Three people can have the exact same kidney number, and completely different futures. One needs dialysis this year. One never will. Nephrologist Dr. Sean Hashmi breaks down the biggest myth in kidney care: that a single eGFR number decides when you need dialysis.

There is no eGFR threshold that automatically triggers dialysis, according to a 2024 review in JAMA. What actually decides timing is a combination of symptoms, fluid status, blood acid level, and potassium, not a single lab value. Dr. Hashmi walks through the landmark IDEAL trial, a randomized study of 828 people that found starting dialysis early bought no survival benefit at all, and explains why preparing early and starting early are two completely different things. He closes with the one medication class proven to slow kidney decline, and a simple two-column tracking method to bring to every appointment.

References:
Flythe JE, Watnick S. Dialysis for chronic kidney failure: a review. JAMA. 2024;332(18):1559-1573.
Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-619.
Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446.
The EMPA-KIDNEY Collaborative Group. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-127.

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The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution. Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.

Your kidneys can lose more than half their function and never once make you feel sick. Nephrologist Dr. Sean Hashmi walks through the real warning signs of kidney disease, including the ones almost everyone misses because they blame them on something else.

Fewer than one in 20 people with early kidney disease are aware they have it, because kidneys are built with so much spare filtering capacity that blood tests can look normal while damage quietly continues underneath.

Dr. Hashmi covers the eight warning signs to watch for as a cluster, from swelling and foamy urine to washed-out fatigue and itchy skin, the visible signs on your ankles, eyes, and nails and why they show up late, and the sign people miss completely: rising blood pressure. He also explains why diabetes and high blood pressure cause about half of all kidney disease with zero symptoms, and the two simple tests, a blood test for creatinine and a urine albumin-to-creatinine ratio, that catch kidney damage years before any symptom appears.

References:
Gong J, Vaduganathan M, Wadhera RK. Chronic kidney disease prevalence and awareness among US adults. JAMA Cardiol. 2026;11(1):77-81.
Romagnani P, Agarwal R, Chan JCN, et al. Chronic kidney disease. Nat Rev Dis Primers. 2025;11(1):8.
Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet. 2021;398(10299):786-802.
KDIGO CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.

Want the evidence-based breakdowns in writing? Sign up for the free weekly newsletter at selfprinciple.org/newsletter.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Practice kindness and gratitude.

Dr.Sean

Do heartburn pills like omeprazole really damage your kidneys? Nephrologist Dr. Sean Hashmi breaks down what the actual research found, how big the risk really is, and who carries it versus who barely does.

Large observational studies do show a higher rate of chronic kidney disease in people who take proton pump inhibitors daily for years, roughly 26 to 50 percent higher depending on the study. But that number is smaller than it sounds once it's anchored in real numbers, and every one of these studies is observational, meaning it cannot prove the pill itself is the cause rather than the reasons someone was prescribed it in the first place. Dr. Hashmi explains the research trap called confounding by indication, the one kidney injury from these drugs that is not a myth, and why dose and time, not the single pill, are what actually drive the risk. He also covers the safe, planned way to taper off a proton pump inhibitor without acid rebound, and who genuinely needs to stay on one.

References:
Lazarus B, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.
Ang SP, et al. Association between proton pump inhibitor use and risk of incident chronic kidney disease. Biomedicines. 2024;12(7):1414.
Rajan P, et al. The association between proton pump inhibitor use and the risk of adverse kidney outcomes. Therap Adv Gastroenterol. 2022;15:17562848221074183.
Praga M, González E. Acute interstitial nephritis. Kidney Int. 2010;77(11):956-961.

Want the evidence-based breakdowns in writing? Sign up for the free weekly newsletter at selfprinciple.org/newsletter.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution. Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.

Dr.Sean

Can kidney disease be reversed? A five-year study in PLOS Medicine found that about one in five people with kidney disease saw their numbers return to the normal range. Nephrologist Dr. Sean Hashmi explains what that finding actually means, and why it is different from the "reverse it naturally" promises flooding your feed.

You cannot regrow kidney filters that have scarred or died, and chronic kidney disease has no cure. But the two numbers that define kidney health, your filtering score and the protein in your urine, can genuinely improve. Dr. Hashmi walks through the four things the evidence says actually move those numbers: controlling blood pressure and blood sugar, the two medication classes proven in the DAPA-CKD and EMPA-KIDNEY trials to slow kidney decline, treating fixable underlying causes, and a plant-predominant, low-salt eating pattern. He also flags the supplement claims that can push potassium or phosphorus to dangerous levels, and addresses the popular claim that blood pressure medications harm the kidneys.

References:
Shardlow A, et al. Chronic kidney disease in primary care: outcomes after five years. PLoS Med. 2016;13(9):e1002128.
Heerspink HJL, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446.
The EMPA-KIDNEY Collaborative Group. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-127.
Kalantar-Zadeh K, et al. Chronic kidney disease. Lancet. 2021;398(10299):786-802.

Want the evidence-based breakdowns in writing? Sign up for the free weekly newsletter at selfprinciple.org/newsletter.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution. Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.

Dr. Sean

Roughly one in twenty CT scans done for something unrelated turns up a silent kidney stone, and "just watch it" is the advice most people hear afterward. Dr. Sean Hashmi, a board-certified nephrologist, walks through what long-term data actually says happens to a silent stone left alone: the risk of a real problem climbs from about 3% at one year to 19% at three years and 31% at five years in a long-term UK cohort, yet close to six in ten stones followed this way for more than five years never needed anything done. He explains which two facts, stone size and location, predict almost everything that follows, why fluid is the one habit that actually helps, why the flush and tonic remedies flooding social media cannot dissolve a real stone, and what a June 2026 meta-analysis of six randomized trials found when researchers compared treating a stone early against watching it: lower odds of a later stone and less than half the risk of eventually needing surgery, without more complications. He also answers two listener questions, one about a stone that grew to 18 millimeters after years of missed follow-up, and one about a newly found 1.5-millimeter stone with no blockage.

References: Darrad et al., BJU International, 2018 (PMID 29675983); Kang et al., Journal of Urology, 2013 (DOI 10.1016/j.juro.2012.11.113); Tuo et al., World Journal of Urology, 2026 (DOI 10.1007/s00345-026-06536-5).

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The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Practice kindness and gratitude.

Can food really lower your creatinine? Right now your feed is full of morning drinks and five-food lists that promise it will. Here is the part they leave out: you can move your creatinine number tonight without helping your kidneys at all.

In this episode, Dr. Sean Hashmi separates what moves the number from what actually protects your kidneys.

Creatinine is not a toxin your kidneys struggle to push out. It is a waste product your muscles make at a steady rate, and your lab number reflects two things at once, how much muscle you carry and how well you filter. A single cooked meat meal can raise your measured creatinine for hours, because cooking meat turns some creatine into creatinine that you absorb directly. Researchers showed this in Diabetes Care in 2014. So skipping meat before a blood draw can drop the number while nothing about your kidneys has changed. Dehydration nudges it up too, and the eGFR on your report is an estimate calculated from a formula, not a direct measurement.

Detox teas do nothing. Your kidneys already filter about 180 liters a day. Even forcing water was tested directly in the CKD WIT trial, published in JAMA in 2018, and after a full year, drinking more water did not slow kidney function decline. A few food changes do genuinely help a little: cutting inorganic phosphate additives, cutting sodium, and a plant-forward, Mediterranean-style pattern, which is what the KDIGO 2024 guidelines point toward.

What actually decides whether someone ends up on dialysis is not a food. It is the medicines with real trial evidence, especially SGLT2 inhibitors, tested in EMPA-KIDNEY and DAPA-CKD, and for people with type 2 diabetes and kidney disease, the GLP-1 drug semaglutide, which cut major kidney events by 24 percent in the FLOW trial. Alongside that, controlling blood pressure and blood sugar protects your kidneys over a decade more than any food list. Ask your doctor one question: given my numbers, am I a candidate for an SGLT2 inhibitor?

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.

Your "normal" cholesterol may be missing two numbers. In March 2026, the American College of Cardiology, the American Heart Association, and ten other organizations rewrote the cholesterol guideline your doctor has used since 2018.

In this episode, Dr. Sean Hashmi breaks down what changed and the two numbers you actually want to know.

The new guideline does two things. It brings back hard, risk-based LDL targets: the higher your cardiovascular risk, the lower your LDL should go, with a named target for each band. And it gives a formal seat to two numbers most standard panels leave off, ApoB and lipoprotein(a).

You have probably heard that cholesterol was never the real problem and statins are a scam. That view is half right and half dangerous. It is wrong on the core science. A landmark analysis from the Cholesterol Treatment Trialists, published in The Lancet in 2010, pooled data from more than 170,000 people and found that for each drop in LDL of about 39 milligrams per deciliter, major cardiovascular events fell by roughly a fifth, and the benefit held even when starting LDL was already low. People born with naturally low LDL get less heart disease. LDL does not just ride along with heart disease, it helps cause it.

Where the skeptics are half right is that a normal LDL on a standard panel can still hide real risk. That is a reason to measure better, not to dismiss cholesterol. ApoB counts the particles themselves, not just the cholesterol inside them, and it catches risk that LDL alone can miss. Lipoprotein(a) is an inherited, sticky particle that about 1 in 5 people carry and almost no one has tested. You only need to measure it once in your lifetime.

Your one move this week: pull up your most recent labs and see whether ApoB and lipoprotein(a) are even listed. For almost everyone, they are not, and that absence is your single ask at your next visit.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.

Should you take blood pressure pills at night or in the morning? For years the advice was to dose at night to protect your heart. Then 21,104 patients put that to the test.

In this episode, Dr. Sean Hashmi walks through what the trials actually found and what protects your heart and your kidneys.

In the TIME trial, published in The Lancet in 2022, evening dosing was no different from morning dosing over five years. About 3.4% of the evening group and 3.7% of the morning group had a heart attack, stroke, or cardiovascular death, a statistical tie. The lesson: take your pills at the time you will actually remember, because the skipped dose is the enemy, not the wrong hour.

You may have read that nighttime dosing cut cardiovascular events almost in half. That came from an earlier Spanish study, the Hygia Chronotherapy Trial, and the effect was so large that the journal later issued a formal expression of concern. When one small study claims a giant effect and a large clean trial finds no difference, you go with the bigger clean trial.

The number you live at matters more than the clock. In SPRINT, published in the New England Journal of Medicine in 2015, pushing systolic pressure below 120 instead of below 140 cut major cardiovascular events and all-cause death. But that target came from automated readings that run lower than an office or home cuff, the trial excluded people with diabetes or a prior stroke, and the intensively treated group had more low-pressure episodes, fainting, and short-term kidney function drops. Set your target with your own doctor.

For your kidneys, ask for two numbers: your eGFR and your urine albumin-creatinine ratio. The second catches protein leaking into the urine, the earliest sign of damage, and most offices skip it. And take any water pill in the morning so it does not wreck your sleep. Treat the trend, not the timing.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.

Are seed oils actually bad for you? Seed oils have been blamed for inflammation, weight gain, diabetes, and heart disease. The uncomfortable part is what happens when you test it: when researchers feed people more of the main fat in seed oils and measure inflammation in their blood, it mostly does not go up.

In this episode, Dr. Sean Hashmi walks through what dozens of human trials and a brand-new 2026 study actually found.

Seed oils like soybean, canola, sunflower, corn, and grapeseed are mostly one fat, an omega-6 called linoleic acid. The fear has a clean logic: more omega-6 becomes arachidonic acid, which drives inflammation. But the body does not run that chain the way the story claims. The conversion from linoleic acid to arachidonic acid is slow and tightly regulated, so eating more barely moves it.

On inflammation, two reviews of controlled trials, 15 trials in 2012 and 30 trials in 2017, found that raising linoleic acid did not raise C-reactive protein or other inflammatory markers. On diabetes, a 2017 analysis in the Lancet Diabetes and Endocrinology pooled nearly 40,000 people and found the highest blood levels of linoleic acid linked to about 35% lower risk. On heart disease, a 2019 analysis in Circulation pooled more than 68,000 people and linked higher levels to lower cardiovascular disease, death, and stroke.

The panic is not entirely wrong. A June 2026 randomized trial in Nutrients found that doubling linoleic acid intake for twelve weeks lowered the omega-3 EPA and tilted the balance toward omega-6, though arachidonic acid did not rise and nobody got sick. That is an argument about dose and balance, not proof the oil is poison.

The real story is that most linoleic acid in the modern diet rides inside ultra-processed food. The oil was never the lever. The food it is hiding in is. This week, count how many meals come from a package or a drive-thru.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Practice kindness and gratitude.

Fatty liver: the only thing that truly reverses it. A video with over 100,000 views says a bitter tonic will empty the fat out of your liver. It will not.

In this episode, Dr. Sean Hashmi covers what genuinely reverses fatty liver and why the detox drinks sold everywhere do nothing.

Fatty liver, now called MASLD, affects about one in three adults. Fat builds up inside liver cells, driven mostly by insulin resistance, too many calories, and fructose from sugary drinks. Most simple fatty liver does not progress, but in a minority it triggers inflammation and scarring, a version called MASH. The 2023 renaming to Metabolic Dysfunction-Associated Steatotic Liver Disease is the tell: if the problem is metabolic, you cannot fix it with a cleanse.

There are three levers, in order of importance. Lever one is weight loss. In a 2015 biopsy-proven study by Vilar-Gomez and colleagues in Gastroenterology, people who lost 10% of their body weight saw resolution of fatty liver in about 90%, and 45% had regression of early scarring. No supplement comes close. Lever two is the diet pattern: a plant-predominant Mediterranean plate, with a hard cut to sugary drinks, because fructose is handled almost entirely by the liver and pushes it to make new fat. Dropping soda is the single highest-yield food change for most people.

Lever three is new. In March 2024 the FDA approved resmetirom (Rezdiffra), and in August 2025 semaglutide became the first GLP-1 cleared for liver disease. In the ESSENCE trial, fatty liver resolution with no worsening of fibrosis occurred in 62.9% of treated patients versus 34.3% on placebo. Both are for moderate to advanced disease only, and both are third line, after diet and weight loss.

Milk thistle, bitter tonics, and liver flush drinks have no biopsy-proven benefit. Start with a real diagnosis, imaging like an ultrasound or a fibrosis scan, not a guess from a symptom video.

The information in this content is for educational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have seen in this content. The views expressed here are my own and do not represent the views of my employer or any affiliated institution.

Never start, stop, or change the dose of any prescription medication without consulting your physician.

Practice kindness and gratitude.