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Chronic kidney disease and the public health: gaps in evidence from interventional trials.

IN RECENT YEARS, CHRONIC KIDNEY DISEASE HAS REceived increased attention as a leading public health problem. The kidney disease burden, measured in terms of prevalence, associated economic costs, and morbidity, is substantial and increasing. In the United States, more than 400 000 individuals have end-stage renal disease (ESRD), for which life can be sustained only with renal replacement therapy such as dialysis or kidney transplantation. In a recent population-based study of US residents 45 years and older, 9.5% had a first-degree relative with ESRD. It is estimated that by 2015, more than 700 000 individuals in the United States will have ESRD, and more than 107 000 ESRDrelated deaths will occur annually. Cardiovascular mortality in patients with ESRD is 10to 20-fold higher than in the general population and is the leading cause of death. Mortality rates for patients with ESRD have shown only modest improvement over the past 2 decades. The prevalence of individuals with chronic kidney disease (CKD) at less severe stages (not requiring renal replacement therapy) has been estimated at 11% of the adult US population, or approximately 19.2 million individuals. There is a robust but poorly understood association between the severity of CKD and increased risks of cardiovascular events and death. For example, in a large communitybased sample, the adjusted hazard ratio for death and cardiovascular events increased inversely as estimated glomerular filtration rate decreased to less than 60 mL/min per 1.73 m. Thus, an increasing proportion of US adults are subject to a disease process that is clearly associated with considerable adverse health consequences.