Why Do People Develop Chronic Kidney Disease? Major Causes and Risk Factors
In Taiwan, about half of new dialysis patients have diabetes, followed by hypertension and glomerulonephritis. Understanding the cause tells you where to start protecting your kidneys.
Why Do Kidneys Fail?
Nephrons cannot regenerate. Any condition that chronically subjects the glomeruli to high pressure, inflammation, ischemia or toxic injury causes nephrons to scar and stop working. Once enough are lost, the survivors are forced to "work overtime" (hyperfiltration), which accelerates their own wear — the central reason CKD keeps progressing.
The Three Leading Causes
1. Diabetic Kidney Disease (the most common)
Long-term high blood glucose damages the glomerular capillaries and basement membrane, letting albumin leak and gradually hardening the glomeruli.
- In Taiwan roughly 45–50% of new dialysis patients have diabetes — the number-one cause
- Globally the picture is similar: diabetes leads the causes of kidney failure in developed countries
- Typical course: albuminuria appears first (A2 → A3), then eGFR gradually declines
- People with type 2 diabetes should have UACR and eGFR checked annually (joint ADA/KDIGO recommendation)
2. Hypertensive Kidney Disease
Sustained high blood pressure hardens the small renal arteries and raises pressure inside the glomeruli, causing ischemic damage and sclerosis. Because the kidneys also regulate blood pressure, a vicious cycle forms: hypertension damages kidneys → damaged kidneys make hypertension harder to control.
- Accounts for about 25–30% of new dialysis patients (figures vary by country and often overlap with diabetes)
- KDIGO 2021 recommends a systolic target of < 120 mmHg for most adults with CKD (using standardized measurement, adjusted for tolerance)
3. Glomerulonephritis
A group of diseases in which the immune system attacks the glomeruli. Common types:
- IgA nephropathy — the most common primary glomerulonephritis in Asia, usually presenting with hematuria and proteinuria
- Focal segmental glomerulosclerosis (FSGS)
- Membranous nephropathy
- Lupus nephritis — kidney involvement in systemic lupus erythematosus
- Post-streptococcal glomerulonephritis — may leave chronic damage if not properly treated
Diagnosis usually requires a kidney biopsy. Many types have specific immunotherapies, so early diagnosis matters.
Other Important Causes
| Cause | Notes |
|---|---|
| Polycystic kidney disease (PKD) | Inherited (usually autosomal dominant); cysts gradually replace normal tissue. Screen if there is a family history. |
| Obstructive nephropathy | Stones, enlarged prostate, tumors, congenital urinary tract anomalies causing chronic obstruction and recurrent infection |
| Drugs and toxins | Long-term NSAIDs, herbal products containing aristolochic acid, lithium, certain chemotherapy and antiviral agents; heavy metals (lead, cadmium) |
| Repeated or severe AKI | Each episode may leave irreversible nephron loss |
| Congenital conditions | Renal hypoplasia, vesicoureteral reflux, kidney injury from perinatal hypoxia or difficult birth |
| Other systemic diseases | Vasculitis, multiple myeloma, amyloidosis, sickle cell disease |
| Infections | Hepatitis B, hepatitis C, HIV-associated nephropathy |
On aristolochic acid: Taiwan once saw large numbers of nephropathy and urothelial cancer cases linked to herbal ingredients containing aristolochic acid (e.g. Guang Fang Ji, Guan Mu Tong, Qing Mu Xiang). The Ministry of Health banned them in 2003. It remains the most prominent example of "folk remedies that harm the kidneys" — and why kidney patients should avoid herbal or supplement products of uncertain origin.
Factors That Accelerate Progression
Even with the cause identified, these factors speed up CKD:
Non-modifiable
- Age (65+)
- Family history
- Low birth weight / prematurity (fewer nephrons from birth)
- Certain genes (e.g. APOL1 variants)
Modifiable
- Poor glucose control
- Poor blood pressure control
- Persistent albuminuria (itself a driver of progression)
- Smoking — accelerates vascular hardening and GFR decline
- Obesity and metabolic syndrome
- Hyperuricemia
- Cardiovascular disease (heart and kidney are one system)
- Nephrotoxic drugs — NSAIDs, contrast dye, some antibiotics
- High-protein, high-sodium diet
- Untreated recurrent urinary infection or obstruction
Taiwan's Particular Situation
Taiwan's CKD burden is heavy, likely due to:
- High diabetes prevalence with suboptimal early control
- An aging population
- Historical medication misuse (analgesics, aristolochic-acid herbs, products of unknown composition)
- Universal health insurance making dialysis highly accessible, so end-stage patients survive and are counted (which also reflects the strength of the care system)
A positive shift: Taiwan launched the Pre-ESRD care program in 2003 and the Early-CKD program in 2012, and newer drugs such as SGLT2 inhibitors are now widely used. New dialysis starts peaked in 2019 and have since declined.
Once You Know the Cause, What Can You Do?
- Treat the cause: control glucose and blood pressure, treat glomerulonephritis, relieve obstruction
- Use medications with proven kidney protection (as assessed by your doctor): ACE inhibitors/ARBs, SGLT2 inhibitors, non-steroidal MRAs, GLP-1 receptor agonists
- Remove accelerators: quit smoking, lose weight, stop NSAIDs, avoid unverified herbal products
- Monitor regularly: eGFR and UACR every 3–12 months depending on risk level
Key Takeaways
- Diabetes, hypertension and glomerulonephritis are the big three, together accounting for over 70% of new dialysis patients
- Nephrotoxic drugs and unverified herbal products are important avoidable causes
- Albuminuria, smoking, obesity and poor glucose/BP control accelerate decline
- Identifying and treating the cause is the most effective way to slow progression
References
- KDIGO. 2024 Clinical Practice Guideline for the Evaluation and Management of CKD. 2024.
- KDIGO. 2021 Clinical Practice Guideline for the Management of Blood Pressure in CKD. 2021.
- KDIGO. 2022 Clinical Practice Guideline for Diabetes Management in CKD. 2022.
- NIDDK. Causes of Chronic Kidney Disease.
- Taiwan Society of Nephrology. Taiwan Renal Data System Annual Report.
- Taiwan Ministry of Health and Welfare. Ban on aristolochic-acid-containing herbal ingredients (2003).
This article summarizes publicly available medical information for educational purposes only and is not medical advice. For any questions about your health, illness or physical care, please seek help through professional medical channels and consult your physician.
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