Markov model has consistently shown that screening diabetic patients for albuminuria is cost-effective [27]. In the RENAAL study, treatment with the ARB losartan reduced albuminuria and slowed the progression of type 2 diabetic nephropathy [59]. In this study, a reduction by 28.6% of the risk of ESRD was estimated to lead to a net savings per patient in ESRD-related cost at 3.5 years by $3522; net cost savings per patient at 3.5 years (between $11,000 and $12,000) was the highest in those with the highest baseline albuminuria (>4000 mg/g creatinine) [59]. In another study, treatment with another ARB, irbesartan, in patients with type 2 diabetic nephropathy led to an average cost savings of as much as $11,922 per patient after 25 years [60]. In non-diabetic nephropathies, similar simulation modeling demonstrated that a reduction of 10%, 20%, and 30% of the rate of progression of CKD in patients with GFR End-stage kidney disease (ESKD) is a major public health problem due to associated adverse health consequences and costs of treatment. People with ESKD require frequent and intensive care that is burdensome to their lifestyles and expensive. In many countries where ESKD care is not publicly funded, people with ESKD are unable to receive treatment, resulting in poor health outcomes and often death. It is projected that in 2030, 14.5 million people will have ESKD and need treatment, yet only 5.4 million will actually receive it due to economic, social, and political factors. There are several options for ESKD treatment. Kidney replacement therapy (KRT) can be delivered through hemodialysis (HD), peritoneal dialysis (PD), or transplantation; alternatively patients can be offered non-dialytic comprehensive conservative care. Understanding the benefits and limitations of each option requires consideration of the individual patient, local context, and capacity. The high cost of HD is a key barrier for many countries. According to recent estimates, the cost of HD for one patient is approximately USD 100,000 per year. Using less costly alternatives such as PD or comprehensive conservative care may be a more suitable option in resource-limited settings. Moreover, HD may not always be the most appropriate treatment option for ESKD. Therefore selecting the best route of care is imperative from a financial, clinical, and patient-centered perspective. Efforts to prevent ESKD through appropriate acute kidney injury (AKI) and chronic kidney disease (CKD) detection strategies are needed to reduce the burden the disease. Health information systems are essential for collecting information to guide surveillance programs and further support decision making with respect to policies and resource allocation. Identifying key barriers to the prevention and appropriate management of ESKD is important if solutions are to be developed. It is necessary to understand the global status of kidney care to inform governmental policies and strategies aimed at improving ESKD care. FOREWORD David Harris AM, MD (USyd), BS, FRACP Professor of Medicine, University of Sydney Director of Nephrology and Dialysis, Western Sydney Renal Service President International Society of Nephrology (2017-19) 2 | Foreword ISN Global Kidney Health Atlas | 2019 On behalf of the International Society of Nephrology (ISN), I am delighted to present the second iteration of the Global Kidney Health Atlas (GKHA). This version is a topical survey that focuses on understanding the global burden of ESKD and capacity for care delivery across countries and regions. The GKHA project is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions, as part of the ISN's Closing the Gaps initiative. The 160 participating countries (out of 182 approached), account for over 98% of the world's population. The survey results provide an overview of the current capacity for ESKD care, focusing on disease prevention and management. The findings will be applied to engage relevant stakeholders across countries and regions to advocate for improved access to and quality of kidney care. The data have appreciable policy implications, as they provide a platform for holding governments accountable by measuring country and region progress over time. We synthesized the various approaches to ESKD care across all world regions; identified opportunities to strengthen relevant health systems; and explored potential mechanisms to capitalize on these opportunities. We found several common barriers to optimal ESKD care delivery across countries and regions: poor funding for ESKD care (dialysis and transplantation), particularly in low income nations; limited workforce capacity; and significant variations in the development and organization of care structures. Most of these challenges reflect economic differences, as well as political and socio-cultural factors. These common challenges should be addressed to strengthen health systems and policies for optimal kidney care. We suggest potential strategies to address these challenges, and discuss them for low and lower-middle income settings where KRT is unavailable or unaffordable. This work is important, as it provides benchmarks for monitoring ESKD care capacity over time; moreover, we provide organizational and country-level recommendations on how gaps in care may be addressed.