Patrick Mark | Professor of Nephrology, University of Glasgow; Honorary Consultant Nephrologist, The Queen Elizabeth University Hospital, Glasgow, UK
Citation: EMJ Urol. 2026; https://doi.org/10.33590/emjurol/WSB518BW
What first drew you to nephrology, and specifically to the cardiorenal relationship between cardiovascular disease and chronic kidney disease (CKD)?
My interest in nephrology as a specialty started when I was a very junior doctor and I was rotating through nephrology. I knew that I wanted to do an internal medicine-based subject, but I didn’t have any specific specialty in mind. I was interested in cardiology at that point, but I rotated through nephrology on a number of occasions as a Junior House Officer, and then as a Senior House Officer, and was very much inspired by a number of the consultants. My interest in the cardiovascular aspects of nephrology came later. I started my PhD and worked with Alan Jardine, my early PhD supervisor. He was one of the absolute pioneers in the UK in recognising the cardiovascular complications of CKD. Working with him is where my interest came from.
Cardiovascular disease is the leading cause of death in people with CKD, yet the heart–kidney relationship is complex and sometimes under-recognised. What are the main factors driving cardiovascular risk in this population, and how can clinicians address them?
It depends a little bit on the severity of CKD. In mild-to-moderate CKD, I think it’s very much the conventional cardiovascular risk factors. As we showed in the Global Burden of Disease report, it’s things like systolic blood pressure, diabetes, high BMI, smoking, and many of these are shared risk factors between CKD and cardiovascular disease itself (diabetes, hypertension, unhealthy lifestyle, and high BMI). That’s recognised in the recent American Heart Association (AHA) Cardiovascular–kidney–metabolic syndrome classification, but essentially it comes back to the conventional cardiovascular risk factors. On a population level, there’s one problem, but then for people with specific renal diseases, be that IgA nephropathy, polycystic kidney disease, etc., there may be other factors at play in CKD progression. Once you have very severe CKD on dialysis, I think other things come into play, much more specific dialysis-related stresses, inflammation, etc., but certainly for the majority of people, at a population level, the conventional cardiovascular risk factors are highly likely to apply to the excess cardiovascular risk seen in CKD. Having abnormal kidney function, but also having albuminuria as well, does seem to exacerbate this adverse relationship, so I think there’s lots of work that still needs to be done.
Over the course of your career, how have approaches to managing cardiovascular risk in patients with CKD changed the most?
There have been quite a few big changes during my career. Firstly, I started nephrology training around the year 2000, so my career is more than a quarter-of-a-century old. Essentially, for the first 10–15 years we had angiotensin-converting enzyme inhibitors. We controlled blood pressure and there were targets but they weren’t that well described, and they were really the only management that was primarily addressed in CKD progression, rather than cardiovascular consequences (although they had some benefits). Over the more recent period, we had the advent of blood pressure targets and CKD through the SPRINT trial, and these targets are generally a bit lower. More importantly, new therapies in the SGLT2 inhibitor class are coming along, with the first in 2020; these were originally diabetes drugs but are now very much CKD and heart failure drugs. Subsequently, the introduction of the non-steroidal mineralocorticoid receptor antagonist class has added to the number of drugs we have available for patients with CKD, not just to reduce CKD progression, but to reduce the risk of heart failure for people with CKD in trials.
There are also more things coming along. We’re seeing with the glucagon-like peptide-1 class, again, a group of drugs that are primarily designed for both diabetes and obesity but do seem to have some benefit on CKD outcomes as well. I think we need to see more data on that. These drugs need to be licensed for CKD indications, but the point is, looking back, we essentially had angiotensin-converting enzyme inhibitors when I qualified, or there was evidence coming through for them, and now we have at least two, three, potentially four new classes of drugs, and new drugs continuing to come along. The management has also changed: better targets, more evidence, more therapies. I would hope it’s an exciting time to be a nephrologist, because there are more therapies to offer our patients.
Looking ahead, how might imaging, biomarkers, or large clinical datasets transform how we predict cardiovascular risk in patients with kidney disease?
Although I’ve done some research looking at imaging and that is exciting, I’ve not looked at biomarkers as much, but they’re obviously useful in some senses, such as highlighting risk in patients or diagnosing things, like N-terminal pro-B-type natriuretic peptide and heart failure. I think the priority to me is still thinking about doing the simple things well; for example, making sure you measure blood pressure, send-off albuminuria and act on it, and implement therapies earlier. I think there are lots of exciting developments.
I think the third point you made around data is more likely to be fruitful than looking for more imaging or blood-based biomarkers, because, whether it’s AI or prompts, data giving us lists of patients who aren’t on appropriate therapy could be a way to make sure that every patient is offered the best therapy for them. That would be great. We already know of many people, even in the UK, who have got blood tests suggesting CKD, which have not been coded for CKD, so they might not be recalled for checks, and they might not be offered therapies. Data can solve that by flagging it to the general practitioner or directly to patients, so I think data does offer lots of opportunities to help.
Your plenary at UK Kidney Week focuses on insights from the latest Global Burden of Disease report on CKD. What do you see as the most important takeaways from the latest data for clinicians and policymakers?
For policymakers, I think the biggest thing is CKD is rising as a cause of death globally. Only three causes of death in the top 10 were rising: CKD, diabetes, and Alzheimer’s. Alzheimer’s we can clearly put down to ageing as a society. I think the other two, CKD and diabetes, clearly reflect cardiometabolic unhealthiness. CKD as an increasing cause of death has to be the biggest thing, and I think there are other things to note. There are more people with CKD globally than ever before, and health systems need to develop around that, thinking about what it means to offer dialysis for the most severe stages of CKD, but also new therapies for the more moderate stages of CKD. If we just take one big headline, however imperfect the data are: CKD is rising as a global cause of death compared to many other things. I think that’s pretty important.
Based on these findings and your research, what changes in policy or healthcare practice would you most hope to see to improve outcomes for people with CKD?
Previously, I have not been an advocate for considering screening for CKD, and I’m still not an advocate for screening the entire population, but I think we need to be much more proactive around screening more at-risk groups, because I strongly believe you should only screen people for things that you can action, because we do not want screening to raise anxiety. We should screen people who are at risk of CKD, make sure that’s implemented, and, ideally, make sure they are offered therapy. So, I would definitely advocate screening for everyone with diabetes and everyone with a history of cardiovascular disease, as well as screening for hypertension and offering those with hypertension a dipstick test of urine to quantify that. I think policymakers need to think about screening in an appropriate, cost-effective, and acceptable manner for both healthcare systems and the wider population. We also need to think about how we might identify more people with CKD in such a way that we can offer treatments, which will reduce the risk of future cardiovascular risk associated with CKD and progressive CKD itself.
Alongside your clinical and research work, you’re involved in teaching and mentoring trainees. What do you enjoy most about working with the next generation of nephrologists and researchers?
I’ve been very fortunate. I’ve worked with lots of really brilliant people over the years. Most work I’ve done wouldn’t have happened without brilliant trainees. I have many great fellows who’ve brought their own ideas. I did my PhD around MRI imaging, now it’s clearly all about coding, big data, and statistics, so I really enjoyed trainees bringing their own ideas to projects. I always try and make projects that we have designed together where they brought not just their skills, but also their ideas, so that they feel it’s something that we’re both passionate about. It’s the notion of working together with someone on a project where we can both feel passionate about different aspects, because doing everything on your own is less rewarding.
What skills do you think will be most important for the next generation of kidney specialists?
First of all, I don’t have all the answers. I feel uneasy saying, ‘listen, these are skills you definitely need’. I think there’s no question that being knowledgeable about data, statistics, coding, and AI, all these tools that were not necessary when I started my research, is key. I don’t know everything about where the future is going. As I said earlier, be excited that there are new therapies. Hopefully, these therapies will be translated to patients pretty quickly. I want the trainees or younger nephrologists to feel excited about our specialty, that we are increasingly able to offer newer and often more specific treatments that may have the prospect of non-progression of CKD/cure of CKD, which was not on the radar when I started. There’s lots to be excited about. I just hope that they feel that way, because I know medical careers are tough. I think that nephrology is a good specialty and should be considered an exciting career with real opportunities to make a difference for patients.
