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Given the alarming predictions of the potentially devastating future epidemic of end-stage renal disease (ESRD), further knowledge is still urgently needed on this topic. The real dimensions of the problem are still unclear. It is difficult to compare Europe and the USA because different criteria are used in data collection and not much information is available, but the epidemic of silent chronic kidney disease seems to be more widespread in the States than in Europe, and more severe in terms of cardiovascular mortality. Defining early chronic renal insufficiency carrying a definite risk of ESRD is not easy, particularly for chronic renal conditions in which the clinical picture is still faint and the renal dysfunction minimal. It is also hard to say which tools are most suitable for diagnosing such renal disorders (renal filtration indexes vs. composite indexes of renal damage, e.g. the NKF's CKD stages). Furthermore, it is still not clear which strategies best identify subjects with these conditions (screening vs. early interception; general population vs. high-risk groups), how effective therapeutic approaches are, which subject categories benefit from early diagnosis and intervention, and how clinical measures should be structured (multidisciplinary case management-based approaches vs. general practitioner-oriented approaches). These issues are discussed in this paper.