[Factors of progression and chronic renal insufficiency and their prevention]

End-stage renal failure is a major cause of health-related expenditures in the Western countries. It can be prevented in many instances by therapeutic intervention first settled in animal models. Murine experimental models of nephron loss have led to the identification of several factors involved in renal disease progression. They include increased glomerular capillary hydrostatic pressure, glomerular hypertrophy, high blood glucose, high-level proteinuria, hypoxia, and genetic factors. The role of glomerular capillary hypertension and hypertrophy cannot, however, be established with certainty in man. Clinical studies have shown that male gender, increased systemic blood pressure, severe urinary albumin loss, type of initial nephropathy, diabetes, and genetic factors, all accelerate progression of renal disease to end-stage renal failure. It is now feasible to halt the progression of renal insufficiency. Clinical trials have demonstrated the beneficial effects of angiotensin converting enzyme inhibitors, particularly in those patients with high-level proteinuria, and of blood glucose control in diabetic patients. The place that restricted protein diet and lipid lowering intervention should take, remains debated. Further clinical trials aimed at testing the efficacy of new drugs including endothelin receptor antagonists are warranted in those patients with vascular or tubulo-interstitial renal diseases.