Chronic kidney disease is one of the most underestimated public health challenges of the twenty-first century. Affecting an estimated 850 million people worldwide, CKD progresses silently in the vast majority of patients, producing few if any symptoms until kidney function has already been substantially lost. By the time many individuals receive a diagnosis, opportunities for meaningful early intervention have often passed. This reality makes prevention — not merely treatment — the most powerful tool available to nephrologists, primary care physicians, and public health systems alike.
Recognizing this urgency, the International Society of Nephrology has placed CKD prevention at the center of its global strategic agenda. Through research, advocacy, community outreach, and the development of clinical tools, ISN (International Society of Nephrology) has committed to transforming how the world identifies, monitors, and responds to kidney disease risk — particularly in the populations most vulnerable to its consequences.
This article explores the current landscape of CKD prevention: who is most at risk, what evidence-based strategies exist to slow or halt disease onset, what medications are changing outcomes, and how social and structural factors must be addressed alongside purely clinical ones.
Understanding Chronic Kidney Disease: The Basics
Chronic kidney disease is defined as a persistent abnormality in kidney structure or function lasting more than three months, with implications for health. It is most commonly measured using two key indicators: the estimated glomerular filtration rate (eGFR), which reflects how efficiently the kidneys filter waste from the blood, and albuminuria, the presence of the protein albumin in urine, which signals damage to the kidney’s filtering membranes.
CKD is classified into five stages based on eGFR values:
- Stage 1: Normal or high eGFR (≥90 mL/min/1.73 m²), with markers of kidney damage present
- Stage 2: Mildly decreased eGFR (60–89 mL/min/1.73 m²)
- Stage 3a/3b: Moderately decreased eGFR (30–59 mL/min/1.73 m²)
- Stage 4: Severely decreased eGFR (15–29 mL/min/1.73 m²)
- Stage 5: Kidney failure (eGFR <15 mL/min/1.73 m²), requiring dialysis or transplantation
Each stage carries distinct risks — not only of progression to kidney failure, but also of cardiovascular disease, which remains the leading cause of death in CKD patients at all stages. This duality makes kidney health inseparable from broader cardiometabolic health, and prevention strategies must account for both dimensions simultaneously.
Who Is Most at Risk? Identifying High-Risk Populations
Effective prevention begins with accurate risk identification. The Chronic Kidney Disease Prognosis Consortium (CKD-PC), whose landmark analyses were published in The Lancet, has provided some of the most comprehensive data on which individuals face the greatest risk of developing CKD or progressing to kidney failure. This research has formed the basis for clinical screening guidelines adopted widely across the nephrology community and endorsed by the International Society of Nephrology.
Primary Risk Factors for CKD
| Risk Factor | Mechanism of Kidney Damage | Notes |
|---|---|---|
| Diabetes mellitus (type 1 and 2) | Hyperglycemia-induced glomerular hyperfiltration and progressive fibrosis | Leading cause of CKD globally; accounts for approximately 40% of cases |
| Hypertension | Elevated intraglomerular pressure, endothelial injury | Both a cause and consequence of CKD; accounts for 25–30% of cases |
| Obesity | Hemodynamic stress, chronic systemic inflammation, glomerulomegaly | Strongly linked to both diabetes and hypertension; an independent risk factor |
| Family history of kidney disease | Genetic susceptibility (e.g., APOL1 variants, polycystic kidney disease genes) | Risk varies substantially by ethnic background and specific genetic profile |
| Prior acute kidney injury (AKI) | Incomplete tubular repair, nephron loss, progressive interstitial fibrosis | Increasingly recognized as a major transition point toward CKD |
| Cardiovascular disease | Reduced renal perfusion, neurohormonal activation, shared pathophysiology | High co-prevalence; each condition accelerates the other |
The relationship between acute kidney injury and subsequent CKD development has received growing attention in recent years. Episodes of AKI — even those considered clinically resolved — can leave lasting structural damage in the kidney. Patients who have experienced hospitalization for AKI, particularly in intensive care settings, carry a significantly elevated long-term risk of CKD and should receive follow-up kidney function monitoring after discharge. This transition from AKI to CKD represents an important and often missed prevention opportunity.
The ISN Global Strategy: Pillars of Prevention
The ISN Global Kidney Health Roadmap, published in Kidney International in 2023 under the leadership of Adeera Levin and colleagues, outlined a clear and ambitious framework for addressing CKD at a global scale. Three foundational pillars define this agenda: prevention of CKD onset and progression, early detection of kidney disease in at-risk individuals, and equitable access to care across income levels and geographies.
These pillars are not sequential but interdependent. Prevention efforts require detection infrastructure. Detection is futile without accessible treatment pathways. And access to care must be designed to reach those most likely to benefit — populations that are too often the last to receive adequate healthcare resources.
World Kidney Day and Community Screening
One of the most visible expressions of the ISN prevention mission is World Kidney Day, co-organized annually with the International Federation of Kidney Foundations. Held each year on the second Thursday of March, World Kidney Day drives public awareness campaigns, free screening events, and policy advocacy in countries across all income levels. The initiative has grown into one of the world’s largest public health awareness campaigns focused on a single organ system, reaching hundreds of millions of people through media, healthcare events, and government partnerships.
Beyond awareness, the International Society of Nephrology has supported and documented community-based screening programs through the ISN Global Kidney Health Atlas (GKHA). These programs aim to bring basic kidney function testing — urinalysis for protein and blood, as well as serum creatinine measurement — to populations who may have no other access point to preventive healthcare. In many low- and middle-income countries, these community screenings represent the first time individuals have ever had a kidney function test performed, illustrating both the scale of unmet need and the potential impact of targeted outreach.
Risk Stratification in Clinical Practice: The Kidney Failure Risk Equation
Identifying who has CKD is only the beginning. Equally important is understanding which patients are at greatest risk of progressing to kidney failure, as this determines the urgency and intensity of the clinical response. The Kidney Failure Risk Equation (KFRE), developed by Navdeep Tangri and colleagues and first published in JAMA in 2011, offers a validated and practical tool for this purpose.
The KFRE uses four readily available clinical variables — age, sex, eGFR, and urine albumin-to-creatinine ratio — to calculate an individual patient’s probability of reaching kidney failure within two and five years. The equation was subsequently validated across 31 multinational cohorts in a study published in the Annals of Internal Medicine in 2016, demonstrating its applicability across diverse ethnic, clinical, and geographic populations. This breadth of validation is a key reason ISN has endorsed the KFRE as a preferred risk communication tool in clinical practice.
Key advantages of incorporating the KFRE into routine practice include:
- Enabling timely and appropriate nephrology referral without over-burdening specialist services with low-risk patients
- Supporting informed conversations between clinicians and patients about prognosis and realistic treatment goals
- Identifying patients who may benefit most from intensive pharmacological intervention
- Facilitating proactive preparation for renal replacement therapy, including vascular access planning and transplant listing
- Providing a common language for risk communication across care settings and disciplines
The KFRE does not replace clinical judgment, but it provides a structured, quantitative framework that is particularly valuable in primary care settings where nephrologists may not be immediately available. Its implementation in electronic health record systems has the potential to generate automated risk flags, prompting earlier action for high-risk patients who might otherwise be managed reactively.
Lifestyle Modification: The Foundation of Primary Prevention
Before any medication is considered, lifestyle modification represents the most fundamental and broadly applicable strategy for CKD prevention. Dietary habits, physical activity, weight management, and smoking cessation each contribute meaningfully to kidney health, and their effects are supported by an expanding body of clinical and epidemiological evidence. For individuals at risk but without established CKD, lifestyle intervention alone may be sufficient to meaningfully reduce the likelihood of disease development.
The DASH Diet and Kidney-Protective Eating Patterns
The Dietary Approaches to Stop Hypertension (DASH) diet — rich in fruits, vegetables, whole grains, and low-fat dairy, while limiting sodium, red meat, and added sugars — was originally developed as a blood pressure intervention. Its benefits for kidney health have since been studied more directly. Analyses published in the Clinical Journal of the American Society of Nephrology, including work by Rebholz and colleagues in 2016, found significant associations between adherence to the DASH dietary pattern and slower decline in eGFR as well as lower levels of albuminuria. These findings underscore how dietary choices that protect the cardiovascular system also protect the kidneys.
Plant-based dietary patterns have attracted further attention as potentially kidney-protective approaches. A review by ISN-affiliated investigators published in Kidney International in 2019 examined the effects of plant-based diets on uremic toxin generation and CKD progression. The findings suggested that diets higher in plant protein and fiber may reduce the production of gut-derived uremic toxins — metabolic byproducts that accumulate in kidney disease and contribute to systemic inflammation and cardiovascular risk. This research has supported growing interest in dietary modification as a non-pharmacological complement to medical management.
Dietary Recommendations for CKD Prevention
| Dietary Component | Recommended Approach | Kidney Health Benefit |
|---|---|---|
| Sodium | Restrict to <2.3 g/day; lower in established CKD | Reduces blood pressure and glomerular hyperfiltration |
| Protein | Moderate intake; favor plant-based sources | Reduces glomerular hyperfiltration; limits uremic toxin generation |
| Fruits and vegetables | Increase intake substantially | Lowers dietary acid load; promotes urinary alkalinization; reduces inflammation |
| Ultra-processed foods | Minimize or eliminate | Reduces dietary phosphate, sodium, and pro-inflammatory additives |
| Sugar-sweetened beverages | Avoid entirely | Reduces risk of hyperuricemia, obesity, insulin resistance, and metabolic syndrome |
| Dietary fiber | Increase intake via whole grains, legumes, vegetables | Supports gut microbiome health and reduces uremic toxin production |
Beyond diet, regular physical activity contributes to blood pressure control, glycemic management, weight reduction, and cardiovascular health — all of which indirectly protect kidney function. Current evidence supports at least 150 minutes per week of moderate-intensity aerobic activity for adults at risk of or living with CKD. Smoking cessation is similarly important: tobacco use is associated with accelerated CKD progression through mechanisms including endothelial damage, increased oxidative stress, and impaired renal hemodynamics.
Pharmacological Prevention: What the Evidence Shows
For individuals whose risk cannot be adequately managed through lifestyle measures alone — particularly those with established diabetes, significant proteinuria, or poorly controlled hypertension — pharmacological intervention becomes essential. The last decade has seen substantial advances in this area, with several drug classes now supported by high-quality trial evidence for their roles in slowing or halting CKD progression.
RAAS Inhibitors: A Long-Standing Cornerstone
Agents that inhibit the renin-angiotensin-aldosterone system (RAAS) — including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) — have been the pharmacological backbone of CKD management in proteinuric patients for over two decades. By reducing intraglomerular pressure and the pro-fibrotic effects of angiotensin II, these agents slow the rate of kidney function decline and reduce proteinuria. They remain first-line therapy for hypertensive patients with CKD and proteinuria, and their use in appropriate populations is broadly recommended by major nephrology guidelines globally.
SGLT2 Inhibitors: A Paradigm Shift in Nephrology
The emergence of sodium-glucose cotransporter-2 (SGLT2) inhibitors as kidney-protective agents represents one of the most significant advances in nephrology in recent decades. Originally developed as glucose-lowering medications for type 2 diabetes, these drugs were found in large randomized controlled trials to dramatically reduce the risk of kidney failure and cardiovascular events, with benefits that extend well beyond their glucose-lowering effects.
The CREDENCE trial demonstrated that canagliflozin reduced the composite risk of kidney failure, doubling of serum creatinine, and cardiovascular or renal death by approximately 30% in patients with type 2 diabetes and CKD with significant proteinuria. The DAPA-CKD trial extended these findings to dapagliflozin, showing comparable benefits across patients with and without type 2 diabetes. Most recently, the EMPA-KIDNEY trial confirmed the broad kidney-protective effects of empagliflozin across a wide range of CKD patients, including those with lower levels of albuminuria than previous trials had examined — an important finding that expands the eligible patient population considerably.
These findings have catalyzed a substantial revision in clinical guidelines internationally. SGLT2 inhibitors are now recommended for eligible patients with CKD by multiple major nephrology and
diabetes organizations, and their integration into standard clinical practice is a priority that ISN (International Society of Nephrology) is actively supporting through education, implementation science initiatives, and global access programs.
Uric Acid Lowering: A Hypothesis Tested and Resolved
For some years, elevated serum uric acid levels were proposed as a modifiable risk factor for CKD progression, with observational data suggesting an association between hyperuricemia and faster eGFR decline. The hypothesis that lowering uric acid with allopurinol might slow CKD progression was directly tested in the CKD-FIX trial, published in the New England Journal of Medicine in 2020 by Badve and colleagues. The trial found that allopurinol did not significantly slow eGFR decline compared to placebo in patients with CKD, with or without gout. These results have largely led to the conclusion that uric acid lowering is not recommended as a strategy to slow CKD progression in the absence of symptomatic gout — an important example of rigorous clinical trial evidence reshaping clinical practice.
Social Determinants of Kidney Health: The Broader Picture
Even the most effective pharmacological and lifestyle interventions cannot achieve their full potential if they are inaccessible to the populations who need them most. The International Society of Nephrology has increasingly emphasized that addressing the social determinants of kidney health is not an optional addendum to prevention efforts — it is a core component of any meaningful global strategy.
A major initiative documented in Kidney International in 2023 examined how food insecurity, housing instability, limited health literacy, and structural barriers to healthcare access disproportionately affect individuals at the highest risk of CKD. The populations most burdened by diabetes, hypertension, and obesity — the primary drivers of CKD — are frequently the same populations with the least access to preventive care, affordable medications, healthy food environments, and culturally appropriate health information.
Key social determinants affecting kidney health include:
- Food insecurity: Limited access to fresh produce, whole grains, and low-sodium foods makes it extremely difficult for individuals to follow kidney-protective dietary patterns regardless of motivation or knowledge
- Housing instability: Disrupts medication adherence, continuity of care, follow-up attendance, and the capacity for sustained self-management
- Healthcare access barriers: Geographic distance, out-of-pocket costs, language differences, and lack of culturally competent services reduce early detection rates in the communities that most need screening
- Health literacy: Low awareness of CKD risk factors, symptoms, and the importance of routine kidney function testing delays help-seeking behavior and self-referral
- Racial and ethnic inequities: Structural racism and historical underinvestment in healthcare systems contribute to disproportionate CKD burden in Black, Indigenous, and other historically marginalized populations worldwide
In response, ISN has supported the development of culturally adapted screening tools and community health worker training programs designed to extend the reach of preventive nephrology into underserved communities. Community health workers — trusted members of the communities they serve — can bridge the gap between formal healthcare systems and individuals who might otherwise never access CKD prevention services. By training and deploying these workers in high-risk communities, ISN-supported programs address the structural roots of CKD inequity in a direct and community-grounded way.
Looking Ahead: The Future of CKD Prevention
The field of CKD prevention is evolving rapidly, with several emerging areas holding particular promise for the decade ahead. As the evidence base expands and new tools become available, the ambition of substantially reducing CKD incidence and progression at a global scale becomes increasingly realistic.
- Precision medicine approaches: Genetic and biomarker profiling may eventually allow for highly individualized risk prediction, enabling prevention strategies to be targeted with considerably greater precision than current population-level approaches
- Digital health tools: Mobile applications and remote monitoring platforms have the potential to support medication adherence, dietary tracking, and blood pressure management at scale, particularly in under-resourced settings where specialist access is limited
- Novel pharmacological agents: Finerenone, a non-steroidal mineralocorticoid receptor antagonist, has demonstrated kidney and cardiovascular benefits in diabetic CKD in large randomized trials, adding to a growing armamentarium of disease-modifying agents available to clinicians
- Integration of CKD prevention into primary care: Expanding the identification and management of early CKD beyond specialty nephrology clinics into primary and community care settings remains a critical implementation priority globally
- Policy-level interventions: Taxation of sugar-sweetened beverages, mandatory sodium reduction in manufactured foods, and universal health coverage policies represent powerful upstream levers that could substantially reduce CKD incidence at the population level
Conclusion
Chronic kidney disease is a condition whose trajectory can be meaningfully altered — if not always prevented — when the right strategies are applied early, equitably, and consistently. With the combination of accurate risk identification, evidence-based lifestyle modification, targeted pharmacotherapy, validated clinical decision-support tools, and serious attention to the social conditions in which people live, a substantial reduction in the global burden of CKD is achievable within this generation.
The International Society of Nephrology has positioned itself at the forefront of this effort — through scientific research, global advocacy, clinical tool development, and community engagement initiatives spanning every region of the world. The ISN Global Kidney Health Roadmap sets out an ambitious but achievable vision: a world in which kidney disease is detected earlier, treated more effectively, and, wherever possible, prevented altogether through informed individual choices and supportive societal structures.
Achieving this vision requires a whole-of-society approach that brings together nephrologists and primary care providers, healthcare systems and public health agencies, clinical researchers and communities. ISN (International Society of Nephrology) remains committed to providing the scientific foundation, the global platform, and the collaborative partnerships necessary to turn the ambition of CKD prevention into a lasting reality for patients everywhere.