San Francisco, May 19, 2025 — Once considered a niche within nephrology, glomerular diseases have emerged as an expanding and complex field requiring specialized expertise. Advancements in pathomechanism, immunopathology, clinical trials, and targeted and emerging therapeutics have transformed the management of these conditions. Therefore, there is growing interest in establishing glomerular disease care as its own subspecialty. In the U.S., this would be under the authority of the American Board of Internal Medicine (ABIM), complete with specific training requirements, board certification, and formal recognition, similar to what has been achieved in cardiology, radiology, surgery, obstetrics and gynecology, and many other specialties.

The Case for Specialization

The complexity of glomerular diseases is indisputable. These conditions encompass a heterogeneous group of rare, genetic, and often immunologically mediated disorders that require expeditious diagnosis, detailed clinical data interpretation, correlation to kidney pathology, familiarity with an expanding array of immunotherapies, their indications,  administration, adverse event mitigation, and clinical trials. The traditional nephrology curriculum often provides only a cursory exposure to this spectrum, resulting in a workforce variably prepared to manage these conditions. Due to the rarity of these disorders, most trainees often encounter very few cases during their training. Or they may not have encountered many of the diagnoses at all during their training.  

A subspecialty certification could standardize training, ensuring clinicians achieve a defined level of expertise. It would also help align graduate medical education with current scientific advancements, workforce needs, and the opportunity for a more diverse career path for the next generation of nephrologists.

With the rapid approval of new therapeutics for IgA nephropathy, lupus nephritis, and complement-mediated diseases, and many more therapeutics and indications on the horizon, demand is increasing for clinicians with experience and expertise in immunonephrology, pharmacology, and biomarker-driven care. Formal certification would lend credibility to these competencies, support academic career development, and improve patient care.

Moreover, the glomerular disease community has already taken meaningful steps toward this vision. Several nephrology fellowship programs offer a third year dedicated to training in glomerular diseases. The number of such programs is rising. The GlomCon Foundation launched its Fellowship Training Program in 2020. Over the past five years, this program has gained substantial popularity, training over 550 participants. Many of these alumni have launched new glomerular disease clinics, participated in groundbreaking clinical trials, and earned recognition as leaders and experts in the field.

Lessons from Other Specialties

The benefits of subspecialization are evident in other medical fields. Cardiology, radiology, obstetrics and gynecology, and oncology have sub-specialized, yielding substantial benefits for their patients, progress, and research in their respective specialties. These subspecialties have also attracted interest from trainees choosing these paths due to the opportunity to focus on areas more aligned with their interests and capabilities. For instance, gynecologic oncology and maternal-fetal medicine have become established subspecialties within obstetrics and gynecology, leading to improved patient outcomes and specialized research. Interventional cardiology, general cardiology, and heart failure specialists are other examples of how emerging subspecialties have served as catalysts for research, innovation, and improved patient care, as well as magnets for applicants and foundations for workforce development.

Potential Pitfalls and Considerations

However, the path toward subspecialization is not without challenges. Nephrology, already one of the most specialized branches of internal medicine, has struggled with recruitment and workforce shortages. Introducing further subspecialization could fragment the field or inadvertently draw talent away from other critical areas, such as dialysis (many who consider nephrology ultimately choose not to due to the focus on dialysis), chronic kidney disease management, or transplant nephrology. Critics have argued that existing nephrology training if optimized, is sufficient to equip clinicians for glomerular disease care without requiring an additional year of fellowship or separate certification. Another concern is access. Glomerular disease disproportionately affects younger patients and those from underserved populations. Creating a subspecialty designation may improve care in academic centers (‘ivory towers’) but could widen the gap in community and rural settings, where access to glomerular expertise is already limited. Efforts to define this subspecialty must, therefore, be coupled with models of care that democratize expertise through appropriate training and certification requirements, teleconsultation, digital pathology, and centralized clinical trial networks.

A Path Forward

If pursued, the creation of a glomerular disease subspecialty should be done with thoughtful stakeholder engagement, incorporating perspectives from academic and community nephrologists, nephrology fellowship directors, ABIM, nephropathologists, patient advocacy groups, and our emerging Centers of Excellence. A tiered training structure may offer a compromise: a certificate of added qualification or a focused practice designation could provide formal recognition without requiring a complete overhaul of the training system.

Ultimately, the question is not whether glomerular diseases deserve focused expertise, as they do, but how best to structure and certify that expertise to enhance the field of nephrology as a whole. As science advances and therapeutic complexity grows, our training and certification structures must evolve in tandem. The time is ripe to consider whether glomerular disease care, long as it is a subspecialty in practice if not in name, should be recognized as such in policy and training.

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