Prevention Strategies for Chronic Kidney Disease in Latin America: A Strategy for the Next Decade—A Report on the Villarica Conference

Abstract

Representatives from 19 Latin American countries gathered to report and deliberate on both the present and future implications of the growing epidemic of chronic kidney disease—as well as cardiovascular disease, diabetes, and hypertension—and to define the role that national health systems need to adopt in order to cope with them. Country-by-country reports provided an excellent overview of the current state of health care in general and chronic diseases in particular. The meeting concluded with a consensus statement on the most urgent needs for the next decade.

Keywords:

• chronic kidney disease
• renal replacement therapy
• prevention
• diabetes
• hypertension
• transplantation

“The First John H. Dirks Chronic Renal Disease Prevention Meeting: Prevention Strategies for Chronic Kidney Disease in Latin America: A Strategy for the Next Decade” was held in Villarica, Chile, November 21–23, 2005. It was organized by Emmanuel Burdmann, John Dirks, Ricardo Correa-Rotter, Sergio Mezzano, and Bernardo Rodriguez-Iturbe, and there were thirty-eight invited participants. The goal was to define the problem of chronic kidney disease and their related risk factors and to lay out some parameters for the development of a plan for prevention and control through a consensus statement on goals, objectives, and actions for the next decade.

Representatives from 19 Latin American countries gathered to report and deliberate on both present and future implications of the growing epidemic of cardiovascular disease (CVD), diabetes, hypertension, and kidney disease, and to define the role that national health systems need to adopt in order to cope with them. William Couser (President ISN), Angel de Francisco, (President, Spanish Society of Nephrology), Garabord Eknoyan (Co-Chair KDIGO), and Patricio Rojas (PAHO) also attended the meeting. A short report on the meeting was published in NCP,[1] and a longer report is available on Gateway–Nephrology (http://www.nature.com/isn/).

Reports by representatives from each Latin American country provided an excellent overview of the current state of health care in general and chronic diseases particular, with special emphasis on CKD, diabetes, and hypertension. (A number of these appear in this issue.) Some aspects of the pathogenesis were reviewed. Slatopolsky (United States) brilliantly elucidated vascular calcification in ESRD patients at risk for coronary artery disease, cardiovascular events, and death. Vascular calcification is clearly linked to the CaP product and, when reduced with Sevelamer in the experimental situation, reduces calcification. It appears that when hypercalcemia is avoided and phosphate reduced in ESRD patients, vascular calcification and subsequent mortality risk may be lessened.

It was quickly apparent that Latin America is very heterogeneous, and there is great variability in the level of health care available from country to country. Some of the reports revealed deeply inequitable social, financial, and medical resources to cope with chronic diseas es and a disturbing ability to move forward. Table 1 lists key data for Latin American countries.

Table 1 Overview of relationship between income and selected health indicators in 15 Latin American countries

Country	Population (millions, 2005)	Average income (USD, 2004)	Life expectancy at birth (2002)	HDI of 177 countries (2002)	Health insurance access	Hypertension (2005, %)	Diabetes, % (Adults, 2001)	ESRDp/m/p (2004)	Transplantation p/m/p (2004)^§
Argentina	39.5	$3,720	74.1	34	100%	28	7.6	584	19.6
Bolivia	8.8	$840	63.7	114	32%	19	7.2	63	n/a
Brazil	186	$3,090	68	72	96%	27	7.5	361	18.6
Chile	16	$4,910	78	43	100%	34	4	685	16.8
Costa Rica	4	$4,670	78	45	98%	25	8	60	20.0
Cuba	11.3	(est) $3,000	76.7	52	100%	30	11.8	149	16.3
Dominican Republic	8.9	$2,080	66.7	98	81%	25	5	103	2.8
El Salvador	6.7	$2,210	70.6	103	80%	n/a	n/a	274	1.8
Guatemala	12	$2,130	65.7	121	20%	31	8.4	150	5.9
Paraguay	6	$1,170	70.7	89	100%	31	7	127	1.2
Peru	28	$5,200	69.7	85	30%	22	7.6	166	2.4
Uruguay	31	$8,400	75.2	46	100%	33	7.2	916	29.7
Venezuela	23	$5,800	73.6	68	100%	32-4	5.6	300	7.8
Mexico	106.2	$6,770	73.3	53	80%	31	10	420	16.8
Columbia	45.3	$2,000	72.1	73	56%	12	8.2	294	10.5

*Income from World Bank Development indicators, 2005.

†UNDP (based on 2002 statistics).

‡Figure for Chile is for 2005 (Costa Rica and Guatmala not published).

^§Latin American Registry of Dialysis and Transplantation, SLANH 2002.

Overall, a number of issues emerged during the meeting:

• The growing prevalence of chronic diseases throughout Latin America. Hypertension averages about 27%, and diabetes about 7.5%. Rodriguez-Iturbe (Venezuela) commented that is estimated that only about 51% of those with hypertension are diagnosed, and only between 10–23% of these are controlled. In Mexico, chronic diseases accounted for 10% of all deaths in 1949 and 50% in 1999 (Garcia-Garcia). Diabetes prevalence was less than 3% in the 1960s, but by 2001 had increased to 10%. Correa-Rotter (Mexico) reported that obesity is expected to increase by 248% between 2000 and 2030.

• The lack of preparedness to deal with chronic diseases. With the exception of Uruguay and Chile, most countries do not have the manpower to deal with chronic diseases. Some, such as Peru, Nicaragua, and several other Central American countries, suffer under the double burden of infectious diseases, which still cause fairly high deaths rates. Studies on incidence and prevalence of chronic diseases, preferably at a national level, are needed to provide a better overview. Most governments have not devoted much attention to funding for chronic diseases. Access to health care is universally available only in Cuba, Uruguay, Argentina, Brazil, and Costa Rica. In countries like Bolivia (32%) and Guatemala (20%), access is limited.

• Lack of access to renal replacement therapy. In Peru (Hurtado), about 30% of the population has access to RRT; in Paraguay, 25%; and in Columbia (Gomez), 56%. Only 32% have access in Bolivia (Plata), and patients in peritoneal dialysis are frequently treated with an intermittent modality given once of twice a week.

• The issues of cost relating to kidney disease. Treating end stage renal disease is too costly for most people in Latin America. The rates of reported ESRD vary widely and correlate to gross national income (GNI), suggesting that the variability has more to do with income than true prevalence. Not surprisingly, the wealthiest countries have the highest reported rates (i.e., Uruguay, 916p/m/p; Brazil, 390p/m/p), while the lowest are Bolivia (63p/m/p) and the Dominican Republic (103p/m/p).

• CKD, and chronic disease in general, is a problem for both richer and poorer countries and individuals, and the youthful demographics of diagnosis adversely affect productivity in the region.

Hypertension, diabetes, and kidney disease generally occur at a younger age than in North America. Dean Jamison[2] has suggested that 10–15% of the economic improvement in developing countries may be due to improvements in overall health. As the prevalence of chronic disease continues to increase requiring (often) expensive life-long care, there will inevitably be economic ramifications.

• The shortage of nephrologists, general physicians, nurses and technicians. Every country reported a serious lack of manpower. Most of the physicians, particularly nephrologists, cardiologists, and diabetologists, are situated in the large cities. In Paraguay, almost all of the 35 nephrologists are in Asuncion, and in El Salvador, 60% of nephrologists are in San Salvador. There is an overall lack of physicians and facilities in most rural areas, leading to unequal access within countries to renal care. Indigenous people and the poor are particularly affected.

• The lack of reliable data and epidemiological studies. With the exception of Chile, Uruguay, Cuba, and (to some extent) Argentina, which have some government-supported programs, there is a shortage of data. Epidemiological studies are too few and mostly too local to support national initiatives. Data, when available, can be unreliable, and there is little interface to connect them. SLANH requests annual data from all countries, but it is submitted on a voluntary basis. Cusumano's (Argentina) report summarizes existing Latin American data for 19 countries.

• The need for screening and intervention studies. There was general agreement that given limited resources, screening, and intervention, studies should be targeted to families of patients, or those with a family history of kidney disease. Almaguer (Cuba) reported on a population-based study on the Isle of Youth, and Mazzuchi (Uruguay) on a more selective study, but overall such programs remain small and local. A screening study being done in public places in Curitiba as part of the Pro-Renal Foundation, as reported by Riella (Brazil), has yielded interesting results. A surprising 30% of asymptomatic participants showed evidence of hematuria and 6% proteinuria, especially in those with a family history of diabetes and hypertension.

• Guidelines. Eknoyan (United States) reviewed all aspects of international global guidelines as formulated by KDIGO. The need to quantify outcomes of critical care, the increasing costs while resources are limited, and the public expectation of more precise knowledge and accountability were a convincing rationale for guidelines. When specifically developed, guidelines assist clinical practice and patient decisions about appropriate care. Bellorin-Font (Venezuela) discussed guidelines as relevant to Latin America, with its variable health care systems and economic conditions. A Latin American KDIGO subgroup is necessary to make appropriate adaptations for the region. Considerable steps have been taken by SLANH using the Renal Health Model. A critical role was to disseminate information to a much wider population of physicians and health care decision-makers.

• The need for standardization of testing and laboratories. It became clear during the meeting that different labs use different standards for diagnosing disease. In the case of kidney disease, for example, there is no standard measure for GRF, urine protein, or creatinine, or an understanding of what levels correspond to the stages of kidney disease. As an example, Massari (Argentina) reviewed the problems of overestimates of GFR. (Note, though, that the MDRD and Cystatin C were probably the best method.)

At the conclusion of the meeting, the following seven recommendations emerged in the form of a consensus statement.

THE 2005 VILLARICA CONSENSUS STATEMENT

1 Data

Since accurate data on renal disease is frequently unavailable it is recommended that careful planning and links with WHO/PAHO, Latin-American registries and national registries be implemented. Significant epidemiological studies dealing with incidence and prevalence of CKD should be carried out in selected Latin American countries and clinical trials involving therapeutic interventions should be considered.

2 Risk Factors

It is recommended that recognition and evaluation of risk factors should be implemented. Of these, low birth weight, obesity, diabetes, and smoking are common in most LA countries. In addition specific risk factors in certain locations and in indigenous peoples and pediatric populations be explored.

3 Primary Prevention

It is recommended that the importance of primary prevention, including healthy eating habits, smoking cessation, moderate alcohol consumption, and physical activity be stressed in patients at risk for CKD. Caution should be exercised in using nephrotoxic drugs, especially NSAIDS and antibiotics, by those at risk or with CKD. Patients with established CKD should be appropriately followed and a policy of timely referral to specialized care should be adopted. The aim is to achieve target blood pressure at or below 130/80, control of hyperlipidemia and glycemia, reduction of albuminuria and normalization of Ca-P and parathormone activity.

4 Training

It is recommended that the urgent need for health professionals in Latin America be addressed. It should be recognized that there is both a shortage and distributional problem of doctors, nurses, epidemiologists, and technicians for renal care. Educational programs on kidney disease should be implemented at all levels, including in medical school curricula.

5 Public Awareness and Advocacy

It is recommended that advocacy and public awareness programs on kidney disease be promoted without delay. The issues related to the increase in renal and cardiovascular disease prevalence should be jointly addressed through medical specialties (epidemiologists, family physicians and cardiovascular and kidney specialists), community based approaches (education and media-based campaigns) and official policy strategies (ministries of health)). This combined approach will allow a more efficient use of existing resources and more effective results of established programs.

6 SLANH Model

It is recommended that the SLANH renal health model be supported in some countries and in consideration with local regulations jointly with the cardiovascular health model already implemented.

7 Future meetings

It is recommended that a second Renal Disease Prevention meeting on Prevention Strategies for chronic Kidney Disease in Latin America be held in 2008.

Participants

Emmanuel Burdmann (Brazil), Bernardo Rodriguez-Iturbe (Venezuela), Sergio Mezzano (Chile), John Dirks (Canada), Ricardo Correa-Rotter (Mexico), William Couser (USA), Maria Cristina Escobar (Chile), Angel de Francisco (Spain), Cristina Marelli (Chile), Garabed Eknoyan (USA), Ezequiel Bellorin Font (Venezuela), Ana Cusumano (Argentina), Guillermo Garcia- Garcia (Mexico), Emilio Mena (Dominican Republic), Pedro Gordan (Brazil), Joao Egidio Romao (Brazil), Leopoldo Ardiles (Chile), Felipe Inserra (Argentina), Raúl Plata (Bolivia), Zulma Cruz Torres (El Salvador), Francisco Santacruz (Paraguay), Randall Lou (Guatemala), Abdías Hurtado (Peru), Manuel Cerdas (Costa Rica), Nelson Mazzuchi (Uruguay), Rafael Gómez (Columbia), Miguel Almaguer (Cuba), Maria Eugenia Bianchi (Argentina), Eduardo Slatopolsky (USA), Santos Depine (Argentina), Rafael Burgos Caldéron (Puerto Rico), Roberto Zatz (Brazil), Miguel Riella (Brazil), Pablo Massari (Argentina), and Aquiles Jara (Chile).