Prevention of progression and remission/regression strategies for chronic renal diseases: can we do better now than five years ago?

The prevalence of chronic renal diseases is increasing worldwide. There is a great need to identify therapies that arrest disease progression to end-stage renal failure. Inhibition of renin-angiotensin system both by ACE inhibitors and angiotensin II receptor antagonists is probably the best therapeutic option available. Several large, multicenter studies have indeed shown a significant reduction in the risk of doubling baseline serum creatinine or progression toward end-stage renal failure in diabetic and nondiabetic patients with chronic nephropathies treated with ACE inhibitors or angiotensin II receptor antagonists. However, the number of patients that reach end-stage renal failure is still considerably high. Significant reduction of the incidence of end-stage renal disease is likely to be achieved in the next future for chronic nephropathies, provided that we can improve the degree of renoprotection. This goal may be attainable with a more complex strategy than with a single or dual pharmacologic intervention on the renin-angiotensin system. Strict control of blood pressure and protein excretion rate, lowering of blood lipids, tight glucose control for diabetics, and lifestyle changes form part of the future multimodal protocol for management of patients with chronic nephropathies.