Optimizing medical management of patients with pre-end-stage renal disease.

Patients with end-stage renal disease have reduced quality of life, high levels of morbidity, and an annual mortality of about 22%. Because the high morbidity and mortality of dialysis patients might be reduced substantially if patients were healthier at the time of initiating renal replacement therapy, this article will present treatment recommendations designed to retard the progression of chronic renal disease, to optimize the medical management of comorbid medical conditions, such as cardiovascular disease, diabetes, and lipid disorders, and to reduce the complications of renal insufficiency, including hypertension, anemia, hyperparathyroidism, and malnutrition. Given the lack of prospective clinical studies in this area, these recommendations are derived from consensus standards for managing dialysis patients or patients with cardiovascular disease, hypertension, diabetes, and lipid disorders, and from expert opinion derived from laboratory investigations of pathophysiology and relevant experimental disease models.