important because proteinuria and renal dysfunction are early sensitive markers of vascular dysfunction and CVD patients are at significantly higher risk of kidney disease than the general population. Resultant medical treatment would focus on the use of ACE inhibitors or angiotensin receptor blockers with a target blood pressure of 120/80 to 130/80 millimeters of mercury. The greater the level of proteinuria, the more treatment is required; thus, the ACE inhibitor dose would be titrated up as proteinuria levels increased. Diuretics and other antihypertensives would be added to meet blood pressure targets. Efforts should be made to obtain low-cost (off-patent) ACE inhibitors or other low-cost antihypertensives. Such treatment should delay or stop the progression of kidney disease and reduce the risk of CVD. Other preventive measures include serum glucose and lipid control and low-dose aspirin if a risk of CVD exists (see chapter 44). ECONOMIC BENEFITS OF INTERVENTION An abundance of literature is available on the economics of ESRD. In the industrial world, treatment is usually readily available and is covered by government or private health insurance. Previous restrictions—for example, treatment being limited to certain age groups—have been removed (Chugh and Jha 1995). Dialysis treatment accounts for 0.7 to 1.8 percent of health care budgets in European countries, even though dialysis patients account for only 0.02 to 0.05 percent of the population (Schiepatti, Perico, and Remuzzi 2003). The most cost-effective option is prevention. Population screening is not particularly cost-effective, given the low incidence of ESRD—namely, 100 to 200 per million population 700 | Disease Control Priorities in Developing Countries | John Dirks, Giuseppe Remuzzi, Susan Horton, and others worldwide (Kher 2002)—and given that testing is not highly accurate. According to Kiberd and Jindal (1998), screening costs around US$20 per test, but the positive predictive value for a single test is only 0.3. Even repeat testing does not improve predictive value dramatically. Screening strategies have, therefore, focused on specific populations at higher risk of ESRD than the general population. Whereas only 2 to 5 percent of more than 1 billion hypertensive patients will ultimately develop nephropathy, approximately 30 percent of type 1 and type 2 diabetic patients will develop overt nephropathy (Satko and Freedman 2001). The conclusion is that treating all diabetics in developed countries with ACE inhibitors is a cost-saving strategy. The modest outlay for ACE inhibitors, which amounts to US$320 per year in the United States and is likely to come down as more ACE inhibitor treatments come off patent, offsets the much larger future costs of dialysis and transplant (Golan, Birkmeyer, and Welch 1999; Kiberd and Jindal 1998). We undertook a crude cost-effectiveness calculation for treating diabetics in developing countries with ACE inhibitors in those cases in which no treatment of ESRD is undertaken. If we use Clark and others’ (2000) assumptions, 82 percent of diabetic patients not using ACE inhibitors would survive for 11 years from the onset of macroproteinuria to ESRD, whereas 72 percent of those using ACE inhibitors would survive for 18 years from the onset of macroproteinuria to ESRD (the annualized death rate for both groups is 1.8 percent). If we make the gross assumption that all patients with ESRD in poor developing countries die, this assumption suggests that, at a discount rate of 3 percent and an annual cost for ACE inhibitors of US$320, the cost per quality-adjusted life year (QALY) saved would be about US$1,100 for treating diabetic patients with macroproteinuria. Because of the lack of data, these calculations apply survival rates in developed countries to developing countries; thus, the rates are likely too high. Using survival rates in developing countries would probably increase the cost per QALY saved, but treatment with ACE inhibitors is nevertheless likely to be an attractive investment (table 36.3). Satko and Freedman (2001) suggest that screening first- and second-degree relatives of ESRD patients may be cost-effective. They cite one study that found 38 percent of first-degree relatives of African-American patients with hypertensive ESRD had some form of renal disease (Bergman and others 1996). Satko and Freedman also cite a study by Freedman, Soucie and McClellan (1997) revealing that in 4,365 incident ESRD patients in the southeastern United States, 14 percent of white patients and 23 percent of black patients had first- or seconddegree relatives with ESRD (the rates would probably have been higher if subclinical nephropathy had been included). Satko and Freedman (2001) recommend annual screening for blood pressure, urinalysis, measurement of serum creatinine and blood urea nitrogen concentration, and testing for diabetes mellitus, when appropriate, for first- and second-degree relatives of ESRD patients. They did not calculate any formal cost-effectiveness results (table 36.3). Kidney transplants are the most cost-effective intervention for ESRD. Transplant costs in developed countries have declined steadily from about US$60,000 in 1970 to about US$10,000 currently (Winkelmayer and others 2002). In addition to facing transplant costs, patients face ongoing costs for immunosuppressive drugs, which start at