Preventing end-stage renal disease: flexible strategies to overcome obstacles.
PURPOSE OF REVIEW: Renin-angiotensin system inhibition has demonstrated effectiveness in clinical studies in slowing the progression of chronic kidney disease. This review analyzes obstacles that have hindered the attainment of optimal results in the renal community, and the need for flexible strategies in overcoming these obstacles. RECENT FINDINGS: Despite the publication of the beneficial effects of renin-angiotensin system inhibitors, an epidemic of end-stage renal disease has developed in the United States. Underprescription of these medicines, and failure to reach goals for blood pressure and urinary protein loss have contributed to this epidemic. Solutions to these problems require flexible analysis that contrasts with the more linear, rigid approaches recently popularized in various disease-management guidelines. The application of renin-angiotensin inhibitors, in an individualized goal-oriented manner sensitive to patient variations, is discussed. A similar approach to hypertension, emphasizing assessment of individual hemodynamic parameters, is proposed. The elimination of rigid limitations to increases in serum potassium and serum creatinine is suggested as a means to enhance prescription of renin-angiotensin system inhibitors. SUMMARY: Optimal treatment of chronic kidney disease requires flexible approaches towards achieving the goals for systolic blood pressure and reduction of urinary protein loss.