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ORIGINAL CONTRIBUTIONS

Received: March 6^th 2015

Accepted: April 11^th 2016

Current status of alternative therapies renal function at the Instituto Mexicano del Seguro Social

Antonio Méndez-Durán,^a Manuel Humberto Ignorosa-Luna,^a Gilberto Pérez-Aguilar,^b Francisco Jesús Rivera-Rodríguez,^c José de Jesús González-Izquierdo,^d Javier Dávila-Torres^e

^aDivisión de Hospitales, Coordinación de Áreas Médicas, Unidad de Atención Médica, Dirección de Prestaciones Médicas

^bDivisión de Hospitales, Coordinación de Áreas Médicas, Unidad de Atención Médica, Dirección de Prestaciones Médicas

^cDivisión de Hospitales, Coordinación de Áreas Médicas, Unidad de Atención Médica, Dirección de Prestaciones Médicas

^dUnidad de Atención Médica, Dirección de Prestaciones Médicas

^eDirección de Prestaciones Médicas

Instituto Mexicano del Seguro Social, Ciudad de México, México

Communication with: Antonio Méndez-Durán

Telephone: 5726 1700, extensión 17144

Email: antonio.mendezd@imss.gob.mx

Background: The IMSS performs systematically the data updating of patients with renal replacement therapy (RRT) by an electronic record management referred as: Census patients with Chronical Renal Failure (CIRC) which aims to meet the prevalence of patients with chronic renal failure and the behavior of RRTat the IMSS.

Methods: A retrospective study includes 212 secondary hospitals with dialysis programs, with both pediatric and adult patients. CIRC data obtained from January to December 2014, number and nominal bonds of peritoneal dialysis (PD) and hemodialysis (HD). Prevalence of patients and therapies by delegation, distribution by gender and age, cause of kidney disease, morbidity and mortality were identified.

Results: 55,101 patients, of whom 29,924 were male (54 %) and 25,177 women (46 %), mean age was 62.1 years (rng: 4-90); 20,387 were pensioners (36.9 %). The causes of renal failure were: diabetes 29,054 (52.7 %), hypertension 18,975 (34.4 %), chronic glomerulopathies 3,951 (7.2 %), polycystic kidneys 1,142 (2.1 %), congenital 875 (1.6 %) and other 1,104 (2 %). HD was given in 41 % of patients, and the remaining 59 % DP; the annual cost was 5,608,290,622 pesos.

Conclusions: The increased prevalence of diabetes mellitus and hypertension affect the onset of RRT, which show a catastrophic financial outlook for the Institute.

Keywords: Renal dialysis; Renal Replacement Therapy; Kidney diseases; Health Programs and plans; Mexico

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The Instituto Mexicano del Seguro Social (IMSS), through 212 general and regional hospitals and 13 high specialty medical units distributed throughout the country, provides care coverage through renal replacement therapy (RRT) to 73% of patients on dialysis in Mexico,^1,2 a country with a total population around 120 million,³ about 12 million of whom present some degree of renal impairment.⁴

Since the electronic development of the Administrative Census of patients with chronic renal failure (Censo de administración de pacientes con Insuficiencia Renal Crónica, CIRC), the online management of the registration data of patients undergoing RRT has been more accurate; this allows objective decision-making for better management of health services; short, medium, and long-term projections; and finding strategies for improvement needed in each of these interventions. Moreover, and closely related to the different levels of care, it also aims to make improvements that will abate the number of patients with chronic renal failure, delay the time of admission to alternative therapies, improve the quality of life of patients, and decrease financial investment for the benefit of the Institute and its enrollees. The institutional registry of patients with CRF is a historic breakthrough for the IMSS, representing a national and international framework to provide the pattern to initiate specific lines of prevention, diagnosis, treatment, and research.

Methods

Retrospective study obtaining information from 212 general and regional hospitals, from electronic record formats for patients in the various forms of dialysis- numeral and nominal data of peritoneal dialysis and hemodialysis- and from the CIRC. The main demographic variables (age, gender, type of replacement therapy), variables related to morbidity (complications of therapy and unrelated to dialysis therapy) and mortality were obtained. It includes the adult and pediatric population. It does not include the records of the 13 Unidades Médicas de Alta Especialidad (UMAE) that make up tertiary care, serving around 3,000 patients (5%), predominantly for hemodialysis. The demographics of each delegation were obtained from the national register provided by the Instituto Nacional de Estadística y Geografía, online version, updated to December 2014, identified by state and gender. These data made it possible to estimate the prevalence in direct relation to the number of the user population in each delegation. The population insured by IMSS was taken from user population records provided by the Dirección de Incorporación y Recaudación (DIR), the Coordinación de Prestaciones Económicas (CPE), the Dirección de Prestaciones Económicas (PDSA), the Unidad de Personal (UP), and the Dirección de Administración y la Administración de Delegaciones (DAED) of IMSS.

 

Data validation   

A database was developed in the electronic program Excel, version 2010 for Windows, separating data by delegation, town, dialysis therapy, gender, and age; morbidity and mortality were taken from the numeral codes. The incidence and prevalence were calculated using statistical formulas for conventional population. The results are presented in tables, charts, and comparative graphs for each of the delegations. The morbidity and mortality variables are grouped into cardiovascular causes, infections, metabolic disorders, water-electrolytic, and other causes. The main causes of morbidity and mortality were identified, as were patient growth projections, financial investment, and human resources and infrastructure needs at 5 and 10 years. The information was validated by the Coordinación de Proyectos Especiales of the División de Hospitales de la Dirección de Prestaciones Médicas.

Results

By December 2014 the Mexican population was recorded at 119,713,203 inhabitants, of which 52,310,086 were enrolled with IMSS (43.7%). Of the total of 55,101 patients, 20,387 were retirees (36.9%) from the 212 general and regional hospitals that make up secondary care. 29,924 (54%) were male and 25,177 (46%) female (Figure 1); the male: female ratio was 1.2:1, the average age was 62.1 years (range: 4-90), the most prevalent age groups were 60 to 69 and 50 to 59. The primary causes of renal failure were diabetes mellitus with 29,054 patients (52.7%), hypertension with 18,975 (34.4%), chronic glomerular disease with 3951 (7.2%), polycystic kidneys 1142 (2.1%), congenital 875 (1.6%), and other 1104 (2%) (Figure 2). The distribution of patients by dialysis modality were: hemodialysis (HD) in 41% of patients, 18% intramural, and 23% extramural or external services; peritoneal dialysis (PD) 59%, automated 27%, and manual 32% (Figure 3).  

The distribution of RRT was diverse, the highest proportion in PD was found in the delegations of Veracruz, Tlaxcala, and Nuevo Leon, and HD in Aguascalientes, Sinaloa, and Sonora (Figure 4).

The total annual cost for direct service was 5,608,290,622.00 pesos (Table I). The largest number of patients was found in Jalisco, State of Mexico East, and Southern Mexico City, and the lowest was in Campeche, Zacatecas, and Baja California Sur. The overall incidence was 124 cases per million users; the delegations with the highest incidence were Tlaxcala, Morelos, and Hidalgo, and the lowest were in Zacatecas, Sinaloa, and Northern Mexico City.

The most frequent complications in PD were peritonitis, fluid overload, and mechanical complications of the catheter; in HD, they were fluid retention, uncontrolled hypertension, and hyperkalemia (Table II). The final outcomes in both therapies were myocardial infarction, sepsis, heart failure, and acid-base balance disorders (Table III). The annual overall growth projection was 11.4%, 6% for peritoneal dialysis and 5.4% for hemodialysis; continuous ambulatory peritoneal dialysis (CAPD) 4.9%, automated peritoneal dialysis (APD) 1.1%, internal HD 1.7%, and external or subrogated HD 3.7%.

Conclusions

Dialytic therapies are a life support for CRF; PD exceeds HD, and the external mode of HD predominates, which presents a continuous increase affecting the finances of the Institute; on the other hand, the increased prevalence of diabetes mellitus and hypertension show a catastrophic scenario and demonstrate the need for more and better resources to contain them. Morbidity and mortality from infectious and cardiovascular causes occupied the top places, mainly given by the primary causes of CRF and complications resulting from the dialysis procedure itself.

Discussion

The number of dialysis patients (NFK 5/5) accounted for 0.1% of the insured population, similar to that reported in various international publications, mainly in North America, which suggests that CRF has similar behavior in Mexico in terms of risk factors for developing chronic kidney disease.^5-7 It is stressed that a very small part of the dialysis population consumes a large amount of the financial resources at the Institute, which places this condition in the top causes of spending, exceeding that observed in programs for breast cancer, cervical cancer, and the human immunodeficiency virus,⁸ a situation that is not unique to the IMSS or Mexico; highly developed countries with advanced health systems derived from higher per capita income see similar behavior today.^9-12

The population distribution by gender was slightly in favor of male patients, and the mean age of the patient entering the dialysis therapy is 62, similar to figures reported in European, North American, and Asian countries; this represents an area of ​​opportunity to influence the risk factors in this group.^13,14

Because Tlaxcala, Hidalgo, Morelos, and Nayarit delegations presented the highest incidence of CRF, they deserve specific investigation as to family and environmental factors that may be related to CKD,^15,16 since these delegations have similar sociodemographic conditions. The main causes of morbidity were infections, causes related to functionality of catheters and vascular access, cardiovascular outcomes, and electrolyte disorders, aspects that provide the opportunity to strengthen and implement strategic lines of specific treatment and research. 

The estimated growth in dialytic therapy patients is 9% per year, which offers a real challenge to the Institute and the Mexican health system,¹⁷ similar data to that reported in the Consenso español 2014, of 9.4%.¹⁸ Although Mexico does not have a national data registry of kidney patients including the Sistema Nacional de Salud as a whole, a year after implementing the CIRC, IMSS provides a more realistic estimate of what happens in the country, by including 73% of the Mexican population on dialysis. These results will provide a framework and guideline to initiate specific lines of prevention, treatment, and research to improve the quality of life of patients on dialysis and to optimize institutional resources.

The real catastrophic scenario of CKD is in stages 3 and 4, where the traditional factors of progression of renal damage (old age, hyperglycemia, dyslipidemia, hypertension, obesity and physical inactivity, metabolic syndrome) have a high prevalence in the general population, which, in the medium and long term, will occupy stages 4 and 5;^19,20 however, these are elevated largely in specific populations (diabetes, hypertension, peripheral vascular disease, coronary artery disease), although treatable,^21,22 where the implementation of primary and secondary prevention, as well as an efficient kidney transplant program, are imperative;²³ in addition, close communication between nephrologists and primary care physicians is critical to improving integrated patient management and streamlining resources,^24-26 which will result in a common benefit for the Institute and society.

References

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