Chronic Kidney Disease (CKD)

Overview

Chronic kidney disease (CKD) is a chronic, progressive condition defined by abnormalities of kidney structure or function present for more than 3 months, with implications for health [1]. Clinically, CKD is evaluated using both estimated glomerular filtration rate (eGFR) and albuminuria (typically urine albumin-to-creatinine ratio, ACR), because reduced filtration and kidney damage markers carry independent prognostic significance [1].

As kidney function declines, the body progressively loses its ability to regulate fluid, electrolytes, acid&ndash;base balance, and clearance of metabolic waste products. Early CKD is frequently asymptomatic and may only be detected through routine laboratory testing, while later disease can present with complications such as anemia, metabolic acidosis, mineral and bone disorder, and fluid overload [1,2].

CKD is a major global health burden and has continued rising as a contributor to morbidity and mortality. Recent global analyses report CKD as a leading and growing cause of death worldwide, with risk concentrated in cardiometabolic disease (diabetes, hypertension, obesity) and aging populations [3]. In Pakistan, available studies suggest a substantial CKD burden, with prevalence varying across cohorts and settings and strongly associated with diabetes, hypertension, and ischemic heart disease&mdash;underscoring the importance of early identification in high-risk groups [4,5].

&nbsp;

Causes

CKD most commonly results from long-standing systemic conditions that damage renal microvasculature and glomerular structures, leading to nephron loss, maladaptive hyperfiltration, and progressive fibrosis [1].

Key causes and contributors include:

<ul>
	<li>Diabetes mellitus (diabetic kidney disease) [1,2]</li>
	<li>Hypertension (hypertensive nephrosclerosis and vascular injury) [1,2]</li>
	<li>Glomerular diseases (e.g., chronic glomerulonephritis) [1]</li>
	<li>Tubulointerstitial disease (including chronic interstitial nephritis) [1]</li>
	<li>Hereditary kidney disease, including polycystic kidney disease [1,2]</li>
	<li>Obstructive uropathy (e.g., kidney stones, prostatic enlargement) [2]</li>
	<li>Recurrent kidney infections and chronic pyelonephritis [2]</li>
	<li>Medication-related nephrotoxicity, including prolonged NSAID exposure and lithium in susceptible individuals [1,2]</li>
</ul>

Signs & Symptoms

CKD may present with visible physical changes as well as internal metabolic and functional disturbances. Symptoms often develop gradually and may be absent until advanced disease [1,2].

Common features include:

<ul>
	<li>Fatigue and reduced stamina</li>
	<li>Reduced appetite and unintentional weight loss</li>
	<li>Swelling of legs, ankles, or feet (fluid retention)</li>
	<li>Shortness of breath (fluid overload and/or anemia)</li>
	<li>Nocturia and sleep disturbance</li>
	<li>Muscle cramps</li>
	<li>Itchy skin (pruritus), particularly in advanced CKD</li>
	<li>Nausea and general malaise</li>
	<li>Hematuria or foamy urine (proteinuria), depending on etiology</li>
</ul>

Because early CKD is frequently asymptomatic, laboratory screening (eGFR and albuminuria) is central to detection&mdash;especially in individuals with diabetes or hypertension [1,2].

CKD is a multisystem disease. As kidney function declines, complications accumulate and the risk of cardiovascular events rises substantially [1,3].

Major complications include:

<ul>
	<li>Cardiovascular disease, including coronary artery disease, heart failure, and stroke [3]</li>
	<li>Hypertension and fluid overload [1]</li>
	<li>Anemia (reduced erythropoietin production) [1,2]</li>
	<li>CKD&ndash;mineral and bone disorder (CKD-MBD), including secondary hyperparathyroidism [1]</li>
	<li>Electrolyte and acid&ndash;base disturbances, including hyperkalemia and metabolic acidosis [1]</li>
	<li>Progression to kidney failure requiring renal replacement therapy (dialysis or transplantation) [1,2]</li>
</ul>

Risk is shaped by the cause of CKD, eGFR category, and albuminuria category&mdash;hence the KDIGO &ldquo;CGA&rdquo; classification (Cause, GFR, Albuminuria) used for staging and prognosis [1].

&nbsp;

Diagnosis

Current guidance emphasizes that CKD diagnosis should not rely on a single reading or one metric alone. Diagnosis requires persistent abnormalities for &ge;3 months [1].

Evaluation may include:

<ul>
	<li>Serum creatinine with eGFR estimation (kidney function) [1,2]</li>
	<li>Urine ACR (kidney damage marker) and urinalysis for blood/protein [1,2]</li>
	<li>Repeat testing to confirm persistence when an abnormality is first detected [1]</li>
	<li>Blood pressure assessment and cardiometabolic risk evaluation [1,2]</li>
	<li>Targeted labs based on presentation (electrolytes, bicarbonate, hemoglobin, etc.) [1,2]</li>
	<li>Renal ultrasound to evaluate size, obstruction, or structural abnormalities when indicated [2]</li>
	<li>Kidney biopsy in selected cases where the cause is unclear or specific pathology will change management [1,2]</li>
</ul>

Management

The management of CKD focuses on slowing progression, reducing complications, and lowering cardiovascular and kidney-failure risk&mdash;rather than short-term symptom-only approaches [1].

<h3>Lifestyle and Behavioral Interventions</h3>

<ul>
	<li>
	Sodium reduction and dietary pattern optimization to support blood pressure and fluid status [1,2]
	</li>
	<li>
	Weight management and physical activity according to individual capacity and comorbidity profile [2]
	</li>
	<li>
	Smoking cessation and cardiovascular risk factor control [2,3]
	</li>
</ul>

<h3>Medical and Structured Care Approaches</h3>

<ul>
	<li>
	Tight control of blood pressure and glycemia in relevant patients, using guideline-directed therapy [1,2]
	</li>
	<li>
	Addressing albuminuria and high-risk progression phenotypes using evidence-based strategies [1]
	</li>
	<li>
	Avoidance of nephrotoxins (particularly unnecessary NSAID exposure), and medication review for dose adjustment as eGFR declines [1,2]
	</li>
	<li>
	Treatment of complications (e.g., anemia, acidosis, CKD-MBD) based on stage and lab evaluation [1]
	</li>
</ul>

Advanced CKD and Kidney Failure Planning 
When eGFR declines substantially or risk of kidney failure becomes high, structured planning for renal replacement therapy may be required, including dialysis modality education and transplant evaluation when appropriate [1,2].

&nbsp;

Key Points

<ul>
	<li>CKD is defined as kidney structure or function abnormalities persisting &gt;3 months, with health implications [1]</li>
	<li>Early CKD is frequently asymptomatic; detection relies on eGFR + albuminuria (ACR) assessment [1,2]</li>
	<li>Diabetes and hypertension are leading drivers of CKD burden and progression risk [1,2]</li>
	<li>CKD substantially increases cardiovascular morbidity and mortality [3]</li>
	<li>Staging uses Cause + GFR category + Albuminuria category (CGA) to guide prognosis and management [1]</li>
	<li>Long-term, individualized management is essential to slow progression and reduce complications [1,2]</li>
</ul>

<h3>References</h3>

<ol>
	<li style="list-style-type:decimal">
	KDIGO. (2024). KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (full guideline, Kidney International). (<a href="https://www.kidney-international.org/article/S0085-2538%2823%2900766-4/fulltext?utm_source=chatgpt.com" style="text-decoration:none">Kidney International</a>)
	</li>
	<li style="list-style-type:decimal">
	National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (Updated recently). What Is Chronic Kidney Disease in Adults? (<a href="https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/what-is-chronic-kidney-disease?utm_source=chatgpt.com" style="text-decoration:none">NIDDK</a>)
	</li>
	<li style="list-style-type:decimal">
	Mark, P.B., et al. (2025). Global, regional, and national burden of chronic kidney disease&hellip; (The Lancet). (<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2825%2901853-7/fulltext?utm_source=chatgpt.com" style="text-decoration:none">The Lancet</a>)
	</li>
	<li style="list-style-type:decimal">
	Khan, A., et al. (2024). Prevalence of Chronic Kidney Disease in a High-Risk Population in Urban Lahore, Pakistan (Cureus / PubMed Central). (<a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC11284504/?utm_source=chatgpt.com" style="text-decoration:none">PMC</a>)
	</li>
	<li style="list-style-type:decimal">
	Cureus (2024). Comparative epidemiology and risk factors of CKD among rural and urban residents in Peshawar, Pakistan (study citing local prevalence baselines and risk factors). (<a href="https://www.cureus.com/articles/266289-a-comparative-study-of-the-epidemiology-and-risk-factors-of-chronic-kidney-disease-among-rural-and-urban-residents-in-peshawar-pakistan?utm_source=chatgpt.com" style="text-decoration:none">Cureus</a>)
	</li>
</ol>

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