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Impact of Pre‐ESRD Management on Dialysis Outcomes: A Review

End-stage renal disease (ESRD) is a growing public health problem worldwide, with an increasing incidence in a progressively aging population. ESRD care is costly, and has drawn much notice from that standpoint. The annual costs of treating patients with ESRD in the United States now exceeds $13 billion, with hospitalization accounting for over 40% of this amount (1-3). Much attention over the past few years has been directed toward reducing the mortality of ESRD patients in the United States, which remains among the highest in the industrialized world. Mortality has remained high despite growing attention to adequacy of dialysis and patients’ nutritional status. Factors present prior to the onset of ESRD that might predict the outcome on dialysis and that might be significantly impacted upon by improved pre-ESRD care are becoming increasingly recognized. These include anemia, left ventricular hypertrophy, hyperparathyroidism, and malnutrition. It stands to reason that measures that safely delay the onset of ESRD would be beneficial to patients, as would any intervention that would reduce premorbid risk factors. This review will focus on the evidence supporting the presumption that pre-ESRD management impacts upon the morbidity, mortality, and costs of dialysis.