, including increasing the dose of dialysis (in the HEMO and ADEMEX trials 94 , 95 ), increasing dialyser flux (in the HEMO trial and MPO trial 94 , 96 ), increasing haemodialysis frequency (for example, the FHN Daily and FHN Nocturnal trials 97 , 98 ), use of haemodiafiltration (the CONTRAST 99 , ESHOL 100 and TURKISH-OL-HDF trials 101 ), increasing the haemoglobin target (for example, the Normal Haematocrit Trial 102 ), use of non-calcium-based phosphate binders (for example, the DCOR trial 103 ), or lowering of the serum cholesterol level (for example, the 4D, AURORA and SHARP trials 104 , 105 , 106 ), none of these or other interventions has clearly reduced all-cause or cardiovascular mortality for patients on dialysis. These disappointments notwithstanding, it is important that the nephrology community perseveres in finding ways to improve patient outcomes.

In the past 5 years, nephrology researchers have increasingly engaged with patients to understand their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that although longevity is valued, many patients would prefer to reduce symptom burden and achieve maximal functional and social rehabilitation. This insight highlights the high symptom burden experienced by patients receiving long-term dialysis 92 , 93 , 96 , 107 . These symptoms arise as a consequence of the uraemic syndrome. Some of these symptoms, such as anorexia, nausea, vomiting, shortness of breath and confusion or encephalopathy, improve with dialysis initiation 108 , 109 , 110 , but many other symptoms, such as depression, anxiety and insomnia do not. Moreover, other symptoms, such as post-dialysis fatigue, appear after initiation of haemodialysis.

Of note, many symptoms of uraemic syndrome might relate to the persistence of protein-bound uraemic toxins and small peptides (so-called middle molecules) that are not effectively removed by the current dialysis modalities. The development of methods to improve the removal of those compounds is one promising approach to improving outcomes and quality of life for patients on dialysis, as discussed by other articles in this issue.

Patients on dialysis report an average of 9–12 symptoms at any given time 92 , 93 , 107 . To determine which of these should be prioritized for intervention, the Kidney Health Initiative used a two-step patient-focused process involving focus groups and an online survey to identify six symptoms that should be prioritized by the research community for intervention. These include three physical symptoms (fatigue, insomnia and cramps) and three mood symptoms (depression, anxiety and frustration) 111 . Parallel to these efforts, the Standardizing Outcomes in Nephrology Group (SONG) workgroup for haemodialysis ( SONG-HD ) has identified several tiers of outcomes that are important to patients, caregivers and health-care providers. Fatigue was identified as one of the four core outcomes, whereas depression, pain and feeling washed out after haemodialysis were identified as middle-tier outcomes 112 , 113 , 114 . Along these same lines, the SONG workgroup for PD ( SONG-PD ) identified the symptoms of fatigue, PD pain and sleep as important middle-tier outcomes 115 , 116 . Despite the importance of these symptoms to patients on dialysis, only a few studies have assessed the efficacy of behavioural and pharmacological treatments on depression 117 , 118 , 119 , 120 , 121 . Even more sobering is the observation that very few, if any, published studies have rigorously tested interventions for fatigue or any of the other symptoms. The nephrology community must now develop standardized and psychometrically robust measures that accurately capture symptoms and outcomes that are important to patients and ensure that these are captured in future clinical trials 122 , 123 .

Approaches to maximizing functional and social rehabilitation are also important to patients with kidney failure. In addition to the above-mentioned symptoms, SONG-HD identified ability to travel, ability to work, dialysis-free time, impact of dialysis on family and/or friends and mobility as important middle-tier outcomes 112 , 113 , 114 . SONG-PD identified life participation as one of five core outcomes, and impact on family and/or friends and mobility as other outcomes that are important to patients 115 , 116 . Given the importance of these outcomes to stakeholders, including patients, it is imperative that nephrology researchers develop tools to enable valid and consistent measurement of these outcomes and identify interventions that favourably modify these outcomes.

Fostering innovation

As described above, the status quo of dialysis care is suboptimal. Residual symptom burden, morbidity and mortality, and economic cost are all unacceptable, which begs the question of what steps are needed to change the established patterns of care. Patients are currently unable to live full and productive lives owing to the emotional and physical toll of dialysis, its intermittent treatment schedule, the dietary and fluid limitations, and their highly restricted mobility during treatment. Current technology requires most patients to travel to a dialysis centre, and current modalities are non-physiological, resulting in ‘washout’, which is defined as extensive fatigue, nausea and other adverse effects, caused by the build-up of uraemic toxins between treatments and the rapid removal of these solutes and fluids over 4-h sessions in the context of haemodialysis. LMICs face additional difficulties in the provision of dialysis owing to infrastructural requirements, the high cost of this treatment, the need for a constant power supply and the requirement for high volumes of purified water. For LMICs, innovations that focus on home-based, low-cost therapies that promote rehabilitation would be especially beneficial.

We contend that initiatives to transform dialysis outcomes for patients require both top-down efforts (for example, those that involve systems changes at the policy, regulatory, macroeconomic and organizational levels) and bottom-up efforts (for example, patient-led and patient-centred advocacy and individual teams of innovators). Top-down efforts are required to support, facilitate and de-risk the work of innovators. Conversely, patient-led advocacy is essential for influencing governmental and organizational policy change. Here, by considering how selected programmes are attempting to transform dialysis outcomes through innovation in support of high-value, high-quality care, we describe how top-down and bottom-up efforts can work synergistically to change the existing ecosystem of dialysis care (Fig.  2 ). The efforts described below are not an exhaustive list; rather, this discussion is intended to provide a representative overview of how the dialysis landscape is changing. Additional articles in this issue describe in more detail some of the bottom-up efforts of innovators to create wearable 124 , portable 125 , more environmentally friendly 126 and more physiological dialysis systems 127 , 128 , priorities from the patients’ perspective 129 , and the role of regulators in supporting innovation in the dialysis space 130 .

Initiatives to transform dialysis outcomes for patients require both top-down efforts (for example, those that involve systems-level changes at the policy, regulatory, macroeconomic and organizational level) and bottom-up efforts (for example, patient-led and patient-centred advocacy efforts and efforts from individual teams of innovators). Both of these efforts need to be guided by priorities identified by patients. Such an approach, focused on patient-centred innovation, has the potential to result in meaningful innovations that support high-quality, high-value care. NGOs, non-governmental organizations.

The Kidney Health Initiative

In 2012, the American Society of Nephrology (ASN) and the FDA established the KHI as an umbrella organization through which the kidney community can work collaboratively to remove barriers to the development of innovative drugs, devices, biologics and food products, in order to improve outcomes for people living with kidney diseases. To advance its mission, KHI has initiated a number of projects composed of multidisciplinary workgroups. A major accomplishment for the KHI was the establishment of a precompetitive environment to promote innovation while ensuring patient safety.

The KHI is the largest consortium in the kidney community, with over 100 member organizations including patient groups, health professional organizations, dialysis organizations, pharmaceutical and device companies, and government agencies. During the first 7 years of its existence, the KHI has launched and in many cases completed projects that have facilitated the development of new therapeutic options for dialysis patients (Box  2 ), as well as published position papers on topics relevant to innovation in haemodialysis care, including innovations in fluid management 131 and symptom management 132 in patients on haemodialysis, recommendations for clinical trial end points for vascular access 133 , perspectives on pragmatic trials in the haemodialysis population 134 and regulatory considerations for the use of haemodiafiltration 135 .

Box 2 Kidney Heath Initiative Projects that Support Dialysis Innovation

Patient and Family Partnership Council

Since 2015, the Kidney Health Initiative (KHI) Patient and Family Partnership Council (PFPC) has helped KHI stakeholders to engage and network with patients and patient organizations. The PFPC also advises industry and research partners of patient needs and preferences as new products are planned and developed. The PFPC continually emphasizes that innovation will only be successful if built around the needs of people with kidney disease and focused on improving their quality of life.

ESRD Data Standard Project

The aim of this project is to create a harmonized common data standard for kidney failure. The availability of a uniform data standard could accelerate the pace of scientific discovery, facilitate the creation of scientific registries for epidemiological surveillance and allow the development of common metrics for value-based health care.

Building Capacity to Incorporate Patient Preferences into the Development of Innovative Alternatives to kidney replacement therapy (KRT)

This project, which is supported by a 3-year contract with the FDA, is based on the premise that access to scientifically valid patient preference information could positively inform the decisions of industry and regulators as they design and review new devices for individuals with kidney failure. This project will collect patients’ preference information and also address a stated goal of the Advancing American Kidney Health (AAKH) initiative, which instructs the FDA to “develop a new survey to gain insight into patient preferences for new kidney failure treatments” 137 .

Clinical Trial Design to Support Innovative Approaches to KRT

This project is intended to facilitate coordinated efforts between regulators and the nephrology community to streamline the clinical development pathway. The primary objectives of the project are to define terminology for future KRT products (for example, wearable, portable, implantable and artificial kidney) and identify the most appropriate trial designs and end points for a variety of KRT products.

Advancing American Kidney Health

In July 2019, President Donald Trump signed an Executive Order on Advancing American Kidney Health (AAKH) 136 , which promises to fundamentally change the clinical care of kidney disease in general and kidney failure in particular. Components of the AAKH that are relevant to dialysis care include a directive for education and support programmes to promote awareness of kidney disease; a shift in the focus of reimbursement initiatives from in-centre haemodialysis to home therapies, transplantation and upstream CKD care; a system that rewards clinicians and dialysis facilities for providing a range of treatments for kidney failure, with the aim of increasing uptake of home dialysis and transplantation; and incentives for nephrology care teams to focus on reducing costs and improving outcomes by providing longitudinal care of patients with kidney disease.

Finally, and perhaps most radically, the AAKH calls on the US Department of Health and Human Services to support premarket approval of wearable and implantable artificial kidneys and welcomes other strategies to facilitate transformative innovation in dialysis devices. The AAKH directive specifically identifies the KidneyX programme (described below) as the vehicle with which to drive this innovation. The AAKH is the most ambitious US policy initiative ever undertaken to transform the care of patients with advanced kidney disease. Its agenda is still being shaped by the federal governmental agencies, with input from professional societies and other kidney community stakeholders, but this initiative provides a framework and support for transformative innovation in dialysis care.

The KHI Technology Roadmap and KidneyX

The KHI Technology Roadmap for Innovative Approaches to KRT, published in 2019 (ref. 137 ), is aimed at supporting the development of innovative dialysis devices by providing guidance on technical criteria, patient preferences, assessment of patient risk tolerances and regulatory, reimbursement and marketing considerations. Key strengths of the Roadmap include its patient-centred focus and the description of multiple solution pathways for different technologies (for example, portable, wearable and implantable devices that may be purely mechanical, cell-based or hybrid systems), each with appropriate timeline projections.

The KRT Roadmap was designed to be complementary to the Kidney Innovation Accelerator (also known as KidneyX). KidneyX is a public–private partnership between the Department of Health and Human Services and the ASN, and is aimed at accelerating the development of drugs, devices, biologics and other therapies across the spectrum of kidney care. The current major focus of KidneyX is to catalyse the fundamental redesign of dialysis, supported by a series of competitions. Phase I prizes focused on innovations in biomaterials, novel biosensors and safety monitors used for haemodialysis, as well as approaches for improved vascular access and the development of novel technologies that replicate kidney function more precisely than conventional dialysis. Phase II focuses on strategies to build and test prototype solutions or components of solutions that can replicate normal kidney function or improve haemodialysis access. KidneyX has also awarded a series of Patient Innovator Challenge prizes to patients who have proposed innovative solutions to problems emanating from their everyday experiences with kidney disease, including approaches to monitoring blood electrolyte levels and increasing the accessibility of patient education resources.

Dutch Kidney Foundation and Neokidney

The Dutch Kidney Foundation (DKF; or Nierstichting Nederland ) was founded in 1968. It supports research into the causes, prevention and treatment of kidney failure. Furthermore, it works to improve the quality of dialysis treatment and increase the number of kidney transplants. All projects are planned and organized with considerable patient involvement. The DKF also offers financial support to kidney research projects by large Dutch multi-centric consortia. These projects not only promote innovation in the Netherlands but also support trans-national European Union (EU)-supported projects with Dutch participation or leadership, such as Horizon 2020 and Horizon Europe.

Neokidney is a partnership between the DKF and several companies that specialize in miniaturization of dialysis equipment (including dialysis pumps) and sorbent technology for dialysate regeneration. This partnership is aimed at developing a small, portable haemodialysis device that will enable more frequent dialysis sessions, permit more flexibility for patients and improve patient quality of life, as well as reduce health-care costs. The first prototype is currently undergoing preclinical testing and is expected to be tested in humans soon, with the aim of demonstrating proof-of-concept for the first portable haemodialysis machine for daily use, requiring only a limited volume of dialysate. In addition to the development of miniaturization technologies, the partnership is also investigating the use of polymer membranes that permit combined filtration and absorption to achieve more effective haemodialysis 138 .

Nephrologists Transforming Hemodialysis Safety

Nephrologists Transforming Hemodialysis Safety (NTDS) is a collaborative initiative of the ASN and Centers for Disease Control and Prevention (CDC) that is aimed at addressing a specific complication inherent to contemporary dialysis — infection. In 2016, the CDC observed that 10% of dialysis patients in the USA died each year as the result of infections — most of which were preventable. The aim of NTDS is to develop and deploy innovations to achieve zero preventable infections in dialysis facilities across the USA. To reach this goal, NTDS uses a multi-pronged approach. For example, education strategies via publications 139 , 140 , 141 , 142 , 143 and webinars that address various aspects of infection prevention and standards of care, use of social media, development of an interactive chapter for trainees and clinicians, and invited lectures are aimed at ensuring that nephrologists, nurses, dialysis administrators and other professionals understand the risk of dialysis-related infections and evidence-based best working practices.

NTDS also interacts with experts in infection detection, prevention and treatment within federal, state and local health departments who can provide advice and assistance that is independent of the regulatory and potentially punitive arms of health departments. NTDS promotes the appropriate use of these experts in settings where expert advice is needed.

To promote leadership among physicians and nurses, NTDS is sponsoring a leadership academy to ensure that knowledge pertaining to evidence-based best working practices is applied to improve workflows in clinical practice. Effective leadership is a requirement, particularly in complex settings, to ensure that patient safety is prioritized and to motivate staff to use best practices.

NTDS are also collaborating with human factors engineers to study the workflows used in haemodialysis facilities and help to define ways of avoiding errors that lead to infection. As a first step in this process, NTDS and human factors engineers have spent time in various haemodialysis facilities to obtain information about the complex processes of care within those facilities, particularly with regard to the use of haemodialysis catheters and approaches to hand hygiene, injection safety and disinfection. Better understanding of current processes may lead to better workflow design.

Finally, based on lessons learned during the Ebola Crisis of 2014, an NTDS work group has designed processes to anticipate and respond to unexpected health-care crises. At the time of writing this Review, the NTDS team is working with CDC and haemodialysis organizations to anticipate and respond to the COVID-19 epidemic and its effect on dialysis care.

The Affordable Dialysis Prize

As discussed earlier, kidney failure remains a death sentence for many residents of LMICs owing to a lack of access to dialysis. In response to the pressing need for cost-effective dialysis options, the International Society of Nephrology in collaboration with the George Institute for Global Health and the Asian Pacific Society of Nephrology launched the Affordable Dialysis Prize in 2017 with the objective of facilitating the design of a dialysis system that would cost less than US $1,000, and provide treatment for less than $5 a day, yet be as safe and effective as existing dialysis systems. The prize was awarded to an engineer for a system that runs off solar power and includes a miniature distiller for producing pure water from any source via steam distillation. The purified water can then be mixed with electrolytes in empty PD bags to produce cheap, homemade dialysis solutions. This strategy identifies the lack of cheap, high-quality water as a major impediment to dialysis in LMICs and LICs. The system will ideally fit into a small suitcase 144 . This device remains under development with the goal of initiating clinical trials and ultimately commercializing the technology.

Empowered in-centre haemodialysis

For some patients with kidney failure, maintenance in-centre haemodialysis will always be the preferred treatment, and despite incentivizing policy levers, they will not be interested in pursuing home dialysis or kidney transplantation. In-centre self-dialysis (also referred to as empowered haemodialysis) originated in Sweden, when a young engineer named Christian Farman returned to haemodialysis in 2010 after a failed transplant. Farman began negotiating with his nurses to perform his own dialysis treatments with staff supervision and caught the attention of other patients 145 . Eventually, the process of self-dialysis within this centre — whereby coaches in the dialysis unit train people to take over control of their own treatments and health — grew so popular that a new unit was built at the hospital for self-dialysis patients only, with patient input into the design of the unit. Since then, self-care units were installed in several haemodialysis units in Europe and the USA, offering patients the autonomy and flexibility of home haemodialysis within the safety of a controlled environment. This approach to empowering patients has not been widely used to date, but deserves rigorous study and evaluation 146 .

Remote monitoring to support self-care

Telemedicine is defined as the electronic exchange of medical information between sites with the aim of improving a patient’s health. Telehealth encompasses a broader set of services such as the provision of educational content. New technologies have broadened the scope of telemedicine and telehealth applications and services, making these tools more accessible and useful in the care of patients who live remotely or have difficulty visiting a clinic. The range of services that can be delivered by telehealth now includes two-way interactive video, device data programming, asynchronous messaging , sensors for remote monitoring and portals to enable patients to access electronic health records. Although relatively understudied in haemodialysis patients to date, telehealth has the potential to increase the acceptance of home dialysis and improve patient satisfaction, while potentially decreasing costs and improving outcomes.

Telehealth and the remote monitoring of dialysis patients has become more commonplace in the past decade, particularly in Australia, where telehealth is used widely for patients receiving home dialysis. Telemedicine is also considered a support tool for kidney care in disaster situations such as earthquakes where many individuals in remote locations can be affected. Telemedicine has also been used for distance monitoring of patients receiving PD 147 , 148 . In the USA, the Bipartisan Budget Act of 2018 included provisions to expand telehealth coverage to include patients on home dialysis. This legislation allows patients on home dialysis to choose to have their monthly care-provider visits take place via telehealth, without geographic restrictions. The ongoing COVID-19 pandemic has also resulted in an unprecedented and rapid expansion in the use of telemedicine for providing health care in many regions worldwide, including for the care of patients undergoing in-centre haemodialysis. The experience gained during this pandemic has the potential to permanently embed telemedicine in health-care delivery in many health-care systems.

Although telehealth has considerable promise for the care of dialysis patients, the implementation of telehealth in clinical practice can be challenging 149 . Telehealth-guided digital interactions have the potential to improve outcomes through the provision of activities such as individualized patient-centred education, remote communication and data exchange, in-home clinical guidance and monitoring, assessment of prescription and/or treatment efficacy and adherence, real-time modification of treatments and early alerts for problems that require intervention, although all of these interventions need to be rigorously tested 150 .

The European Kidney Health Alliance

The European Kidney Health Alliance (EKHA) is a non-governmental organization based in Brussels, Belgium, which advocates for kidney patients and the nephrology community at relevant bodies of the EU and also at European national organizations. The EKHA represents all of the major stakeholders in kidney care, including physicians, patients, nurses and foundations. The actions of the EKHA are supported by a dedicated group of Members of European Parliament. Of note, according to the treaty of Lisbon 151 , health-care systems are the responsibility of the national authorities of EU countries, which limits the role of the European Commission to one of complementing national policies and fostering cooperation. The EKHA has undertaken several initiatives in the area of kidney care, mainly focusing on measures to decrease the costs of kidney care while maintaining quality of care and access for all appropriate candidates, and to reduce demand for dialysis by promoting efforts to prevent the progression of kidney disease, and encouraging kidney transplantation as the KRT of choice 66 , 152 . In 2021, the EKHA will focus on reimbursement strategies and access to KRT, especially home haemodialysis.

The Nephrology and Public Policy Committee is a similar initiative created by the European Renal Association–European Dialysis and Transplant Association (ERA–EDTA). This committee aims to translate important kidney-related clinical topics into public policy, including the search for novel biomarkers of CKD, improving transition between paediatric and adult nephrology, and improving collaboration between the ERA-EDTA Registry and the guidance body of the ERA-EDTA, European Renal Best Practice 153 .

Beating Kidney Disease

Together with the Dutch Federation for Nephrology and the Dutch Kidney Patients Association, the DKF has initiated a strategic agenda for research and innovation in the Netherlands. This initiative, called Beating Kidney Disease (Nierziekte de Baas) will promote four specific research areas 154 : prevention of kidney failure, including root causes such as other chronic diseases; personalized medicine including genome and big data analyses, and studies of rare diseases; patient-centred outcomes and quality of life, transplantation and home haemodialysis; and regenerative medicine including bio-artificial kidneys. In collaboration with the EKHA, the Beating Kidney Disease initiative will be proposed as a framework for future initiatives at the Directorate General for Health and Food Safety of the European Commission, and the European Commissioner of Health. Similar to European initiatives that have promoted transplantation 152 , 155 , 156 , these efforts will emphasize shifts in policy action to strengthen institutional frameworks, improve education, training and information, optimize registries, and ensure appropriate benchmarking in nephrology.

Conclusions

The past 50 years have seen rapid changes in how and to whom dialysis is provided. From a global perspective, the escalating numbers of patients who require dialysis mean that even current costs are not sustainable, and yet most people who develop kidney failure forego treatment owing to a lack of access, with millions of lives lost every year as a consequence. Also important, the limitations of current dialysis treatment in alleviating patient suffering, morbidity and mortality are now viewed as unacceptable. Consequently, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization to ensure that in the future, people living with kidney failure have more and better treatment options than exist today.

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Jonathan Himmelfarb & Rajnish Mehrotra

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Competing interests.

J.H. declares that The Kidney Research Institute and the Center for Dialysis Innovation at the University of Washington, which he directs, has received gift and grant support from the Northwest Kidney Centers, a not-for-profit dialysis provider. The Center for Dialysis Innovation has also received a Phase I prize from KidneyX, and a grant from the Veterans Administration. J.H. is also a founder and holds equity in AKTIV-X Technologies, Inc. R.V. has consulted for Baxter Healthcare, B. Braun and Neokidney. R.M. has received an honorarium from Baxter Healthcare and serves as a member of the Board of Trustees of the Northwest Kidney Centers. M.T. has received a lecture fee from B. Braun, which was donated to charity.

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Nature Reviews Nephrology thanks M. Verhaar, who co-reviewed with M. van Gelder, and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Related links

Affordable Dialysis Prize: https://www.dialysisprize.org/

Dutch Kidney Foundation: https://www.narcis.nl/organisation/RecordID/ORG1238896/Language/en

ESRD Data Standard Project: https://khi.asn-online.org/projects/project.aspx?ID=78

European Kidney Health Alliance: http://ekha.eu/

Kidney Health Initiative: https://khi.asn-online.org/

KidneyX: https://www.kidneyx.org/

Neokidney: https://www.nextkidney.com/

Nephrologists Transforming Hemodialysis Safety: https://www.asn-online.org/ntds/

Nephrology and Public Policy Committee: https://www.era-edta.org/en/nppc/

Nierstichting Nederland: https://nierstichting.nl/

Patient and Family Partnership Council: https://khi.asn-online.org/pages/?ID=1

SONG-HD: https://songinitiative.org/projects/song-hd/

SONG-PD : https://songinitiative.org/projects/song-pd/

Standardizing Outcomes in Nephrology Group (SONG): https://songinitiative.org/

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Himmelfarb, J., Vanholder, R., Mehrotra, R. et al. The current and future landscape of dialysis. Nat Rev Nephrol 16 , 573–585 (2020). https://doi.org/10.1038/s41581-020-0315-4

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• Michael I. Norton

A survey of more than 130 HBR readers asked how they use rituals to start their days, psych themselves up for stressful challenges, and transition when the workday is done.

While some may cringe at forced corporate rituals, research shows that personal and team rituals can actually benefit the way we work. The authors’ expertise on the topic over the past decade, plus a survey of nearly 140 HBR readers, explores the ways rituals can set us up for success before work, get us psyched up for important presentations, foster a strong team culture, and help us wind down at the end of the day.

“Give me a W ! Give me an A ! Give me an L ! Give me a squiggly! Give me an M ! Give me an A ! Give me an R ! Give me a T !”

• Michael I. Norton is the Harold M. Brierley Professor of Business Administration at the Harvard Business School. He is the author of The Ritual Effect and co-author of Happy Money: The Science of Happier Spending . His research focuses on happiness, well-being, rituals, and inequality. See his faculty page here .

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Striking findings from 2023

Pew Research Center has gathered data around some of this year’s defining news stories, from the rise of artificial intelligence to the debate over affirmative action in college admissions . Here’s a look back at 2023 through some of our most striking research findings.

These findings only scratch the surface of the Center’s research from this past year .

A record-high share of 40-year-olds in the U.S. have never been married, according to a Center analysis of the most recent U.S. Census Bureau data . As of 2021, a quarter of 40-year-olds had never been married – up from 6% in 1980.

In 2021, the demographic groups most likely not to have ever been married by age 40 include men, Black Americans and those without a four-year college degree.

A Center survey conducted in April found that relatively few Americans see marriage as essential for people to live a fulfilling life compared with factors like job satisfaction and friendship. While majorities say that having a job or career they enjoy (71%) and having close friends (61%) are extremely or very important for living a fulfilling life, far fewer say this about having children (26%) or being married (23%). Larger shares, in fact, say having children (42%) or being married (44%) are not too or not at all important.

About half of Americans say the increased use of artificial intelligence in daily life makes them feel more concerned than excited – up 14 percentage points from last year, according to an August survey . Overall, 52% of Americans say they feel this way, an increase from 38% in December 2022.

Just 10% of adults say they are more excited than concerned about the increased use of AI, while 36% say they feel an equal mix of these emotions.

The rise in concern about AI has taken place alongside growing public awareness of the technology. Nine-in-ten adults say they have heard either a lot (33%) or a little (56%) about artificial intelligence. The share of those who have heard  a lot  is up 7 points since December 2022.

For the first time in over 30 years of public opinion polling, Americans’ views of the U.S. Supreme Court are more negative than positive, a July survey found . A narrow majority (54%) have an unfavorable view of the high court, while fewer than half (44%) express a favorable one.

The court’s favorable rating has declined 26 percentage points since 2020, following a series of high-profile rulings on issues including affirmative action in college admissions, LGBTQ+ rights and student loans. The drop in favorability is primarily due to a decline among Democrats and Democratic-leaning independents, just 24% of whom express a favorable opinion of the court.

A growing share of U.S. adults say the federal government should take steps to restrict false information online, even if it limits freedom of information, a June survey found . The share of U.S. adults with this view has risen from 39% in 2018 to 55% in 2023.

In the most recent survey, 42% of adults took the opposite view, saying the government should protect freedom of information, even if it means false information can be published.

Still, Americans remain more likely to say that tech companies – rather than the U.S. government – should be responsible for restricting false information online. About two-thirds (65%) said this in June.

The number of U.S. children and teens killed by gunfire rose 50% in just two years, according to a 2023 analysis of data from the Centers for Disease Control and Prevention (CDC). In 2019, there were 1,732 gun deaths among U.S. children and teens under 18. By 2021, that figure had increased to 2,590.

The gun death  rate  among children and teens – a measure that adjusts for changes in the nation’s population – rose 46% during that span.

Both the number and rate of children and teens killed by gunfire in 2021 were the highest since at least 1999, the earliest year for which this information is available in the CDC’s mortality database.

Most Asian Americans view their ancestral homelands favorably – but not Chinese Americans, according to a multilingual, nationally representative survey of Asian American adults .

Only about four-in-ten Chinese Americans (41%) have a favorable opinion of China, while 35% have an unfavorable one. Another 22% say they have a neither favorable nor unfavorable view. This stands in contrast to how other Asian Americans view their ancestral homelands. For instance, about nine-in-ten Taiwanese and Japanese Americans have a very or somewhat favorable opinion of their place of origin, as do large majorities of Korean, Indian and Filipino Americans.

While Chinese Americans’ views of China are more mixed, they still have a more favorable opinion of the country than other Asian adults do. Just 14% of other Asian Americans view China favorably.

Even before the Israel-Hamas war, Israelis had grown more skeptical of a two-state solution. In a survey conducted in March and April , prior to the war, just 35% of Israelis thought “a way can be found for Israel and an independent Palestinian state to coexist peacefully.” This share had declined by 9 percentage points since 2017 and 15 points since 2013.

Among both Arabs and Jews living in Israel, there have been declines over the past decade in the share of people who believe that a peaceful coexistence between Israel and an independent Palestinian state is possible.

A majority of Americans say they would tip 15% or less for an average restaurant dining experience, including 2% who wouldn’t leave a tip at all, an August survey shows . The survey presented respondents with a hypothetical scenario in which they went to a sit-down restaurant and had average – but not exceptional – food and service. About six-in-ten (57%) say they would leave a tip of 15% or less in this situation. Another 12% say they would leave a tip of 18%, and a quarter of people say they’d tip 20% or more.

Adults in lower-income households and those ages 65 and older are more likely than their counterparts to say they would tip 15% or less in a situation like this.

Partisan views of Twitter – the social media platform now called X – have shifted over the last two years, with Republican users’ views of the site growing more positive and those of Democratic users becoming more negative, according to a March survey . The share of Republican and GOP-leaning users who said the site is mostly bad for American democracy fell from 60% in 2021 to 21% earlier this year. At the same time, the share of Republican users who said the site is mostly good for democracy rose from 17% to 43% during the same span.

Democrats’ views moved in the opposite direction during that time frame. The percentage of Democratic and Democratic-leaning Twitter users who said the platform is good for American democracy decreased from 47% to 24%, while the share who said it is bad for democracy increased – though more modestly – from 28% to 35%.

These changes in views follow Elon Musk’s takeover of the platform in fall 2022.

Nearly half of U.S. workers who get paid time off don’t take all the time off their employer offers, according to a February survey of employed Americans . Among those who say their employer offers paid time off for vacation, doctors’ appointments or to deal with minor illnesses, 46% say they take less time off than they are allowed. A similar share (48%) say they typically take all the time off they are offered.

Among those who don’t take all their paid time off, the most common reasons cited are not feeling the need to take more time off (52% say this), worrying they might fall behind at work (49%), and feeling badly about their co-workers taking on additional work (43%).

Smaller shares cite other concerns, including the feeling that taking more time off might hurt their chances for job advancement (19%) or that they might risk losing their job (16%). Some 12% say their manager or supervisor discourages them from taking time off.

An overwhelming majority of Americans (79%) express a negative sentiment when asked to describe politics in the United States these days, a July survey found . Just 2% offer a positive word or phrase, while 10% say something neutral.

Among those who volunteered an answer, 8% use the word “ divisive” or variations of it, while 2% cite the related term “polarized.” “Corrupt” is the second-most frequent answer, given by 6% of respondents.

The top 15 most cited words also include “messy,” “chaos,” “broken” and “dysfunctional.” Many respondents are even more negative in their views: “terrible,” “disgusting,” “disgrace” and the phrase “dumpster fire” are each offered by at least 1% of respondents.

Around half of Americans (53%) say they have ever been visited by a dead family member in a dream or in another form, according to a spring survey . Overall, 46% of Americans report that they’ve been visited by a dead family member in a dream, while 31% report having been visited by dead relatives in some other form.

Women are more likely than men to report these experiences.

While the survey asked whether people have had interactions with dead relatives, it did not ask for explanations. So, we don’t know whether people view these experiences as mysterious or supernatural, whether they see them as having natural or scientific causes, or some of both.

For example, the survey did not ask what respondents meant when they said they had been visited in a dream by a dead relative. Some might have meant that relatives were trying to send them messages or information from beyond the grave. Others might have had something more commonplace in mind, such as dreaming about a favorite memory of a family member.

More Americans disapprove than approve of selective colleges and universities taking race and ethnicity into account when making admissions decisions, according to another spring survey , fielded before the Supreme Court ruled on the practice in June. Half of U.S. adults disapprove of colleges considering race and ethnicity to increase diversity at the schools, while a third approve and 16% are not sure.

Views differ widely by party, as well as by race and ethnicity. Around three-quarters of Republicans and Republican leaners (74%) disapprove of the practice, while 54% of Democrats and Democratic leaners approve of it.

Nearly half of Black Americans (47%) say they approve of colleges and universities considering race and ethnicity in admissions, while smaller shares of Hispanic (39%), Asian (37%) and White (29%) Americans say the same.

The share of Americans who say science has had a mostly positive effect on society has declined since 2019, before the coronavirus outbreak, a fall survey shows : 57% say science has had a mostly positive effect on society, down from 73% in 2019.

About a third of adults (34%) now say the impact of science on society has been equally positive and negative. And 8% say science has had a mostly negative impact on society.

Democrats have become much more likely than Republicans to say science has had a mostly positive impact on society (69% vs. 47%). This gap is the result of steeper declines in positive ratings among Republicans than among Democrats since 2019 (down 23 points and 8 points, respectively).

Nearly three-in-ten Americans express an unfavorable opinion of both major political parties – the highest share in at least three decades, according to a July survey . Overall, 28% of Americans have an unfavorable opinion of both the Republican and Democratic parties. This is more than quadruple the share in 1994, when just 6% of Americans viewed both parties negatively.

A majority of Americans say TikTok is a threat to national security, according to a survey conducted in May . About six-in-ten adults (59%) see the social media platform as a major or minor threat to national security in the United States. Just 17% say it is  not  a threat to national security and another 23% aren’t sure.

Views vary by partisanship and age. Seven-in-ten Republicans and GOP leaners say TikTok is at least a minor threat to national security, compared with 53% of Democrats and Democratic leaners. Conservative Republicans are more likely than moderate or liberal Republicans – or Democrats of any ideology – to say the view the app as a major threat.

Nearly half of those ages 65 and older (46%) see TikTok as a major threat to national security, compared with a much smaller share (13%) of adults ages 18 to 29.

Read the other posts in our striking findings series:

• Striking findings from 2022
• Striking findings from 2021
• 20 striking findings from 2020
• 19 striking findings from 2019
• 18 striking findings from 2018
• 17 striking findings from 2017
• 16 striking findings from 2016
• 15 striking findings from 2015
• 14 striking findings from 2014
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Private, selective colleges are most likely to use race, ethnicity as a factor in admissions decisions

Americans and affirmative action: how the public sees the consideration of race in college admissions, hiring, asian americans hold mixed views around affirmative action, more americans disapprove than approve of colleges considering race, ethnicity in admissions decisions, hispanic enrollment reaches new high at four-year colleges in the u.s., but affordability remains an obstacle, most popular.

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