1. ESRD: State of the Art and Charting the Challenges for the Future Beth Israel Deaconess and Harvard Medical School April 23 – 26, 2009 A teaching hospital of Harvard Medical School

2. Introductions Welcome and Outline: Making a Difference –Tom F. Parker lll –Theodore I. Steinman

3. A teaching hospital of Harvard Medical School Steering Committee Chairmen: Tom F. Parker and Theodore I. Steinman William M. Bennett, MD Allan J. Collins, MD Richard J. Cronin, MD Francis L. Delmonico, MD Raymond Hakim, MD William L. Henrich, MD Alan Hull, MD: –Honorary Chairman Prof. Norbert Lameire J. Michael Lazarus, MD Edmund Lowrie, MD Andrew S. Narva, MD Allen R. Nissenson, MD Eberhard Ritz, MD

4. A teaching hospital of Harvard Medical School Sponsors with appreciation Platinum Level –Amgen –Genzyme

5. A teaching hospital of Harvard Medical School Sponsors with appreciation Gold Level –Abbott Laboratories –American Renal Associates, LLC –Dallas Nephrology Associates, PA –Renal Ventures Management –Watson Pharmaceuticals

6. A teaching hospital of Harvard Medical School Sponsors with appreciation Silver Level –AMAG Pharmaceuticals, Inc –NxStage –U. S. Renal –Fresenius Medical Care, NA Contributors –B. Braun Medical, Inc. –DaVita

7. A teaching hospital of Harvard Medical School Program Endorsements American Society of Nephrology National Kidney Foundation Renal Physicians Association International Society of Nephrology European Dialysis and Transplant Association/European Renal Association

8. A teaching hospital of Harvard Medical School Purpose of the meeting Explore medical and non-medical determinants of outcomes in the ESRD population –Medical: state of art lectures that cover the issues impacting ESRD –Non-medical: Impact on outcomes of government regulations and payment, guidelines, insurance companies, dialysis providers…. Use the information to plan new care initiatives and opportunities

9. A teaching hospital of Harvard Medical School Knowledge has value only in so far as we can put it toward good purpose

10. A teaching hospital of Harvard Medical School Eugene O’Neill, a marvelous and controversial playwright, observed once that “There is no present or future, only the past happening over and over again.” Did he have RRT in mind when saying this.

11. A teaching hospital of Harvard Medical School The charge given to our speakers: Determine the accomplishments in ESRD RRT over the past 20 years Determine the impediments to improving RRT over the past 20 years Understand the science to further improve outcomes Understand the environment in which to apply the science Outline the best approaches for care over the next 5 years

12. A teaching hospital of Harvard Medical School The Setting Our Milieu –20% of facility patients die each year –A program that costs $34,000,000,000/year –$20,000 per patient per year in hospitalizations –Less than 20% rehabilitation –Survival results no better than colon ca. 104,000 new ESRD patients – 2005 –97,143 In Center HD –6875 PD –2424 Pre-emptive transplant

13. A teaching hospital of Harvard Medical School Is this the best that we can do?

14. A teaching hospital of Harvard Medical School Is the Problem? The Science The interpreter of the science –The nephrologist and other caregivers The dialysis service provider The patient –Demographics –Reluctance to participate in optimal care

15. A teaching hospital of Harvard Medical School Is the Problem? The payment system –Effect on innovation –Tenuous dependence EPOGEN Commercial payors –Medical Director conflicts of interest Guidelines

16. A teaching hospital of Harvard Medical School (Our) world is (what it is), not because of those who do bad things, but because of those who look on and do nothing." -Albert Einstein

17. A teaching hospital of Harvard Medical School The Historical Perspective Co-Chairs: Drs. Mark Zeidel and Sushrat Waiker 2:10 – 2:40 - What did we learn from the 1989 Dallas Conference on Mortality in Dialysis – Dr. Alan R. Hull