Advances in Ethical, Social, and Economic Aspects of Chronic Renal Disease in Bolivia.

Since 2005, great progress has been made in health care provision to patients with terminal renal failure in Bolivia. Access to dialysis and transplantation is regulated by the Ministry of Health, based on clinical criteria, applied equitably, without favoritism or discrimination based on race, sex, economic means, or political power. Until December 2013, there were no restrictions in dialysis and transplantation in Health Insurance institutions, but they covered only 30% of the population. Now the remaining 70% has access to free dialysis funded by the communities where patients live, with funds coming from the government and taxes on oil products. More than 2,231 people are getting dialysis, reaching a population growth of >60% annually. The number of hemodialysis units has increased by >200% (60 units), making access easier for end-stage renal failure patients. Treatment protocols have been drawn up to guarantee the best quality of life for the patients. The Law on Donation and Transplantation was enacted in 1996, and Supplementary Regulations were enacted in 1997 with various amendments over the past 5 years. A National Transplant Coordination Board, working under the National Renal Health Program, supervises and regulates transplants and promotes deceased-donor transplantation in an attempt to cover the demand for donors. Rules have been drawn up for accreditation of transplant centers and teams to guarantee the best possible conditions and maximum guaranties. Since January 2014, the National Renal Health Program has been providing free kidney transplants from living donors.

Preemptive Renal Transplantation-The Best Treatment Option for Terminal Chronic Renal Failure.

Renal transplantation is the best therapeutic option for end-stage chronic renal disease. Assuming that it is more advisable if performed early, we aimed to show the clinical, social, and economic advantages in 70% of our patients who were dialyzed only for a short period. For this purpose, we retrospectively collected data over 28 years in 142 kidney transplants performed in patients with <6 weeks on dialysis. 66% of our patients were 30-60 years old; 98% of the patients had living donors. At transplantation, 64% of our patients had no public support; however, 64% of them returned to work and got health insurance 2 months later. Full rehabilitation was achieved in all cases, including integration to the family, return to full-time work, school and university, sports, and reproduction. Immunosuppression consisted of 3 drugs, including steroids, cyclosporine, and azathioprine or mycophenolate. The cost in the 1st year, including patient and donor evaluation, surgery, immunosuppression, and follow-up, was $13,300 USD versus $22,320 for hemodialysis. We conclude that preemptive renal transplantation with <6 weeks on dialysis is the best therapeutic option for end-stage renal failure, especially in developing countries such as Bolivia, where until last year, full public support for renal replacement therapy was unavailable.

Post-transplantation Infections in Bolivia.

Over 26 years, we found 46 infectious episodes in 350 kidney transplant recipients. Fifteen were urinary tract infections, recurrent in 4 patients. There were 8 cytomegalovirus infections, three of them fatal when intravenous (IV) ganciclovir was not available. Seven patients had a reactivation of tuberculosis (TB) in the pleura, cervical spine, lumbar spine, knee, ankle, skin and peritoneum, respectively, and were all resolved satisfactorily with conventional anti-TB therapy. Three patients transplanted before routine prophylaxis with the use of acyclovir developed an extensive herpes zoster infection in the 1st 6 months after transplantation, which was resolved with the use of oral acyclovir, and 1 had a disseminated herpes simplex infection resolved with the use of IV acyclovir. Three patients transplanted before routine prophylaxis with trimethoprim sulfa developed Pneumocystis carinii pneumonia in the 1st 6 months after transplantation, which was fatal in one of them. In 2 patients, we found a Nocardia infection, confined to the lung, which was cured in one of the cases and systemic and fatal in the other. Two patients transplanted before routine prophylaxis with the use of nystatin developed esophageal candidiasis in the 1st 6 months after transplantation. One patient developed infective endocarditis in a stenotic bicuspid aortic valve and died 10 years later after another incident of infective endocarditis at the prosthetic aortic valve. Two patients developed an extensive condyloma at the penis, perianal region, and perineum owing to human papillomavirus, requiring extensive surgical resection and podophyllin applications. Another patient developed fatal post-transplantation lymphoproliferative disease due to Epstein-Barr virus infection 15 years after transplantation. One patient developed a severe and fatal mucocutaneous leishmaniasis with no response to conventional antimonial therapy. It is interesting to note that despite Chagas disease being endemic in Bolivia, we had no patients with reactivation or transmission through the graft even though many of the patients and donors were serologically positive for Chagas disease.

The cardiac sodium channel mRNA is expressed in the developing and adult rat and human brain.

Expression of the rat (RH-I/SkM2) and human (hH1/SCN5A) tetrodotoxin-resistant (TTX-R), voltage-sensitive sodium channels is thought to be specific to cardiac tissue. We detected RH-I/SkM2 mRNA in newborn rat brain using both RNase protection assay analysis and in situ hybridization and in adult rat brain using RNase protection assay analysis. This expression was observed primarily in developing limbic structures of the cerebrum and diencephalon, and in the medulla of the brain stem. Using RT-PCR analysis, we detected hH1/SCN5A mRNA in both fetal and adult human brain. Interestingly, mutations in the human cardiac sodium channel are known to lead to cardiac abnormalities, which result in arrhythmias and frequently in sudden cardiac death. If these mutant channels were also expressed in limbic regions of the brain, alterations in channel function could have drastic effects on the brain's signaling ability, possibly promoting seizure activity.

Guía de archivos para la historia de los pueblos indigenas en Bolivia / Guide arvchives for the history of indegenous people in Bolivia

Esta Guía de archivos recoge la información disponible hasta hoy en torno a los archivos existentes en Bolivia: sus características físicas, el estudio de su conservación. Presenta información por ciudades y al interior de cada una, por archivos, tanto civiles como eclesiásticos. Se proporciona además una bibliografía sobre los archivos de cada ciudad, así como una bibliografía sobre fuentes impresas relacionadas a los pueblos indigenas

Guía de archivos para la historia de los pueblos indigenas en Bolivia / Guide arvchives for the history of indegenous people in Bolivia

Esta Guía de archivos recoge la información disponible hasta hoy en torno a los archivos existentes en Bolivia: sus características físicas, el estudio de su conservación. Presenta información por ciudades y al interior de cada una, por archivos, tanto civiles como eclesiásticos. Se proporciona además una bibliografía sobre los archivos de cada ciudad, así como una bibliografía sobre fuentes impresas relacionadas a los pueblos indigenas