World Kidney Day 2011: Protect Your Kidneys, Save Your Heart

Abstract

March 10, 2011, will mark the celebration of the sixth World Kidney Day, an annual event jointly sponsored by the International Society of Nephrology and the International Federation of Kidney Foundations. Since its inception in 2006, World Kidney Day has grown dramatically to become the most widely celebrated event associated with kidney disease in the world and the most successful effort to raise awareness among both the general public and government health officials about the dangers of kidney disease, especially CKD. In 2011, World Kidney Day draws attention to the large, and often unappreciated, role played by reduced kidney function in increasing premature cardiovascular disease (CVD), which is the most common cause of morbidity and mortality worldwide.1World Health Organization. 2008-2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Available at: http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf. Accessed December 27, 2010.Google Scholar Can a focus on early detection and prevention of kidney disease really improve long-term cardiovascular health? In this editorial, we hope to convey the message that increased attention to the kidneys can indeed improve long-term health outcomes by reducing both kidney and CVD and should therefore be a central component of any global health strategy intended to reduce the enormous and growing burden of chronic noncommunicable diseases. CVD is the most common of the chronic noncommunicable diseases that affect global mortality. About 30% of all deaths occurring worldwide and 10% of all the healthy life that is lost to disease are accounted by CVD alone.1World Health Organization. 2008-2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Available at: http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf. Accessed December 27, 2010.Google Scholar Although there has been some decline in mortality because of CVD in developed countries, no such decline has been reported in developing countries, socially disadvantaged minority populations, or people with accompanying CKD.2Anderson G.F. Chu E. Expanding priorities—confronting chronic disease in countries with low income.N Engl J Med. 2007; 356: 209-211Crossref PubMed Scopus (150) Google Scholar, 3Narayan K.M. Ali M.K. Koplan J.P. Global noncommunicable diseases—where worlds meet.N Engl J Med. 2010; 363: 1196-1198Crossref PubMed Scopus (217) Google Scholar The presence of CKD significantly increases the risk of a cardiovascular event in individuals with diabetes and with hypertension.4Bakris G.L. Ritz E. World Kidney Day 2009: hypertension and kidney disease is a marriage that should be prevented.Am J Kidney Dis. 2009; 53: 373-376Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Atkins R.C. Zimmet P. World Kidney Day 2010: diabetic kidney disease—act now or pay later.Am J Kidney Dis. 2010; 55: 205-208Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar However, less well appreciated is the fact that CKD itself is a strong risk factor for CVD, independent of diabetes, hypertension, or other conventional CVD risk factors.6Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8722) Google Scholar, 7Tonelli M. Wiebe N. Culleton B. et al.Chronic kidney disease and mortality risk: a systematic review.J Am Soc Nephrol. 2006; 17: 2034-2047Crossref PubMed Scopus (1167) Google Scholar This is especially true when an increase in proteinuria, a major target of any CKD screening program, is present.6Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8722) Google Scholar, 7Tonelli M. Wiebe N. Culleton B. et al.Chronic kidney disease and mortality risk: a systematic review.J Am Soc Nephrol. 2006; 17: 2034-2047Crossref PubMed Scopus (1167) Google Scholar, 8Hillege H.L. Fidler V. Diercks G.F. et al.PREVEND Study GroupUrinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population.Circulation. 2002; 106: 1777-1782Crossref PubMed Scopus (1318) Google Scholar, 9Klausen K. Borch-Johnsen K. Feldt-Rasmussen B. et al.Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes.Circulation. 2004; 110: 32-35Crossref PubMed Scopus (563) Google Scholar A 20- to 30-fold increase in CVD in patients with ESRD has long been recognized, but the increased risk for CVD associated with lesser degrees of reduction in kidney function was definitively demonstrated only in 2004. Go and colleagues reported an independent and graded association between glomerular filtration rate (GFR) and risk of death, cardiovascular events, and hospitalizations in a community-based study of >1.1 million individuals.6Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8722) Google Scholar Is this dramatic increase in CVD risk associated with CKD really because of decreased kidney function or does it just reflect the coexistent diabetes or hypertension that are present in most of these patients? The independent effect of CKD has been well-documented in many studies,7Tonelli M. Wiebe N. Culleton B. et al.Chronic kidney disease and mortality risk: a systematic review.J Am Soc Nephrol. 2006; 17: 2034-2047Crossref PubMed Scopus (1167) Google Scholar with one study in a high-risk population showing that the risk of cardiac death is increased by 46% in those with a GFR between 60 and 90 mL/min and by 131% in those with GFR between 30 and 60 mL/min, independent of traditional CVD risk factors, including diabetes and hypertension.10van Domburg R.T. Hoeks S.E. Welten G.M. Chonchol M. Elhendy A. Poldermans D. Renal insufficiency and mortality in patients with known or suspected coronary artery disease.J Am Soc Neph. 2008; 19: 158-163Crossref PubMed Scopus (66) Google Scholar The increased risk for cardiovascular events and mortality in people aged >55 years with CKD alone is equivalent, or even higher, to that seen in patients with diabetes or previous myocardial infarcts.11Rashidi A. Sehgal A.R. Rahman M. O’Connor A.S. The case for chronic kidney disease, diabetes mellitus, and myocardial infarction being equivalent risk factors for cardiovascular mortality in patients older than 65 years.Am J Cardiol. 2008; 102: 1668-1673Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Both general6Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8722) Google Scholar, 12McCullough P.A. Li S. Jurkovitz C.T. et al.Kidney Early Evaluation Program InvestigatorsCKD and cardiovascular disease in screened high-risk volunteer and general populations: the Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004.Am J Kidney Dis. 2008; 51: S38-S45Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar and high-risk populations13McCullough P.A. Jurkovitz C.T. Pergola P.E. et al.Kidney Early Evaluation Program InvestigatorsIndependent components of chronic kidney disease as a cardiovascular risk state: results from the Kidney Early Evaluation Program (KEEP).Arch Intern Med. 2007; 167: 1122-1129Crossref PubMed Scopus (206) Google Scholar, 14McCullough P.A. Li S. Jurkovitz C.T. et al.Kidney Early Evaluation Program InvestigatorsChronic kidney disease: prevalence of premature cardiovascular disease and relationship to short-term mortality.Am Heart J. 2008; 156: 277-283Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar exhibit an increased risk of CVD with CKD. This increased risk for CVD is not confined to the elderly people—in volunteers with an average age of 45 years, the risk for myocardial infarct, stroke, and all-cause mortality was doubled in those with CKD.14McCullough P.A. Li S. Jurkovitz C.T. et al.Kidney Early Evaluation Program InvestigatorsChronic kidney disease: prevalence of premature cardiovascular disease and relationship to short-term mortality.Am Heart J. 2008; 156: 277-283Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar In considering the value of recommending screening for CKD in addition to conventional CVD risk factors in selected individuals, data showing that the risk of CVD is better correlated with proteinuria (albuminuria) as compared with GFR alone are particularly relevant because proteinuria is virtually always a marker of kidney disease and is not a conventional CVD risk factor.6Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8722) Google Scholar, 8Hillege H.L. Fidler V. Diercks G.F. et al.PREVEND Study GroupUrinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population.Circulation. 2002; 106: 1777-1782Crossref PubMed Scopus (1318) Google Scholar, 9Klausen K. Borch-Johnsen K. Feldt-Rasmussen B. et al.Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes.Circulation. 2004; 110: 32-35Crossref PubMed Scopus (563) Google Scholar, 15Astor B.C. Hallan S.I. Miller III, E.R. Yeung E. Coresh J. Glomerular filtration rate, albuminuria, and risk of cardiovascular and all-cause mortality in the US population.Am J Epidemiol. 2008; 167: 1226-1233Crossref PubMed Scopus (267) Google Scholar With regard to proteinuria as a predictor of subsequent CVD events, the Prevention of Renal and Vascular End-stage Disease study showed a direct linear relationship between albuminuria and risk of cardiovascular death in the general population even at levels of albumin excretion generally considered within the “normal” range (15-29 mg/d); this risk was increased more than 6-fold when albumin excretion exceeded 300 mg/d.8Hillege H.L. Fidler V. Diercks G.F. et al.PREVEND Study GroupUrinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population.Circulation. 2002; 106: 1777-1782Crossref PubMed Scopus (1318) Google Scholar Recent data from the US National Health and Nutrition Examination Survey database as well as from Japan also document an independent effect of albuminuria on risk of both CVD and all-cause mortality at all levels of GFR.15Astor B.C. Hallan S.I. Miller III, E.R. Yeung E. Coresh J. Glomerular filtration rate, albuminuria, and risk of cardiovascular and all-cause mortality in the US population.Am J Epidemiol. 2008; 167: 1226-1233Crossref PubMed Scopus (267) Google Scholar, 16Irie F. Iso H. Sairenchi T. et al.The relationships of proteinuria, serum creatinine, glomerular filtration rate with cardiovascular disease mortality in Japanese general population.Kidney Int. 2006; 69: 1264-1271Crossref PubMed Scopus (279) Google Scholar In patients with heart failure but without diabetes or hypertension, increased urinary albumin predicts both cardiovascular and all-cause mortality independent of reduced GFR.17Jackson C.E. Solomon S.D. Gerstein H.C. et al.CHARM Investigators and CommitteesAlbuminuria in chronic heart failure: prevalence and prognostic importance.Lancet. 2009; 374: 543-550Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar Similar results are obtained by studying patients with coronary disease or previous myocardial infarcts in whom proteinuria conferred a greater risk of mortality than reduced GFR, although both adversely influenced outcomes.18Tonelli M. Jose P. Curhan G. Sacks F. Braunwald E. Pfeffer M. Cholesterol and Recurrent Events (CARE) Trial InvestigatorsProteinuria, impaired kidney function, and adverse outcomes in people with coronary disease: analysis of a previously conducted randomized trial.Br Med J. 2006; 332: 1426Crossref PubMed Scopus (168) Google Scholar Of interest, not only the likelihood but also the time to development of a cardiovascular event is accelerated substantially by the presence of proteinuria at all levels of GFR.19Matsushita K. Selvin E. Bash L.D. Franceschini N. Astor B.C. Coresh J. Change in estimated GFR associates with coronary heart disease and mortality.J Am Soc Nephrol. 2009; 20: 2617-2624Crossref PubMed Scopus (204) Google Scholar In individuals without diabetes, with normal serum creatinine levels undergoing percutaneous coronary interventions, about 78% have demonstrable CKD when screened more stringently for estimated GFR and urine protein.20Malyszko J. Bachorzewska-Gajewska H. Malyszko J.S. et al.Prevalence of chronic kidney disease in elderly patients with normal serum creatinine levels undergoing percutaneous coronary interventions.Gerontology. 2010; 56: 51-54Crossref PubMed Scopus (32) Google Scholar Not only is the presence of CKD a likely factor in accelerating development of coronary disease in these patients, but it has also been associated with an increase in other risks including hemorrhagic complications, contrast nephropathy, restenosis, and death.10van Domburg R.T. Hoeks S.E. Welten G.M. Chonchol M. Elhendy A. Poldermans D. Renal insufficiency and mortality in patients with known or suspected coronary artery disease.J Am Soc Neph. 2008; 19: 158-163Crossref PubMed Scopus (66) Google Scholar Thus, multiple studies now confirm that proteinuria is a graded risk factor for CVD and is independent of GFR, hypertension, and diabetes, and that this risk extends down into ranges of albumin excretion which is generally considered to be normal.21Hemmelgarn B.R. Manns B.J. Lloyd A. et al.Alberta Kidney Disease NetworkRelation between kidney function, proteinuria, and adverse outcomes.JAMA. 2010; 303: 423-429Crossref PubMed Scopus (789) Google Scholar, 22Gansevoort R.T. de Jong P.E. The case for using albuminuria in staging chronic kidney disease.J Am Soc Nephrol. 2009; 20: 465-468Crossref PubMed Scopus (87) Google Scholar Moreover, this increased cardiovascular risk has been well demonstrated in several studies in which urine dipsticks were used to screen for increased protein excretion.6Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8722) Google Scholar, 18Tonelli M. Jose P. Curhan G. Sacks F. Braunwald E. Pfeffer M. Cholesterol and Recurrent Events (CARE) Trial InvestigatorsProteinuria, impaired kidney function, and adverse outcomes in people with coronary disease: analysis of a previously conducted randomized trial.Br Med J. 2006; 332: 1426Crossref PubMed Scopus (168) Google Scholar, 23Chronic Kidney Disease Prognosis ConsortiumAssociation of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis.Lancet. 2010; 375: 2073-2081Abstract Full Text Full Text PDF PubMed Scopus (2681) Google Scholar Although there has been concern that CKD diagnosed by reduced GFR alone identifies predominately older adults at increased risk because of age alone,24Abdelhafiz A.H. Brown S.H. Bello A. El Nahas M. Chronic kidney disease in older people: physiology, pathology or both?.Nephron Clin Pract. 2010; 116: 19-24Crossref Scopus (66) Google Scholar the connection between proteinuria as an independent risk factor for cardiovascular mortality has been confirmed by meta-analysis of 22 separate, general population, cohort studies, and in both older (>65) and younger people of several nationalities and racial groups.23Chronic Kidney Disease Prognosis ConsortiumAssociation of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis.Lancet. 2010; 375: 2073-2081Abstract Full Text Full Text PDF PubMed Scopus (2681) Google Scholar The final and most important point is that from a clinical perspective, there are provocative data which suggest that kidney-targeted interventions designed to reduce proteinuria and slow progression of CKD can also reduce CVD risk. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers are of documented benefit in slowing the progression of established CKD in patients with and without diabetes.25Brenner B.M. Cooper M.E. 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. 2001; 345: 861-869Crossref PubMed Scopus (6036) Google Scholar, 26Ruggenenti P. Perna A. Gherardi G. et al.Renoprotective properties of ACE-inhibition in non-diabetic nephropathies with non-nephrotic proteinuria.Lancet. 1999; 354: 359-364Abstract Full Text Full Text PDF PubMed Scopus (763) Google Scholar, 27Ruggenenti P. Perna A. Gherardi G. et al.Ramipril Efficacy in Nephropathy. Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial.Lancet. 1998; 352: 1252-1256Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar, 28GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia)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.Lancet. 1997; 349: 1857-1863Abstract Full Text Full Text PDF PubMed Scopus (1730) Google Scholar, 29ESCAPE Trial GroupStrict blood pressure control and progression of renal failure in children.New Engl J Med. 2009; 361: 1639-1650Crossref PubMed Scopus (629) Google Scholar Of interest related to slowing progression, the incidence of CVD in CKD is significantly higher, with more rapid loss of GFR independent of other risk factors, suggesting that interventions that slow progression may also reduce CVD.19Matsushita K. Selvin E. Bash L.D. Franceschini N. Astor B.C. Coresh J. Change in estimated GFR associates with coronary heart disease and mortality.J Am Soc Nephrol. 2009; 20: 2617-2624Crossref PubMed Scopus (204) Google Scholar Prevention of Renal and Vascular Endstage Disease Intervention Trial reported a 40% (but not significant) reduction in cardiovascular events over 4 years in patients screened from a general population with no risk factors except increased albumin in the urine who were treated with angiotensin-converting enzyme inhibitor therapy.30Asselbergs F.W. Diercks G.F. Hillege H.L. et al.Prevention of Renal and Vascular Endstage Disease Intervention Trial (PREVEND IT) InvestigatorsEffects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria.Circulation. 2004; 110: 2809-2816Crossref PubMed Scopus (470) Google Scholar In this pilot study, this effect was most notable in people with albumin excretion rates of >50 mg/d; furthermore, a post hoc cost-effectiveness analysis noted that the intervention is likely cost effective in that population.31Atthobari J. Asselbergs F.W. Boersma C. et al.Prevention of Renal and Vascular Endstage Disease Intervention Trial (PREVEND IT) Study GroupCost-effectiveness of screening for albuminuria with subsequent fosinopril treatment to prevent cardiovascular events: a pharmacoeconomic analysis linked to the prevention of renal and vascular endstage disease (PREVEND) study and the prevention of renal and vascular endstage disease intervention trial (PREVEND IT).Clin Ther. 2006; 28: 432-444Abstract Full Text PDF PubMed Scopus (116) Google Scholar In the Reduction in End Points in Non–Insulin-Dependent Diabetes Mellitus With the Angiotensin II Antagonist Losartan study, cardiovascular end points were significantly reduced in direct proportion to the reduction of albuminuria with angiotensin-converting enzyme inhibitor therapy in individuals with type 2 diabetes, and albuminuria proved to be the only predictor of cardiovascular outcome.32Eijkelkamp W.B. Zhang Z. Remuzzi G. et al.Albuminuria is a target for renoprotective therapy independent from blood pressure in type II diabetic patients with nephropathy. Post hoc analysis from the Reduction in End Points in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial.J Am Soc Nephrol. 2007; 18: 1540-1546Crossref PubMed Scopus (275) Google Scholar The potential benefit of kidney-targeted therapies has recently been highlighted by observations that higher doses of renin–angiotensin system blockers than required for blood pressure control alone can further reduce proteinuria independent of effects on blood pressure or GFR, and that addition of salt restriction or diuretics, both very inexpensive interventions, can further enhance the proteinuria-reducing effect of renin–angiotensin system blockade.33Muirhead N. Rene de Cotret P. Chiu A. Pichette V. Tobe S. Smart (Supra Maximal Atacand Renal Trial) InvestigatorsSupramaximal dose of candesartan in proteinuric renal disease.J Am Soc Nephrol. 2009; 20: 893-900Crossref PubMed Scopus (141) Google Scholar, 34Vogt L. Waanders F. Boomsma F. de Zeeuw D. Navis G. Effects of dietary sodium and hydrochlorothiazide on the antiproteinuric efficacy of losartan.J Am Soc Nephrol. 2008; 19: 999-1007Crossref PubMed Scopus (285) Google Scholar Data are not yet available to establish that screening for CKD and subsequent interventions will reduce cardiovascular mortality and be cost effective in younger people (<55).35Fried L. Are we ready to screen the general population for microalbuminuria?.J Am Soc Nephrol. 2009; 20: 686-688Crossref PubMed Scopus (29) Google Scholar However, it is now known that albuminuria is a better predictor of renal and cardiovascular events than blood pressure alone, that reducing proteinuria is more protective of the heart and kidney than lowering blood pressure alone, and that identification of CKD may improve cardiovascular outcomes. As celebrations of the sixth World Kidney Day approach on March 10, 2011, it is noteworthy that prior to the past decade, kidney disease was seen by most government and public health authorities as largely confined to patients with ESRD, thankfully a rare condition because the enormous cost of renal replacement therapy disproportionately consumes scarce healthcare resources and is well beyond the means of countries inhabited by >80% of the world’s population.36El Nahas M. The global challenge of chronic kidney disease (Nephrology Forum).Kidney Int. 2005; 68: 2918-2929Crossref PubMed Scopus (133) Google Scholar, 37Barsoum R.S. Chronic kidney disease in the developing world.N Engl J Med. 2006; 354: 997-999Crossref PubMed Scopus (352) Google Scholar Much has changed. We now appreciate that kidney disease is not rare—some 10% of the population has evidence of kidney disease. And we know these individuals are not of concern just because a few will progress to ESRD, but more because they carry a greatly enhanced risk of premature death from CVD, the single largest and most expensive healthcare threat we confront at a global level.1World Health Organization. 2008-2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Available at: http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf. Accessed December 27, 2010.Google Scholar Just as progress is being made in treating most of the traditional cardiovascular risk factors, CKD has emerged as yet another risk factor that causes substantial vascular toxicity independently. Fortunately, there is good news. Biomarkers of CKD (proteinuria, estimated GFR) are easy and relatively inexpensive to measure, and one of these, proteinuria, emerges early in the evolution of generalized vascular disease. Thus, kidney-targeted detection and prevention programs seem to offer a valuable opportunity to institute early preventive measures that go beyond traditional cardioprotective approaches. There is now compelling evidence that including selective screening for CKD in global health programs designed primarily to reduce CVD will significantly improve the outcomes of not only kidney disease, but especially the noncommunicable diseases like diabetes and CVD that dominate future healthcare strategies. Road maps for accomplishing this have already been presented for both developed38Levey A.S. Schoolwerth A.C. Burrows N.R. et al.Comprehensive public health strategies for preventing the development, progression, and complications of CKD: report of an expert panel convened by the Centers for Disease Control and Prevention.Am J Kidney Dis. 2009; 53: 522-535Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar, 39James M.T. Hemmelgarn B.R. Tonelli M. Early recognition and prevention of CKD.Lancet. 2010; 379: 1296-1309Abstract Full Text Full Text PDF Scopus (438) Google Scholar and emerging1World Health Organization. 2008-2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. Available at: http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf. Accessed December 27, 2010.Google Scholar, 40Perico N. Bravo R.F. de Leon F.R. Remuzzi G. Screening for chronic kidney disease in emerging countries: feasibility and hurdles.Nephrol Dial Transplant. 2009; 24: 1355-1358Crossref PubMed Scopus (37) Google Scholar countries. However, effective implementation of such strategies will only come when both the general public and the kidney community work together to convince health authorities that it is in the public interest to do this. It is our sincere hope that worldwide celebration of World Kidney Day 2011 will provide an opportunity to reinforce the message that kidney disease is indeed common, harmful, and treatable, and that protecting your kidneys is an important health strategy that may save your heart.