On the epidemic of cardiovascular disease in patients with chronic renal disease and progressive renal failure: a first step to improve the outcomes.

Hundreds of thousands of individuals are alive today because of the availability of dialysis for the treatment of patients with end-stage renal disease (ESRD). From the outset, it was evident that this was a costly therapy and would require specialized training. The federal government responded by providing financial support and medicine by establishing the discipline of nephrology to provide specialized training. As a result, the center stage that ESRD has come to occupy was dictated by a successful treatment in the purview of a new discipline by a model and well-intentioned, but restrictive, law that provided support only to the terminal stage of kidney disease. That this natural evolution was short-sighted has become a belated, but well-deserved, focus of attention. The care of chronic renal disease (CRD) patients cannot start after the onset of ESRD when renal replacement therapy is initiated but must be set into motion when renal failure first begins to exert its detrimental effects on the metabolic balance, function, and structure of the body. Attentive care is needed throughout the course of progressive renal failure, because once CRD begins to progress, there is an increasing number of detrimental consequences whose cumulative burden will exert its ravages on the body simultaneously with that of the ongoing loss of renal function. Consequently, the patient with CRD who presents in ESRD has already sustained considerable, often irreversible, loss of body function. Preventive measures to circumvent this eventuality are most effective, cost-efficient, and of greatest benefit when instituted early in the course of progressive CRD. This is probably truest of cardiovascular disease, which is the leading cause of mortality of patients on dialysis and following transplantation. The report of the National Kidney Foundation Task Force on Cardiovascular Disease in CRD is a first attempt to promulgate and provide evidence-based recommendations for this holistic approach to the care of patients with renal disease.