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Editorial Chronic Kidney Disease in the Developing World: Internationally, chronic kidney disease (CKD) has been compared to an iceberg: one million people worldwide with end-stage renal failure form the visible tip, while tens of millions more with some degree of kidney dysfunction lurk below. Nevertheless, 90% of those already diagnosed and receiving renal replacement therapy (RRT) are from the developed world. This, leads one to wonder if the underwater mass estimates are not themselves a product of the sorely under-reported, early CKD in the global South - where the looming threat might better be characterized as volcanic, its eruption threatening to crush precarious health systems already struggling under the double burden of infectious and emerging chronic diseases.[1] In the West, about 60% of all patients with end-stage renal failure have diabetes and hypertension, the two conditions paving the road to CKD. The global epidemic of type-2 diabetes is expected to reach 400 million people by 2030. The more disturbing underlying reality is that while prevalence in developed nations is projected to increase by 60-70%, the increase in developing countries is expecting a 250% explosion.[2] U.S. spending on its ESRD program reached a record $25.2 billion in 2002 (an 11.2% increase over 2001),[3] making it clear that Third World countries and their health systems have no way to financially confront this crisis, and will be forced to leave millions to die without treatment. Thus, CKD and related chronic conditions will become the “silent partners” of HIV/AIDS and other infectious killers. At its ground-breaking meeting in March, 2004 - “Preventing the Progression of Kidney Disease: Toward Global Equity” - the International Society of Nephrology convened experts in the field at the Bellagio Study Center to address these chilling facts, which threaten to exacerbate health disparities and the “health care divide” worldwide. They called upon the international medical community, governments, and financing agencies to work together in an all-out effort to stem the tide of the epidemic, and to develop evidence-based prevention strategies workable for resource-poor health systems, giving priority to “the regions of the world showing greatest risk.”[4] Without a doubt, one of those regions is Central America and the Caribbean, where the epidemiological picture contains two additional elements predisposing its populations to CKD risk. First, its ethnic-racial composition is similar in many ways to U.S. minority communities, with significant indigenous and African Diaspora segments, which in the USA exhibit ESRD incidence rates at twice and nearly four times the rates as whites, respectively.[3] Second is the presence of widespread poverty itself (40%): low socioeconomic status has been identified as a risk factor for development of renal insufficiency in research such as the Multiple Risk Factors Intervention Study (MRFIT).[1] Yet, recent data from the Latin American Registry (2001) indicates that, except for Puerto Rico, the incidence of chronic patients in dialysis in Central America and the Caribbean is 60 pmp or less, and prevalence in dialysis is less than 100 pmp. This suggests that the region already faces a crisis of under-diagnosis and under-reporting of substantial consequence. Such a pressing situation has prompted the 9th Central American and Caribbean Congress on Nephrology and Hypertension, held this month in Cuba, to adopt prevention of CKD as its main theme (see Specialists Look at Renal Disease in the Region ). Participants will be drawing on accumulated findings and dialogue to more clearly define options for formulating preventive strategies. In this month’s MEDICC Review, we share with you aspects of the Cuban experience in prevention and comprehensive management of CKD, as the Cuban “school of nephrology” advances within the international current of prevention-based approaches ( MR Interview: Round Table with Two Generations of Cuban Nephrologists ). A guest Spotlight column by Dr. Raúl Herrera outlines Cuba ’s National Program for Chronic Kidney Disease, Dialysis and Renal Transplantation . In Effect of Primary Health Care in Cuba on the Prevention of Chronic Kidney Disease ,Dr. Miguel Almaguer examines the impact of the neighborhood doctor program on preventive practices islandwide, especially the role of family physicians, who now provide nearly 100% national coverage. We are especially pleased to reflect two very recent developments in Cuban nephrology as they relate to health outcomes: the first concerns the expansion of dialysis centers in the country from 31 to 47, on the basis of a national study of chronic renal patients ( Bringing Services Closer to Home: MR Visits a New Dialysis Center in Cuba ).The second is a set of new research, involving three separate studies whose goal is national implementation of effective prevention strategies for CKD and related chronic conditions ( Cuban Studies Aim for National CKD Prevention ). Initial results of a pioneering study in total population on Cuba’s Isle of Youth are being presented at the Central American and Caribbean Congress, and will be reported in our June issue. Among the longer-term objectives of the Cuban research is to study the increasingly evident and complex relationship among illnesses sharing vascular damage as a common denominator - CKD, cardiovascular disease, diabetes, hypertension, and cerebrovascular disease among them. The obvious importance of this and similar investigations is their potential to lead to adoption of comprehensive prevention programs, beginning at the community level, for this entire group of chronic conditions. In this context, early diagnosis of vascular damage among children takes on added significance ( Hypertension in Children: Diagnosis and Treatment for Renovascular Hypertension over a 15-Year Period ). Several articles this issue reflect experience in the development and use of Cuban products: the first two in renal patients ( Broad Use of Cuban Recombinant Human Erythropoietin (ior-EPOCIM) in Dialysis Patients at the Institute of Nephrology and Use of Recombinant Streptokinase for Hemodialysis Catheter Recovery ), and the third describing a breakthrough in late April, as Cuban scientists announced the successful completion of clinical trials on a new cholera vaccine ( Cuba Announces New Cholera Vaccine At “Health for All” Trade Fair ). You’ll find our news this month reflects key developments mainly in international cooperation: from our Top Story: Cuba Marks 15 Years of Treating Chernobyl Victims , to headlines including A Decade of Medical Donations Cements Cuba-Canada Cooperation and Running for a Cure: Terry Fox Inspires Cuba . Last but certainly not least, we carry the story of 34-year-old Hector Despaigne of eastern Cuba, Latin America’s Longest Heart Transplant Survivor, 19 Years Later - a living reminder that developing nations’ potential is not only in broad-based prevention, but also can, and should be, in generating the human resources and institutions capable of integrating and making accessible the latest techniques of modern science. The Editors References
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