Ecuador
Ecuador (el Ecuador)
We often think of nations that have a more limited kidney care healthcare ecosystem as being deficient in understanding the burden of kidney disease (Figure 1). Most of the time, we see these nations start the process of understanding how kidney disease (dialysis and CKD) affect their society (and national budgets) by developing kidney disease registries. Registries are an important first step in tackling all the complexities that come with nephrologic and financial management of kidney disease/failure.
But...what if you don't have the governmental willingness/support to create a kidney disease registry? How then do you go about understanding the burden of kidney disease in your country? The ingenious researchers representing Ecuador in this year's NephroWorldCup (La Tri) faced this very challenge.
Figure 1: Etiologies of kidney failure in Ecuador (note the absence of CKDu)
La Tri enter the NephroWorldCup as a pre-registry nation. Researchers pieced together data from various existing databases, performed a number of cross-reference queries and internal validations, and interviewed nephrologists across the country to understand four (4) areas in kidney disease management:
the burden of CKD and ESKD
the costs
the mechanism of kidney care delivery by nephrologists
the perceptions and experiences of kidney care by primary care providers
To begin, the researchers analyzed the burden of ESKD and CKD. ESKD has exploded in Ecuador. Piecing together data from various databases, the prevalence of ESKD in CY 2008 was approximately 400 patients; a prevalence that has jumped to over 7000 in CY 2018 (Figure 2). The team predicts a prevalence of 18,255-24,474 by CY 2023.
Figure 2: Prevalence of dialysis patients from 2015-2018 | Black line represents incidence
This explosive growth is, in part, due to the scourge of diabetes mellitus and hypertension. It is also due to an increase in CKD awareness and diagnoses (Figure 3).
Figure 3: Identification of patients with CKD
All those patients require treatment; and all that treatment costs the Ecuadorian society a lot of money. Eleven percent of its total public health budget is spent on just one diagnosis and treatment: ESKD and dialysis.
And the number of Nephrologists in-country to serve those patients continues to be under strain. In 2019, there were 16.6 Nephrologists per million population (pmp); nearly all of those specialists are located exclusively in-or-near the urban areas (Figure 4).
Figure 4: Nephrologist resources in the Western Hemisphere | Presented at the 2019 Global Kidney Health Academy and American Society of Nephrology annual meeting | Courtesy of the International Society of Nephrology
Lastly, given the few Nephrologists in Ecuador and their scarcity outside of urban centers, much of the early recognition/identification of CKD patients falls at the feet of the primary care physician. Unfortunately the lack of awareness that CKD is a growing societal burden and/or education about how simple blood and urine tests can identify people with CKD hinder this effort.
Video 1: Value of a registry | Courtesy of the National Organization of Rare Disorders
So where does this leave La Tri? This team really plays harder on the field than the paper would suggest. Being able to characterize the nation's kidney disease burden on many levels in the absence of a kidney disease registry is a tremendous feat (Video 1). There are certainly limitations on the completeness of the data and the extent to which even granular patterns can be uncovered by using the methods of the researchers. Nevertheless, in a nation with an explosion of CKD and no legitimate database that captures this event, La Tri is to be commended!