in Latin America

Clinical Nephrology, Vol. 85 – Suppl. 1/2016 (S1-S5)

Burden of end-stage renal disease (ESRD) in Latin America Original ©2016 Dustri-Verlag Dr. K. Feistle ISSN 0301-04305S DOI 10.5414/CNP85S■■■ e-pub: ■■month ■■day, ■■year

Key words chronic kidney disease – dialysis – kidney transplant – Latin America – end-stage renal disease

Received ■■■ accepted in revised form ■■■ Correspondence to Dr. Guillermo Rosa-Diez Nephrology Division, Hospital Italiano de Buenos Aires, Peron 4190, Buenos Aires, Argentina guillermo.rosadiez@ hospitalitaliano.org.ar

Guillermo Rosa-Diez1,2, María Gonzalez-Bedat1,2, Alejandro Ferreiro1,2, Guillermo García-García2, Juan Fernandez-Cean2, and Walter Douthat2 1Executive

Board of the Latin American Dialysis and Transplant Registry (RLADTR), and 2Sociedad Latinoamericana de Nefrología e Hipertensión (SLANH)

Abstract. Introduction: Endstage renal disease (ESRD) represents a major challenge for Latin America (LA). Epidemiological information needed to assist in the development of ESRD care in the region. The Latin American Dialysis and Renal Transplant Registry (RLADTR), has published several reports and its continuity has implied a sustained effort of the entire LA Nephrology community. This paper summarizes the results corresponding to year 2012. Methods: Our methods have been reported previously. Participant countries complete an annual survey collecting data on incident and prevalent patients undergoing renal replacement treatment (RRT) in all modalities. Results: 20 countries participated in the surveys, more than 90% of the Latin America. The prevalence of ESRD under RRT in LA increased from 119 patients pmp in 1991 to 661 pmp in 2012. HD continues to be the treatment of choice in the region (82%). A wide rate variation in incidence is observed: from 472.7 in Jalisco (Mexico) to 14 pmp in Guatemala. Diabetes remained the leading cause of ESRD. The most frequent cause of death was cardiovascular. There is a wide rate variation of nephrologist by country, from 1.8 pmp in Honduras to 45.2 pmp in Cuba. Discussion: The heterogeneity or even absence of registries in some LA countries is congruent with the inequities in access to RRT in such countries, as well as the avalaibility of qualining training programs as well as cooperation programs between LA countries to help the least developed start ESRD programs. In this spirit, RLADTR is training personnel to carry out dialysis and transplant registries in LA.

Introduction Latin America (LA) is a geopolitical region extending from the Rio Bravo (México) in the north, to Tierra del Fuego (Argentina) •

in the south. Its surface area (22,522,000 km2) represents ~ 13.5% of the emerging surface of the planet. Its population of 588,640,000 speak Spanish and Portuguese almost exclusively and has a wide ethnic diversity [1]. The region is going through a fast demographic and epidemiological transition process characterized by a reduction in mortality and birth rates, accompanied by rapid lifestyle changes as the population becomes increasingly urban (79.3% of total population is urban). This is associated with an increase in chronic noncommunicable diseases, including chronic kidney disease (CKD). However, the burden of infectious disease has not decreased. Re-emerging diseases, such as dengue and chagas disease, continue to be prevalent. From a socioeconomic point curred in the last few years, including an increase in the gross national income (GNI), from 2,784 USD in the year 1991 to 9,314 USD in 2012. The percentage of the population living below the poverty line has decreased from 22.4 in 1999 to 10.4% in 2010, and life expectancy at birth has risen from 68 years (1990) to 74 years (2010) [2]. End-stage renal kidney disease (ESRD) represents a major challenge for the region. In the 1999 – 2010 period, the disabilityadjusted life year (DALY) in ESRD patients increased by 20% in the US and by 58% in Latin America and the Caribbean [3]. This is aggravated by the need to better understand and treat a disease of nontraditional causes affecting predominantly agricultural communities, prevalent in young men, and unrelated to diabetes and hypertension [4]. Epidemiological information needed to assist in the development of CKD care guidelines is heterogeneous and scarce in the region [5].

2016_Suppl 1_05Rosa Diez / 12. April 2016, 12:55 PM

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Populations in million


HD 631.1 173.2 450.5 983.3 324.1 28.3 245.3 399.6 159.2 82.8 160.7 445.8 49.3 310.7 151.8 246.2 1,262.2 145.1 661.8 354.9 408

at n mer a

76 67 74 80 74 80 79 76 72 72 73 77 74 77 75 72 79 73 77 74 75

Life expentancy at birth

ro nat ona n ome hemod a y tran p ant pmp pat ent per m on popu at on

13,690 2,220 11,640 14,290 7,020 8,850 6,051 3,600 5,360 3,130 2,140 9,680 1,690 9,030 3,310 5,680 18,370 5,570 13,670 12,460 7,777

GNI

Prevalence and incidence or ESRD in RRT.

Argentina 41,071,973 Bolivia 10,298,804 Brasil 198,422,734 Chile 17,302,959 Colombia 47,735,137 Costa Rica 4,797,523 Cuba 11,294,588 Ecuador 15,517,357 El Salvador 6,288,306 Guatemala 15,050,785 Honduras 7,921,612 Jalisco 7,543,233 Nicaragua 5,978,890 Panamá 3,801,361 Paraguay 6,674,932 Perú 29,948,330 Puerto Rico 3,651,545 Dominican Rep. 10,163,853 Uruguay 3,395,080 Venezuela 29,942,692 Total no. of countries, LA 476,801,694

Country

Table 1.

n

PD 34.5 17.1 41.3 58.3 143.1 20.2 10.3 38.7 331.4 24.3 15.7 449.0 10.5 88.4 5.1 41.2 92.6 11.9 71.0 61.1 60 th a un t on n

Total RRT 833.1 222.4 663.2 1,239.4 564.4 329.8 326.8 456.4 556.1 134.5 180.0 1,427.6 63.9 472.7 177.1 351.4 1,740.1 185.1 1,038.3 477.7 601.0 dney ra t

Prevalence rate pmp Total dialysis LFG 665.7 167.4 190.3 32.0 491.8 171.4 1041.6 197.8 467.2 97.2 48.6 281.2 255.6 71.2 438.2 18.2 490.6 65.5 107.0 27.4 176.4 3.7 894.8 532.8 59.9 4.0 399.1 73.7 156.9 20.2 287.4 64.0 1354.8 385.3 157.0 28.0 732.8 305.4 416.0 61.7 468 133.0 not reported

157.4 96.2 173.2 175.7 79.1 NR 101.1 184.3 NR 14.0 189.6 472.7 31.8 NR 16.5 30.4 397.4 NR 142.9 NR 151

76.2 21.4 78.9 72.0 88.4 17.8 90.9 78.1 0.0 8.7 0.0 16.3 0.0 75.0 70.2 86.3 86.3 45.7 96.4 16.9 51.3

% Tx cadaveric

per tonea d a y

1,265 84 4,957 243 767 135 132 114 25 92 4 449 11 60 47 160 80 46 83 290 9,044

Incidence Kidney Tx rate number

30.8 8.2 25.0 14.0 16.1 28.1 11.7 7.3 4.0 6.1 0.5 59.5 1.8 15.8 7.0 5.3 21.9 4.5 24.4 9.7 15.1

Kidney Tx rate

26.8 2.3 15.1 7.6 2.0 4.6 45.2 6.1 5.2 6.6 1.8 6.0 2.8 7.1 6.6 10.1 26.6 8.3 44.2 16.8 13.4

Nephrologists pmp

rena rep a ement treatment

1,100 24 3,000 132 95 22 510 95 33 100 14 45 17 27 44 301 97 84 150 502 6,392

Number of nephrologists

Rosa-Diez, Gonzalez-Bedat, Ferreiro, et al.

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Burden of end-stage renal disease (ESRD) in Latin America

To help address these needs, the Latin American Dialysis and Renal Transplant Registry (RLADTR) was founded in 1991; it collects data from 20 countries – members of the Sociedad Latinoamericana de Nefrología e Hipertension (SLANH). It has published several reports [6, 7, 8, 9, 10] and its continuity is due to a sustained effort of the entire LA nephrology community. This paper summarizes the results corresponding to the year 2012.

Methods Our methods have been reported precountries complete an annual survey collecting data on incident and prevalent patients undergoing renal replacement treatment (RRT) in all modalities: hemodialysis (HD), peritoneal dialysis (PD), living with a functioning graft (LFG), number of nephrologists, CKD etiology, etc. Until 2011, data from Mexico was collected from local registries (Jalisco) and was extrapolated to create population estimates, assuming these were representative of the whole country. Since 2012, these data are exclusively referred to as data from Jalisco. Prevalence and incidence were compared with previous years. These variables were correlated with the gross national income and the life expectancy at birth. The causes of admission to dialysis and death were described. For the was applied, and a p < 0.05 was considered

Results 20 countries participated in the surveys, more than 90% of Latin America (Table 1). The prevalence of ESRD under RRT in LA increased from 119 patients per million population (pmp) in 1991 to 601 pmp in 2012 (HD 408 pmp, PD 60 pmp, and LFG 133 pmp). Only 6 countries have a prevalence above the media: Brasil, Argentina, Uruguay, Chile, Jalisco (Mexico), and Puerto Rico reported rates between 663 to 1,740 patients pmp, respectively. •

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The increase in the prevalence of patients in RRT has occurred in all modalities. HD continues to be the treatment of choice in the region (82%), and 45% of HD patients are located in Brazil. PD prevailed only in El Salvador and Jalisco (Mexico) (67.6% and 50.2%, respectively). PD was also common in Colombia, although the percentage of Colombian PD patients has consistently decreased in the last years from 54% in 2000 to 30.6% in 2012. In the remaining countries, 3.2% (Paraguay) to 41.6% (Costa Rica) of the patients were on PD. The kidney transplant rate increased from 3.7 pmp in 1987 to 6.9 pmp in 1991 and to 19 pmp in 2012, although it showed remarkable variations in that year 59.5 pmp in Jalisco, 30.8 pmp in Argentina, and 1.8 pmp in Nicaragua. Owing to the higher population, a higher number was registered in Brazil, with 4957 kidney transplants. A total of 199 double kidney-pancreas transplants were performed (Brazil 120, Argentina 63, Uruguay 5, Colombia 5, Costa Rica 5 and Chile 1). The total number of transplants in 2012 was 9044, 55.7% were cadaveric donors (the highest percentages were observed in Uruguay (96.4%) and Cuba (90.9%)). The total RRT prevalence correlated positively with GNI (r 0.89; p < 0.001) and life expectancy at birth (r 0.54; p < 0.01). Data for incidence of RRT were sent by 15 countries comprising 88.5% of the Latin American population (Table 1). A wide rate variation in incidence was observed: from 472.7 in Jalisco (Mexico) to 14 pmp in Guatemala. A tendency to rate stabilization/little growth was reported in most countries, exincidence (38 in 2008 to 184 pmp in 2012). cantly with GNI only (r2 0.59; p < 0.05). Diabetes remained the leading cause of ESRD, the highest incidence reported by Jalisco (Mexico) (59%) and Paraguay (49.5%) and the lowest by Uruguay (23.9%) and Chile (17.8%). The incidence of diabetes showed a correlation with total RRT prevalence and incidence (r 0.65; p < 0.05 and r 0.61; p < 0.05, respectively) and showed no correlation with GNI and life expectancy at birth. The most frequent cause of death was cardiovascular (57%). Infections and neo-


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Rosa-Diez, Gonzalez-Bedat, Ferreiro, et al.

plasms accounted for 13% and 6% of the causes of death, respectively. There is a wide rate variation of nephrologist by country, from 1.8 pmp in Honduras to 45.2 pmp in Cuba.

Discussion This report shows that the prevalence of treated RRT continues to increase, particularly in countries with 100% public health or insurance coverage for RRT, where it approaches rates comparable to those displayed by developed countries with better GNI. The incidence also continues to increase in both; countries that have not yet extended their coverage to 100% of the population as well as countries that have an adequate program for timely detection and treatment of CKD and its associated risk factors. Even though renal transplant is a feasible, available, and increasingly-used modality for RRT in all Latin American countries, its growth rate is still not as fast as it should be in order to compensate for the increased prevalence of patients on waiting lists (whose magnitude is not yet reported to the RLADTR). Peritoneal dialysis is still an underutilized RRT method in the region; this fact particularly contrasts with the continued expansion of hemodialysis. Diabetes and hypertension are the leading causes of ESRD admission to RRT; cardiovascular and infectious complications are still the major causes of death in patients undergoing RRT. In most Latin American countries reporting is voluntary, therefore, the Latin American registry has weaknesses such as a wide variability in data consistency. The quality of the data from a regional registry, such as RLADTR, is determined by what is provided by its respective national registries. The heterogeneity or even absence of registries in some LA countries is congruent with the inequities in access of ESRD patients to RRT in such countries as well as the availability of With the premises of providing universal healthcare and improving access to prevention programs for nontransmissible diseases, the Strategic Plan from the Pan American Health Association (OPS) has proposed a concrete goal for ESRD in LA: to reach •

a RRT prevalence of at least 700 patients pmp by 2019 [3]. To reach such a goal will require, amongst other actions, the development of CKD prevention programs as well as the training of personnel for assistance of ESRD patients (this includes at least a rate of 20 nephrologists pmp in each country) and the promotion and development of data collection registries. The SLANH is currently running training programs as well as cooperation programs between LA countries to help the least developed start CKD programs. In this spirit, RLADTR is training personnel to run dialysis and transplant registries in LA [5].

Acknowledgments Delegates to the LADTR from the National Societies of Nephrology: Marinovich S. (Argentina), Gonzalez-Bedat M. (Uruguay), Fernandez S. (Bolivia), Lugon J. (Brasil), Poblete-Badal H. (Chile), Miranda S. (Chile), Gómez R. (Colombia), Cerdas Calderón M. (Costa Rica), Hernandez M. (Costa Rica), Almaguer-López M. (Cuba), Freire N. (Ecuador), Leiva-Merino R. (El Salvador), Rodríguez G. (Honduras), LunaGuerra J. (Guatemala), García-García G. (México), Bochicchio T. (México), Cano N. (Nicaragua), Iron N. (Nicaragua), Cuero C. (Panamá), Cuevas D. (Paraguay), Saavedra A. (Perú), Pereda C. (Perú), Tapia C. (Perú), Cangiano J. (Puerto Rico), Rodríguez S. (Dominican Republic), González H. (Venezuela), Duro Garcia V. (Sociedad Latinoamerican y Caribeña de Trasplante.

Conflict of interest

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