Chronic renal insufficiency: current understandings and their implications

Chronic renal insufficiency (CRI) is underrecognized and undertreated even in sophisticated health care systems. This is particularly distressing in light of the growing number of effective interventions available to slow the progression of kidney disease and ameliorate many of its comorbid conditions. Progress, to a certain extent, is impeded by the lack of generally accepted definitions, clear diagnostic criteria, and practical screening tests. Available epidemiologic data suggest that 800,000 Americans have creatinine levels >/=2.0 mg/dL and over 6 million have levels >/=1.5 mg/dL. Population-based surveys show that age, male gender, and black race are predictors of kidney disease. For reasons that are not well understood, the incidence of kidney failure has nearly doubled over the last 15 years, indicating a parallel increase in CRI. This trend has significant economic implications. Other implications of CRI related to the use and availability of health care resources are appropriate referrals to nephrologists and early intervention to optimize care of patients with CRI. A multipronged approach to providing optimal care involves interventions that may delay the progression of renal dysfunction, proactive prevention of uremic complications, measures to forestall the progress of comorbid conditions, and timely preparation of patients for renal replacement therapy. Early recognition of CRI, expeditious referral for specialty care, and the utilization of a comprehensive program of care optimization will help meet the nation's goals as articulated in the National Institutes of Health's Healthy People 2010: Chronic Kidney Disease.