Strategies for national health care systems in emerging countries: The case of screening and prevention of renal disease progression in Bolivia

Abstract

There are close to 1 million people in the world who are alive simply because they have access to one form or another of renal replacement therapy (RRT). Ninety percent live in high-income countries. Little is known of prevalence and incidence of chronic kidney disease and of end-stage renal disease (ESRD) in middle-income and low-income countries, where the use of RRT is scarce or nonexistent. However, no intervention is undertaken, these people will experience progression to ESRD and death from uremia, because RRT is out of reach for them. These are the individuals for whom efforts should be focused to prevent or delay progression toward ESRD. In 1992, the Mario Negri Institute for Pharmacological Research in Bergamo, Italy, with the cooperation of the young doctors of the Ospedale Giovanni XXIII in La Paz (Bolivia), activated a specific project titled "El Proyecto de Enfermedades Renales en Bolivia" (The Project for Renal Diseases in Bolivia). The project sought to demonstrate that in emerging countries the best strategies against renal disease are prevention and early detection. After proper training of local personnel at the Clinical Research Center "Aldo e Cele Dacco" of the Mario Negri Institute in Bergamo, Italy, an educational campaign titled "First Clinical and Epidemiological Program of Renal Diseases"-under the auspices of the Renal Sister Center Program of the International Society of Nephrology-was conducted in 3 selected areas of Bolivia, including tropical, valley, and plains areas. The goal was to define the frequency of asymptomatic renal disease in these areas by screening a large population of patients at relatively low costs. The screening was formally performed at first-level health centers (Unidad de Salud). Participants were instructed to void a clean urine specimen, and a dipstick test was performed. Patients with positive urinalysis were enrolled in a follow-up program with subsequent laboratory and clinical checks. The study was conducted by 21 clinical centers. Apparently healthy patients (14,082) were enrolled over a period of 7 months. Urinary abnormalities were found on first screening in 4261 patients, but only 1019 patients (23.9%) were available for follow-up. At second urinalysis, 35% of patients had no abnormalities. In the remaining positive group of patients, further investigations disclosed the following abnormalities: urinary tract infection (48.4%), isolated hematuria (43.9%), chronic renal failure (1.6%), renal tuberculosis (1.6%), and other diagnoses 4.3% (kidney stones, 1.3%; diabetic nephropathy, 1%; polycystic kidney diseases, 1.9%). The experience gained from this initial screening program formed the basis for a second study aimed to prevent renal disease progression in a selected Bolivian population with high altitude polycythemia. In conclusion, our studies show that mass screening of the population for renal disease is feasible in developing countries and can provide useful information on frequency of renal diseases. Also, in patients with altitude polycythemia, l...

The message for World Kidney Day 2009: hypertension and kidney disease—a marriage that should be prevented

“…There have been many consensus panels over the past decade to approach ways to achieve better blood pressure control and educate physicians to the stages of CKD [13,14]. The road to improving outcomes is to focus on public awareness and screening programs as well as programs to educate both patients and physicians.…”

“…Data from the KEEP screening program in the US have also indicated that blood pressure values are most likely to be at goal once a patient is aware they have kidney disease [15]. Data from Bolivia highlight the observation that once kidney disease is diagnosed, more appropriate interventions to reduce CKD risk factors such as hypertension are instituted [13].…”

The Message for World Kidney Day 2009

“…Data from the KEEP screening program in the United States has also noted that BP values are most likely to be at goal once a patient is aware they have kidney disease (15). Data from Bolivia highlight the observation that once kidney disease is diagnosed, more appropriate interventions to reduce CKD risk factors such as hypertension are instituted (13).…”

“…There have been many consensus panels over the past decade to approach ways to achieve better BP control and educate physicians to the stages of CKD (13,14). The road to improve outcomes is to focus on public awareness and screening programs as well as programs to educate both patients and physicians.…”

Editorial

“…Structured, long-term cooperation between paediatric nephrologists in HIC and LMIC is a well known modality that involves not only joint clinical and educational activities but also managerial and financial aid through sustainable projects agreed with local health authorities [14]. Some examples are Sudan [8,15], Nicaragua [9] and Guatemala [16], to name but a few.…”