Cardiovascular disease is the major cause of death in patients with renal failure and even mild renal disease is associated with increased cardiovascular risk. Patients with cardiovascular disease have a worse outcome if they have even mild renal disease.8
The early symptoms of renal failure are fatigue with poor exercise tolerance. These can develop when the GFR is as high as 30 mL/min and can be exacerbated by the presence of anaemia, which can occur with GFRs of 30-40 mL/min. Deteriorating renal function leads to poor appetite with subsequent weight loss, fluid retention with associated ankle swelling and shortness of breath on exercise, loss of libido, and nocturia due to polyuria from osmotic diuresis. Many of these symptoms improve when the anaemia is corrected with appropriate use of erythropoietin (EPO) and iron supplements. Prior treatment with EPO has been found to be a significant factor in maintaining employment once dialysis commences.9 The level of symptoms should determine the start of dialysis rather than blood tests or GFR measurements. It is more important that a patient remains relatively well and in employment rather than waiting to become really ill and then requiring prolonged rehabilitation.