Peritoneal dialysis in Mexico
2003; Elsevier BV; Volume: 63; Linguagem: Inglês
10.1046/j.1523-1755.63.s83.18.x
ISSN1523-1755
Autores Tópico(s)Healthcare cost, quality, practices
ResumoPeritoneal dialysis in Mexico. While Mexico has the thirteenth largest economy, a large portion of the population is impoverished. About 90% of the population is Mestizo, the result of the admixture of Mexican Indians and Spaniards, with the Indigenous peoples concentrated in the southeastern region. Treatment for end-stage renal disease (estimated 268 patients per million population) is largely determined by the limited healthcare system and the individual's access to resources such as private insurance (~15%) and governmental sources (~85%). With only 5% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under severe economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico uses proportionately more peritoneal dialysis than other countries; 1% of the patients are on automated peritoneal dialysis, 19% on hemodialysis and 80% on CAPD. Malnutrition and diabetes, important risk factors for poor outcome, are prevalent among the patients in CAPD programs. Peritoneal dialysis in Mexico. While Mexico has the thirteenth largest economy, a large portion of the population is impoverished. About 90% of the population is Mestizo, the result of the admixture of Mexican Indians and Spaniards, with the Indigenous peoples concentrated in the southeastern region. Treatment for end-stage renal disease (estimated 268 patients per million population) is largely determined by the limited healthcare system and the individual's access to resources such as private insurance (~15%) and governmental sources (~85%). With only 5% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under severe economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico uses proportionately more peritoneal dialysis than other countries; 1% of the patients are on automated peritoneal dialysis, 19% on hemodialysis and 80% on CAPD. Malnutrition and diabetes, important risk factors for poor outcome, are prevalent among the patients in CAPD programs. Mexico is a country of inequities. According to the World Bank, Mexico is the world's thirteenth largest economy, eighth largest exporter of goods and services, and fourth-largest oil producer1The World Bank Group http://www.worldbank.orgGoogle Scholar. The gross national product per capita ($5080 US), however, has not increased in the same proportion. Education and public services are problems that have not been completely resolved: 10% of people aged ≥15 years are illiterate, 21% of Mexican homes do not have sewerage, 10% do not have drinking water on tap, and 5% do not have an electricity supply2Instituto Nacional de Estadistica: Geografia e Informatica http://www.inegi.gob.mxGoogle Scholar. Therefore, while the macro-economy seems to have been appropriately developed in recent years, many problems in the micro-economy have not been fully addressed. Health care is another unsolved problem. As in many countries, in Mexico this issue is closely related to the individual's purchasing power. Those with the highest purchasing power (∼15% of the total population) have access to private medicine (via private insurance or on a fee-for-service basis), whereas people with less purchasing power are entitled to social security (∼40%; provided by the Social Security Institutes), and those living in poverty (the remaining 45%) only have access to the basic medical services provided by the Health Secretariat2Instituto Nacional de Estadistica: Geografia e Informatica http://www.inegi.gob.mxGoogle Scholar. Thus, end-stage renal disease (ESRD) treatment is largely determined by the limitations of the health care system. Dialysis supply is not restricted in the private sector. There are some restrictions and limitations in the social security system, where the funding is subject to annual budgetary considerations. The dialysis treatment provided by the Health Secretariat has the most severe limitations and is very restricted because of economic constraints. According to the National Institute of Statistics, Informatics and Geography (INEGI), there were 97.5 million people living in Mexico in the year 2000. Of these, only 6.04 million (6.2%) are considered to be Indigenous. The vast majority of people in Mexico (about 90%) are Mestizos, the result of the admixture between Spaniards and Mexican Indians. The Indigenous people are concentrated in southeastern Mexico (Oaxaca, Chiapas, Veracruz and Yucatán states), the poorest region in the country. No reliable data about national ESRD epidemiology are available in Mexico; however, in the state of Jalisco (in the west of Mexico) data are incorporated with the Registry of Dialysis and Transplantation (REDTJAL)3Brien H. García H. García G. et al.Epidemiología de la insuficiencia renal crónica en Jalisco.Boletin Colegio Jalisciense Nefrologia. 2001; 5: 6-8Google Scholar. This state registry holds complete data relating to renal replacement therapy since 1998 and has been the basis for the Mexican data appearing in the latest reports of the Latin American Society of Nephrology and Hypertension4Sociedad Latino Americana de Nefrologia e Hipertension http://www.slanh.orgGoogle Scholar. According to the latter, the prevalence of ESRD in Mexico was 268 patients per million in 1999. These data do not mean that Mexico has a lower ESRD prevalence than developed countries or other Latin American countries, such as Puerto Rico, Uruguay, Chile or Argentina. Rather, this reflects the limited availability of renal replacement therapy Figure 1. Thus, it is not surprising that countries with low incomes tend to report a low prevalence of renal failure prevalence. According to the Pan American Health Organization, developing countries such as Mexico spend only 5% of their gross national product on health, whereas developed countries such as the United States or Canada spend up to 14% of their gross national product on health5Pan American Health Organisation http://www.paho.orgGoogle Scholar. Moreover, in absolute terms, the gross national product of Mexico is lower than the amount spent only on health care in the United States5Pan American Health Organisation http://www.paho.orgGoogle Scholar. If we further consider that ESRD treatment in Mexico is provided by public health care institutions (which have important economic limitations), it is not surprising that many Mexican patients with ESRD do not receive renal replacement therapy. It is broadly known that Mexico is the country that uses proportionally more peritoneal dialysis than other nations. In 1990, Mexico employed peritoneal dialysis in 90% of ESRD patients6Westman J. Worldwide Dialysis Update.Annual Survey by Baxter Healthcare Inc. Deerfield, 1993Google Scholar. Nine years later, the most recent data show that the use of peritoneal dialysis has been reduced to 81%4Sociedad Latino Americana de Nefrologia e Hipertension http://www.slanh.orgGoogle Scholar. This is still the greatest use of peritoneal dialysis reported worldwide. According to commercial sources (Laboratorios Pisa, SA de CV) there are 25,000 patients currently on chronic dialysis in Mexico, and, in agreement with the most recent REDTJAL Report3Brien H. García H. García G. et al.Epidemiología de la insuficiencia renal crónica en Jalisco.Boletin Colegio Jalisciense Nefrologia. 2001; 5: 6-8Google Scholar, 19% of these patients are on hemodialysis, 1% on automated peritoneal dialysis, and 80% on continuous ambulatory peritoneal dialysis (CAPD). It is expected that, on conservative calculations (with respect to the present growth rate), there will be 75,000 patients on dialysis programs by the year 2010. The treatment of these patients will present a great challenge for the economically limited health institutions within Mexico. Two important conditions in the Mexican CAPD population require special attention: diabetes mellitus and malnutrition. Diabetes mellitus (about 90% is type 2 in Mexico) causes about 40% of ESRD in Mexico. Other causes are: unknown etiology (31%), chronic glomerulonephritis (14%), polycystic renal disease (6%), nephrosclerosis (4%), and others (5%)3Brien H. García H. García G. et al.Epidemiología de la insuficiencia renal crónica en Jalisco.Boletin Colegio Jalisciense Nefrologia. 2001; 5: 6-8Google Scholar. This is particularly worrying, considering that Mexicans and individuals of Mexican origin living in other countries (such as, Mexican Americans) seem to have a higher prevalence of diabetes mellitus than other populations, around 10%7Amato J.D. Paniagua J.R. Prevalencia de la insuficiencia renal crónica en la población derechohabiente del Instituto Mexicano del Seguro Social.in: García M.C. Reyes H. Viniegra L. Las Múltiples Facetas de la Investigación en Salud: Proyectos Estratégicos del Instituto Mexicano del Seguro Social. Editorial Sestante, SA de CV, Mexico City2000: 153-170Google Scholar,8Lerman I.G. Villa A.R. Martinez C.L. et al.The prevalence of diabetes and associated coronary risk factors in urban and rural older Mexican populations.J Am Geriatr Soc. 1998; 46: 1387-1395Crossref PubMed Scopus (25) Google Scholar and 25%9West S.K. Klein R. Rodriguez J. et al.Diabetes and diabetic retinopathy in a Mexican-American population: Proyecto VER.Diabetes Care. 2001; 24: 1204-1209Crossref PubMed Scopus (120) Google Scholar,10Bastida E. Cuellar I. Villas P. Prevalence of diabetes mellitus and related conditions in a south Texas Mexican American sample.J Community Health Nurs. 2001; 18: 75-84Crossref PubMed Scopus (24) Google Scholar, respectively. In addition to this high prevalence, diabetes mellitus, in conjunction with hypoalbuminemia-malnutrition, old age, lymphopenia, and a high peritoneal transport rate, are the most significant risk factors for mortality identified in the Mexican population on CAPD11Cueto-Manzano A.M. Quintana-Piña E. Correa-Rotter R. Long-term CAPD survival and analysis of mortality risk factors: 12-year experience of a single center.Perit Dial Int. 2001; 21: 148-153PubMed Google Scholar,12Cueto-Manzano A.M. Correa-Rotter R. Is high peritoneal transport rate an independent risk factor for CAPD mortality?.Kidney Int. 2000; 57: 314-320Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar. From multivariate analysis, diabetes is the most significant predictor of mortality. This is not surprising, as it is well known that diabetics have multiple comorbid conditions that may negatively affect outcome in CAPD. These include old age, hypoalbuminemia, low serum creatinine, and a high peritoneal transport rate Table 1.Table 1Some of the most important predictors for mortality in CAPD Mexican patients(modified from11Cueto-Manzano A.M. Quintana-Piña E. Correa-Rotter R. Long-term CAPD survival and analysis of mortality risk factors: 12-year experience of a single center.Perit Dial Int. 2001; 21: 148-153PubMed Google Scholar)VariableNon-diabetics (N = 102)Diabetics (N = 65)P valueAge years38.3±15.455.4±13.3<0.0001Serum albumin g/dL3.20±0.702.84±0.570.001Serum creatinine mg/dL10.8±4.17.06±2.9<0.0001Creatinine D/P ratio0.67±0.110.71±0.120.03 Open table in a new tab Hypoalbuminemia has been repeatedly shown to be a predictor of mortality in CAPD patients. In the Mexican setting, patients with a serum albumin ≥3.5 g/dL had significantly better survival than patients with serum albumin <3 g/dL11Cueto-Manzano A.M. Quintana-Piña E. Correa-Rotter R. Long-term CAPD survival and analysis of mortality risk factors: 12-year experience of a single center.Perit Dial Int. 2001; 21: 148-153PubMed Google Scholar,12Cueto-Manzano A.M. Correa-Rotter R. Is high peritoneal transport rate an independent risk factor for CAPD mortality?.Kidney Int. 2000; 57: 314-320Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar. Serum albumin is a marker of a number of different conditions, but one of the most important is malnutrition, which is highly prevalent in the peritoneal dialysis population in the country. The frequency of malnutrition in Mexico is one of the highest reported worldwide. In a sample of 90 CAPD patients, malnutrition was present in 82%. Furthermore, the greatest numbers of malnourished patients had moderate (N = 22) and severe (N = 34) degrees of malnutrition13Espinosa A. Cueto-Manzano A. Velázquez C. et al.Prevalence of malnutrition in Mexican CAPD diabetic and non-diabetic patients.Adv Perit Dial. 1996; 12: 302-306PubMed Google Scholar. In addition, Mexican women and diabetics seem to be particularly prone to develop more severe malnutrition13Espinosa A. Cueto-Manzano A. Velázquez C. et al.Prevalence of malnutrition in Mexican CAPD diabetic and non-diabetic patients.Adv Perit Dial. 1996; 12: 302-306PubMed Google Scholar. Other populations that might be at increased risk for malnutrition and subsequent mortality while on CAPD treatment are those with a high peritoneal transport rate. Patients with fast peritoneal transport develop the lowest serum albumin levels14Díaz A.A. Gamba G. Abasta-Jiménez M. Correa-Rotter R. Serum albumin and body surface area are the strongest predictors of the peritoneal transport type.Adv Perit Dial. 1994; 10: 47-51PubMed Google Scholar, which in turn may be partially explained by a greater protein loss in the dialysate15Cueto-Manzano A.M. Gamba G. Correa-Rotter R. Peritoneal protein loss in patients with high peritoneal permeability. Comparison between continuous ambulatory peritoneal dialysis and day-time intermittent dialysis.Arch Med Res. 2001; 32: 197-201Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar. A direct correlation between peritoneal transport rate and malnutrition, however, has not yet been demonstrated. Even though in a cross-sectional study in Mexican patients we have reported a negative association between serum albumin and peritoneal transport rate, a correlation between transport rate and nutritional status (evaluated by a nutritional index, including clinical, biochemical and anthropometric variables) was not supported16Cueto-Manzano A.M. Espinosa A. Hernández A. Correa-Rotter R. Peritoneal transport kinetics correlate with serum albumin but not with the overall nutritional status in CAPD patients.Am J Kidney Dis. 1997; 30: 229-236Abstract Full Text PDF PubMed Scopus (30) Google Scholar. In summary, most of the Mexican people are Mestizos; only about 6% are of indigenous origin. Mexico is a country with marked inequities: it is the thirteenth largest economy in the world, but has a high prevalence of poverty. Mexico continues to be the country with proportionally the largest utilization of CAPD in the world. Malnutrition and diabetes mellitus are highly prevalent in Mexican patients on CAPD programs, and these conditions are important risk factors for a poor outcome.
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