Economic, Social, and Psychological Factors

The global economic burden of CKD is substantial and projected to increase. One study collected treatment costs across 31 countries using health expenditure data from the World Bank. The costs included dialysis, renal transplantation, and disease-associated complications. CKD was defined using "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria involving urine albumin to creatinine ratio (UACR) and glomerular filtration rate (GFR, G1-G5). While the researchers found gaps in the cost expenditures, the data that they found suggested that costs increased as CKD worsened. For example, the mean annual average disease management costs for all countries increased by 165% from stages G3 to G5. The authors recommended identifying CKD in its early, silent stages to prevent disease progression which contributes to the higher cost expenditures.

Treatment costs for CKD disproportionately affect socially and economically disadvantaged groups. Black populations living in poor neighborhoods have an almost 60% risk of developing CKD. Food insecurity, obesity, racism, and heavy metal exposures might contribute to the increased risk. Studies examining the effects of food deserts, defined by the US Department of Agriculture (USDA) as the lack of access to healthy, affordable food in low-income communities, have found mixed results regarding their connection to childhood obesity, a risk factor for type 2 diabetes and future kidney disease. The conclusion: more studies were needed.

Poor populations are least likely to be able to afford the catastrophic health expenditures, defined as more than 30% of their income, to pay for advanced CDK treatment. Evidence suggests that high health care costs for advanced CKD adversely impacts household income, potentially worsening vulnerable populations economic status.

In addition to the economic impacts of CKD, mental health and quality of life are also adversely impacted. Decreased renal function appears to be a risk factor for cognitive impairment which can lead to a reduced quality of life. Up to 60% of hemodialysis patients have cognitive impairment, the exact physiologic mechanisms contributing to this manifestation have not been fully elucidated, but the effects of the buildup of uremic toxins and accumulated microvascular damage have been hypothesized to play a role. A study in Amman, Jordan surveyed 103 CKD patients in nephrology clinics to determine the prevalence of anxiety and depression and the impact these conditions had on quality of life. They found that almost 58% had depression and over 50% had anxiety. Approximately 22% of those with depression had moderate to severe depression. Depression was moderately to strongly correlated with worse quality of life such as reduced physical activity, social relationships, and environmental domains.

Prevention Summary

The increasing prevalence of CKD represents a global public health failure. The ancient adage, "Let thy food be thy medicine," is as true now as it was when it was first uttered. People consume food (i.e., plants and animal products) every day. What they eat and drink impacts their health.

Rising rates of obesity, type II diabetes mellitus, and hypertension indicate poor nutrition and lifestyles in many countries. Gut microbes prefer high fiber fruits and vegetables, not refined sugars, highly processed foods, or sugary carbonated sodas that many people consume. Food choices are influenced by culture, affordability, and accessibility. The inability or unwillingness of individuals to change their diet and exercise patterns should not be viewed as individual failures, but rather, as lifestyle failures that societies have created.

In response to the obesity crisis, the US FDA approved anti-obesity drugs such as Semaglutide, Liraglutide (GLP-1 analogues), and Setmelanotide (MC4R agonist) which could serve as important catalysts to mitigate the problem. These incretin hormone analogues might not only reduce obesity rates, but might also reduce rates of diabetes, hypertension, and ultimately, CKD. Therefore, the use of these medications might be transformative for people's health in the 21st century.

The FDA does not regulate herbs or supplements, some of which could cause kidney injuries in unsuspecting consumers. Short of issuing warnings on the labels of these products, there should be efforts to educate the public about the potential dangers that these products pose. The FDA does regulate drugs. Improving the warning labels about potential kidney injuries in over-the-counter drugs such as NSAIDs might help prevent future injuries. For potentially nephrotoxic prescription drugs, physicians should warn their patients about the risks when prescribing certain antibiotics, antifungals, chemotherapeutic drugs, and radiocontrast agents.

In some communities, particularly in poor neighborhoods, it's difficult to avoid heavy metal exposures. Pet studies have shown the ubiquity of these compounds. Rising rates of CKD in pets, particularly cats, suggest possible environmental exposures that might threaten their human owners over time. Veterinary surveillance of heavy metals, chemicals including PFASs could provide early warning systems for human exposures. For example, in the US, Banfield Pet Hospitals are a nationwide network of veterinary providers. The large datasets that they generate have been used to predict CKD in cats, the leading cause of death in geriatric cats. Using a One Health approach, their datasets could provide a goldmine of information for animal and human health exposures to heavy metals, toxins, and other potentially nephrotoxic chemicals. An integrated surveillance system of pets and their owners might provide a useful early CKD disease detection and prevention system.

Microbial pathogens, most recently SARS-CoV-2, can cause acute kidney injury and potentially CKD. If available, vaccines are a vital strategy to prevent or mitigate severe infections. The challenge is to counter the misinformation that could dissuade the public from getting vaccinated. Preventing pathogen transmission through personal protective equipment and other methodologies should be promoted.

The Human Microbiome project has revealed the critical role that gut microbes play in metabolic health. There is evidence that dysbiosis of the gut microbiome might influence kidney health, including a possible link to CKD progression. Understanding these connections, and how they might affect the kidneys, should be a priority. Once the optimum gut microbial ratios are identified, screening methodologies could be developed for surveillance purposes. Prebiotics, probiotics, and if indicated, fecal transplants could be developed for preventive efforts.

Given the high economic, social, and psychological costs of CKD, it behooves governments to do all they can to prevent it. Renal disease has been called a "silent killer" and has long been recognized as a contributing factor to cardiovascular disease. Given the magnitude of the problem, CKD prevention programs have not received the support that they deserve.

For example, in the US, Congress funded the Prevention and Public Health Fund (PPHF) through the Patient Protection and Affordable Care Act of 2010. The goal of the PPHF was to enhance health care quality, improve health outcomes, and most importantly, prevent disease. An examination of the planned use of the PPHF funds reveals that none were being directly allocated for the prevention of kidney disease or CKD. Notably, $72 million was being allocated to improve and enhance diabetes prevention and control strategies, and $4 million was being allocated to improve blood pressure and cholesterol levels to prevent cardiovascular disease. While neither of these funds specifically mentioned CKD prevention, they did address risk factors for it. None of the previous years' PPHF allocations targeted kidney disease or CKD prevention directly. As of June 2025, with the Trump Administration cutting funding, it's hard to know what programs are being supported.

CKD prevention efforts should include campaigns targeting health care professionals and the public. HHS's Medical School Curriculum Initiative, designed to reduce health disparities in American communities, could include education on preventing CKD since kidney disease disproportionately affects racial and ethnic minority groups. K-12 health curricula should include information about kidneys and kidney disease prevention.

Diagnosis and Treatment Summary

Since early stages of CKD are clinically silent, diagnosing it during this period is important to reduce the risk of disease progression. The current reliance on estimating GFR is problematic because it uses an equation that depends upon creatinine which is influenced by factors such as age, sex, and muscle mass. Finding new biomarkers has been an important challenge.

The gut microbiome appears to play a role in CKD progression. Microbial ratios have the potential to serve as important diagnostic, prognostic, and therapeutic tools for the disease. The science is in its infancy, but the potential payoff could be enormous. Developing therapeutic microbial cocktails to breakdown urea and creatinine could provide an important adjunct or alternative to renal replacement therapies such as dialysis. Unlike dialysis, side effect risks from gut microbiome manipulation appears to be minimal. Using the gut mucosal surface area as a site to breakdown urea and creatinine might be an area of further research.

Early CKD detection and surveillance might be accomplished with "smart toilets." Urine monitoring technologies using "smart toilets" with diagnostic capabilities might provide cost effective "precision health" care for at risk individuals. Multi-institutional research centers have been developing this technology to track blood or glucose in urine. Monitoring for albumin and signs of renal abnormalities might also help track the development and progression of CKD.

Artificial intelligence and machine learning led to a revolution in the science of understanding protein folding. These technologies could be applied to kidney organogenesis. Growing personalized replacement kidneys in vitro would be an optimal therapeutic choice for late-stage CKD. The challenge of finding kidney donors and the need for lifelong immunosuppressive therapy would no longer be necessary.

Growing replacement organs in vivo in humanized pigs would be a less optimal alternative, although research in this area is ongoing. The organs would not be as personalized as those grown in vitro, and the ethics of using animals to harvest organs might be politically unacceptable.

Reducing the damage from acute kidney injury through insults such as drugs, toxins, or infections might reduce the incidence of some CKD cases. Developing therapeutics from paracrine growth factors such as epidermal growth factor and insulin-like growth factor, that reduce inflammation, might be worth exploring and possibly supporting. Since pets, particularly cats, are vulnerable to environmental insults, a One Health approach would involve testing these factors in the animals and humans that suffer from acute kidney insults.

Take Home Points for Addressing CKD

Prevention

  1. Promoting high fiber, low sugar diets, exercise, and the use of newly approved anti-obesity incretin hormone analogues, if indicated, should be a public health priority.
  2. Warning labels on over-the-counter herbs and supplements found to cause kidney injuries should be mandatory.
  3. Investigating the apparent increasing prevalence of CKD in cats for possible human implications should be conducted.
  4. Joint human and animal surveillance systems for environmental heavy metal and chemical exposures including PFASs should be implemented.
  5. Surveillance of occupational exposures to heavy metals and chemicals that might cause acute kidney injuries should be part of environmental surveillance programs.
  6. Developing and administering vaccines to prevent or reduce severe infection from nephrotoxic pathogens should be a public health priority.
  7. Research of the gut microbiome, particularly butyrate-producing bacteria, to better understand bacterial ratios for CKD screening and preventive purposes should be supported.
  8. Kidney and CKD education and awareness for health professionals and the public should be a priority.

Diagnosis and Treatment

  1. New biomarkers to improve kidney disease diagnosis and screening are needed.
  2. Manipulating the gut microbiome as a possible treatment site to breakdown urea and creatine might reduce CKD progression.
  3. "Smart toilet" technology might be useful to diagnose and monitor early CKD to reduce disease progression.
  4. Artificial intelligence and machine learning could be used to research and develop in vitro renal organogenesis. A grand challenges competition might move things along.
  5. In vivo development of humanized pig kidneys might be useful.
  6. Therapies to reduce the effects of inflammatory cytokines and increase paracrine growth factors might facilitate healing in acute kidney injuries.
  7. Wearable dialysis units might improve the mental, physical, and social challenges of end-stage CKD treatment.
  8. Bacteriophage therapy might be a useful antibiotic adjunct or alternative for multi-drug-resistant bacterial kidney infections (i.e., pyelonephritis).
  9. Improved access to nutritional advice and monitoring for people living with CKD is needed.
  10. Improved mental health care for people living with CKD is also needed.