A Surprising Find: Discovering Unexpected Gems on a Sunday Morning

Andrew Kowalski, MD, FASN

“A Disease on the rise and nobody seems to know they have it”

This past Sunday I was reading through the News Reels on my iPad and was intrigued by the title of an article “This disease is on the rise—and many people don’t know that they have it.”

Well that sure captured my attention. In a brief moment of surprise I wondered if I can “have it.” Then as reality set in, I dove into the article looking for this mysterious condition. To my surprise the article was about the global rise in the incidence of kidney disease. I was not expecting this, sure kidneys disease is incredibly important, frequently downplayed and overlooked as a “abnormal lab value” when in reality it drives and amplifies many of the conditions that the general public fears about; heart attack, stroke, heart failure, systemic aches and pains and possibly early death. But rarely have I seen the topic of kidney disease take a seat at the head of the table. What I am excited by is that kidney disease has had somewhat of a resergance in interest, whether its related to new medications that can slow progression, or deeper discoveries that suggests most kidney disease maybe preventable. Whatever it is the momentum needs to keep moving.

CKD has been referred to as a “silent epidemic,” and the description could not be more accurate. Unlike illnesses that manifest with early warning signs, CKD typically develops without symptoms and prevails for years, undetected and ninja-like, until kidney function is already substantially compromised.

The kidneys are remarkably resilient organs, able to mask injury for years, even decades, through compensatory mechanisms. In the setting of injury as can commonly be seen in the hospital setting, the kidneys have a remarkable ability to heal and “bounce back,” although usually left with some degree of residual damage, it is still impressive. Unfortunately, this silence is deceptive. By the time patients feel unwell, when swelling, fatigue, loss of appetite, or shortness of breath emerge, irreversible damage has often occurred. At that point, the disease has progressed to advanced stages, narrowing the window for meaningful intervention. This characteristic makes CKD unique among chronic illnesses, both in its stealth and in the tragic opportunities it presents, for prevention has often been far overlooked and beyond recuperation.

Globally, the numbers are sobering. CKD now affects nearly one in ten adults, and it has climbed into the top ten causes of death worldwide. In the United States, over 37 million adults are estimated to have CKD, yet a staggering 90 percent remain undiagnosed. This statistic should cause any reader to pause. A condition that has been shown to be prevented, if addressed early, and can then positively infuelnce the risk of future heart disease and cerebrovascular disease (ie. stroke, dementia) is almost entirely undiagnosed!!!!

These numbers reflect not only the sheer prevalence of the disease, but also the enormous gap in detection and awareness. Much of the increase parallels the rise in diabetes, hypertension, and obesity, which are themselves modern epidemics fueled by dietary patterns, sedentary lifestyles, and an aging population. In fact, type 2 diabetes and hypertension together account for roughly two-thirds of all CKD cases, yet even within these high-risk groups, screening is inconsistent! Awareness campaigns for cancer, cardiovascular disease, and even osteoporosis have had a tremendous amount of time in the spotlight and as a result have reshaped health systems and patient behavior. Kidney disease, however, remains overshadowed, rarely featured in headlines or public health campaigns.

Be a voice and ask your doctor and/or talk to your family, friends and community

There are many reasons for this invisibility, and it is not just one issue, but the sum of many. Early CKD produces no pain or dramatic symptoms, so patients rarely seek evaluation. Even when mild symptoms do emerge, such as subtle fatigue, ankle swelling, or increased nighttime urination they are commonly misattributed to aging, stress, poor habitual practices or labeled as a complication of a preexisting condition. Screening practices add to the problem…we do not have a clear or concise protocol to follow, and the stigma of kidney disease is that it will appear later due to other conditions. While routine blood pressure checks and cholesterol panels are standard in primary care, kidney health testing is not considered part of the “routine check up’” even though the same tests are often ordered.

Measurements such as creatinine, estimated glomerular filtration rate (eGFR) or urine albumin creatinine ratio (ACR) are critical for early detection, but they are not consistently ordered or even looked at through the “lens of CKD detection.” Even if these tests are ordered routinely, they not interpreted as CKD prevention unless that was the intent of ordering them.

Socioeconomic and racial disparities compound this problem. Black, Hispanic, and Indigenous populations experience disproportionately higher rates of CKD, yet they often face barriers to access, late referrals to nephrology, and poorer transplant availability, reflecting structural inequities in healthcare delivery (a soap-box topic for another time).

At its core, CKD represents a gradual “death” of nephrons, the microscopic units responsible for filtering blood and maintaining fluid, electrolyte, and acid-base balance. The pathophysiology of this process is multifactorial but centers on consistent repeated injury slowly destroying the tissue until the labs return as abnormal. In diabetes, elevated glucose levels cause glycation end-products, oxidative stress, and inflammation, damaging the delicate glomerular capillaries and thickening basement membranes. In hypertension, constant intraglomerular pressure accelerates scarring and nephron loss. Over time, as functional units are lost, the surviving nephrons undergo hyperfiltration (working harder to compensate), but this adaptation eventually collapses and accelerating the decline in renal function. Beyond these primary drivers, systemic inflammation, obesity, metabolic syndrome, and vascular injury contribute to what is increasingly recognized as a cardio-renal-metabolic syndrome: a web of interconnected conditions that reinforce one another.

The public health consequences of CKD progression are profound. CKD is not an isolated disorder of the kidneys, it is a condition that magnifies systemic disease processes throughout the body. Cardiovascular disease is the most striking example. Patients with CKD are far more likely to die from a heart attack or stroke than from kidney failure itself! Even early stages of CKD independently increase cardiovascular risk, as impaired kidney function promotes endothelial dysfunction, vascular calcification, and chronic low-grade inflammation. Beyond cardiovascular outcomes, CKD patients are more vulnerable to infections, hospitalization, frailty, and cognitive decline, all a result of chronic inflammation leading to quiet progressive damage. Healthcare costs skyrocket as CKD progresses, particularly with dialysis initiation or transplantation. In the United States, dialysis alone consumes billions annually, representing one of the most expensive chronic therapies in medicine. These costs are paralleled by devastating human burdens: diminished quality of life, dependence on machines, and the psychological toll of chronic illness.

One would make the assumption that if a problem is discovered that hemorrhages billions of dollars annually (given the financial stress the US has been undergoing recently) someone would raise their hand.

”Umm…excuse me…we should look at this.”

But this is the United States of Capitalism and pocket stuffed lobbyists

that determine patient life and health-span. Silly for me to make the ridiculous assumption as keeping people healthy would make the top 30 list of important topics to tackle.

Despite these challenges, CKD is NOT an inevitable march toward kidney failure and dialysis. Early detection and proactive management can stop or at least substantially slow progression. The foundation begins with identifying those at highest risk, individuals with diabetes, hypertension, cardiovascular disease, or a family history of kidney disease. And let’s challenge ourselves now, what if we took the LARGE amount of data suggesting that early signs of metabolic disease will progress to more substantial cardiac and renal disease and use it? THE MAP IS THERE! If we start early ripples can become waves and we in the healthcare industry can alter the inevitable.

• Kidney function testing is part of routine care, we are not looking at it through the correct lenses. Adding annual urine aLu min creatinine ratios and careful looking at serum creatinine with eGFR estimation are manageable and only takes seconds of time.

  
  

• Public campaigns that normalize kidney health metrics, akin to cholesterol and blood pressure awareness, could bridge the current awareness gap.

  
  

• Implementing community-based interventions are particularly important in high-risk populations, where culturally tailored outreach and mobile screening can reduce disparities (thank you National Kidney Foundation).

Looking ahead, the trajectory of CKD will depend largely on whether health systems, clinicians, and patients rise to the challenge of early recognition and comprehensive prevention. If CKD continues to be overlooked, millions more will advance silently to dialysis and transplant, often unaware they even had kidney disease. But if awareness grows, if kidney health becomes part of everyday health conversations, if screening is looked at through the lens of all diseases, and if patients are empowered with both knowledge and asking about new therapies, the story can change.

CKD need not remain a silent epidemic. With proactive care, evidence-based treatments, and public health commitment, millions of lives can be improved, and countless cases of kidney failure can be prevented.

For more information or to speak with a nephrologist close to you in the Midwest or New Jersey check out www.nephdocs.com