Retardation of kidney failure -- applying principles to practice.

Over the next decade, the number of patients with end-stage renal disease (ESRD) treated by dialysis may double, and even developed nations will have difficulty in coping with this alarming increase. This review will outline the proven and unproven strategies that have the potential to retard the progression of chronic kidney disease (CKD). Recently, a number of randomised clinical trials have demonstrated the efficacy of several strategies to slow the progression of CKD. Proven strategies include adequate blood pressure control (with angiotensin blockade), and for diabetic nephropathy good glycaemic control. Other potentially beneficial strategies include smoking cessation, lipid control and aldosterone blockade. The early institution of these strategies has the potential to regress established CKD as well as improve the long-term cardiovascular outcomes of these patients. Proof of the efficacy in humans of promising experimental approaches, such as the administration of growth factors (e.g., recombinant bone morphogenetic protein-7), anti-fibrotic agents (e.g., pirfenidone) and novel anti-proteinuric drugs (e.g., pentosan polysulphate), is awaited. Finally, the primary prevention of CKD, at least in part, by the eradication of type 2 diabetes and obesity (through improvement of lifestyle factors), and adequate treatment of hypertension, have the potential to eliminate up to half of the most common causes of CKD (or ESRD) in developed countries.