Complications of chronic renal insufficiency: Beyond cardiovascular disease

The less rigorous attention to the management of the complications of chron ic renal insufficiency (CRI) and its comorbid conditions has potentially tr agic consequences. In fact, with early recognition and intervention, many o f the complications of CRI and its comorbid conditions can be ameliorated o r prevented. We review here the most prevalent, troublesome, and potentiall y preventable complications and comorbidities of CRI with a View toward dev eloping high-quality, cost-effective strategies for delivering early interv entional care, Complications of CRI include malnutrition, anemia, disorders of divalent ion metabolism and osteodystrophy, metabolic acidosis, and dys lipidemia, Important comorbid conditions of CRI are hypertension, diabetes mellitus, and cardiovascular disease. Clinical intuition suggests that earl y intervention will avert morbidity related to the hypoalbuminemia and othe r nutritional disorders of CRI, the metabolic acidosis, and the dyslipidemi as, but prospective data are lacking at present, Correction of anemia, usua lly with recombinant human erythropoietin, may be key to the prevention of cardiac disease and other comorbidities of CRI. Incipient disorders of bone and mineral metabolism are managed prospectively using such measures as pr otein restriction to reduce phosphorus intake, phosphate binders, calcium s upplementation, and Vitamin D analogues. Hypertension, whatever its origina l etiology, is clearly an important risk factor for the progression of kidn ey failure and for the development of diffuse vascular disease; appropriate and aggressive treatment is essential. In patients with diabetic nephropat hy, the principles of both primary and secondary prevention have been valid ated in several large trials of glycemic and blood pressure control. The se eds of these insidious, challenging, and costly comorbid conditions are sow n very early in CRI, at a time when they are-in theory-most amenable to int ervention. We therefore must be as proactive as possible in the timely impl ementation of relatively simple therapies that have the potential to preven t some of these adverse outcomes of CRI. (C) 2000 by the National Kidney Fo undation, Inc.