[How do we optimize the management of chronic renal failure?]

Optimization of the management of chronic renal failure (CRF) is aimed at decreasing morbidity and mortality risks of CRF patients, due to the progression of CRF toward end-stage renal disease (ESRD), and to CRF-related complications with functional or life-threatening consequences. The so-called spontaneous progression of CRF toward ESRD depends on factors related to the primary renal disease, and on non-specific factors mainly related to hypertension and renal functional adaptations to nephron loss. Secondary prevention of CRF needs: early identification of primary renal disease, in order to start specific therapies; the treatment of hypertension; dietary advice on protein intake; prevention of events and drug toxicity potentially harmful to renal function. Clinical events appear late in the course of CRF, following several disorders often present for a long time: hypertension, dyslipidemia, phosphocalcic disorders, anaemia, malnutrition). These disorders should be screened for, and treated, as a part of tertiary prevention measures. When dialysis becomes unavoidable, early information and medical preparation of the patient are mandatory, giving the best chances of success to the applied dialysis method. Unfortunately, most CRF patients are referred at a late stage of the disease, when the effects of therapeutic interventions are limited; this results in increased length of hospital stays, increased risk of early dialysis complications, and decreased capacity to be treated at home.