Emma Schwedt

Improving the management of chronic kidney disease in Uruguay: a National Renal Healthcare Program.

Background: Uruguay has implemented a chronic kidney disease (CKD) prevention program. Aims: The objectives of the study are to assess the results of the National Renal Healthcare Program (NRHP). Methods: This study is a cohort study of nondialysis-registered patients from October 2004 to March 2008. We made a comparison between patients under nephrology care (NC) or the care of a primary care physician (PCP; prereferral). In the outcome analysis, the primary endpoint was end-stage renal disease (ESRD) and the secondary endpoints were progression of CKD, compliance with the therapeutic goals and death. ESRD/mortality predictors were determined by Cox analysis. Results: The study comprised 2,219 patients aged 67.4 ± 13.5 years, of whom 52.5% were male, 42.1% hypertensive, 16.9% had diabetic nephropathy, and 61.3 and 21.4% were in CKD stages III and IV, respectively. At baseline, NC patients showed a better control than patients under the care of a PCP: systolic blood pressure ≧160 mm Hg (22.4 vs. 31.1%); total cholesterol <5.8 mmol/l (56.6 vs. 42.5%); and low-density lipoprotein cholesterol <2.9 mmol/l (41.2 vs. 29.1%). Control improved in patients under the care of a PCP according to years of enrollment. Outcome analysis (1,188 patients) showed a significant improvement in targets, with 56% of the patients stabilizing. CKD stage IV, diabetic nephropathy, proteinuria and hypertension increased the risk of ESRD; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and age <65 years decreased the risk. Conclusions: Our results highlight the best management of CKD patients in both groups and the impact of the NC and renin-angiotensin-aldosterone system blockers.

Risk Factors and Prevention of End Stage Renal Disease in Uruguay

Uruguay is a developing country with a privileged established program for renal replacement therapy (RRT) for all patients with end stage renal disease (ESRD) since 1981. In December 2004, the RRT prevalence reached 916 patients per million population. The ESRD incidence has not changed significantly in the last eight years, differing with what is observed in other countries. In contrast, the ESRD incidence secondary to diabetic nephropathy has shown a permanent increase. The prevention of chronic kidney disease (CKD) began in 1989 with the Program of Prevention and Treatment of Glomerulonephritis (PPTG), being extended in 2002 to all CKD and canalized through the National Program of Renal Healthcare (NPRH) since 2004. The registry of glomerulonephritis has been demonstrated in recent years: patients are referral to nephrologists earlier, there is an increase of the frequency of patients with “clinical remission,” and thus there is a decrease of the frequency of ESRD in the first three months after referral. The NPRH has been developed in a progressive way with the involvement of government authorities and the active participation of the nephrologists. A global prevention program, integrating the prevention of CKD, cardiovascular diseases, hypertension, and diabetes was developed. The first steps of the program have had important achievements: a rational reorientation of nephrologic care in the first level of attention, patient access to renoprotective medications without cost; a registration system of patients, the creation of a formal multidisciplinary team, and the instauration of a continuous medical education program.