The problem a historical perspective

After the widespread availability of dialysis, it became apparent in the late 1980s that the quality of life of dialyzed patients was far from adequate and their annual mortality rate (about 20% in the United States) was too high (9,10). As it turned out, a principal reason for these poor outcomes was the heavy burden of comorbid conditions with which patients were being initiated on dialysis rather than the adequacy of dialysis (11,12). In fact, it has been shown that the state of health in which individuals with kidney failure present to a nephrologist is a major determinant of their outcome on RRT, be it dialysis or kidney transplantation. (13).

Well after maintenance dialysis became widely available and into the closing years of the past century, nephrology had categorized kidney disease by cause (glomerulonephritis, obstructive nephropathy, lupus nephritis, etc.). This approach is clearly useful when the diagnosis facilitates the specific treatment of a given disease. Unfortunately, in many cases, it is not possible to determine the exact cause of the kidney disease and often there are no specific therapies that would reverse the kidney injury due to a disease. Moreover, there are indications that the number of ESRD patients whose kidney failure is due to these traditional kidney diseases is diminishing, whereas those due to diabetes and hypertension is constantly increasing, especially in the elderly (10,14). In the vast majority of these individuals, the kidney disease is asymptomatic, certainly in its early stages and well after more than

half of normal kidney function is lost. Also, it has become increasingly evident that the loss of kidney function and the systemic complications that develop during the course of kidney disease (anemia, hypertension, bone disease, and cardiovascular disease) are uniform and independent of the underlying etiology of the kidney disease. Despite this realization, the situation remained confusing for quite some time as varying terminologies were used to identify and describe these patients, originating with the now abandoned historical "Bright's disease" to the still used horrible term of "pre-dialysis" patients. The cacophony of terms that came into use to describe these patients (chronic renal failure, chronic renal disease, chronic renal insufficiency, etc.) coupled with the use of the rather insensitive serum creatinine as a measure of kidney function accounts for the non-descript and confusing situation that prevailed in the first years of the current millennium (15,16).

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