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STATUS OF RENAL REPLACEMENT THERAPY AND. PERITONEAL DIALYSIS IN MEXICO. Alfonso M. Cueto-Manzano and Enrique Rojas-Campos.
Peritoneal Dialysis International, Vol. 27, pp. 142–148 Printed in Canada. All rights reserved.

0896-8608/07 $3.00 + .00 Copyright © 2007 International Society for Peritoneal Dialysis

PD IN THE DEVELOPING WORLD

STATUS OF RENAL REPLACEMENT THERAPY AND PERITONEAL DIALYSIS IN MEXICO

Alfonso M. Cueto-Manzano and Enrique Rojas-Campos

Mexico is struggling to gain a place among developed countries; however, there are many socioeconomic and health problems still waiting for resolution. While Mexico has the twelfth largest economy in the world, a large portion of its population is impoverished. Treatment for endstage renal disease (377 patients per million population) is determined by the individual’s access to resources such as private medical care (approximately 3%) and public sources (Social Security System: approximately 40%; Health Secretariat: approximately 57%). With only 6% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico is still the country with the largest utilization of peritoneal dialysis (PD) in the world, with 18% on automated PD, 56% on continuous ambulatory PD (CAPD), and 26% on hemodialysis. Results of PD (patient morbi-mortality, peritonitis rate, and technique survival) in Mexico are comparable to other countries. However, malnutrition and diabetes mellitus are highly prevalent in Mexican patients on CAPD programs, and these conditions are among the most important risk factors for a poor outcome in our setting. Perit Dial Int 2007; 27:142–148

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KEY WORDS: Mexico; diabetes mellitus; malnutrition. Correspondence to: A.M. Cueto-Manzano, Unidad de Investigación Médica en Epidemiología Clínica, Hospital de Especialidades, 4 piso, CMNO, Belisario Dominguez 1000, Col. Independencia, Guadalajara, Jalisco, CP44349, Mexico. [email protected] Received 7 September 2005; accepted 6 April 2006. 142

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n 1994, a financial crisis thrust millions of Mexicans into poverty. Since then, much effort has been put into reconstructing the country (1). Notwithstanding, Mexico, with its 106.1 million population in 2004 (2), continues to be a country of huge contrasts, with enormous gaps remaining between rich and poor, urban and rural areas, and between different geographical areas. According to the World Bank, Mexico had the world’s twelfth largest economy in 2004, with a gross domestic product (GDP) of 676497 million USD, and a per capita gross national income of 6770 USD (1). In the current year, Mexico’s exports to the world market reached 165393 million USD and the growth of per capita GDP was 2.7% in the past year (2). However, the biggest problem continues to be inequality in wealth distribution. The Gini index, one of the most commonly used measures for comparing inequality among countries, reflects a 50% inequality in income distribution (an index of 0% represents perfect equality, an index of 100% implies perfect inequality) (1), with 39% of the population living at the poverty line and 13% at the extreme poverty line (2). In our country, illiteracy in people older than 15 years is 7%, 12% of homes have no excretal disposal system, 4% have no piped water, and 2% have no electric lighting (2). Additionally, although life expectancy at birth is now 74 years, the mortality rate in children under 5 years is 28 per 1000 inhabitants, and malnutrition among children is approximately 8% (1). HEALTHCARE SYSTEM AND DIALYSIS AVAILABILITY

In 2003, the annual national health expenditure as a proportion of the GDP was 6.1%; there were 1.24 hospi-

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Unidad de Investigación Médica en Epidemiología Clínica, UMAE, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico

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Figure 1 — Healthcare coverage of the Mexican population, showing the complexity of the health systems.

of 939 versus 166 patients per million population respectively (5). EPIDEMIOLOGICAL DATA FOR ESRD

No comprehensive data on the nationwide epidemiology of ESRD are available in Mexico, which makes any global analysis difficult; however, there has been serious effort to create a National Dialysis Registry in recent years. The National Transplant Center was created in 2000, and one of its functions is to keep the National Transplant Registry updated (6). At present, some national data about dialysis are extrapolated from regional registries or facilitated by commercial sources. The Jalisco State Dialysis and Transplant Registry (7) has incorporated complete information on RRT since 1998 and has been the basis for the Mexican data appearing in reports of the Latin American Society of Nephrology and Hypertension (SLANH). Accordingly, the SLANH Annual Report 2002 (the most recent report was published in 2005) showed a prevalence of dialysis (both HD and PD) and renal transplant of 305 and 72 patients per million population in our country, respectively (8), that is, a total national RRT prevalence of 377 per million population. In the same report, an acceptance rate of 103 new patients for RRT per million population was reported. These data place Mexico at a medium dialysis treatment rate within Latin America, but may also reflect the limited availability of RRT and the presence of data subregistry in our setting. TREATMENT OF ESRD

It is broadly known that Mexico is still the country that uses proportionally more PD than the rest of the world (9). In the 1990s, Mexico employed PD in 91% of ESRD patients (10); more than a decade later, the use of PD has been reduced to 86% (8). In 1992, in the IMSS system, 52% of patients were on intermittent PD and 48% on continuous ambulatory peritoneal dialysis (CAPD) (11). At present, intermittent PD has virtually disappeared. Double-bag systems were introduced in our country around 1996; at present, practically all CAPD patients are on this system. In 1998, automated PD (APD) was introduced in Mexico City and Guadalajara; thereafter, a slow but progressive increase in its use has been observed nationwide. According to commercial sources (Laboratorios Pisa, SA de CV), the number of ESRD patients receiving renal replacement in our country increased at an annual rate of approximately 10% during the past 5 years (Table 1). Although the total number of patients in each type of 143

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tal beds and 1.28 physicians per 1000 inhabitants (3). Healthcare is provided by different systems in our country (Figure 1). Those people with the highest purchasing power have access to private medical care (approximately 3% of the total population, via private insurance or on a fee-for-service basis) (4). Workers in the formal economy (approximately 40%) and their nuclear families are covered by the Social Security system (4), which is comprised of several institutions, each of which is funded by contributions from employers, employees, and government. The Mexican Institute of Social Security (IMSS) is the largest institution in this system and serves about 80% of the covered population. The Social Security system also includes the State Workers’ Social Security and Services Institute, Petróleos Mexicanos, the Armed Forces, and the Navy. Finally, people with less purchasing power and those living in poverty (the remaining 57%) have access only to the basic medical services provided by the Health Secretariat (4). Consequently, treatment of end-stage renal disease (ESRD) is determined largely by the limitations of the corresponding healthcare system. Dialysis (and renal transplantation) is not restricted in the private sector. On the contrary, the Social Security system is an equal opportunity system for patients but, in practice, there may be some restrictions and limitations as funding is subject to annual budgetary considerations. The renal replacement treatment provided by the Health Secretariat has the severest limitations and is very restricted due to economic constraints. In fact, a recent study performed in the state of Jalisco (a western state of Mexico) has shown significant differences in access to renal replacement therapy [RRT; hemodialysis (HD), peritoneal dialysis (PD), and renal transplant] between insured and uninsured populations: an incidence rate of 327 versus 99 patients per million population and a prevalence rate

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TABLE 1 Growth in the Number of Mexican End-Stage Renal Disease Patients According to Type of Renal Replacement Therapya Year 2001 2002 2003 2004 2005b

HDc

APDc

CAPDc

Renal transplantd

7540 8640 9725 9240 10 920

1073 1635 3344 6437 7770

20387 21725 22381 22 823 23 310

1330 1472 1697 1743 867

HD = hemodialysis; APD = automated peritoneal dialysis; CAPD = continuous ambulatory peritoneal dialysis. a Information from Laboratorios Pisa, SA de CV, and Centro Nacional de Trasplantes. b Data updated 31 July 2005. c Prevalence counts. d Incidence counts.

Figure 2 — Growth of the different dialysis modalities in Mexico as percentage of the total number of patients during the past 5 years. Information provided by commercial sources: Laboratorios Pisa, SA de CV. 144

Health Secretariat, and 21% through private medicine. In 1999, there were 66 centers performing HD and 271 performing PD in Mexico (15). At present, there is no information on the numbers of HD or PD programs, nor is there information on those programs in which a nephrologist is in charge. Considering the small number of nephrologists (a total of 419 had been certified by the Mexican Board of Nephrology up to 2004) in a country with a continuously increasing ESRD population, it can be expected that some dialysis programs are under the charge of non-nephrologist doctors. It is less probable that a non-nephrologist is taking care of HD patients, as an official norm was established in 1999 that only nephrologists could be in charge of HD units. However, this is not the case for PD programs, which are not regulated in the same way. As a result, a number of these units are under internists’ responsibility. Additional issues waiting to be solved are shortages of specialized renal nurses (because of a low number of training programs) and experienced surgeons installing peritoneal catheters. It is not completely clear why PD has been much more frequently used than HD in our setting; however, nonmedical factors seem to be more significant than medical factors. The Social Security system and other public institutions (the major organizations providing dialysis treatment) have a policy of using PD as the first line of treatment for ESRD; HD is regularly used as the second option when PD fails. This behavior might be due to several reasons, but economics and the small number of nephrologists may play important roles. In a country with a shortage of kidney specialists, it is easier for a non-nephrologist doctor (i.e., an internist) to run a PD than a HD program. On the other hand, PD was cheaper than HD, and this may be of huge relevance for institutions with economic restrictions. In a cost–benefit analysis done in 1996, the monthly cost of CAPD was reported to be about 367 USD ($4034 Mexican pesos), whereas the cost of HD was 1073 USD ($11 803 Mexican pesos) (16). The presence of local producers of PD fluids and competition between different enterprises (Laboratorios Pisa, Baxter, and Fresenius) may have influenced the lowering PD costs. Notwithstanding, this marked difference seems to be disappearing as, at the present time, according to commercial sources (Laboratorios Pisa) and considering only dialysis supply costs (dialysis fluid, dialyzers, dialysis kits) for the public sector (not for private or general consumers), the monthly cost (in USD) is about $567 for CAPD, $627 for APD, and $467 for HD. It is known that different reimbursements to hospitals and doctors for PD or HD modalities may influence the selection of one modality over the other; however, this

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dialysis therapy has been increasing every year, the proportion of patients receiving HD remains roughly the same, while the percentage of those receiving CAPD has decreased and the percentage of those on APD has increased since 2001 (Figure 2). In 2002, there were 21725 prevalent patients on PD in Mexico, an absolute number that was behind only the United States in context of the world (12–14). In July 2005, there were 42000 patients on chronic dialysis in Mexico; 26% of these patients were on HD, 18% on APD, and 56% on CAPD. This picture still corresponds to the largest use of PD reported worldwide. Of patients on PD, 88% are treated through the Social Security system (75% in the IMSS), 7% through the Health Secretariat, and 5% through private medicine. Of patients on HD, 76% are treated through the Social Security system (68% in the IMSS), 3% through the

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OUTCOME ON CAPD

Several of the following conditions in the Mexican CAPD population require special attention. Even though it has been demonstrated also in our setting that late referral to the nephrologist is associated with poorer CAPD outcome (18), late initiation of dialysis, as judged by creatinine clearance (7.3 ± 3.8 mL/ minute) (19), is frequently observed in our setting and is more pronounced in disadvantaged populations (median creatinine clearance 3.1 mL/minute) (20). It has been shown that Mexican CAPD patients have peritoneal small-solute clearances that are similar to recommended values and associated with acceptable outcome (21); however, it does not seem to be a current practice to perform periodical dialysis dose measurements in our patients, despite loss of residual renal function. Adjustments to dialysis regimens are more frequently dictated by clinical and other laboratory evaluations. In the IMSS system, cross-sectional data from 1992 showed an annual mortality rate of 34% with intermittent PD and 17% with CAPD (11). In 1993, CAPD patient survival at 1 and 3 years was reported in a tertiary healthcare center of the Health Secretariat in Mexico City as

67% and 48% respectively (22). Almost 10 years later, with more experience gained in the same center, patient survival at 1, 3, 5, 8, and 10 years was reported as 85%, 68%, 50%, 39%, and 29%, respectively (19). Similar survival within the first 2 years was reported more recently in a multicenter study conducted in various regions of the country (21). In the Hospital de Especialidades, CMNO, IMSS, in Guadalajara, we recently found survival rates of 90%, 78%, and 72% for 1, 2, and 3 years, respectively. Diabetes mellitus (DM), in conjunction with hypoalbuminemia–malnutrition, old age, lymphopenia, and high peritoneal transport rate, has been the most significant risk factor for mortality identified in the Mexican CAPD population (19,22,23). The ADEMEX study (21), the largest clinical trial performed in PD, corroborated the importance of DM, old age, and hypoalbuminemia as predictors of poor outcome in our CAPD population. This study also established a neutral role of peritoneal clearances in determining patient outcome, and that the survival benefit of PD is obtainable within a range of clearances achievable in usual practice. Diabetes mellitus (around 90% is type 2 in Mexico) causes at least 40% of ESRD in Mexico (7,11,19). This is particularly worrying, considering that Mexicans (24) and individuals of Mexican origin living in other countries (such as Mexican Americans) (25) seem to have a higher DM prevalence than other populations. Moreover, non-communicable diseases such as DM, hypertension, and obesity have increased markedly in our country in recent years (26). In addition, two thirds of type 2 DM patients attending primary healthcare medical units in our setting had nephropathy (40% early nephropathy) (27). They are not being identified at early stages when reno-protection is most effective (28); thus, precious time is being lost and an increase in diabetic ESRD patients may be seen in the near future. In addition, the Mexican population is experiencing the ageing phenomenon: in year 2000, subjects older than 60 years represented 6.8% of the total population; in 2005 they represented 8%, and for the year 2020 they will represent 12% (29). Thus, because of the high prevalence of DM in the Mexican population, the phenomenon of ageing, and the fact that type 2 DM is tending to be present at younger ages in our setting, it is very likely that more diabetics will live long enough to develop ESRD in decades to come. Several groups have proposed strategies for solving this problem (30) and, fortunately, ESRD was included for the first time in the National Health Plan in 2004 as a priority problem. There are also plans to include ESRD treatment (PD and HD) in a Popular Health Insurance instituted by the Health Secretariat for the non-covered 145

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was not a factor in choosing therapy modality in Mexico as, in the public sector (where the vast majority of dialysis patients are treated), there is no reimbursement at all (doctors have fixed salaries). An additional factor for the preponderance of PD may be that all the training centers for residents in nephrology belong to the Social Security system or the Health Secretariat; thus, it is possible that staff nephrologists and residents have selection bias and/or more experience with PD as RRT. Finally, most HD units in our setting are located in the largest urban areas, which constitutes an obstacle for those patients living a great distance from those centers and thus leads to a preference for PD. Renal transplantation has also grown at an approximate rate of 10% annually in the past 5 years (Table 1); however, there is still much to do in this regard as the waiting list continues to lengthen progressively. In our country, most renal transplants are from living donors (6,17), although the number of cadaveric donors has been increasing in recent years. In 2001, 15% of all renal transplants were from cadaveric donors, whereas, in 2004 the percentage increased to 27% (6). In 1999, there were 75 registered centers performing renal transplants in Mexico (15) and 10 more centers were added late in 2004 (6). Most of these centers belong to the Social Security system or the Health Secretariat.

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(1 episode every 24 months) compared to “Y” or conventional systems (37), even in the poorest population with disadvantaged conditions (37). Double-bag systems have also been associated with a reduction in the coagulase-negative staphylococcal infection rate (38). There is no current published information about the prevalence of ultrafiltration failure or problems with compliance in our setting. No formal comparisons of survival between CAPD and HD have been reported, probably (at least in part) because HD is generally used as a secondline treatment for patients with PD failure and comparisons between these techniques in these conditions would not be the most appropriate. Nonetheless, survival reported in Mexican CAPD populations seems to be similar to other series, even in the case of the people without Social Security (20) who live under more disadvantaged conditions (poverty, lack of public services, illiteracy). In summary, Mexico is a country with marked contrasts: it is listed among the 15 largest economies in the world, but wealth is unequally distributed. In addition, many socioeconomic and health problems are still waiting for resolution. The complexity of healthcare coverage in Mexico and the existence of several health systems with different financial resources result in significant differences in access to RRT. The lack of a nationwide ESRD data system prevents global analyses; however, several local and regional experiences may provide some light in this respect while a National Dialysis Registry is created during the next years. In spite of an increase in the use of HD during the past 10 years, Mexico is still the country with the largest utilization of PD in the world. Results of PD in Mexico seem to be comparable with other countries; however, the presence of malnutrition and DM (which are highly prevalent and may increase in the future) among Mexican patients constitutes a great challenge. REFERENCES 1. The World Bank Group (accessed July, 2005): http:// www.worldbank.org 2. The United Nations Economic Commission for Latin America (CEPAL) (accessed July, 2005): http:// www.cepal.org 3. Secretaría de Salud (accessed July, 2005): http:// www.salud.gob.mx 4. Instituto Nacional de Estadística, Geografía e Informática (accessed July, 2005): http://www.inegi.gob.mx 5. García-García G, Monteon-Ramos JF, García-Bejarano H, Gomez-Navarro B, Hernandez Reyes I, Lomeli AM, et al. Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL). Kidney Int Suppl 2005;

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population, although this is not yet in practice. Results in this regard will be expected in future years. Hypoalbuminemia has repeatedly been shown a predictor of mortality in CAPD patients. In the Mexican setting, patients with a normal serum albumin level have significantly better survival than patients with hypoalbuminemia (19,21–23). Serum albumin is a marker of a number of different conditions but one of the most important is malnutrition, which is highly prevalent in the country’s PD population. The frequency of malnutrition in Mexican CAPD patients seems to be one of the highest reported worldwide, at 82% (31). In addition, women and diabetics in our population seem to be particularly prone to developing more severe malnutrition (31). Recently, it has been demonstrated that the oral administration of a dried egg albumin-based supplement may improve the nutritional status of these malnourished patients (32); such a safe, effective, and cheap measure may be of utility for this huge problem. Other populations that might be at increased risk for malnutrition and subsequent mortality while on CAPD treatment are those with a high peritoneal transport rate. Patients with fast peritoneal transport develop the lowest serum albumin levels (33), which in turn may be partially explained by greater protein loss into the dialysate (34). A direct correlation between peritoneal transport rate and malnutrition, however, has not been clearly demonstrated. Even though, in a cross-sectional study performed in Mexican patients, a negative association between serum albumin and peritoneal transport rate was reported, a correlation between transport rate and nutritional status (evaluated by a nutritional index including clinical, biochemical, and anthropometric variables) was not supported (35). Alternatively, a higher inflammatory status present in those patients with high peritoneal transport rate (higher serum C-reactive protein and serum and dialysis interleukin 6 levels) in our setting (36) may explain their higher mortality, and could influence the development of malnutrition. Before the introduction of double-bag disconnect systems in Mexico, technique survival at 1, 3, 5, 8, and 10 years was reported as 82%, 61%, 40%, 29%, and 18%, respectively (19). More recently in our hospital, and with the employment of double-bag systems, technique survival at 1, 2, and 3 years was 90%, 61%, and 50%, respectively. The most significant predictive factors for technique failure seem to be DM status, peritonitis, lymphopenia, and hypoalbuminemia (19). The peritonitis and exit-site infection rates with the conventional “standard spike” connection system were 1.0 ± 2.8 and 0.3 ± 1.3 episodes/patient/year respectively (19). Double-bag systems have clearly improved the peritonitis rate

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Nephrol 2002; 13:1307–20. 22. Gamba G, Mejia JL, Saldivar S, Pena JC, Correa-Rotter R. Death risk in CAPD patients. The predictive value of the initial clinical and laboratory variables. Nephron 1993; 65: 23–7. 23. Cueto-Manzano AM, Correa-Rotter R. Is high peritoneal transport rate an independent risk factor for CAPD mortality? Kidney Int 2000; 57:314–20. 24. Lerman IG, Villa AR, Martinez CL, Cervantes Turrubiatez L, Aguilar Salinas CA, Wong B, et al. The prevalence of diabetes and associated coronary risk factors in urban and rural older Mexican populations. J Am Geriatr Soc 1998; 46:1387–95. 25. West SK, Klein R, Rodriguez J, Muñoz B, Broman AT, Sanchez R, et al. Diabetes and diabetic retinopathy in a Mexican-American population: Proyecto VER. Diabetes Care 2001; 24:1204–9. 26. Velazquez-Monroy O, Rosas Peralta M, Lara Esqueda A, Pastelin Hernandez G, Sanchez-Castillo C, Attie F, et al. Prevalence and interrelations of noncommunicable chronic diseases and cardiovascular risk factors in Mexico. Arch Cardiol Mex 2003; 73:62–77. 27. Cueto-Manzano AM, Cortés-Sanabria L, Martínez-Ramírez HR, Rojas-Campos E, Barragan G, Alfaro G, et al. Detection of early nephropathy in Mexican type 2 diabetes mellitus patients. Kidney Int Suppl 2005; 97: S40–5. 28. Martínez-Ramírez HR, Jalomo-Martínez B, CortésSanabria L, Rojas-Campos E, Barragán G, Alfaro G, et al. Renal function preservation in type 2 diabetes mellitus patients with early nephropathy: a comparative prospective cohort study between primary health care doctors and a nephrologist. Am J Kidney Dis 2006; 47:78–87. 29. Consejo Nacional de Población (accessed: February, 2006): http://www.conapo. gob.mx 30. Treviño A. La Insuficiencia Renal Crónica en México. Mexico City; Editorial Manual Moderno; 2001. 31. Espinosa A, Cueto-Manzano A, Velázquez C, Hernández A, Cruz N, Zamora B, et al. Prevalence of malnutrition in Mexican CAPD diabetic and non-diabetic patients. Adv Perit Dial 1996; 12:302–6. 32. González-Espinoza L, Gutiérrez-Chávez J, Martín del Campo F, Martínez-Ramírez HR, Cortés-Sanabria L, RojasCampos E, et al. Randomized, open-labeled, controlled clinical trial of the oral administration of an egg albuminbased protein supplement on continuous ambulatory peritoneal dialysis patients. Perit Dial Int 2005; 25:173–80. 33. Díaz A, Gamba G, Abasta-Jiménez M, Correa-Rotter R. Serum albumin and body surface area are the strongest predictors of the peritoneal transport type. Adv Perit Dial 1994; 10:47–51. 34. Cueto-Manzano AM, Gamba G, Correa-Rotter R. Peritoneal protein loss in patients with high peritoneal permeability. Comparison between continuous ambulatory peritoneal dialysis and daytime intermittent dialysis. Arch Med Res 2001; 32:197–201. 35. Cueto-Manzano AM, Espinosa A, Hernández A, Correa147

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97:S58–61. 6. Centro Nacional de Trasplantes (accessed July, 2005): http://www.cenatra. gob.mx 7. Breien Alcaraz H, García Bejarano H, García García G, Gómez Navarro B, Hernández Reyes I, Lomeli AM, et al. Epidemiología de la insuficiencia renal crónica en Jalisco. Boletín del Colegio Jalisciense Nefrología 2001; 5:6–8. 8. Cusumano AM, Di Gioia C, Hermida O, Lavorato C, on behalf of the Latin American Registry of Dialysis and Renal Transplantation. The Latin American Dialysis and Renal Transplantation Registry annual report 2002. Kidney Int Suppl 2005; 97:S46–52. 9. Cueto-Manzano AM. Peritoneal dialysis in Mexico. Kidney Int Suppl 2003; 83:S90–2. 10. Westman J. Worldwide dialysis update. In: Annual Survey. Deerfield, IL: Baxter Healthcare Inc.; 1993. 11. Su-Henrández L, Abascal-Macias A, Mendez-Bueno FJ, Paniagua R, Amato D. Epidemiologic and demographic aspects of peritoneal dialysis in Mexico. Perit Dial Int 1996; 16:362–5. 12. United States Renal Data System (accessed: July, 2005): http://www.usrds.org 13. Australia and New Zealand Dialysis and Transplant Registr y (ANZDATA) (accessed: July, 2005): http:// www.anzdata.org.au 14. European Renal Association and European Dialysis and Transplantation Association (ERA-EDTA) Registry (accessed: July, 2005): http://www.era-edta-reg.org/ index.jsp. 15. Sociedad Latino-Americana de Nefrología e Hipertensión (SLANH) (accessed: July, 2005): http://www.slanh.org. 16. Otero Cagide F, Schettino MA, Rodríguez Rodríguez A, Aguilar Martinez C, Barzalobre Sanchez A, Cardona Chavez JG, et al. Cost effectiveness analysis in patients with chronic renal insufficiency in dialysis. Nefrología Mexicana 2002; 23:147–56. 17. Cueto-Manzano AM, Rojas-Campos E, Rosales G, Gómez B, Martinez HR, Cortés-Sanabria L, et al. Risk factors for longterm graft lost in kidney transplantation: experience of a Mexican single center. Rev Invest Clin 2002; 54:492–6. 18. Sabath E, Vega O, Correa-Rotter R. Referencia temprana al nefrólogo: impacto sobre la hospitalización inicial y los seis primeros meses en diálisis peritoneal continua ambulatoria. Rev Invest Clin 2003; 55:489–93. 19. Cueto-Manzano AM, Quintana-Piña E, Correa-Rotter R. Long-term CAPD survival and analysis of mortality risk factors: 12-year experience of a single center. Perit Dial Int 2001; 21:148–53. 20. Garcia G, Briseño G, Luquin H, Ibarra M, Cueto A. Timing of dialysis initiation and patient survival among disadvantaged populations in Mexico [Abstract SA-PO402]. J Am Soc Nephrol 2004; 15:390A. 21. Paniagua R, Amato D, Vonesh E, Correa-Rotter R, Ramos A, Moran J, et al. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. J Am Soc

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Rotter R. Peritoneal transport kinetics correlate with serum albumin but not with the overall nutritional status in CAPD patients. Am J Kidney Dis 1997; 30:229–36. 36. Cueto-Manzano AM, Salazar M, Valera-Gonzalez I, RojasCampos E, Martinez-Ramirez HR, Cortes-Sanabria L, et al. Association between the peritoneal transport rate and systemic inflammation marker in continuous ambulatory peritoneal dialysis (CAPD) [Abstract]. J Am Soc Nephrol

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2002; 13:201A. 37. Monteón F, Correa-Rotter R, Paniagua R, Amato D, Hurtado ME, Medina JL, et al. Prevention of peritonitis with disconnect systems in CAPD: a randomized controlled trial. Kidney Int 1998; 54:2123–8. 38. Garcia G, Tachiquin N, Ibarra M, Luquin H, Cueto A. Risk of peritonitis among poor CAPD patients in Mexico [Abstract SU-PO290]. J Am Soc Nephrol 2004; 15:597A.

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