Management of patients with chronic renal insufficiency in the northeastern United States

Comorbid conditions that develop during chronic renal insufficiency (CRI) c ontribute to the high morbidity and mortality among patients with end-stage renal disease (ESRD). Thus, appropriate management during CRI may lead to improved ESRD outcomes. A retrospective cohort study was performed to descr ibe the management of patients with CRI. A total of 602 patients with CRI ( creatinine greater than or equal to1.5 mg/dl for women and greater than or equal to2.0 mg/dl for men) were seen between October 1994 and September 199 8 at five nephrology outpatient clinics in the Boston area. The mean (SD) a ge of the patients was 63 (15.5) yr, and 53% were male. At the first nephro logy visit, mean (SD) serum creatinine was 3.2 (1.6) mg/dl, and mean (SD) p redicted GFR was 22.3 (8.9) ml/min per 1.73 m(2). Laboratory tests for iron levels were performed in only 18% of patients, serum parathyroid hormone l evels were obtained in only 15%, lipid studies were obtained in fewer than half, and among patients with diabetes, only 28% had a glycosylated hemoglo bin level measured. A hematocrit <30% was present in 38%, and abnormal calc ium-phosphorus metabolism was noted in 55%. Only 59% of patients who had he matocrit <30%, received recombinant human erythropoietin. Among patients wh o received recombinant human erythropoietin, only 47% received iron. Angiot ensin-converting enzyme inhibitor use was recorded for only 65% of patients with diabetes (49% of patients overall). Among patients who were known to have progressed to ESRD, only 41% had permanent access placed before initia tion of dialysis. There seems to be room for improvement in the management of patients with CRI, which could result in a slower rate of progression of CRI and reduced severity of comorbid conditions.