End-stage renal disease and its treatment in Latin America in the twenty-first century.

The Latin American Society of Nephrology and Arterial Hypertension's Dialysis and Transplant Registry was chartered in 1991. It collects information on ESRD and its treatment in 20 countries of the region. The prevalence of patients on renal replacement therapy (RRT) increased from 129 pmp in 1992 to 447 pmp in 2004; in 2004, 56% of the patients were on hemodialysis, 23% on peritoneal dialysis, and 21% had a functioning kidney graft. The highest rates of prevalence were reported in Puerto Rico (1027 pmp), Chile (686 pmp), and Uruguay (683 pmp). Hemodialysis was widely used, except in El Salvador, Mexico, Guatemala, Nicaragua, and the Dominican Republic, where peritoneal dialysis predominated. Incidence rate increased from 27.8 pmp to 147 pmp in the same period of observation; the lowest rate was reported in Guatemala (11.4 pmp) and the highest in Puerto Rico (337.4 pmp). Diabetes mellitus was the leading cause of renal failure in incident patients; the highest rates were reported in Puerto Rico (62.2%) and Mexico (60%). Forty-four percent of the incident population were older than 65 years. Access to renal replacement therapy was universal in Argentina, Brazil, Chile, Cuba, Puerto Rico, Uruguay, and Venezuela, while was restricted in other countries. Main causes of death in dialysis were cardiovascular (44%) and infectious disease (26%). The rate of renal transplantation increased from 3.7 pmp in 1987 to 14.5 in 2004; fifty-three percent of the organs came from cadavers. Overall, donation rate was 5.9 pmp. In conclusion, the prevalence and incidence rates have increased over the years, and diabetes mellitus has emerged as the leading cause of kidney disease in the region. Although the rate of kidney transplantation has increased, the number remains insufficient to match the growing demand. The implementation of renal health programs in the region is urgently needed.

Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela.

Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela. Numerous studies have documented the presence of racial and minority disparities regarding the impact of renal disease and access to renal replacement therapy (RRT). This problem is less well documented in Latin America. Venezuela, like most countries in the region, is subject to severe constraints in the allocation of resources for high-cost chronic diseases, which limits the access of patients with chronic kidney disease to RRT. Although access to health care is universal, there is both a deficit in coverage and disparity in the access to RRT, largely as a result of socioeconomic limitations and budget constrains. With current rising trends of the incidence of end-stage renal disease (ESRD) and costs of medical technology, the long-term goal of complete RRT coverage will become increasingly out of reach. Current evidence suggests that prevention of progression of renal disease is possible at relatively low cost and broad coverage. Based on this evidence, the Ministry of Health has redesigned its policy with respect to renal disease based on 4 elements: 1. Prevention by means of early detection and referral to multidisciplinary health teams, as well as promotion of health habits in the community. 2. Prevention of progression of renal disease by pharmacologic and nonpharmacologic means. 3. An increase in the rate of coverage and reduction of disparities in the access to dialysis. 4. An increase in the rates of renal transplantation through better organ procurement programs and reinforcement of transplant centers. However, the projected increase in the number of patients with ESKD receiving RRT will represent a serious burden to the health care system. Therefore, implementation of these policies will require the involvement of international agencies as well as an adequate partnership between nephrologists and health care planners, so that meeting the increasing demands of ESKD programs may be balanced with other priorities of our national health system.

Organ and tissue procurement system: a novel intervention to increase organ donation rates in Venezuela.

The limited number of organs and tissues available for transplantation in Venezuela and the need to improve outcomes for patients with life-threatening end-stage organ failure or inadequate quality of life resulted in the development and implementation of an organ and tissue procurement system by the Venezuelan National Transplant Organization. This procurement system, a 24-hour, nationwide, free phone service for detection of potential organ donors, connects callers with transplant coordinators. The on-call coordinator supervises family approach as well as maintenance, transport, and allocation of the organs and tissues. During a period of 21 months, the phone service received 1191 calls (713 requesting information to become a voluntary donor, 207 requesting information about donation and transplantation, and 271 reporting potential donors). Of the potential donors, 74% were men and 67% were aged between 11 and 40 years, and most came from hospital intensive care units, emergency departments, and trauma shock units. The main causes of death were trauma and stroke. Reasons why donation was not accomplished included early cardiorespiratory arrest and denied consent. In conclusion, establishing the procurement system resulted in an increase in the detection, referral, and maintenance of potential donors; doubling of the number of donors per million population; and an increase in the number of cadaveric transplants.

Transplant coordination program: a useful tool to improve organ donation in Venezuela.

Donor shortage is the single most important limitation for allowing adequate growth of transplant programs. Transplant coordination programs have been shown to provide solutions to this situation worldwide. To evaluate the efficacy of transplant coordination programs in Venezuela, a pilot program was implemented at a 1200-bed teaching hospital. The implementation of this program included an assessment of the hospital's donation practices such as donor identification, maintenance, brain-death diagnosis, family consent for donation, and timely transport and allocation of organs and tissues. A follow-up 1 year after the implementation of the transplant coordination program demonstrated a 7-fold increase in the number of donors compared with the 2 previous years when the program did not exist. During the first year of application, the transplant coordination program resulted in solutions in how to address issues surrounding the procurement process in a hospital with a high potential donor rate; a linkage between the coordinator and the medical staff through educational activities; increased skills of hospital staff; and a methodology that should be applied extensively in hospitals with high donor potential to deal with the organ shortage.

End-stage renal disease and its treatment in Venezuela.

In Venezuela there are 3234 new cases (132 per million population [pmp]) requiring renal replacement therapy each year, and only 40% of these are admitted to the different modalities of dialysis. In the year 2000, there were 195 patients pmp in chronic hemodialysis (4700 patients). Diabetes, glomerular diseases, and hypertension account for more than 60% of the patients in chronic dialysis. Gross mortality in hemodialysis is around 20%, and cardiovascular causes are the primary cause of death (39.5%). Hospital admission in the dialysis patients amounts to 4.6 days/patient/year. Rehabilitation is inadequate. Only 45% of the dialysis patients report normal home or work activities. Transplantation in Venezuela has a general graft survival rate of 83% at 1 year (90% for living related grafts) and 50% (64% for living related grafts) at 10 years. Future tendencies include emphasis in preventive strategies, including early detection and treatment of diabetes and hypertension, as well as efforts to increase the rate of renal transplantation.

Seguridad en la conversión de ciclosporina tradicional a ciclosporina como microemulsión en trasplante renal estable: estudio cooperativo / Safety of the conversion of cyclosporine a to cyclosporine in microemulsion in stable renal transplant patient: a colaborative study

Estudios recientes evidencian que la presentación en microemulsión de la ciclosporina ofrece ventajas gracias a un perfil farmacocinético más estable y un manejo clínico de los pacientes más fácil. Con el objeto de evaluar la seguridad de la conversión 1:1 de ciclosporina tradicional (CyT) a ciclosporina en microemulsión (CyN) llevamos a cabo un estudio clínico abierto en 18 pacientes con transplante de riñon por más de 6 meses, con edad promedio de 40.9 ñ 3.2 años (rango 18-65), 56 por ciento del sexo femenino, quienes permanecieron en control durante todo el período de estudio. Después de dos semanas de observación, el estudio se dividio en dos fases: I: durante 4 semanas los pacientes recibieron CyT a una dosis fija promedio de 3.056 ñ 0.25 mg/Kg/d y una fase II: durante las siguientes 6 semanas cuando se realizó la conversión a CyN con ajustes de la dosis en caso necesario (dosis promedio administrada 2.887 ñ 0.21 mg/Kg/d). En ambas fases se realizó monitoreo semanal de evolución clínica, de parámetros de laboratorio que incluyeron función renal, niveles de Ciclosporina A (CyA), hematología y examen de orina asi como la aparición de efectos adversos. Los resultados no mostraron diferencias significativas en los parámetros de laboratorio en las diferentes fases, ni tampoco hubo diferencias en las dosis de ciclosporina administrada. En cuanto a la incidencia de efectos adversos en ambas fases se reportó hiperplasia gingival (5 por ciento) lo que se relacionó de manera "probable" a la ciclosporina y en la fase II se reportó temblor fino (17 por ciento) se relacionado "definitivamente" a la droga. Los pacientes manifestaron tolerar la droga "muy bien" en 72.23 por ciento de los casos y "bien" en 16.66 por ciento. En conclusión, nuestros hallazgos muestran que la conversión de CyT a CyN es segura y bien tolerada por los pacientes y considerando las ventajas en las propiedades farmacocinéticas que se reflejan en el manejo clínico y la ausencia de incremento de efectos adversos importantes, recomendamos el uso preferencial de CyN en el tratamiento inmunosupresor de pacientes con trasplante renal estable

Impacto del programa de coordinadores hospitalarios en la obtención de riñones para trasplante renal / Role of the transplant coordinator program in organ procurement for transplant

La dificultad para la obtención de órganos para trasplante es uno de los principales factores que limitan el desarrollo de los programas de reemplazo de órganos. En la búsqueda de altervativas para incrementar la donación de órganos, se llevó a cabo un estudio piloto del Centro Nacional de Diálisis y Trasplante con el Programa de Coordinadores Hospitalarios (PCH), durante 6 meses, para cumplir las siguientes funciones: difundir programas de educación contínua, detección y vigilancia de donantes potenciales, solicitud de autorización familiar e interconexión informativa. Se detectaron 45 predonantes con una edad promedio de 25.8 ñ 1.6 años, 36 del sexo masculino (80 por ciento). Ninguno estaba registrado como donante voluntario. Las principales causas de muerte fueron: los traumatismos cráneo-encefálicos en un 57.8 por ciento y los accidentes cerebrovasculares en 22.2 por ciento. El 42.3 por ciento de los predonantes fue detectado en los servicios de emergencia, 33.3 por ciento en las unidades de cuidado intensivo y el 24 por ciento en recuperación de cirugía. La efectividad de conversión de predonantes a donantes fue de 19 por ciento. El 71 por ciento no pudo ser convertido a donante efectivo por las siguientes causas: negativa de autorización familiar 44 por ciento, paro cardio-respiratorio precoz 13 por ciento, función renal alterada 6 por ciento, falta de apoyo ventilatorio 6 por ciento, antígeno de superficie para hepatitis B (+) 6 por ciento, no disponibilidad del equipo quirúrgico 3 por ciento. En el 9 por ciento restante no se reportó la causa. Se cpncluye que el Programa de Coordinación Hospitalaria es efectivo para la detección de pre-donantes, suministrando además una información útil tanto para determinar posibles fallas en el manejo de donantes potenciales como para evaluar y orientar las campañas de captación de donantes voluntarios

Necesidades y demanda de riñones para trasplante en Venezuela / Needs and demands of kidneys for transplantantion in Venezuela

El número de donantes de órganos disponibles para trasplante en la actualidad es insuficiente. A pesar de múltiples esfuerzos realizados, no se ha logrado hasta la fecha mejorar esa deficiencia. Esto ha determinado un incremento progresivo de la lista de espera de órganos para trasplante. El objetivo principal de este trabajo es cuantificar la necesidad de riñones para trasplante, así como la oferta de los mismos en relación a la demanda en Venezuela. Se presenta un resumen de la actividad de trasplante renal en el país, apreciándose que a partir de 1993 hay un predominio de los trasplantes con donante cadavérico, sin llegar a un nivel óptimo. La actividad anual de trasplante se estabilizó entre 1989 y 1991 en 6 trasplantes /millón de habitantes, decreciendo dicha tasa a 4,3 en 1992. El cálculo del número de donantes necesario para cubrir la demanda real existente corresponde a 10 donantes/millón de habitantes. Esto contrasta con la tasa de donación de solo 2.01 y 1.92 donantes/millón alcanzada en 1990 y 1991 respectivamente. La causa más frecuente de no donación fue la ausencia de autorización familiar. Basados en el análisis de los factores que inciden en la escasez de órganos para trasplante se presentan algunas recomendaciones para aumentar la disponibilidad de donantes de órganos en el país. Estas medidas incluyen mejorar algunos aspectos educativos y legales en el campo de la donación de órganos e iniciar un programa de coordinadores hospitalarios de trasplante, siguiendo el modelo español, que puedan detectar y evaluar los donantes potenciales así como coordinar los aspectos logísticos del trasplante