[Value of early management of patients with chronic renal failure]

The objective of early referral in patients with chronic renal failure is to prevent complications as the disease progresses to the stage where dialysis or transplantation become necessary. Early diagnosis requires a systematic assessment of glomerular function in all patients with signs suggestive of renal disease. Screening programs are also recommended in populations at risk with vascular disease, diabetes, occupational exposure to nephrotoxic substances, or a potentially nephrotoxic treatment. Once stabilized, chronic renal failure usually progresses inevitably to end-stage disease. In France, the estimated annual incidence of chronic renal failure defined as creatininemia > 200 or 300 mumol/l is approximately 200 patients per million inhabitants and that of end-stage disease at 80 per million. Although access to replacement therapy is not limited in France, a certain number of patients are still seen at a late stage of the disease. When dialysis is initiated after the development of severe uremia, patients generally have a poor nutritional status, more severe acidosis and anemia and poorly controlled hypertension; the first dialysis session often occurs in an emergency setting. In this issue of La Presse Médicale, Jungers et al. demonstrate the higher morbidity and increased cost of the first hospitalization in patients without prior follow-up. An optimal treatment aimed at preserving renal function as long as possible can have a beneficial effect on preventing higher morbidity and mortality after beginning substitution therapy. Nephrology referral should be centered on controlling anemia with recombinant human erythropoietin, high blood pressure with appropriate drugs (particularly converting enzyme inhibitors), nutritional status with adapted protein-calorie intake, and renal osteodystrophy with calcium carbonate or recombinant growth hormone in children. Patients must also be prepared for definite dialysis both in terms of medical risk (hepatitis B vaccination) and psychosocial adaptation.