Chronic Kidney Disease

Chronic kidney disease (CKD) is a progressive loss of kidney function, defined as eGFR below 60 mL/min/1.73 m² or evidence of kidney damage (such as urine albumin ≥30 mg/g) lasting more than three months. CKD is staged G1–G5 based on eGFR, with G5 representing kidney failure requiring dialysis or transplantation. Hypertension and diabetes are the two most common causes, accounting for roughly 70 percent of new kidney failure cases in the United States. Early CKD is usually silent; symptoms such as fatigue, edema, and decreased urine output emerge in later stages. Approximately 37 million Americans have CKD, and most are undiagnosed.

• Usually none until late stages (CKD is a 'silent' disease in stages G1–G3)
• Fatigue and decreased energy
• Swelling in ankles, feet, and legs (edema)
• Foamy or bubbly urine (proteinuria)
• Decreased urine output
• Shortness of breath (fluid accumulation)
• Nausea, loss of appetite, metallic taste (late-stage uremia)
• Persistent itching (uremic pruritus)

KDIGO 2024 guidelines and the NKF recommend annual eGFR and urine ACR for all adults with diabetes or hypertension, plus for those with known CKD risk factors including obesity, APOL1 high-risk genotype, history of acute kidney injury, or a family member on dialysis. APOL1 genetic testing is clinically available and can identify Black patients at markedly elevated risk even before kidney disease is detectable — discuss with your nephrologist whether testing is appropriate for you.

Slowing CKD progression centers on treating underlying causes and reducing intraglomerular pressure. ACE inhibitors or ARBs are essential for patients with proteinuric CKD and/or diabetes. SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) reduce CKD progression and cardiovascular events independent of diabetes status — KDIGO 2024 designates them as first-line kidney-protective agents alongside ACE/ARB for appropriate patients. Finerenone, a non-steroidal mineralocorticoid antagonist, reduces CKD progression in diabetic kidney disease. Blood pressure target below 120/80 mmHg is recommended by SPRINT data. Avoidance of nephrotoxins (NSAIDs, IV contrast without precaution, certain antibiotics) is critical. When eGFR approaches 20, dialysis planning and transplant evaluation should begin promptly.