risk markers for CVD than were elevation of blood pressure or dyslipidemia [37]. Can interventions prevent or retard CKD? An increasing number of patients treated by RRT worldwide suffer from diabetic nephropathy and hypertension. In the US and some European countries, diabetic nephropathy is the leading cause of ESRD, accounting for more than 40% of patients [40, 41]. This situation is likely to worsen over the next 20 years as the number of patients suffering from diabetes, mainly type 2, will increase from 154 million to 370 million; this increase will be most noticeable in the developing countries, where the number of diabetics will triple from 99 million to 286 million [42]. Diabetic nephropathy already accounts for more than 30% to 40% of ESRD in countries such as Malaysia, Turkey, Korea, Qatar, and the Philippines [42]. Changing trends in the etiology of ESRD in some European countries also show an increase in type 2 diabetic nephropathy and in the number of patients with hypertension and renovascular disease [43]. As with diabetes mellitus, the global burden of hypertension is due to increase over the next decade [44]. Almost one-third of the population is projected to have hypertension by 2025, an increase of around 60% with a total of 1.56 billion affected [44]. The global rise in the number of overweight and obese individuals is likely to have an impact on type 2 diabetes, hypertension, and CKD. In fact, obesity is the sole risk factor that is currently increasing in parallel with the rise in ESRD [45]. Type 2 diabetes mellitus (DM), obesity, and hypertension are potentially preventable diseases. Research in China [46], the US [47], some parts of Europe, Finland [48], and Sweden [49] has shown that lifestyle modifications, including weight loss and exercise, can reduce the incidence of overt type 2 DM in overweight patients with impaired glucose tolerance by one-half. Similar results were reported with the insulin-sensitizing agent metformin [47]. In addition, recent evidence suggests that angiotensin-converting enzyme (ACE) inhibition also prevents the onset of albuminuria in type 2 DM [50]. Whether this observation is due to a genuine prevention of albuminuria or merely its normalization by treatment is difficult to ascertain, because the patients were not evaluated after ACE inhibitor administration was discontinued. Furthermore, ACE inhibition also might have a salutary effect on the incidence of diabetes. Hypertension is also preventable by lifestyle modifications including weight loss and a reduction in dietary salt intake [51]. The Dietary Approaches to Stop Hypertension (DASH) diet, which includes a high intake of fruit and vegetables as well as a reduction in saturated fat intake, has proven effective in reducing both systolic and diastolic blood pressure [52, 53]. The DASH-sodium trial showed an additive beneficial effect of combining dietary salt restriction [53]. Lifestyle modifications have the potential to reduce type 2 DM, obesity, and hypertension, but they are difficult to sustain. Also, their adaptability to low-income societies is doubtful as this would require a cultural, societal, as well as economic shift. In low-economy societies, economic forces push individuals to adopt “obesegenic” diets [54]. Healthy diets are expensive; high-sugar, highfat diets as well as canned foods, which are highly salted, are much cheaper than fresh fruit and vegetables. Lowincome individuals might not even have the option of exercise, as they have limited time for leisure and are “time-poor” as well as cash-poor [54]. Nephrology Forum: Chronic CKD 2923 Social deprivation has been shown in numerous surveys including NHANES III to be a risk factor/marker for CKD [9]. Pharmacologic approaches aimed at weight loss might be more successful, although agents such as sibutramine (a central norepinephrine and serotonin reuptake inhibitor) and orlistat (a gastric pancreatic lipase inhibitor) are not without their side effects, thus reducing compliance and sustainability [55]. Surgical bariatric interventions have been advocated for morbid obesity with good short-term results but decreasing efficacy at 10 years [56]. A large body of evidence suggests that reduction of blood pressure and proteinuria can lower the rate of progression of CKD in patients with diabetic and nondiabetic nephropathy by as much as 50% [30, 57]. In most of these studies, ACE inhibition or the use of angiotensinreceptor blockers (ARBs) has proven protective through combined antihypertensive and antiproteinuric effects [57]. The protective effect of these agents might be proportional to their proteinuria-lowering effects [30]. Reduction of albuminuria and proteinuria is key to the prevention of the progression of diabetic nephropathy. Remuzzi’s group has argued that aggressive and multifactorial risk reduction interventions can either normalize the annual rate of loss of renal function or even reverse the trend [30]. In high-risk ethnic minorities such as the Northern Territories’ Aborigines, treatment with an ACE inhibitor not only decreased the incidence of ESRD but also reduced mortality rates [58]. It is of interest that when such treatment programs had to be discontinued because of administrative difficulties, there was a surge in both morbidity and mortality within a short period of time [57]. Is screening for CKD cost-effective? A model simulation based on the