Chronic Kidney Disease

Overview

Chronic kidney disease is a condition in which kidneys are damaged or have a problem with their structure that prevents them from filtering blood the way they should. As a result, waste and extra fluid can build up in the body.

Chronic kidney disease can present it different ways. Most often it develops slowly. However, sometimes it can develop as a result of a sudden event or as a complication of another disease. Other times it may progress at a faster rate. Advanced, persistent chronic kidney disease typically cannot be reversed, but steps can be taken to protect kidneys from more damage. In some people, it  chronic kidney disease can lead to kidney failure. Kidney failure means that the kidneys have less than 15 percent of normal kidney function. People with kidney failure need dialysis or a kidney transplant to survive.  

Related Terms:

• End-stage kidney disease
• Renal disease
• Kidney failure treated by dialysis
• Kidney transplant
• Kidney failure

Signs and Symptoms

Most people in the early stages of chronic kidney disease do not have symptoms. They may have no symptoms until their kidney disease is advanced.  

Symptoms May Develop as Chronic Kidney Disease Progresses 

People with chronic kidney disease may get swelling, called edema. Edema can happen when the kidneys cannot remove extra fluid and salt from the body. Edema can occur in the legs, feet, ankles, hands, or face. Edema is more common when kidney disease is very advanced or when there is a lot of protein leaking into the urine.

As chronic kidney disease becomes more advanced, symptoms may include:

• Loss of appetite, nausea, or vomiting
• Feeling tired or having sleep problems
• Trouble concentrating
• Needing to urinate less often
• Foamy urine
• Itching, numbness, dry skin, or darkened skin
• Weight loss
• Muscle cramps
• Chest pain or shortness of breath
• Swelling (also known as edema)  usually in legs, ankles, and feet.

Kidney Failure

If kidney function drops to less than 15 percent normal, symptoms from the buildup of waste products and extra water in the body may develop. This may include:

• Swelling (edema), usually in the legs, ankles and feet
• Headaches
• Feeling itchy
• Feeling tired during the day and sleep problems at night
• Nausea, loss of taste, appetite, or weight loss
• Low red blood cell count (anemia)
• Little or no urine
• Muscle cramps, weakness, or numbness
• Confusion, trouble focusing, or memory problems

In Children

Children in early stages of kidney disease may have few or no symptoms. As kidney disease gets worse, symptoms in children may include:

• Swelling (edema) in the feet, legs, hands, or face
• Increased or decreased urine output
• Foamy urine
• Pink or cola-colored urine caused by blood in the urine
• Decreased appetite
• Feeling tired
• Fever
• High blood pressure
• Itchy skin
• Nausea or vomiting
• Shortness of breath
• Trouble concentrating
• Weakness
• Weight loss
• Stunted growth
• Delayed puberty

Related Health Effects

Chronic kidney disease can lead to a number of serious complications. Complications may include:

• Heart and blood vessel disease, including stroke and heart attack
• High blood pressure
• Anemia
• Mineral and bone disorder
• Metabolic acidosis
• Malnutrition
• Electrolyte imbalances in the blood, especially high potassium

People with chronic kidney disease also have a higher risk of developing acute kidney injury, a sudden loss of kidney function caused by illness, injury, or certain medicines. Acute kidney injury may cause more kidney damage and worsen kidney function in the short and long term.

Causes and Risk Factors

The most common causes of chronic kidney disease in adults are diabetes and high blood pressure.

Diabetes

High blood sugar (glucose) levels can damage the kidneys’ filters. Over time, kidneys can become so damaged that they no longer do a good job filtering waste and extra fluid from the blood. Kidney disease caused by diabetes is called diabetic kidney disease.

High blood pressure

High blood pressure can damage blood vessels and other parts of the filtering system in the kidneys. Extra fluids in the body can raise blood pressure even more, creating a dangerous cycle.

Kidney Diseases That Are not Caused by Diabetes or High Blood Pressure

• Glomerular diseases, such as membranous nephropathy, focal segmental glomerulosclerosis, (lmmunoglobulin A) lgA nephropathy, and lgA vasculitis
• Hemolytic uremic syndrome and thrombotic thrombocytopenic purpura
• Polycystic kidney disease 
• Rare genetic conditions, such as Alport syndrome 
• Disorders in which the body's immune system attacks its own kidneys, such as systemic lupus erythematosus and Goodpasture's disease 

Other Risk Factors

Other risk factors for chronic kidney disease in adults include:

• Acute kidney injury
• Certain cancers and related conditions, such as multiple myeloma
• Drugs that are toxic to the kidneys
• Hepatorenal syndrome and cardiorenal syndrome, in which liver disease or heart disease damages the kidneys
• Infections
• Kidney stones with complications
• Metabolic syndrome
• Renal artery stenosis
• Severe obesity
• Sickle cell disease
• Heart disease
• A family history of kidney disease
• Personal history of acute kidney injury
• Aging
• High risk genes variants, such as APOL1 
• Lack of access to healthcare, nutritious food, transportation and other resources that enable health 

African American, Hispanic, American Indian, Native Hawaiian, and other Pacific Islander populations are more likely than white Americans to have advanced kidney disease, including kidney failure. The higher rates of diabetes, high blood pressure, poverty, and other risk factors that these groups experience may contribute to their higher kidney failure risk. In addition, populations with ancestry from certain parts of Western and Southern Africa have higher rates of high risk “APOL1” gene variants that increase risk of kidney disease.

Causes in Children

Kidney disease in children can be caused by birth disorders, hereditary diseases, infection, nephrotic syndrome, systemic diseases, trauma, and urine blockage or reflux. Birth disorders that keep the urinary tract from developing normally cause most childhood chronic kidney disease cases in the United States. Chronic kidney disease is more common in male children than in female children. In North America, Black teenagers are two to three times more likely to develop chronic kidney disease compared with White children.

Prevention Guidance

Managing Diabetes, High Blood Pressure, and Heart Disease

• Keep blood sugar numbers close to your goal.
• The blood pressure goal for most people is below 130/80 mm Hg.
• Take all your medicines as prescribed. Talk with your healthcare provider about medicines that can treat diabetes, high blood pressure and heart disease while protecting your kidneys, such as Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), Sodium Glucose cotransporter 2 inhibitors (SGLT2-i ), Glucagon-like Peptide-1 Receptor Agnostics (GLP-1 RA) and Mineralocorticoid Receptor Antagonists (MRA).
• Limit the daily use of over-the-counter pain medicines. Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can damage your kidneys.
• Keep your cholesterol levels in the target range to help prevent heart attacks and stroke.

The following lifestyle choices may improve your overall health and lower the risk of kidney disease and its primary risk factors (diabetes and high blood pressure):

• Make healthy food choices: Choose foods like fresh fruits, fresh or frozen vegetables, whole grains, beans, nuts, unsaturated fats and lean proteins. 
• Try the Dietary Approaches to Stop Hypertension (DASH) eating plan, which research shows may help lower blood pressure.
• Be active for 30 minutes or more on most days.
• Aim for a healthy weight: Being overweight makes the kidneys work harder and may damage the kidneys. The NIH Body Weight Planner is an online tool to help tailor calories and physical activity plans to achieve and stay at a healthy weight.
• Quit Smoking: For tips on quitting, go to Smokefree.gov.
• Reduce Alcohol Intake: Drinking too much alcohol can increase blood pressure and add extra calories, which can lead to weight gain. Limit alcohol intake to one drink per day for women and two drinks per day for men. One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor.

Diagnosis

Early kidney disease usually does not have any symptoms. Testing is the only way to check kidney function.

Reasons to test for for kidney disease include:

• Diabetes
• High blood pressure
• Heart disease
• A family history of kidney failure
• Personal history of acute kidney injury
• Personal history of cancer

People living with diabetes should get checked every year. People living with high blood pressure, heart disease, or a family history of kidney failure should talk with their healthcare provider about how often they should get tested.

Blood Test for Glomerular Filtration Rate

To check for kidney disease, healthcare providers use a blood test that checks how well the kidneys are filtering blood, called GFR. The results of the test mean the following:

• A rate of 60 or more is in the normal range for most adults but is low for young people.
• A rate of less than 60 may mean you have kidney disease.
• A rate of 15 or less is called kidney failure. Most people below this level will soon need dialysis or a kidney transplant.

Tests for GFR estimate your kidney function based on the amount of creatinine or cystatin C in your blood. Creatinine is a waste product from the normal breakdown of muscles in the body. Cystatin C is a protein produced by cells. Kidneys remove creatinine and cystatin C from the blood. When the kidneys aren’t working well, creatinine and cystatin C can build up in the blood.

Urine Test for Albumin

Healthcare providers also use a urine test to check for kidney damage. The urine test checks for albumin, a protein that can pass into the urine when the kidneys are damaged. A healthcare provider can check for albumin in urine in two ways:

• Placing a strip of chemically treated paper, called a dipstick, into a urine sample. The dipstick changes color if albumin is present.
• A urine albumin-to-creatinine ratio test measures and compares the amount of albumin with the amount of creatinine in a urine sample. A urine albumin result of less than 30 mg/g or less is normal; 30 mg/g or more may be a sign of kidney disease. If albumin is found in a urine sample, a provider may repeat the urine test one or two more times to confirm the results.
• A urine albumin-to-creatinine ratio (UACR) test is a more reliable test that compares the amount of albumin with the amount of creatinine in a urine sample. A result of less than 30 mg/g is normal. Higher values may be a sign of kidney disease.  
• If albumin is found in a urine sample, a provider may repeat the urine test to confirm the results. To diagnose chronic kidney disease, a provider will look for two UACR results at or above 30 mg/g at least three months apart. 

Diagnosis in Children

Healthcare professionals use a child's medical and family history,  a physical exam, and blood and urine laboratory assessments to diagnose kidney disease in children. To confirm the diagnosis, healthcare professionals may use one or more of the following tests:

• Urine tests, to look for protein, blood, and other cells in the urine
• Blood tests, to test the glomerular filtration rate and to look for underlying diseases
• Imaging tests, to see the size and shape of the kidneys and identify any abnormalities
• Kidney biopsy, to check for kidney damage and help identify the cause of the kidney disease
• Genetic tests, to look for specific gene mutations

Treatment and Management

Managing chronic kidney disease involves keeping track of your disease status using GFR (a blood test for kidney function) and UACR (a urine test for kidney damage), managing blood pressure, controlling blood sugar if you have diabetes, avoiding kidney toxins, and managing any complications like heart disease, bone disease, and anemia.  

In early stages of kidney disease, targeted therapies for specific kidney diseases may improve or stabilize kidney health. In addition, many people with chronic kidney disease take medicines prescribed to lower blood pressure, control blood glucose (sugar), and lower cholesterol including Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), Sodium Glucose cotransporter 2 inhibitors (SGLT2-i), Glucagon-like Peptide-1 Receptor Agnostics (GLP-1 RA) Mineralocorticoid Receptor Antagonists (MRA), and statins. These medicines can slow the loss of kidney function, delay kidney failure, and reduce the risk of heart disease. You should avoid medicines that further damage the kidneys, including non-steroidal anti-inflammatory drugs (NSAID) like ibuprofen. 

While early chronic kidney disease is often managed in primary care, people with advanced disease are more likely to develop metabolic acidosis, anemia, and bone disease and should see a nephrologist (or kidney doctor).  As kidney disease advances, dietary advice becomes even more important and seeing a registered dietitian can be helpful. If the levels of phosphorus or potassium in your blood get too high, a provider may prescribe a phosphate or potassium binder with meals to lower their levels. A phosphate or potassium binder is a medicine that acts like a sponge to soak up, or bind, phosphorus or potassium while it is in the stomach. If you develop anemia, you may need iron risk foods or an iron supplement. If you develop metabolic acidosis, you may need to reduce high protein foods or take a bicarbonate supplement.  

Kidney failure means that the kidneys have less than 15 percent of normal kidney function. To replace lost kidney function, there are currently three treatment options: 

• Hemodialysis 
• Peritoneal dialysis 

Kidney transplant 

When kidney failure is treated by dialysis or kidney transplant it is called end-stage kidney disease. Without treatment with dialysis or transplant, kidney failure will lead to death. Some people with kidney failure choose not to have dialysis or a transplant. People may make this choice when treatment is unlikely to extend their length of life or when the burden of treatment outweighs its benefits. People who choose not seek dialysis or transplant will continue to receive care from their healthcare team, focused on reducing symptoms and improving quality of life. People who make this choice may also consider palliative care to help maximize the quality of life or hospice in support of end-of-life care. 

Treatment in Children

Healthcare professionals treat kidney disease in children by first treating or controlling any underlying condition that may be causing kidney damage. Some children with acute kidney injury may need dialysis for a short time while their kidneys recover. Kidney failure in children is often treated with a kidney transplant following a limited time on dialysis. About one-third of the kidneys transplanted into children are from living donors.

Living With Chronic Kidney Disease

Doing well with kidney disease is a challenge, but there are many steps you can take to feel better and stay active.

Manage Stress and Depression

Long-term stress can raise blood pressure and blood sugar and lead to depression. Physical activity and sleep help reduce stress. Listening to music, focusing on something calm or peaceful, or meditating may also help. Depression is common among people with a chronic, or long-term, illness and can make it harder to manage kidney disease. People with kidney disease and depression should seek medical care to address depression as well as kidney disease.

Make Healthy Food Choices 

What you eat can slow kidney disease progression, reduce symptoms in advanced disease, and make you feel better. What you should eat will depend on how advanced your kidney disease is, the specifics of your kidney disease, and your preferences. Avoid foods and drinks that are treated with extra potassium or phosphorus. Ask your doctor to refer you to a dietitian to develop a meal plan that works for you. Or, find a registered dietitian who specializes in kidney disease through the Academy of Nutrition and Dietetics online.

Stay Active

Physical activity is an important part of staying healthy for people living with kidney disease. Being active makes the muscles, bones, and heart stronger. Physical activity can also be an important part of a plan to manage depression.

Sleep

People who have kidney failure may have trouble sleeping. Sleep loss can affect quality of life, energy level, and mood. Restless legs syndrome, sleep apnea, pain, or itching may make it hard to sleep. Avoid caffeine after lunchtime and avoid alcoholic drinks and electronics before bed.

Prepare for Healthcare Visits

You will need regular check-ups with your health care provider to track your kidney function and to help you prevent your kidney function from getting worse. Your health care team can also help to identify and manage symptoms related to kidney disease. Make a list of questions before appointments and if possible, ask a trusted friend or family member to take notes, ask questions, offer support, and help remember what the provider said during the visit.

Caring for a Child with Kidney Disease

You can help your child with kidney disease by following all dietary instructions given by your child’s healthcare team, making sure your child takes all medicines as prescribed, and talking with your child’s healthcare team before giving your child any medicines or supplements that have not been prescribed. Work with your child’s school to limit missed educational and social opportunities while kidney disease is being treated.

Find Clinical Trials

Clinical trials uncover better ways to prevent, diagnose, treat, and understand diseases and conditions. To ensure results apply to everyone, volunteers of all ages, sexes, and backgrounds, including both healthy individuals and those with specific medical conditions, are needed. Find clinical trials on kidney disease.

Research Information

The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world. NIH invests most of its budget in medical research seeking to enhance life and to reduce illness and disability. NIH-funded research has led to breakthroughs and new treatments helping people live longer, healthier lives, and building the research foundation that drives discovery.  

NIH conducts and supports research into many diseases and conditions, including kidney disease. Researchers are studying many aspects of kidney disease, such as:

• Genetics
• The relationship between kidney disease and heart disease
• New ways to slow or prevent progression
• Disease pathways that lead to chronic kidney disease
• How our environment and social factors affect gene variants linked to an increased risk of developing kidney disease
• The impact of medical nutrition therapy on chronic kidney disease progression
• How anti-inflammatory diets affect patients with chronic kidney disease

NIH’s Chronic Kidney Disease in Children Study is examining the risk factors for progression of chronic kidney disease and the link between chronic kidney disease and cardiovascular disease in children. Additionally, the Kidney Precision Medicine Project is exploring novel disease injury and recovery pathways, and targets for the treatment of kidney disease.

Find NIH-funded research projects using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies.