Chronic Kidney Disease Poses Challenges in Latin America

Latin America is the region with the highest burden of chronic kidney disease (CKD), in terms of disability-adjusted life years and premature deaths. This situation partly results from many countries’ difficulties in implementing early detection and providing treatments for CKD and renal failure. There are enormous disparities in resources and access, according to the 2023 report for Latin America from the International Society of Nephrology Global Kidney Health Atlas, which was published in Kidney International Supplements and presented at the 2024 World Congress of Nephrology.

Magdalena Madero, MD, an internal medicine specialist and head of nephrology at the Dr Ignacio Chávez National Institute of Cardiology in Mexico City, Mexico, emphasized that the magnitude of the problem should alert authorities to the need for early intervention.

“The most important thing would be to raise awareness so that we can conduct early detection of kidney disease in high-risk populations. We now have drugs that can prevent its progression and avoid the need for dialysis or transplantation, which are the most expensive therapies. Early detection is cost-effective,” Madero told the Medscape Spanish edition.

Epidemiology and Costs

To draft the report, which updates the previous 2019 edition, the authors reviewed literature and official data and conducted a survey of key professionals from 22 of 31 countries in Latin America and the Caribbean, representing 96.5% of the region’s population.

The median prevalence of CKD in the region is 10.2% (95% CI, 8.4%-12.3%), which is higher than the global median of 9.5% (95% CI, 5.9%-11.7%). The most affected countries or territories include Puerto Rico (16.8%), Costa Rica (14.8%), and Mexico (13.8%).

The highest proportions of deaths attributed to CKD are found in Mexico, El Salvador, and Nicaragua (9.8% [95% CI, 9.3-10.2]; 10.2% [95% CI, 9.2-10.9]; and 11.9% [95% CI, 11.1-12.6], respectively).

The median prevalence of treated renal failure in the region is 684 (95% CI, 457-858) per million population, which is lower than the global median of 822.8 per million. The lowest prevalence in the region was recorded in Nicaragua and the highest in Puerto Rico.

The median incidence of treated renal failure in the region was 134.5 (95% CI, 31-181) per million population, which is lower than the global median of 145.5 per million. The lowest rate was found in Nicaragua (33 per million) and the highest in Mexico (526.5 per million).

All countries have at least one modality of renal replacement therapy. According to 2020 data from the Latin American Dialysis and Renal Transplantation Registry of the Latin American Society of Nephrology and Hypertension, 67% of people with renal failure were treated with in-center hemodialysis (n = 290,099) and 9.3% with peritoneal dialysis (n = 40,450), while 23.6% received a kidney transplant (n = 102,772). Home hemodialysis, a strategy that loans equipment and is used “with good results in countries like Canada and the United States,” is practically not used in Latin America, said Madero.

Despite being promoted by the Pan American Health Organization as the most cost-effective dialysis strategy to expand access for patients with terminal CKD, home peritoneal dialysis is applied in more than 10% of the population requiring renal replacement only in the following five countries: Guatemala (19.9%), Panama (21.1%), Colombia (40.6%), Mexico (60%), and Nicaragua (73.3%).

Cost data for dialysis were available in 15 countries (55%). The median annual costs for hemodialysis ($17,241; 95% CI, $14,275-$25,861) and peritoneal dialysis ($15,846; 95% CI, $10,173-$19,893) were lower than the respective global medians: $18,959 and $19,380. The highest annual costs for hemodialysis and peritoneal dialysis were recorded in Costa Rica ($103,444 and $24,203, respectively) and the lowest in Brazil for hemodialysis ($9,615) and in Mexico for peritoneal dialysis ($5,474). “In countries like Mexico and Guatemala, peritoneal dialysis costs almost half as much as hemodialysis, while in others, peritoneal dialysis is much more expensive,” said Madero. The fact that Mexico produces fluids for this dialysis modality avoids import costs and helps explain this situation.

Examining the Workforce

Most countries did not provide information on public financing of drugs. Only 7 (31.8%) of the 22 countries that responded to the survey reported having free public financing for dialysis drugs, although the proportion doubled when asked about coverage for those used in transplants. Only Brazil and Nicaragua publicly cover medication for CKD outside of dialysis, representing a regional proportion of 5%, far below the global proportion (27%).

Only Costa Rica and Puerto Rico have registries for all levels of kidney care: CKD, dialysis, transplantation, and acute kidney injury. Others, such as Argentina, Brazil, Chile, Colombia, Paraguay, and Uruguay, have registries for the first three levels (excluding acute kidney injury). Guatemala has only for dialysis and transplants and Mexico only for transplants.

The median number of nephrologists in Latin America is 12.5 (95% CI, 8.5-25.9) per million population, similar to the global median, with approximately 10 times more nephrologists for adults than for children. The rate also varies between countries and decreases as countries fall into the middle- and low-income categories. For example, per million population, Uruguay has 64.47 professionals, Argentina 25.95, Mexico 10.45, and Haiti 0.44. The regional median of nephrologists in training is 1.4 (95% CI, 0.9-2.7) per million population, similar to the global figure.

The ratio of treated patients with CKD per nephrologist in the region is 54.1, being highest in Mexico (182.3) and lowest in Uruguay (18.5).

In 95% of the region’s countries that responded to the survey, nephrologists concentrate on the medical care of patients with renal failure, with little involvement of other health professionals. This finding is “bad because all the responsibility falls on nephrologists, and there are very few,” said Madero. “We should empower nurses and other professionals to run peritoneal dialysis clinics and have much more power among patients.”

Regarding specialist deficits, the most reported shortage in the 22 countries that responded to the survey was transplant surgeons (86%), followed by pediatric nephrologists (73%) and nephrologists (68%). Considering the multidisciplinary team, the most needed are dietitians, dialysis nurses, renal patient care nurses, renal nurses, and dialysis technicians (55%, 59%, 45%, 41%, and 36%, respectively). Of the 17 specialties considered, the countries reporting the most deficits are Nicaragua (17) and Paraguay (17), followed by the Cayman Islands, British Virgin Islands, and Haiti with 16. At the other end, Brazil reported only needing transplant surgeons, and Uruguay, vascular access coordinators, and pediatric nephrologists.

“The region has a high burden of kidney disease, and this analysis highlights significant disparities in care delivery capacity, especially between low- and middle-income countries and high-income countries within the region. Fragmented funding structures and prohibitive costs for individuals, particularly regarding renal replacement therapies, in addition to the shortage of specialized health workers, are major issues. There remains significant underutilization of cost-effective dialysis therapies, such as peritoneal dialysis, and inadequate management of CKD for those who choose not to receive or cannot access renal replacement therapies, further affecting the ability to care for renal failure patients,” the researchers concluded in the report.

Madero disclosed receiving fees and grants from AstraZeneca, Bayer, Boehringer Ingelheim, and the Renal Research Institute. Other authors declared conflicts of interest in the article.

This story was translated from the Medscape Spanish edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.