an indication for transplantation. Several studies have suggested better outcomes with early initiation of hemodialysis in this setting. Additional signs that suggest need for early hemodialysis initiation include energy intake less than 20 kcal/kg/d, serum albumin concentration of less than 4.0 g/dL, and decrements in other nutritional indices such as transferrin, prealbumin, insulin growth factor-1, and lean body mass. Alternative interventions may be necessary in cases when dietary counseling alone fail to optimize dietary intake. Enteral delivery of nutrition may be necessary, including oral protein, amino acid, and/or 340 THOMAS et al energy supplements; feeding through nasogastric tubes or percutaneous endoscopic gastroscopy or jejunostomy tubes, or institution of intradialytic parental nutrition. Evidence supporting these approaches is limited, however. Only a few studies evaluating the efficacy of oral nutrition supplementation in stage 5 CKD patients have been published. For example, Eustace and colleagues [60] found that oral amino acid supplementation improved serum albumin concentration in stage 5 CKD patients. Caglar and colleagues [61] noted that intradialytic oral nutritional supplementation improved several nutritional parameters in a subgroup of malnourished stage 5 CKD patients. However, the role of supplemental enteral nutrition in patients with advanced CKD or in dialysis patients remains controversial, and a primary care provider should consider expert consultation before initiating any of these therapies. In conclusion, uremic malnutrition is prevalent in CKD patients, and several studies have established a correlation between malnutrition and poor clinical outcome. Management of nutrition in CKD and dialysis patients can be difficult and involvement of dieticians with experience in the treatment of kidney disease patients is recommended. Summary Patients with CKD present several complex management issues to health care providers. The staging system introduced in 2002 by the National Kidney Foundation is a significant accomplishment, which stratifies patients according to disease severity. In addition, the K/DOQI guidelines are an Table 1 Mainstay of treatment in chronic kidney disease complications Complication Treatment Osteodystrophy Vitamin D supplementsa Calcium supplementsa Intestinal phosphate bindera Anemia Recombinant erythropoietinb Transfusion in urgent casesb Cardiovascular Statinsc Blood pressure control via ACE inhibitor and/or angiotensin receptor blockersd Specific CAD interventionse Dyslipidemia Statinsc Fibratesc a K/DOQI Guidelines: http://www.kidney.org/professionals/kdoqi/guidelines_bone/index. htm. b K/DOQI Guidelines: http://www.kidney.org/professionals/kdoqi/guidelines_anemia/ index.htm. c Kariske B, Cosio FG, Beto J, et al. American Journal of Transplantation 2004;4:13–53. d Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. K/DOQIGuidelines: http://www.kidney.org/professionals/KDOQI/guidelines_bp/ index.htm. e Clinical Practice Gui. CHRONIC KIDNEY DISEASE AND ITS COMPLICATIONS 341 excellent tool for management of CKD and dialysis patients and recommend treatments according to disease stage. These interventions may reduce morbidity and mortality in these patients. With early identification and treatment of anemia, renal osteodystrophy, uremic malnutrition, hyperlipidemia, and cardiovascular disease, primary care physicians and nephrologists together are making significant strides toward extending and improving the lives of patients with chronic renal disease. Table 1 briefly summarizes current treatment and preventive measures. References [1] Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038–47. [2] Levin A. KDOQI clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease. Am J Kidney Dis 2006;47:S11–5. [3] Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: a position statement from kidney disease: improving global outcomes (KDIGO). Kidney Int 2005;67:2089–100. [4] Coresh J, Astor BC, Greene T, et al. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003;41:1–12. [5] Hsu CY, Vittinghoff E, Lin F, et al. The incidence of end-stage renal disease is increasing faster than the prevalence of chronic renal insufficiency. Ann Intern Med 2004;141: 95–101. [6] World Health Organization. Nutritional anaemias: Report of a WHO scientific group. 1968. [7] Besarab A, Levin A. When people develop chronic kidney disease (CKD), their kidneys become damaged and over time may not clean the blood as well as healthy kidneys. If kidneys do not work well, toxic waste and extra fluid accumulate in the body and may lead to high blood pressure, heart disease, stroke, and early death. However, people with CKD and people at risk for CKD