Our objective was to clarify the pathological characteristics of native kidney biopsies and their association with clinical findings in patients with increased serum creatinine. Patients with elevated serum creatinine at native renal biopsy were included. Demographics, clinical details, and pathological findings of kidney biopsies were collected. Characteristics among subgroups based on serum creatinine, estimated glomerular filtration rate, and proteinuria levels were compared. Correlation analysis was performed to explore the relationship between clinical variables and pathological findings. The predictive value of clinical indexes for chronic pathological findings was examined using logistic regression. A total of 1478 patients were enrolled. The mean age was 47.4 years, and 58.1% were male. The most prevalent kidney disease group was immune complex mediated glomerulonephritis, followed in order by podocytopathy, metabolism-associated glomerulonephropathy and tubulointerstitial nephritis. The clinicopathological characteristics differed significantly among subgroups. Chronic pathological changes were mostly observed in patients with serum creatinine 3.0-4.5 mg/dL (265-398 μmol/L) or proteinuria 0.3-3.5 g/day. Serum creatinine was associated with tubulointerstitial changes, while albumin showed a stronger correlation with glomerular changes. The combination of serum creatinine and albumin can predict interstitial fibrosis and tubular atrophy (IFTA) at an area under the curve (AUC) of 0.647 (95% confidence interval 0.585-0.706). Clinicopathological characteristics of native kidney biopsy differed significantly by renal function and proteinuria in patients with elevated serum creatinine. The combination of serum creatinine and albumin can predict IFTA at a fair performance. Understanding of these associations helps to guide clinicians in the decision-making process regarding the timing and necessity of kidney biopsies.