Accessibility and growth of hemodialysis in Latin America

On 31 December 2021, a total of 449,683 patients were included in KRT in LA, corresponding to an overall unadjusted prevalence of 872 per million persons (pmp) (Table 1). The prevalence ranged from 2.894 pmp in Puerto Rico to 89 pmp in Nicaragua. Eleven countries showed a rate greater than 700 pmp (Argentina, Brazil, Chile, Colombia, Ecuador, El Salvador, Guatemala, the estates of Jalisco and Aguascalientes (Mexico), Panama, Puerto Rico, and Uruguay) a prevalence outlined as the main objective to reach for the region by 2019, in the joint collaboration plan signed between Pan American Health Organization (PAHO) and SLANH. In 2021, the prevalence rate resumed the progressive increase previous to the pandemic, whose deleterious effect was notorious in 2020 (848 pmp) having been 866 pmp in 2019, 810 pmp in 2018, and 778 in 2017 (Fig. 1).

Figure 1. Unadjusted prevalence rates per million population (pmp) of patients in KRT. 

By treatment modality, 68% of the prevalent patients were treated by HD (n = 307.514) and 9% by PD (39.397) and 23% of the patients had a living functional graft (n = 102.772). HD continues to be the most prevalent modality over the years. While PD reached a plateau on its prevalence, KT increased steadily throughout the past 10 years (Fig. 2). HD was the most frequent modality in all countries except in Costa Rica, where LFG reached 224 pmp and PD 144 pmp while HD only 45 pmp. Considering both dialysis modalities together, these were more frequent compared to LFG in the region as a whole and in each country separately. Puerto Rico should be highlighted as the region with the highest prevalence of LFG (718 pmp) (Fig. 3).

Figure 2. Unadjusted prevalence rates per million population (pmp) of patients in kidney replacement therapy by modality. 

Figure 3. Unadjusted prevalence rates per million population (pmp) of patients under renal replacement therapy, by treatment modality. 

In 2021, 92,411 patients started KRT in LA, representing a total unadjusted incidence rate of 179 pmp (Table 1). The majority of the patients started KRT in HD modality while only 6% in PD. PD represented more than 10% of the incident modality in only nine countries (Jalisco/Aguascalientes [in Mexico] 11%, Argentina 15%, Chile 16%, Dominican Republic and El Salvador 22%, Panama 26%, Colombia 42%, Nicaragua 86%, and Costa Rica 88%).

Kidney transplant rate in the region was 16 pmp, varying from countries with rates close to 1 pmp in Peru and Venezuela to 68 pmp, as is the case of Jalisco/Aguascalientes (Table 1).

The total prevalence of KRT correlated positively with gross domestic product per capita and LEB (Fig. 4A and B).

Figure 4. (A) Association between gross domestic product per capita and prevalence of KRT pmp. (B) Association between life expectancy at birth and prevalence of KRT per pmp. 

Finally, great heterogeneity was reported in the number of nephrologist/population rate, from 3 pmp in Honduras to 52 pmp in Uruguay. Only Argentina, Brazil, Cuba, Ecuador, Puerto Rico, and Uruguay have more than 20 nephrologist pmp.

Fourteen countries reported data for mortality showing a significant heterogeneity between them. The overall unadjusted mortality rate was 17%.

Development of renal registries in Latin America

A patient registry is an organized system that applies methodology derived from observational studies to collect standardized data (clinical records and others) to evaluate specific results. Collected information is used to achieve predetermined scientific, clinical, or health policy purposes, such as describing the natural history and rising awareness of the disease, estimating the clinical and cost-effectiveness relationship of the products of healthcare services, and measuring or monitoring the risk profile and patient safety, as well as evaluating the quality of healthcare^6-8.

The implementation of a registry of patients with CKD (including all stages in the progression of disease) is difficult to achieve, given the high costs involved. On the other hand, patients with ESKD are easily accessible and constitute the most severe subgroup in terms of comorbidities and healthcare costs⁹.

A KRT registry (KRTR) involves the systematic and continuous collection of a population-based data set of patients with ESKD who are treated with dialysis or kidney transplant (KT). In this way, the KRTR represents a useful tool for epidemiological research and planning and improvement in quality of care, as well as enabling countries to monitor and evaluate the progress made. Moreover, it allows estimation of the impact of interventions on patients in their previous stages of CKD, and accordingly, planning of health-care policies to prevent disease progression. To that end, having good-quality records make it possible to set up the databases required to carry out such analyses. From this perspective, the capacity of a KRTR to achieve these objectives is based on the quality of its data and on the control procedures used to obtain quality information^9-11.

The lack of available data, particularly in emerging economies, leaves information gaps in health care and outcomes in patients with kidney disease¹². The heterogeneity, or even the absence, of KRTRs in some countries is consistent with the inequities in access to KRT for patients with ESKD worldwide^11,12. Many low- and middle-income countries (and also some high-income countries) do not have kidney registries yet, and if they do, the registries collect data on an incomplete and voluntary basis and at an aggregate level. In response to this inequality, various actions have been carried out at regional, as well as global, levels.

In 2014, the PAHO proposed to reach the prevalence of patients on dialysis for at least 700 patients per million inhabitants by 2019 in every LA country. Since then, PAHO and the SLANH have been providing training and certification courses for national delegates and workshops to strengthen the national registries and regional workshops to evaluate results and planning activities, with participation of representatives of all the 20 countries of SLANH¹³.

In this setting, the event included the participation of at least one representative of PAHO, a representative of the Ministry of Health, a representative of the National Society of Nephrology, and the current or potential delegates of the National Registry in each country. A visit to a dialysis centre (possibly public), where the case report originates for registration, and there was practical teaching activity of evaluation in situ with local actors. The preliminary results were variable and not uniform. There was a concordance between the characteristics of each country of the region and the results. The outcome always depended on the strength of the relationship between each of the main stakeholders: the National Nephrology Societies, the Ministry of Health, and the Social Security administration. Overall results also depended on the political scenario and continuity of the health-care policies.

In 2017, in Panama, it was possible to verify the progress in the construction and operation of the National Registries of almost all the participating countries, according to a novel classification of categories of registries by complexity and data quality¹³ (Table 2). PAHO and LARDRT provided technical support to a group of countries that showed significant progress (Dominican Republic, Panama, and El Salvador) and others that showed modest progress (Guatemala, Peru, Mexico, Paraguay, and Ecuador). The registries of Mexico and Brazil were still partial and did not cover the entire country. Honduras, Bolivia, and Costa Rica suggested little or no progress. The registries with the highest qualification were those from Argentina, Colombia, and Puerto Rico, followed by Uruguay and Cuba.

Despite these efforts, although the situation of KRTRs has improved in LA, the heterogeneity and inequities in their development still remain. Table 3 shows the current situation of the national LA dialysis and transplant registries, recently presented at the World Congress of Nephrology (Thailand, 2023).