Clinical Review

Recent advances :General management of end stage renal disease

BMJ 1997; 315 doi: (Published 29 November 1997) Cite this as: BMJ 1997;315:1429

This article has a correction. Please see:

  1. Robert Walker (, associate professor
  1. a Department of Medicine, Otago Clinical School Of Medicine, Dunedin, New Zealand
  • Accepted 24 July 1997


The criteria for accepting patients for renal replacement therapy have been widened over the past decade. Morbidity and mortality, however, remain high in people with end stage renal disease, and the medical, social, and economic repercussions of this condition are widespread. This review aims to identify the ways in which primary care physicians or non-specialists can reduce morbidity and mortality in people with end stage renal failure. It will look at recent developments in our understanding and management of the factors that contribute to the increased mortality and morbidity in patients with end stage renal failure. Dialysis and transplant registries around the world report that cardiovascular diseases and infection remain the major causes of death. However, detailed review of the provision and technical aspects of dialysis and transplantation, and the ethical issues associated with selection criteria or withdrawal from renal replacement therapy, are outside the scope of this article.


Recent articles (1990–6) on cardiovascular disorders, anaemia, hyperparathyroidism, and nutrition related to end stage renal disease were identified from a search of Medline. Key words used included chronic renal disease, anaemia, erythropoietin, ischaemic heart disease, cardiac disease, lipids and lipoproteins, hyperparathyroidism, calcium, phosphate, and nutrition. Because few large clinical trials on the treatment of end stage renal disease were found, this review is also based on observational studies and on review articles covering pathophysiology, clinical management, and reported best clinical practice from leading nephrologists.

Cardiovascular disease

Cardiac disease is the major cause of death in patients with end stage renal disease. It accounts for about 40% of deaths in most large registries, and the high mortality persists after renal transplantation.1 2 In patients receiving any form of renal replacement therapy, the relative risk of death from myocardial ischaemia is five times greater than in the normal population.3 Several factors contribute to …

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