1. Sheffield Kidney Institute

2. Lysaght, J Am Soc Nephrol, 2002 RRT 1990 2000 2010 426,000 1,065,000 2,095,000

3. Sheffield Kidney Institute Adjusted incident rates & annual percent change Figure 2.2 Incident ESRD patients; Medical Evidence form data; rates adjusted for age, gender, & race.

4. Sheffield Kidney Institute There are 1,065,000 people on dialysis worldwide 90 % of them live in North America, Japan, and Europe, whose population is less than 20 % of world population

5. Sheffield Kidney Institute K/DOQI CKD Classification StageDescriptionGFR 1Kidney damage/normal GFR>90ml/min 2Mild renal insufficiency89-60 3Moderate renal insufficiency59-30 4Severe renal insufficiency29-15 5Kidney Failure<15

6. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4 X X X

7. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4 AT RISK

8. Sheffield Kidney Institute S I P Risk Factors in CKD Genetic/Relatives of CKD Race Gender Age Diseases: DM, HT, auto-immune, Rheumatic Infections: Malaria, HIV, HCV, Streptococcus

9. Sheffield Kidney Institute USAUK

10. Sheffield Kidney Institute S I P Risk Factors in CKD BP Glycaemia Dyslipidemia Weight Smoking INFECTIONS: HCV, HIV, Malaria, schisto

11. Sheffield Kidney Institute HIV

12. Sheffield Kidney Institute MRFIT Study

13. Sheffield Kidney Institute

15. AIRC, Jurkovitz et al, 2003

16. Sheffield Kidney Institute Iseki et al, 2003

17. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4 Established CKF

18. Sheffield Kidney Institute S I P Risk Factors in CKD Modifiable BP Proteinuria Dyslipidemia Smoking

19. Sheffield Kidney Institute Locatelli et al 1996

20. Sheffield Kidney Institute Locatelli et al 1996

21. Sheffield Kidney Institute Attman et al 1999

22. Sheffield Kidney Institute Bonnet et al 2001

23. Sheffield Kidney Institute Non-DN DN Orth 2002

24. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4 Established CKF

25. Sheffield Kidney Institute Hypertension <125/75 Proteinuria <1g/d Lipids <5 Smoking STOP Alcohol Weight

26. Sheffield Kidney Institute ACEI/ARB NDCCB  -blocker ACEI/ARB NDCCB STATIN STOP Renoprotection Cardioprotection

27. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4 X X X

28. Sheffield Kidney Institute GUIDELINES ESRD Lack of resources Lack Nephologists Lack Dialysis Death

29. Sheffield Kidney Institute What to do???????? Community Health Education and Awareness Programmes (CHEAP) Screening programmes Train a new generation of Nephro-epidemiologists Inform General practitioners Train Community Health Work Assistants Engage communities, NGO and Pharmaceutical industry

30. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4 AT RISK

31. Sheffield Kidney Institute K/DOQI At-risk Population + CKD 1 At-risk Population –DM, HT –Obese individuals –Relatives of CKD –Ethnic/racial populations at risk –Infections: malaria, Schisto, HCV, HIV

32. Sheffield Kidney Institute DM Treat Prevent Screen PREVENTION

33. Sheffield Kidney Institute

34. IGT 2000:197m 2025:380m DM 2000:155m 2025: 300m DN 2000:15-30m 2025:30-60m

35. Sheffield Kidney Institute Obesity/Glucose intolerance Da Qing IGT and Diabetes Study (Pan et al, 1997) Exercise (4h/week) Diet Diet + exercise Diabetes Prevention Programe (Molitch et al 2003) Metformin v Lifestyle modification Finnish Diabetes Prevention Study (Lindstrom et al, 2003) Lifestyle

36. Sheffield Kidney Institute

37. Obesity/Glucose intolerance Da Qing IGT and Diabetes Study (Pan et al, 1997) Exercise (4h/week)-36% Diet-31% Diet + exercise-42% Diabetes Prevention Programe (Molitch et al 2003) Metformin-31% Lifestyle modification-58% Finnish Diabetes Prevention Study (Lindstrom et al, 2003) Lifestyle-58%

38. Sheffield Kidney Institute Diabetes prevention « if everybody exercised few hours a week, type 2 diabetes would be virtually nonexistent » Ken Goodrick M.D. (Baylor College of Medicine) TIME 5 February 2001

39. Sheffield Kidney Institute HT Treat Prevent Screen PREVENTION

40. Sheffield Kidney Institute Lifestyle Modifications & CKD Salt Restriction Weight Reduction Exercise

41. Sheffield Kidney Institute DASH-Salt Na: 141 mmol/d Na: 106 Na: 65

42. Sheffield Kidney Institute

46. Evolution

47. Sheffield Kidney Institute PRE-CKD CKD 1 CKD 2 CKD3 ESRF CKD4

48. Sheffield Kidney Institute What to do???????? Community Health Education and Awareness Programmes (CHEAP) Screening programmes Inform General practitioners Train a new generation of Nephro-epidemiologists Train Community Health Work Assistants Engage communities, NGO and Pharmaceutical industry

49. Sheffield Kidney Institute K/DOQI At-risk Population + CKD 1 At-risk Population –DM, HT –Obese individuals –Relatives of CKD –Ethnic/racial populations at risk –Infections: malaria, Schisto, HCV, HIV

50. Sheffield Kidney Institute The oedematous woman - Gerard Dou 1662 (Louvre Museum)

51. Sheffield Kidney Institute What to do???????? Community Health Education and Awareness Programmes (CHEAP) Screening programmes Inform General practitioners Train a new generation of Nephro-epidemiologists Train Community Health Work Assistants Engage communities, NGO and Pharmaceutical industry

52. Sheffield Kidney Institute

53. 677 hypertensive type 2 diabetics –166 (24.5 %) : BP < 140/90 – 81 (7.53 %): BP < 130/85 – 22 (3.25 %): BP < 130/80 FAMUS BP Control Study

54. Sheffield Kidney Institute What to do???????? Community Health Education and Awareness Programmes (CHEAP) Screening programmes Train a new generation of Nephro-epidemiologists Inform General practitioners Train Community Health Work Assistants Engage communities, NGO and Pharmaceutical industry

55. Sheffield Kidney Institute Sheffield School of Nephrology

56. Sheffield Kidney Institute What to do???????? Community Health Education and Awareness Programmes (CHEAP) Screening programmes Inform General practitioners Train a new generation of Nephro-epidemiologists Train Community Health Work Assistants Engage communities, NGO and Pharmaceutical industry

57. Sheffield Kidney Institute

58. What to do???????? Community Health Education and Awareness Programmes (CHEAP) Screening programmes Inform General practitioners Train a new generation of Nephro-epidemiologists Train Community Health Work Assistants Engage communities, NGO and Pharmaceutical industry

59. Sheffield Kidney Institute

60. Adjusted incident rates & annual percent change Figure 2.2 Incident ESRD patients; Medical Evidence form data; rates adjusted for age, gender, & race.

61. Sheffield Kidney Institute