Survival among patients with kidney failure in Jalisco, Mexico.

ESRD is a serious public health problem in the state of Jalisco, Mexico. This study evaluated mortality in poor patients who initiated dialysis at the Jalisco Health Secretariat, compared with Hispanic patients without medical insurance who initiated dialysis in the United States. All patients who received a diagnosis with ESRD between February 1 and December 31, 2003, were studied prospectively at a single institution that provides care to the poor of Jalisco. Data from an American national dialysis registry and Cox proportional hazards models were used to compare the adjusted survival among Jalisco patients with that of a contemporaneous group of incident Hispanic patients who did not have Medicare or private insurance cover and who initiated peritoneal dialysis in the United States. Of 274 consecutive patients who presented with a clinical diagnosis of ESRD in Jalisco, mean estimated GFR at dialysis initiation was very low (3.9 +/- 2.4 ml/min per 1.73 m(2)), and <10% were previously known to a nephrologist. Of the 274 patients, 102 (37.2%) did not initiate dialysis therapy, 71 (69.6%) of whom died during follow-up. The majority (n = 49) of such deaths occurred in-hospital before dialysis initiation. Of 172 patients who initiated dialysis, 36 (20.9%) died within the first 90 d of renal replacement therapy. An additional 31 (18.0%) patients died during a median follow-up of 186 d. When all 274 Jalisco patients who presented with ESRD were considered, survival was 49.6% at the end of follow-up. Unadjusted mortality rates among those who survived at least 90 d after dialysis initiation were 19.2 (95% confidence interval [CI] 13.5 to 27.3) and 5.9 (95% CI 4.6 to 7.7) per 100 patient-years in Jalisco and American patients, respectively. After adjustment, the risk for death remained nearly three-fold higher in Jalisco patients (hazard ratio 2.7; 95% CI 1.5 to 4.7). Poor patients with kidney failure in Jalisco have very advanced disease at the time of first nephrologic contact and have exceedingly high rates of mortality after dialysis initiation. Our findings demonstrate a tremendous opportunity to reduce morbidity and mortality from kidney disease in Jalisco and perhaps other regions of Mexico.

Risk of peritonitis among disadvantaged CAPD patients in Mexico.

BACKGROUND/AIMS: Continuous ambulatory peritoneal dialysis is the first-choice treatment for ESRD in Mexico. Peritonitis is the most frequent cause of morbidity and is among the leading causes of technique failure in our country. Our objective was to compare the efficacy of the standard and double-bag disconnect systems for the prevention of peritonitis in a high-risk population with poor living standards, and high prevalence of malnutrition and diabetes rates. METHODS: Episodes of peritonitis registered between July 1989 and June 2003 were included. Patients were divided in conventional and double-bag groups. Between July 1989 and May 1999, all patients used the conventional system. From May 1999, all incident patients were placed on a double-bag disconnect system. RESULTS: Six-hundred and forty-seven patients started dialysis in the study period, 383 in the conventional group, and 264 in the double-bag. The peritonitis rate observed was 1 episode per 7.2 patient-months in the conventional group, and 1 episode per 25.1 patient-months in the double-bag system (p < 0.001). Cumulative peritonitis-free survival rate at 6 (50 vs. 82%), 12 (27 vs. 69%) and 24 (12 vs. 45%) months, respectively, was significantly lower in the conventional group (p < 0.001). Technique survival at 1 (75 vs. 85%), 2 (68 vs. 80%), and 3 years (50 vs. 80%), was worse in the conventional group (p < 0.001). By multivariate analysis, the only factor associated with peritonitis was the connecting system. CONCLUSIONS: We conclude that switching from a standard to a double-bag system using electrolytically produced sodium hypochlorite disinfectant markedly decreased the peritonitis rate, even in a high-risk population like ours.

Cardiovascular risk factors in the Mexican population.

Chronic degenerative disorders have become a major health problem in Mexico. Cardiovascular diseases represent the first cause of death in our country. Diabetes mellitus (DM) has emerged as the main health problem in Mexico. Its prevalence doubled from < 3% in the 1960s to 6% in the 1980s. Between 1993 and 2000, diabetes mellitus increased from 6.7% to 8.2%, a 22% growth over a seven-year period. In 1995, the cost of the treatment of DM represented 15.48% of the health budget and 0.79% of the GDP. The prevalence of hypertension (HTN) increased from 10% in 1933 to 20% in 1990 and from 23.8% to 30.7% between 1993 and 2000. The expenditures from HTN in 1999 corresponded to 13.9% of the health budget, and 0.71% of GDP. Dyslipidemias are very common. Close to 40% of the population has levels of HDL cholesterol < 35 mg/dL, 24.3% has fasting triglycerides > 200 mg/dL, and 10% has hypercholesterolemia. The prevalence of obesity increased from 21.4% in 1993, to 23.7% in the year 2000. Eight percent of the population has a glomerular filtration rate < 60 mL/min, and 9.1% has proteinuria. Twenty-four percent uses tobacco regularly, and 13% had the habit in the past. Smoking is more frequent among diabetics (34%).In conclusion, cardiovascular risks factors are highly common among the Mexican population and increasing at alarming rates. Preventive programs targeted to decrease their prevalence are urgently needed in Mexico and should become a national priority.

Is renal replacement therapy for all possible in developing countries?

Chronic kidney disease is a worldwide public health problem. More than one million individuals in the world are on maintenance dialysis, a number that is estimated to double in the next decade. Access to dialysis is significantly different between developed and developing nations. Close to 80% of the world dialysis population is treated in Europe, North America, and Japan, representing 12% of the world's population. The remaining dialysis patients are treated in the developing world. This disparity is likely due to the high cost and complexity of renal replacement therapy (RRT). Dialysis is so costly that is out of reach for low-income countries, which are struggling to provide preventive and therapeutic measures for communicable diseases and other basic needs. Providing renal care to all developing nations, although a difficult task, is not impossible. A number of strategies are proposed. These include the prevention of kidney disease, as well as dialysis and transplantation. Dialysis programs should be decentralized, and kidney transplantation should be promoted as the treatment of choice. The use of generic immunosuppressive drugs can make this therapy more affordable. Peritoneal dialysis seems a good, affordable, therapy for patients living in areas where hemodialysis is not available. Governments should provide funds not only for RRT but also for the prevention of kidney failure. The provision of tax incentives and reaching a critical number of patients on RRT could be incentives for industry to lower the cost of dialysis. The challenges are enormous, but renal care for all could be achieved through a concerted effort between nephrologists, governments, patients, charitable organizations, and industry.