Editorials
Treatment of Diabetic Nephropathy: Changing Landscapes and New Horizons
Until the early 19th century, diabetes mellitus (DM) was regarded as a disease of the kidney, in which one of the signs was that of an increase in the volume of urine and wasting. Only after the identification of glucose in blood and urine in the late 18th century was it recognized as a metabolic disorder. It was noted in parallel that patients with DM may show presence of coagulable urine containing albumin as a sign of kidney disease. After the advent of availability of insulin in the early 1920s, which led to increased survival, diabetic nephropathy became more apparent.A New Therapeutic Era in the Management of Diabetic Kidney Disease
Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease (ESKD) worldwide. After 2 decades of negative trials, in the last few years there has been a major and welcome shift in the therapeutic options to treat DKD. Nephrologists will be in the forefront of implementation of these new therapies as well as in the education of their colleagues and patients on the benefits and possible side effects of these novel therapies.The Ultrasound-Augmented Physical Exam for Nephrologists: Beyond the Kidney
Recent developments in handheld ultrasound technology, including cloud-based image archiving, artificial intelligence–enhanced image guidance, and the development of the capacitive micromachined ultrasound transducer—a microchip alternative to conventional piezoelectrics—are driving down the cost of ultrasound devices and facilitating image acquisition for novice learners. These technologic adaptations lower the barrier for entry and accelerate an already burgeoning trend of adoption of point-of-care ultrasound (POCUS) among medical providers.Home Hemodialysis
This special issue of ACKD on home hemodialysis (HHD) represents a timely reflection on the state of HHD in the United States. President Trump's executive order of July 2019 (Advancing American Kidney Health Initiative) laid out an ambitious agenda for expanding the use of home dialysis and preemptive kidney transplantation in the United States. This issue is a compendium of articles that are wide in their breadth and scope, representing an attempt to address a variety of issues involved in implementing such a complex and difficult task.Dialysis: Please Try This at Home!
Yes, in 2021, we are able to say that the quality of life and freedom to do the things we love can be possible while on dialysis. A special mention to the photograph on the cover of this issue dedicated to home hemodialysis (see credits in the issue), which exemplifies that.Nephrology Critical Care: A Darwinian Evolution
While hospitals across the nation continue to expand their capacity to care for critically ill patients, the practice of medicine in the intensive care unit (ICU) has evolved from being solo intensivist-driven to a multidisciplinary care model. The latter involves a myriad of clinicians as well as pharmacists, physical therapists, nutritionists, and subspecialists that usher a diverse and complementary expertise.1 Among many subspecialists in the ICU, the nephrologist serves as an invaluable asset in many commonly encountered conditions, including electrolyte/acid-base derangements and most notably acute kidney injury (AKI).COVID-19 and the Kidney Community: Coalescing in Crisis
The coronavirus disease 2019 (COVID-19) pandemic has led to significant changes to the practice of kidney medicine. The ability to provide acute dialysis is strained due to high rates of acute kidney injury (AKI), which occurs in up to 30% to 40% of hospitalized patients. The presence of AKI in the setting of COVID-19 is associated with high morbidity and mortality.1 Figure 1 illustrates various manifestations of COVID-19 in the kidney. The need for social distancing has resulted in a shift to outpatient telemedicine for many patients with kidney disease.Reenvisioning the Adult Nephrology Workforce: The Future of Kidney Care in the United States
The cover image in this issue of Advances in Chronic Kidney Disease illustrates the various components (pieces) that make up the nephrology workforce. Although our nephrology community strives to complete this puzzle, these pieces are dynamic and constantly evolving. It is up to our community to react to changes in kidney care to ensure our workforce is able to provide optimal care for patients with kidney disease.Future of Nephrology Workforce: Reimagining Educational Value
The definition of this term states “people engaged in or available for work in any enterprise or company”. Should we be satisfied in simply creating the future workforce? Or should we redefine in how we even articulate what the future of our profession may look like? Should we not be raising the bar to say that we want to nurture the next generation of compassionate and astute clinicians, scientists, and leaders? If so, then we need to reimagine how to do that and tread with caution as we pass on the knowledge to that generation.Dialysis Access: The Future Is Already Here
At the time of this writing, we are in the midst of a full-blown pandemic – the likes of which none of us have seen in our lifetimes. It is in times such as these that our profession and the care of our patients is seen through an unfiltered lens. The American Society of Diagnostic and Interventional Nephrology and the Vascular Access Society of the Americas in an effort to protect the mainstay of our patients' access to adequate dialytic care came together to publish a joint statement in March of 2020 sharing that maintaining dialysis accesses “will be instrumental in maintaining health and survival for patients with end-stage kidney disease (ESKD) as well as protecting hospitals from an eventual wave of high urgency/emergency procedures to deal with lost dialysis accesses.” Dialysis access truly is the lifeline of our patients – the infamous “Achilles Heel,” and in these dire times, our patients' need for a reliable, low-risk access becomes blatantly obvious.Interventional Nephrology: What, Who, Why?
These 2 words can mean different things from a patient's or a provider's perspective. For the patient, it is a “lifeline” to undergo a life-sustaining treatment, day after day, and lack of an optimal access can literally be a death sentence. Whether be it lack of achieving or maintaining the vascular access.O Complement, Where Aren't Thou
The innate immune system represents the oldest arm of mammalian host defense, of which the complement cascade is of paramount importance. Complement serves several roles, including direct cellular killing, tagging of foreign and self-debris for cell-mediated clearance, and modulation of the adaptive immune response. The Human Genome Organization Gene Nomenclature Committee recognizes 56 proteins within the complement pathway. Given this complexity, most medical students and clinicians devote little time to understanding the intricacies of the cascade.Poisoning, Toxicology, and the Nephrologist
In 2017, the American Association of Poison Control Centers reported more than 2.1 million human toxic exposures across the United States. In fact, toxic exposures with serious outcomes have increased every year since 2000.1 Although the 3208 resulting or related deaths were far fewer than the total referrals and interventions, concerns remain. Most reported exposures were due to a few classes of prescription medications (analgesics, sedative/hypnotics, antipsychotics, antidepressants) or readily available cleaning or personal care products.Toxicology and Kidney: Not so Innocent Bystander
Patients are exposed to numerous prescribed and over-the-counter medications. Unfortunately, drugs remain a relatively common cause of acute and chronic kidney injury. By some estimates, up to 1-in-3 cases of acute kidney injury (AKI) can be attributed to the effect of prescribed drugs and endogenous/exogenous toxins. However, establishing causality in drug-induced kidney disease is challenging and requires knowledge of the biological plausibility of the agent, mechanism of injury, time course, and assessment of competing risk factors.Advances in Chronic Kidney Disease as Syntopicon
Advances in Chronic Kidney Disease began its life under the aegis of Allen R. Nissenson as the first Editor-in-Chief of Advances in Renal Replacement Therapy.1 Dr. Nissenson's expressed desire was for A-R-R-T to become the “art” of renal replacement therapy. He explicitly stated this aspiration, echoing the enthusiastic prose of Dr. Seuss, in his inaugural editorial in April 1994, “The ARRT of Uremia Therapy.”1 Instrumental to the journal's conception was much the effort of Garabed Eknoyan—a long-time advisor-contributor to the National Kidney Foundation in so many ways.Cardiovascular Calcifications Among Patients With Uremia: Answers to Hard Questions
A 56-year-old woman with long-standing history of diabetes mellitus and end-stage renal disease is evaluated for severely painful indurations covering both thighs. She is obese and has been on warfarin therapy for atrial fibrillation. A skin biopsy obtained from the indurated area demonstrates calcifications involving subcutaneous arterioles and adjacent adipocytes. A diagnosis of uremic calciphylaxis is made. Prior radiological examinations demonstrate diffuse arterial and valvular calcifications involving coronary, mesenteric, carotid, femoral and aortic beds, and mitral and tricuspid valves.Lupus Nephritis: Breaking the Lull
Systemic lupus erythematosus (SLE) has a prevalence of 241 per 100,000 people in the United States.1 Young women are disproportionately affected and disease burden is highest in blacks and lowest in whites in studies that report data by race.1 Up to 75% of SLE patients will develop kidney disease, which is often asymptomatic and detected only by urinalysis. Pathologic classification of lupus nephritis (LN) is based on the location and degree of glomerular involvement coupled with the activity and chronicity of histologic changes.Lupus Nephritis: How Far Have We Come, and Where Are We Headed?
Of all the organ domains involved in systemic lupus erythematosus (SLE), renal disease is associated with the greatest morbidity and mortality. Relative age-adjusted mortality in SLE patients with renal disease compared to those without is greater at every level of renal involvement and stage of CKD.1,2 Recent data show decreased trends in the burden of end-stage renal disease (ESRD) due to lupus nephritis (LN) in the United States. However, greater than 50% of SLE patients will develop LN and an unacceptably high number (up to 44% of patients with class III or IV LN) progress to ESRD by 15 years requiring renal replacement therapy in the form of dialysis or kidney transplant.Erythropoiesis-Stimulating Agents and Cancer: Myth or Truth
Erythropoiesis-stimulating agents (ESAs) have been implicated in causing cancer progression. This belief has been largely based on trials in the early 2000s of ESA use in malignancy with high hemoglobin (Hgb) targets and large ESA doses to attain the targets. More recent trials using ESA doses with Hgb targets similar to current goal levels in CKD have not confirmed this increased risk of cancer progression for most malignancies.Anemia Treatment After 30 Years of Erythropoietic Stimulating Agents: No Longer Business as Usual?
The publication date of this issue of ACKD, July-August 2019, is almost exactly 30 years after the approval by the Food and Drug Administration (FDA) of epoetin alfa in June 1989. There has been considerable evolution in the treatment of anemia in patients with CKD since that time despite the fact that erythropoietic stimulating agents (ESAs) remain the mainstay of that therapy. In the 1990s, we discovered the necessity of adequate iron supplementation to achieve the targeted erythropoietic response to ESAs.Eradicating the Viral Triad in Hemodialysis Units
In this issue of Advances in Chronic Kidney Diseases, Dr James Novak as Guest Editor has curated a collection of manuscripts from a cadre of nephrologists whose curiosity includes the viral nephropathies. The authors present a well-researched group of articles that comprehensively review the vast majority of contemporary viral disorders with which most nephrologists will engage at some point in their careers. However, the bulk of nephrologists will be concerned with 3 viruses more than others, hepatitis C virus (HCV), hepatitis B virus (HBV), and the human immunodeficiency virus-1 (HIV).Warning: Kidney Virus Detected
The variety of genes on the planet in viruses exceeds, or is likely to exceed, that in all of the rest of life combined. —Edward O. Wilson In 1993, the number of viruses that infected vertebrates, specifically mammals, was estimated at 1,000,000 and 320,000, respectively.1 By 2012, 219 human virus species had been identified, with 3–4 novel viruses projected to emerge each year from mammalian and avian reservoirs.2 Advances in genetics during the past few decades have facilitated the detection of more and more occult viruses, previously unrecognized within the human genome, the accumulation of which is collectively known as the human virome.Dr. Conn Lives on: Insights Into Screening and Genetics of Primary Aldosteronism
This issue of Advances in Chronic Kidney Disease features an old standard, hypertension. This topic is reviewed periodically. This time, Dr. Kausik Umanath has taken up the gauntlet to press forward our collective mission to diagnose and treat this most fundamental medical problem early, accurately, and efficiently. In this issue, the variegation of the pathophysiology of hypertension will be revealed along with its treatments. In Dr. Umanath's Guest Editorial, you will see a glimpse of what is contained within, but first, a story.Hypertension: A Common but Complex Condition
Hypertension is a common condition known to cause significant cardiovascular events including death, stroke, and heart failure.1,2 Our understanding of the pathogenesis and optimal approaches to therapy has evolved tremendously over the past 50 years.3 Despite these advances, only 50% of individuals achieve blood pressure control according to National Health and Nutrition Examination Surveys 2015-2016 data.4 Hypertension remains a significant global health problem, and in this issue of Advances in Chronic Kidney Disease, we have put together a set of manuscripts covering several key issues in both the pathogenesis and management of hypertension.The Many Faces of Infection in CKD: Evolving Paradigms, Insights, and Novel Therapies
In 1961, Schreiner was the first to note unique susceptibility to infection among patients with kidney failure.1 It was assumed that general debility from chronic uremia increased the risk of infection; thus, it was postulated that reversal of the uremic state would reduce the risk of infection.2 Unfortunately, kidney replacement therapy has not reduced the problem of infection; it has only changed the paradigm.3 Dialysis superimposes myriad new problems onto patients already suffering relentless deterioration from underlying multisystem disease and poor wound healing.Hemodialysis Catheter Device Protection: Damned if We Do; Patients Are Damned if We Don't
In this issue of Advances in Chronic Kidney Disease, Guest Editor Mohanram Narayanan, MD, reinvigorates the prior theme of infections in kidney patients. Infections are frequent in nephrology patients and often deadly. Each of Dr. Narayanan's authors pointedly contributes his/her wisdom to the infection theme. So, before reading more, please read each article carefully to enhance your practical working knowledge on behalf of your patients.Leadership in Nephrology: Vital to the Future of Our Profession
When surveyed in 2016 by the Renal Physicians Association, young nephrologists expressed surprise at the speed and manner in which nephrology as a field was changing and “the unique opportunity for leadership” inherent to the profession. The notable concern for a “lack of physician leadership” was balanced by the general sentiment that nephrologists are “uniquely positioned to lead” the way in providing innovation to chronic health care management.Leadership as Tribal Leader
In this final 2018 issue of Advances in Chronic Kidney Disease, our Guest Editor Rebecca Schmidt takes the lead on leadership. She has compiled a series of articles that compress 2 important and sometimes nebulous concepts into digestible format with the assistance of her contributing authors. Each article adds to the others to provide a roadmap to establishing a successful career in medicine and specifically nephrology.A Tale of Two Failures: A Guide to Shared Decision-Making for Heart and Renal Failure
Heart failure and kidney disease are common and rapidly growing conditions in the United States. It is estimated that there are currently 6.5 million adults in the United States1 and 23 million adults worldwide who suffer from heart failure.2 Approximately 30 million Americans have evidence of chronic kidney disease (CKD).3 The presence of either condition is associated with a higher morbidity and mortality than the general population. Approximately 40% of patients with end-stage renal disease (ESRD) have heart failure.Cardiorenal Syndrome: A Call to Action for a Pressing Medical Issue
Thomas Lewis used the term “cardiorenal” in his lecture titled “Paroxysmal Dyspnoea in Cardiorenal Patients” in which he discussed his clinical observations on patients with dyspnea related to advanced heart and kidney disease (referred to as cardiac and uremic asthma in the lecture).1 However, researchers in the 19th and early 20th century had already noted the interactions between the heart and the kidney and performed eloquent experiments highlighting the impact of venous congestion on kidney function.It Is Really Time for Ammonium Measurement
In this issue of Advances in CKD, Guest Editors, Jose A. Arruda and Daniel Batlle, have assembled an A-list of clinician-scientists to review the old and new concepts of renal tubular acidosis (RTA). In an era in which dialysis and CKD dominate nephrology clinical practice, is it not nice to encounter something different every now and then? A low-serum venous total CO2 (referred to as bicarbonate, hereafter), of which the etiology is not readily apparent, is one of the many respites for acid-base mavens of nephrology.Renal Tubular Acidosis and the Nephrology Teaching Paradigm
The renal tubular acidosis (RTA) syndromes, while relatively rare, are of great interest among students of pathophysiology because they offer a model of disease in which the biochemical, physiologic, molecular, and, in some cases, genetic basis of its pathogenesis can be examined.1 Understanding the mechanisms causing RTA also offers a paradigm for nephrology teaching. Practicing physicians as well as adult and pediatric nephrologists in the academic setting who teach trainees at all levels ought to have a solid understanding of the RTA syndromes.Diabetes and the Kidney: Sweet Dreams
A spoonful of sugar makes the medicine go down. —Robert B. Sherman, Richard M. Sherman; 1964 With apologies to Julie Andrews, a spoonful of sugar might be considered child abuse in this modern era of diabetes and obesity. As of 2015, more than 700 million adults worldwide have diabetes or impaired glucose tolerance, and about half of these are unaware of the diagnosis.1 Almost certainly, the glut of type 2 diabetes has been fueled by the expanding obesity epidemic (pun intended). In the United States, the prevalence of obesity tripled from 13% in 1960 to 38% in 2014.Diabetic Kidney Disease (c. 2018)
Diabetes has become a global pandemic that rivals almost any other that has come before it. In the year 2015, 415 million people in the world were living with diabetes, and by the year 2040, that number is projected to rise to 642 million. Most of these people, 95%, have type 2 diabetes. More sobering, there is no evidence that the steadily upward trend in diabetes frequency will abate despite unequivocal evidence that type 2 diabetes is largely preventable, especially by healthy lifestyle choices.Disturbances in Acid-Base, Potassium, and Sodium Balance in Patients With CKD: New Insights and Novel Therapies
The kidney plays a critical role in the regulation of acid-base, potassium, and sodium balance, a role that can be compromised by a decrease in kidney function caused by CKD (defined as an eGFR < 60 mL/min/1.73 m2). Because of the high prevalence of type II diabetes and hypertension, progressive damage to the kidney resulting in CKD is increasingly common in the world's population. Furthermore, it is likely that the prevalence of CKD will only increase as the population ages.Hyperkalemia: Inpatient PaniK
In this issue, Guest Editor Jeffrey Kraut determined to “go back to the basics” of nephrology and assembled an august group of authors whose expertise spans the gamut of electrolytes and acid-base disorders. The table of contents represents a carefully curated compilation of articles, each of which is a minireview and state-of-the-art appraisal of the literature on a particular topic. In alignment with this familiar group of topics, I have chosen to concentrate on inpatient hyperkalemia. Rather than opining on the panoply of potassium abundance disorders, I devote my time and yours to matters of all things done wrong when confronted with inpatient hyperkalemia, a common finding that evokes a “PaniK” disorder.Acute Kidney Injury: A Paradigm in Quality and Patient Safety
The first contemporary description of the syndrome of acute tubular necrosis (synonymously used with the clinical diagnosis of acute kidney injury) was reported by Drs. Bywaters and Beal.1 That specific case was a clinical description of a young woman who had suffered crush injuries during the “London Blitz,” with the probably cause of ATN resulting from a combination of ischemic injury and rhabdomyolysis. It turns out that there have been prior historical references hinting toward nephrotoxic injury.The AKI Clinic for Fragile Patients
The recent terrorist attack in Manchester, England, at a pop “musical” concert1 represents a somber reminder of the London Blitz—the “lightning war”—prosecuted by Hitler against Great Britain during World War II. The dome of the church on the cover illustration, provided by Guest Editor, Charuhas Thakar, represents the hope of the Londoners who survived the protracted bombing that lasted 9 months, and our own hope that an effective resolution to the abject, lawless acts of violence by fanatical and radical terrorists comes soon.Prophylactic Hemodialysis for Protection Against Gadolinium-Induced Nephrogenic Systemic Fibrosis: A Doll's House
No doubt you, like I, have been informed by your radiologist that your advanced CKD or ESRD patient “must undergo hemodialysis” to prevent gadolinium-based contrast agent (GBCA)-induced nephrogenic systemic fibrosis (NSF) following a magnetic resonance imaging (MRI) study. Few disorders in nephrology have generated more excitement and fear than this devastating dermatologic disorder, first described in 2001 as a case series of 13 patients originally discovered in 1997 at the Sharp Clinic.1 This disfiguring and disabling skin-scarring disorder, formerly labeled as nephrogenic fibrosing dermopathy, is attributed to the deposition of gadolinium chelates in the skin and other organs, hence, the “systemic” term.Scared to the Marrow: Pitfalls and Pearls in Renal Imaging
Medical science can only flourish when it is conducted in alignment with society's interests. We value the health of our patients and want to ensure the safety of our diagnostic procedures. Often the quality and value of these procedures are increased with intravascular contrast. Common contrast materials include iodinated contrast (useful in too many X-ray-enhanced examinations to list) and gadolinium-based contrast for nuclear magnetic resonance imaging.The Renal Tubulointerstitium
The renal tubulointerstitium is an often underappreciated compartment of the kidney but of great importance in acute kidney disease and CKD. As early as the 1970s, Bohle and colleagues1 recognized that kidney function did not correlate well with the severity of glomerular disease but rather with the relative interstitial volume. We now know that the microenvironment encompassing the tubulointerstitium is composed of tubular epithelial cells, interstitial cells, peritubular capillary endothelium, pericytes, and extracellular matrix, which have complex structural and functional relationships.The Tubulointerstitium: Dark Matter
Relegated to a less glamorous position than the glomerulonephritides, the tubulointerstitial compartment or tubulointerstitium of the kidney has been the dark matter of the kidney universe.1 In the same fashion that dark matter predominates over atomic matter, the tubulointerstitium does so over the glomerular compartment. In fact, dark matter and the tubulointerstitium hold their respective universes together. In this issue, some of the mysteries of kidney dark matter are revealed by Cynthia Nast and the authors she has enlisted.A Fundamental Theorem of Telehealth
In 2009, Friedman proposed the Fundamental Theorem of Informatics,1 which stipulates that a person working in partnership with an information resource (eg, an informatics system such as a computer) is “better” than that same person unassisted (Fig 1A). Similarly, Friedman described what informatics is not, explaining that informatics is more about people than technology (Fig 1B). Current advances in the use of health care informatics for the treatment of chronic illness have expanded into the realm of telehealth, and Friedman's theorem can be equally applied to its intent.Nephrology and Telehealth: Now? or Now!
In this issue of Advances in Chronic Kidney Disease, Clarissa Diamantidis, Andrew Narva, and colleagues provide examples of telehealth within the field of nephrology that are actively utilized today. They also offer descriptions of real-world approaches to the development and sustainability of such telehealth programs.One Isn't the Loneliest of Numbers: N-of-1 Trials
In this issue of Advances in Chronic Kidney Disease by Guest Editors, Donald Molony and Joshua Samuels, evidence-based medicine (EBM) once again comes to the fore. This issue represents an encore of sorts, reinvigorating many of the concepts which they promoted with their authors in Volume 19, Issue 1 of this journal, “Evidence-Based Nephrology.”Translation of Evidence Into Clinical Practice
Evidence-based medicine (EBM) emerges from the belief that delivery of care to patients will be more effective and efficient if decisions are based, as much as possible, on unbiased robust evidence regarding prognosis, etiology, diagnosis, and therapy/prevention. Although acknowledging a degree of uncertainty in every clinical decision, EBM has always challenged practitioners to pursue evidence to reduce uncertainty as much as possible. Application of only the most rigorous evidence can minimize the uncertainly inherent in medical decisions.Advanced CKD: Preparing for a Storm to Avoid a Disaster
Traditionally, advanced CKD is the stage when we try to prepare a patient for the possible need for renal replacement therapy (RRT). Our difficulty as clinicians in this preparation is multifold: all patients do not progress uniformly; an individual patient's trajectory of decline can hasten or slow; comorbidities may cause death before needing RRT; acute kidney injury may herald the need for more urgent initiation of dialysis; and patients may resist our treatment plans and tell us they are fine.Improving Transitions in CKD: Failure Mode
In this issue of ACKD, Maria DeVita with her collaborators summarize the important points to consider as patients transition from Stage 4 to Stage 5 CKD. The earlier transition from Stage 3A to Stage 3B portends enhanced cardiovascular risk, and these heart and vascular risks and overall mortality increase exponentially through Stages 4 and 5.1,2 The importance of safe navigation through the course of Stage 4 cannot be overemphasized. This is particularly relevant in terms of patient education and modality of renal replacement therapy.Intensive Care Unit Renal Replacement Therapy: Less Is More (or Better)
Acute kidney injury (AKI) is on every nephrologist's mind. Although it took some time for the transition to the nomenclature of CKD stages from chronic kidney failure, the rapid assimilation of “AKI” into the internal medicine vernacular has been relatively light speed. Now, AKI must be considered a cause of CKD, although not necessarily in the fashion of a 5/6 nephrectomy—an immediate cause of CKD that is accompanied by a tremendous degree of compensatory hypertrophy unseen in the human analogue.Changing Faces of Critical Care Nephrology
The intensive care unit is dynamic and constantly evolving. Four years ago, we devoted an issue to Critical Care for the Nephrologist. Since then, there has been sufficient change in the field to devote another issue of “Advances in Chronic Kidney Disease” to the topic of critical care nephrology, which we have called “Changing Faces of Critical Care Nephrology.”PGX: Pharmacogenomics During Generation X
Years ago, a pharmacologist informed a group of physicians treating high blood pressure that a great deal of time was spent treating patients with hydralazine who would not respond to it. He stated that a hydralazine test dose of 10 mg would resolve the issue for many. No blood pressure–lowering response from that dose would predict an equally impotent result from the ensuing and multiple, relatively slow dose escalations—the wont of most treating individuals. Consciously or not, the pharmacologist was stating that the relationship between a drug and its efficacy, which represented the culmination of multiple metabolic and biologic factors, lay in the genes.It is all About “ADME”
We now live in an era of personalization, seeking products and experiences that are designed for an individual based on their inherent characteristics. Culturally, we have a strong interest in what makes us unique. Commercial genetic testing companies such as 23andMe exemplify both the public's interest in knowing their genetic background and how far research and DNA mapping have come to make these services available widespread. Recent data published by the Impact of Personal Genomics found that among people using commercial personal genomic testing, prior diagnosis of a disease was significantly associated with interest in genomic testing for that specific condition.Geriatric CKD: Value-Based Nephrology
Each nephrologist in the United States is now participating in a value-based purchasing (VBP) plan. Nephrology patients, particularly geriatric individuals with advanced CKD or ESRD represent the bulk of our current and future VBP-based decision-making. Therefore, nephrologists must become more adept at value-based decision-making, and these decisions must align with the values of patients.The Elderly With CKD: Proceed With Care
The forecasted surge in the elderly population continues at pace, fueled by world population growth and increased longevity, particularly in developed nations.1,2 In the United States, the Baby Boomer generation is now moving into their 60s and 70s. With the burgeoning elderly segment of society, the rates of CKD have risen in parallel. Not only are people living longer, but they are living to reach kidney failure. Despite the possibility that estimation equations for glomerular filtration rate (GFR) may overestimate CKD in the elderly, the numbers remain in the millions in the United States alone (over 10 million for CKD Stage 3 or higher).Transforming Hemodialysis Vascular Access Care: One Aspect at a Time
ESRD is a global health challenge. The number of patients receiving renal replacement therapy (RRT) is expected to rise from 2.6 million to 5.5 million by 2030, with most of the growth expected to occur in Asia.1 The epidemiological challenge posed by ESRD and CKD in the United States appears to be stabilizing, but the associated cost continues to escalate. Medicare cost for ESRD care rose above 34 billion dollars with 73% of it toward hemodialysis (HD) in 2011.2 Although the use of peritoneal dialysis has increased in recent years, the brunt of the anticipated increased need for RRT is likely to be borne by the HD modality.Vascular Access: Inukshuk
An inukshuk (pl. inuksuit) is a figure constructed from unworked stones or boulders (Fig 1) that is used for communication among the Inuit in the Arctic.1 In Inuktitut, the language of the Inuit, inukshuk means “to act in the capacity of a human.” Inuksuit serve several functions including acting as hunting and navigational aids, coordination points, and messaging centers. In addition to their practical functions, inuksuit are venerated and possess spiritual connotations. For those who survive and thrive in the Arctic in the “Old Way,” mindfulness and appreciation of the import of guidepost inuksuit are critical.Nephrohepatology: Managing the Nexus of Liver and Kidney Interactions
There are, in truth, no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs – Sir William Osler (1849-1919).Hepatology and Nephrology: Nimbus
Our two Guest Editors, Jay Koyner and Michael Heung bring forth the ever-emerging issue of concurrent liver and kidney disease and those individuals with acute or chronically impaired hepatic function who develop kidney dysfunction acutely or chronically. They note that increasingly nephrologists have specialized in areas outside their usual work, for example, the onco-nephrologist. Furthermore, they discuss the nascent subspecialist, the hepato-nephrologist.Crossing Vessel and Crossroads With Urology
A 4-year-old boy undergoes robotic-assisted laparoscopic pyeloplasty for possible ureteropelvic junction obstruction. An antenatal ultrasound had identified left-sided hydronephrosis. Postnatal ultrasound confirmed this finding, but radionucleotide imaging at 2 years revealed no evidence of obstruction. Serial ultrasounds were performed, and these revealed worsening hydronephrosis; a repeat radionucleotide scan was consistent with obstruction at the uteropelvic junction (UPJ). Intraoperative pyelogram confirmed the diagnosis (Fig. 1).Set Theory: Nephrology ∩ Urology
Each new patient encounter for me engenders 2 proclamations. The first is the formal introduction of name, and the second is to define who I am, a nephrologist, and who I am not, a urologist. The Guest Editors, Dr Hoenig, an adult nephrologist, and Dr Neu, a pediatric nephrologist, have placed us at the crossroads of Nephrology and Urology in this issue of Advances in Chronic Kidney Disease. Their intent and that of the invited authors of this review is for nephrologists to more fully acknowledge and comprehend what urologists do because some urological disorders affect the practice of Nephrology.Secondary Hypertension: Beginnings and Transitions
…it is well to recognize that the extra pressure is a necessity–as purely a mechanical affair as in any great irrigation system with old encrusted mains and weedy channels…Get it out of your heads, if possible, that the high pressure is the primary feature, and particularly the feature to treat.1,2Hypertension in CKD: Sodium Still at the Nexus
The co-editors of this issue of Advances in Chronic Kidney Disease, Drs John Sperati and Adam Whaley-Connell, have succeeded in bringing together a series of articles that comprehensively, yet concisely, describe that which is most contemporarily important in the area of secondary hypertension. Notably, this issue was purposefully placed to follow the most recent issue of Advances in Chronic Kidney Disease co-edited by Cohen, Goldman, and Sim and which focused on hypertension in general. Aldosterone, the intrarenal renin-angiotensin system, pharmacologically and inadvertently induced aggravation of high blood pressure, catecholaminergic excess, insulin resistance and diabetes, sodium and extracellular volume expansion, and cardiotonic steroids, are all discussed within the context of secondary hypertension.The Heterogeneity and Diversity of Hypertension in CKD
Historically, hypertension (HTN) has been approached as a unique disease with emphasis on conforming to a unified and singular approach. Booker T. Washington once said “In all things social we can be as separate as the fingers, yet one as the hand in all things essential to mutual progress.” There has been a similar approach toward HTN throughout this country and the world. We have united hand and fist in the fight against HTN. Health professionals and society have made a concerted effort to raise awareness, identify, and treat this disease.Ambulatory Blood Pressure Monitoring: Mercury Rising
In this issue of Advances of Chronic Kidney Disease, the 3 coeditors, Debbie Cohen, Jesse Goldman, and John Sim, have marshaled the efforts of 11 sets of authors to provide the readership with updates of the diagnosis and management of the most prevalent cardiovascular disease, hypertension. The 11 articles expansively cover the engaging and multidimensional relationship between hypertension and the kidney. However, this editorial will reflect on some of the vagaries encountered in the day-to-day practice of managing hypertension.M.I.A.M.I.: The Whealth Di$parity
Drs Deidra C. Crews and Yoshio N. Hall tackle the subject of health disparity in CKD in this issue of Advances in Chronic Kidney Disease. What does that mean? At a basic level, one or more socially disadvantaged groups experiences worse health, less quality of care, or inferior outcomes to a comparator group. Disparity variables often include those of social or political significance: race, ethnicity, poverty level, literacy (general or health related), immigrant status, sexual orientation, and English proficiency.Social Disadvantage: Perpetual Origin of Kidney Disease
CKD affects approximately 26 million Americans, is the ninth leading cause of death in the United States, and costs the federal government more than $79 billion annually, including $34 billion for ESRD.1-3 Progressive CKD disproportionately affects socially disadvantaged groups, particularly racial-ethnic minorities and persons of low socioeconomic means.1,4,5 The magnitude and persistence of these disparities have led the US government to prioritize their elimination while also attempting to reduce the overall burden and costs of CKD.The Need for Collaboration to Improve Cardiovascular Outcomes in Patients With CKD
The global population of patients who have CKD is increasing at a staggering rate. Individuals with CKD are at risk of progressing to ESRD, but they also are exposed to a disproportionate rate of cardiovascular complications. The convergence of CKD and cardiovascular illnesses poses a unique problem for the public health. In the United States, 26 million people have some form of CKD, and more than 600,000 patients have ESRD and, thus, require some form of kidney replacement therapy.1 In Taiwan and Japan, the prevalence of ESRD is reported to be ∼2500 per million population, whereas in the United States, Portugal, and Singapore, ESRD occurs in 1600 to 2000 per million population.Kidney Failure: Cardiorenal and Venorenal
This issue of Advances in Chronic Kidney Disease is guest-edited by John P. Middleton and Uptal Patel. It is a timely one and is focused on the hope that CKD and cardiovascular disease (CVD) providers can collaborate with and learn from each other. CVD is rampant among patients with CKD. Patients with heart failure, valvular disorders, and arrhythmic disorders occupy significant space in the realm of CKD. The concomitance of cardiac and kidney disease has led to the nosology of cardiorenal syndrome that conveys the kidney as victim, types 1 and 3, and perpetrator of the syndrome, types 2 and 4.Focal and Segmental Glomerulosclerosis—Are We There Yet?
Focal and segmental glomerulosclerosis (FSGS) has been increasing in incidence over several decades. It is the underlying cause of nephrotic syndrome in 40% of adults and 20% of children and is the most common primary glomerular lesion resulting in end-stage kidney disease in the United States.1 FSGS is not a single disease but a morphologic pattern of injury that develops from a wide range of etiologies. The terminology refers to the pattern of scarring in the glomerulus (glomerulosclerosis), which is focal (involving only a portion of the glomerular population) and segmental (affecting only a portion of the glomerular tuft).FSGS: Forme Pleine or Forme Fruste
Several years ago, I was asked by a physician-colleague to conduct a consultation on her spouse who had enjoyed robust health. Apparently, proteinuria was present, and the couple was worried. He was a young, adult, white man: no hypertension, no edema, normal serum creatinine, an absence of erythrocyturia and lipiduria, and a urine protein-to-creatinine ratio between 0.6 and 1.0 g of total protein per gram of creatinine were reported. The ratio of the urine albumin-to-creatinine ratio to the urine protein-to-creatinine ratio was nearly 0.7 g albumin-to-total protein (normal range <0.4), indicating that the bulk of proteinuria was albuminuria.CKD and the Interdisciplinary Team: The Logic Behind the Trend
CKD is a term that has been coined in the last decade, one that encompasses a wide spectrum of kidney diseases that lead to persistent kidney injury. CKD is a morbid condition as cure remains elusive. In many instances, the disease is “progressive” and end-stage kidney disease (ESKD) is imminent, committing the individual to lifetime kidney replacement therapy in the form of dialysis or kidney transplantation. In other instances, the disease is “mild” with a low likelihood of progression, and yet a diagnosis of CKD may be just as grim because many studies have shown that CKD is an independent predictor of cardiovascular disease and mortality.Resolved: The Case for CKD Clinics
The title of this issue of Advances in Chronic Kidney Disease by Guest Editors Davis, Jalal, Weis-Malone, and Zuber is self-explanatory. The tenet is that a nephrology group will derive “more” from initiating a successful interdisciplinary CKD clinic than if it does not. To prove this hypothesis has been a vexing issue and an enraging debate. Part of the problem is that the “more” has been solely interpreted on a cost basis. The cost of establishing an interdisciplinary CKD clinic was generally considered higher than any revenue that could be generated by the clinic, thereby establishing it as a losing proposition.Diabetic Kidney Disease: An ACEI (or an ARB) in the Hole
In this issue of Advances of Chronic Kidney Disease, the co-guest editors, Kevin Ho and Amy Jayne McKnight, deliver a state-of-the art review of diabetic kidney disease (DKD). The contributing authors have carefully reflected on various facets of this critically important condition, which constitutes the predominant diagnosis of ESRD within the United States. Their composition and melding of basic and clinical sciences related to DKD is outstanding and prescient. By contrast, I will wax toward the present.The Changing Landscape of Diabetic Kidney Disease: New Reflections on Phenotype, Classification, and Disease Progression to Influence Future Investigative Studies and Therapeutic Trials
Diabetic kidney disease (DKD) occurs in approximately 1/3 of adults with diabetes. Growth of CKD has increased in parallel with rising prevalence rates of diabetes. This growth has occurred irrespective of the increased use of glucose-lowering medications and antihypertensive therapy, including the use of renin-angiotensin-aldosterone system (RAAS) inhibitors.1 The adjusted increase in DKD prevalence was 34% from 1988 to 2004 through 2005 to 2008 despite reciprocal decreases in mean hemoglobin A1c, systolic and diastolic blood pressures, and low-density lipoprotein cholesterol levels over the same time period.The Evolution of Treating Glomerular Diseases: Letting Science Lead the Way
Nephrologists treating glomerular diseases used to joke that the job was easy. There were only a handful of immunomodulatory therapies available, and the nephrologist just had to rotate through them until finding one that worked. Of course, this trial-and-error approach was not entirely accurate, but, like every joke, it possessed a kernel of underlying truth. As a mentor of ours liked to say about patients who did not respond to a first- or second-line therapy, “The thing about glomerular diseases is that the therapies work for some of the people all of the time, but all of the people none of the time.”1Treatment of Nephrotic Syndrome: Retrospection
In this issue of Advances in Chronic Kidney Disease, the guest editors, Drs. Radhakrishnan and Bomback, have assembled a retinue of glomerulologists to advance the theme of essentially “what's new” in the treatment of glomerulonephritis—a truly heterogeneous group of disorders. The 10 papers contained herein do just that, informing the reader of novel therapies and breakthroughs that have demonstrated efficacy in the treatment of the various glomerulonephritides, ranging from well-known disorders to ultraorphan diseases,1 which affect less than 0.0020% of a defined population.Cancer and the Kidney: The Growth of Onco-nephrology
Onco-nephrology is a rapidly growing area of nephrology that has recently garnered increased attention by specialty societies, such as the American Society of Nephrology and National Kidney Foundation, as well as several prominent journals.1-5 Many of us during our nephrology fellowship training and in earlier years of practice encountered cancer patients with various kidney-related insults, including acute kidney injury (AKI), tumor lysis syndrome (TLS), hypercalcemia, lactic acidosis, and other electrolyte and acid-base disturbances.Onco-nephrology: Time to Intravasate
I was recently confronted by the case of a patient with immunoglobulin E myeloma who had mild, acute kidney injury (AKI). Recalling that there is significant mortality associated with AKI in oncology, I was concerned. If the situation worsened precipitously, embarking on a potentially prolonged course of renal replacement therapy might prove even more precipitous. Nonetheless, the question to answer was immediately apparent: “Did this patient require a kidney biopsy?” There was neither a profound degree of proteinuria nor a discernible trend in declining kidney function, but the patient was manifesting MGRS—indicative of a monoclonal gammopathy of renal significance—when monoclonal gammopathy of undetermined significance is no longer undetermined or insignificant, as coined by the International Kidney and Monoclonal Gammopathy Research Group.Rise of the Small Machines: Salvation
If you had not noticed, you are probably working harder than ever to remain as productive as before. Given the ongoing financial and regulatory landscapes in nephrology and medicine, in general, this scenario represents a formula for disaster and self-implosion. More than ever, we must acknowledge and invoke the mantra of former Walt Disney Company cartoonist, Carl Barks: “Work smarter, not harder.” Thinking small, not small thinking, portends large advances in nephrology. Machine automation on the small scale will permit us to do this, and technical innovation, particularly in the field of nanotechnology, which uses “machines” that manipulate matter on the scale of 1 to 100 nm to perform specific functions, is our future.Who Impels Nephrology: Women
About 1 year ago, Jerry Yee asked me if I would co-guest edit an issue of Advances in Chronic Kidney Disease about women and kidney disease with Sharon Silberger. I agreed, and we formulated a table of contents and began to invite authors. Unfortunately, Sharon died September 6, 2012 after a long battle with chondrosarcoma. This issue is dedicated to her. Amy Williams and Connie Davis graciously agreed to step in as co-guest editors.Education in CKD—Learning in the 21st Century
“Education is the most powerful weapon which you can use to change the world.” —Nelson Mandela.The Guitar-Maker: Model Education
This issue of Advances in Chronic Kidney Disease is dedicated to the nephrological education of medical learners of all types as well as patients Guest editors Campbell, Sturdivant, and Ullian present a group of authors who yield some answers to the questions each author poses. However, as anticipated, the reader may formulate more questions than answers, and that is not a bad thing because that is how we learn. As medical information and the ways to obtain it increase at rates that are far beyond anyone's capacity to appreciate, much less absorb them, one must be selective, for it is this selectivity that ultimately determines the depth to which one learns a concept.Pregnancy and Kidney Disease—The Miracle Continues Against All Odds
As many features of pregnancy appear to be miraculous, the kidney's adaptive responses are no less so. In an uncomplicated pregnancy, the nephrologist rarely gets involved because of the fine orchestration between the various mediators and the kidney. When complications do arise, however, either because of hypertensive conditions, acute kidney injury (AKI), or underlying kidney diseases, the nephrologist's contribution becomes paramount. It is ironic to note that what the nephrologist should do to care for these patients is based on limited clinical evidence.Pregnancy and Kidney Disease: Crossroads No More
In this issue of Advances of Chronic Kidney Disease, the Guest Editors, Susan Hou and Belinda Jim, have carried to term 12 papers that that provide an up-to-date and comprehensive set of directions for the intersections of obstetrics and nephrology and hypertension. Like most drivers, the rules of entry into an intersection are practiced more than recalled and performed exactly as once taught and learned. Thus, preventable illness still occurs in situations in which nephrological care could forestall substantial morbidity and mortality to fetus and mother.Bon Appétit: Time to Eat for Better Kidney Health
We all need to eat (and each of us almost always has a number of extreme food likes and dislikes), which may be why research on dietary factors and medical conditions continues to garner substantial interest well beyond the traditional scientific community and consistently infiltrates the general public media. Yet under the surface of each tidy sound bite or headline with proclamations such as “Lycopene Linked to Reduced Stroke Risk” in the New York Times1 or “Diet Sodas May Hurt Kidneys” on National Public Radio,2 the science of studying nutrition and chronic diseases is complex and challenging.Nutrition in CKD: Songgaar | Burungaar
This issue of Advances in Chronic Kidney Disease provides equipoise regarding dietary therapy in CKD. The guest editors, Drs. Holly Kramer and Julie Lin, have patiently plaited together a series of up-to-date reviews regarding the whys and wherefores of nutritional intervention in patients with nondialysis-dependent CKD and those with ESRD. Kramer and Lin challenge you, the reader, to examine current views of medical nutritional therapy issues relevant to kidney patients, with the overarching mission of undergirding you with greater knowledge, so that you may take action with timely, structured decision-making on behalf of CKD patients with nutritional issues, possibly the area that receives the least volume of formalized training in nephrology.Critical Care Nephrology: Update in Critical Care for the Nephrologist
Like the tide, over the past 15 years critical care has changed—back and forth and back again. In 2001, the pivotal PROWESS (Protein C Worldwide Evaluation in Severe Sepsis) clinical trial led to the approval of the first targeted therapy in patients with sepsis and a high risk of death, activated protein C (APC).1 However, subsequent negative studies led to the PROWESS-SHOCK trial,2 a randomized clinical trial mandated by the European Medicines Agency, Europe's equivalent of the US Food and Drug Administration.Newphrologist: The Intensive Care Kidney Specialist
The tsunami of CKD has now possibly generated an even greater wave of acute kidney injury (AKI) that is sweeping over the world. The causes and frequencies of AKI differ markedly between developed and developing nations, but the wave of AKI continues to rise.1 The pre-eminent risk factor for the development of AKI is CKD, and older patients are at risk for multiple reasons.2 The elderly have less kidney regenerative capacity and often have chronic medical conditions that render them more greatly susceptible to kidney insults, such as ischemic heart disease.Gout: A Step Forward
With a small first step, a primitive organism made the transition from a stable aquatic environment to the harsh, arid climate of land. In some as yet undeciphered way, this evolutionary leap set in place a series of further steps that would eventually lead to the development of hyperuricemia and gout in man.Uric Acid: A Clearer Focus
Plasma phosphorus and uric acid/urate levels were removed from clinical laboratories' metabolic panels nearly 3 decades ago. There was insufficient evidence for their continued measurement. Moreover, fears of treating asymptomatic hyperuricemia with allopurinol, with its risk of side effects and hypersensitivity, contributed to uric acid's removal from the metabolic panel. Subsequently, the evidence base for both of these nephrocentric molecules developed. This issue of Advances in Chronic Kidney Disease converges on uric acid/urate, which gained preeminence in hominoids by virtue of the loss of the uricase gene during evolution through the Miocene Epoch.Evolving Strategies in the Diagnosis, Treatment, and Monitoring of Myeloma Kidney
For physicians who treat patients with multiple myeloma, it is the best of times. Sensitive bioassays are now readily available to assist with the diagnosis and monitoring of these patients. Perhaps more significantly, however, the last decade has seen a revolution in the chemotherapeutic approach with the development of highly effective chemotherapies. In addition, there have been remarkable advances in understanding the underlying pathogenesis of myeloma-associated renal diseases. These developments combined to bring together a group of hematologists, pathologists, and nephrologists who have specific interests in myeloma.Monoclonal Gammopathies: Disambiguation
Nearly two years ago, at one of Detroit's Intra-City Kidney Grand Rounds, two prominent nephrologists somewhat feverishly debated the basics concerning the management of a case of acute kidney injury in a patient with multiple myeloma who required hemodialysis. Hypercalcemia was not present and had been ruled out of the usual differential diagnostic possibilities. Intravenous radiocontrast had not imperiled the renal organs, and antibiotic-associated nephrotoxicity was also absent. Any question of the adequacy of the effective circulatory volume had been dispensed with and there was no outpouring of urate and/or phosphate from cells as a consequence of chemotherapy.Live Kidney Donation: Gaps Remain
In this issue of Advances in Chronic Kidney Disease, national and international experts discuss living donor transplantation, focusing primarily on the “donor” perspective. In this editorial, we intend to highlight the most important aspects of living donor transplant practices in the United States while summarizing the relevant information provided in the articles included in the issue.Living Kidney Donation: More Than Two to Tango
In this issue of Advances of Chronic Kidney Disease, our Guest Editors Davis, Patel, and Samaniego-Picota have carefully elicited from their contributors the essentials of kidney donor health issues. Their tenet that potential recipients should all be offered living kidney donation is both powerful and provocative. In an ideal world, they are certainly right, and the respective authors in this issue must right-size this proposal within the constraints of our real-world health care, juxtaposing the various forces and constraints of finances, culture, and technology.Harm in Nephrology: Its Systematization
Confident in the classical biophysical knowledge that governs vectorial translocation of molecules in solution, most nephrologists are unmistakably shaken when things go awry for their patients undergoing hemodialysis or other renal replacement therapies. The calculations and formulas were without error, but errors occurred anyway, with harm as the extant corollary. The reason is simple, what happens to ideal gases and solvents is not ideal when one deals with the variability of reality in man, where “to err is human.”Primum Non Nocere—Preventing Harm in Nephrology Practice
Primum non nocere, which translates to “First (Above all), do no harm,” is taught conceptually to all medical students, and the common myth is that this is derived from the Hippocratic Oath. But primum non nocere is Latin, and Hippocrates was Greek. Use of the Greek language died out during the Middle Ages, and the Hippocratic Oath was translated into Latin, likely both by monks and physicians, and first appeared in print in Latin in the fifteenth century.1 Although it is true that the Hippocratic Oath, both the original and classic translations, includes comments on never harming patients with either dietary or medicinal advice, this concept was better laid out in the Hippocratic Corpus in Epidemics (Bk 1, Sect 11), where it was stated that “The physician must….have two special objects in view with regard to disease, namely, to do good or to do no harm.” This book was not known in medieval Europe and was not printed until the sixteenth century in Latin translation.Glomerular Grievances and CKD
Glomerular disease has been estimated to occur in approximately 18 per 100,000 people, although the exact incidence is difficult to determine.1 Factors such as recognition of urinary abnormalities, renal biopsy practice, infections, health resources, socioeconomic conditions, and environmental factors significantly affect the incidence of glomerular disorders, which actually may be higher than reported. In addition, systemic and vascular diseases such as diabetes and hypertension substantially increase the incidence of nephropathies associated with CKD.The Global Role of Kidney Transplantation
World Kidney Day on March 8, 2012 provides a chance to reflect on the success of kidney transplantation as a therapy for end-stage kidney disease that surpasses dialysis treatments, both for the quality and quantity of life that it provides and for its cost-effectiveness. Anything that is both cheaper and better, but is not actually the dominant therapy, must have other drawbacks that prevent replacement of all dialysis treatment by transplantation. The barriers to universal transplantation as the therapy for end-stage kidney disease include the economic limitations that, in some countries, place transplantation, appropriately, at a lower priority than public health fundamentals, such as clean water, sanitation, and vaccination.The Renal Amalgam: Where Renal Pathology Fits
An amalgam is composed of metallic alloys that somehow by virtue of their individual properties fit together and become more than the sum of its constituent parts: this is the essence of nephrology. Recalling that the kidney performs a myriad of functions, it is only apropos that the discipline has required a coalition of several constituencies: electrolyticians, endocrinologists, dialyticians, hypertensionologists, and renal pathologists. This coalition, somewhat amorphous at first, congealed to become what we now acknowledge as the discipline of nephrology.
