abortion medical ethics essay

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Following the leak of a draft decision by the Supreme Court that would overturn Roe v. Wade, the Medical School’s Louise King discusses how the potential ruling might affect providers.

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How a bioethicist and doctor sees abortion

Alvin Powell

Harvard Staff Writer

Her work touches questions we can answer and questions we can’t. But her main focus is elsewhere: ‘the patient in front of me.’

With the leak Monday of a draft decision by the Supreme Court that would overturn Roe v. Wade, the future of abortion in the U.S. has been a highly charged topic of conversation all week. Doctors are among those wondering what’s next. Louise King is an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and a Brigham and Women’s Hospital physician whose practice includes abortion services. King, who is also the director of reproductive bioethics for the Center for Bioethics at the Medical School, spoke with the Gazette about ethical dimensions of abortion and how a ruling against Roe might affect providers.

Louise King

GAZETTE: In the U.S., abortion is framed in broad ethical terms: life versus death, privacy versus government intrusion, etc. From a medical ethics standpoint, what are the important concerns to be balanced on this issue?

KING: I frame the topic in the context of the patient in front of me. In other words, I look primarily to autonomy and beneficence in the context of doing good for the patient. That might mean upholding that person’s choice not to proceed with what is still a very dangerous proposition, namely carrying a pregnancy to term and delivering. If someone says to me, “I’m pregnant and do not wish to be pregnant,” for a multitude of reasons, I support that decision, because the alternative of carrying to term is risky. I want to protect that person’s bodily autonomy. From a reproductive justice standpoint, I want to support persons who have uteri in making decisions about when they wish to have a family, how they want that to look, whether they want to have a family at all, in expressing their sexuality, and in all kinds of different things.

I don’t believe that life begins at conception. Among the minority of people in this country who believe that’s the case, some are vocal and aggressive in imposing that belief on others, which may happen with this upcoming decision. But quite a number of students that I meet who believe life begins at conception still don’t believe that they have the right to impose that belief on others. To contextualize what we ask of persons with uteri when we make abortion illegal, it’s helpful to compare instances where we could ask people to undergo very risky procedures to help others. For example, we don’t demand that people give blood. It’s not a big deal and it could save lives every day, but we don’t demand that anybody donate blood or bone marrow. We don’t demand kidney donations, which are less risky than childbirth nowadays.

So we generally don’t ask one human being to give so completely of themselves to another, but we do so when it’s a pregnant person. That, I believe, does not comport with our ethics. But it also doesn’t fully address the concerns of persons who believe life begins at conception. They come to those beliefs honestly, but I think they have to explore them more deeply and figure out whether, even if true — do they hold up to the point where we require somebody to have a forced pregnancy to term? I would say, within my understanding of ethics, no.

“It’s not a big deal and it could save lives every day, but we don’t demand that anybody donate blood or bone marrow. We don’t demand kidney donations, which are less risky than childbirth nowadays.”

GAZETTE: Abortion is one of the most divisive issues in the country. Is the medical profession unified on it one way or another?

KING: That’s hard to say definitively. No study or survey exists to truly quantify this. The American Medical Association and the America College of Obstetricians and Gynecologists say that abortion is health care, and I agree. ACOG is very strong in their wording about supporting the right to access abortion. Unfortunately, only 14 percent of practicing OBGYNs provide abortion care. As a profession, our words and actions don’t match. I think there’s a multitude of reasons for that. One is the stigma associated with providing abortion care in some parts of the country.

I would guess that most providers feel similarly to the majority of Americans — that abortion is health care and should be available. While I’ve met some medical students and practicing physicians in all kinds of disciplines who feel strongly that abortion is unethical, the vast majority that I’ve spoken to feel as I feel: that it’s health care and should be provided.

GAZETTE: A big part of the debate over the decades has centered on viability. Is this an issue for science to determine? Is it an issue for society? Is it an issue for religion?

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KING: I don’t think that science can tell us definitively when life begins. Life is a broad term and includes a variety of living entities. I don’t think that religion can define it because we have freedom of religion and religions see this differently. Rabbis will explain that in the Torah, it’s very clear that an embryo is simply an extension of a woman’s body, like a limb, and should not be considered another person until birth. The leaked decision presumes that one version of Christianity’s assessment of this prevails, which seems to violate our understanding of freedom of religion in this country.

Ultimately, “when life begins” isn’t the right question because it’s unanswerable. The question then must be: How do we as a society come up with a compromise that upholds the autonomous rights of the persons in front of us who may become pregnant, who may have excessive risks associated with a pregnancy, or who may simply not wish to be pregnant, that also observes whatever our society’s agreed-upon understanding is of when a protected entity exists.

I think Massachusetts absolutely gets it right. If you read the Roe Act : Abortion is allowed for any reason in the first and second trimesters, and then abortion for medical reasons or lethal fetal anomalies can extend into the third trimester with careful consideration between patient and medical teams. To me, that is an exceptionally well-thought-out compromise. This is a societal decision. It shouldn’t be made by a minority of persons based on their narrow definition of “when life begins.”

GAZETTE: If something like the leaked draft decision emerges, is there a potential for medical providers to get caught in the middle?

KING: Overturning Roe would turn the question over to the states. That would mean that those providers who exist within the states that are clearly going to go forward with legislation to outlaw abortion would be in dire situations. In Massachusetts, we could provide the care we’re already providing and would expect people to travel from out of state to us. I don’t think that the long-arm statutes would reach a provider here, that somebody could come after me from Texas if somebody traveled from Texas to me and I provided care. But if I traveled to Texas, for a conference, it might. Legal experts aren’t sure.

GAZETTE: Have you ever been threatened because you’ve offered abortions?

KING: I haven’t, but many of my colleagues have. I did my training in Texas, so I lived a long time in the South. I’ve not been threatened directly, but spoken sternly to by many people who disagreed with me. I mentioned earlier that there are plenty of people who believe life begins at conception but who do not feel they should impose their viewpoints on others — those are people I met in Texas and Louisiana. There are a lot of people like that, but they can’t speak up for fear of being ostracized. The sense that I have through all the conversations I’ve had over many years is that we are all talking past each other. You started off by saying this is a topic that divides our country, but it doesn’t. The vast majority of people are settled on having abortion as an option, having contraception as an option, and having sex education available. There’s a group of politicians who make it appear that we’re divided and build their political careers off of that. It’s incredibly disheartening and unethical for them to do so.

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Ethics and Morality

Ethics and abortion, two opposing arguments on the morality of abortion..

Posted June 7, 2019 | Reviewed by Jessica Schrader

Abortion is, once again, center stage in our political debates. According to the Guttmacher Institute, over 350 pieces of legislation restricting abortion have been introduced. Ten states have signed bans of some sort, but these are all being challenged. None of these, including "heartbeat" laws, are currently in effect. 1

Much has been written about abortion from a philosophical perspective. Here, I'd like to summarize what I believe to be the best argument on each side of the abortion debate. To be clear, I'm not advocating either position here; I'm simply trying to bring some clarity to the issues. The focus of these arguments is on the morality of abortion, not its constitutional or legal status. This is important. One might believe, as many do, that at least some abortions are immoral but that the law should not restrict choice in this realm of life. Others, of course, argue that abortion is immoral and should be illegal in most or all cases.

"Personhood"

Personhood refers to the moral status of an entity. If an entity is a person , in this particular sense, it has full moral status . A person, then, has rights , and we have obligations to that person. This includes the right to life. Both of the arguments I summarize here focus on the question of whether or not the fetus is a person, or whether or not it is the type of entity that has the right to life. This is an important aspect to focus on, because what a thing is determines how we should treat it, morally speaking. For example, if I break a leg off of a table, I haven't done anything wrong. But if I break a puppy's leg, I surely have done something wrong. I have obligations to the puppy, given what kind of creature it is, that I don't have to a table, or any other inanimate object. The issue, then, is what kind of thing a fetus is, and what that entails for how we ought to treat it.

A Pro-Choice Argument

I believe that the best type of pro-choice argument focuses on the personhood of the fetus. Mary Ann Warren has argued that fetuses are not persons; they do not have the right to life. 2 Therefore, abortion is morally permissible throughout the entire pregnancy . To see why, Warren argues that persons have the following traits:

• Consciousness: awareness of oneself, the external world, the ability to feel pain.
• Reasoning: a developed ability to solve fairly complex problems.
• Ability to communicate: on a variety of topics, with some depth.
• Self-motivated activity: ability to choose what to do (or not to do) in a way that is not determined by genetics or the environment .
• Self-concept : see themselves as _____; e.g. Kenyan, female, athlete , Muslim, Christian, atheist, etc.

The key point for Warren is that fetuses do not have any of these traits. Therefore, they are not persons. They do not have a right to life, and abortion is morally permissible. You and I do have these traits, therefore we are persons. We do have rights, including the right to life.

One problem with this argument is that we now know that fetuses are conscious at roughly the midpoint of a pregnancy, given the development timeline of fetal brain activity. Given this, some have modified Warren's argument so that it only applies to the first half of a pregnancy. This still covers the vast majority of abortions that occur in the United States, however.

A Pro-Life Argument

The following pro-life argument shares the same approach, focusing on the personhood of the fetus. However, this argument contends that fetuses are persons because in an important sense they possess all of the traits Warren lists. 3

At first glance, this sounds ridiculous. At 12 weeks, for example, fetuses are not able to engage in reasoning, they don't have a self-concept, nor are they conscious. In fact, they don't possess any of these traits.

Or do they?

In one sense, they do. To see how, consider an important distinction, the distinction between latent capacities vs. actualized capacities. Right now, I have the actualized capacity to communicate in English about the ethics of abortion. I'm demonstrating that capacity right now. I do not, however, have the actualized capacity to communicate in Spanish on this issue. I do, however, have the latent capacity to do so. If I studied Spanish, practiced it with others, or even lived in a Spanish-speaking nation for a while, I would likely be able to do so. The latent capacity I have now to communicate in Spanish would become actualized.

Here is the key point for this argument: Given the type of entities that human fetuses are, they have all of the traits of persons laid out by Mary Anne Warren. They do not possess these traits in their actualized form. But they have them in their latent form, because of their human nature. Proponents of this argument claim that possessing the traits of personhood, in their latent form, is sufficient for being a person, for having full moral status, including the right to life. They say that fetuses are not potential persons, but persons with potential. In contrast to this, Warren and others maintain that the capacities must be actualized before one is person.

The Abortion Debate

There is much confusion in the abortion debate. The existence of a heartbeat is not enough, on its own, to confer a right to life. On this, I believe many pro-lifers are mistaken. But on the pro-choice side, is it ethical to abort fetuses as a way to select the gender of one's child, for instance?

We should not focus solely on the fetus, of course, but also on the interests of the mother, father, and society as a whole. Many believe that in order to achieve this goal, we need to provide much greater support to women who may want to give birth and raise their children, but choose not to for financial, psychological, health, or relationship reasons; that adoption should be much less expensive, so that it is a live option for more qualified parents; and that quality health care should be accessible to all.

I fear , however, that one thing that gets lost in all of the dialogue, debate, and rhetoric surrounding the abortion issue is the nature of the human fetus. This is certainly not the only issue. But it is crucial to determining the morality of abortion, one way or the other. People on both sides of the debate would do well to build their views with this in mind.

https://abcnews.go.com/US/state-abortion-bans-2019-signed-effect/story?id=63172532

Mary Ann Warren, "On the Moral and Legal Status of Abortion," originally in Monist 57:1 (1973), pp. 43-61. Widely anthologized.

This is a synthesis of several pro-life arguments. For more, see the work of Robert George and Francis Beckwith on these issues.

Michael W. Austin, Ph.D. , is a professor of philosophy at Eastern Kentucky University.

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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

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The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Support for legal abortion is widespread in many countries, especially in Europe

Nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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• Further clarity on cooperation and morality David S Oderberg Journal of Medical Ethics Apr 2017, 43 (4) 192-200; DOI: 10.1136/medethics-2016-103476
• Freedom of conscience in Europe? An analysis of three cases of midwives with conscientious objection to abortion Valerie Fleming , Beate Ramsayer , Teja Škodič Zakšek Journal of Medical Ethics Feb 2018, 44 (2) 104-108; DOI: 10.1136/medethics-2016-103529
• Mere sincerity Edward Collins Vacek Journal of Medical Ethics Apr 2017, 43 (4) 201-202; DOI: 10.1136/medethics-2016-103885
• A reasonable objection? Commentary on ‘Further clarity on cooperation and morality’ Trevor G Stammers Journal of Medical Ethics Apr 2017, 43 (4) 203; DOI: 10.1136/medethics-2016-103884
• Conscientious objection in healthcare and the duty to refer Christopher Cowley Journal of Medical Ethics Apr 2017, 43 (4) 207-212; DOI: 10.1136/medethics-2016-103928
• Conscientious objection in healthcare: why tribunals might be the answer Jonathan A Hughes Journal of Medical Ethics Apr 2017, 43 (4) 213-217; DOI: 10.1136/medethics-2015-102970
• Conscientious objection in healthcare, referral and the military analogy Steve Clarke Journal of Medical Ethics Apr 2017, 43 (4) 218-221; DOI: 10.1136/medethics-2016-103777
• Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies Udo Schuklenk , Ricardo Smalling Journal of Medical Ethics Apr 2017, 43 (4) 234-240; DOI: 10.1136/medethics-2016-103560
• Two conceptions of conscience and the problem of conscientious objection Xavier Symons Journal of Medical Ethics Apr 2017, 43 (4) 245-247; DOI: 10.1136/medethics-2016-103702
• Response to: ‘Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies’ by Schuklenk and Smalling Richard John Lyus Journal of Medical Ethics Apr 2017, 43 (4) 250-252; DOI: 10.1136/medethics-2016-103643
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I'm a Democrat who moved to Florida to be closer to my boyfriend. I was nervous about the politics and weather but have been most dismayed by the cost of living.

• David Maughan, 32, moved from Richmond, Virginia, to Oakland Park, Florida, last year.
• As a progressive, Maughan said he was nervous about Florida's culture war politics.
• But he's found Floridians to be accepting and welcoming, especially in the LGBTQ+ community.

This as-told-to essay is based on a conversation with David Maughan, a 32-year-old human resource analyst who moved from Richmond, Virginia, to Oakland Park, Florida, in August 2023 to be closer to his boyfriend. He shared his thoughts about living in the Sunshine State with Business Insider.

David : My Florida story started in 2020 when I met a guy named Brandon. We met online, like a lot of relationships nowadays, especially during early COVID. He lived in South Florida.

I was born and raised in Central Pennsylvania but had been living in Richmond, Virginia, since I was about 25.

Brandon and I dated casually for a couple of months and then became official. We were long-distance, going back and forth between Virginia and Florida for about three years. We knew we wanted to be together in the same place, so it became a question of which one of us would move. I work remotely, so it was easier for me to make the move.

I had a lot of concerns about moving to Florida

First of all, it was a big move away from my entire support system. I'm part of the LGBTQ+ community and that was something I felt was really strong in Richmond.

Thinking about starting over and making new friends in your 30s is daunting. I knew I would be with my boyfriend, and I had met a lot of his friends, so there would be a built-in friendship circle to some extent, but I still wanted to make my own friends.

But my top two concerns were the state politics and the weather. Many of my Richmond friends understood the first but didn't get my concerns about the weather. Everyone says the weather in Florida is great, but they don't realize that Florida is hot hot . In the summer, it's 90 to 95 degrees every day. It's exhausting. You don't want to go outside. Some people love that. But for me, it was a huge concern.

The other primary concern I had was politics. I consider myself a progressive and a Democrat. I call myself a pragmatic progressive. In Richmond, I had been very involved in volunteering for local Democratic campaigns. It's more than just a hobby for me; it's something I'm really passionate about.

Everyone in progressive circles looks at Florida in horror because of what the governor , state legislature, and state Supreme Court do. They've pushed really far-right policies, from gerrymandering congressional districts to passing a six-week abortion ban . These are not acceptable policies to me.

My boyfriend and I had a lot of conversations about those concerns before the move. He has a little saying: Florida is trash, but it's my trash. And I understand, he's lived here a long time.

I made the move in August 2023.

I moved to Oakland Park, which is a suburb of Fort Lauderdale. Oakland Park is small population-wise, but the surrounding Broward County has almost 2 million people. So, it's a much bigger metro area than I was used to.

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Overall, it's a comfortable place to live. But it's been a bit of a mixed bag for me so far. I love the community I've been able to find here. I found an LGBTQ+ adult sports league to participate in, and the nightlife nearby is good.

I think part of why it's been so easy to make friends is that a lot of people are also transplants . I haven't gotten any criticism from native Floridians about moving here. They've been welcoming.

But in terms of the downsides, Florida has a really car-centric design, which makes it uncomfortable to get around any other way. There are six-lane roads with traffic flying down them. There are signs that say bikes can share the road, but you'd have to be insane to do that. Even biking to the beach is difficult. I think I've only been to the beach three times in eight months.

I'm still getting used to Florida's topography. Richmond is a place with hills and rivers. But here, it's obviously flat as can be. There are a lot of single-family homes, low-rise apartments, and strip malls. A lot of the neighborhoods don't have good sidewalks, which was surprising to me.

I can't complain too much about the weather because I moved here in August when it started to cool off. The fall and winter have been nice. But we'll see how my first full summer goes.

Florida has dug into waging culture wars

Florida's elected leaders are pretty far-right. But I don't think the people of Florida are as far-right. That's an important difference. A lot of the races here are really close. And when you look at some of the ballot referendums that get put on the ballot in Florida , they are often for very progressive issues like reforming felon disenfranchisement.

I've tried to get involved with politics at the local level, where I feel I can make an impact. I got plugged into a group called Broward Young Democrats.

The area where I live is pretty accepting of the LGBTQ+ community for the most part. Wilton Manors, the town right next to Oakland Park is known as a "gay mecca." At the local level, there's a strong, supportive community.

But while I haven't experienced any direct harassment, and I don't fear for my safety, it is certainly concerning to think about what Florida might try to do down the road. If they're trying to ban transgender medical care today , what's to stop them from trying to pass discriminatory laws against all gay people tomorrow?

The cost of living is way higher in Florida

The biggest example is my rent. I had a one-bedroom apartment in Richmond that was 700 square feet, and I paid $1,400 a month, which at the time felt kind of expensive.

But here, I have a one-bedroom apartment that's about 800 square feet and it runs me $2,400 a month. It's a full thousand dollars more for an almost identical apartment.

Car insurance is also more expensive here. I pay double what I paid in Richmond. I had to reorient a lot of things in my budget when I moved here. I had to cancel some services, and I adjusted my retirement savings.

My apartment here is really nice, though. I decided I wanted to make sure I was happy with my living space, knowing the concerns I had about the state. Because if I was unhappy with the state politics and I had an apartment I hated, I would have been really miserable.

Florida is the right choice for me right now

Living here has obviously been great for my relationship with Brandon. We've been able to deepen our relationship and build a life together. That's the number one benefit, and it's been amazing.

But when I think longer-term, I don't see myself living here for the rest of my life. It's been a topic of conversation between us because I don't see myself buying property here, mainly because of the climate risk with hurricanes and flooding.

I'd like to buy property somewhere else, maybe in DC or Philly, somewhere more North. Then we could maybe rent an apartment or a condo down here and become snowbirds because I don't know if I'll able to be able to pull Brandon away from Florida entirely. He's got roots here.

And I always tell people: Love will make you do crazy things.

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A Terrorist Attack in Russia

The tragedy in a moscow suburb is a blow to vladimir v. putin, coming only days after his stage-managed election victory..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

From “The New York Times,” I’m Sabrina Tavernise, and this is “The Daily.”

A terrorist attack on a concert hall near Moscow Friday night killed more than 100 people and injured scores more. It was the deadliest attack in Russia in decades. Today, my colleague Anton Troianovski on the uncomfortable question it raises for Russia’s president, Vladimir Putin. Has his focus on the war in Ukraine left his country more vulnerable to other threats?

It’s Monday, March 25.

So Anton, tell us about this horrific attack in Russia. When did you first hear about it?

So it was Friday night around 8:30 Moscow time that we started seeing reports about a terrorist attack at a concert hall just outside Moscow. I frankly wasn’t sure right at the beginning how serious this was because we have seen quite a lot of attacks inside Russia over the last two years since the full scale invasion of Ukraine, and it was hard to make sense of right away. But then within a few hours, it was really looking like we were seeing the worst terrorist attack in or around the Russian capital in more than 20 years.

On Friday night, Crocus City Hall was the venue for a concert by an old time Russian rock group called Picnic. It was a sold-out show. Thousands of people were expected to be there. And before the start of the concert, it appears that four gunmen in camouflage walked into the venue and started shooting.

We started seeing videos on social media, just incredibly awful graphic footage of these men shooting concertgoers at point blank range. In one of the videos, we see one of them slitting the throat of one of the concertgoers. And then what appears to have happened is that they set the concert hall on fire. Russian investigators said they had some kind of flammable liquid that they lit on fire and basically tried to burn down this huge concert hall with wounded people in it.

Some of these people ended up trapped as the building burned, as eventually, the roof of this concert hall collapsed. And it seems as though much of the casualties actually came as a result of the fire as opposed to as a result of the shooting.

The actual attack, it looks didn’t take more than 15 to 30 minutes. At which point, the four men were able to escape. They got into a white Renault sedan and fled the scene.

It took the authorities clearly a while to arrive. The attackers were able to spread this horrific violence for, as I said, at least 15 minutes or so. So among other things, there’s a lot of questions being raised right now about why the official response took so long.

And you said the perpetrators got away. What happened next?

So it looks like they were caught at some point hours after the attack. On Saturday morning, the Kremlin said that 11 people had been arrested in connection to the attack, including all four perpetrators. They were taken into custody according to the Russian authorities in the Bryansk region of Russia, roughly a five-hour drive from the concert hall in southwestern Russia, also pretty close to the border with Ukraine.

Obviously, we have to take everything that the Russian authorities are saying with a grain of salt. And as we’ve been reporting on this throughout the weekend, we have very much tried to verify all the claims that the Russian authorities are making independently. And so our colleagues in the visual investigations unit of the times have been working very hard on that.

And what we can say based on the footage of the attack that was taken by many different individuals and posted to social media, it very much looks like the four men who were detained who Russia says were the attackers, in fact, are the same people who were seen doing the shooting in those videos of the attack judging by their clothes, judging by their hairstyle, judging by their build and other identifying characteristics that our colleagues have been looking at. So it does appear that by Saturday morning, the men who directly carried out this attack had been taken into custody.

Wow. So the Russian government actually apprehended the perpetrators, according to our reporting work that our colleagues have done. So who are these guys?

We don’t know much about them. The Russian government says that none of them are Russian citizens. After the arrest, throughout the weekend, videos, short clips of interrogations of these men have been popping up on the Telegram social networks, clearly leaked or provided by Russian law enforcement. You see these men bloodied, hurt.

And is this Russian interrogators abusing them?

Yes. That is very much what it looks like. And it’s also notable that the Russian authorities aren’t even hiding it. Two of the suspects in those videos are heard speaking Tajik. So that’s the language spoken in Tajikistan, a Central Asian country, but also in some of the surrounding countries, including Afghanistan.

At the end of the day, this is still very much a developing situation, and there’s a ton that we don’t know. But hours after the attack, the Islamic State, ISIS, took responsibility. And they then really tried to emphasize this by even releasing a video on Saturday showing the attack taking place as it was filmed apparently by one of the attackers. And US intelligence officials have told our colleagues in Washington that they indeed believe this to be true, that they believe that this ISIS offshoot did carry out this attack.

Wow. So the Americans actually think that ISIS, the extremist group that we know so well from Iraq and Syria, carried out this attack.

Yes. And all of this is really remarkable because just a few weeks ago, on March 7, the United States actually warned publicly that something just like this could happen. The US embassy in Moscow issued a security alert, urging US citizens to avoid large gatherings over the next 48 hours. They said that the embassy is monitoring reports that extremists have imminent plans to target large gatherings in Moscow to include concerts.

Crazy. That is a very specific warning.

Absolutely. And of course, the statement mentioned that specific 48-hour time frame. But nevertheless, it feels really significant.

And did the Russian authorities respond to that?

They did, and frankly, they responded mostly by ridiculing it. This is all obviously happening against the backdrop of the worst conflict between Moscow and the West since the depths of the Cold War. And so Vladimir Putin actually publicly dismissed this warning. He called it blackmail in a speech that he gave just three days before the attack last Tuesday.

So despite the specificity publicly at least, the Russian authorities did not take it seriously.

That is remarkable. And so three days later, this huge attack happens. Where is Putin in all of this? And who is he blaming? What’s his version of events?

So he’s coming off this Russian election season, as you know, where he declared this very stage managed victory and after that had been taking a victory lap of sorts. But Putin doesn’t appear on camera until around 19 hours after the attack. At that point, Russian state television airs a five-minute speech by Putin.

[NON-ENGLISH SPEECH]

He’s sitting at this nondescript desk surrounded by two Russian flags, but it’s not clear where he is located at that point. It doesn’t look like he’s at the Kremlin.

And Anton, what does he say?

So he describes the horror of this attack. He declares Sunday a national day of mourning. He says the most important thing is to make sure that the people who did this aren’t able to carry out more violence.

He also says that the four men who carried out the attack were captured as they were moving toward Ukraine. And he claims that based on preliminary information, as he put it, there were people on the Ukrainian side who were going to help these men cross the border safely. And remember, this is an extremely dangerous militarized border given that Russia and Ukraine have been in a state of full scale war for over two years now.

And as he ends the speech, He. Says that Russia will punish the perpetrators, whoever they may be, whoever may have sent them.

So what’s important about all that is first of all, that Putin did not mention the apparent Islamic extremist connection here that Western officials have been talking about, and that is in front of all of us given that Islamic State has claimed responsibility for the attack. But he does set the stage for blaming Ukraine for this horrific tragedy, even though it seems that Putin and the Russian government may be alone in thinking that.

We’ll be right back.

So Anton, the Islamic State has claimed responsibility for this attack, but Putin ignores that and kind of obliquely points the finger at Ukraine. What do we actually know about who did this?

Well, let’s start with the group that claimed responsibility for this attack. That’s ISIS, the Islamic State. And in particular, US officials are talking about a branch of ISIS called ISIS-K or Islamic State Khorasan, which is an Islamic State affiliate that’s primarily active in Afghanistan and that in recent years has gained this reputation for extreme brutality.

They might be best known in the US for being the group behind the Kabul Airport bombing back in 2021 right after the Taliban took over when thousands of Afghans were trying to escape. That was a bombing that killed 13 American troops and 171 civilians, and it really raised ISIS case profile.

So this terrorist group is mainly based in Afghanistan. What do they want with Russia?

So what’s notable is our colleague Eric Schmitt in Washington talked to an expert over the weekend who said ISIS-K has really developed an obsession with Russia and Putin over the last two years. They say Russia has Muslim blood on its hands.

So it looks like the primary driver in this enmity against Russia is Russia’s alliance with Bashar al-Assad, the Syrian president, who is also a sworn enemy of ISIS. And Russia intervened, of course, on Assad’s behalf in the Syrian civil war starting back in 2015. But it’s not just Syria. So the experts we’ve talked to say that in the ISIS-K propaganda, you also hear about Russia’s wars in the Southern region of Chechnya in the 1990s and the early 2000s.

And also even about the Soviet Union’s war in Afghanistan throughout the 1980s. There’s this really long arc of Russia’s and the Soviet Union’s wars in Muslim regions that appears to be driving this violent hatred of Russia on the part of ISIS-K.

OK. So ISIS-K is pointing not only to Russia’s actions in Syria but actually further back into Russian history, even Soviet history, to its war in Chechnya and then to the Soviet’s war in Afghanistan. Yet Putin in his speech ignores the group entirely and instead points in the direction of Ukraine. Is there a chance that this attack could have been carried out by Ukraine?

Well, look. It is true that Ukraine has carried out attacks inside Russia that put Russian civilians at risk. There have been several bombings that American officials have ascribed to parts of the Ukrainian government. Perhaps most famously, there was the bombing that killed Darya Dugina, the daughter of a leading Russian ultranationalist back in the summer of 2022.

That was a bombing that happened just outside Moscow. And of course, there have been various drone strikes by Ukraine against things like Russian energy infrastructure even just in the last few weeks. But we really don’t see any evidence right now of any connection of the Ukrainian state to this attack. US officials tell us they don’t see anything, and we haven’t in our own reporting come across such a connection either.

And there is, of course, the context of the US has said very clearly that they don’t want to see Ukraine carrying out big attacks inside Russia. American officials have said that doing so is counterproductive, could lead to the risk of greater escalation by Putin in his war. And we’re in an extremely sensitive time right now when it comes to US support for Ukraine.

The US, of course, has given all these weapons, tens of billions of dollars in aid to Ukraine. But right now, $60 billion in aid are stuck in US Congress. And you would think that Ukraine wouldn’t want to do anything right now —

That could risk that.

That could risk that. Exactly. I mean, also, let’s just say, I mean, this was an incredibly horrific attack, and we haven’t seen anything from Ukraine in the way they’ve carried themselves in defending against Russia in this war that would make us think they would be capable of doing something like this.

Anton, just to step back for a moment. I mean, it’s interesting because this attack, it really doesn’t remotely fit into Putin’s obsession about where the threat is coming from in the world to Russia, right? His obsession is Ukraine. And this kind of short circuits that.

Absolutely. I mean, Russia has had a real Islamic extremism problem for decades going back to the 1990s to those brutal wars against Chechen separatists that were a big part of Putin coming to power and developing his strongman image.

So it’s really remarkable how we’ve arrived at this turning point here for Putin where he used to be someone who really portrayed himself as the man keeping Russians safe from terrorism. Now the threat of terrorism coming from Islamic extremists doesn’t really fit into that narrative that Putin has because now Putin’s narrative is all about the threat from Ukraine and the West and that the most important thing to do now for Russian national security is to win the war against Ukraine.

And does the security failure here have anything to do with Russia actually being obsessed with Ukraine? Like it’s kind of taken its eye off the ball?

Well, look. The Russian domestic intelligence agency, the FSB, they’re the ones who are supposed to keep the country safe from terrorism. But that has also been the agency that has been charged with asserting control over the territories in Ukraine that Putin has occupied, and the FSB has been spending all this time hunting down dissidents of Putin.

Just a few hours before the attack on Friday, Russia officially classified the so-called LGBT movement, as they put it, on their list of terrorists and extremists. So terrorists in the current Putin narrative are anyone who disagrees with him, who criticizes the war, and who doesn’t fit into the Kremlin’s conception of so-called traditional values, which has become such a big Putin talking point.

So the FSB has been pretty busy but not in terms of Islamic terrorism. In terms of its own people.

Exactly. We don’t know for sure obviously how the FSB is apportioning its resources, but there’s a lot of reason to believe that as the leadership of that organization has been looking at Putin’s priorities in Ukraine and in terms of cracking down on dissent domestically, they could well have lost sight of the risks of actual terrorism inside Russia.

Which is pretty remarkable, right, Anton? Because you and I know and we’ve spoken a lot about on the show, a big part of the reason that Putin actually appeals, his argument to Russians is that he’s the security guy. Think what you will about him. He’s the guy who’s fundamentally going to keep you safe. And here we have this attack.

That’s right. And so he needs to continue making the case that he knows how to keep Russia safe. And that’s why my colleagues and I have been watching a lot of Russian state TV this weekend. And this ISIS claim of responsibility barely comes up. And when it does come up, it’s often being referred to as fake news. Instead, Russian propaganda is already assuming that it was Ukraine and the West that did this. We’ll see if the Russian public buys that.

But if you look at the way the last two years have gone in Russia, I think you have to draw the conclusion that Russian propaganda is extremely powerful. And I think if this message continues, it’s quite likely that very many Russians will believe that Ukraine and the West had something to do with this attack.

And so the worry now, as we look ahead, is that Putin could end up using this to try to escalate his war even further, which shows us why this is such a tenuous and perilous moment because at the same time, this attack reminds us that Russia faces other security risks. And as Putin deepens that conflict with the West, he may be doing so at the cost of introducing even more instability inside the country.

Anton, thank you.

Thank you, Sabrina.

Late Sunday night, the four men suspected of carrying out the concert hall attack were arraigned in a court in Moscow and charged with committing an act of terrorism. All four are from Tajikistan but worked as migrant laborers in Russia. They range in age from 19 to 32 and face a maximum sentence of life in prison. Also on Sunday, Russian authorities said that 137 bodies had been recovered from the charred remains of the concert hall, including those of three children.

Here’s what else you need to know today.

In January, I underwent major abdominal surgery in London, and at the time, it was thought that my condition was non-cancerous. The surgery was successful. However, tests after the operation found cancer had been present.

In a video message on Friday, Catherine, Princess of Wales, disclosed that she’d been diagnosed with cancer and has begun chemotherapy, ending weeks of fevered speculation about her absence from British public life.

This, of course, came as a huge shock, and William and I have been doing everything we can to process and manage this privately.

In her message, Middleton did not say what kind of cancer. She had or how far it had progressed but emphasized that the diagnosis has required meaningful time to process.

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• v.4(4); 2018 Nov

History, Current Advances, Problems, and Pitfalls of Nephrology in Russia

The anatomy and physiology of kidneys as well as kidney diseases have been studied in Russia since the 18th century. However, there was a surge in interest in the 1920s, with numerous researchers and clinicians making substantial advances in the understanding of the pathophysiology, pathology, and diagnostics of kidney diseases. The field of nephrology as clinical practice can be traced back to 1957–1958, when the first beds for patients with kidney diseases became available and the first hemodialysis procedure was performed. Nephrology and hemodialysis units were opened soon after, offering kidney biopsy, corticosteroid and immunosuppressive therapies, and dialysis for acute renal failure and end stage of renal disease. In 1965 kidney transplantation commenced. Between 1970 and 1990, the number of centers providing care for patients with kidney diseases increased; however, they were insufficient to meet the demands of native kidney disorders and renal replacement therapy. To address this, several educational institutions established postgraduate programs in nephrology and dialysis, and professional societies and journals were funded. While economic changes at the end of the 1990s resulted in a rapid increase of dialysis service, kidney transplantation and pathology-based diagnostics of kidney diseases remained underdeveloped. During the last 2 decades cooperation among international professional societies, continuing medical education courses, and the translation and implementation of international guidelines have resulted in substantial improvements in the quality of care provided to patients with kidney diseases.

We describe the history and development of clinical nephrology, dialysis, kidney transplantation, education in nephrology and dialysis, professional societies and journals, and registry of patients on renal replacement therapy in Russia during almost 60 years. We also present the most recent registry data analysis, address current problems and difficulties, and stress the role of incorporation into the international nephrology community.

Key Message

Nephrology in Russia, despite currently experiencing many difficulties, made great advances during the 60 years of its development. General nephrology, nephropathology, and renal replacement therapy are developing fast; implementation of international guidelines, access to modern educational tools, and cooperation with international professional societies are improving the quality of care of renal patients and ensuring further progress.

Historical Aspects

Russian scientists have been interested in the anatomy and physiology of kidneys as well as kidney diseases since the 18th century. Professor Shumlansky investigated renal anatomy and defended his thesis entitled “De structura renum: Tractatus physiologicoanatomicus” in 1776; the paper was republished in Strasburg in 1788 [ 1 ]. In 1853 Professor Polunin [ 2 ] described acute renal failure in patients with cholera, and Professor Zakharyin [ 3 ] published his paper entitled “Association between protein-containing urine and convulsions in pregnant women,” which was one of the first descriptions of eclampsia. Professor Bogolybov [ 4 ] defended his PhD thesis entitled “Renal pathology of parenchymal inflammation (Bright's disease)” in 1862, and in 1876 Professor Stolnykov [ 5 ] designed the quantitative method to detect protein levels in the urine. He also studied hemoglobinuria [ 6 ], and he published the association between renal ischemia and left ventricular hypertrophy in 1880 [ 7 ]. In 1882, Professor Ivanovsky [ 8 ] published his paper entitled “Bacterial inflammation of kidneys as a consequence of erysipelas.”

The first widely recognized historical case of kidney disease in Russia was the illness of Czar Alexander III, who suffered from severe edema, ascites, itching, dyspnea, and hemoptysis. His urinalysis showed the presence of proteins and casts, and he was diagnosed with “chronic interstitial inflammation of kidneys” and died from pulmonary edema on October 20, 1894. Among the attending doctors of Czar Alexander III during his last fatal illness were Professor Ernst Viktor von Leyden from Germany and Professor Grigory Zakharyin [ 9 ].

The most important achievement in the field of kidney diseases in 19th century Russia was the first model of nephrotoxic nephritis, developed by Professor Lindemann while working in Professor Mechnikov's laboratory. Lindemann [ 10 ] published his research entitled “Sur le mode d'action de certains poisons renaux” in the Annals of Institute Pasteur in 1900, in which he demonstrated the nephrotoxicity of heterologous anti-kidney sera in experimental animals. This model remains the most widely used animal model of crescentic glomerulonephritis.

The next phase of research commenced in the 1920s. In 1921, Professor Zymnitsky [ 11 ] implemented a simple kidney function test, based on the relative density of urine, which was known as the modified Volhard test. In 1929, Professor Tareev [ 12 ] published his book entitled “Anemia in Bright's disease.” He later published several monographs, summarizing his clinical experience, and highlighting the most important issues of pathophysiology, pathology, and clinical presentation of kidney diseases: “Kidneys and the Body” (1932), “Hypoproteinemic syndrome” (1933), “Kidney diseases” (1936), “Nephritis” (1958), “Fundamentals of Nephrology” (1972) [ 13 , 14 , 15 , 16 , 17 ], and many others, all of which became handbooks for several generations of nephrologists. In 1950, Professor Lang [ 18 ] published the monograph “Hypertensive disease,” in which he stressed the role of essential hypertension in kidney damage. In 1963, Professor Gynetsynsky [ 19 ] published “Physiological mechanisms of water-electrolyte balance,” where he described the details of water reabsorption in the distal nephron.

Development of Nephrology in Russia

General nephrology.

Nephrology as a field of medical practice started its development in Russia (which was then the Soviet Union) in 1957. An initiative of Professor Woffsy, one of the most recognized internists, introduced the first beds for patients with kidney diseases in the internal diseases unit of Moscow City Hospital No. 52 [ 20 ]. Professor Ratner, who as a resident studied internal medicine with Professor Lang in the then Leningrad (now known as Saint Petersburg), was invited to manage the patients and played a leading role during the fledging years of nephrology in Russia. Under her direction the nephrology beds transformed into the first nephrology unit in 1964, and in the same year, the first kidney biopsy in the Soviet Union was performed in the unit. Professor Ratner was also the first to successfully use corticosteroids to treat glomerulonephritis at the end of 1950s. The patient was a child with severe nephrotic syndrome. Immunosuppressants were first used by the initiative of Professor Tareev in 1959, and in 1961, Professors Woffsy and Ratner [ 21 ] published a paper entitled “Corticosteroid therapy of glomerulonephritis” in the Annals of Academy of Medical Science.

The first pediatric nephrology unit at the National Medical Research Center of Children's Health (the Research Institute of Pediatrics) was opened in 1965 by the initiative of Professor Studenikin, again headed by Professor Ratner. In 1970, Professor Veltischev started the division of inherited and acquired kidney diseases in the Research Clinical Institute of Pediatrics (which was then the Research Institute of Pediatrics and Children's Surgery), headed by Professor Ignatova till 2006 [ 22 ].

The second nephrology unit opened in Moscow City Hospital No. 52 in 1971, followed soon after with nephrology units opened in Moscow City Hospital No. 24 and the Moscow City Hospital n.a. S.P. Botkin (first headed by Dr. Alexander Lokshin). Other hospitals in Moscow, Saint Petersburg, and most big cities used the Moscow City Hospital No. 52 experience as a model when opening their respective units.

Professor Ratner was active as the leader of the rapidly growing renal service in Moscow until the end of 1980s. Her main interests were glomerulonephritis, transplanted kidney issues, and tubulointerstitial disorders, on which along with Professors Serov and Tomilina, she published a book entitled “Renal dysfunctions” in 1977 [ 23 ]. She also established a school of clinical nephrology, which is currently headed by Professor Tomilina.

In 1993 Professor Tomilina initiated the merging of two nephrology units - one for patients with native kidney diseases and the other for recipients of transplanted kidney - with the dialysis and outpatient units to create the Moscow City Nephrology Center, based in Moscow City Hospital No. 52. In 1998, the first intensive care unit for patients with kidney diseases opened in this center. The Moscow City Nephrology Center provides high-quality care for patients with any type of native and transplanted kidney diseases, not only to Moscow citizens, but also to referred patients. Professor Tomilina [ 24 ] recently summarized her clinical experience and published a monograph entitled “Selected Chapters in Nephrology.” The nephrology unit of the Moscow City Hospital n.a. S.P. Botkin also became a tertiary referral center at the beginning of 2000. The main priority of both centers is kidney biopsy with high-quality pathology diagnostics for a wide range of renal diseases. The nephropathology unit, which performs kidney biopsy readings for a vast majority of the population in Moscow, the surrounding area, and referred patients from other regions, is actually part of the Moscow City Nephrology Center.

Leading the intense development of clinical and research nephrology in Leningrad were Professor Ryabov, Professor Stavskaya, Dr. Jdanova, and Professor Bagrov - the successor of Professor Gynetsynsky, representing the Novosibirsk physiology school. For almost 50 years Professor Bagrov worked in the field of renal physiology and pathophysiology in close association with clinical practice. His monograph entitled “Water-electrolyte balance in Heart Failure” was published in 1984 [ 25 ]. A complex nephrology service, including the first outpatient unit for patients with kidney diseases, was organized in Leningrad in 1977 by Professor Ryabov. In 2003, several outpatient nephrology units in Saint Petersburg were merged under Professor Komandenko, and in 2008, the Saint Petersburg City Nephrology Center was opened. Currently, there are many nephrology units in Moscow, Saint Petersburg, and other big cities actively treating patients with glomerulonephritis, systemic diseases, diabetes, amyloidosis, chronic kidney disease (CKD) complications, and even orphan diseases such as atypical hemolytic uremic syndrome, Fabry disease, and cystinosis.

Unfortunately, the exact disease spectrum for CKD is not known, because general statistics, based on the main diagnosis only, does not represent CKD epidemiology. However, the database of the nephrology unit of the Moscow City Hospital n.a. S.P. Botkin provides some information and gives an impression of the disease spectrum. Table ​ Table1 1 represents unpublished data analysis.

Spectrum of CKD causes

Nephrology unit of Moscow City Hospital n.a. S.P. Botkin, 1994–2017 ( n = 18,368 cases).

The care and management of CKD include (1) CKD diagnostics and stratification; (2) monitoring of proteinuria, eGFR, and blood pressure; (3) treatment of underlying kidney diseases and measures for prevention of CKD progression; and (4) diagnostics, evaluation, and treatment of anemia, metabolic bone disease, cardiovascular complications, etc. Nephroprotection strategies, erythropoiesis-stimulating agents, iron supplementation, and phosphate binders are widely used. Diagnostic approaches and treatment of glomerulonephritis, including use of corticosteroids, immunosuppressants (cyclophosphamide, calcineurin inhibitors, mycophenolates, rituximab), and plasmapheresis are in agreement with international and national guidelines.

Of note, the International KDIGO Clinical Practice Guidelines for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder; for Anemia in Chronic Kidney Disease; for Lipid Management in Chronic Kidney Disease; for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease; and for Glomerulonephritis were translated to Russian and widely implemented [ 26 , 27 , 28 , 29 , 30 ]. The translation of KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder is currently in progress.

Hemodialysis (HD) techniques, invented and developed in western countries, immediately raised great interest in the Soviet Union. The first paper presenting an international experience of “artificial kidney” use was published by Dr. Parin [ 31 ] in 1955. The first Soviet “Artificial Kidney Apparatus” (AKA-60) was invented in 1957 by Yury Kozlov and his colleagues in the Research Institute of Experimental Surgical Technologies; production of the AKA-60 commenced in the Factory of Medical Equipment in Kazan [ 32 ].

In 1958, the first HD procedure using the Moeller dialysis machine was performed by Professors Pytel, Lopatkin, and Djavadzade at the University Clinic of Russian National Research Medical University n.a. N.I. Pyrogov (then the 2nd Moscow Medical Institute), based in Moscow City Hospital No. 1. Professor Pytel, a recognized urologist, was specifically interested in nephrology and had already studied crush syndrome and hepatorenal syndrome. In 1961, he published a monograph entitled “Artificial kidney and its clinical usage”, which was the first Russian monograph in the field [ 33 ].

Between 1958 and 1960 four “Experimental renal laboratories” for the treatment of patients with acute renal failure (ARF) opened: one in the Hematology Research Center (then the Research Institute of Blood Transfusion), one in Moscow Hospital No. 1, one in the Moscow City Hospital n.a. S.P. Botkin, and one in the 1st Moscow Medical University n.a. I.M. Sechenov (then the 1st Moscow Medical Institute). In 1960, the department of HD for patients with ARF, working in cooperation with the “Laboratory of Artificial Kidney” headed by Professor Gert Kulakov, was opened in the Moscow City Hospital n.a. S.P. Botkin. It was headed by Dr. Melikyan, who was one of the pioneers of HD in Russia and worked actively for 4 decades.

The year 1962 saw the first ever procedure not using donor blood with AKA-60 [ 34 ]. In 1964, the modified AKA-140 was invented, with production starting in Leningrad in 1969. HD was primarily used for the treatment of ARF in the setting of obstetric and surgical complications, poisoning, Hanta virus hemorrhagic fever, and crush syndrome. By 1971 more than 50 HD centers, equipped with AKA machines were successfully implemented throughout the Soviet Union. This allowed the expansion of indications for HD to chronic renal failure. The first dialysis unit for patients with end-stage renal disease (ESRD) was started in Moscow City Hospital No. 24 in 1967.

In 1963, the first pediatric patient, a 3-year-old child, was treated with HD. The first pediatric HD unit for the treatment of children with ARF was established in 1976 in the St. Vladimir Children's Hospital (then the Children's Hospital n.a. I.V. Rusakov), headed by Dr. Zverev. It was the only such unit in the country for many years, and later became the first center for children with hemolytic uremic syndrome; in 1991 peritoneal dialysis (PD) was successfully performed for the first time in Russia at this center.

Between 1971 and 1973 Hemodialysis System 6 (SHD-6) was invented by Professor Kulakov and engineer Balabanov. The new model of HD machine enabled HD procedures to be performed on 6 patients simultaneously [ 32 ]. The first two machines were introduced in 1974 in the “Laboratory of Artificial Kidney” in the Moscow City Hospital n.a. S.P. Botkin. Later, the SHD-8 replaced the SHD-6 and was introduced to clinical practice in many cities. In 1976, the first arteriovenous fistula was placed by Dr. Timokhov and Dr. Melikyan at the Moscow City Hospital n.a. S.P. Botkin, with arteriovenous fistula swiftly replacing shunts as the standard dialysis access technique in most HD units for ESRD patients soon after. The nephrology service in Leningrad first included HD units, working in cooperation with clinical nephrology and outpatient units; Professor Shostka coordinated this work.

During the next 2 decades, the number of HD units increased; however, they were insufficient to meet the demands of dialysis care for the ESRD patients. The biggest challenge for the dialysis service was the Spitak (Armenia) earthquake in 1988. At least 400 earthquake victims developed crush syndrome, and many of them with ARF were treated with HD. Most victims were evacuated from Armenia to Moscow and other major cities.

The economic changes following the collapse of the Soviet Union resulted in the substantial growth of dialysis care services. Unfortunately, this growth was not accompanied by the development of dialysis machine production, and now only imported equipment is used in the Russian Federation. While many intensive care units were equipped with dialysis machines that performed HD and continuous hemodiafiltration, the PD program for adult patients was started in 1995 to improve dialysis services; the first three units were opened in the Moscow City Clinical Hospital No. 52, Moscow City Hospital n.a. S.P. Botkin, and Moscow City Clinical Hospital No. 7, followed by Mariinskaya City Hospital, Saint Petersburg, and later in the other big cities. The PD unit of Moscow City Clinical Hospital No. 52 is actually the biggest in the Russian Federation.

In 2002, the Ministry of Health issued an order regarding “Excellence of Organization of Dialysis Care,” whereby public-private partnership implementation resulted in a rapid increase in the HD outpatient units. The International KDIGO and ERBP Guidelines concerning CKD and acute kidney injury were translated to Russian and widely implemented [ 30 , 35 , 36 ].

Evaluation of the disease spectrum of ESRD is based on the data from the Registry of patients on renal replacement therapy (RRT), started by the Russian Dialysis Society in 1998. The available individual data analysis is shown in Table ​ Table2 2 [ 37 ].

Causes of ESRD in patients on hemodialysis and peritoneal dialysis

Russian Dialysis Society Registry, 2011–2013 ( n = 15,880 patients).

The evaluation and management of patients receiving RRT include monitoring of dialysis dose and key quality indicators, blood pressure, body mass index, serum albumin, hemoglobin, total cholesterol, total calcium, serum phosphates, and parathyroid hormone. Comorbidities, treatment patterns, mortality, and survival are also evaluated on a regular basis. Patients on RRT receive antihypertensive medications, iron supplementation, erythropoiesis-stimulating agents, phosphate binders, and calcimimetics.

Transplantation

The first kidney transplantation from a deceased donor was performed by Dr. Voronoy in 1933 in Kherson (now a territory of Ukraine). While the procedure was not successful, the first ever attempt, published in 1936, enabled further developments [ 38 ]. The first successful kidney transplantation from a living donor, in this case a relative, was performed by Professor Petrovsky at the Russian Research Center of Surgery in 1965. In 1967, the National Medical Research Center of Transplantology and Artificial Organs n.a. V.I. Shumakov (then the Research Institute of Organ and Tissue Transplantation, first headed by Professor Solovyov) was created by Professor Petrovsky. Professor Petrovsky, along with Professor Solovyov and his group, published a book entitled “Kidney transplantation” in 1969 [ 39 ], when the program of kidney transplantation from deceased donors was initiated and widely implemented by Professor Shumakov, who headed the Research Institute of Organ and Tissue Transplantation for more than 30 years since 1974. The number of centers performing kidney transplantation exclusively from deceased donors increased over the next 2 decades. Professor Phyliptsev played a leading role in the implementation of kidney transplantation for almost 3 decades. In 1990, the first center for pediatric kidney transplantation was opened in the Russian Children's Clinical Hospital.

In 1992, the federal legislation regarding “transplantation of organs and/or tissues” was introduced, whereby only direct relatives are allowed to donate kidneys for transplantation. Several regulatory documents have been released since the order addressing “regalement of brain death diagnostics” (2014). The program of kidney transplantation from living donors commenced in 1999 in the National Medical Research Center of Transplantology and Artificial Organs, headed by Professor Moysuk, who summarized the experience of the first 2 years in the article “Kidney transplantation from living relative donor” [ 40 ].

The first Department of Nephrology came from the Department of Internal and Occupational Diseases of the 1st Moscow Medical University n.a. I.M Sechenov (formerly known as the Faculty of Medicine of Imperator's Moscow University, created in 1755), which started in 1930 and was headed by Professor Tareev from 1950. Under his leadership, nephrology became one of the main priorities, and in 1966 the Clinic of Nephrology, Internal and Occupational Diseases opened, merging the Department of Nephrology, the Department of Internal and Occupational Diseases, and the Nephrology and HD units. Between 1986 and 2017, the head of the Clinic of Nephrology was Professor Mukhin. In 1972, Professor Tareev initiated the Laboratory of Nephrology Problems, which was headed by his daughter, Professor Tareeva, from 1975 [ 41 ].

An educational course on hemodialysis at the Russian Medical Academy of Continuous Postgraduate Education (formerly the Central Institute of Medical Qualification, created in 1930) was initiated by Professor Kulakov in 1965, based at the “Laboratory of Artificial Kidney”. In 1982, this educational course developed into the first Department of Nephrology and Hemodialysis, headed by Professor Kulakov [ 32 ]. The Department was, and still is, based in the Moscow City Hospital n.a. S.P. Botkin; the close relationships between academia and clinical practice ensured the development of the field. Currently the Department is headed by Professor Ermolenko, one of the opinion leaders in the field, whose monograph entitled “Chronic Hemodialysis” was published in 1982 [ 42 ].

In 1996, the Research Institute of Nephrology was created at the 1st Saint Petersburg Medical University n.a. I.P. Pavlov (formerly the Women's Medical Institute, and later the 1st Leningrad Medical Institute), with Professor Ryabov as the first director. The Institute of Nephrology merged the Course of Nephrology and Dialysis (later the Department of Nephrology and Dialysis, headed by Professor Eacayan), the Department of Internal Medicine (formerly the Department of Internal Diseases, created in 1914 and headed by Professor Lang from 1919 to 1921), and several laboratories with the clinical nephrology unit.

A course of “efferent therapy” was started in 1994 at the Saint Petersburg Medical Academy of Postgraduate Education (formerly the Imperator's Clinical Institute, created in 1896). The course was later changed to the Department of Nephrology and Efferent Therapy and existed until 2011, when the Saint Petersburg Medical Academy of Postgraduate Education merged with the Saint Petersburg Medical Academy n.a. I.M. Mechnikov (formerly the Institute of Psychoneurology, created in 1907) under the name North-Western State Medical University n.a. I.M. Mechnikov.

In 2004, the Department of Nephrology, headed by Professor Tomilina, opened in the Moscow State University of Medicine and Dentistry (formerly the Moscow Institute of Medicine and Dentistry, created from the Moscow State Institute of Dentistry in 1949). This is a unique institution, providing postgraduate education in the fields of clinical nephrology, nephropathology, dialysis, and transplantation.

All of the abovementioned institutions provide professional education for residents and PhD students as well as certification courses and short-term continuing medical education (CME) courses.

The Society of Nephrology and Immunopathology, as part of the Moscow Scientific Society of Therapeutics created in 1895, started its work in 1958 and is currently active, conducts monthly meetings, and is devoted to selected issues of clinical nephrology, immunonephrology, and nephropathology.

The Scientific Society of Nephrology (SSN) was founded in 1969 by Professor Tareev, who was the President of the Society for almost 15 years. The congresses of the SSN have been conducted every 6 years since 1974, and during the intervening years Nephrology Summer Schools, initiated by Professor Natochin, the successor of Professor Gynetsynsky, were the most important events.

First contacts with ISN leadership were established by Professor Tomilina in 1994, when she invited Professor Brenner and Professor Dirks to attend the SSN meeting in Moscow. In 1995, the first CME course under the aegis of the ISN, ERA-EDTA, and IPNA was conducted in Moscow. The formal organizer was the SSN, but Professor Tomilina was the driving force. Among the invited international speakers were Professor Cameron and Professor Lameire. Unfortunately, due to formal official regulations the SSN was unable to continue its work for several years. The Scientific Society of Russian Nephrologists, the successor of the SSN, was started in 2005, conducting congresses and plenary assemblies and creating national guidelines and protocols.

In 1997, the Union of Pediatric Nephrologists was funded by an initiative of Professor Papayan [ 22 ]. In 1998, the Russian Dialysis Society (RDS) was established, with Professor Tomilina as the first president. This society is currently the most active professional society of nephrologists in Russia. It is affiliated with the ISN, ERA-EDTA, and EKHA, and cooperates with KDIGO, ERBP, and WKD leadership. The RDS is specifically dedicated to the education of nephrologists throughout the Russian Federation, and conducts up to five CME conferences each year in Moscow, Saint Petersburg, and the big cities in Siberia, Volga, Far East, North West, North, and South Regions. Numerous international leaders of nephrology deliver talks at these meetings as invited speakers, as well as conducting ISN Educational Ambassadors Courses. The RDS also supports the registry and the journal Nephrology and Dialysis (see below). Translations of most KDIGO and ERBP Guidelines and World Kidney Day Editorials were undertaken and published by RDS initiatives [ 26 , 27 , 28 , 29 , 30 , 35 , 36 , 43 , 44 ].

The first journal to publish papers with nephrology articles in Russian was Urology and Nephrology , which was started in 1968 on the basis of the Urology journal, issued since 1965. The journal Nephrology was started by Professor Smirnov in Saint Petersburg in 1997 and was the first journal to publish a wide range of articles in the field.

In 1998, the journal Nephrology and Dialysis (an official journal of the RDS) was initiated by Professor Tomilina. This journal is the most influential nephrology journal in Russia with one of the highest impact factors among all medical journals in Russia. The journal Clinical Nephrology was started in 2009, and was edited by Professor Mukhin till 2017.

In 1998, Professor Tomilina initiated the registry of patients on RRT. The registry data is published every other year in the journal Nephrology and Dialysis , providing detailed information about many aspects of RRT in Russia. These include information not only about the number of centers and patients, but also on issues of anemia, hypertension, CKD-MBD management, viral hepatitis diagnostics and treatment, and many other aspects. The registry is affiliated with the ERA-EDTA Registry, providing data for international publications.

The most recent analysis, which includes published data till the end of 2015 [ 45 ] and unpublished data up to the end of 2016, shows that the total number of centers providing RRT is 506 (including 466 providing HD, 111 for PD, and 37 for kidney transplantation), with many centers providing two or three modalities. Of note, only centers providing care to both adult and pediatric patients with ESRD were included, while centers providing care specifically to patients with acute kidney injury were not registered. The number of patients with ESRD on HD + PD by the end of 2016 was 44,771 (33,876 on HD, 8,537 on PD, and 2,358 living with transplanted kidney); the mean ratio was 305 per million inhabitants. Furthermore, the number of patients on HD in 2016 was 78% greater than that in 2010, mainly due to the development of public-private partnership.

Current Problems

• Absence of nephrology courses for students in Medical schools
• Relatively short-term professional postgraduate education (2-year residency, absence of fellowship programs)
• Lack of certified nephrologists
• Under-recognition of CKD burden by health authorities and policy makers
• Under-diagnostics of CKD in the adult population
• Lack of cooperation among nephrologists and general practitioners, endocrinologists, cardiologists, and other specialists
• Under-diagnostics of CKD and ESRD in the pediatric population
• Lack of nephrology units, disproportionate to the number of dialysis units, especially outside big industrial areas
• Lack of renal pathologists and unavailability of kidney biopsy in many regions
• Under-development of PD
• Uneven distribution of dialysis service throughout the territory of the country, with several remote regions still poorly covered by RRT
• Lack of transplantation and insufficient organ har vesting
• Insufficient funds for research

Conclusions

Nephrology in Russia, despite currently experiencing many difficulties, made great advances during the 60 years of its development. General nephrology, nephropathology, and RRT are developing fast. Implementation of international guidelines, access to modern educational tools, and cooperation with international professional societies are improving the quality of care of renal patients and ensuring further progress.

Statement of Ethics

No ethic approval is required for this type of study.

Disclosure Statement

The author declares no conflict of interest.

Acknowledgments

The author thanks Dr. Anton Andrusev, Dr. Sergey Lashutin, and Prof. Natalia Tomilina for their valuable help.