A practical approach to the management of patients with chronic renal failure

The number of patients with significant chronic renal failure is expanding rapidly in the United States. All physicians and medical-care providers wil l have an increasingly important role in the detection and management of re nal failure in patients who are not undergoing dialysis, Patients with diab etes or hypertension should be carefully monitored for the development of r enal insufficiency by using screening tools such as blood pressure measurem ent, determination of serum creatinine, urinalysis, and determination of 24 -hour urinary microalbuminuria, In order to slow the progression of renal d isease, attenuate uremic complications, and prepare patients with renal fai lure for renal replacement therapy, all medical-care providers should "take care of the BEANS." Blood pressure should be maintained in a target range lower than 130/85 mm Hg, and in many patients, angiotensin-converting enzym e inhibitors may be beneficial. Erythropoietin should be used to maintain t he hemoglobin level at 10 to 12 g/dL, Access for long-term dialysis should be created when the serum creatinine value increases above 4.0 mg/dL or the glomerular filtration rate declines below 20 mL/min. Nutritional status mu st be closely monitored in order to avoid protein malnutrition and to initi ate dialysis before the patient's nutritional status has deteriorated. Nutr itional care also involves correction of acidosis, prevention and treatment of hyperphosphatemia, and administration of vitamin supplements to provide folic acid. Specialty referral to nephrology should occur when the creatin ine level increases above 3.0 mg/dL or when the involvement of a nephrologi st would be beneficial for on going management of the patient.