Unmet Needs of CKD in Latin America: A Review from Expert Virtual Working Group

Public interest in chronic kidney disease and dialysis: a 20-year data analysis

Chronic kidney disease (CKD) is a growing global health challenge. As the disease progresses, it can lead to end-stage renal disease, necessitating dialysis or kidney transplantation. However, access to these life-saving treatments is often limited by geographic, financial, and resource constraints, underscoring the importance of public awareness and interest. This study examined global and U.S. search trends related to CKD and dialysis using Google Trends™ data from 2004 to 2024. Public search activity was measured using the Relative Search Interest (RSI) index, which ranges from 0 to 100. Both CKD and dialysis exhibited an upward trend in search activity worldwide and in the U.S., as indicated by a positive slope in linear regression analysis (all p < .0001), though some fluctuations and regional differences were observed. Pearson's correlation analysis demonstrated a strong relationship between the U.S. dialysis RSI scores from Google Trends and real-world dialysis incidence rates from the United States Renal Data System (USRDS) (r = 0.961, p < .0001). Notably, in 2020, search activity for both CKD and dialysis declined, likely due to disruptions caused by the COVID-19 pandemic. The study highlights the potential of Google Trends as a valuable tool for assessing public interest and awareness of kidney health, providing insights that can inform public health strategies and educational initiatives. However, relying solely on Google Trends data to assess public interest is insufficient, due to inherent limitations and biases. Findings derived from search trends should be interpreted with caution and ideally supplemented with additional research methodologies.

Group Medical Care Models Transforming Access to Kidney Disease Treatment: An Argentine Experience

As the prevalence of kidney disease rises in Latin America, there is increasing awareness of the importance of early detection and prevention. However, in a region characterized by socioeconomic inequality, variable access to care, and an overwhelmed primary health system, health professionals must find new and innovative ways of delivering care that is cost effective and mindful of patients' needs and social determinants of health. Group medical care (GMC), a model combining group visits and peer support with personalized care, has emerged as an intervention with proven benefits in clinical outcomes, patient satisfaction, and cost effectiveness in the management of chronic illnesses. In this article we present the case of Renalida, a kidney clinic in Argentina that has adopted GMC to improve access, engagement, and standards of care for older patients with chronic kidney disease (CKD). Beyond it being the first documented case of GMC for CKD in Latin America, Renalida brings to light many of the common barriers to effective early CKD care throughout the region and proposes a viable and holistic solution. In addition, we explore future directions, including the application of implementation science to leverage strategies such as GMC to improve both access to and quality of CKD care.

Access to Care During Pregnancy for Patients With Chronic Kidney Disease and Kidney Failure in Latin America: A State of the Art with an International Comparison

Access to kidney care is a problem in Latin America, similar to many other low- to medium-income countries. Uneven access and deep discrepancies in quality of care beset this large part of the world that encompasses North America (Mexico) and Central and South America. Access to kidney care during pregnancy can be seen as a marker of overall achievements and needs in nephrology. We suggest that this issue should be systematically considered and compared across settings when health care systems are evaluated. If this were done, pregnancy would be in the spotlight, and this would increase awareness of the problems that need to be dealt with and could guide interventions to improve kidney care in young women. This review discusses some epidemiological and clinical issues, as well as barriers to optimal care of pregnancy in patients with chronic kidney disease encountered in Mexico and other Latin American countries, contextualized with a brief overview on barriers and challenges in other continents.

Pediatric Kidney Care in Northern Central America: A Survey of Pediatric Nephrologists

Chronic kidney disease (CKD) is a public health problem worldwide. Guatemala, El Salvador, Honduras, and Nicaragua are among the top six countries of the continent with high mortality and years of life lost attributable to CKD. The magnitude of the gap in delivering pediatric kidney care in northern Central America has never been systematically documented, hindering the possibility of planning prevention and effective management. A survey was sent to the directors of pediatric kidney care referral centers in the aforementioned countries to understand the epidemiology and current state of the programs. The area has a total population of 40.4 million; 17 million (41%) are younger than 21 years. The median incidence of pediatric kidney failure (pKF) was 8.4 per million age-related population (pmarp), and the median prevalence was 34 pmarp. Peritoneal dialysis (PD) was the most prevalent kidney replacement therapy (KRT) in the form of continuous ambulatory peritoneal dialysis (CAPD). Hemodialysis (HD) was used in 26.5% of patients, and 30% had an arteriovenous fistula (AVF). Few children had access to transplantation (0.9 transplants pmarp). The rate of pediatric nephrologists pmarp ranged between 1.5 (Honduras) and 2.3 (Guatemala) pmarp. The public health system funds all four referral centers, but kidney foundations play an essential role. This article offers insight to support the development of a multinational plan for prevention, effective management, and strategic use of available resources for pediatric kidney care, including support from national and international initiatives.

Inside CKD: Cost-Effectiveness of Multinational Screening for CKD

Introduction

Early detection of chronic kidney disease (CKD) could slow its progression; however, most patients in earlier stages remain undiagnosed. Our study objective was to assess the cost-effectiveness of multinational CKD screening strategies from the payer perspective across general and higher-risk populations.

Methods

Using the published Inside CKD microsimulation, we projected virtual closed populations to assess CKD screening strategies in 31 countries or regions over a lifetime horizon. We considered people aged ≥ 65 or ≥ 45 years in the general population and in high-risk subgroups (type 2 diabetes [T2D], hypertension, or cardiovascular disease [CVD]). Simulated populations could receive 2 serum creatinine (SCr) tests assessing estimated glomerular filtration rate (eGFR), "2 eGFR only", or an additional urinary albumin-to-creatinine ratio test (UACR), "2 eGFR and 1 UACR", versus current practice. Eligible patients received renin-angiotensin system inhibitors (RASi).

Results

Screening the general population aged ≥ 45 years for CKD was cost-effective versus current practice in all countries or regions using the "2 eGFR and 1 UACR" strategy, and cost-effective in all but 1 country using the 2 eGFR only strategy. The 2 eGFR and 1 UACR strategy showed consistently higher cost-effectiveness. Screening general populations aged ≥ 45 years increased projected CKD diagnosis rates per 100,000 persons eligible for screening from 459 by current practice to 7475 patients using 2 eGFR only, or 14,392 using 2 eGFR and 1 UACR. Similar trends in cost-effectiveness and diagnosis rates were observed in persons aged ≥ 65 years.

Conclusion

CKD screening may be cost-effective in general populations worldwide, including in populations aged ≥ 45 years. Our analysis corroborates global guideline recommendations for simultaneous eGFR and UACR testing if considered in the context of local factors.

Composite dietary antioxidant index is associated with renal anemia: a cross-sectional study

An increasing evidence suggested that chronic kidney disease (CKD) is closely related to oxidative stress, and dietary antioxidant intake can serve as a primary preventive measure for CKD. However, the relationship between composite dietary antioxidant index (CDAI) and renal anemia is not well understood. We postulated that elevated CDAI levels would be inversely related to a higher likelihood of renal anemia. The standardized calculation of CDAI was performed to investigate the relationship between them by a binary regression model. A non-linear relationship was examined through restricted cubic spline curves, and then pinpointed the inflection point. Subgroup analysis was then used to assess the robustness of the model. Finally 5880 participants were included in the study and a notable correlation between CDAI and renal anemia was found (P < 0.0001). In the multivariate linear regression model with adjustment for all confounding variables, the odds ratio (OR) and 95% confidence interval (CI) was 0.96 (0.94, 0.98; P < 0.0001), A non-linear relationship between CDAI and renal anemia was explored through restricted cubic splines, with a inflection at 6.005. Before the inflection point, for each unit rise in CDAI, the prevalence of renal anemia decreased by 5.7%. Subgroup analysis showed no statistically significant differences in interactions between any subgroups (P > 0.05). Our findings indicated a non-linear negative correlation between CDAI and renal anemia. The causal relationship still needs to be further clarified through large-scale prospective studies.

Diabetic Nephropathy-Associated Impaired Aortic Function Is Not Mediated by Mean Arterial Pressure and Its Determinants

Objective: The study aimed to assess the potential impacts of mean arterial pressure (MAP) and its determinants (cardiac output and systemic vascular resistance) on diabetic nephropathy (DNP)-associated impaired aortic function. Methods: This multi-ethnic study included 115 chronic kidney disease (CKD) patients (67 non-dialysis and 48 dialysis). Six aortic function measures were evaluated by SpygmoCor. The stroke volume was determined by echocardiography. Results: Hypertensive nephropathy (HNP) (53.9%), DNP (32.2%), glomerulonephritis (19.1%), and HIV-associated nephropathy (7.8%) composed the major CKD etiologies. Concurrent HNP and DNP were present in 31.1% of the patients. Participants with compared with those without concurrent HNP and DNP experienced more frequent established cardiovascular disease (43.2% versus 14.9%, p = 0.01), a faster pulse wave velocity (p = 0.001), and smaller total arterial compliance as an indicator of proximal aortic stiffness (p = 0.03). DNP was associated with each aortic function measure (p < 0.001-0.02) independent of potential confounders and MAP, as well as its determinants. HNP was not related to aortic function (p > 0.05 for all relationships). MAP and its determinants did not mediate the potential impact of DNP on aortic function (-4.1-6.4% contribution). Covariates that were associated with impaired aortic function measures included MAP and its determinants (p < 0.001-0.01). Conclusions: Mean or distending arterial pressure and its determinants were associated with impaired aortic function in the overall CKD population. However, these hemodynamic factors did not mediate DNP-associated impaired aortic function. Our results suggest that blood pressure lowering can be anticipated to improve impaired aortic function in the overall CKD population but not when it is solely induced by DNP.

Barriers to early diagnosis of chronic kidney disease and use of sodium-glucose cotransporter-2 inhibitors for renal protection: A comprehensive review and call to action

Chronic kidney disease (CKD) affects approximately 13% of people globally, including 20%-48% with type 2 diabetes (T2D), resulting in significant morbidity, mortality, and healthcare costs. There is an urgent need to increase early screening and intervention for CKD. We are experts in diabetology and nephrology in Central Europe and Israel. Herein, we review evidence supporting the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for kidney protection and discuss barriers to early CKD diagnosis and treatment, including in our respective countries. SGLT2 inhibitors exert cardiorenal protective effects, demonstrated in the renal outcomes trials (EMPA-KIDNEY, DAPA-CKD, CREDENCE) of empagliflozin, dapagliflozin, and canagliflozin in patients with CKD. EMPA-KIDNEY demonstrated cardiorenal efficacy across the broadest renal range, regardless of T2D status. Renoprotective evidence also comes from large real-world studies. International guidelines recommend first-line SGLT2 inhibitors for patients with T2D and estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m2, and that glucagon-like peptide-1 receptor agonists may also be administered if required for additional glucose control. Although these guidelines recommend at least annual eGFR and urine albumin-to-creatinine ratio screening for patients with T2D, observational studies suggest that only half are screened. Diagnosis is hampered by asymptomatic early CKD and under-recognition among patients with T2D and clinicians, including limited knowledge/use of guidelines and resources. Based on our experience and on the literature, we recommend robust screening programmes, potentially with albuminuria self-testing, and SGLT2 inhibitor reimbursement at general practitioner (GP) and specialist levels. High-tech tools (artificial intelligence, smartphone apps, etc.) are providing exciting opportunities to identify high-risk individuals, self-screen, detect abnormalities in images, and assist with prescribing and treatment adherence. Better education is also needed, alongside provision of concise guidelines, enabling GPs to identify who would benefit from early initiation of renoprotective therapy; although, regardless of current renal function, cardiorenal protection is provided by SGLT2 inhibitor therapy.

The Future of Kidney Care in Low- and Middle-Income Countries: Challenges, Triumphs, and Opportunities

CKD affects about 850 million people worldwide and is projected to be the fifth leading cause of death by 2040. Individuals from low- and middle-income countries (LMICs) bear the bulk of CKD. They face challenges including lack of awareness among the general population, as well as health care providers, unique risk factors such as genetic predispositions, infectious diseases, and environmental toxins, limited availability and affordability of diagnostic tests and medications, and limited access to KRTs. The inadequate health system infrastructure, human resources, and financing mechanisms to support comprehensive and integrated kidney care worsen the situation. Overcoming these challenges needs concerted efforts toward early detection, intervention, and multidisciplinary follow-up, policy, collaboration, advocacy, and financing. To achieve this, there is need for individual governments to include kidney health among the key health priorities and build capacity toward resilient health care systems. Integrating kidney care using the roadmaps of well-established management systems for other chronic diseases, such as HIV, has the potential to expedite the widespread adoption of kidney health. The aim of this article is to provide an overview of the current state and future prospects of kidney care in LMICs, highlighting the main challenges, ongoing efforts, and opportunities for improvement. We present case studies of exemplary efforts from three continents of the world with the highest densities of LMICs and propose potential strategies for a sustainable solution.

Uremic Stomatitis: A Latin American Case Series and Literature Review

BACKGROUND

Uremic stomatitis is often unfamiliar to healthcare professionals. This study presents five cases of uremic stomatitis, providing a comprehensive analysis of their demographic distribution, clinicopathological features, and management strategies based on existing literature.

METHODS

Data were collected from centers across Brazil, Argentina, Venezuela, and Mexico. Electronic searches were conducted in five databases supplemented by manual scrutiny and gray literature.

RESULTS

The series consisted of three men and two women with a mean age of 40.2 years. Lesions mostly appeared as white plaques, particularly on the tongue (100%). The median blood urea level was 129 mg/dL. Histopathological analysis revealed epithelial changes, including acanthosis and parakeratosis, with ballooned keratinocytes in the suprabasal region. Oral lesions resolved subsequent to hemodialysis in three cases (75%). Thirty-seven studies comprising 52 cases of uremic stomatitis have been described hitherto. Most patients were male (65.4%) with a mean age of 43.6 years. Clinically, grayish-white plaques (37.3%) and ulcers/ulcerations (28.9%) were common, particularly on the tongue (30.9%). Hemodialysis was performed on 27 individuals. The resolution rate of oral lesions was 53.3%.

CONCLUSION

Earlier recognition of uremic stomatitis, possibly associated with long-term uremia, holds the potential to improve outcomes for patients with undiagnosed chronic kidney disease.

Causes of Chronic Kidney Disease and Their Associations with Cardiovascular Risk and Disease in a Sub-Saharan Low-Income Population

Introduction

The causes of chronic kidney disease (CKD) in people living in Sub-Saharan Africa await identification. Also, whether cardiovascular risk and disease extent differ among patients with different CKD etiologies is uncertain.

Methods

In this prospective cross-sectional study, we examined the presumed causes of chronic kidney disease (CKD) and their relationships with cardiovascular risk and disease in 743 consecutive patients from a sub-Saharan low-income population.

Results

Hypertensive nephropathy (HNP) (60.2%), diabetic nephropathy (DNP) (24.4%), HIV associated CKD (20.0%) and glomerular disease (13.6%) comprised the major CKD etiologies upon enrolment at the hospital nephrology clinic. Pulse pressure was larger in patients with concurrent HNP and DNP than in those with HNP only (p<0.001). Pulse pressure and systolic blood pressure were larger in HNP or/and DNP patients than those with HIV associated CKD and glomerular disease (p=0.04 to <0.001). Cardiovascular disease was more prevalent in patients with HNP and concurrent HNP and DNP than those from other etiologic categories (p<0.05). HNP and DNP were associated with pulsatile pressures (pulse pressure and systolic blood pressure) independent of one another (p<0.01). In adjusted product of coefficient mediation analysis, mean arterial or distending pressure accounted fully for the potential impact of HNP on pulsatile pressures (103.9-115.7%) but not for that of DNP on the respective pressures (-2.0%-(-)7.5%).

Conclusion

HNP is by far the most prevalent presumed cause of CKD in this African population. Cardiovascular risk and disease differ markedly across CKD etiological categories.

[Quantification of the burden of chronic kidney disease in Latin America: an invisible epidemicQuantificação da carga da doença renal crônica na América Latina: uma epidemia invisível]

Objective

1) Describe the burden of chronic kidney disease in Latin American countries between 1990 and 2019; and 2) Estimate the correlation between disability-adjusted life years (DALYs) and the Sociodemographic Index and the Healthcare Access and Quality Index.

Methods

Secondary and ecological analysis, based on the 2019 Global Burden of Diseases, Injuries and Risk Factors Study. Standardized mortality rates, years of life lost to due to premature death (YLLs),years of healthy life lost due to disability (YLDs) and DALYs due to chronic kidney disease were reported for 1990, 2005, and 2019. Information was disaggregated by country, sex, age group, and sub-cause.

Results

Between 1990 and 2019, the burden of chronic kidney disease increased considerably in Latin American countries, becoming one of the main causes of mortality and DALYs. The standardized rate of DALYs for chronic kidney disease was largely due to the weight of premature deaths rather than disability. In 2019, Nicaragua, El Salvador, Mexico, and Guatemala had the highest standardized mortality rates for chronic kidney disease and DALYs, while Uruguay had the lowest.

Conclusions

Chronic kidney disease is an invisible epidemic that places an excessive burden in terms of mortality and DALYs on Latin American countries. It is essential to join forces to tackle the disease in the region, and promote local actions that address the particularities of each country.

Capacity for the management of kidney failure in the International Society of Nephrology Latin America region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

Successful management of chronic kidney disease (CKD) in Latin America (LA) continues to represent a challenge due to high disease burden and geographic disparities and difficulties in terms of capacity, accessibility, equity, and quality of kidney failure care. Although LA has experienced significant social and economic progress over the past decades, there are still important inequities in health care access. Through this third iteration of the International Society of Nephrology Global Kidney Health Atlas, the indicators regarding kidney failure care in LA are updated. Survey responses were received from 22 of 31 (71%) countries in LA representing 96.5% of its total population. Median CKD prevalence was 10.2% (interquartile range: 8.4%-12.3%), median CKD disability-adjusted life year was 753.4 days (interquartile range: 581.3-1072.5 days), and median CKD mortality was 5.5% (interquartile range: 3.2%-6.3%). Regarding dialysis modality, hemodialysis continued to be the most used therapy, whereas peritoneal dialysis reached a plateau and kidney transplantation increased steadily over the past 10 years. In 20 (91%) countries, >50% of people with kidney failure could access dialysis, and in only 2 (9%) countries, people who had access to dialysis could initiate dialysis with peritoneal dialysis. A mix of public and private systems collectively funded most aspects of kidney replacement therapy (dialysis and transplantation) with many people incurring up to 50% of out-of-pocket costs. Few LA countries had CKD/kidney replacement therapy registries, and almost no acute kidney injury registries were reported. There was large variability in the nature and extent of kidney failure care in LA mainly related to countries' funding structures and limited surveillance and management initiatives.

Risk factors associated with glomerular filtration rate in Mexican adults with type 2 diabetes mellitus

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is related to glomerular filtration rate (GFR) impairment, which is one of the main causes of chronic kidney disease. The objective of this study was to identify the risk factors related to GFR in Mexican adults with T2DM, using a validated multiple linear regression model (MLRM), with emphasis in body adiposity, glycemic control, duration of the diabetes and other relevant risk factors.

MATERIALS AND METHODS

A cross-sectional, analytical, and observational study was carried out in 252 adults with a previous diagnosis of T2DM. Body mass index (BMI) and waist circumference (WC) were determined and a fasting blood sample was collected for glucose, creatinine and HbA1c determinations. GFR was calculated with the Cockcroft-Gault equation adjusted for body surface area. Four MLRM were performed to determine the factors related to the GFR; it was evaluated whether these models complied with the statistical assumptions of the linear regression model.

RESULTS

The average age of the participants was 60 ± 12 years, 62.3% of them were women. GFR correlated with BMI and WC; age and duration of the diabetes were associated inversely. Model 4 of the MLRM reported a coefficient of determination of 53.5% where the variables BMI (β = 1.31), male sex (β = -6.01), duration of T2DM (β = -0.57), arterial hypertension (β = -6.53) and age (β = -1.45) were simultaneously and significantly related to the GFR.

CONCLUSIONS

Older age, male sex, longer duration of T2DM and the presence of arterial hypertension were associated with a decrease in the GFR; BMI and WC were directly associated. No effect of glucose and HbA1c on GFR was observed.

[Renoprotection. About World Kidney Day]

The World Kidney Day was founded in 2003 by doctor Joel D. Kopple, American nephrologist, who in the session in the Congress of the International Federation of Kidney Foundations explained the need to implement the celebration on a day that alludes to this organ, in order to direct preventive actions for kidney disease and raise awareness in the medical community and the general population on the importance of caring for the kidneys. 3 years later, the proposal was accepted and as of 2006 World Kidney Day is celebrated. The diffusion is found throughout the world and in each place there are talks, courses, workshops, cultural activities and even marathons related to the prevention, diagnosis and treatment of kidney disease. Chronic kidney disease (CKD) is a disorder with a chronic, degenerative, and lethal evolution. Managing CKD requires a large amount of human, financial, and infrastructure resources. It impairs the quality of life and negatively affects survival. On the other hand, it leads to dialysis and kidney transplant treatments, which are expensive enough to put any health institution at financial risk, especially those most vulnerable. The main idea of these non-profit international organizations is to promote the well-being and improve the quality of life of people with CKD with and without dialysis, and to promote kidney transplantation as the first treatment option.

Translating the efficacy of dapagliflozin in chronic kidney disease to lower healthcare resource utilization and costs: a medical care cost offset analysis

AIMS

Dapagliflozin was approved for use in patients with chronic kidney disease (CKD) based on results of the DAPA-CKD trial, demonstrating attenuation of CKD progression and reduced risk of cardio-renal outcomes and all-cause mortality (ACM) versus placebo, in addition to standard therapy. The study objective was to assess the potential medical care cost offsets associated with reduced rates of cardio-renal outcomes across 31 countries and regions.

MATERIALS AND METHODS

A comparative cost-determination framework estimated outcome-related costs of dapagliflozin plus standard therapy versus standard therapy alone over a 3-year horizon based on the DAPA-CKD trial. Incidence rates of end-stage kidney disease (ESKD), hospitalizations for heart failure (HHF), acute kidney injury (AKI), and ACM were estimated for a treated population of 100,000 patients. Associated medical care costs for non-fatal events were calculated using sources from a review of publicly available data specific to each considered setting.

RESULTS

Patients treated with dapagliflozin plus standard therapy experienced fewer incidents of ESKD (7,221 vs 10,767; number needed to treat, NNT: 28), HHF (2,370 vs 4,684; NNT: 43), AKI (4,110 vs. 5,819; NNT: 58), and ACM (6,383 vs 8,874; NNT: 40) per 100,000 treated patients versus those treated with standard therapy alone. Across 31 countries/regions, reductions in clinical events were associated with a 33% reduction in total costs, or a cumulative mean medical care cost offset of $264 million per 100,000 patients over 3 years.

LIMITATIONS AND CONCLUSIONS

This analysis is limited by the quality of country/region-specific data available for medical care event costs. Based on the DAPA-CKD trial, we show that treatment with dapagliflozin may prevent cardio-renal event incidence at the population level, which could have positive effects upon healthcare service delivery worldwide. The analysis was restricted to outcome-associated costs and did not consider the cost of drug treatments and disease management.