Chronic kidney disease (CKD) represents a substantial health burden in the United States, with a particularly high prevalence among obese individuals. Obesity contributes to renal injury through complex pathophysiological mechanisms—including but not limited to glomerular hyperfiltration, inflammatory signaling, and ectopic adipose deposition—that accelerate kidney damage and drive progression to end-stage renal disease (ESRD). Sleeve gastrectomy (SG), the most performed bariatric procedure worldwide, has emerged not only as an effective intervention for weight reduction but also as a strategy to mitigate CKD progression. This chapter provides a comprehensive review of the epidemiology and economic impact of kidney disease in the USA, an in-depth analysis of the pathophysiological processes underlying obesity-related renal injury, and a detailed evaluation of the reno-protective effects of SG. Furthermore, a thorough comparison of SG with both conventional medical therapies—including GLP-1 receptor agonists—and alternative surgical options is presented. Future perspectives are discussed with an emphasis on mechanistic insights and the evolving role of metabolic surgery in CKD management among obese populations.