Caring for patients with end-stage renal disease (ESRD) and its myriad complications represents a major challenge. According to the United States Renal Data System (USRDS), there are approximately 600,000 patients with ESRD receiving renal replacement therapy (RRT) as of 2010. In the United States and globally, it is estimated that there are an estimated 2 million people currently receiving some form of RRT. Most of those patients can be found in industrialized countries with well-developed health care delivery systems. It has been suggested that this number may represent only 10% of patients globally with ESRD, with the remaining 90% of ESRD patients lacking access to maintenance RRT.
In addition to the burden that ESRD imposes on the patient, treatment of ESRD also carries a significant societal burden associated with the costs of providing such therapy. Those costs stem from the direct cost of therapy and by way of the requisite infrastructure necessary to provide chronic dialysis care. The worldwide expenditure on such care for the decade ending in 2010 is estimated to have been in excess of US $1.1 trillion. This cost grows annually, and with emerging markets and global growth of dialysis options for countries and regions that have not historically had access to them, the global cost of this care is only expected to rise.
The growing prevalence of chronic kidney disease (CKD) and ESRD associates not only with growing worldwide populations but also with the rising global rates of obesity, hypertension, and diabetes mellitus. These populations are likely to benefit from early nephrology referral with focused efforts on delaying the progression of CKD to ESRD.
Against this backdrop, it is critical to appreciate that most cases of ESRD occur as the slow progression of CKD over the course of months to years. The interval between the diagnosis of CKD and the development of ESRD offers an opportunity to meaningfully intervene, abate, or at least slow the rate of CKD progression. Interventions have varying levels of efficacy. In this chapter we briefly review the mechanisms of CKD progression and proceed to discuss the various tools and approaches directed at slowing that progression.
et al: The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int 2011;80:1258.
A. Referral to Nephrology
When, during the longitudinal management of a patient with CKD, is the appropriate time to refer a patient to a nephrologist is one of the most common questions asked by primary care providers. Individual providers differ with respect to their comfort managing CKD and its clinical manifestations. Observational data vary on the impact of early nephrology referral with respect to long-term outcomes, including rate of glomerular filtration rate (GFR) decline, time to ESRD, and overall cost of treatment.