Chronic kidney disease: the five stages explained

In short

Chronic kidney disease is common across the Middle East because diabetes and high blood pressure, the two leading causes, are both at epidemic levels in the region.
Creatinine alone is not enough to assess kidney function. The eGFR calculated from it is what actually tells you how well your kidneys are working.
Stages 1 through 3 usually cause no noticeable symptoms, which is why early detection through regular blood and urine tests matters enormously.
Ibuprofen, diclofenac, and other over-the-counter painkillers are among the most common causes of kidney damage in the region and are often sold without a prescription.
Dehydration in a hot climate can temporarily raise creatinine and mimic kidney disease, and a doctor should retest after proper hydration before making a diagnosis.

What this article covers

What are the kidneys and what does eGFR actually measure?
Why is CKD so common across the Middle East?
How does heat and dehydration affect creatinine and eGFR readings?
Does CKD cause symptoms you can notice?
Painkillers and herbal remedies: overlooked causes of kidney damage
How does a doctor monitor kidney function over time?
What can you do to slow the progression of CKD?
When does dialysis become necessary, and what are the options?

What are the kidneys and what does eGFR actually measure?

The two kidneys sit on either side of the lower back, each roughly the size of a fist. Their main jobs are filtering waste products and excess fluid from the blood, regulating blood pressure and the balance of salts and minerals, and producing a hormone that stimulates the production of red blood cells. Each kidney contains about one million tiny filtering units called glomeruli.

Chronic kidney disease, or CKD, means that kidney function has declined permanently for more than three months. This is quite different from acute kidney injury, which is a short-term fall in kidney function caused by dehydration, a medication, or a brief illness and which can fully recover. The decline in CKD is gradual and is usually silent for years.

The estimated glomerular filtration rate, or eGFR, is the main measure of how well the kidneys filter the blood. It is calculated from the creatinine level in the blood, adjusted for age and sex, and expressed as millilitres per minute per 1.73 square metres of body surface area. A healthy young adult typically has an eGFR above 90.

Creatinine alone is an imperfect guide because it depends heavily on muscle mass. A thin elderly person may have a creatinine in the normal range while already having significantly reduced kidney function, whereas a heavily muscled young person may have a mildly raised creatinine with perfectly normal kidneys. The eGFR adjustment corrects for much of this, making it a more reliable indicator.

The five CKD stages by eGFR (KDIGO classification)

Stage	eGFR (mL/min/1.73m²)	Kidney function
Stage 1	90 or above	Normal or high with evidence of kidney damage (e.g. protein in urine)
Stage 2	60 to 89	Mildly reduced with evidence of kidney damage
Stage 3a	45 to 59	Mild to moderate reduction
Stage 3b	30 to 44	Moderate to severe reduction
Stage 4	15 to 29	Severely reduced; preparing for kidney replacement
Stage 5	Below 15	Kidney failure requiring dialysis or transplantation

Why is CKD so common across the Middle East?

A 2025 analysis from the Global Burden of Disease study found that CKD affects between 10 and 15 percent of adults worldwide, with type 2 diabetes and high blood pressure accounting for the largest share of cases. Both conditions are at epidemic levels across the Middle East and North Africa, making the region one of the highest-burden areas for kidney disease globally.

In Saudi Arabia, Kuwait, the UAE and other Gulf states, some surveys record diabetes prevalence above 20 percent of adults. This means a very large population of kidneys exposed to progressive glomerular damage, because poorly controlled diabetes gradually destroys the small blood vessels inside the filtering units.

High blood pressure causes harm by a different mechanism, exerting continuous high-pressure stress on the vessels that supply the glomeruli from the outside. When diabetes and hypertension coexist in the same person, which is common, the combined damage is substantially greater than either condition alone.

An underappreciated regional factor is chronic dehydration. In Gulf countries, Iraq, Jordan, and other hot and arid areas, outdoor workers and people who do not drink enough in extreme heat face repeated episodes of reduced kidney blood flow. Recurrent heat-related dehydration over years can cause cumulative kidney harm even in the absence of diabetes or hypertension.

How does heat and dehydration affect creatinine and eGFR readings?

A very common clinical mistake in the region is interpreting a raised creatinine immediately as chronic kidney disease. Dehydration reduces the volume of blood reaching the kidneys so filtration slows temporarily, creatinine rises, and eGFR falls. When normal hydration is restored, the creatinine returns to baseline.

Distinguishing acute dehydration-related kidney impairment from true CKD is therefore critical. A doctor should retest creatinine after ensuring the patient has been properly hydrated for several days. If values normalise within a few days, the problem was acute and reversible rather than a permanent chronic process.

Outdoor workers in construction, agriculture, and similar roles are particularly vulnerable to repeated dehydration episodes that can cause cumulative kidney harm over years, even without an underlying kidney disease. In extreme heat with heavy physical labour, fluid needs are far higher than the standard two litres a day that most people think of.

The practical advice: if a raised creatinine appears unexpectedly on a routine test in someone who feels otherwise well, ask for the test to be repeated after several days of good fluid intake before any diagnosis is made. This simple step prevents a great deal of unnecessary alarm.

Where does your eGFR sit?

eGFRmL/min/1.73m²

Moderate

Mild

Normal

0 15 30 60 90 120

Source: KDIGO 2012 Clinical Practice Guideline for CKD

Does CKD cause symptoms you can notice?

In stages 1, 2, and 3 there are usually no noticeable symptoms at all. The kidneys have a large functional reserve and compensate for the declining capacity silently for a long time. This is what makes early detection without testing nearly impossible, and why regular screening matters for anyone with diabetes, hypertension, or a family history of kidney disease.

As function falls toward stages 4 and 5, symptoms of waste accumulation begin to appear: deep and persistent fatigue, changes in urine output, swelling in the ankles, feet and face from fluid retention, shortness of breath, nausea, poor appetite, skin itching, and pallor from the anaemia that develops when the kidneys can no longer make adequate erythropoietin.

High blood pressure that is becoming increasingly difficult to control can be an early sign that the kidneys are involved, even before other symptoms appear. Frothy or foamy urine, which indicates protein leaking through damaged filters, is another early sign that patients sometimes notice and mention but may not connect to kidney health.

Back pain is a common misconception: it is not a symptom of CKD and the kidneys do not hurt in chronic disease. Kidney pain typically comes from stones or infection. Assuming that back pain means kidney trouble leads people to investigate the wrong thing.

Painkillers and herbal remedies: overlooked causes of kidney damage

Non-steroidal anti-inflammatory drugs, the NSAIDs, including ibuprofen, diclofenac, and naproxen, reduce blood flow to the glomeruli by constricting the small vessels that maintain filtration pressure. A 2020 review in the American Journal of Kidney Diseases confirmed that regular NSAID use significantly increases the risk of kidney deterioration in people with high blood pressure, pre-existing CKD, or low fluid intake.

The regional problem is that these painkillers are sold freely without a prescription across much of the Middle East. Many people take them daily or near-daily for back pain, joint pain, or headaches without realising that even short courses can harm a kidney that is already under metabolic stress. The risk is not theoretical: NSAID-related kidney injury is a well-documented contributor to CKD progression in the region.

Traditional herbal remedies represent a parallel risk. Aristolochic acid, present in some plants used in folk medicine across Arab countries under various local names, has been scientifically established as a cause of severe and permanent kidney damage even in small quantities. Some slimming preparations and herbal formulas marketed for kidney cleansing contain compounds that have not been adequately tested and may be nephrotoxic.

A 2025 study in Nutrients testing Lebanese and regional folk herbs found hepatic and renal toxicity signals in animal models for several commonly used plants. The practical rule is straightforward: if you have CKD, hypertension, or diabetes, do not take any herbal preparation or supplement without telling your doctor, because natural does not mean safe for a damaged kidney.

How does a doctor monitor kidney function over time?

Regular monitoring is a cornerstone of CKD management. The routine blood panel includes creatinine and the eGFR calculated from it, potassium (which rises as the kidneys weaken and can cause dangerous cardiac arrhythmias), sodium, bicarbonate to measure acid balance, phosphorus and calcium, parathyroid hormone (PTH), and a full blood count to assess for anaemia.

Urine testing is equally important and should not be overlooked. The presence of albumin in the urine, known as albuminuria or proteinuria, is one of the earliest signs of glomerular damage and one of the strongest predictors of progression. The doctor measures the albumin-to-creatinine ratio in an early morning urine sample, which is a more accurate approach than a random spot test.

Kidney ultrasound gives information about the size, shape, and cortex thickness of both kidneys, and can detect stones, cysts, or obstruction. Shrunken kidneys with a thinned cortex suggest long-standing chronic damage, while a kidney that is swollen in an acute setting may still have good recovery potential.

The frequency of monitoring depends on the stage: annual checks are usually enough in stages 1 and 2, every six months in stage 3, and more frequently in stages 4 and 5 under the care of a specialist nephrologist who can plan the timing of kidney replacement therapy.

What can you do to slow the progression of CKD?

The primary goal in CKD management in most cases is not complete cure but slowing progression as long as possible. The two most powerful tools are tight control of blood sugar and blood pressure. Keeping HbA1c below 7 percent and blood pressure consistently below 130 over 80 millimetres of mercury have been shown in multiple trials to substantially slow the decline in eGFR.

Drugs from the ACE inhibitor or angiotensin receptor blocker (ARB) classes protect the glomeruli through a mechanism beyond blood pressure lowering and are strongly recommended in the early stages of CKD, particularly when proteinuria is present. Do not stop these medications on your own even if you notice a temporary small dip in kidney function at the start of treatment, as this is an expected effect and does not mean harm.

Diet plays a real role: reducing sodium intake helps control blood pressure and fluid retention, and limiting excessive protein reduces the filtration burden on damaged glomeruli. In stages 3 and beyond, potassium and phosphorus also need to be managed carefully. Work with a renal dietitian rather than following generic online advice, because the right restrictions depend entirely on your individual blood results.

Stopping smoking is important because smoking accelerates vascular damage including the small vessels in the kidney. Maintaining a healthy weight reduces metabolic pressure on the kidneys. Drinking enough water in a hot climate, enough to keep urine light yellow rather than dark, prevents repeated episodes of dehydration-related kidney stress that can cause cumulative harm over time.

Practical steps to slow CKD progression

1Keep HbA1c below 7 percent if you have diabetes
2Control blood pressure to below 130 over 80 mmHg
3Take your kidney-protecting medicines consistently and do not stop them yourself
4Avoid ibuprofen, diclofenac and other NSAIDs
5Reduce salt and avoid heavily salted processed and canned foods
6Drink enough water to keep urine light, especially in hot weather
7Stop smoking and maintain a healthy weight

When does dialysis become necessary, and what are the options?

When eGFR falls below 15 and is accompanied by symptoms of kidney failure such as severe nausea, dangerous fluid accumulation, rising potassium threatening cardiac rhythm, or breathlessness, kidney replacement therapy becomes necessary. The three options are haemodialysis, peritoneal dialysis, and kidney transplantation.

Haemodialysis is the most common form of kidney replacement in the region. It is performed in specialist centres three times a week for sessions of around four hours each. Preparation requires creating a vascular access point, usually an arteriovenous fistula in the arm, which is formed surgically weeks to months before dialysis begins. Haemodialysis extends life but requires regular travel to a centre and considerable time commitment.

Peritoneal dialysis uses the lining of the abdomen as a natural filter and is performed daily at home using fluid exchanges through a surgically placed catheter in the abdominal wall. It suits people who cannot travel easily to a centre or who prefer greater independence. It requires training but allows more flexibility in daily life.

Kidney transplantation offers the best quality of life and survival when it is accessible. Access varies considerably across the region: Saudi Arabia, Jordan, and Egypt have established transplant programmes, while in countries affected by conflict such as Yemen and Syria, even access to regular dialysis can be a serious practical challenge. If transplantation is a possibility for you, a specialist can begin the assessment process well before dialysis becomes urgent.

In the Sihtak app you can log your creatinine, eGFR, and urine protein results over time to spot trends, ask the AI assistant to explain what a result means, and set reminders for your next kidney test appointment. A practical tool to help you stay on top of your monitoring, alongside your doctor's care.

Frequently asked questions

Does a raised creatinine always mean I have kidney disease?

Not necessarily. Creatinine is affected by muscle mass, dehydration, and some medications. A doctor calculates your eGFR from the creatinine and repeats the test after proper hydration before drawing any conclusion. A one-off raised creatinine in an otherwise well person often turns out to be dehydration.

Is it safe to take ibuprofen if I have a kidney problem?

No. NSAIDs including ibuprofen and diclofenac are harmful to the kidneys, especially in people with CKD, hypertension, or diabetes. Paracetamol (acetaminophen) at correct doses is the safer alternative for most types of pain, but discuss this with your doctor.

Are herbal remedies safe to use with CKD?

Not automatically. Several herbs commonly used across the region contain compounds that are toxic to the kidneys, and some interact with prescribed medicines. Tell your doctor everything you take and ask before starting anything new, because natural does not mean safe for a kidney that is already under stress.

Will I always need dialysis if I have CKD?

Not necessarily. Many people live for decades with stable CKD stages 1 through 3 and never reach dialysis, particularly if blood pressure, blood sugar, and risk factors are well controlled. The goal of management is to keep eGFR stable for as long as possible, and this is genuinely achievable in many cases.

Is exercise safe with chronic kidney disease?

Moderate physical activity is safe and beneficial in stages 1 through 4 in most cases. It helps control blood pressure, body weight, and blood sugar, all of which slow CKD progression. Discuss with your doctor the appropriate type and intensity for your current stage.

Does CKD cause back pain?

No. Chronic kidney disease does not typically cause back pain. Kidney pain comes from kidney stones or infection, not from CKD. If you have back pain and CKD, the two are usually unrelated and the back pain should be investigated on its own merits.

Do I need a special diet with CKD?

Yes, particularly in the more advanced stages. In stages 1 and 2 the main advice is reducing sodium and avoiding excessive protein. From stage 3 onward, potassium and phosphorus also need to be watched. A renal dietitian can create a plan based on your specific blood results rather than a generic one-size-fits-all approach.

Sources

This content is for health education only and is not a substitute for medical advice. If you have symptoms that worry you, see your doctor.