Living with One Kidney — Adapting, Thriving, and Protecting Long-Term Renal Health

Andrew Kowalski, MD, FASN

Introduction

Many individuals are born with or acquire a solitary kidney due to congenital absence (renal agenesis), surgical removal (nephrectomy), or organ donation.

While living with one kidney is often compatible with a normal, healthy life, it presents a unique physiological and metabolic scenario that demands attention to long-term renal health. This blog explores the implications of living with a single kidney, outlines potential risks, discusses lifestyle modifications to safeguard kidney function, and reviews appropriate pharmacologic supports.

Image from the National Kidney Foundation

Physiological Adaptation to a Single Kidney

After the loss or absence of one kidney, the remaining kidney undergoes compensatory hypertrophy, increasing in size and function to maintain glomerular filtration rate (The amount of blood filtered per minute; GFR). Initially, this hyperfiltration (increased work within the kidny to remove toxins) is beneficial, preserving balance within the body. However, over time, sustained hyperfiltration may lead to glomerular sclerosis, proteinuria, and a gradual decline in kidney function—mimicking the pathophysiology of early CKD.

Key concerns in long-term adaptation:

• Increased intraglomerular pressure

• Higher risk of microalbuminuria and proteinuria (increases the risk of progression)

• Predisposition to hypertension (hormonal changes within the kidney may lead to a direct and indirect increase in blood pressure)

• Elevated risk with comorbidities like diabetes or obesity (due to increased inflammation)

Risk of CKD Progression in Solitary Kidney Patients

While many people with one kidney maintain normal renal function for life, several factors influence the risk of progression to CKD:

Risk Factor	Impact
Hypertension	Increases glomerular pressure and accelerates damage
Proteinuria	Marker and mediator of renal damage
Obesity and Metabolic Syndrome	Promotes hyperfiltration, inflammation, and insulin resistance
Diabetes Mellitus	Raises risk of microvascular damage to glomeruli
History of AKI	Even one episode can reduce nephron reserve in the solitary kidney
High Protein Intake	May contribute to glomerular hyperfiltration in predisposed individuals

Lifestyle Modifications for Renal Preservation

1. Nutritional Adjustments

   Moderate protein intake: Aim for 0.8 g/kg/day of high-quality protein unless otherwise indicated (e.g., athletes, undernourished).

   Salt restriction: Target <2,300 mg/day sodium to control blood pressure and reduce hyperfiltration.

   Plant-forward diet: Emphasize fruits, vegetables, whole grains, legumes—supporting endothelial health and reducing acidosis. This also implies a reduction in highly processed "comfort foods" like baked goods, cookies, candies and so forth.

   Hydration: Maintain adequate fluid intake, avoiding both dehydration and fluid overload.

   Limit nephrotoxins: Avoid NSAIDs, excessive protein supplements, contrast dyes, and unverified herbal remedies.

2. Physical Activity

   Engage in moderate aerobic and resistance training: supports cardiovascular health, insulin sensitivity, and weight control. If possible choose resistance training over cardio. The benefits of increased and/or stable muscle mass exponentially outweighs aerobic exercise, which can decrease muscle mass if not careful.

   Avoid high-contact sports (e.g., football, martial arts) without protective gear to reduce trauma risk.

3. Weight Management

   Obesity promotes glomerular hyperfiltration and accelerates sclerosis. Maintain a healthy BMI (18.5–24.9).

4. Blood Pressure Control

   Target <130/80 mmHg. Home monitoring is encouraged.

   Lifestyle changes should be paired with pharmacological treatment if necessary.

Supporting Medications for Renal Protection

When used appropriately, medications can significantly reduce the risk of CKD progression in solitary kidney patients. Many of the medications used today work together to protect the kidney.

Medication Class	Role in Renal Health
ACE inhibitors / ARBs	Reduce intraglomerular pressure, control blood pressure, lower proteinuria
SGLT2 inhibitors (e.g., dapagliflozin)	Shown to protect kidney function even in non-diabetic patients (under study)
Statins	Manage dyslipidemia and reduce vascular risk, indirectly benefiting renal circulation
Diuretics (thiazide or loop)	Useful in volume control if hypertension or edema present
Vitamin D analogs	Considered if PTH levels elevate due to reduced nephron mass
Sodium bicarbonate	For those with metabolic acidosis; slows CKD progression

Note: Close monitoring of eGFR and serum potassium is essential when using ACEi/ARB and SGLT2i.

Monitoring and Follow-up

Regular surveillance ensures early detection of complications and timely intervention:

Monitoring Parameter	Recommended Frequency
Serum creatinine and eGFR	Every 6–12 months (more often if comorbidities present)
Urine albumin-to-creatinine ratio (ACR)	every 6 months or as indicated by your provider
Blood pressure	Every clinical visit or home monitoring
Electrolytes (K+, Na+, bicarbonate)	Annually or with medication adjustments
Lipid profile	Annually

Psychological and Social Considerations

Living with one kidney may bring emotional concerns—especially for organ donors, cancer survivors, or those who experienced traumatic loss of an organ. It’s important to:

• Foster positive reinforcement and health literacy

• Address anxiety with education and reassurance

• Encourage peer support or counseling where necessary

Image from "One Kidney, Two Lives" ANNA DAUGHERTY IN TXEX ON DECEMBER 7, 2015

Conclusion

Living with one kidney, while often asymptomatic, requires a proactive and informed approach to health management. With strategic lifestyle changes, appropriate medication, and regular monitoring, individuals with a solitary kidney can live full, healthy lives while minimizing their risk of CKD progression. Early intervention, empowerment through knowledge, and holistic care form the cornerstone of long-term renal wellness in this unique population.

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