associated with the disease itself and its progression, including end-stage renal disease (ESRD). Indirect costs are defined as those incurred for non-renal care in cases where people with CKD have excess risk or consume excess health care resources relative to the non-CKD population. These indirect costs include those arising from excess adverse events (such as stroke) in people with CKD, from excess bed days in general hospital admissions and from excess infections. 17. CKD is classified in five stages, according to the level of kidney damage and the ability of the kidneys to filter blood. The glomerular filtration rate (GFR) measures the amount of blood that passes through the tiny filters in the kidneys, called glomeruli, each minute. As the disease progresses, the GFR falls. 18. The National Service Framework for Renal Services defines normal renal function as estimated GFR (eGFR) at or above 90 ml/min/1.73 m2 with no evidence of kidney damage, and classifies CKD in five stages using the US National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) system. The National Institute for Health and Clinical Excellence (NICE) recommends sub-division of stage 3, as shown in Table 1. The focus in this paper is on stages 3–5 CKD, defined as GFR 5 ml/min/1.73m2 during the follow-up period. 37. A longitudinal US study of 1,120,295 adults found that a reduced GFR was associated with increased risks of death, cardiovascular events and hospital admission that were independent of known risk factors, a history of cardiovascular disease and the presence of documented proteinuria.14 The adjusted HRs for adverse events increased sharply with an Egfr The global challenge of chronic kidney disease Principal discussant: MEGUID EL NAHAS Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom CASE PRESENTATION A 48-year-old African woman presented at the Sheffield Kidney Institute complaining of lethargy as well as nausea and vomiting. She had always lived in a sub-Saharan African country devastated over the last quarter-century by war and internal conflict. Over the last 3 years, her health had been deteriorating, with progressive swelling of her legs. She had had nocturia for the last 5 to 6 years. She also mentioned that her two pregnancies had been complicated by severe hypertension and edema and were therefore terminated early. She was not followed up subsequently, and she returned to her village, which has only one general medical practitioner and a witch doctor. She also gave a family history of chronic kidney disease (CKD); her older brother died from endstage renal disease (ESRD) a few years ago. When she sought a medical opinion in the capital city of her country one year prior to her arrival in Sheffield, she was told that she had severe hypertension, heavy proteinuria, and progressive renal insufficiency. Some medication was dispensed to her, but she failed to renew her prescription because of its prohibitive cost. When her The Nephrology Forum is funded in part by grants from Amgen, Incorporated; Merck & Co., Incorporated; and Dialysis Clinic, Incorporated. Key words: end-stage renal disease, diabetic nephropathy, hypertension. C 2005 by the International Society of Nephrology condition deteriorated, she returned to the capital city’s main hospital, where ESRD was diagnosed. She was told that little could be offered to her in view of the lack of dialysis facilities. She was advised to go back to her village to die. This she would not accept and decided to visit her daughter, who had sought asylum in the UK a few months prior to her own arrival. When the patient presented to the Sheffield Kidney Institute, she was severely anemic; her hemoglobin was 6.7 g/dL with significant microcytosis (MCV, 72 fl) and hypochromia (MCHC, 28 g/dL). The serum urea was 67 mmol/L and serum creatinine level was 1299 lmol/L (14.8 mg/dL). She was hyperkalemic (K, 6.8 mmol/L) and severely acidotic (serum bicarbonate, 12 mmol/L). Her serum protein and albumin were low at 46 g/L and 18 g/L, respectively. Serum calcium was low, 2.1 mmol/L, and phosphorus raised, 2.2 mmol/L, with a high intact PTH level of 576 pg/mL. Clinically, the patient was fluid overloaded with marked peripheral edema, raised jugular venous pressure, and bilateral basal lung crepitations. Her blood pressure was high, 187/94 mm Hg, and cardiac auscultation revealed a gallop rhythm. Urinalysis showed: +1 protein and 1+ blood. The 24-hour urinary protein excretion was 0.9 g. A chest radiograph revealed marked cardiomegaly and congested lung fields. Ultrasound scan of her kidneys showed them to be small, approximately 6 to 7 cm. It was apparent that the patient was in end-stage renal failure and required the immediate initiation of hemodialysis, which was instituted through a tunneled jugular venous catheter. Over the subsequent 4 weeks, her condition started to improve, her blood pressure was normalized through fluid removal, her anemia improved with intravenous iron supplementation and the institution of erythropoietin treatment, and attention started to be paid to her severe malnutrition. DISCUSSION PROF. MEGUID EL NAHAS (Professor of Nephrology, Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK): This unfortunate lady is a sad example of an all-too-common