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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.

An economic evaluation can provide insights into the cost-effectiveness of different kidney replacement therapy modalities to inform decisions on how to best allocate limited resources. This evidence-based Guideline is aimed at equipping policymakers and medical personnel with insight into the principles of economic evaluation within the context of policies for kidney-failure services, and increasing their confidence in requesting and using economic evidence derived from such evaluations.

Chronic kidney disease (CKD) is associated with the highest occurrence of catastrophic healthcare expenditure (CHE) both globally and across all diseases. However, CHE alone does not provide a complete measure of the financial burdens of CKD on a household, especially for those with very low incomes or who forego therapy altogether. A more comprehensive assessment of direct, indirect and long-term costs is crucial to advancing equitable and effective universal health coverage.

Fetal exposure to an adverse intrauterine environment is associated with an increased risk of numerous chronic diseases in later life. Here, Luyckx and Brenner highlight the emerging developmental risk factors for chronic kidney disease and hypertension, including high birth weight, maternal diabetes mellitus and rapid growth during childhood. The authors discuss the burden imposed on resource-poor countries by suboptimal nutritional intake, and address the benefits of nutritional interventions in reducing the global epidemic of these chronic diseases.

Announced in this Comment and in collaboration with Nature Medicine is the convening of the Access to Dialysis in Low- and Middle-Income Countries Commission, which will explore Thailand’s experiences with changing its dialysis coverage policy, offering lessons for other countries with universal health coverage systems.

The use of traditional remedies is highly prevalent in the developing world and is increasing in Western countries. Despite the frequent assumption by patients that alternative or complementary remedies are 'safe', many of these medicines can cause acute kidney injury. This Review outlines the factors contributing to the nephrotoxicity of traditional remedies and edible plants (including contamination, erroneous preparation and incorrect administration), and the mechanisms and types of renal damage associated with these medicines.

Among global destabilizing events, natural disasters often receive widespread attention whereas protracted conflicts and economic crises fade into the background. Low- and middle-income countries bear the brunt of this indifference, resulting in severely weakened health systems. People who require dialysis are particularly vulnerable, necessitating urgent collaboration to ensure equitable and sustainable care during such crises.

Pregnancy-associated acute kidney injury is a risk factor for maternal and fetal morbidity and mortality and a driver of health inequity worldwide. This Consensus Statement from the Acute Disease Quality Initiative provides recommendations on the causes, diagnosis, management and follow-up of pregnancy-associated acute kidney injury.

Rationing of scarce health-care resources is distressing. Clinicians therefore require clear guidance, which should be developed systematically and transparently through multi-stakeholder engagement. Rationing is seldom required in high-income settings but is often necessary in low-income settings. Global solidarity and health system strengthening are required to reduce the need for rationing.

The high global burden of kidney disease highlights an urgent need for early diagnosis and the implementation of interventions to prevent disease progression. Such an approach requires the identification and management of risk factors and equitable access to quality care.

Kidney disease is strongly linked with cardiovascular diseases, hypertension, diabetes, infections and other health conditions, as well as social determinants of health and climate change. Consequently, a holistic approach to promote well-being, protect individual health and improve access to quality primary care will support kidney health.

The devastating effects of war are far-reaching and particularly affect people with kidney disease. The Ukrainian conflict has highlighted problems encountered in the provision of support for this vulnerable group. On the basis of these and previous experiences in massive disasters, we propose a sustainable action plan to prepare for similar logistical challenges in future conflicts.

Long COVID, which refers to post-acute and chronic sequelae of SARS-CoV-2 infection, can affect nearly every organ system and all demographic groups. The high and growing toll of long COVID calls for an urgent need to understand how to prevent and treat it. Governments and health systems must address the care needs of people with long COVID.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.

This Review examines the concept of kidney lifespan and how increases in haemodynamic and metabolic demands in the kidney can lead to nephron overload, which is a common feature of progressive kidney disease and therefore represents a therapeutic target.

Many children die from preventable and/or treatable kidney disease in low-resource settings. Here, the authors examine strategies to improve the care of these children, including the need to invest in disease prevention and early detection, promote disease awareness and education, and adapt treatments to expand provision.

Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of the disease. The authors of this Review describe the different inequities that affect kidney health and care worldwide, and consider potential solutions to help to mitigate these.

During disasters, the morbidity and mortality of patients with kidney disease far exceeds that of the general population. Here, the authors discuss the medical and logistical problems that are faced by these patients and their care-givers during mass disasters and suggest pragmatic approaches to improve patient outcomes.

In this Review, the authors summarize the challenges associated with the care of patients with kidney disease during the COVID-19 pandemic. They describe the major challenges and missed opportunities, global inequalities in health care, and offer a framework for future pandemic preparedness.