Urological footprint of chronic kidney disease: A nephrologist perspective on early detection and collaborative management

Table 1 Urological manifestations across chronic kidney disease stages and their clinical outcomes

CKD stage	Urological manifestations	Impact on CKD outcomes	Clinical implications
Stage 1-2 (early CKD)	Polyuria, nocturia	Early signs of tubulointerstitial damage; often missed, delaying diagnosis	Need for early screening and symptom recognition
Stage 3-4 (moderate CKD)	LUTS (urgency, frequency, hesitancy), recurrent UTIs	UTIs accelerate nephron loss; LUTS complicate fluid balance	Routine urological evaluation; manage comorbidities like diabetes/BPH
Stage 5 (ESKD, pre-dialysis)	Bladder dysfunction (DU, BO), anuria, incontinence	Disuse atrophy, fibrosis, increased infection risk, poor dialysis outcomes	Multidisciplinary care; monitor bladder function and infection risk
Dialysis-dependent	Reduced bladder capacity, poor sensation, persistent LUTS	LUTS persist despite anuria; linked to lower QoL	Use of validated questionnaires; targeted symptom management
Post-transplant	Ureteral stenosis, VUR, persistent LUTS	Surgical complications and persistent symptoms affect graft function	Coordinated nephrology-urology follow-up

CKD: Chronic kidney disease; ESKD: End-stage kidney disease; LUTS: Lower urinary tract symptoms; DU: Detrusor underactivity; BO: Bladder oversensitivity; VUR: Vesicoureteral reflux; UTI: Urinary tract infection; QoL: Quality of life; BPH: Benign prostatic hyperplasia.

Table 2 Lower urinary tract symptoms and urine output pattern by chronic kidney disease stage

CKD stage	LUTS	Urine output pattern
Stage 1 eGFR (> 90)	Mild frequency, possible urgency in glomerular disease	Normal or slightly increased (polyuria in some cases)
Stage 2 eGFR (60-89)	Nocturia, mild urgency/frequency	Normal or mildly reduced
Stage 3 eGFR (30-59)	Nocturia, urgency, incontinence, hesitancy	May show reduced concentration ability, nocturnal polyuria
Stage 4 eGFR (15-29)	Urinary retention, overflow incontinence, weak stream	Marked reduction in output (oliguria)
Stage 5 eGFR (< 15 or ESKD)	Severe LUTS, incontinence, poor bladder sensation	Severely reduced or absent (anuria), dialysis-dependent

CKD: Chronic kidney disease; eGFR: Estimated glomerular filtration rate; ESKD: End-stage kidney disease; LUTS: Lower urinary tract symptoms.

Table 3 Common bladder dysfunction types in dialysis patients

Type of dysfunction	Description	Prevalence
DU	Weak bladder muscle contraction; leads to incomplete emptying	Common in long-term dialysis patients, may coexist with sensory deficits
BO	Heightened sensation despite low urine volume; causes urgency	Frequently reported; often overlaps with other dysfunctions
Overflow incontinence	Bladder overfills due to poor emptying; leaks involuntarily	Less common but clinically significant; may result from DU
Loss of bladder sensation	Patients may not feel the need to urinate, even when bladder is full	Often underdiagnosed; contributes to silent retention and overflow
Small bladder capacity	Due to long-term anuria and disuse, bladder shrinks in volume	Very common in anuric patients; reversible with restored urine output
Mixed dysfunction	Combination of two or more dysfunction types	Frequently observed; requires individualized assessment and management

DU: Detrusor underactivity; BO: Bladder oversensitivity.

Table 4 Clinical recommendations for bladder dysfunction in dialysis patients

Recommendation	Evidence grade	Practical notes/applicability
Use validated questionnaires (e.g., IPSS, OABSS) for early detection of LUTS in dialysis patients	2B	Low-cost, feasible in most clinical settings; useful for screening but limited by patient self-reporting bias
Perform uroflowmetry and PVR measurement in symptomatic patients	1B	Provides objective assessment; requires equipment and trained staff, may be less feasible in resource-limited centers
Refer dialysis patients with persistent LUTS to urology for further evaluation (urodynamics, cystoscopy if indicated)	1C	Strong recommendation despite limited trial data; referral may be challenging in rural/Low-resource areas
Implement bladder training and fluid management strategies to improve storage/voiding symptoms	2C	Non-invasive, low-cost, but requires patient adherence and education
Consider pharmacological therapy (e.g., antimuscarinics for BO, alpha-blockers for voiding dysfunction) when conservative measures fail	2B	Evidence mainly extrapolated from non-CKD populations; careful monitoring needed due to altered drug clearance in ESKD
Incorporate routine LUTS/QoL assessment into dialysis care protocols	1C	Improves holistic patient management; feasible with minimal resources if integrated into dialysis unit workflow

Where 1 = strong recommendation, 2 = weak; A = high-quality evidence, B = moderate, C = low. IPSS: International Prostate Symptom Score; OABSS: Overactive Bladder Symptom Score; LUTS: Lower urinary tract symptoms; BO: Bladder oversensitivity; QoL: Quality of life; CKD: Chronic kidney disease; ESKD: End-stage kidney disease.

Table 5 Risk of urinary tract infections and their sequelae across different stages of chronic kidney disease in patients with urological causes

CKD stage	Risk of UTI	Contributing factors	Common sequelae	Clinical implications
Stage 1-2	Mild to moderate	(1) Structural abnormalities; and (2) Incomplete bladder emptying	(1) Occasional pyuria; and (2) Mild renal inflammation	Early detection and urological management can prevent progression
Stage 3	Moderate	(1) Reduced renal clearance; and (2) Recurrent infections	(1) Accelerated GFR decline; and (2) Onset of antibiotic resistance	Close monitoring and tailored antimicrobial therapy are essential to slow progression
Stage 4	High	(1) Impaired immune response; and (2) Chronic colonization	(1) Frequent hospitalizations; and (2) Risk of systemic infection	Repeated or resistant infections can hasten CKD progression; aggressive infection control is needed
Stage 5 (ESKD)	Very high	(1) Dialysis-related risks; and (2) Severe urinary tract dysfunction	(1) Sepsis; and (2) Multidrug-resistant organisms	Multidisciplinary care essential; infection prevention is critical

CKD: Chronic kidney disease; ESKD: End-stage kidney disease; UTI: Urinary tract infection.

Table 6 Stage-based nephro-urological management pathway in chronic kidney disease

CKD stage	Routine urological screening	Referral triggers	Co-management goals
Stage 1-2 (early CKD)	(1) Urinalysis (proteinuria, hematuria); (2) Kidney/bladder ultrasound; and (3) History of LUTS, recurrent UTIs, stone disease	(1) Recurrent UTIs; (2) Hematuria not explained by nephrology; and (3) Suspected obstruction (hydronephrosis, poor bladder emptying)	(1) Identify and treat reversible urological causes early; and (2) Prevent progression of CKD
Stage 3-4 (moderate CKD)	(1) Post-void residual measurement Uroflowmetry if LUTS present; and (2) Stone risk assessment (metabolic work-up)	(1) Persistent LUTS despite medical therapy; and (2) Recurrent stones Obstructive uropathy on imaging	(1) Slow CKD progression; (2) Prevent recurrent infections and obstruction; and (3) Optimize bladder function
Stage 5 (ESKD, pre-dialysis)	(1) Focused urological history and exam; and (2) Imaging for obstruction if symptoms/signs present	(1) Hydronephrosis or ureteral stricture; and (2) Severe LUTS impacting quality of life	(1) Prepare for renal replacement therapy; and (2) Ensure unobstructed urinary tract before transplant
Dialysis-dependent	(1) Catheter/vascular access infection surveillance; and (2) Bladder function assessment in long-term dialysis	(1) Recurrent UTIs or urosepsis; and (2) Catheter-related complications	(1) Prevent infection; (2) Manage bladder dysfunction; and (3) Maintain quality of life

CKD: Chronic kidney disease; ESKD: End-stage kidney disease; LUTS: Lower urinary tract symptoms; UTI: Urinary tract infection.