The future of renoprotection

Abstract

Chronic kidney diseases are emerging as a global threat to human health. Renal replacement therapy by dialysis or renal transplantation prolongs survival in patients with end-stage renal disease (ESRD) and, in most cases, provides a good quality of life. In all wealthy countries, new patients on dialysis outnumber those who die, and the group of patients on renal replacement therapy is growing. The provision of adequate treatment to all is absorbing a large proportion of the health care budget and is being looked at with concern by policymakers. Because rationing of dialysis or deciding that some patients cannot be treated is out of the question, clinicians should be looking for ways to prevent the need for dialysis in as many patients as possible. Simple and inexpensive treatments are plausible and possibly effective. There is robust experimental evidence that proteinuria is responsible for interstitial inflammation and subsequent fibrosis, which thereby contributes to progressive renal function loss. Clinical studies and clinicopathologic correlations in patients with progressive nephropathies indicate that observations in experimental models are relevant to understanding human disease. Researchers have identified an important correlation between urinary protein excretion and rate of glomerular filtration rate decline in patients with diabetic and nondiabetic chronic nephropathy. Renoprotection is a strategy that aims to interrupt or reverse this process. The current therapeutic approach for proteinuric chronic nephropathies is based on blockade of the renin-angiotensin system with angiotensin converting-enzyme inhibitors and/or angiotensin-receptor blockers that limit proteinuria, and reduce glomerular filtration rate decline and risk of ESRD more effectively than other antihypertensive treatments. Full remission of the disease, however, is seldom obtained, particularly when pharmacologic intervention is started late. For those who do not respond, treatment procedures to achieve remission and/or regression must include a multimodel strategy to implement renoprotection. The role of lifestyle changes, including smoking cessation, should not be overlooked. A more concerted, strategic, and multisectorial approach, underpinned by solid research evidence, is essential to help reverse the increasing incidence of these chronic diseases, not just for a few beneficiaries, but equitably and on a global scale.