Home Therapies in Latin America

EVIDENCE BASED INSIGHT

Home Therapies in Latin America

September 21, 2020 • 5 min read

JUAN CARLOS BERBESSI, MD


Kidney disease is increasing throughout Latin America, and Fresenius Medical Care Latin America (FME-LATAM) is treating nearly 40,000 patients. Hemodialysis and peritoneal dialysis (PD) are the two most prevalent renal replacement therapy options, although PD is currently underutilized. Home hemodialysis (HHD) is rarely used because it is not included in government healthcare coverage. Given this situation, FME-LATAM is working to increase the number of patients who choose PD. This includes encouraging policy makers, physicians, nurses, and patients to understand why PD should be the first option for treatment. A longer-term goal is to educate all healthcare stakeholders about the additional benefits of HHD. 

Latin America comprises those countries on the American continent where a Romance language (a language derived from Latin) predominates, with Spanish and Portuguese as the primary languages spoken. As of 2020, the population of Latin America and the Caribbean is 656,353,521, equivalent to 8.55 percent of the world’s total population. 

Like many regions of the world, chronic kidney disease (CKD) is a major challenge for Latin American countries due to its epidemic proportions and the high burden it places on patient populations and public healthcare systems. Diabetes and hypertension are the leading causes of admission to dialysis, and the prevalence of kidney disease is expected to continue increasing throughout the region in the coming years. 

Fresenius Medical Care Latin America (FME-LATAM) operates in most Latin American countries (excluding Mexico and Puerto Rico, which are part of Fresenius Medical Care North America), with subsidiaries in seven countries: Argentina, Brazil, Chile, Colombia, Ecuador, Panama, and Peru. During 2019, FME-LATAM provided renal replacement therapy (RRT) to nearly 40,000 patients in 233 dialysis centers in 23 countries across Latin America.1

The number of patients with end-stage kidney disease (ESKD) on RRT in Latin America increased from 119 per million population (pmp) in 1991 to 660 pmp in 2010. Within the region, there is significant variation in the number of patients on RRT, reflecting significant disparities in access to treatment. Diabetes remained the leading cause of ESKD, with figures showing the highest incidence reported in Puerto Rico (66.8 percent), Mexico (61.8 percent), and Colombia (42.5 percent), and the lowest in Cuba (26.2 percent) and Uruguay (23.2 percent). The prevalence and incidence of RRT continues to increase. In countries with 100 percent public health or insurance coverage for RRT, the rates are comparable to those noted in developed countries with higher gross national income (GNI) (Figure 1).2

Figure 1 | Latin American Dialysis and Renal Transplantation Registry 1991-2010 (all modalities)

RENAL REPLACEMENT THERAPY OPTIONS

FME-LATAM offers two main RRT options: hemodialysis (HD) and peritoneal dialysis (PD). A third option, home hemodialysis (HHD) is rarely used. 

Hemodialysis
Of the renal replacement modalities, HD is generally more widely used (413 pmp) than PD (135 pmp) or living with a functioning graft (LFG) (11 pmp) across Latin America (Figure 2).3,4

  • HD proportionally increased more than PD and transplant, continuing to be the treatment of choice in the region (75 percent). 
  • The kidney transplant rate increased from 3.7 pmp in 1987 to 6.9 pmp in 1991 and to 19.1 in 2010. The total number of transplants in 2010 was 10,397, with 58 percent being deceased donors. Total RRT prevalence correlated positively with GNI (r = 0.86; p < 0.05) and life expectancy at birth (r = 0.58; p < 0.05). The global incidence rate correlated significantly only with GNI (r = 0.56; p < 0.05). 
  • Home PD is offered to approximately 12 percent of patients in Latin America. The figure exceeds 30 percent in some countries, but in other locations, it is only 6 percent. This significant heterogeneity is explained by socioeconomic and regional variations. 

In 2009, FME-LATAM implemented the EuCliD clinical data system. As of 2019, over 217 Latin American dialysis centers were using the system to collect, register, assess, and supply information. 

Figure 2 | Prevalence of RRT in Latin America (per million population)

Peritoneal dialysis
Across Latin America, PD is the most commonly available home therapy modality for ESKD patients. Limited financial and health resources are characteristic of this large and diverse region. Accordingly, the Latin American Society of Nephrology and Hypertension recommends PD as the primary modality, especially in locations where patients have significant difficulties accessing dialysis.5

Colombia, Guatemala, and El Salvador prescribe PD in 30 percent or more of ESKD patients. It is estimated that approximately 25 percent of the world’s PD population is found in Latin America. There are approximately 5,106 PD patients (3,748 continuous ambulatory peritoneal dialysis [CAPD] and 1,358 automated peritoneal dialysis [APD]) across the FME-LATAM centers, with Colombia and Argentina maintaining the largest PD programs. 

As of Q1 2020, Colombia has the largest PD utilization rate in Latin America (>30.76 percent). Eighty percent of patients use the CAPD modality. Additionally, there is one nephrologist for every 80 dialysis patients. The nurse-to-patient ratio in the PD program is 1 to 45, with approximately half of all patients presenting with catheters. The peritonitis rate in PD patients is one episode per 39.91 patient-months. The controllable PD dropout rate (transfer to HD only) is 16 percent per year. Reimbursement is nearly equal between HD and PD (Figure 3). 

Figure 3 | Number of CAPD and APD patients in Fresenius Medical Care-Colombia from 2010 to 2019

Even though the prevalence of RRT patients in Argentina is higher than the Latin American average, the percentage prescribed PD is low. CAPD was introduced in Argentina three decades ago, and 35.7 percent of the dialysis centers can provide this treatment; however, the number of patients on this modality should be considerably higher. PD showed significant growth in Argentina since 2009, from 3.9 percent to 6.5 percent. 

In Chile, there has been a significant decline in PD patient enrollment in recent years, but patients are tracked through a well-organized national registry. The reimbursement, per patient per year, is a significant accomplishment in the region, and the service is universally covered by public funds managed through Fondo Nacional de Salud (FONASA), the financial entity entrusted to collect, manage, and distribute state funds for health in Chile. Half the patients starting PD transitioned from HD treatment, and there is significant use of APD. 

Latin America represents an important region for PD as a treatment modality. Although penetration, clinical practice, and economic issues are heterogeneous throughout the region, PD continues to be an underutilized RRT strategy.

Many factors contribute to this underutilization, and the FMELATAM team continues working to reduce the gap between the actual number of PD patients and the desired number of them. Critical to closing this gap as well as sustaining a patient on PD are: 

  • Physician and patient education and comfort with PD as a modality 
  • Peritonitis control and prevention 
  • Use of more biocompatible solutions in preserving the peritoneal membrane 
  • Careful management of volume status 

Diagnostic and prevention programs for hypertension and diabetes, appropriate policies promoting the expansion of PD and organ procurement, and transplantation as cost-effective forms of RRT are needed in the region. 

PD should be supported by “first option of therapy” policies, combined with effective patient selection programs and psychosocial support services. Educating physicians, nurses, patients, and caregivers is also critical. Furthermore, to improve the number of RRT prescriptions in the region, it is imperative to collaborate with healthcare system stakeholders and payors on designing adequate reimbursement policies and incentives programs (Figure 4).6

Figure 4 | Evolution of the number of RRT patients in Latin America by treatment modality (1991–2010)

Home hemodialysis
Although HHD is consistently associated with markedly improved patient quality of life and rehabilitation, it is a rare or unavailable therapy in Latin America. This is because HHD is not included in any of the region’s government healthcare programs. 

Better identification of the specific barriers for HHD in Latin American country health systems is critical to overcoming them. Programs that provide patients, physicians, and healthcare system stakeholders with direct experience of HHD could increase acceptance and motivation for this home-based therapy.

Meet The Experts

JUAN CARLOS BERBESSI, MD

Chief Medical Officer, Fresenius Medical Care Latin America

References

  1. Gonzalez-Bedat M, Rosa-Diez G, Pecoits-Filho R, et al. Burden of disease: prevalence and incidence of ESRD in Latin America. Clin Nephrol 2015;83(7 Suppl 1):3-6.
  2. Rosa-Diez G, Gonzalez-Bedat M, Pecoits-Filho R, et al. Renal replacement therapy in Latin American end-stage renal disease. Clin Kidney J 2014 Aug;7(4):431-36.
  3. Pecoits-Filho R, Rosa-Diez G, Gonzalez-Bedat M, et al. Renal replacement therapy in CKD: an update from the Latin American Registry of Dialysis and Transplantation. J Bras Nefrol 2015;37(1):9-13.
  4. Gonzalez-Bedat MC, Rosa-Diez G, Ferreiro A. El Registro Latinoamericano de Diálisis y Trasplante Renal: la importancia del desarrollo de los registros nacionales en Latinoamérica. Nefrol Latinoam 2017;14(1):12-21.
  5. Gonzalez-Bedat M et al. Burden of disease.
  6. Rosa-Diez G, et al. Renal replacement therapy in Latin American end-stage renal disease.