Rethinking CKD: AKI's Long-Term Impact and the Push for Earlier Intervention

Chronic kidney disease (CKD) is no longer defined solely by declining kidney function, clinicians are increasingly relying on urine protein trends, genetic testing, and risk stratification tools to guide diagnosis and treatment. As therapies for CKD continue to expand, questions remain about how quickly these advances reach everyday practice and how conditions like acute kidney injury (AKI) factor into long-term outcomes.

To address these questions, HCPLive spoke with Matthew Breeggemann, MD, assistant clinical professor in the Division of Nephrology and medical director of the nephrology-based Kidney Stone Prevention Center at the University of California, San Francisco (UCSF). Breeggemann discussed how a detailed patient history, genetic testing, and biopsy findings inform CKD management, why it can take years for new therapies to become routine practice, and what he believes will define the next era of kidney care.

Q&A:

Why a Detailed Patient History Matters for CKD Management

HCPLive: You care for patients with a range of kidney conditions, including CKD, AKI, hypertension, electrolyte disorders, and kidney stones. How does seeing these different aspects of kidney disease influence the way you approach CKD management?

Breeggemann: I think for me it's really helpful to get a detailed history when you first meet a patient—this includes the patient and the patient's family—and to try to fit those pieces of the puzzle together. You'll see patients where it seems really straightforward, like diabetes, and you're fairly certain their kidney disease is due to diabetes. But you might have another patient who has diabetes, hypertension, kidney stones, and other potential causes for their chronic kidney disease. Those cases are more complicated, and it's important to do your due diligence as a clinician to make sure you're not missing anything, because all of those things should be addressed—they're often treated differently. So it's very important to approach care that way.

Beyond eGFR: What Else Informs a New CKD Diagnosis

HCPLive: When a patient is first being diagnosed with CKD, what are the most important things you want to understand about that patient beyond their eGFR and creatinine values?

Breeggemann: I'll lean on eGFR just a little bit, but what I really want to see is the trend. eGFR, or estimated glomerular filtration rate, is based on a blood test measuring creatinine or, in some cases, cystatin C. You might have a patient whose eGFR has been stable at, say, 50 milliliters per minute for the last 10 years. They have chronic kidney disease, and neither of you wish they did, but it's been well managed and hasn't progressed. Then you might have another patient whose eGFR was 50 a year ago and is now 25—a major decrease. Those are patients you'll want to monitor much more closely through labs and appointments.

With CKD care becoming increasingly personalized, our center also performs a substantial amount of genetic testing for kidney disorders, and those findings have changed how we approach and manage some patients with CKD. We also perform a high number of kidney biopsies, which can help determine the etiology of CKD along with the degree of acute and chronic kidney damage. We assess adherence to therapies, since patients may not always follow a treatment plan due to side effects, cost, or insurance approval. We want to make sure patients understand why we're recommending what we recommend, and, importantly, we take into account the patient's priorities for their own care to make sure we're honoring their treatment preferences.

Closing the Gap Between CKD Evidence and Everyday Practice

HCPLive: Many patients with CKD still reach advanced stages of disease despite having effective therapies available. Where do you think the biggest gaps remain in translating evidence into everyday practice?

Breeggemann: This has been studied across medicine as a whole, and it's quite interesting to read about. It takes approximately 17 years following a new medical intervention or therapy for it to become routinely used in clinical practice. That seems like an incredibly long time, because it is, but it's probably best explained by the time needed to change clinical guidelines, disseminate information to clinicians, and change old habits among providers who are otherwise very busy caring for hundreds or thousands of patients. Insurance review and approval is another factor—these therapies are often expensive, and insurers need to approve and cover costs for many patients. There can also be individual hospital and clinic review processes for new therapies, among many other factors.

For CKD therapies specifically, I can think of some potential issues: delays in diagnosis, delays in referral to a nephrologist, and the need for clear communication between primary care and other subspecialists. You can imagine patients seeing endocrinologists, nephrologists, cardiologists, and primary care—we need to make sure it's clear who's going to prescribe the therapy, since that often overlaps multiple fields. You also need patient buy-in and adherence to the recommended therapy, along with cost, insurance coverage, and potential side effects. That said, a lot of the therapies we have available in nephrology, especially those aimed at reducing protein levels in patients with chronic kidney disease, are generally pretty well tolerated.

The Long-Term Association Between AKI and CKD Progression

HCPLive: AKI and CKD are often discussed separately, but we know episodes of acute kidney injury can influence long-term kidney outcomes. How has our understanding of this relationship changed in recent years?

Breeggemann: An episode of acute kidney injury, or AKI, should not be viewed as a simple, transient condition, even when labs improve and seem to suggest that. For instance, creatinine peaks with AKI and then improves over time, but it would be a mistake in the large majority of cases to say no additional evaluation or monitoring is needed. We know that, at a tissue level, these episodes of AKI can lead to structural changes in the kidney, inflammation, and damage to cells and blood vessels inside the kidney. It's likely these changes explain the risk that recurring episodes of AKI pose for the eventual development of CKD, and patients with existing CKD are at even higher risk for disease progression when they experience an episode of AKI compared with someone without CKD.

There are also mild and more severe cases of AKI, and the most severe episodes place patients at higher risk. Many patients who experience an AKI may not even be aware they had one, due to a lack of symptoms or because they weren't informed by their medical team. Roughly 15% of hospitalized patients have an AKI, and they should be monitored after discharge—but we know many aren't, so there's often no post-AKI surveillance labs, and care for these patients is inconsistent.

What Will Define the Next Era of CKD Management

HCPLive: As kidney care moves toward earlier intervention, what do you think will define the next era of CKD management?

Breeggemann: I like to think we're on track for improving care for those with CKD, with greater clinical knowledge and better detection. We have the tools we need to find these patients and refer them to nephrologists and other subspecialists on a more timely basis than ever before. This should allow better coordination between subspecialties—nephrology, endocrinology, cardiology, and others really need to work together to best care for these patients, rather than assuming one specialty will manage the condition primarily, because that often leads to delays in effective therapy.

We also have risk stratification tools, like kidney risk prediction calculators, that help assess which patients are more likely to progress. There are precision approaches incorporating genetic testing, imaging, and other techniques that are really valuable. I'd also highlight subspecialty clinics and centers of excellence often embedded within nephrology clinics at select sites. For example, at UCSF we have a glomerulonephritis clinic, a kidney stone prevention clinic that I run, and a polycystic kidney disease center. These can be useful options for patients with specific causes for their CKD.

How the Definition and Management of CKD Have Evolved

HCPLive: CKD is no longer viewed simply as progressive loss of kidney function. How has the way we define and understand CKD changed in 2026, and what does that mean for how clinicians should care for patients?

Breeggemann: The definition of CKD largely remains unchanged—it's primarily based on lab findings like creatinine, cystatin C, and urinary albumin levels. But the way we understand and manage CKD has changed considerably. Sometime around the early 1980s, clinicians realized that how much urine protein a patient excreted was a significant risk factor for the potential progression of their chronic kidney disease—the higher the urine protein, the higher the risk of progression. Normal, healthy kidneys don't allow a significant amount of protein to leave via the urine, so higher urine protein levels mean worse kidney function, and failure to reverse those levels leads to worsening kidney function over time. This is an important target that nephrologists and other providers focus on when treating all forms of CKD. I'd add that genetic testing can be incredibly helpful in understanding the etiology of a patient's CKD, especially when more obvious causes like diabetes or hypertension are absent.

The Role of Patient Advocacy Groups in CKD Care

HCPLive: Was there anything I didn't ask about that you wanted to add or highlight to today's discussion?

Breeggemann: There are certainly patient advocacy groups available. Some patients have rare forms of CKD—perhaps a rare kidney stone disorder—and groups like the Oxalosis and Hyperoxaluria Foundation help patients with conditions like hyperoxaluria, which can lead to stones and chronic kidney disease. These advocacy groups can connect a patient to a provider or center of excellence clinic near them, which can help relieve the anxiety and stress that comes with a new diagnosis and get patients the care they need promptly. There are many new therapies for CKD, kidney stone disorders, and especially glomerular disorders, and it can be overwhelming for a patient to navigate on their own. Seeking out a patient advocacy group is incredibly valuable.