Chronic kidney disease as a global public health problem: Approaches and initiatives – a position statement from Kidney Disease Improving Global Outcomes

Abstract

Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. There is now convincing evidence that CKD can be detected using simple laboratory tests, and that treatment can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of cardiovascular disease (CVD). Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Understanding the relationship between CKD and other chronic diseases is important to developing a public health policy to improve outcomes. The 2004 Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on ‘Definition and Classification of Chronic Kidney Disease’ represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community. The 2006 KDIGO Controversies Conference on CKD was convened to consider six major topics: (1) CKD classification, (2) CKD screening and surveillance, (3) public policy for CKD, (4) CVD and CVD risk factors as risk factors for development and progression of CKD, (5) association of CKD with chronic infections, and (6) association of CKD with cancer. This report contains the recommendations from the meeting. It has been reviewed by the conference participants and approved as position statement by the KDIGO Board of Directors. KDIGO will work in collaboration with international and national public health organizations to facilitate implementation of these recommendations. Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. There is now convincing evidence that CKD can be detected using simple laboratory tests, and that treatment can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of cardiovascular disease (CVD). Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Understanding the relationship between CKD and other chronic diseases is important to developing a public health policy to improve outcomes. The 2004 Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on ‘Definition and Classification of Chronic Kidney Disease’ represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community. The 2006 KDIGO Controversies Conference on CKD was convened to consider six major topics: (1) CKD classification, (2) CKD screening and surveillance, (3) public policy for CKD, (4) CVD and CVD risk factors as risk factors for development and progression of CKD, (5) association of CKD with chronic infections, and (6) association of CKD with cancer. This report contains the recommendations from the meeting. It has been reviewed by the conference participants and approved as position statement by the KDIGO Board of Directors. KDIGO will work in collaboration with international and national public health organizations to facilitate implementation of these recommendations. Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. The declaration of World Kidney Day to be observed annually beginning in March 2006 sends a clear message to the public, government health officials, physicians, allied health professionals, patients, and families that ‘CKD is common, harmful, and treatable’.1Levey A.S. Andreoli S.P. DuBose T. et al.Chronic kidney disease: common, harmful and treatable – World Kidney Day 2007.Am J Kidney Dis. 2007; 49: 175-179Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar The recognition of CKD as a public health problem has evolved, in part, from the acceptance of the conceptual model, definition, and classification of CKD proposed by the National Kidney Foundation Kidney Disease Outcome Quality Initiative in 2002 and modified by Kidney Disease Improving Global Outcomes (KDIGO) in 20042National Kidney Foundation K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar, 3Levey A.S. Coresh J. Balk E. et al.National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Ann Intern Med. 2003; 139: 137-147Crossref PubMed Scopus (3462) Google Scholar, 4Levey A.S. Eckardt K.U. 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: 2089-2100Abstract Full Text Full Text PDF PubMed Scopus (2202) Google Scholar (Figure 1; Tables 1 and 2). As a result, physicians, investigators, and public health officials across the world can now more easily ascertain CKD irrespective of cause, study its antecedents and outcomes, determine risk factors for its development and progression, and develop strategies for its detection, evaluation, and treatment.Table 1KDIGO definition of CKDStructural or functional abnormalities of the kidneys for ≥3 months, as manifested by1. Kidney damage, with or without decreased GFR, as defined by Pathologic abnormalities Markers of kidney damage Urinary abnormalities (proteinuria) Blood abnormalities (renal tubular syndromes) Imaging abnormalities Kidney transplantation2. GFR <60 ml/min/1.73 m2, with or without kidney damageCKD, chronic kidney disease; GFR, glomerular filtration rate; KDIGO, Kidney Disease Improving Global Outcomes. Open table in a new tab Table 2Current CKD classification based on severity and therapyStageDescriptionGFR (ml/min/1.73 m2)ICD-9 CM codeTreatment1Kidney damage with normal or ↑ GFR≥90585.12Kidney damage with mild ↓ GFR60–89585.21–5 T if kidney transplant recipient3Moderate ↓ GFR30–59585.34Severe ↓ GFR15–29585.45Kidney failure<15 (or dialysis)585.5585.6 (if ESRD) V codes for dialysis or transplantation5D if dialysis (HD or PD)CKD, chronic kidney disease; GFR, glomerular filtration rate; ↑, increased; ↓, decreased. Open table in a new tab CKD, chronic kidney disease; GFR, glomerular filtration rate; KDIGO, Kidney Disease Improving Global Outcomes. CKD, chronic kidney disease; GFR, glomerular filtration rate; ↑, increased; ↓, decreased. In the US, 9.6% of non-institutionalized adults are estimated to have CKD.5Coresh J. Byrd-Holt D. Astor B.C. et al.Chronic kidney disease awareness, prevalence, and trends among US adults, 1999 to 2000.J Am Soc Nephrol. 2005; 16: 180-188Crossref PubMed Scopus (627) Google Scholar,6Stevens L.A. Coresh J. Greene T. Levey A.S. Assessing kidney function – measured and estimated glomerular filtration rate.N Engl J Med. 2006; 354: 2473-2483Crossref PubMed Scopus (2161) Google Scholar Studies from Europe, Australia, and Asia confirm the high prevalence of CKD.7de Zeeuw D. Hillege H.L. de Jong P.E. The kidney, a cardiovascular risk marker and a new target for therapy.Kidney Int Suppl. 2005; 98: S25-S29Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 8Chen J. Wildman R.P. Gu D. et al.Prevalence of decreased kidney function in Chinese adults aged 35 to 74 years.Kidney Int. 2005; 68: 2839-2845Google Scholar, 9Hallan S.I. Coresh J. Astor B.C. et al.International comparison of the relationship of chronic kidney disease prevalence and ESRD risk.J Am Soc Nephrol. 2006; 17: 2275-2284Crossref PubMed Scopus (515) Google Scholar, 10Chadban S.J. Briganti E.M. Kerr P.G. et al.Prevalence of kidney damage in Australian adults: the AusDiab kidney study.J Am Soc Nephrol. 2003; 14: S131-S138Crossref PubMed Google Scholar Outcomes of CKD include not only progression to kidney failure but also complications of reduced kidney function and increased risk of cardiovascular disease (CVD). Patients with CKD are far more likely to die, principally from CVD, than to develop kidney failure.11Keith D. Nicholls G. Guillion C. et al.Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization.Arch Intern Med. 2004; 164: 659-663Crossref PubMed Scopus (1283) Google Scholar There is now convincing evidence that CKD can be detected using simple laboratory tests, and that certain treatments can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce its associated CVD risk.2National Kidney Foundation K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar, 12National Kidney Foundation K/DOQI clinical practice guidelines for managing dyslipidemias in chronic kidney disease.Am J Kidney Dis. 2003; 41: S1-S92PubMed Google Scholar, 13National Kidney Foundation K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease.Am J Kidney Dis. 2003; 42: S1-S202Crossref PubMed Scopus (648) Google Scholar, 14National Kidney Foundation K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease.Am J Kidney Dis. 2004; 43: S1-S290PubMed Google Scholar, 15National Kidney Foundation K/DOQI clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease.Am J Kidney Dis. 2006; 47: S1-S145PubMed Google Scholar, 16Chobanian A.V. Bakris G.L. Black H.R. et al.The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.JAMA. 2003; 289: 2560-2572Crossref PubMed Scopus (15057) Google Scholar, 17Sarnak M.J. Levey A.S. Schoolwerth A.C. et al.Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.Hypertension. 2003; 42: 1050-1065Crossref PubMed Scopus (864) Google Scholar, 18American Diabetes Association Standards of medical care in diabetes-2006.Diabetes Care. 2006; 29: S1-S85PubMed Google Scholar Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Although there is still much to learn about the impact of treatments and their optimal combinations for CKD, it is not too early to begin implementation. Chronic diseases are now the leading causes of death worldwide. The World Health Organization (WHO) estimates that there were approximately 58 million deaths worldwide in 2005, with 35 million attributed to chronic disease.19World Health OrganizationPreventing chronic diseases: a vital investment: WHO global report.2005Google Scholar,20Yach D. Hawkes C. Gould C.L. et al.The global burden of chronic diseases: overcoming impediments to prevention and control.JAMA. 2004; 291: 2616-2622Crossref PubMed Scopus (937) Google Scholar In developed countries and lower-middle-income developing nations, CVD and cancer were the leading causes of death. In low-income developing countries, infections remained the leading cause of death, but chronic non-communicable diseases were on the rise. The WHO report called for governments to provide leadership in addressing the projected continued increase in deaths due to chronic diseases. While CKD is not mentioned in the 2005 WHO report,19World Health OrganizationPreventing chronic diseases: a vital investment: WHO global report.2005Google Scholar it is now recognized that CKD is common in people with CVD and with CVD risk factors, and that CKD multiplies the risk for adverse outcomes in these conditions.17Sarnak M.J. Levey A.S. Schoolwerth A.C. et al.Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.Hypertension. 2003; 42: 1050-1065Crossref PubMed Scopus (864) Google Scholar CKD is also reported to be a risk factor for adverse outcomes in other chronic diseases such as infections and cancer,21Fried L.F. Katz R. Sarnak M.J. et al.Kidney function as a predictor of non-cardiovascular mortality.J Am Soc Nephrol. 2005; 16: 3728-3735Crossref PubMed Scopus (229) Google Scholar and should be studied in more detail. Understanding the relationship between CKD and other chronic diseases is important to develop a public health policy to improve outcomes (Figure 2). KDIGO is an independent non-profit foundation governed by an international Board of Directors with the stated mission to ‘improve the care and outcomes of kidney disease patients worldwide through promoting coordination, collaboration and integration of initiatives to develop and implement clinical practice guidelines’.22Eknoyan G. Lameire N. Barsoum R. et al.The burden of kidney disease: improving global outcomes.Kidney Int. 2004; 66: 1310-1314Abstract Full Text Full Text PDF PubMed Scopus (340) Google Scholar The KDIGO Controversies Conference on ‘Definition and Classification of Chronic Kidney Disease’ was held in Amsterdam in November 2004, attended by an international group of experts, represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community.4Levey A.S. Eckardt K.U. 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: 2089-2100Abstract Full Text Full Text PDF PubMed Scopus (2202) Google Scholar In 2006, KDIGO convened another Controversies Conference to build on and extend the recommendations of the 2004 conference. The agenda, selected presentations, and abstracts of the meeting are posted on the KDIGO website (http://www.kdigo.org/content-cconf.htm#Public%20Health). Specifically, the conference addressed two major topics. The plenary session included presentations on CKD screening and surveillance, standardization of creatinine measurement, experience in measuring and reporting the estimated glomerular filtration rate (eGFR), implementation of albuminuria testing, revisions to the ninth International Classification of Disease, and public policy initiatives. Breakout sessions focused on CKD classification (group 1), CKD screening and surveillance (group 2), CKD, and public policy (group 3). The plenary session included presentations on the WHO perspective on chronic disease, and on associations of CKD with other chronic diseases: CVD, infections, and cancer. The model for assembling evidence to evaluate and classify CKD as a risk factor for CVD (Table 3) was the paradigm used for evaluating the association of CKD with other chronic diseases. Breakout groups focused on CVD risk factors and CVD as risk factors for CKD development and progression (group 4), and CKD as a risk factor for adverse outcomes of chronic infections (group 5) and of cancer (group 6).Table 3Approach to evaluation of CKD as a risk factor for CVD in CVD risk factor conditionsCVD risk factorCKD prevalenceCKD as a risk factor for CVD morbidityCKD as a risk factor for CVD mortalityHypertension↑↑↑Diabetes↑↑↑Dyslipidemia↑↑↑CKD, chronic kidney disease; CVD, cardiovascular disease; ↑, increased. Open table in a new tab CKD, chronic kidney disease; CVD, cardiovascular disease; ↑, increased. Each breakout group was asked to formulate both clinical and research recommendations based on evidence and opinion. The groups did not perform a systematic review or grading of available evidence. This report contains the recommendations made at the meeting and has been reviewed by the conference participants (Appendix) and approved as position statement by the KDIGO Board of Directors. These recommendations will be pursued by the KDIGO Board with the World Health Organization and other international and national public health organizations. CKD is a heterogeneous condition, whose clinical manifestations and course depend on the cause and type (pathology), severity, rate of progression, and comorbid conditions. The group examined the need to refine the CKD classification to include additional clinical information, to evaluate the utility of adopting a coding system, which subdivides CKD by presumed cause, and to identify key research questions that would facilitate or improve the understanding and application of the CKD classifications system worldwide. The rationale for the recommendations is that development and adoption of a consistent framework for classification of CKD will facilitate international collaborations and allow for scientific discoveries to be more readily adopted worldwide. KDIGO should not change the existing classification at this time. The classification system endorsed by KDIGO in 2004 includes severity and modality of treatment for kidney failure (Table 2). It is acknowledged that additional clinical information (Table 4) is required for the evaluation and management of individual cases of CKD. However, the potential benefits of adding information was thought to be outweighed by the disadvantages of increased complexity and incomplete description of an essentially heterogeneous condition. The current classification system was deemed to be clear, simple, and useful, as evidenced by its ongoing endorsement and adoption worldwide. Moreover, there was concern that further additions would detract from the attempt to maintain a simple message applicable across various disciplines and communities. There was discussion of whether albuminuria is a marker of kidney damage in non-diabetic as well as diabetic kidney disease. Data from the Heart Outcomes and Prevention Evaluation Study indicate that ‘microalbuminuria’ was associated with same relative risk for progression to ‘clinical proteinuria’ in non-diabetic and diabetic kidney diseases,23Mann J.F.E. Gerstein H.C. Qi-Long Y. et al.Development of renal disease in people at high cardiovascular risk: results of the HOPE randomized study.J Am Soc Nephrol. 2003; 14: 641-647Crossref PubMed Scopus (125) Google Scholar suggesting that the current threshold for albuminuria as a marker of kidney damage (a spot urine albumin-to-creatinine ratio >30 mg/g) is applicable to diabetic and non-diabetic kidney diseases.Table 4Key elements for description of CKD in clinical practiceDomainExampleSeverityGFR levelTreatmentTherapies for causes of kidney diseaseTreatment modality for kidney failureMarker of kidney damage and severityPathologic abnormalityMagnitude of albuminuria/proteinuriaImaging abnormalitiesCause of kidney diseaseDiabetic kidney diseaseNon-diabetic kidney disease Glomerular diseases Tubulointerstitial diseases Vascular diseases Cystic diseasesDisease in the kidney transplant recipientPresence and severity of complicationsHypertensionAnemiaMalnutritionBone and mineral diseasePresence and severity ofDiabetescomorbid conditionsCardiovascular diseaseChronic infectionsCancerPrognosisPast history or risk factors for fast progressionRisk factors for cardiovascular disease Open table in a new tab KDIGO should work with the WHO to adopt the USA modifications to ICD-9 CM and in updates to ICD-10 and subsequent revisions. It is important that coding systems capture the elements of the current classification system. The ninth version of the International Classification of Disease in the USA (ICD-9 CM) has adopted a revised coding system that incorporates the current CKD staging system. There was consensus that current (version 10) and future (version 11) iterations of ICD should incorporate and maintain this coding system so that more epidemiologic information could be gained from administrative data. Healthcare providers in different countries have variable familiarity with these codes. Nonetheless, each country does have a system of coding and variable obligations for reporting. The consistency of evolving iterations of ICD is essential for following trends over time, and potentially for cross country comparisons, as well as providing essential information to regional public health authorities.KDIGO should facilitate the development of a uniform ‘essential data set’ for description of CKD for coding purposes. There is a need to describe an essential data set for coding to ensure that a minimal amount of data is obtained on all patients identified as having CKD. Although no final recommendations were made, key elements could include the information provided in Table 4. For research purposes, the inclusion of race, ethnicity, socio-economic status, and level of education would improve understanding the impact of CKD worldwide. Research recommendations from the 2004 KDIGO conference on definition and classification of CKD remain high priority.4Levey A.S. Eckardt K.U. 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: 2089-2100Abstract Full Text Full Text PDF PubMed Scopus (2202) Google ScholarAdditional studies are needed to:•Define the societal and individual implications of over- and underdiagnosis of CKD. This should include analysis of the impact of health behaviors, and evaluation of the costs of testing, labeling, and resource utilization in different countries.•Systematically analyze the performance of current GFR estimating equations in different populations and their use:— for some specific testing or treatment strategies, such as frequency of testing for complications or for drug dosing— in special patient populations such as patients with reductions in kidney mass due to surgery or a past history of acute kidney injury— in chronic diseases, due to concerns about muscle wasting and malnutrition (see reports by groups 5 and 6).Identify new markers of kidney damage and new filtration markers (for example cystatin C) and analyze their performance in different patient populations. The group discussed strategies for implementation of screening and surveillance for CKD in developed and developing countries. Screening is an activity, whereby persons in a defined population who are not aware of CKD are tested to detect the disease and, if present, are subsequently treated to reduce the risk of progression of CKD and its complications. Surveillance refers to an activity to provide key information on CKD, such as time, location, magnitude, and severity, in order to guide implementation of medical and public health measures to control progression of CKD and its complications. It is not known whether screening the general population would be cost-effective.24Boulware L.E. Jaar B.G. Tarver-Carr M.E. et al.Screening for proteinuria in US adults: a cost-effectiveness analysis.JAMA. 2003; 290: 3101-3114Crossref PubMed Scopus (300) Google Scholar,25Atthobari J. Asselbergs F.W. Boersma C. et al.Cost-effectiveness of screening for albuminuria and subsequent treatment with an ACE inhibitor to prevent cardiovascular events: a pharmacoeconomic analysis linked to the PREVEND and the PREVEND IT studies.Clin Ther. 2006; 28: 432-444Abstract Full Text PDF PubMed Scopus (112) Google Scholar Targeted screening should be directed at subgroups of the population who would derive the most benefit from CKD detection. Among developed and developing nations, the risk for CKD is increased in people with CVD risk factors or established CVD, in whom CKD multiplies the risk for adverse outcomes of CVD. Thus, the ‘CKD subgroup’ of patients with CVD and CVD risk factors constitutes a high-risk group requiring special attention.2National Kidney Foundation K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar As discussed by groups 5 and 6, patients with some chronic infectious diseases and cancers may also be at increased risk. In conditions where the prevalence of CKD is increased and the risk of complications due to preventable factors is high, including adjustment of drug doses to avoid toxicity, screening for CKD may be warranted. In these groups, screening for CKD could be implemented using existing infrastructures for the detection of other chronic conditions. Many countries have registries for patients treated by dialysis and transplantation. However, these programs overlook people with severe CKD who die before the onset of kidney failure or are not treated with dialysis or transplantation despite the onset of kidney failure. In principle, a surveillance program for CKD stages 4 and 5 would enable countries to monitor the magnitude and the care of this high-risk, high-cost population, and possibly to reduce both the risk of progression to kidney failure and the cost of dialysis and transplantation.2National Kidney Foundation K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar A surveillance program for patients with CKD stage 3 would reach many more people and might be an effective way to lower rates of CVD and death, especially among the elderly with CVD risk factors or CVD. However, such a larger surveillance program would require more resources and the available data to assess the costs and benefits is incomplete. All countries should have a targeted screening program for CKD (Table 5).Table 5High-risk groups for targeted screening program for CKDHighest priority Hypertension Diabetes Cardiovascular diseaseTo be considered Older age Family history of kidney disease Other cardiovascular disease risk factors Exposure to toxic drugs Certain chronic infections Certain cancersCKD, chronic kidney disease. Open table in a new tab Target groups should include patients with hypertension, diabetes and cardiovascular disease. Other groups might include families of patients with CKD, individuals with hyperlipidemia, obesity, metabolic syndrome, smokers, patients treated with potentially nephrotoxic drugs, some chronic infectious diseases and cancers (see reports from groups 5 and 6), and age >60 years.Tests for CKD screening should include both a urine test for proteinuria and a blood test for creatinine to estimate GFR. Tests for proteinuria should be selected and performed according to local guidelines. (This article refers to tests for proteinuria as tests for detection of proteinuria, including tests for albumin only; and tests for albuminuria as tests for detection of albumin only.) Verification of proteinuria would require two out of three positive tests.3Levey A.S. Coresh J. Balk E. et al.National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Ann Intern Med. 2003; 139: 137-147Crossref PubMed Scopus (3462) Google Scholar In selected populations with an increased risk for glomerulonephritis, testing for hematuria should also be performed. Equations for estimating GFR should be appropriate for standardization of the serum creatinine assay and application to majority racial and ethnic groups.Frequency of testing should be according to available guidelines and the target group to be tested. In the absence of specific recommendations, testing need not be more frequent than once per year.All countries should have a surveillance program for CKD stages 4–5 and strive to include earlier stages. If possible, data on risk factors for development and progression of CKD most relevant for the specific population should be included. Surveillance for CKD could be incorporated into existing surveillance programs (such as those for hypertension, diabetes, cardiovascular diseases, infectious diseases, and cancer) and data from such programs should be used for surveillance of CKD risk factors. Data could be obtained from random samples of the general population or (possibly) populations receiving medical care or (ideally) registries of stages 4 and 5 CKD. Data should be collected at a frequency of every 5–10 years, or more often, depending on disease dynamics, interventional strategies, and regional resources. Additional components of a CKD surveillance program could be: consequences of CKD (mortality), education/awareness (public and professionals), health system capabilities (primary and specialty care), quality of care markers (appropriate treatment/referrals), and health policy goals. CKD, chronic kidney disease. Evaluate target groups for screeningCompare specificity and sensitivity of different screening tests in various settings, including verification of proteinuriaDefine optimal timing interval for screening and surveillanceAnalyze costs, benefits and risks of screening programs The group discussed the need for CKD public policy programs in developed and developing countries, and steps to implement them. In some countries, the incidence of kidney failure due to some types of CKD is stabilizing or declining, possibly reflecting early detection and treatment.26Lysaght M.J. Maintenance dialysis population dynamics: current trends and long-term implications.J Am Soc Nephrol. 2002; 13: S37-S40PubMed Google Scholar,27US Renal Data System USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2005Google Scholar Although the prevalence of kidney failure varies substantially throughout the world, the number of patients and the cost of providing dialysis and transplantation continue to