Volume 21 Issue 11, November 2025

The involvement of patients with lived experience of kidney disease in nephrology research can strengthen the relevance and uptake of evidence to achieve better outcomes. The past two decades have seen increased efforts to involve patients and caregivers, particularly in research priority setting, study design and dissemination. However, further efforts are needed to improve the transparency and diversity of patient involvement in research.

Africa has a high prevalence of chronic kidney disease (CKD), but efforts to address this burden lag behind those of high-income regions. In the past 20 years, progress has been made in collaborative efforts to share clinical and diagnostic skills and better define the epidemiology and pathophysiology of CKD in Africa.

In the past 20 years, awareness of the huge environmental impact of kidney care has increased considerably. Although opportunities to reduce this impact have been identified and innovative approaches developed, implementation of these strategies remains slow. System-wide action is urgently required to improve the sustainability of kidney care.

Since publication of the first issue of Nature Reviews Nephrology 20 years ago, advances across various subspecialities of nephrology have provided insights into disease processes and led to the development of new therapeutics for people with kidney disease. However, despite this progress, many kidney diseases remain untreatable, the costs of kidney disease care are immense, and vast inequities persist in disease burden and access to care. In this Viewpoint, we ask experts from several key subspecialties of nephrology to reflect on progress made over the past 20 years, remaining challenges and the steps needed to move the field forward.

Here, the authors discuss communication between the ER and other intracellular organelles under physiological and pathological conditions. They highlight the potential role of this crosstalk in the pathogenesis of kidney diseases and discuss potential therapeutic strategies aimed at modulating this crosstalk.

Available evidence suggests that the kidney stroma mediates cell communication and supports a variety of processes during kidney development and in the adult kidney. This Review describes the developmental origins of the stroma and current understanding of its roles in the growth and patterning of renal epithelia and endothelia, and in the maintenance and repair of the adult organ.

In this Review, the authors focus on the role of collagen IV in Gould syndrome and Alport syndrome. They discuss the molecular and phenotypic similarities and differences between these syndromes, as well as potential targeted therapeutic strategies.

This Review discusses the pathophysiology of kidney stone formation and examines the contribution of urinary risk factors and genetic variants. The authors also consider current approaches to the management of nephrolithiasis, including the role of metabolic evaluation and interventions for prevention of kidney stone recurrence.