1. Chronic kidney disease: [insert title here] Insert name, title, date here Insert acknowledgements here

2. StageDescription GFR (ml/min/1.73 m 2 ) U.S Prevalence (1000s) China Prevalence (1000s) 1 Kidney Damage with Normal or  GFR  90 5,60062,894 2 Kidney Damage with Mild  GFR 60-895,70037,516 3 Moderate  GFR 30-597,40017,655 4 Severe  GFR 15-293001103 5Kidney Failure< 15 or Dialysis391331 CKD: Staging System and Prevalence NKF-K/DOQI, 2002; Zhang et al, Lancet 2012

3. Future definitions of CKD may also incorporate information on proteinuria Composite ranking by adjusted relative riskComposite ranking by unadjusted absolute risk Albuminuria stageDescription and range of proteinuria stages, ACR or dipstick A1A2A3 Optimal and high-normal HighVery high and nephrotic NormalMildHeavy GFR stage DescriptionRange (ml/min/ 1.73m 2 ) <10 mg/g 10-29 mg/g 30-299 mg/g 300-1999 mg/g ≥2000 mg/g Range (ml/min/ 1.73m 2 ) 10-29 mg/g or negative 30-300 mg/g or trace to 1+ >300 mg/g or ≥ 2+ 1 High and optimal > 105 > 90 90-104 2Mild 75-89 60-89 60-74 3a Mild to moderate 45-59 3b Moderate to severe 30-44 4Severe15-29 5 Kidney failure < 15 Levey, Ann Intern Med 2011

4. CKD and ESRD are associated with exceedingly high mortality ESRD vs general populationStage 3-4 CKD vs general population (GP) Jager, from ERA-EDTA and USRDS data Alberta Kidney Disease Network, unpublished data 50 60 40 30 20 10 0 20253035404550556065707580 General population Dialysis 7.8 10.6 13.9 17.6 2.5 Expected remaining life-years Age (years) Europe US Whites 250 80-85 200 150 100 50 0 70-7560-6550-5540-4530-3520-25 Age groups GP males Stage 3 males Stage 4 males GP females Stage 3 females Stage 4 females Mortality rate per 1000 pt-yr

5. Proteinuria by dipstick further increases the risk of poor outcomes Hemmelgarn, JAMA 2010 N=920,985 mild: trace or 1+; heavy: ≥2+

6. What do people with CKD die from? Cardiovascular disease is a major cause USRDS, 2010 ADR National Vital Statistics Report, CDC 2010 Cardiovascular disease 42.0% Infection 3.6% Withdrawal 9% All other 33.0% Malignancy 4% Cardiovascular disease 31.0% All other 33.1% Malignancy 23.2% Lung disease 5.3% Self-harm 1.4% Alzheimers 3.1% Infection 12% ESRD, USAGeneral population, USA

7. Risk factors for CKD are similar to those for other NCDs Diabetes Hypertension Relative with CKD CV disease Age, minority status UTI, nephrolithiasis Acute renal failure UT obstruction Chronic infections Nephrotoxins Smoking, obesity, dyslipidemia NKF-K/DOQI, 2002

8. CKD often coexists with other NCDs Hypertension Cardiovascular disease This suggests that addressing CKD will improve outcomes for other NCDs also CKD Diabetes

9. 9 Lysaght, J Am Soc Nephrol, 2002 1990 2000 2010 426,000 1,490,000 2,500,000 ESRD is increasingly common worldwide Frequency of ESRD

10. The global burden of CKD is greatest in developing countries and in the poor White et al, WHO Bull 2008; Nugent et al, NCP 2011 Territories are sized in proportion to the absolute number of people who die of CKD each year. Even within countries, burden of CKD is concentrated among the poorest. Renal replacement is available only to a wealthy few.

11. Individuals who were aware that they had CKD eGFR (ml/min/1.73 m 2 ) -NHANES 1988-94 and 1999-2000 surveys in the US general population (19,589);Adults aged 20 years and older; - China National Survey of Chronic Kidney Disease; Adults aged 18 years and older; - Self-reported awareness of CKD -Awareness of CKD is even lower in developing countries Coresh et al, JASN 2005; Zhang et al. Lancet, 2012 Most people affected by CKD are unaware

12. Detecting CKD is cheap and efficient Kidney function (eGFR) estimated using simple equations applied to results of blood test (serum creatinine; $0.75) Albuminuria detected using semi-quantitative urine dipstick ($0.02) or quantitative urine albumin:creatinine ratio ($2.50) Consistent presence of low eGFR or abnormal albuminuria indicates presence of CKD NKF-K/DOQI, 2002

13. Inexpensive treatments for CKD improve CV and renal outcomes Control of hypertension ACEI or ARB use Statin use Control of blood sugar (in diabetic patients) Smoking cessation Prevention of obesity Remuzzi, Lancet 2012

14. Summary CKD is common, expensive, and associated with very poor outcomes CKD often coexists with other NCDs Many of the affected are unaware…but CKD is cheaply and easily detected using routine tests Effective and cost-effective treatments for CKD are available Detection and management of CKD should be integrated into national NCD programs