As with other patients, the renally impaired should undergo preoperative cardiac assessment to assign risk level prior to surgery or any invasive procedure. In patients with advanced chronic renal failure (glomerular filtration rate <20 ml/min), bleeding time determination should be performed before invasive surgery and if bleeding time is prolonged, desmopressin (l-desamino-8-d-arginine vasopressin) should be [...]

Cardiovascular Disease
Cardiovascular disease accounts for about 50% of all deaths in ESRD. This mortality is attributed in part to risks during progressive renal insufficiency. Modifiable risk factors such as smoking, obesity, and insufficient physical inactivity should be addressed and corrected, if possible.

Aggressive Control of Hypertension
Hypertension accelerates the progression of chronic renal insufficiency irrespective of the primary cause of kidney failure. Aggressive blood pressure control slows progression of renal insufficiency and is by far the most important available tool to slow progression of renal failure. The optimal blood pressure in persons with chronic renal insufficiency is uncertain. [...]

Anemia
Anemia in renal failure results in multisystemic disabling symptoms, excess cardiovascular morbidity (left ventricular hypertrophy, ischemic heart disease, congestive heart failure), worsening of diabetic retinopathy, and possibly accelerated progression renal failure.

Once azotemia is detected, a comprehensive history and physical examination should be per­promptly detect the most readily reversible cause of renal insufficiency, a foley catheter should be placed and kidney ultrasound obtained to help exclude outlet obstruction (prostate, uterus). Sonography also will establish the presence of two kidneys, while defining kidney size and location. In [...]

The paucity of specific symptoms and signs in early renal insufficiency necessitates vigilance to detect renal failure. Depending on muscle mass, the serum creatinine concentration becomes elevated only after 60 to 70% of glomerular filtration rate is lost.

Application of evidence-based management of progressive renal insufficiency prior to onset of end-stage renal disease (ESRD) affords a reasonable probability of decreasing mortality and morbidity while delaying ESRD. This review provides strategies that may prolong the interval between discovery of kidney disease and ESRD, and also may improve patient outcomes in chronic renal insufficiency.