Do patients with normalized estimated Glomerular Filtration Rate (eGFR) still have Chronic Kidney Disease (CKD)?

CKD Diagnosis Persists Despite eGFR Normalization if Kidney Damage Markers Remain

Yes, patients can still have chronic kidney disease even if their eGFR normalizes, because CKD is defined by the presence of either reduced eGFR OR evidence of kidney damage (such as albuminuria) persisting for at least 3 months. 1

Understanding CKD Definition Beyond eGFR

CKD diagnosis requires either of the following criteria to persist for ≥3 months 1:

• Reduced eGFR (<60 mL/min/1.73 m²), OR
• Evidence of kidney damage regardless of eGFR level 1

Evidence of kidney damage includes 1:

• Albuminuria (UACR ≥30 mg/g)
• Glomerular hematuria
• Pathological abnormalities on kidney biopsy
• Radiographic abnormalities (reduced kidney size, cortical thinning)
• Other urinary sediment abnormalities

CKD Stages 1-2: Normal or High eGFR WITH Kidney Damage

Patients with eGFR ≥60 mL/min/1.73 m² are classified as CKD Stage 1 or 2 if they have persistent evidence of kidney damage 1:

• Stage 1 CKD: eGFR ≥90 mL/min/1.73 m² PLUS kidney damage (typically albuminuria) 1
• Stage 2 CKD: eGFR 60-89 mL/min/1.73 m² PLUS kidney damage 1

This is particularly important in diabetic kidney disease, where patients may have elevated or high-normal GFR in early years after diagnosis, yet kidney biopsy can show histological evidence of diabetic glomerulopathy 1.

Confirming Chronicity After eGFR Improvement

When eGFR normalizes, establish whether CKD persists by 1:

1. Repeat albuminuria testing - Two of three specimens collected within 3-6 months should be abnormal to confirm persistent albuminuria 1
2. Review historical data - Past measurements of eGFR and albuminuria establish chronicity 1
3. Assess for structural damage - Imaging showing reduced kidney size or cortical thinning indicates irreversible damage 1
4. Consider kidney biopsy findings - Pathological evidence of fibrosis and atrophy confirms chronic damage 1

Critical Clinical Pitfall: Don't Assume Recovery Equals No CKD

The most common error is assuming that eGFR normalization means CKD has resolved. 2 While referral to nephrology can lead to eGFR improvement or stabilization (48.2% of Stage 2 patients showed significantly improved eGFR slope), this does not eliminate the CKD diagnosis if kidney damage markers persist 2.

An initial decline in eGFR with certain medications (ACE inhibitors, ARBs, MRAs, SGLT2 inhibitors) followed by stabilization represents hemodynamic adaptation, not progressive kidney deterioration, and should not prompt discontinuation of therapy 3. However, persistent albuminuria despite eGFR improvement still indicates ongoing kidney damage requiring continued CKD management 1.

Ongoing Risk Despite Normal eGFR

At any eGFR level, the degree of albuminuria independently predicts 1:

• CKD progression risk
• Cardiovascular disease events
• Mortality

Patients with normalized eGFR but persistent albuminuria remain at elevated cardiovascular and mortality risk compared to those without kidney damage markers 1. This risk is continuous, with even albuminuria below traditional threshold values (>3.9 mg/g in men, >7.5 mg/g in women) associated with adverse outcomes 1.

Management Implications

Continue CKD-specific interventions if kidney damage persists despite normal eGFR 1:

• Blood pressure control targeting kidney-protective goals
• ACEI or ARB therapy for patients with albuminuria (UACR 30-300 mg/g or >300 mg/g) 1
• Annual monitoring of both eGFR and albuminuria 1
• Cardiovascular risk reduction strategies
• Avoidance of nephrotoxic medications (NSAIDs, certain antibiotics) 1

The diagnosis of CKD is not removed simply because eGFR returns to normal range—persistent evidence of kidney damage maintains the diagnosis and necessitates ongoing nephrology care. 1