RESUMO
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.
