PUBLIC POLICY

A Public Health Action Plan Is Needed for

Chronic Kidney Disease
Anton C. Schoolwerth, Michael M. Engelgau, and
Thomas H. Hostetter
In 2005, chronic kidney disease (CKD) meets all criteria for classification as a public health problem in
the United States. It imposes a large burden on society that is increasing despite ongoing efforts to
control the disease. The burden is unevenly distributed by race and economic status, whereas
evidence suggests that preventive strategies could substantially reduce the burden. Finally, there are
indications that such strategies are not yet in place. A broad and coordinated public health approach
to the burgeoning health, economic, and societal challenges of CKD is needed to complement present
clinical approaches, increase awareness, promote early detection, and facilitate prevention and
treatment.
© 2005 by the National Kidney Foundation, Inc.
Index Words: Kidney disease; Public health; Surveillance; Prevention; Outcomes; End-stage renal
disease.

Why is Chronic Kidney Disease (CKD)
a Public Health Problem?
A disease or condition becomes a public
health problem when several criteria are
met (Table 1).1,2 First, it should impose a large
societal burden that is growing larger, despite
existing control efforts, and one that is ex-
pected to increase in the future. This burden is
experienced in terms of mortality or morbid-
ity, quality of life, and cost and is perceived as
a serious threat by leaders in public health, by
epidemiologists, by clinicians, and by the pub-
lic, that is, there is a sense of fear that the
disease is “out of control.” Second, the burden
imposed by the disorder should be uneven; in
many cases, this means that minorities and
disadvantaged people are affected dispropor-
tionately. Third, there should be evidence that
preventive strategies could substantially re-
duce the burden imposed by the condition.
From the Centers for Disease Control and Prevention,
Division of Diabetes Translation, Atlanta, GA; Section of
Hypertension/Nephrology, Dartmouth Medical School,
Hanover, NH; and National Kidney Disease Education Pro-
gram, National Institute of Diabetes and Digestive and Kidney
Diseases, National Institutes of Health, Bethesda, MD.
The findings and conclusions in this report are those of the
author(s) and do not necessarily represent the views of the
funding agency.
Address correspondence to Anton C. Schoolwerth, MD,
MSHA, One Medical Center Drive, 2M, Lebanon, NH 03756.
E-mail: anton.c.schoolwerth@hitchcock.org
© 2005 by the National Kidney Foundation, Inc.
1548-5595/05/1204-0012$30.00/0
doi:10.1053/j.ackd.2005.07.012
Finally, there should be evidence that such
strategies are not yet in place. Here, we de-
scribe how chronic kidney disease (CKD)
meets these criteria.
With regard to the first criterion, there are
now more than 385,000 persons with end-
stage renal disease (ESRD) in the U.S. Milder
forms of CKD that do not yet require renal
replacement therapy are even more common
than ESRD. The total number of Americans
living with CKD is now estimated to be 19.2
million, representing 11% of the adult US pop-
ulation, which dwarfs the 0.22% of the popu-
lation with kidney failure.3 However, it is
from this large pool of early CKD individuals
that the ESRD population emanates.
The burden of CKD is growing, and this
growth can be appreciated by examining the
history of ESRD/kidney failure in the United
States. During the past 3 decades, the inci-
dence and prevalence of ESRD have risen
progressively. For example, annual new cases
of kidney failure increased from approxi-
mately 14,500 in 1978 to 100,500 in 2002,
whereas the total number of persons living
with kidney failure rose from 42,000 to
431,000, respectively.4 Over the 11-year period
from 1990 to 2001, the national prevalence of
ESRD rose 104%, an increase that occurred in
all 50 states and the District of Columbia.5
Estimates for 1993 to 1995 were that 2% of
white men, 1.7% of white women, 5.5% of
black men, and 6.3% of black women would
develop ESRD during their lifetime.6 Five

418 Advances in Chronic Kidney Disease, Vol 12, No 4 (October), 2005: pp 418-423
 A Public Health Action Plan For CKD
Table 1. Criteria for a Disease or Condition To
Be a Public Health Problem.
High disease burden
Affects many people
Has increased recently
Is likely to increase in future
Experienced in terms of mortality/morbidity,
quality of life, and cost
Perceived as a threat and out of control
Uneven distribution: affects minorities and
disadvantaged people disproportionately
Evidence that prevention strategies could reduce
burden
Evidence that prevention strategies not yet in
place
Data from1,2
years later, however, these estimates had in-
creased (to 2.5%, 1.8%, 7.3%, and 7.8%, respec-
tively).7 In terms of incidence, projections to
the year 2010 show an annual increase of 4.1%
in incident cases of ESRD,8 but recent data
from the US Renal Data System indicate the
rate of increase is lessening.4 By 2030, the
estimated annual number of persons with
new onset of kidney failure is expected to
exceed 450,000, and those living with kidney
failure are expected to number more than 2
million.9
CKD causes premature morbidity and mor-
tality and reduces quality of life, but treating it
is expensive. For those who have progressed
to ESRD, yearly death rates approximate
20%.4 CKD patients have a risk of cardiovas-
cular disease (CVD) that is 10 to 30 times that
of people without kidney disease10 –13; indeed,
the major cause of death in kidney patients is
CVD, which is much more likely than pro-
gression to kidney failure.10 Deaths of patients
with ESRD were estimated at 71,000 in 2000
and are expected to increase to 352,000 in
2030.9 Recently, using data from death certif-
icates, the Centers for Disease Control and
Prevention listed kidney disease as the ninth
leading cause of death in the United States.14
However, this statistic probably underesti-
mates the burden of kidney disease because
CKD patients have a greater likelihood of
dying from comorbidities of kidney disease
than of progressing to ESRD. In addition to
reducing the quantity of life, CKD reduces
substantially the quality of life. Despite this
419
large burden, CKD is often not recognized as
a serious health problem in the United States.
Recently, data from a large, diverse popu-
lation have shown that progressive decreases
in the glomerular filtration rate (GFR) were
associated with increased risks of death, car-
diovascular events, and hospitalization.11
These risks were independent of known risk
factors, a history of CVD, or the presence of
documented proteinuria. In comparison with
a GFR ⱖ60 mL/min/1.73 m2 of body surface
area, the risk of death was 80% higher at an
estimated GFR (in mL/min/1.73 m2) of 30 to
44 and nearly 600% higher with an estimated
GFR ⬍15.8 Against the same standard (ⱖ60
mL/min/1.73 m2), the risks of any cardiovas-
cular event and hospitalization were 2.0 and
1.5, respectively, at an estimated GFR of 30 to
44 and 3.4 and 3.1 at an estimated GFR of less
than 15.8
Treating kidney failure imposes a large eco-
nomic burden on patients, the health care
system, and society. Although persons with
kidney failure represent less than 1% of the
Medicare population (those with kidney fail-
ure, regardless of age, are eligible for Medi-
care funding), their care consumes 6.7% of the
health care expenditures by the Centers for
Medicare and Medicaid Services. In 2002, total
expenditures (Medicare plus private payers)
exceeded $25 billion, of which approximately
two thirds was provided by Medicare.4 Even
so, the health care resources used in toto for
CKD patients (without ESRD) actually exceed
those used by the ESRD population; recent
data from a large Health Maintenance Orga-
nization and from the United States Renal
Data System indicate that the ratio is 1.6 to 2.4
(or higher) to 1.15,16 The fact that now 1 in 9
Americans are estimated to have CKD and
another 20 million are at risk for developing
CKD has resulted in the sense of fear among
some of the general public that the disease is
“out of control.”
CKD clearly meets the second criterion for
a public health problem (uneven distribution)
because it disproportionately affects racial
and ethnic minorities, among whom worse
outcomes and higher costs of treatment are
common. African Americans and Native
Americans are at especially increased risk.
Elsewhere, international data suggest that
420 Schoolwerth, Engelgau, and Hostetter
CKD is a worldwide public health problem.17
Age alone is a key predictor of CKD, and 11%
of persons aged 65 years or over who do not
have diabetes or hypertension have moder-
ately to severely decreased kidney function.3
As for kidney failure specifically, diabetes is
currently the most common cause, accounting
for nearly one half of new cases of ESRD, and,
by 2006, it is expected to surpass all other
causes of new cases combined (hypertension,
glomerulonephritis, others).9
The third and fourth criteria for classifica-
tion as a public health problem (Table 1) are
also met by CKD: preventive strategies could
reduce its burden, and there is evidence that
such strategies are not yet in place.17,18 The
burden that CKD imposes is tremendous, but
there is good news—we have the requisite
knowledge to prevent or at least delay the
disease’s onset, progression, and comorbidi-
ties. “Upstream” preventive strategies are not
yet in place, but, if implemented effectively,
they could reduce the burden of CKD.
The Potential for Prevention Exists
There are many reasons to believe that the
burden of CKD can be reduced substantially.
One key will be the early identification of
those who are at risk; there is evidence that
the disease can be detected in its early stages
and that adverse outcomes can be prevented
or delayed.17
Clinical diagnosis of CKD has become sim-
plified. The most sensitive test for early CKD
is urine albumin. At its earliest stage of low-
grade albumin leakage, the term microalbu-
minuria is applied. Current recommendations
call for testing annually in people with diabe-
tes.17,19,20 The simplification in this approach
has been the recognition that a spot or un-
timed urine collection with assay of albumin
and creatinine concentrations allows their ra-
tio to be calculated. This ratio can supplant the
more cumbersome timed collection. Although
urine testing for risk groups other than diabe-
tes has not been so codified, testing for pro-
teinuria, at least with simple dipstick meth-
ods, has been calculated to be cost effective in
hypertensive people.21 Also, the GFR can be
reasonably accurately estimated simply from
the serum creatinine using an equation vali-
dated in a large number of subjects with CKD
in combination with the variables of age, sex,
and race.17 Thus, timed urine collections are
now rarely needed to detect CKD; rather a
single determination of serum creatinine and
spot urine sample for an albumin to creatinine
ratio suffices.
At present, preventive care practices18 in-
clude maintaining stringent blood pressure
control to a target of 130/80 mm Hg, using
angiotensin-converting enzyme inhibitors
(ACEIs) and angiotensin II receptor blockers
in both diabetic and nondiabetic nephropa-
thies, maintaining careful glycemic control in
those with diabetes, and following a low-pro-
tein diet.22–28 Treatment with ACEIs can be
effective at all levels of kidney dysfunction,
even if started late in the course of disease.29
Additional reports indicate that treating dys-
lipidemia,30 losing weight,31 quitting smok-
ing,32 and managing anemia33,34 may also
help delay progression of early CKD.
The benefits of treating early kidney dis-
ease may extend beyond the kidney itself.
Indeed, a recent publication indicated that in
the general population the presence of albu-
minuria (a key indicator of kidney disease)
predicted both cardiovascular and noncardio-
vascular mortality.35 In many cases, mi-
croalbuminuria is simply the renal manifesta-
tion of a generalized abnormality of vascular
function.36 A recent report showed that treat-
ment with fosinopril (an ACEI) of individuals
who were identified from screening as having
microalbuminuria led to a reduction in both
albuminuria and in cardiovascular events,37
the latter being the major cause of death in
patients with chronic kidney disease, as noted
earlier.13
Several studies have shown the potential
for preventing or delaying the initial onset of
diabetic kidney disease18; this is often done by
treating patients who have diabetes with
ACEIs, which prevents the development of
microalbuminuria (early diabetes-related kid-
ney disease).38,39 Early in diabetes, patients
may have heightened kidney function, which
manifests itself as glomerular hyperfiltration.
Such a state may precede the development of
microalbuminuria and the subsequent decline
in GFR in diabetes.40 – 42
Unfortunately, at the present time, many
 A Public Health Action Plan For CKD
patients with CKD still receive suboptimal
care.43– 45 The problem is both underdiag-
nosed and undertreated. The reasons for this
are likely complex. Screening with quantita-
tive urinary albumin measurements is under-
used in patients with diabetes. Also, the usual
clinical index of kidney function, the serum
creatinine concentration, is often poorly inter-
preted by clinicians. In addition, people at risk
because of diabetes or hypertension are often
unaware that CKD can be caused by these
conditions.17,46
A Public Health Approach for CKD
CKD is not being detected early enough to
initiate treatment regimens and reduce death
and disability.46 In addition, many interven-
tions are not being delivered early enough in
the disease process to improve outcomes. Fi-
nally, most individuals with CKD are un-
aware that they have this disorder.17,46,47
Thus, the issue of CKD extends beyond a
clinical problem, addressed only by health
care providers, to a major public health issue
requiring multilevel efforts. Initiatives should
be undertaken to make health care providers,
policy makers, and the general population
more aware of the seriousness of CKD, its risk
factors, and opportunities for early detection
through screening. Persons identified with
CKD should be provided appropriate educa-
tional materials to explain the treatment regi-
mens and benefits of undertaking therapy. We
must work with health care delivery organi-
zations to ensure access to high-quality care at
a population-based level, and we need data
and information systems for health care policy
makers to make informed decisions that will
effectively address CKD.
The United States Renal Data System col-
lects, analyzes, and distributes information on
ESRD patients.4 However, at present, there is
no data surveillance system for tracking pa-
tients with CKD in stages before dialysis or
transplantation, unless they are 65 years or
more and covered by Medicare (and thus can
be tracked by the Centers for Medicare and
Medicaid Services). The Centers for Disease
Control and Prevention has national surveil-
lance systems in place for many chronic dis-
eases (eg, diabetes), but its data are scant for
421
CKD. Clearly, to get a better understanding of
the nature and extent of the CKD burden and
to inform policy decisions, national surveil-
lance data on this disorder need to be made
available.
Additional public health efforts to address
CKD are sorely needed, but some important
first steps have already occurred. These have
included publication of the NKF K/DOQI
Clinical Practice Guidelines on Chronic Kid-
ney Disease, a meeting of interested stake-
holders to assess priorities48 and the establish-
ment of the National Kidney Disease
Education Program (NKDEP).49 Sponsored by
the National Institute of Diabetes and Diges-
tive and Kidney Diseases, NKDEP was cre-
ated to reduce the morbidity and mortality
caused by kidney disease and its complica-
tions. Through public education and system-
level initiatives such as the improvement in
laboratory reporting of kidney function, the
NKDEP aims to raise awareness that kidney
disease is serious, that it is important to test
those at risk, and that treatment is available to
prevent or slow progression of the disease.49
Addressing CKD effectively will require
multiple initiatives. A comprehensive effort
will include not only patient and professional
education but also the education of payers
(Medicare, Medicaid, the health insurance in-
dustry) on the seriousness and costs of CKD
and opportunities for prevention. In addition,
the involvement or cooperation of business,
members of the community, and government
will be required; national, state, and local in-
itiatives will all be needed. More surveillance
and research efforts will be needed to measure
and track the CKD burden, identify popula-
tions at risk, and to target program efforts.
Conclusion
The burden of chronic CKD, as measured by
human suffering and economic costs, is ex-
ploding as we move through the early years of
the 21st century, making it a major public
health problem. Currently, we have the tools
to prevent or delay the onset of CKD and to
limit its progression where it has already
struck. Unfortunately, the extent to which we
have applied these tools is suboptimal. A
comprehensive public health approach will be
422 Schoolwerth, Engelgau, and Hostetter
needed to effectively address this major pub-
lic health problem.
References
1. Vinicor F: Is diabetes a public-health disorder? Dia-
betes Care 17:22-27, 1994 (suppl 1)
2. Saadine JB: Vision loss: A public health problem?
Ophthalmology 110:253-254, 2003
3. Coresh J, Astor BC, Greene T, et al: Prevalence of
chronic kidney disease and decreased kidney func-
tion in the adult US population: Third National
Health and Nutrition Examination Survey. Am J Kid-
ney Dis 41:1-12, 2003
4. US Renal Data System: USRDS 2002, 2003 and 2004
annual data reports. Atlas of end-stage renal disease
in the United States. Bethesda (MD): National Insti-
tutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases, 2002, 2003, 2004
5. Pirtle CJ, Schoolwerth AC, Giles WH, Brown DW,
Mokdad AH, Ford ES. State-specific trends in chronic
kidney disease-United States, 1990-2001. MMWR
Morb Mortal Wkly Rep 53:918-920, 2004
6. Merrill RM, Kessler LG, Udler JM, et al: Comparison
of risk estimates for selected diseases and causes of
death. Prev Med 28:179-193, 1999
7. Kiberd BA, Clase CM: Cumulative risk for developing
end-stage renal disease in the US population. J Am
Soc Nephrol 13:1635-1644, 2002
8. Xue, JL, Ma JZ, Louis TA, et al: Forecast of the number
of patients with end-stage renal disease in the United
States to the year 2010. J Am Soc Nephrol 12:2753-
2758, 2001
9. Gilbertson D, Solid C, Xue JL, et al: Projecting the US
ESRD population by 2030. US Renal Data System:
Data presented at the 2003 American Society of Ne-
phrology Annual Meeting, San Diego, CA. Available
at: http://www.usrds.org/presentations_2003.htm.
Accessed August 10, 2005
10. Anavekar NS, McMurray JJV, Velazquez EJ, et al:
Relation between renal dysfunction and cardiovascu-
lar outcomes after myocardial infarction. N Engl
J Med 351:1285-1295, 2004
11. Go AS, Chertow GM, Fan D, et al: Chronic kidney
disease and risks of death, cardiovascular events, and
hospitalization. N Engl J Med 351:1296-1305, 2004
12. Menon V, Sarnak MJ: The epidemiology of chronic
kidney disease stages 1 to 4 and cardiovascular dis-
ease: A high-risk combination. Am J Kidney Dis 45:
223-232, 2005
13. Sarnak MJ, Levey AS, Schoolwerth AC, et al: Kidney
disease as a risk factor for development of cardiovas-
cular disease: A statement from the councils on kid-
ney in cardiovascular disease, high blood pressure
research, clinical cardiology and epidemiology and
prevention. Circulation 108:2154-2169, 2003
14. Mokdad AH, Marks JS, Stroup DF, et al: Actual
causes of death in the United States, 2000. JAMA
291:1238-1245, 2004
15. Hunsicker LG: The consequences and costs of chronic
kidney disease. J Am Soc Nephrol 15:1363-1364, 2004
16. Smith DH, Gullion CM, Nichols G, et al: Cost of
medical care from chronic kidney disease and comor-
bidity among enrollees in a large HMO population.
J Am Soc Nephrol 15:1300-1306, 2004
17. National Kidney Foundation: K/DOQI clinical prac-
tice guidelines for chronic kidney disease: Evaluation,
classification and stratification. Am J Kidney Dis 39:
S1-S266, 2002 (suppl 1)
18. de Jong PE, Brenner BM: From secondary to primary
prevention of progressive renal disease: The case for
screening for albuminuria. Kidney Int 66:2109-2118,
2004
19. American Diabetes Association: Nephropathy in dia-
betes. Diabetes Care 27:S79-S83, 2004 (suppl 1)
20. Eknoyan G, Hostetter T, Bakris GL, et al: Proteinuria
and other markers of chronic kidney disease: A posi-
tion statement of the National Kidney Foundation
(NKF) and the National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK). Am J Kid-
ney Dis 42:617-22, 2003
21. Boulware LE, Jaar BG, Tarver-Carr ME, et al: Screen-
ing for proteinuria in US adults: A cost-effectiveness
analysis. JAMA 290:3101-3114, 2003
22. Parving HH, Andersen AR, Smidt UM, et al: Early
aggressive antihypertensive treatment reduces the
rate of decline in kidney function in diabetic nephrop-
athy. Lancet 1:1175-1179, 1983
23. Lewis EJ, Hunsicker LG, Bain RP, et al: The effect of
angiotensin converting enzyme inhibition on diabetic
nephropathy. N Engl J Med 329:1456-1462, 1993
24. Maschio G, Alberti D, Janin G, et al: Effect of angio-
tensin converting enzyme inhibitor benazepril on the
progression of chronic renal insufficiency. N Engl
J Med 334:939-945, 1996
25. The Gruppo Italiano di Studi Epidemiologici in
Nephrologia (GISEN) Group: Randomised placebo-
controlled trial of effect of ramipril on decline in
glomerular filtration rate and risk of terminal renal
failure in proteinuric non-diabetic nephropathy. Lan-
cet 349:1857-1863, 1997
26. Brenner BM, Cooper ME, de Zeeuw D, et al: Effects of
losartan on renal and cardiovascular outcomes in
patients with type 2 diabetes and nephropathy.
N Engl J Med 345:861-869, 2001
27. Lewis EJ, Hunsicker LG, Clarke WR, et al: Renopro-
tective effects of the angiotensin-receptor antagonist
irbesartan in patients with nephropathy due to type 2
diabetes. N Engl J Med 345:851-860, 2001
28. Pedrini MT, Levey AS, Lau J, et al: The effect of
dietary protein restriction on the progression of dia-
betic and non-diabetic renal diseases: A meta-analy-
sis. Ann Intern Med 124:627-632, 1996
29. Ruggenenti P, Perna A, Remuzzi G: ACE inhibitors to
prevent end-stage renal disease: When to start and
why possibly never to stop: a post hoc analysis of the
REIN Trial results. J Am Soc Nephrol 12:2832-2837,
2001
30. Bianchi S, Bigazzi R, Caiazza A, et al: A controlled
prospective study of the effects of atorvastatin on
proteinuria and progression of kidney disease. Am J
Kidney Dis 41:565-570, 2003
31. Morales E, Valero A, Léon M, et al: Beneficial effects
 A Public Health Action Plan For CKD
of weight loss in overweight patients with chronic
proteinuric nephropathies. Am J Kidney Dis 41:319-
327, 2001
32. Schiffl H, Lang SM, Fischer R: Stopping smoking
slows accelerated progression of renal failure in pri-
mary renal disease. J Nephrol 15:270-274, 2002
33. Xue JL, St. Peter WL, Ebben JP, et al: Anemia treat-
ment in the pre-ESRD period and associated mortality
in elderly patients. Am J Kidney Dis 40:1153-1161,
2002
34. Gouva C, Nikolopoulos P, Ioannidis JP, et al: Treating
anemia early in renal failure patients slows the de-
cline of renal function: A randomized controlled trial.
Kidney Int 66:753-760, 2004
35. Hillege HL, Fidler V, Diercks GF, et al: Urinary albu-
min excretion predicts cardiovascular and noncardio-
vascular mortality in general population. Circulation
106:1777-1782, 2002
36. Jensen JS, Borch-Johnsen K, Jensen G, et al: Mi-
croalbuminuria reflects a generalized transvascular
albumin leakiness in clinically health subjects. Clin Sci
(Colch) 88:629-633, 1995
37. Asselbergs FW, Diercks GFH, Hillege HL, et al: Ef-
fects of fosinopril and pravastatin on cardiovascular
events in subjects with microalbuminuria. Circulation
110:2809-2816, 2004
38. Mathiesen ER, Hommel E, Hansen HP, et al: Random-
ized-control trial of long-term efficacy of captopril on
preservation of kidney function in normotensive pa-
tients with insulin-dependent diabetes and mi-
croalbuminuria. BMJ 23:1478-1485, 1999
39. Lacourciere Y, Belanger A, Godin C, et al: Long-term
comparison of losartan and enalapril on kidney func-
tion in hypertensive type 2 diabetics with early ne-
phropathy. Kidney Int 58:762-769, 2000
40. Mogensen CE: Prediction of clinical diabetic nephrop-
423
athy in IDDM patients. Alternatives to microalbumin-
uria. Diabetes 39:761-767, 1990
41. Nelson RG, Bennet PH, Beck GJ, et al: Development
and progression of renal disease in Pima Indians with
non-insulin-dependent diabetes mellitus. N Engl
J Med 335:1636-1642, 1996
42. Pinto-Sietsma SJ, Janssen WMT, Hillege HL, et al:
Urinary albumin excretion is associated with renal
functional abnormalities in a non-diabetic population.
J Am Soc Nephrol 11:1882-1888, 2000
43. McClellan WM, Knight DF, Karp H, et al: Early de-
tection and treatment of renal disease in hospitalized
diabetic and hypertensive patients: important differ-
ences between practice and published guidelines.
Am J Kidney Dis 29:368-375, 1997
44. Obrador GT, Ruthazer R, Arora P, et al: Prevalence of
and factors associated with suboptimal care before
initiation of dialysis in the United States. J Am Soc
Nephrol 10:1793-1800, 1999
45. Nissenson AR, Collins AJ, Hurley J, et al: Opportuni-
ties for improving the care of patients with chronic
renal insufficiency: Current practice patterns. J Am
Soc Nephrol 12:1713-1720, 2001
46. Coresh J, Byrd-Holt D, Astor BC, et al: Chronic kidney
disease awareness, prevalence, and trends among US
adults, 1999 to 2000. J Am Soc Nephrol 16:180-188, 2005
47. Levey AS, Coresh J, Balk E, et al: National Kidney
Foundation practice guidelines for chronic kidney
disease: Evaluation, classification, and stratification.
Ann Intern Med 139:137-147, 2003
48. Parker TF, Blantz R, Hostetter T, et al, and Council of
American Kidney Societies: The chronic kidney dis-
ease initiative. J Am Soc Nephrol 15:708-716, 2004
49. Hostetter TH, Lising M: National Kidney Disease
Education Program. J Am Soc Nephrol 14:S114-S116,
2003 (suppl 2)