OVERVIEW OF PERITONEAL DIALYSIS IN LATIN AMERICA

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1 Peritoneal Dialysis International, Vol. 27, pp Printed in Canada. All rights reserved /07 $ Copyright 2007 International Society for Peritoneal Dialysis OVERVIEW OF PERITONEAL DIALYSIS IN LATIN AMERICA Roberto Pecoits-Filho, 1 Hugo Abensur, 2 Alfonso M. Cueto-Manzano, 3 Jorge Dominguez, 4 José Carolino Divino Filho, 5 Juan Fernandez-Cean, 6 Ana Mireya Ortiz, 7 Gustavo Moretta, 8 Alfonso Ramos, 9 Mauricio Sanabria, 10 Ricardo Sesso, 11 and Ramon Paniágua 12 Center for Health and Biological Sciences, 1 Pontifícia Universidade Católica do Paraná, Curitiba, Brazil; Nephrology Division, 2 Universidade de Sao Paulo; Unidad de Investigación Médica en Enfermedades Renales, 3 UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, Mexico; Dialysis and Transplantation Service, 4 Miguel Perez Carreño Hospital, Caracas, Venezuela; Medical and Scientific Affairs, 5 Baxter Latin América, Mexico City, Mexico; Servicio de Asistencia Renal Integral (SARI), 6 Montevideo, Uruguay; Nephrology Division, 7 Pontifícia Universidad Católica de Chile, Santiago, Chile; Universidad Nacional del Noroeste de Buenos Aires (UNNOBA), 8 Argentina; Servicio de Medicina Interna, 9 Hospital General de Zona #2, IMSS, Hermosillo, Sonora, Mexico; RTS Clinica Nueva, 10 Bogotá, Colombia; Nephrology Division, 11 Federal University of Sao Paulo, Brazil; Unidad de Investigación Médica en Enfermedades Nefrológicas, 12 Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México Latin America is a heterogeneous region comprised of 20 countries, former colonies of European countries, in which Latin-derived languages are spoken. According to the Latin American Society of Nephrology and Hypertension/ Sociedad Latino Americana de Nefrologia e Hipertensión (SLANH), the acceptance rate for renal replacement therapy is 103 new patients per million population. In Latin America, hemodialysis is the predominant form of replacement therapy for end-stage renal disease; however, some countries employ peritoneal dialysis (PD) in 30% or more patients. In particular, Mexico is the country with the largest PD utilization in the world, and furthermore, it is estimated that approximately 25% of the world s PD population may be found Latin America. Data concerning clinical practice and long-term outcome of PD in Latin America are scarce, although regional registries are increasing in number and quality. In this review article, we present an overview of the situation of PD in several countries of Latin America, based on the registry of the SLAHN, national registries, and personal communication with PD experts from different countries. Perit Dial Int 2007; 27: KEY WORDS: Latin America. Correspondence to: R. Pecoits-Filho, Center for Health and Biological Sciences, Imaculada Conceição, 1155, Curitiba, PR Brazil. r.pecoits@pucpr.br Received 13 February 2007; accepted 27 February Latin America is a heterogeneous region comprised of 20 countries, former colonies of European countries, where Romance (Latin derived) languages are spoken (i.e., Spanish, Portuguese, and French). Covering a territory of 20.5 million km 2, the population of Latin America was 551 million in the year 2005, and is growing at an annual rate of 1.3%, concentrated primarily (78%) in urban areas (1). Latin America has made some progress in economic issues; for example, per capita gross national intake is currently US$4,008 and its mean annual growth is 4.4% (2); however, 37% of the population is still living in poverty, and the inequality of the region is one of the highest in the world with respect to income distribution (1). The human development index is 0.8 in this region (3), and the illiteracy rate is 9.5% in people older than 15 years of age; homes without piped water and sanitation comprise 11% and 26% respectively (1). As for the health issues, life expectancy at birth is now 72 years, and the elderly population (>65 years) is 8.7% of the total, but it should increase to 12.6% by 2020 (1). The mortality rate in children under 5 years of age is 32 per 1000 inhabitants, 8.8% of newborns have low birth weight (<2.5 kg), and energy intake in the adult population is 2861 kcal/day. Another major problem is the low percentage of gross domestic product designated to healthcare in these countries, which is reflected in the low rates of physicians (1.8), nurses (0.8), and hospital beds (1.9) per 1000 inhabitants (4). 316

2 PDI MAY 2007 VOL. 27, NO. 3 OVERVIEW OF PD IN LATIN AMERICA CHRONIC KIDNEY DISEASE AND PERITONEAL DIALYSIS (PD) IN LATIN AMERICA According to the Latin American Society of Nephrology and Hypertension/Sociedad Latino Americana de Nefrologia e Hipertensión (SLANH) annual report of 2002 (the most recent report published), a prevalence of dialysis [both hemodialysis (HD) and PD] and renal transplantation of 363 patients per million population (pmp) was reported (5). In the same document, an acceptance rate of 103 new patients pmp for renal replacement therapy was observed (5). In Latin America, HD is the predominant form of replacement therapy for end-stage renal disease (ESRD) (6), although four countries (Colombia, Guatemala, El Salvador, and Mexico) employ PD in 30% or more of their ESRD patients (Table 1; Figure 1). In particular, Mexico is the country with the largest PD utilization in the world (7), and it is estimated that approximately 25% of the world s PD population may be found in Latin America. Data concerning clinical practice and long-term outcome on PD in Latin America (8) are scarce, although regional registries are increasing in number and quality. Patient survival does not appear to be different; however, technique survival has been reported to be lower compared to other centers in developed countries (9,10). It should be mentioned, however, that those reports from Latin-American countries included patients still using non-disconnecting PD systems, which are not utilized in the vast majority of patients at present and could have influenced the lower technique survival rate. A significant reduction in peritonitis has been shown with the more recent use of disconnecting systems (11); it is expected that the latter may improve technique survival, although no published information is available on this subject. In the following section, we present an overview of the situation of PD in several countries in Latin America, based on the registry of the SLANH, national registries, and personal communication with PD experts from different countries. ARGENTINA Argentina has over patients on dialysis. Access to renal replacement therapy (both HD and PD) is universal and all patients have a healthcare provider. A large proportion (30%) of patients are covered by the Programa de Atención Médica Integral (PAMI), while only less than 3% are in the public system. Almost all dialysis centers are private (95%); about half have national capital and 43% belong to international chains. Reimbursement for dialysis (US$903) includes transport of patients to the unit, peritoneal or vascular access, erythropoietin, calcitriol, iron, vitamins, phosphate binders, antibiotics, and professional charges. The penetration of PD is low (4.5%), and automated peritoneal dialysis (APD) is used in less than 1% of dialysis patients. Peritoneal dialysis solutions from Baxter, Fresenius, and Periline are available in 1.5%, 2.5%, and 4.25% glucose TABLE 1 Prevalence of Renal Replacement Therapy in Countries Included in the Latin American Society of Nephrology and Hypertension Registry, Based in the Year 2001 [Adapted from Ref. (5)] Country HD (n) PD (n) Total (n) HD (pmp) PD (pmp) Total (pmp) Argentina Brazil Chile Colombia Costa Rica Cuba Ecuador Guatemala Mexico Paraguay Peru Puerto Rico Uruguay Venezuela Total HD = hemodialysis; PD = peritoneal dialysis; pmp = per million population. 317

3 PECOITS-FILHO et al. MAY 2007 VOL. 27, NO. 3 PDI % Figure 1 Prevalence of peritoneal dialysis in different countries of Latin America. concentrations. Calcium solution is available in low and standard concentrations. With respect to volume, 1-, 2-, 2.5-, 3-, 5-, and 6-L bags are available. Peritoneal catheters are usually implanted by surgeons. Dropout rate was 27% in 2005 and 45% in Peritonitis is caused by gram-positive organisms in over 60% of cases (mainly Staphylococcus epidermidis), gram-negative in 19%, and fungus in 5%. The peritonitis rate is 1 episode/ 27 patient-months. BOLIVIA The population of Bolivia is approximately 8.3 million and slightly over 400 people are on dialysis; however, the two transplant units serve only a small part of the dialysis population. Hemodialysis treatment varies in clinical practice, depending on financial conditions and coverage. There is still significant use of in-center intermittent PD, many times with a rigid catheter and an open system, with exchanges performed by medical residents, and associated with high mortality and infection rates. The solutions used are locally produced and approximately 80 patients are maintained in a high turnover system. At present, the public insurance system is discussing the introduction of continuous ambulatory peritoneal dialysis (CAPD) with local health providers. There are public hospitals, private hospitals, and institutions related to oil companies and military centers that are capable of performing PD in the main cities of Santa Cruz, Cochabamba, and La Paz. There is a law of the Social Security System stating that patients cannot be dialyzed for more than 52 weeks. BRAZIL Brazil ranks third in the world in number of dialysis patients, although it is estimated that only one third of patients are diagnosed with chronic kidney disease. According to the annual census of the Brazilian Society of Nephrology, there are over (383 pmp) patients on dialysis today, and a little more than 6500 on PD ( accessed 3 October 2006). More than 3000 transplants are performed every year, 47% from a living donor. Automated PD is currently used in almost 40% of patients. Available solutions are glucose-based and lactate-buffered, at volumes of 1, 2, 2.5, and 6 L. Glucose concentrations include 1.5%, 2.5%, and 4.25%, with both standard and low calcium concentrations. Connection systems for CAPD are the twin-bag and Andy-disc set, manufactured by Baxter Healthcare and Fresenius Medical Care respectively. In January 2006 there were 619 clinics in the country, of which 69% were privately owned and 31% public. Reimbursement (in October 2006) was US$52.40 per dialysis session for HD and US$716 per month for PD. Reimbursement for APD was slightly higher, at US$937 per month. Patients are universally covered, 90% by the government system. Catheter implantation is usually performed by the surgeon, although programs of interventional nephrology are being developed and in an increasing number of clinics, the nephrology service has became responsible for catheter implantation. Usual CAPD prescription is four 2-L exchanges/day with one hypertonic solution at night; standard calcium solutions are widely utilized. Automated PD prescription consists of 8 20 L using a mixture of 318

4 PDI MAY 2007 VOL. 27, NO. 3 OVERVIEW OF PD IN LATIN AMERICA glucose concentrations, and the wet day is preferred. In an ongoing, large, multicenter study (ECMDP; unpublished observation) including more than 3000 patients, the main cause of dropout is mortality (mainly cardiovascular), followed by peritonitis. The peritonitis rate is 28 episodes/patient-month, caused by Staphylococcus aureus and S. epidermidis in the majority of cases, with major regional differences. Culture results are negative in almost 40% of cases. CENTRAL AMERICA: GUATEMALA, EL SALVADOR, PANAMA, HONDURAS, NICARAGUA, AND COSTA RICA There are major differences in PD practice and penetration in Central America. While in Guatemala and El Salvador PD is the renal replacement therapy in more than half of patients, in Panama, Honduras, Nicaragua, and Costa Rica there are smaller PD programs, and HD predominates. In most of these countries, the nephrologists are responsible for catheter implantation. The CAPD prescription is usually 8 L and intermittent PD is widely used in some countries. In Guatemala, the reimbursement system allows for universal access to dialysis through social security, but in most of the other countries, the reimbursement system is not well defined. Automated PD is very common in Panama, but used in 16% of patients in El Salvador and Honduras, and less than 1% of patients in Guatemala. The main problems with PD are reimbursement issues, high cardiovascular mortality, and the widespread use of intermittent PD in some countries. CHILE In recent years there has been a significant decrease in enrollment of PD patients in Chile. Despite this, the country keeps track of its almost 600 patients (83 pediatric) through a well-organized national registry. In 2005, reimbursement per patient per year was US$14,654 for PD and US$10,909 for HD, universally covered by public funds (FONASA). Half the patients starting PD originated from HD treatment. There is a very high use (almost 80%) of APD. The main cause for dropout was mortality and 7% of patients died in 2006, due mainly to cardiovascular disease (40% of all deaths). Mortality rate due to peritonitis was only 4%. During last year (2006), 6.5% were transferred to HD and 2% received a transplant. The main cause of transfer to HD was peritonitis, followed by poor compliance and ultrafiltration failure. More than 65% achieve adequate Kt/V targets. The peritonitis rate was 1 episode/39 patientmonths, with 29% of cultures negative. The main cause of peritonitis was S. epidermidis. COLOMBIA The information from Colombia was based on the data from Renal Therapy Services clinics, which represent a large proportion (more than 60%) of the dialysis patients in the country. Peritoneal dialysis has a large penetration (>40%) and, currently, 34% of PD patients utilize cyclers. In Colombia, there is 1 nephrologist for every 80 dialysis patients; the nurse/patient ratio in the PD program is 1/45. Currently, nephrologists implant catheters in half of the patients. Gross mortality in PD is 16%, slightly lower than the HD mortality rate of 19%. The peritonitis rate in APD is 1 episode/32 patient-months and for CAPD the peritonitis rate is 1 episode/26 patientmonths. The main micro-organism causing peritonitis is S. epidermidis. The average volume prescribed is 7.6 L for CAPD and 11.2 L for APD. The controllable PD dropout rate (transfer to HD only) is 16% per year. Reimbursement is nearly equal between HD and PD. ECUADOR In Ecuador, it is estimated that only 25% of patients with chronic kidney disease have access to dialysis or transplant, due most likely to the fact that the insurance systems (ISSFA from the military and ISSPN from police) cover only a small part of the population. It is estimated that only 5% are able to cover dialysis expenses from private resources. The reimbursement for HD is US$1,300 and includes all access, medication, treatment of comorbidities, and laboratory services. No public transplant program is available. Baxter, Fresenius, and Nipro are present in Ecuador in the HD market, but only Baxter is involved with PD. Automated PD is available for 20% of patients. Glucose concentrations of 1.5%, 2.5%, and 4.25% are available in 2-L and 2.5-L bags. Automated PD utilizes 5-L bags in prescriptions that vary from 10 to 20 L. There is one pediatric PD unit. The catheter used is a Quinton Curl Cath (Quinton, Bothell, Washington, USA), inserted percutaneously with local anesthesia or surgically. The main reasons for dropout are acute catheter dysfunction and ultrafiltration loss. The main microorganism involved in peritonitis is S. aureus. MEXICO The current number of patients on renal replacement therapy in Mexico can be approximated at in a population of over 107 million people. With respect to the health system, about 50% of the population is covered by three social security institutions: Instituto Mexicano del Seguro Social (IMSS), Instituto de 319

5 PECOITS-FILHO et al. MAY 2007 VOL. 27, NO. 3 PDI Seguridad y Servicios Sociales para los Trabajadores del Estado (ISSSTE), and the armed forces. The remaining half of the population has no public coverage. In the past 2 years a new voluntary popular insurance administered by the Health Ministry began support for the low-income population, currently 10 million people. Only patients within the social security systems have universal coverage including renal replacement therapy. Only one institution, the IMSS, takes care of about 80% of the current ESRD patients on treatment. The IMSS has about 160 hospitals with PD and/or HD programs. However, only 233 nephrologists are under contract and they are focused mainly on HD and transplant programs; therefore, most of the PD patients are taken care of by internists. The ratio of patients to nephrologists/internist is usually over 300:1. Furthermore, the overload at the existing units is a major limitation for PD. There is no official inclusion of surgeons on the PD staff; therefore, peritoneal access is a significant problem in Mexico. The penetration of APD is approximately 35%. Prescription of CAPD is usually four exchanges of 2 L. Death is the main cause of dropout. Baxter, Fresenius, and Pisa are present in the PD field and offer only standard glucosebased solutions. Recently, icodextrin solutions were registered and have begun to be utilized in Mexico. PARAGUAY Paraguay has fewer than 500 patients on dialysis and at present, 10 patients on PD in a recently created unit. All patients use Baxter solutions (2000 ml; 1.5%, 2.5%, 4.25%). At the moment, there is no availability of APD. In the only PD center, the surgeons implant the catheters. PERU Peritoneal dialysis in Peru is performed mainly (90%) in hospitals related to the Seguro Social del Essalud. The remaining PD patients are located in a public hospital. There are no private clinics. Three companies are active in the country (Baxter, Fresenius, and Trifarma), with solutions of 2, 2.5, and 5 L in all glucose concentrations. Nephrologists usually implant the catheters. Approximately 60% of dropouts are due to peritonitis; the main bacteria involved are S. aureus, S. epidermidis, and Pseudomonas. URUGUAY The information from Uruguay is based on the compulsory national registry, which has been ongoing since 320 the start of renal replacement therapy in that country. ( Most CAPD patients use 2 L, four times per day, using solutions with glucose concentrations of 1.5%, 2.5%, and 4.25%, lactate buffered, and with calcium concentrations of 1.75 and 1.25 mmol/l. Baxter is the only company involved in PD activity in the country. There are 50 dialysis centers (40 HD and 10 PD). Of these, 6 centers are public, 18 centers belong to collective health institutions (prepaid health institutions), and 26 centers are privately owned by nephrologists. There is a National Foundation (FNR) that finances all chronic HD, PD, and renal transplantation. The entire population is covered and patients do not pay for the treatment. The price of each HD and PD session is approximately US$70 and US$267 per month per patient, respectively, for the remuneration of all those who work in the PD unit (nurses, nephrologists, dietitians, and social assistants). The FNR pays directly to the provider for the dialysis solutions; the clinics do not participate in the payment process. It is estimated that nephrologists implant 50% of the catheters. In 2004 the incidence of peritonitis was 1 episode/ 31 patient-months, due most frequently to gram-positive organisms, particularly S. epidermidis. Negative cultures occur in 29% of cases. In 2004, 16.5% of PD patients were on APD and a shortage of cyclers was a limitation for the development of APD programs. VENEZUELA There are approximately 9000 patients on dialysis in Venezuela; 2000 are on PD. Dialysis is performed in public hospitals (15%) and for-profit units (85%), although dialysis as well as drugs are paid by social security. The APD penetration is 20%. Baxter, Fresenius, and Nipro are present in the country. CAPD patients use 2-L and 2.5-L bags. Catheters are most often placed by surgeons. The micro-organisms found during peritonitis are gram-positive in 52% of cases, gram-negative in 44%, and fungus in 4%. SUMMARY AND CONCLUSIONS Latin America represents an important region in PD, although penetration, clinical practice, and economic issues are very heterogeneous throughout the different countries. In this review, we presented data from the perspectives of several countries. Although the data presented was based on information varying from personal communications to registries of higher quality, we believe it represents an interesting overview of the current situation of PD in Latin America, and perhaps will stimu-

6 PDI MAY 2007 VOL. 27, NO. 3 OVERVIEW OF PD IN LATIN AMERICA late an increase in the presentation of local information globally. Given that Latin America has accumulated significant experience with PD (due to the large number of patients and long exposure to the method), we anticipate that this experience could be increasingly shared with other regions of the world, particularly those with similar environments. ACKNOWLEDGMENTS The authors are grateful to the important contributions of Susana Marcos (Argentina), Adela Lopez (Panama), Elsa Morillo (Ecuador), Rosana Chaud (Peru), Carlota González (Uruguay), and Adriana Paladini (Brazil). REFERENCES 1. CEPAL. The United Nations Economic Commission for Latin America. Available at: [accessed 1 November 2006] 2. World Bank. The World Bank Group. Available at: [accessed 1 November 2006] 3. The United Nations. Available at: [accessed 1 November 2006] 4. The Pan American Health Organization. Available at: [accessed 1 November 2006] 5. SLANH. Sociedad Latinoamericana de Nefrología e Hipertensión. Available at: [accessed 1 November 2006] 6. Cusumano AM, Di Gioia C, Hermida O, Lavorato C; Latin American Registry of Dialysis and Renal Transplantation. The Latin American Dialysis and Renal Transplantation Registry annual report Kidney Int Suppl 2005; 97: S Cueto-Manzano AM, Quintana-Pina E, Correa-Rotter R. Long-term CAPD survival and analysis of mortality risk factors: 12-year experience of a single Mexican center. Perit Dial Int 2001; 21: Saade M, Joglar F. Chronic peritoneal dialysis: seven-year experience in a large Hispanic program. Perit Dial Int 1995; 15: Nakamoto H, Kawaguchi Y, Hiromichi S. Is technique survival on peritoneal dialysis better in Japan. Perit Dial Int 2006; 26: Rotellar C, Black J, Winchester JF, Rakowski TA, Mosher WF, Mazzoni MJ, et al. Ten years experience with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1991; 17: Monteon F, Correa-Rotter R, Paniagua R, Amato D, Hurtado ME, Medina JL, et al. Prevention of peritonitis with disconnect systems in CAPD: a randomized controlled trial The Mexican Nephrology Collaborative Study Goup. Kidney Int 1998; 54: