Research directions: New clinical frontiers

One of the greatest remaining challenges facing nephrology research is obta ining data with detail and precision for the three large, yet "forgotten," populations that span the spectrum of kidney disease: patients with chronic renal insufficiency (CRI), peritoneal dialysis patients, and kidney transp lant patients. Studies of these populations, particularly the CRI group, ar e hampered by the relative mobility of these patients, the lack of stringen t epidemiologic or clinical definitions, and the tendency to extrapolate da ta from hemodialysis populations into other clinical settings. This article suggests a two-pronged approach to a research agenda: first, by recognizin g the need for better data regarding the natural history of these kidney fa ilure subsets and their comorbidities; and second, by directing greater eff ort at identifying rational, efficacious, and cost-effective interventions to influence their natural history positively. Specific efforts are suggest ed In all three populations. For patients with CRI, studies should be direc ted at (1) identifying high-risk patients; (2) determining methods for maki ng optimal referrals to the nephrologist; (3) identifying and managing CRI, its complications, and its comorbid conditions; and (4) establishing proce sses for the smooth transition to dialysis. The peritoneal dialysis populat ion will benefit from studies addressing the treatment of anemia and its ab ility to modify cardiovascular illness and quality of life. Kidney transpla nt studies should also focus on the identification and management of comorb id conditions, as well as the effects of various interventions on quality o f life. Rational evidence-based care of these conditions, which are critica lly important to patients, their families, and the health care system in ge neral, must await the conduct of well designed prospective observational an d interventional trials. (C) 2000 by the National Kidney Foundation, Inc.