How a Nephrologist Diagnoses and Manages Chronic Kidney Disease

As a diverse collection of disorders with different underlying causes, genetic profiles, and rates of progression, chronic kidney disease (CKD) is highly heterogeneous and can be complicated to diagnose.

Matthew Breeggemann, MD, a nephrologist, 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), has faced his fair share of these patients with acute kidney injury, CKD, electrolyte disorders, and hypertension, noting the necessity of paying attention to all facets of disease management.

"You'll see patients where it's really straightforward, like diabetes, and you're pretty certain their kidney disease is due to diabetes. But you might have another patient with diabetes, hypertension, kidney stones, and other reasons they might have chronic kidney disease," Breeggemann told HCPLive in this interview. "It's about ensuring you're doing your due diligence as their clinician, their nephrologist or provider, and making sure you're not missing anything."

That diagnostic groundwork carries directly into how Breeggemann manages patients once a cause is identified, starting with the tools he relies on to pin down etiology in more complex cases.

Genetic Testing and Biopsy in CKD Workup

"Our center also performs a substantial amount of genetic testing for kidney disorders, and these findings have definitely led to changes in how we approach and manage some patients with CKD," Breeggemann said.

Identifying disease-causing genetic variants in patients with CKD can support prognostication and personalized management, including nephroprotection strategies and decisions around kidney transplantation, and is also important for genetic counseling and reproductive family planning.

Genetic testing is often paired with tissue-level evaluation. "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," Breeggemann noted.

A kidney biopsy can be used even after a CKD diagnosis has already been made, to identify the exact root cause of damage, measure active inflammation against permanent scarring, and guide targeted treatment in ways standard blood and urine tests cannot.

Diagnostic testing, however, is only part of the picture. Breeggemann said his approach also weighs whether patients are able to follow through on treatment and what they themselves want out of care. "We also assess adherence to therapies," he said, pointing to barriers such as side effects, cost, and insurance approval that can get in the way even when a treatment plan is medically sound. Just as important, he said, is factoring in "the patient's priorities for their own care," to ensure management stays aligned with what patients themselves want.

Which Patients With CKD Need Closer Monitoring?

Asked which clinical values guide his treatment decisions in CKD, Breeggemann pointed to a single lab value used differently than many might expect.

"I'll lean on the eGFR a bit, but really I look at the trend," he explained.

A stable reading over time, even if abnormal, can be reassuring. "You might have a patient whose eGFR, based on a blood test like creatinine or, in some cases, cystatin C, is stable, say 50 milliliters per minute for the last 10 years," he said. "It's actually been really stable and well managed. It hasn't progressed at all."

The slope of that trend line, he said, can carry more clinical weight than the number itself. "You might have another patient whose eGFR was 50 a year ago and is now 25. It's decreased by a major degree, and those are patients you'll keep a much closer eye on through lab monitoring and appointments."

Where CKD Care Still Falls Short

Beyond individual patient management, Breeggemann pointed to a systemic gap affecting CKD care broadly: the time it takes for new therapies to actually reach patients.

"Across medicine as a whole, it's quite interesting — it takes approximately 17 years following a new medical intervention or therapy to be routinely used in clinical practice," he said. "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 busy caring for hundreds or thousands of patients."

In CKD specifically, that lag is compounded by hurdles more specific to the disease: delayed diagnosis, delayed referral to a nephrologist, and communication gaps between primary care and the range of subspecialists who may share responsibility for a CKD patient's care.

"You can imagine how some of these patients might be seeing endocrinologists, nephrologists, cardiologists, and of course primary care," Breeggemann said. "We need to make sure who's going to prescribe the therapy, which often overlaps multiple fields." Patient buy-in, adherence, cost, and insurance coverage add further friction to getting new CKD therapies into routine use.

Even so, Breeggemann pointed to one factor working in favor of CKD patients: many newer CKD therapies are easier to stay on than the adoption timeline alone might suggest. "A lot of the therapies that we have available to us in nephrology, especially those aimed at reducing protein levels in patients with chronic kidney disease, generally are pretty well tolerated," he said.

Taken together, Breeggemann's account points to a broader pattern in CKD care: closing the gap between available therapies and everyday practice may depend as much on communication and coordination across specialties as on the science behind CKD treatment itself.

Editor’s Note: Breeggemann reports disclosures with Novo Nordisk.

References

1. Wilson S, Mone P, Jankauskas SS, Gambardella J, Santulli G. Chronic kidney disease: Definition, updated epidemiology, staging, and mechanisms of increased cardiovascular risk. The Journal of Clinical Hypertension2021;23(4):831-834. doi:10.1111/jch.14186

2. Knoers NVAM, van Eerde AM. The Role of Genetic Testing in Adult CKD. Journal of the American Society of Nephrology2024;35(8):1107-1118. doi:10.1681/asn.0000000000000401