Role of Metabolic Abnormalities During the Progression of Chronic Kidney Disease and Preventive Strategies

Chronic kidney disease (CKD) is characterized by persistent renal impairment or dysfunction that lasts for at least 3 months, and typically has a progressive and irreversible trajectory. The increasing prevalence of metabolic disorders, such as hyperuricemia, dyslipidemia, obesity, and type 2 diabetes mellitus, have contributed to the increasing incidence of CKD, and it is now a significant public health concern worldwide. Accumulating evidence underscores the intricate relationships of the different metabolic disorders and how they promote the initiation and progression of CKD, and ultimately lead to end-stage renal disease (ESRD). Metabolic abnormalities promote CKD progression by various mechanisms, including oxidative stress, chronic inflammation, dysregulation of autophagy, glomerular hyperfiltration and disruption of hemodynamics, endothelial dysfunction, and dysbiosis of gut microbiota. Ectopic lipid deposition and lipid peroxidation-induced redox imbalance lead to mitochondrial dysfunction, excessive production of reactive oxygen species (ROS), and activation of the p38 MAPK, ERK, and JNK signaling pathways. Metabolic dysregulation activates NF-κB signaling pathways and NLRP3 inflammasomes, leading to increased production of pro-inflammatory factors, lysosomal dysfunction, and impaired autophagic clearance, followed by accumulation of metabolic waste and podocyte injury. Obesity and hyperlipidemia can cause excessive activation of the renin-angiotensin-aldosterone system (RAAS), which then causes glomerular hyperfiltration, endothelial and mesangial cell injury and proliferation, and ultimately glomerulosclerosis. Multiple interventions that target these mechanisms have shown therapeutic potential, and these include pharmacological treatments (xanthine oxidase inhibitors to reduce uric acid levels, statins for lipid regulation, and SGLT2 inhibitors and GLP-1 receptor agonists to improve renal and cardiovascular outcomes), lifestyle interventions (low-salt and low-protein diets, weight management, smoking cessation, and alcohol limitation), intermittent fasting, and microbiome-targeted therapies. This review analyzes the pathways by which metabolic abnormalities affect the onset and progression of CKD, identifies strategies that have potential use for prevention or treatment, and offers a robust theoretical foundation for the future development of effective clinical interventions.