Care Focus Should Shift From Managing CKD to Maintaining Kidney Health

Authors of a review article detailing the conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference in December 2023 argued that the primary focus of care for chronic kidney disease (CKD) should shift from managing disease progression and complications to maintaining kidney health and preventing CKD. The latter strategies have “received limited attention, despite their potential to save millions of lives, reduce health care costs, and lessen environmental burdens.”

According to the reviewers, CKD is expected to be the fifth leading cause of death in the world by 2040. Currently, about half of CKD deaths occur due to lack of access to kidney replacement therapy (KRT), either dialysis or transplantation. Since “the cost of KRT is extraordinarily high,” addressing CKD requires early interventions to prevent those at risk from developing CKD, they wrote.

CKD is also a major driver of cardiovascular disease. Cardiovascular-kidney-metabolic health represents a complex interplay of risk factors, including elevated blood pressure and blood glucose, dyslipidemia, and obesity, which together increase the risk of CKD and cardiovascular disease. However, the authors noted CKD incidence, and these risk factors can be addressed with diet, exercise, and a supportive environment. Cardiometabolic disorders, such as obesity, type 2 diabetes, and hypertension, “account for the majority of CKD cases worldwide.” They argued that CKD could be treated more similarly to type 2 diabetes or cardiovascular disease, where prediabetes or hypercholesterolemia identifies patients at elevated risk and serves as a cue for lifestyle intervention.

By the time CKD is diagnosed, kidney function has already declined substantially. The subclinical phase of CKD then “represents an opportunity for preventive intervention,” the reviewers wrote, since earlier interventions are likely to be more successful.

Dietary patterns including high intakes of sodium, red meat, high-glycemic processed foods, and sugar-sweetened beverages are associated with a greater risk of incident CKD, as well as cardiometabolic disorders. Additional factors that negatively affect kidney health include infections, exposure to environmental toxins, low nephron number, and prolonged exposure to high heat with inadequate access to water.

Screening could identify patients at high risk of CKD who may benefit from preventive interventions, though screening strategies and frequency should be researched for clinical effectiveness and cost-effectiveness, the authors noted. Currently existing risk equations may be used but do not capture all factors that increase risk of CKD, and polygenic risk scores and biomarkers may improve prediction. However, genetic and biomarker-based predictions require validation to confirm their utility.

Both lifestyle changes and medications can be utilized for CKD prevention or regression. Physical activity may reduce the risk of CKD as well as type 2 diabetes and its complications. Regarding diet and lifestyle, the authors cited a post-hoc analysis of the Look AHEAD trial, noting that in participants with type 2 diabetes and obesity, intensive lifestyle modifications resulted in an 8.6% loss of body weight compared to 6% for support and education only. Despite the relatively small difference between groups in weight loss, the intensive lifestyle modification group showed a 31% decrease in incidence of very high-risk CKD compared to the support and education group.

Drug therapies that may help prevent or regress CKD in patients with T2D or obesity include sodium-glucose cotransporters-2 inhibitors (SGLT2i), nonsteroidal mineralocorticoid receptor antagonists, and glucagon-like peptide 1 (GLP-1) receptor agonists. In contrast to GLP-1s and SGLT2i, the reviewers wrote, “Prevention of CKD has not been observed with the glucose-lowering agents metformin, sulfonylureas, insulin, or dipeptidyl peptidase-4 inhibitors.”

According to the authors, the consensus of meeting participants was to implement a lifespan approach to sustaining kidney health that considers the physical, mental, and social determinants of health. The goals, they said, should be risk prediction plus safe, effective, and accessible interventions.

Reference

Ortiz A, Arreola Guerra JM, Chan JCN, et al. Preventing chronic kidney disease and maintaining kidney health: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2025;108(4):555-571. doi:10.1016/j.kint.2025.04.005