By Ryan DuBosar
On Thursday morning, a nephrologist issued a call to action to slow the silent epidemic of chronic kidney disease (CKD), reporting that 15% of the U.S. population has the condition yet 90% of them are unaware of it.
“Thirty-seven million Americans live with CKD … Most don't know it. You can change that,” Rajiv Agarwal, MD, MS, professor emeritus at the Indiana University School of Medicine and a staff physician at the Richard L. Roudebush VA Medical Center in Indianapolis, told attendees at Internal Medicine Meeting 2026.
“We probably ought to be screening a lot more people than what we might be doing right now, because we are just focusing on [screening patients with] diabetes,” he said. “We're not doing a very good job in United States. About approximately a third of the patients who need UACR [urine albumin-to-creatinine ratio] get a UACR. Two-thirds of the people don't even get this measure.”
Dr. Agarwal called on physicians to screen every patient with diabetes and every patient with hypertension annually with estimated glomerular filtration rate (eGFR) and UACR.
“There is really a dual-test mandate. It's very clear that we need exactly two tests to diagnose kidney disease,” Dr. Agarwal said. He'd also like to retire the dipstick test for CKD screening because dipsticks detect protein levels greater than 150 to 200 mg/dL. UACR levels between 30 to 299 mg/g are invisible to the dipstick.
In patients who do have CKD, clinicians should consider the four pillars of drug therapy: renin-angiotensin system blockade, sodium-glucose transporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists. Prescribe these drugs proactively, Dr. Agarwal said, because time equals tissue and therapeutic inertia carries costs.
“If you use all these four therapies, you can potentially reduce the risk of [negative] outcomes by 75%,” Dr. Agarwal said.
But he acknowledged an important barrier to care: prior authorization. The average physician practice loses 14.6 hours per week to getting prior authorizations.
“What we are facing is that we have effective therapies out there, but we have to go and beg someone to get them to prescribe for a patient,” he said. “It becomes a problem. The patient goes through the cracks.”
He also offered some specific advice on using renin-angiotensin system blockade: the 30% rule. A creatinine rise of less than 30% after starting angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers is expected, benign, and protective. These drugs dilate the efferent arteriole, causing reduced glomerular filtration pressure and creatinine to rise. This is a hemodynamic effect, not acute kidney injury, Dr. Agarwal said.
If eGFR drops 30% and there's no obvious reason, don't panic, just look at UACR levels.
“I just had a patient last week in my clinic. His eGFR went from like 32 to about 25, but his UACR improved like 40%, and I said, ‘Look, you are on the path of recovery. Keep doing what you are [doing],’ instead of saying that ‘I'm concerned about your eGFR and I'm going to stop these drugs.’”
For patients you're particularly worried about, calculate the Kidney Failure Risk Equation, Dr. Agarwal said. The equation uses age and sex, eGFR, and UACR to calculate kidney failure risk. Validated in more than 30 countries and 700,000 patients, it provides two- and five-year kidney failure probability and outperforms eGFR alone as a referral trigger.
If the equation reveals less than 3% risk, continue primary care management and annual monitoring, he said. Between 3% and 5%, consider a nephrology consultation. Between 5% and 10%, a referral is recommended, and above 10%, a referral is required, Dr. Agarwal said.
Finally, for a patient with CKD, perform at every visit the mandatory trio of UACR, eGFR, and potassium levels. UACR detects structural damage progression, and rising levels signal therapeutic failure while eGFR tracks functional decline rate. A decline in eGFR may indicate a rapid progression and require escalation of care. Serum potassium levels can be changed by medical therapies, and hyperkalemia management enables continued use of kidney-protective therapies, Dr. Agarwal said. ■