[Perspectives on treatment of the renal failure]

The next decade will face an increase in the number of patients affected by end-stage renal disease. In line with the growing incidence of type 2 diabetes, hypertension and old age in the general population, we can expect a dramatic increase of uremic patients needing a substitutive treatment of renal function. On the basis of the current trends, we expect an exponential growth of cardiovascular complications in both dialysis and transplant populations. Progress in the treatment of end-stage renal disease will aim at the prevention of cardiovascular complications, that remain the leading cause of morbidity and mortality in uremic patients. Preventive interventions for cardiovascular complications should focus on traditional risk factors, such as hypertension, dyslipidemia and obesity, diabetes mellitus, smoking, as well as on the non traditional risk factors inherent in the uremic state, such as anemia, hyperphosphoremia, hyperhomocysteinemia, inflammation and malnutrition. Recent and future innovations in peritoneal dialysis solutions include a larger use of icodextrin, a glucose polymer able to enhance ultrafiltration while inducing less glycation and caloric absorption, and perhaps improving blood pressure control. The gene therapy directed to the mesothelial cells should bring about improvements in nutrition, cardiovascular comorbidity, and dialysis adequacy. Patients submitted to increased hemodialysis time or to the implementation of a night or daily hemodialysis program have shown better blood pressure control, cardiovascular stability, tolerability and perhaps reduced mortality. Modifications of dialysis schedules clearly indicate another road to future improvements in renal replacement therapy. In the field of kidney transplantation, much improvement has already been achieved regarding the prevention of acute rejection, and the new therapeutic strategies are aimed at reducing the incidence of the adverse reactions of immunosuppressive drugs, as well as of the chronic allograft nephropathy. Induction of transplantation tolerance remains the most attractive target, which now seems closer than before because many of the mechanisms involved in the tolerance induction have been better elucidated.