View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Kidney International, Vol. 68, Supplement 97 (2005), pp. S18–S22 Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela EZEQUIEL BELLORIN-FONT,NIDIA PERNALETE,JOSEFINA MEZA,CARMEN LUISA MILANES, and RAUL G. CARLINI National Center of Dialysis and Transplantation, Ministry of Health and the Division of Nephrology, Hospital Universitario de Caracas; Division of Nephrology Hospital Universitario Ruiz y Paez,´ Ciudad Bol´ıvar; and Hospital Jose Gregorio Hernandez,´ Puerto Ayacucho, Venezuela Access to and coverage of renal replacement therapy in Venezuela, como la mayor´ıa de pa´ıses en la region, ´ est´a su- minorities and ethnic groups in Venezuela. Numerous studies jeta a severas limitaciones de recursos economicos ´ asignados have documented the presence of racial and minority dispari- al tratamiento de enfermedades cronicas ´ de alto costo, re- ties regarding the impact of renal disease and access to renal stringiendo as´ıelingreso de pacientes renales a las TRR. A replacement therapy (RRT). This problem is less well docu- pesar de que el acceso al sistema de salud es universal, existe mented in Latin America. Venezuela, like most countries in un d´eficit de cobertura y una inequidad en el acceso a las TRR, the region, is subject to severe constraints in the allocation of en gran parte debido tanto a factores socioeconomicos ´ como resources for high-cost chronic diseases, which limits the ac- presupuestarios. Con el constante incremento en la incidencia cess of patients with chronic kidney disease to RRT. Although de la ERC, as´ı como en el costo de la tecnolog´ıa m´edica, el ob- access to health care is universal, there is both a deficit in cov- jetivo de lograr una cobertura completa parece ser cada d´ıa m´as erage and disparity in the access to RRT, largely as a result distante. Actualmente, existen evidencias que demuestran que of socioeconomic limitations and budget constrains. With cur- la prevencion ´ de la progresion ´ del dano ˜ renal es posible, a un rent rising trends of the incidence of end-stage renal disease bajo costo y con una mayor cobertura. Basado en lo anterior, el (ESRD) and costs of medical technology, the long-term goal of Ministerio de Salud ha redisenado ˜ sus pol´ıticas en relacio ´ nala complete RRT coverage will become increasingly out of reach. ERC a partir de cuatro elementos: 1. La prevencion ´ de la ERC a Current evidence suggests that prevention of progression of re- trav´es de la deteccion ´ oportuna y la referencia a grupos de salud nal disease is possible at relatively low cost and broad coverage. multidisciplinarios, as´ı como la promocion ´ de la salud en la co- Based on this evidence, the Ministry of Health has redesigned munidad. 2. Prevencion ´ del deterioro de la funcion ´ renal, tanto its policy with respect to renal disease based on 4 elements: 1. con medidas farmacologicas ´ como no farmacologicas. ´ 3. Incre- Prevention by means of early detection and referral to multidis- mentar la cobertura y disminuir las inequidades en el acceso a ciplinary health teams, as well as promotion of health habits in las TRR. 4. Aumentar el numero ´ de trasplantes renales a trav´es the community. 2. Prevention of progression of renal disease by de mejores sistemas de procuracion ´ y el reforzamiento de los pharmacologic and nonpharmacologic means. 3. An increase in programas de trasplante. Sin embargo, el incremento proyec- the rate of coverage and reduction of disparities in the access tado en el numero ´ de pacientes con ERC que requerir´an TRR, to dialysis. 4. An increase in the rates of renal transplantation representar´a una seria presion ´ al sistema de salud. Por lo an- through better organ procurement programs and reinforcement terior, la implementacion ´ de estas pol´ıticas de salud requerir´a of transplant centers. However, the projected increase in the de la participacion ´ de organismos internacionales, as´ı como de number of patients with ESKD receiving RRT will represent a la estrecha colaboracion ´ entre los nefrologos ´ y el Ministerio de serious burden to the health care system. Therefore, implemen- Salud, que permitan equilibrar la creciente demanda de servi- tation of these policies will require the involvement of inter- cios de pacientes con ERC con otras prioridades de salud en national agencies as well as an adequate partnership between nuestro pa´ıs. nephrologists and health care planners, so that meeting the in- creasing demands of ESKD programs may be balanced with other priorities of our national health system. Numerous studies have documented disparities in kid- Resumen ney disease and access to renal replacement therapy Numerosos estudios han documentado la presencia de in- (RRT) among ethnic minority groups. In the United equidades entre gruposetnicos ´ y minoritarios, en relacion ´ al States, these disparities in the prevalence of end-stage re- impacto de la enfermedad renal cronica ´ (ERC) y el acceso a la terapias de reemplazo renal (TRR) en estos grupos. Estas de- nal disease (ESRD) are more evident for African Amer- sigualdades no han sido bien documentadas en Latinoam´erica. icans, Hispanics, and Native Americans [l–5]. Although a discussion on potential causes behind these disparities is beyond the scope of this presentation, most investigators agree that a wide spectrum of factors, including biologi- Keywords: access to RRT, inequity in RRT, RRT in minority group. cal, environmental, socioeconomic, lifestyle, and cultural C 2005 by the International Society of Nephrology conditions may influence, to a greater or lesser degree, the S-18 Bellorin-Font et al: Coverage of RRT in Venezuela S-19 development and/or progression of renal disease among tem, result in disparities in access to medical care among the different groups. indigenous communities. The problem of disparity in access to RRT in minor- ity groups is less well documented in other countries of the American Continent. However, the economic impact INCIDENCE AND PREVALENCE OF CKD IN and strain on human and technical resources for the care VENEZUELA of chronic kidney disease (CKD) and RRT are greater The major causes of ESRD in Venezuela are diabetic on developing countries whose health care systems are nephropathy and hypertension, accounting for almost already overburdened with demands for primary care. 50% of patients on dialysis, followed by glomerulonephri- In Venezuela, the cost of the national dialysis program tis, obstructive uropathy, and tubulointerstitial nephritis for roughly 7500 patients is 4 times the expenditure for [7]. The prevalence of diabetic nephropathy has increased the vaccination program and 20 times that of the malaria progressively, reaching 27% by the year 2001. The rea- prevention program. The prevalence of ESRD is 292 per sons for the increase are multifactorial. In Venezuela, million population (pmp), similar to the average for Latin late referral to specialized nephrologic care likely plays American countries (278 pmp) [6], but far lower than in an important role. Indeed, diabetes mellitus accounts the United States (1131 pmp) [2], Japan (1397 pmp), and for only 3.0% of the consultations in nephrology clin- the European Union (644 pmp). Venezuela, like most ics of the national hospital network, after hypertension, Latin American countries, has severe constraints in the al- glomerular diseases, CKD, urinary tract infection, and lu- location of resources for high-cost chronic diseases, which pus nephropathy.By the time patients with diabetes reach affect not only minorities but a great proportion of the nephrologists, they already have a moderate-to-severe population. Therefore, there is severe limitation in re- decrease in glomerular filtration rate, thus limiting the sources for RRT. benefits of early interventions to slow the progression of renal disease. Information about the incidence of renal diseases or ETHNIC COMPOSITION OF SOCIETY IN risk factors for CKD in indigenous groups in Venezuela is VENEZUELA scarce. In a recent report, Herrera and Rodriguez-Iturbe Society in Venezuela is mainly an amalgam of 3 races, [8] showed that the incidence of ESRD in Goajiro Indians resulting in a predominant mestizo population (a mixture was 220 pmp, 1.7 times higher than the estimate for the of whites, blacks, and Indians). Therefore, ethnic cate- country [8]. Although possible risk factors associated with gories can be regarded as points along a continuum rather increased incidence of CKD in indigenous people have than as distinct categories. Physical appearance and skin not been clearly established, the authors suggest that a color, rather than ethnicity per se, become the major cri- combination of high rates of poststreptococcal glomeru- teria for classification. Approximately 52% to 82% of the lonephritis and a lower nephron endowment may be re- Venezuelan population is classified as mestizo, about 21% sponsible [8]. Indeed, the incidence of poststreptococcal are white, 10% are black, and only 1.5% (315,815 peo- glomerulonephritis was nearly twice that in other regions ple) is composed of over 25 different indigenous tribes. of the state; and low birth weight, a condition presumed The majority of the Indian groups live in communities associated with increased risk of CKD, was 23%. relatively isolated socially and geographically, and they The epidemiologic information about CKD and risk preserve most of their lifestyles and cultural traditions. factors in other Indian tribes in Venezuela is even more The Goajiro Indians are the largest tribe, compris- limited. In fact, most of the information concerning mor- ing about 60% of the total indigenous population of bidity is categorized by districts and no differentiation Venezuela. They occupy part of the Zulia State in the bor- between Indians and the rest of the population is made der between Venezuela and Colombia. The second and in the reports, thus increasing the difficulty of obtaining third largest groups of Venezuelan Indians, comprising reliable data.