Burden of disease: Closing the gaps in the burden of end-stage kidney disease in Latin America.

End-stage kidney disease (ESKD) represents a major challenge for Latin America (LA). The Latin American Dialysis and Renal Transplantation Registry (LADRTR) has published several reports, and its continuity has implied a sustained effort of the nephrology community to improve care of ESKD in the region; this paper summarizes results of the year 2014. Methods have been reported previously; participant countries complete annual surveys collecting data on incident and prevalent patients undergoing renal replacement therapy (RRT) in all modalities. 20 countries participated in the surveys (more than 90% of the region). Prevalence of treated ESKD in RRT increased from 119 patients per million population (pmp) in 1991 to 709 pmp in 2014; hemodialysis continues to be the treatment of choice in the region (68%). A wide variation was observed in the incidence rate, from 421 pmp in Jalisco (Mexico) to 23 pmp in Paraguay; diabetes was the cause of 36% of incident cases. Additionally, great heterogeneity was observed in the number of nephrologists by country, from 2 pmp in Colombia to 53 pmp in Uruguay. Heterogeneity, or even absence of registries in some LA countries, is concordant with inequities in RRT access as well as with the limited availability of qualified personnel. The LADRTR is leading the personnel training to develop and strengthen national dialysis and transplant registries in LA within the frame of the Pan-American Health Organization (PAHO) - Sociedad Latinoamericana de Nefrología e Hipertension (SLANH) cooperation program.

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

INTRODUCTION: End-stage 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 Per million population (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 availability of qualified personnel. The SLANH is currently running 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.

Latin American special project: kidney health cooperation project between Uruguay and Bolivia.

Uruguay and Bolivia are two countries that show heterogenicity of the Latin American region, including the national income, the expenditure on health and the services for renal care. In Bolivia, there is manpower shortage for renal care with only 5 nephrologists per million people (pmp) and the prevalence of patients on dialysis is only 200 pmp. This is much lower than the mean prevalence rate of renal replacement therapy for Latin America as a whole. Uruguay on the other hand has more dedicated renal resources with 50 nephrologists pmp, and renal replacement therapy is provided to ~ 1,000 dialysis patients pmp. In November 2012, a collaborative project financed by the Uruguayan International Cooperation Agency was signed by both the Uruguay and Bolivia Ministries of Health, and the goal was to develop a comprehensive program for the prevention and management of all stages of chronic kidney disease (CKD) in Bolivia. The specific objectives were to: a) promote renal healthcare in the primary healthcare setting, b) identify kidney disease in populations at risk, and c) optimize patient care at all stages of CKD, including dialysis and transplantation supported with a national ESRD registry in Bolivia. As a first step, delegates from the Bolivian Health Ministry, visited Uruguay in April 2014, primarily to strengthen the development of tools required for developing and maintaining a national registry. In addition, during this visit, a meeting with the president of the Latin American Society of Nephrology and Hypertension (SLANH) culminated in designing a training program for peritoneal dialysis. This highly cooperative relationship is advancing the prevention and care of CKD in Bolivia and may serve as a model for international approaches to advance system level CKD care in countries with limited healthcare resources.

Burden of disease: prevalence and incidence of ESRD in Latin America.

INTRODUCTION: Chronic kidney disease (CKD) represents a major challenge for Latin America (LA), due to its epidemic proportions and high burden to the population affected and to public health systems. METHODS: Our methods have been reported previously: This paper shows the data for the last 10 years until 2010, from the Latin American Dialysis and Renal Transplantation Registry (RLADTR). RESULTS: 20 countries participated in the surveys, covering 99% of Latin America (LA). The prevalence of end-stage renal disease (ESRD) under renal replacement therapy (RRT) in LA increased from 119 patients per million population (pmp) in 1991 to 660 pmp in 2010 (hemodialysis (HD) 413 pmp, peritoneal dialysis (PD) 135 pmp, and LFG 111 pmp). HD proportionally increased more than PD and transplant and continues to be the treatment of choice in the region (75%). The kidney transplant rate increased from 3.7 pmp in 1987 to 6.9 pmp in 1991 and to 19.1 in 2010. The total number of transplants in 2010 was 10,397, with 58% being deceased donors. The total RRT prevalence correlated positively with gross national income (GNI) (r = 0.86; p < 0.05) and life expectancy at birth (r = 0.58; p < 0.05). The global incidence rate correlated significantly only with GNI (r = 0.56; p < 0.05). Diabetes remained the leading cause of ESRD. CONCLUSION: The prevalence and incidence of RRT continues to increase. In countries with 100% public health or insurance coverage for RRT the rates are comparable to those displayed by developed countries with better GNI. PD is still an underutilized strategy for RRT in the region. Diagnostic and prevention programs for hypertension and diabetes, appropriate policies promoting the expansion of PD and organ procurement as well as transplantation as cost effective forms of RRT are needed in the region.

National kidney dialysis and transplant registries in Latin America: how to implement and improve them.

The Strategic Plan of the Pan American Health Organization, 2014-2019, Championing Health: Sustainable Development and Equityrecognizes that "Chronic kidney disease, caused mainly by complications of diabetes and hypertension, has increased in the Region." This Plan includes the first concrete goal on chronic kidney disease: to achieve a prevalence rate for renal replacement therapy of at least 700 patients per million population by 2019. National dialysis and transplant registries (DTR) are a useful tool for epidemiological research, health care planning, and quality improvement. Their success depends on the quality of their data and quality control procedures. This article describes the current situation of national DTRs in the Region and the content of their information and health indicators, and it offers recommendations for creating and maintaining them. It points to their heterogeneity or absence in some countries, in line with the inequities that patients face in access to renal replacement therapy. The complete lack of information in Caribbean countries prevents their inclusion in this communication, which requires immediate attention.

Utilization of peritoneal dialysis in the acute setting.

Peritoneal dialysis (PD), although classically described and utilized in the treatment of patients with end-stage renal disease, can also be utilized in the acute setting in different clinical situations. Recent studies showed that, in patients with acute renal failure, it is possible to obtain reasonable dialysis doses with adequate metabolic and electrolytic control and low incidence of complications by utilizing continuous PD through a cycler at high volume. In patients with congestive heart failure without end-stage renal disease, PD is capable of promoting clinical improvement with slow removal of liquids, becoming an attractive alternative for situations of rapidly or slowly worsening cardiac function. In patients submitted to chronic hemodialysis but who have vascular access difficulties, PD can also be utilized as a "bridge," thereby avoiding the use of central venous catheters, which can be associated with infectious complications such as bacterial endocarditis. New studies must be realized showing other indications for PD.

Overview of peritoneal dialysis in Latin America.

Latin America is a heterogeneous region comprised of 20 countries, former colonies of European countries, in which Latin-derived languages are spoken. According to the Latin American Society of Nephrology and Hypertension/Sociedad Latino Americana de Nefrologia e Hipertensión (SLANH), the acceptance rate for renal replacement therapy is 103 new patients per million population. In Latin America, hemodialysis is the predominant form of replacement therapy for end-stage renal disease; however, some countries employ peritoneal dialysis (PD) in 30% or more patients. In particular, Mexico is the country with the largest PD utilization in the world, and furthermore, it is estimated that approximately 25% of the world's PD population may be found Latin America. Data concerning clinical practice and long-term outcome of PD in Latin America are scarce, although regional registries are increasing in number and quality. In this review article, we present an overview of the situation of PD in several countries of Latin America, based on the registry of the SLANH, national registries, and personal communication with PD experts from different countries.

Online Continuing Medical Education for the Latin American Nephrology Community.

A continuing medical education (CME) course was implemented for Latin American nephrologists in 2013. The topic was Immunopathology in native and transplanted kidneys. The course was given in Spanish and Portuguese. The activities included a distance education seven-week asynchronous online modality with multiple educational strategies. Thirty hours of study workload were estimated to complete the course. Four hundred and ninety-eight physicians coming from 18 countries registered for the course; 442 of them participated in it. Of those who participated, 51% received a certificate of completion and 29% a certificate of participation. Sixty-five percent of registrants participated in the case discussions. Eighty-six percent were very satisfied and 13% were satisfied. Lack of time to devote to the course was the main limitation expressed (62%), while Internet access or difficulties in the use of technology were considered by only 12 and 6% of participants, respectively. There was a significant increase in knowledge between before and after the course; the average grade increased from 64 to 83%. In conclusion, technology-enabled education demonstrated potential to become an instrument for Latin American nephrologists.

Los registros nacionales de diálisis y trasplante renal en América Latina: cómo implementarlos y mejorarlos / National kidney dialysis and transplant registries in Latin America: how to implement and improve them

El Plan Estratégico de la Organización Panamericana de la Salud, 2014-2019, En pro de la salud: Desarrollo sostenible y equidad, reconoce que "La enfermedad renal crónica causada principalmente por las complicaciones de la diabetes y la hipertensión ha aumentado en la Región". En él se define por primera vez una meta concreta sobre la enfermedad renal crónica: alcanzar una prevalencia del tratamiento de sustitución de la función renal de por lo menos 700 pacientes por millón de habitantes en 2019. Los Registros de Diálisis y Trasplante (RDT) nacionales constituyen una herramienta útil para la investigación epidemiológica, la planificación de la atención de salud y la mejora de su calidad. Su éxito depende de la calidad de sus datos y los procedimientos de control de calidad. En este artículo se describen la situación actual de los RDT nacionales de la Región, sus contenidos informativos e indicadores de calidad, y ofrecen recomendaciones para crearlos y mantenerlos. Se destaca su heterogeneidad o ausencia en algunos países en consonancia con las inequidades de acceso a los tratamientos de reemplazo renal que afrontan los pacientes. La carencia total de información en países del Caribe impide incluirlos en esta comunicación, lo que requiere inmediata atención.

The Strategic Plan of the Pan American Health Organization, 2014-2019, Championing Health: Sustainable Development and Equityrecognizes that "Chronic kidney disease, caused mainly by complications of diabetes and hypertension, has increased in the Region." This Plan includes the first concrete goal on chronic kidney disease: to achieve a prevalence rate for renal replacement therapy of at least 700 patients per million population by 2019. National dialysis and transplant registries (DTR) are a useful tool for epidemiological research, health care planning, and quality improvement. Their success depends on the quality of their data and quality control procedures. This article describes the current situation of national DTRs in the Region and the content of their information and health indicators, and it offers recommendations for creating and maintaining them. It points to their heterogeneity or absence in some countries, in line with the inequities that patients face in access to renal replacement therapy. The complete lack of information in Caribbean countries prevents their inclusion in this communication, which requires immediate attention.

Infective endocarditis in chronic haemodialysis: two treatment strategies.

BACKGROUND: Infective endocarditis (IE) is more frequent in patients on chronic haemodialysis (CHD) than in the general population and vascular access is the more frequent identified port of its entry. According to experimental and clinical studies the vascular access may also interfere with the treatment of IE. To improve the treatment of IE in CHD, patients were temporarily switched to peritoneal dialysis (PD) after the removal of the vascular access. In this preliminary report the outcome of IE in those CHD patients switched to PD is compared with the outcome in IE patients who remained on CHD. METHODS: All cases of IE that occurred during a 5 year period were retrospectively analysed. The Duke criteria for IE were used for diagnosis. All patients underwent transoesophageal echocardiography. All patients were treated with the same schedule of antibiotic treatment. The vascular access of a patient was removed when it was judged to be the source of infection. RESULTS: Twenty-one patients were studied. Twelve patients had been temporarily switched to PD after the diagnosis of IE and nine patients had remained on CHD treatment. There were not statistically significant differences between the two groups with respect to demographic data, comorbid diseases and the frequency of Staphylococcus aureus as the causative germ. In-hospital mortality was 8.3% in patients switched to PD and 55.5% in patients maintained on HD (P: 0.03). CONCLUSIONS: The data presented here suggest that the high mortality of IE in CHD patients may also be associated with the vascular access necessary for HD. If these results are confirmed by prospective studies with higher numbers of patients, PD could turn out to have a place in the treatment of IE in CHD patients.

Utilidad de la ecografía para la cateterización venosa central en pacientes en hemodiálisis periódica / Usefulness of ultrasound for central venous catheterization in patients on regular hemodialysis

Introducción: las complicaciones asociadas a la colocación de catéteres venosos centrales son frecuentes. El objetivo de este estudio es analizar los resultados de la aplicación de la ecografía para la colocación de los accesos venosos en pacientes en hemodiálisis periódica. Método: se realizaron 122 procedimientos en 101 pacientes en tratamiento hemodialítico periódico. Las punciones se realizaron en la vena yugular interna (VYI). Se realizó previamente valoración ecográfica de la región. En 94 procedimientos la punción se realizó guiada por ecografía. Resultados: sesenta y seis pacientes tenían ambas VYI normales. Treinta y dos pacientes tenían una sola VYI normal y tres pacientes tenían ambas trombosadas. La VYI derecha se comprobó trombosada o chica en 27,7% de los pacientes, y la izquierda trombosada, chica o ausente, en 10% de los pacientes. La punción fue exitosa en 119 venas yugulares puncionables. En 74,8% de los casos la punción guiada por ecografía se realizó en el primer intento. En 4,2% se realizó en el segundo o tercer intento. En 21,0% la punción se realizó a ciegas luego de identificar la VYI por ecografía. Se puncionó la arteria carótida en un caso (0,8%). Fue la única complicación relacionada con la punción. Conclusiones: se comprobó una elevada frecuencia de anomalías en la VYI en los pacientes estudiados. El procedimiento de punción precedido de ecografía, así como la punción guiada por ecografía, permitió alcanzar un porcentaje elevado de éxitos y minimizar las complicaciones.

Summary Background. Complications associated with central venous catheterization procedures are frequent. The aim of this study is to analyze the outcomes of echography for venous procedures in patients on periodic haemodialysis. Methods. A hundred and twenty-two (122) procedures were performed in 101 patients on periodic haemodialysis. Punctures were performed in the internal jugular vein (IJV) previous echographic assessment of the puncture site. Many procedures (94) were guided by ecography. Results. Sixty-six patients had normal IJV, 32 patients had only one normal IJV and 3 had both veins with thrombus. Thrombotic or small right IJV was seen in 27,7% patients while thrombotic, small or absent left IJV in 10%. Puncture procedures succeeded in 119 jugular veins. In 74,8% cases, a guided puncture by echography was performed at the first attempt, while 4,2% at the second or third attempt. Punctures were performed after identifying IJV by echography in 21,0%. One complication related to punctures occurred: the carotid artery was punctured in one case (0,8%). Conclusions. Abnormalities in IJV were frequent in the studied group of patients. Both preceded or guided punctures were successful, and minimized complications.

Résumé Introduction: Les complications associées à la mise de cathéters veineux centraux sont fréquentes. Le but de ce travail est d'analyser les résultats de l'application de l'échographie pour le placement des accès veineux chez des patients en hémodialyse périodique. Méthode: on a analysé 122 procédés chez 101 patients en traitement hémodialytique périodique. Les ponctions ont été faites dans la veine jugulaire interne (VJI). On avait fait au préalable une évaluation échographique de la région. A 94 procédés la ponction a été guidée par échographie. Résultats: 66 patients avaient les deux VJI normales. 32 patients en avaient une seule normale et trois patients en avaient les deux thrombosées. La VJI droite s'est montrée thrombosée ou étroite à 27,7% des patients, et la gauche thrombosée, étroite ou absente à 10% des patients. La ponction a eu du succès dans 119 veines jugulaires ponctionables. A 74,8% des cas la ponction guidée pas échographie a été faite au premier essai. A 4,2% , au deuxième ou troisième essai. A 21,0% la ponction a été faite en aveugle, après avoir identifié la VJI par échogra-phie. Une fois on a ponctionné l'artère carotide (0,8%). Elle a été la seule complication liée à la ponction. Conclusions: On a constaté une fréquence élevée d'anomalies à la VJI chez les patients étudiés. Le procédé de ponction précédé d'échographie, ainsi que la ponction guidée par échographie, ont permis d'atteindre un haut pourcentage de succès et de diminuer les complications.

Evaluación del programa de diálisis para el tratamiento de la insuficiencia renal crónica en el Uruguay / Evaluation of the dialysis program for treatment of patients with chronic renal failure in Uruguay

El programa de Diálisis y Trasplante Renal para el tratamiento de los pacientes con insuficiencia renal crónica comenzó en el Uruguay en 1980, con la creación del Fondo Nacional de Recursos (FNR) que permitió financiar la diálisis y el trasplante renal. Se puede estimar que antes de esta fecha, alrededor de 400 personas con insuficiencia renal crónica fallecían anualmente en nuestro país sin recibir tratamiento de sustitución de la función renal. A partir de 1981, el número de pacientes en tratamiento y el número de nuevos pacientes ingresados cada año ha aumentado progresivamente. En diciembre de 1998, 2322 personas, 717 por millón de población (pmp), estaban en tratamiento de sustitución de la función renal; 2069 en tratamiento con diálisis y 253 con un trasplante renal funcionante. En el año 1998 ingresaron a diálisis 432 pacientes, siendo la tasa de incidencia 133 pmp. Estas tasas muestran que el Programa ofrece una aceptable cobertura asistencial a los pacientes con insuficiencia renal extrema. Los resultados del Programa son similares a los registrados en países desarrollados. La valoración de la aptitud física de los pacientes en 1998 mostró que el 57,9 por ciento fueron catalogados con actividades sin limitaciones y 3,5 por ciento fueron considerados incapaces de autocuidado. La expectativa de vida de los pacientes en diálisis ha aumentado en el período 1981-1998. La tasa de mortalidad no ajustadas descendió desde 24,9 por ciento en 1981 a 13,8 por ciento en 1998. Durante el período, aumentó el promedio de edad de los pacientes en tratamiento y la evolución de las tasas de mortalidad ajustadas mostró que si se hubiera mantenido constante el promedio de edad y la distribución por sexo y nefropatía, el descenso de la mortalidad en el período hubiese sido 72,9 por ciento. La comparación estandarizada para edad con la mortalidad de la población general del Uruguay mostró que la mortalidad en diálisis era 17 veces mayor que la de la población general en 1981 y que disminuyó a solo 4 veces mayor en 1998. La obtención de mejores resultados observados durante el período 1981-1998, podría atribuirse, entre otras causas, a la mejor calidad del tratamiento, vinculada a la adquisición de experiencia, al uso de mejor tecnología y a la mejor distribución de los centros de diálisis en todo el país, que ha permitido que los pacientes pueden acceder al tratamiento sin necesidad de grandes desplazamientos...

Encuesta epidemiológica de hipertensión arterial en Montevideo: prevalencia, factores de riesgo, plan de seguimiento / Epidemiologic survey of arterial hypertension in Montevideo: prevalence, risk factors, follow-up plan

Se presentan los resultados de un análisis de la encuesta sobre hipertensión arterial (HA) realizada en Montevideo, Uruguay en 1986. Se encuestaron 1.392 personas. La prevalencia estandarizada de HA en la población de Montevideo fue 20 por ciento. Entre los hipertensos (n=402), 71 por ciento tenía cifras elevadas de presión arterial en el momento de la encuesta. En el análisis multivariado, las variables significativamente asociadas a HA, ordenadas según su importancia, fueron: edad, obesidad, antecedentes familiares de HA, nefropatía, diabetes, personalidad ansiosa y sedentarismo. La estimación de riesgo de HA en una persona menor de 40 años, sin ninguno de los factores considerados en este análisis, es de 1.67 por ciento. Si tiene antecedentes familiares de HA, el riesgo aumenta a 4,7 por ciento. Si además presenta todos los factores potencialmente reversibles (obesidad, personalidad ansiosa y sedentarismo), la probabilidad de HA llega a 34,9 por ciento. Los resultados, para una persona entre 40 y 60 años, son 13.3, 31.7 y 83.6 por ciento y para una persona mayor de 60 años, son 33.6, 60.4 y 97.7 por ciento respectivamente. En un plazo mayor de 5 años se realizará una segunda encuesta a las mismas personas para estudiar incidencia de HA, evolución, morbilidad y mortalidad de la población de hipertensos