Early identification and active management of patients with renal impairment in primary care can improve outcomes The number of patients with end stage renal disease is growing worldwide. About 20-30 patients have some degree of renal dysfunction for each patient who needs renal replacement treatment.1 Diabetes and hypertension are the two most common causes of end stage renal disease and are associated with a high risk of death from cardiovascular disease. Mortality in patients with end stage renal disease remains 10-20 times higher than that in the general population. The focus in recent years has thus shifted to optimising the care of these patients during the phase of chronic kidney disease, before the onset of end stage renal disease. This review summarises current knowledge about the various stages of chronic renal disease, the risk factors that lead to progression of disease, and their association with common cardiovascular risk factors. It also provides strategies for intervention at an early stage of the disease process, which can readily be implemented in primary care, to improve the overall morbidity and mortality associated with chronic renal disease. #### Summary points Significant renal dysfunction might be present even when serum creatinine is normal or only slightly abnormal Renal function declines progressively once creatinine clearance falls by about 25% of normal, but symptoms are often not apparent until renal failure is advanced The baseline rate of urinary protein excretion is the best single predictor of disease progression The prevalence of common cardiovascular risk factors is high in chronic renal disease; early identification and effective control of these risk factors is important to improve outcomes Cardiovascular disease accounts for 40% of all deaths in chronic renal disease Potentially reversible causes should be sought when renal function suddenly declines Irreversible but modifiable complications (anaemia, cardiovascular disease, metabolic bone disease, malnutrition) …