ABSTRACT
A significant delay in identifying pre-ESRD patients is not infrequent in the U.S.A. because an early examination for proteinuria is not common, and renal disease is infrequently documented even when proteinuria and/or an elevated serum creatinine level have existed. Although there are accepted strategies for slowing the progression of renal disease such as the use of an angiotensin converting enzyme (ACE) inhibitor in diabetic patients or suboptimal blood pressure control in hypertensive patients, these strategies are seldom employed. It is also particularly alarming that the patients are often low in the overall health status, hypoalbumic, or anemic at dialysis initiation, and begin dialysis without permanent vascular access or without any education regarding dialysis therapy in many instances.