problem we encounter in the UK and other Western countries, namely, 2918 Nephrology Forum: Chronic CKD 2919 0 200 400 600 800 1000 1200 1400 1600 India Pakistan Egypt Tunisia Mexico Argentina S.Arabia PPP(US$/year) Prevalence ESRD (Patients/million population) Trend Fig. 1. Purchasing power parity (PPP) and prevalence of ESRD in selected developing countries (modified from [4]). asylum-seekers and immigrants who come to the West not as much for political or economic motives but for medical treatment. Her case highlights the plight of millions of patients worldwide in developing countries who are denied access to renal replacement therapy (RRT) because of a lack of facilities and resources. Globally, the number of patients with end-stage renal disease (ESRD) is increasing steadily. Currently, more than 1.6 million individuals worldwide undergo RRT, mostly hemodialysis. Most of these patients (90%) live in the developed world, which accounts for only 20% of the world population [1–3]. In fact, 56% of all patients receiving RRT live in only 5 countries, the United States (US), Japan, Brazil, Italy, and Germany, which represent only 12% of the global population [1]. The stark and alarming reality is that 112 countries representing a population of 600 million remain without RRT [1]. It is therefore not surprising that 1 million patients die every year worldwide from ESRD. Most countries in sub-Saharan Africa, where our patient comes from, have few or no RRT facilities [4]. In Asia, the Indian sub-continent has very limited facilities for a growing population (exceeding 1 billion). In fact, India has a prevalence of patients on RRT of less than 15/million of population (pmp) when at least 200 to 300 pmp is expected [1, 5]. In China, the prevalence varies from around 100 pmp in major urban centers to as little as 3 to 5 pmp in huge and overpopulated rural areas [1, 6]. Similar discrepancies have been described in Russia, where the annual incidence of ESRD is as low as 15 pmp [1, 7]. Comparing this to the annual incidence in the US of over 360 pmp (prevalence: ∼1400 pmp) and Europe of around 150 pmp (prevalence: ∼700 pmp), it becomes apparent that a huge gap in resources prevents the developing, low-income countries from providing treatment to an ever-increasing number of patients with ESRD [1–3]. In fact, in the developing world, the prevalence of ESRD is proportionate to national income and economy (Fig. 1). As there are no major differences in incidence of ESRD among developing countries, it is most likely that the major, if not sole, determinant of prevalence is the capacity and sustainability of RRT programs; these are all financially determined. This gloomy situation is likely to worsen over the next decade, as the number of patients with ESRD appears to be rising annually by 5% to 8%, with an expected 2 million patients undergoing RRT by 2010 [2, 8]. Undoubtedly, few of these will be in the developing world, where the cost of such treatment is prohibitive; the expected cost in the US by 2010 to treat more than 600,000 patients will reach around $29 billion [1–3]. The global challenge in nephrology over the next decade is not to provide RRT to the millions who cannot afford it; nor is it to encourage these patients to seek treatment in the West, where resources are already at breaking point. Instead, the nephrology community should try to shift the emphasis away from treatment of ESRD to the early detection and prevention of progressive chronic kidney disease (CKD). Early detection and prevention of CKD should in principle reduce the global burden of this chronic non-communicable disease through management of risk factors and interventions aimed at slowing the development and/or the progression of CKD. To achieve such a goal, it is imperative that we embark on global screening programs for CKD. In this Forum, I will review the rationale for such programs and the requirements for their implementation. For a screening program to be successful, certain criteria have to be met: The disease screened must be common. Its natural history and stages should be well defined. Screening tests should be reliable and affordable. The prognostic significance of detected abnormalities must be established. Interventions must exist that can successfully 2920 Nephrology Forum: Chronic CKD treat those with the disease. Finally, the entire process of screening and treatment must be cost-effective. I will address these issues in relation to CKD, and will examine staffing and financial issues pertinent to the implementation of detection and prevention programs. Is screening warranted? In whole population terms, the number of ESRD patients worldwide represents a small percentage (0.1%). Therefore, patients with CKD have long been underserved by many health authorities and governments. In developing countries, this has been compounded by other conflicting health priorities, including those of communicable diseases, especially AIDS. However, emphasis is slowly shifting both in the West and in the developing world as the realization of the scale of non-communicable diseases, including CKD, and their impact on health care is growing. In the US, data derived from the third National Health and Nutrition Examination Survey (NHANES III) suggest that as many as 11% of the entire adult US population is affected by some degree of CKD [9]. In