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• W4306409664 abstract "Introduction Ecuador is a small country located in South America. It borders to the north with Colombia, to the southeast with Peru, and to the west with the Pacific Ocean. The equator, dividing the earth into the northern and southern hemispheres, passes through the country (Figure 1). Ecuador is a democratic country with a presidential system. It was a Spanish colony until the third decade of the 20th century, when independence was obtained. As of 2022, the Ecuadorian population is estimated to be 17,933,987, with a population density of 68 habitants/km2 and 50.4% of the population are women (1). The capital of Ecuador is Quito; Quito, Guayaquil, and Cuenca form the biggest cities in the country. In these cities, highly complex medical procedures and specializations are developed and practiced at third-level state hospitals and in private centers that work as external providers for the state. Since 2012, ESKD has been recognized as a “catastrophic disease” by the Ecuadorian government, meaning all dialysis and kidney transplants costs related to ESKD are covered by Ecuadorian state. This ESKD coverage includes active and passive workers that have contributed to the social insurance system, representing 34% of the Ecuadorian population. These patients attend the social insurances’ healthcare centers for treatment. Health coverage is also provided to those who do not have a formal job and those who have not have contributed to social insurance. These individuals represent 66% of the population, and they receive health coverage from public health system centers (2). The police and military population receive health coverage from the police and military health insurance system, which covers, free of charge, all ESKD expenses (2–3).Figure 1.: Map of Ecuador with number and distribution of dialysis centers across the country. Numbers in the figure represent the number of private dialysis centers available for each province.Local Prevalence of ESKD In May 2022, the Ecuadorian health minister reported there were 19,400 patients on RRT, which represents a local ESKD prevalence of 1074 patients per million population with an annual incidence in 2021 of 206 patients per million population (3,4). This high local ESKD incidence and prevalence consumes 11% of the national healthcare budget. Currently, this unsustainable kidney healthcare system is the result of a lack of primary prevention policies and programs for diabetes, hypertension, obesity, and CKD (4). Also, the lack of local ESKD and CKD registries have prevented individuals at high risk of ESKD from being identified accurately, along with complicating the planning, investigation, and distribution of available resources. Fortunately, at the start of 2021, ESKD, dialysis, and transplant registries were created and ESKD information data is now more accurately collected and registered (5). The etiologies of ESKD are the same as those worldwide (diabetes, hypertension, glomerular diseases, etc.) and most frequent causes of mortality are cardiovascular disease, infections, and treatment abandonment (6). Local RRT Available The predominant renal replacement technique for Ecuadorian patients with ESKD is conventional hemodialysis (HD), with 94% of local patients with ESKD receiving this technique, and this trend is ascending, as in Latin America (6). The remaining 6% of the ESKD population are those receiving peritoneal dialysis (PD) and kidney transplant patients; this subgroup is stationary without an ascending trend. Home dialysis is present only as PD, which is used by only 2%–3% of the ESKD population. Use of PD has not grown over the years; the main explanation for this is that the decision for which type of RRT is prescribed is made by neither the patient nor the nephrologist. The final decision about which renal replacement technique the patient will receive is made by a public functionary that assigns dialysis treatments, and this decision is mostly to prescribe HD. Also, the government does not force private dialysis centers to have PD in their portfolio services. Home HD is not performed. The Ecuadorian state cannot afford the costs of kidney palliative care for the ESKD population who prefer conservative treatment instead of dialysis. If palliative-conservative care is needed, patients must be able to fund this care themselves. Nephrology Evolution in Ecuador Self-Financed Period (from 1972 until 2012) The field of nephrology in Ecuador has two marked periods, each one with its own characteristics. This first period is characterized by self-financing of kidney disease costs by patients. RRTs were available only for people who could afford the costs involved. Many patients could not receive treatment three times a week, treatments were irregular, quality of life was precarious, treatment acceptance was scarce, and morbidity and mortality were high in this period (7). Also, in the beginning of this period, HD was performed using a Scribner shunt (8), water treatment plants were not available, and dialysis treatments were performed using 120 L of tap water (9). All of these difficulties were reflected in the patient’s quality of life. In this time period, patients were highly anemic due to lack of erythropoietin; hemoglobin levels were maintained between 6–7 g/dl on the basis of blood transfusions, which contributed to a high incidence of hepatitis B in patients with ESKD, who then required specific dialysis centers for their care. Due to this high prevalence of a severely anemic state, most patients with ESKD were not able to exercise or to work/provide for their family. Also, there were not enough dialysis centers to provide ESKD treatments to patients. Most dialysis centers were initially located in the biggest cities of Ecuador (Quito, Guayaquil, and Cuenca), and patients from smaller cities had to travel up to 125 miles to reach the nearest dialysis center to receive dialysis treatments, further complicating treatment adherence and compliance. Nephrologist training was precarious. Nephrologist specialization studies were not available in the country. Therefore, if someone was interested in nephrology, it was mandatory to leave the country and study overseas, covering all of the expenses themselves, which was hard for young Ecuadorian doctors due to the fragile local economy. Technologic and medical advances in HD evolved over time and, by the 2000s, most patients were cannulated using the Cimino–Brescia arteriovenous fistula (10), erythropoietin was available, and anemia treatment improved significantly (11). This period of Ecuadorian nephrology was characterized by high morbidity and mortality, bad treatment adherence, and people lacked the resources to afford and benefit from all of the technologic and treatment improvements that were available with the evolution of medicine. Current State: ESKD Costs Covered by the Government (since 2012) All medical and treatment advances in Ecuadorian nephrology were also accompanied by a legal modification developed in 2012 called the “Law of Catastrophic and Rare Diseases” (12). Once this law was instituted, the Ecuadorian government assumed the responsibility of covering all ESKD treatment costs for all Ecuadorians, whether at public hospitals and dialysis centers, or through private dialysis centers that collaborate with local government as external providers. All patients with ESKD, without restriction, have access to HD, PD, and both living and deceased donor kidney transplants, free of charge (12). For this reason, since 2012, the number of patients and private dialysis centers have grown quickly. Currently, there is at least one dialysis center in 21 of the 24 provinces of Ecuador (Figure 1). By 2020, there were 87 dialysis centers in the country. This has improved the difficulties involved in traveling far distances to receive HD treatment. Private dialysis centers that desire to work with the state in providing dialysis services for ESKD treatments can collaborate as “external providers.” The Role of Private Dialysis Centers in ESKD Treatments Private dialysis centers can work and collaborate with local government to provide dialysis treatments to the Ecuadorian ESKD population after a qualification process performed by the local health authority. This qualification process evaluates several aspects, such as infrastructure, equipment, human talent, waste management, operational capacity, and location. Quality inspections are performed annually, which are necessary to approve the necessary “operating license.” Every 4 years, a licensing process is performed and centers that do not comply with the requirements are sanctioned, which can range from economic sanctions to complete center closure. Annual quality inspections are also performed (13). Once private dialysis centers overcome the qualification process, patients are assigned to dialysis units to receive integral ESKD treatment by georeferencing, with the patient’s home address being the reference (13,14). Private dialysis centers that gain permission to become “external providers” for ESKD treatment sign a contract with the government. Obligations of Private Dialysis Centers The contract for external providers specifies certain obligations that private centers are forced to accomplish. These specifications include standard and high-efficiency conventional HD with bicarbonate, three sessions per week from 3.5 to 4 hours, equilibrated Kt/V not below 1.4, bioimpedance spectroscopy for dry weight adjustment, HD machines with ultrafiltration and sodium profiles, water treatment system with double reverse osmosis system, and requirements of International Organization for Standardization 23.500-2 certification for HD treatment services (14,15). Also, reuse of material (lines and filters) is not allowed; centers who reuse material are severely sanctioned. With regard to human talent, one nephrologist is required for every 50 patients, one nurse for every seven patients, and a psychologist, nutritionist, social worker, and continuous health monitoring (chest x-rays, abdominal and vascular access ultrasound) are mandatory for the contract. Vascular access creation must be provided by private dialysis centers, and it is specified by contract as follows: one arteriovenous fistula (native or graft) and/or one tunneled or temporal vascular catheter per year if necessary. If one patient exceeds the vascular access annual quota, the public system is supposed to cover that need. Performing basic imaging studies are also mandatory at private dialysis centers. One chest x-ray and abdominal and parathyroid ultrasounds per year are required. Medications for ESKD treatment must be provided by private dialysis centers. ESKD medications listed on the “national medication bucket list” must be provided for free, including those for Hypertension, anemia, insulin, secondary hyperparathyroidism (13). It is important to emphasize that, at present, the only medications available for these patients are oral calcium-based phosphate binders and calcitriol. Lanthanum-based, ferric-based, and sevelamer phosphate binders; oral and intravenous calcimimetics; and vitamin-D agonists are not covered by local government. This lack of medication has complicated severe secondary hyperparathyroidism (parathyroid hormone >2000 pg/ml) treatment in patients with prolonged HD, for which parathyroidectomy surgery has been used successfully (16). Private Dialysis Centers’ Remuneration for ESKD Treatments For all ESKD treatments, the government pays a value of US$112 per HD session, for 12–14 sessions per month. This budget has been official since 2012 without further modifications. This has complicated the generalized performance of online hemodiafiltration treatments, due to its more elevated cost. This technique is offered to those patients who would benefit the most from it, such as patients who are elderly (>70 years), are hemodynamic unstable, have heart failure, are malnourished, etc. (17). Ecuadorian Nephrology Education The first nephrology postgraduate program was developed in 2012 at the Central University of Ecuador to help to combat the local low rate of nephrologists per number of inhabitants present in 2010 (one nephrologist per 100,000 inhabitants) (18). Three generations of nephrologists were formed in the following years. However, a nephrologist training program is not currently available in Ecuador. For this reason, most general doctors must travel overseas, to countries like the United States, Spain, Brazil, Mexico, Argentina, or Uruguay, to study for nephrologist specialization. The Ecuadorian Society of Nephrology was legally recognized in July 2012, although nephrologists have been working in Ecuador over the last 50 years. At present, Ecuador has 387 nephrologists, which represents 15.7 nephrologists per million population or 1.5 per 100,000 inhabitants (19) Current Status of Ecuadorian Patients with ESKD Legal and technologic improvements in dialysis treatments have produced a social reinsertion of 87% of patients. In the past, due to several limitations, patients were not able to work to provide and take care for their families (20). At present, with improvements in anemia, uremia, and volume overload control, Ecuadorian patient health has improved, and patients feel better. Up to 30% of patients continue as active workers. Urea reduction ratio, Kt/V values, mortality, and complications are reported at similar rates as in other specialized centers from high-income countries (21). Table 1 shows the principal characteristics of the current state of Ecuadorian nephrology. Table 1. - Current state of kidney health in Ecuador Ecuadorian Kidney Health Parameters Analyzed Value Total country population (million) 17.9 ESKD prevalence, pmp 1074 ESKD 2021 annual incidence, pmp 206 Nephrologists/population rate 2.1/100,000 Private dialysis centers (n) 87 Local dialysis modality prevalence Hemodialysis (%) 94 Peritoneal dialysis (%) 3 Patients on hemodialysis (n) 19,400 Male patients on hemodialysis (%) 56 Patients starting hemodialysis with temporal catheter (%) 86 Patients on transplant waiting list (n) 297 ESKD treatments costs (dialysis, kidney transplant) Free pmp, per million population. Coronavirus disease 2019 (COVID-19) had a large effect on the HD population and HD workers. Local studies (21,22) reported that 32% of patients were infected, with a mortality of 22%. COVID-19 contributed an additional 6% to mortality of patients on HD in 2020, and 49% of HD workers were infected, without deaths, with COVID-19. This elevated mortality and prevalence was clearly diminished after the postvaccination era. Currently, COVID-19 prevalence in patients is 1.5% and 1.1% in HD workers (23) Improvement Opportunities in the Ecuadorian Kidney Health System The Ecuadorian dialysis system has strengths and weaknesses. One strength the 100% coverage of RRT expenses. Opportunities for improvement in Ecuadorian nephrology are listed below: (1) Currently, ESKD services consume up to 11% of the national health budget and, if this unsustainable spending continues, ESKD funding will deplete funding reserves. Cost distribution and sharing between the public and private system could relieve some of these expenses. In the past, before the 2012 law was approved, kidney transplants could be performed privately so that people who were able to afford the costs, and had a living related donor, could receive the transplant in private hospitals. In this way, public resources could be diverted to those who had a lower income, rather than the current system that covers “everything to everyone.” After rigorous training and qualification processes, private centers could be qualified to develop a private living-donor kidney transplantation program, relieving the public system of the current potential collapse in funding. (2) The decision process for the dialysis modality should change. When the dialysis modality decision is made between patients and their nephrologists, outcomes are better (24). At present, the decision between HD and PD is made by a public functionary that works at patients disdribution department. If this patients distribution system is changed as mentioned above, the distribution of patients with ESKD between PD and HD therapies will be more uniform, breaking the current trend of 96% of patients on HD versus 3% of patients on PD. (3) Kidney supportive care for patients who are highly comorbid, the elderly, or for those who do not want to receive dialysis treatments should be added to the national health budget for ESKD services. Currently, there is no palliative care for patients with ESKD, which, in some cases, forces patients to receive dialysis when they may prefer conservative treatment. (4) The national dialysis and kidney transplant registry could be strengthened to improve the priority system and the hyperimmunized group of patients. By improving the prioritization system, those patients who are really in need of kidney transplantation could be identified and transplanted sooner. Regarding the hyperimmunized group of patients, the Spanish PATHI program (National program for hyperimmunized patients access to kidney transplant) (25) could be replicated in Ecuador. This group of patients could be identified so desensitization strategies could be planned for them before/after transplant. (5) Finally, it is essential that local health authorities implement strategies for prevention and earlier CKD detection as soon as possible to stop the trend of a rapid rise in CKD. Health programs for hypertension, diabetes, and obesity treatment and prevention must be strengthened and created. For this, strengthening of the local primary care system is mandatory. These prevention strategies are more profitable, less aggressive, and save costs to patients and the Ecuadorian state if compared with the actual ESKD coverage model. To conclude, Ecuadorian nephrology has evolved and provides, free of charge, treatment to all patients with ESKD, resulting in survival rates and service quality similar to other high-income countries, depending on the center analyzed (26). However, the current ESKD policy system is unsustainable, with exceedingly low rates of PD and kidney transplant, palliative care, and prevention programs. Ecuador needs to increase the academic training of adult and pediatric nephrologists and kidney health researchers, kidney transplant rate, and the use of home dialysis techniques. Disclosures All authors have nothing to disclose. Funding None." @default.
• W4306409664 created "2022-10-17" @default.
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• W4306409664 date "2022-12-01" @default.
• W4306409664 modified "2023-09-27" @default.
• W4306409664 title "Global Dialysis Perspectives: Ecuador" @default.
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