Disparities in Renal Care in Jalisco, Mexico

doi:10.1016/j.semnephrol.2009.10.001

Seminars in Nephrology

Volume 30, Issue 1, January 2010, Pages 3-7

https://doi.org/10.1016/j.semnephrol.2009.10.001 Get rights and content

Summary

End-stage renal disease represents a serious public health problem in Mexico. Close to 9% of the Mexican population has chronic kidney disease (CKD) and 40,000 patients are on dialysis. However, the fragmentation of our health care system has resulted in unequal access to renal replacement therapy. In addition, poor patients in Jalisco with kidney failure have very advanced disease at the time of dialysis initiation, suggesting lack of access to predialysis care. To address these issues, a number of strategies have been implemented. Among them a renal replacement therapy program for which the cost of treatment is shared by government, patients, industry, and charitable organizations; the implementation of a state-funded hemodialysis program that provides free dialysis for the poor; the establishment of a university-sponsored residency program in nephrology and a postgraduate training in nephrology nursing; and a screening program for early detection and control of CKD. In conclusion, access to renal care is unequal. The extension of the Seguro Popular to cover end-stage renal disease treatment nationwide and the implementation of community screening programs for the detection and control of CKD offers an opportunity to correct the existing disparities in renal care in Jalisco and perhaps in other regions of Mexico.

Section snippets

Access to Renal Replacement Therapy

There are significant differences between the insured and uninsured groups starting renal replacement therapy (RRT). In a report from the Jalisco State Dialysis and Transplant Registry,⁷ the acceptance and prevalence rates in the insured population were significantly higher (327 pmp and 939 pmp, respectively) than patients without medical insurance (99 pmp and 166 pmp, respectively). The transplant rate also was different, at 72 pmp for those with health insurance and 7.5 pmp for those without

Mechanisms of Disparities

The reasons for these disparities and high mortality rates are multiple. First, the public health system in Jalisco, as in the rest of Mexico, is multitiered and centralized. The Mexican Institute for Social Security covers all private-sector salaried workers and their families, representing 44% of the population. The Institute of Social Security and Services for Civil Servants covers an additional 5%, private insurance accounts for 2% of the population, and 7% are covered by the Seguro

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This chapter discusses CKD as a complex biosocial problem, one, which reflects the particular ways in which sick bodies are produced as outcomes of social, political, and economic processes. In doing so, it focuses on the role of anthropology and its capacity to produce contextual and comparative analyses of the processes of disease emergence and related healthcare responses. The chapter provides a brief overview of the main themes anthropologists have examined in the broad domain of renal care, followed by two interlinked contributions such studies make to the study of complex healthcare issues in the context of global health. These contributions are analytical and methodological in character. Via both avenues, the chapter highlights anthropology’s valuable contribution to understandings of CKD, their outcomes, and healthcare arrangements.
End-Stage Renal Disease in Mexico
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End-stage renal disease (ESRD) represents a serious public health problem in Mexico. It is reported among the 10 leading causes of death, and it is the second cause of years of life lost to premature death in the country. Over 65,000 patients are on dialysis. Mexico is among the countries with the highest incidence and prevalence of treated ERSD in the world [421 per million population (pmp)], and it has experienced one of the greatest proportionate increases of ESRD (122%) over the last decade. Although continuous ambulatory peritoneal dialysis continues to be a frequent modality of treatment in Mexico, hemodialysis has experienced a significant growth in recent years. The introduction of legislation on organ donation and transplantation in 1984 resulted in a significant increase in kidney transplantation rates from 1.57 pmp in 1984 to 22.8 pmp in 2015. Similarly, organ and tissue donation rate increased from 6.4 pmp in 2006 to 16 pmp in 2015. The fragmentation of our health care system has resulted in unequal access to renal replacement therapy. Although patients with social security have universal access to renal replacement therapy, it is severely restricted or nonexistent in patients without it. It is of paramount importance to consider ESRD a public health priority in Mexico. Renal care should include prevention programs, as well as dialysis and transplantation. An effort should be made to decentralize the dialysis programs and to promote transplantation as the treatment of choice. The extension of Seguro Popular to cover ESRD treatment nationwide and the implementation of community, chronic kidney disease targeted-screening programs, offer an opportunity to enhance the prevention and control of ESRD in Mexico.
Epidemiological Characteristics of the Largest Kidney Transplant Program in Mexico: Western National Medical Center, Mexican Institute of Social Security
2016, Transplantation Proceedings
Citation Excerpt :
Our results contrast with the results from the two other health care systems, in which the number of transplantations performed is far lower due to the limited access to the mentioned resources. García et al have previously documented the contrasts in the care of ESRD in our country, since the rate of kidney transplantations in patients with social security is 72 patients per million inhabitants, while the same rate in the general population is only 7.5 patients per million inhabitants [4]. As with the rest of the country, the proportion of living donors, whether among relatives or with non–genetically related individuals, is the highest.
According to the National Transplant Center (CENATRA), in 2013, a total of 2707 transplantations were performed in Mexico; of them, 10% (270 transplantations) were done in our Tertiary Care Hospital (Western National Medical Center). This means that one in 10 transplant recipients undergoes transplantation at our medical center. The aim of our study was to describe the characteristics of and to compare changes in the kidney transplantation program over time.
This was a cross-sectional study. Data were collected from the hospital transplant registry from January 1994 to December 2014.
During the study period, 3643 kidney transplantations were conducted; most were living donor 3236 (89%), and only 407 patients (11%) received a graft from a deceased donor. Of living donors, 2786 (87%) were related, and 450 (13%) were genetically unrelated. The average recipient age was 28 years, and the average age of the donor was 34 years. It was observed that siblings donated more frequently (51%), followed by parents (34%). Among unrelated donors, spouses donated the most (66%). In 80% of cases, the cause of end-stage renal disease (ESRD) was unknown (80%). The most frequent renal replacement therapy was peritoneal dialysis (54%), followed by hemodialysis (18%); only 5% of patients received preemptive kidney transplant. The most frequent immunosuppression scheme was tacrolimus, mycophenolate mofetil, and prednisone in 70% of patients.
The Western National Medical Center is the largest kidney transplantation program in Mexico. The main activity is living donor transplantation. Recipients are relatively young persons with unknown etiology of ESRD.
Reproducible model to perform kidney transplantation in a low-resource population
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Citation Excerpt :
In Mexico, as in other parts of the world, there are substantial disparities in access to organ transplantation [18–21]. In our country, the transplant rate among uninsured patients is 7 pmp compared with 72 pmp among those with health insurance [11]. We reported the implementation of a cost-effective medical model to succeed in the instauration of a transplant program that can be copied and implemented in low-resource populations.
In several countries, organ transplantation is limited. We describe the implementation of a model to perform kidney transplantation in a low-resource population through a financial mechanism sharing public, patient, and private foundations funds.
This was a cohort study of 100 low-resource patients undergoing renal transplantation at the Hospital General of México. The mean age of the transplanted population was 30.07 ± 11.4 years, from which 84% reported an income <400 USD/month. Ninety percent of grafts were obtained from live donors.
The survival rate at 1 year after the procedure was 98%. Patient rehabilitation after transplantation included the incorporation of individuals into productive life and work. The economically active population increased from 8% to 40% after the transplant procedure. The model was successfully implemented as the result of (i) adequate incorporation of medical staff with solid experience in organ transplantation; (ii) institutional public policy and collaboration between diverse services to support donors and receptors; and (iii) financial collaboration to attract resources and funds to guarantee access to immunosuppressants.
Our results led toward an operational, reproducible model for transplanting patients in developing and financial crisis countries, reflecting beneficial long-lasting effects on the patient from the therapeutic, clinical, and economic points of view.
Multidisciplinary care for poor patients with chronic kidney disease in Mexico
2013, Kidney International Supplements
Coordinated multidisciplinary care (MDC) could improve management and outcomes of patients with chronic kidney disease (CKD). We opened a nurse-led, MDC CKD clinic in Guadalajara, Mexico. We report the clinic's results between March 2008 and July 2011. The records of 353 patients with CKD stage 3 and 4 were reviewed. Data were collected prospectively. Mean age was 59.1±15.5 years; 54.4% were female and 63.7% were diabetic. We observed significant changes in the quality of care between baseline and follow-up. Compliance with practice guidelines for angiotensin II receptor blockers (ARB) and beta blockers increased from 30.6% to 46.6%, and from 11% to 19%, respectively; for statins from 41.4% to 80.3%; for erythropoietin and calcium binders from 10.5% to 23.4%, and from 41.9 to 82.6%, respectively. At last visit, 90% of patients were on ACE inhibitors/ARB. Blood pressure <130/80 mm Hg increased from 23% to 38%. Serum glucose ≤130 mg/dl increased from 54.4% to 67.7%. Serum cholesterol >160 mg/dl decreased from 64.8% to 60.3%. At last visit, 70% of the patients had a serum Hgb ≥11.0 g/dl, and 80.1% and 65.1% had a normal serum calcium and serum phosphate, respectively. In conclusion, we observed a trend in the improvement of quality of care of CKD patients similar to those reported by other MDC programs in the developed world. Our study demonstrated that a nurse-led MDC program could be successfully implemented in developing countries.

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: Supported in part by the Registro de Dialisis y Trasplante del Estado de Jalisco and the Fundacion Hospitales Civiles de Guadalajara.

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Disparities in Renal Care in Jalisco, Mexico

Summary

Section snippets

Access to Renal Replacement Therapy

Mechanisms of Disparities

Lancet

Kidney Int

Kidney Int

Kidney Int

Estadisticas

Estadisticas por tema

2008 atlas of end-stage renal diseaseInternational comparisons

Peritoneal dialysis in Latin AmericaChronic kidney disease and dialysis in Mexico

Perit Dial Int