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A similar scenario plays out in our clinical practices everyday.

My patients say that they feel

fine; why do we need to have a discussion about dialysis when I feel fine? But that is our chargeto
do the best we can, to preserve remaining kidney function, and to get them safely through this
transitional storm from advanced CKD to RRT, with limited hospitalizations and limited comorbid
events. We know that preparedness for RRT takes time; therefore, similar to NOAA, we also have to
issue early warnings. However, we need to make a concerted effort to reach our patients without
alienating them. I cannot tell them exactly when the storm will hit or what its exact intensity will be as
yet, only that it is coming. With this enlightenment, we may be able to encourage patients to get on
transplant lists, find a living kidney donor, obtain appropriate access, or at least have them become
less overwhelmed about the uncertainly of CKD progression.
This issue of Advances in Chronic Kidney Disease is focusing on the management of patients
with Stage 4 or 5 CKD. The purpose is to help educate clinicians as to what is the optimal approach
to care for those patients with a steady decline in kidney function despite the best efforts of all
involved. The issue is structured to address the obstacles we face in navigating the many facets of
this disease. These obstacles include identifying those at most risk; the financial implications; how to
gain trust and provide counsel through this transition; and to provide guidance on the clinical
management of the complex and myriad problems that arise in this population. We are all well aware
that CKD is a progressive condition and, fortunately, we are able to delay this progression in many
patients. Clearly, early intervention to redirect the slope of decline helps increase dialysis-free
survival.3, 4

Unfortunately, however, there are still a sizeable number of patients progressing to end-stage
kidney disease. Many studies investigating delay of progression of CKD have excluded advanced
CKD, as it has generally been held that once glomerular filtration rate (GFR) drops below
25 mL/min/1.72 m2, there is an unrelenting progression to end-stage kidney disease. Therefore, there
is a gap in knowledge about how best to manage those with CKD 4 or 5. 5 Instead of maintaining the
status quo as a patient's disease progresses, we may in fact need to step it up.
Management decisions need to be based on goals and outcomes, and someone with a GFR of
19 mL/min/1.72 m2 may need to be managed differently than someone with a GFR of
35 mL/min/1.72 m2. Specifically, strategies used to delay progression need to be modified as one
progresses further along this continuum. Because few studies focus on this population of advanced
CKD patients, the contributing authors have teased out data from articles referring to various levels of
CKD (When hard data are lacking regarding these advanced scenarios, expert opinion is provided.)
One of the most difficult jobs of a nephrologist is managing and counseling those patients who we
anticipate will need RRT in their lifetime. The job becomes more difficult as the patient progresses
closer to this need.
The issue begins with an overview of the topic by Dr Azzour Hazzan and colleagues. The
discussion focuses on the epidemiology and challenges in the management of advanced CKD while
also addressing some barriers to optimal care. The authors describe the extent of our knowledge, the
limitations of our care, and propose a mechanism to improve the process; recurrent themes
throughout this issue. Next is an article from Dr Robert Provenzano, who describes the financial
realities of CKD, emphasizing that changes are needed if we truly want to optimize the care of this
population. He provides the readers with an excellent explanation of the recent changes in health
care and ways in which insurers have changed, and will continue to change, this landscape. In
keeping with the notion of optimizing care, Dr Peter Wojciechowski and colleagues review a risk
prediction model for progressive CKD intended to establish the appropriate allocation of our time and

effort, first and foremost, to those who are at highest risk of progression and most likely to need RRT.
We need to learn to put our resources where they will do the most good. The fourth article in this
issue, by Dr Jaime Green, is intended to help us educate our patients and improve our interactions
with them, -when the possible becomes probable, by providing an in-depth review of the resources
available to nephrology providers. This is one of the most difficult undertakings for a nephrologist. We
can all learn from her insights.
Overall, there has been tremendous evidence-based progress in managing patients with all
stages of CKD, albeit with gaps in our knowledge for those with the most advanced disease. The
articles in the issue ofAdvances in Chronic Kidney Disease review the current understanding and
management challenges encountered in these patients. Given that we cannot yet abolish CKD, these
contributors hopefully will provide some guidance to our care of these vulnerable patients and help
them weather the storm.


Demoulin, N., Beguin, C., Labriola, L., and Jadoul, M. Preparing renal replacement therapy in
stage 4 CKD patients referred to nephrologists: a difficult balance between futility and insufficiency. A
cohort study of 386 patients followed in Brussels. Nephrol Dial Transplant. 2011; 26: 220226
National Weather Service Glossary. http://weather.gov/glossary. Accessed May 11, 2016.Toor,
M.R., Singla, A., Kim, J.K., Sumin, X., DeVita, M.V., and Michelis, M.F. Preventing the progression of
chronic kidney disease: two case reports and review of the literature. Int Urol
Nephrol. 2014; 11:21672174