Renal Disease in Colombia

Abstract

Chronic renal disease represents a problem of public health in Colombia. Its prevalence has increased in last decade, with a prevalence of 44.7 patients per million (ppm) in 1993 to 294.6 ppm in 2004, considering that only 56.2% of the population has access to the health. This increase complies with the implementation of Law 100 of 1993, offering greater coverage of health services to the Colombian population. The cost of these pathologies is equivalent to the 2.49% of the budget for health of the nation. The three most common causes of renal failure are diabetes mellitus (DM; 30%), arterial hypertension (30%), and glomerulonephritis (7.85%). In incident patients, the DM accounts for 32.9%. The rate of global mortality is 15.8%, 17.4% in hemodialysis and 15.1% in peritoneal dialysis. In 2004, 467 renal transplants were made, 381 of decease donor with an incidence of 10.3 ppm.

The excessive cost of these pathologies can cause the nation's health care system to collapse if preventative steps are not taken. In December of 2004, the Colombian Association of Nephrology with the participation of the Latin American Society of Nephrology and Arterial Hypertension wrote the “Declaration of Bogotá,” committing the state's scientific societies and promotional health companies to develop a model of attention for renal health that, in addition to implementing national registries, continues to manage renal disease.

Keywords:

• renal failure
• chronic renal failure
• dialysis
• renal dialyses
• risk factors

GENERAL ASPECTS

The Republic of Colombia is located in the north part of South America and has a population as of December 2004 of 45.3 million inhabitants, an area of 1.100.000 km², and a density of 37.7 inhabitants per km². The life expectancy is 71.8 years, PNB per capita of U.S. $2,000, and a gross internal product of U.S. $97,400,000 (see Table 1).[1]

Table 1 Colombian health finance indicators, 2002

Health expenditure, total (% of GDP)	2002	8.1
Health expenditure, public (% of GDP)	2002	6.7
Health expenditure, public (% of total health expenditure)	2002	82.9
Health expenditure per capita ($)	2002	151.0

In the last decade, Colombia underwent a change in the social security system. In December 1993, there was a reform in the social security system, and the law 100 was enacted. It creates an integral system with the following objectives:

1. To guarantee the economic and health benefits to those who have sufficiently affiliated themselves in a labor or economic system.

2. To guarantee the benefit of complementary social services.

3. To guarantee the extension of coverage until the population accedes to a system by means of a mechanism that, in developing the beginning of constitutional solidarity, allows that sectors without sufficient economic capacity can accede to the system and be granted benefits in integral form.

Although only 56.2% of the Colombian population has access to health care, the implementation of this law increased considerably the coverage of patients with renal disease (specifically through access to renal therapies) who before 1993 did not have any possibility of surviving.

The General System of Social Security in Health (SGSSS), according to its financing, is structured in two regimes: subsidized and contributing. The SGSSS operates in the subsidized regimen (heath subsidies for the poor and vulnerable population) in a decentralized manner, and the departments, districts, and municipalities assume the financing, with the resources of the subaccount of the foundation of the Solidarity and Guarantee (Fosyga), of an obligatory health plan, pos-S, for these people. This plan is administered by organizations created especially for such a purpose—promotional companies of health (EPS), administrators of the subsidized regime (ARS), and shared in common companies of health (ESS)—that contract services and represent the users with the institutions providing the health services (IPS). In the contributing regime (affiliation by means of the payment of a quotation of 12% on the income of the cotizante), the SGSSS is operated directly by promotional organizations of health (EPS), who are responsible for collection, contracts, and direct service.

These organizations offer an obligatory plan of health (POS) that includes the management of chronic renal disease and the available renal therapies (i.e., dialysis and transplant).

Like the rest of Latin American countries, in Colombia, chronic renal disease constitutes a problem of public health, with ascending social repercussion and important economic and ethical implications.

In Colombia, exact data do not exist on the prevalence and the incidence of terminal renal disease or the different etiologies; thus, their impact has been underestimated on the people and the society. The lack of basic information does not allow for suitable planning as far as resources in the programs of the prevention of renal disease.

It is thought that in Latin America, the frequency of renal disease must be similar throughout the region; nevertheless, ample variation of its prevalence was observed in the different countries. The greatest ones are Puerto Rico and Uruguay, with 976 patients per million (ppm) and 737 ppm, respectively. In Argentina, Brazil, and Chile, the prevalence is greater than 300 ppm; Mexico has 263 ppm, and countries like Bolivia, Salvador, Guatemala, Honduras, and Paraguay have a smaller prevalence of 100 ppm.[2]

When compared with other worldwide registries, the prevalence in Latin America was found to be far lower. The greatest ones are in Japan (1,624 ppm)[3] and the United States (1,446 ppm).[4] The prevalence of the patients of the European Union are around 644 ppm; Australia, 386 ppm;[5] and Singapore 646 ppm.

The entrance of new patients to renal therapies (incident) in Latin America is around 84 ppm, but it varies within the different countries. The United States has an incidence of 296 ppm; Japan, 229 ppm; and the European Union has an incidence of 120 ppm.[2]

This smaller prevalence and incidence of patients with renal failure in Latin America follows a smaller proportion of those with health care coverage of the population; in addition, in several Latin American countries, the access to dialysis and transplant is limited.

The number of transplants by million inhabitants is also low in the region, with rates of 10.8 ppm being very low in comparison to European countries (e.g., Spain, 47 ppm) and the United States (46 ppm). Again, though, the incidence and prevalence of renal disease in Colombia have been very difficult to evaluate, because in this country, there does not exist a real registry due to the lack of commitment from the different dialysis organizations to reporting these data to the respective state organizations and the Colombian Association of Nephrology.

INCIDENCE AND PREVALENCE OF RENAL DISEASE

The most recent data on the prevalence of arterial hypertension and diabetes mellitus, both important risk factors in Colombia, date from 1999, with an incidence of arterial hypertension of 12.3% and prevalence of DM type 2 of 2%.[6] Another investigation reported a prevalence of HTA of 7.5% and of diabetes mellitus of 4.7%.[7]

The number of patients in renal replacement therapy (RRT) in Colombia has increased dramatically from 1993, when the new Law of social security was implemented.

At the end of 1970, there were no more than 100 patients in the programs of RRT; as of December 1993, there were 1,660 patients in dialysis in the country, which corresponds to a prevalence of 44.7 ppm; five years later, upon the implementation of Law 100 from December 1993, there were 5,200 patients in therapies of dialysis, a prevalence of 127 ppm; by December 31 of 2004, there were 13,347 patients, a prevalence of 294.6 ppm and an incidence of 90.26 ppm. It is likely that this does not reflect a real increase in the prevalence by millions of patients but is more likely due to better coverage, with greater access by renal patients to the programs available. Considering that 43.8% of the Colombian population does not have access to social security, the present prevalence is not reflective of reality — there is still a high percentage of people who suffer from renal affections who do not have coverage and are not identified.

The most important causes of the chronic renal failure according to data of 2004 are mellitus diabetes in 30.15%, arterial hypertension in 30.08%, glomerulonephritis in the 7.85%, and other causes for 31.89% (see Figure 1). In all, 56.5% of the population was men, and the average age was 52 years. The causes of renal failure in the incident patients are mellitus diabetes (32.9%), hypertension (29.4%), glomerulonephritis (7.67%), and other diagnoses including unknown causes (29.89%) (see Figure 2). The average of age of the incident patients was of 54 years.

Figure 1 Distribution of causes of ESRD among chronic dialysis in Colombia 2004.

Figure 2 Distribution of causes of ESRD among incident patients Colombia 2004.

DIALYSIS IN COLOMBIA

By December 31, 2004, Colombia had 100 centers of dialysis in all the territory, 97 of which that do peritoneal dialysis. There were 8,447 patients in hemodialysis (HD), and 4,900 in peritoneal dialysis (PD), for a total of 13,347 patients.

All of the hemodialysis patients use solutions with bicarbonate, and the reuse of dialyzers or some other elements are forbidden.

The global mortality is 15.8%, 17.4% in HD and 15.1% in PD. There are no studies of long-term survival in the country, but there are center reports with a 10-year global survival of 50% (57% on HD and 27% on PD). There is also a report of a five-year survival rate of 54% in hemodialysis and 46% in peritoneal dialysis.[8]

The main causes of mortality are cardiac, 27.6%; cerebrovascular, 5.72%; neoplasm, 3.16%; infectious, 13.87%; metabolic, 13.19%; others, 25.05%; unknown, 11.38% (see Figure 3).

Figure 3 Causes of death Colombia 2004.

RENAL TRANSPLANT

Colombia had by December 2004 twelve active centers of renal transplant: one in Medellín, three in Cali, seven in Bogotá, and a center in Bucaramanga. A total of 467 renal transplants and eight combined (kidney-liver) transplants were made, with an incidence of 10.3 transplants ppm, a number that is very low and reflects a minimum rate of donation as well as a poor commitment of the public organizations in the programs of renal transplantation (see Table 2).

Table 2 Renal transplants in Colombia year 2004 by regions

City	Deceaseddonor	Living donor	Total
Medellín	192	3	195
Bogota	117	69	186
Cali	57	13	70
Bucaramanga	15	1	16
Total	381	86	467

In 2004, there were approximately 2,184 patients with funcionante renal transplant, and the waiting lists had approximately 276 patients. Only patients with all the respective authorizations were included.

The number of deceased donors in 2004 were 60 in Bogotá (population 7,029,928, donation rate of 8.53 ppm), 35 in Cali (population 2,800,000, donation rate of 12.5 ppm), 110 in Medellín (population 2,500,000, donation rate of 44 ppm) and 8 in Bucaramanga (population 804,618, donation rate of 10 ppm). Altogether, there were 213 effective kidney donors, with a donation rate of 4.7 ppm.

Until December 2004, 2,869 transplants had been made in Medellín, 802 in Cali (490 from deceased donors), 848 in Bogotá (547 from deceased donors), and 235 in Bucaramanga, with a total of approximately 4,442 renal transplants.

SOCIO-ECONOMICAL IMPACT

Previous to Law 100 from December 1993, the financing of treatments for patients with terminal renal disease was the responsibility of such patients, and some institutions of health. This Law defined the plans of benefits of the SGSSS and the related high costs and included this pathology in the Obligatory Plans of Health (subsidized POS and POS).

The average cost of a session of hemodialysis in December 2004 was $218,000 (approximately U.S. $91), $2,842,000 by patient/month (U.S. $1,184). The monthly cost of a patient in peritoneal dialysis oscillates around $2,780,000 (U.S. $1,160). Having a population of 13,347 patients in the different renal therapies, the annual cost is U.S. $188,222,976.

These costs include the erythropoietin administration, parenteral iron, anti-hypertensive medicines, insumes of dialysis, the honoraria of the medical personnel, nutrition, social work, and psychology, and some laboratory examinations.

The hospitalization costs, complications, and other medicines are not included. Some organizations include the costs of vascular accesses within the dialysis tariffs.

As far as renal transplant, the cost of each transplant is $29,000,000 (U.S. $12,083). In all, 467 transplants were made at a cost of U.S. $5,642,761. In controls of post-transplant patients, there are approximately 2,184 patients with an annual cost of U.S. $3,509,596.

The total cost in procedures of dialysis and transplants in Colombia in 2004 rose to U.S. $197,375,333, which corresponds to 2.49% of the budget in health of Colombia, for a population equivalent to 0.034%.

PREVENTION STRATEGIES

Promotion and prevention are the fundamental pillars for the diminution of chronic renal disease. One strategy is to take the general population and to look for risk factors, while another is to take single factors of the population at risk (e.g., diabetic, hypertensive, patients with glomerular diseases) and to implement programs that help to diminish or to avoid the progression of the renal disease.

Until recently, the efforts made to promote programs of promotion and prevention in renal disease were very limited, but Law 100 of 1993 provided the tools necessary to make these programs. The progressive increase of patients with renal disease threatens to collapse the health system of Colombia within a few years, making it very important to turn aside all other efforts and try to identify and take early action in these patients.

In December of 2004, in the city of Bogotá, a workshop called “A Model of Renal Health: New Symbiosis between Public Health, Clinical Nephrology and Primary Attention” took place. It was developed by the Colombian Association of Nephrology with the collaboration of the Latin American Society of Nephrology and Arterial Hypertension (a subcommittee of Renal Health). A sustainable and tenable renal health model was proposed by Drs. Rafael Burgos Calderón and Santos Depine. This resulted in the “Declaration of Bogotá,”[9] where a commitment was made to create the mechanisms necessary to change the attention toward renal disease to the newer model of renal health, to establish the national registries of renal disease, and to continue to update the guides and procedures of managing the disease and renal health among others. After the Declaration of Bogotá, the Ministry of Social Protection, the Colombian Association of Nephrology, and some EPS and Fedesalud begin to work on the guides of managing the renal disease in Colombia and implementing the model of attention of renal health. The model is advanced enough today to be replicated in other cities of the country (e.g., Barranquilla, Cali).

It is also very important to promote programs of renal transplant, although these are not financially attractive for the different EPS from the country. It is also important to make strategies so that the EPS become interested in this type of programs and facilitate communication between these organizations and the groups of investigation, promotion and prevention.

CONCLUSIONS

The incidence and prevalence of the renal disease in Colombia have increased remarkably in the last decade. To a large extent, it was the result of the implementation of Law 100 of 1993, which furthered the coverage of this disease to more people in the country. It represents a high cost to the society not only in morbidity but also in mortality. Diabetes mellitus and hypertension continue to be the most prevalent causes of renal failure in this country, and the incident is growing in the last few years, especially diabetes mellitus. It is fundamental to develop all of the necessary programs to avoid anything that might jeopardize the health care system in Colombia.

ACKNOWLEDGMENTS

The author would like to offer thanks to the Association Colombiana de Nefrología, Fresenius Medical Care, and Baxter Laboratory for data, and to Monica Maria Rojas for help in the revision of the manuscript.