Failure to Obey Lawful Order

Failure to Obey Lawful Order

Progression toward end-stage renal disease is usually inexorable in patients with diabetic and nondiabetic nephropathy. These patients can be identified at an early stage based on history, abnormal urinalysis or reduced glomerular filtration. Recent advances have made it possible to slow the progression of chronic renal failure. Major interventions include antihypertensive therapy, dietary protein restriction and, in patients with diabetes, strict glycemic control and angiotensin-converting enzyme inhibitor therapy. Collaboration with a nephrologist can help guide the family physician in the appropriate use of these modalities and help avoid common complications. Major efforts in slowing the progression of renal failure may lead to a decreased incidence of end-stage renal disease, with savings in morbidity, mortality and cost.

The reduced homeostatic and synthetic capacity of the failing kidney presents many challenges to the practicing physician. The majority of renal diseases steadily progress to end-stage renal disease. At that point, renal replacement therapy is usually necessary. Fortunately, many therapies have recently been shown to successfully slow the progression of renal failure.

Understanding which patients are at risk for end-stage renal disease allows the physician to identify patients who may benefit from therapy to limit the renal complications and retard progression of chronic renal failure.

Any disease that leads to significant impairment of glomerular filtration may initiate an inevitable progression toward end-stage renal disease. (Mitch, Walser, Buffington & Lemann, 1976) Fortunately, proven therapies that retard the progression of renal failure are available; thus, it is essential to identify patients who are at risk. Identification of patients with chronic renal failure is often difficult, since renal failure often remains asymptomatic until the latter stages of disease. Clearly, patients with established renal dysfunction are...

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