SPOTLIGHT

Cuba’s National Program for Chronic Kidney Disease, Dialysis and Renal Transplantation

By Raúl Herrera Valdés, MD, PhD

In the Central American and Caribbean context, Cuba shares many of the economic limitations suffered by other countries. At the same time, Cuba has advanced along the route of equity described by PAHO as critical to improving health in the region, being one of the least socially stratified countries in the area.[1] In addition, 96.2% of the country’s adult population is literate and the average educational level is ninth grade. The health system is universal, public, and free-of-charge, with coverage extended to 100% of the population.

Cuba ’s resource-scarce environment, coupled with public health principles, has reinforced a commitment to primary health care and prevention as the centerpiece of the system. Cuba’s infant mortality is 5.8 per 1,000 live births (2004); and the main causes of death are non-communicable chronic diseases, with only 1% from communicable diseases. The Cuban population is one of the fastest aging in the Americas.

Significant attention has been paid to developing human resources in health, resulting in 60.4 physicians per 10,000 inhabitants [2].

National Chronic Renal Disease Program

In today’s world, the epidemic evolution of chronic renal insufficiency constitutes a serious problem, the implications of which are not only medical, but also social, economic, organizational and political. The fact that end-stage renal disease (ESRD) is a phased process suggests that prevention should be applied in all phases, beginning with healthy individuals and risk groups. As a result, in 1996 a national program was approved, offering essential guidelines for prevention, based on continuing evaluation of the epidemiological situation and progressive incorporation of preventive strategies at all levels of care.

Epidemiological Background of CKD in Cuba

In 1988, a study was carried out in Pinar del Río Province (population: 700,000), on a sample of complete families - 11,804 persons in all - under the regular care of 21 family physicians in ten municipalities. Of these, 9,580 persons were screened, or 81% of the total sample. Screening revealed 34 persons with serum creatinine levels above 1.2 mg/dl. Only two of these, or 6%, had been previously diagnosed (showing creatinine levels above 4 mg/dl). The remaining 32, or 94%, at creatinine levels under 4 mg/dl., were newly diagnosed with the study. Age group distribution confirmed higher prevalence with age: 61% of positive cases were 65 or older. Among all age groups, with serum creatinine levels above 1.2 mg/dl., prevalence was estimated in at least 3,550 pmp [3] , a result ratified in later national studies[4]. Of this estimate, in 2003, 880 pmp were registered and placed in follow-up by family physicians; nevertheless, this indicated a substantial gap in cases still to be detected and treated with interventions aimed at slowing disease progression. By 2004, the incidence of Cuban patients in dialysis was 111 pmp and prevalence was 149 pmp (160.8 by March, 2005); with 16.6 transplants pmp [5].

Structure of the National Program

Cuba’s National CKD Program offers guidelines for specific actions at each of three prevention levels: primary prevention (by family physicians), intended for healthy and at-risk populations in order to inhibit the development of disease; secondary prevention (mainly by clinical nephrology services), intended for patients suffering from chronic renal disease, to delay progression or achieve regression of their illness, and avoid complications; and tertiary prevention (by renal replacement therapy services) for ESRD patients, to attain patients’ social rehabilitation. The divisions between these levels are in fact artificial, and the aim is to achieve a single, integrated line of care, since the patient constitutes a single, bio-psycho-social being evolving over time[6,7,8].

Implementation of Prevention Strategies: Resources and Infrastructure

In an effort that is just beginning, a total of 280 nephrologists and 150 residents have been distributed regionally in 47 hospital-based nephrology services. From these centers, they will provide essential guidance in prevention and treatment of renal disease for the country’s family physicians across the country, through the 444 community polyclinics where the family doctors are clustered. Completing the infrastructure are 33 hospitals for organ procurement, nine renal transplantation centers, and five tissue-typing laboratories[2,5].

National Direction and Coordination

The Program is directed and coordinated by the Institute of Nephrology, the national reference center for the specialty, which is also responsible for developing human resources in the field, generating scientific research, and continuously improving levels of patient care.

Perspectives for 2005-2006

The accelerated development of Cuba’s National Nephrology Network over the last two years, strengthened by technological and structural improvements in the Institute itself as national coordinating center, place Cuban nephrology at a qualitatively new stage in its ability to address the comprehensive management and prevention of renal disease -particularly in its capability to influence health outcomes.

From 2005 forward, the following objectives for Cuban nephrology have been defined:

This goal rests on the fulfillment of specific objectives:

1) Consolidate and develop the National Network of Nephrology Services.

Facilities: Over the last two years in Cuba, the number of nephrology services with dialysis increased from 31 to 47. Of the 31 already in existence, new dialysis centers were built in 10; for 2005, new centers will be built in four more and the remaining 17 will be remodeled. In addition, this year one more new service will be opened, bringing the total to 48.

Technology: From 2002 to 2004, the number of artificial kidneys available to patients increased from 303 to 427, or 41%. All dialysis centers are equipped with reverse osmosis water treatment.

Human resources: Over the last two years, 150 new residents have begun their training in nephrology, which will bring to over 400 the number of specialists in the country. This is the highest ratio of nephrologists per inhabitant in Latin America.

Indicators: As a result of the Network’s development, 14.7% more new patients were admitted into dialysis in 2004 compared with 2003, reaching an incidence (new cases per year) of 111 per million inhabitants (pmp). The resulting 11.2% increase in total number of patients in dialysis boosted prevalence to 149 pmp. Internationally, the average increase in prevalence is 7-10% annually. Mortality rates for patients in dialysis also decreased by 8.3%. In 2005, the goal is to continue improving these indicators.[5]

Clinical Practice Guidelines in Nephrology: This year, Cuban guidelines will be written, covering prevention, clinical practice, dialysis and transplantation.

2) Remodel and refurbish the national Institute of Nephrology.

Facilities and Technology: In 2005, the Institute is one of many hospitals being remodeled, increasing the number of beds, creating outpatient services and imaging departments, and improving conditions in the hemodialysis center and laboratories.

Human Resources and Teaching: Forty residents are in training at the Institute. A computer and language laboratory were opened in early 2005, with 18 work stations. The Institute carries out continuing education programs including bibliographic updates, seminars, and specialized courses for professionals and technicians in the various fields represented at the institution.

Medical Attention and Research: Improvements in the Institute’s architectural and technological infrastructure and the continuous education of its human resources will have direct repercussions in patient care, both in terms of the number of patients treated and the quality of care, incorporating modern diagnostic and therapeutic techniques. Optimal conditions are thus being created for developing scientific research into renal diseases, in particular related to prevention and clinical trials. The existence of the National Nephrology Network, coordinated by the Institute, facilitates multi-center research.

3) Establish community-based epidemiological laboratories to study the behavior of chronic kidney disease (CKD). In 2005, particular attention is being paid to establishing community-based epidemiological laboratories to study the behavior of CKD, and its relation to cardiovascular disease, diabetes mellitus and hypertension. This is the point of departure for developing a strategy for preventive actions: global actions for the entire population; particular actions for risk groups and for each stage of CKD, addressing the disease’s etiology; and specific actions tailored to each patient. At the same time, medical care should be guaranteed for 100% of newly diagnosed patients. (See MR Feature: Cuban Studies Aim for National CKD Prevention, this issue).

Isle of Youth Study (ISYS): The first of these studies has been initiated on the Isle of Youth, in total population of over 80,000.

Havana-Cerro Municipality : A phased study is being carried out, beginning with a sample of risk groups, including field tests of new models of prevention and care.

Pinar del Río Province: A study of 45,000 persons-at-risk is being designed, to analyze and corroborate the studies mentioned above, assessing their application and extension to larger populations.

Parallel to this research, efforts are being made to extend the prevention program, with its already identified actions for controlling risk factors, throughout the whole country. Building upon this and the results of the studies themselves, an important objective will be to offer post-graduate training to family doctors focusing specifically on improving their competency to address non-communicable chronic diseases that have vascular damage as their common denominator. The hypothesis can already be put forward that further training for family doctors may be one way to provide better preventive care and follow-up to 100% of the patients diagnosed through such mass screenings - providing a possible solution to this ethical, as well as clinical, problem.

4) Develop the National Nephrology Informatics Network. In 2005, the National Nephrology Informatics Network is being put in place, made up of three components:

• Linkup for nephrology services among themselves and with the Institute, as their national coordinating center.
• Development of IT infrastructure in the Isle of Youth health system, including the family doctor-nurse offices, and their connection with the national coordinating center.
• Development of the Institute’s intranet capabilities, automating all the Institute’s functions (management, administration, scientific and national coordination activities).

References and Notes

1. Empleo, ingreso, seguridad y asistencia social. In Investigación sobre desarrollo humano y equidad en Cuba, 1999. Edited by Centro de Investigaciones de la Economía Mundial. Programa de Naciones Unidas para el Desarrollo (PNUD-UNDP). Habana, Caguayo, SA, 2000, pp. 63-67.
2. Annual Health Statistics Report 2003. Ministry of Public Health, National Health Statistics Bureau, Cuba. Edited by Zacca Peña E, Havana, 2003.
3. Herrera Valdés R, Almaguer López M: Atención de la insuficiencia renal crónica por el sistema de salud en Cuba. In Insuficiencia Renal Crónica, Diálisis y Trasplante: 1ra Conferencia de Consenso. Edited by Pan American Health Organization (PAHO). Washington, DC, 1989, pp. 131-136.
4. Valdivia J, Almaguer M: Aplicación de un programa de nefrología comunitaria en Cuba. Nefrología XII (Suppl 2):160, 1992.
5. Data from: National Coordinating Center of the CKD Program, Institute of Nephrology, Havana, Cuba, December 2004.
6. Herrera Valdés R, Magrans Ch, Buch A, Mañalich Comas R et al.: La insuficiencia renal crónica y la estrategia de Cuba para las enfermedades crónicas no transmisibles hasta el año 2000. Nefrología XIII (Suppl 5): 41-45, 1993.
7. Programa de prevención de la insuficiencia renal crónica. Ministerio de Salud Pública. Cuba, 1996.
8. Almaguer López M: Prevención de las enfermedades renales crónicas. In Tratado de Nefrología (Vol. II). Edited by Treviño Becerra A. México DF, Editorial Prado, 2003, pp. 2003-2027.

THE AUTHOR

Director, Institute of Nephrology, Havana; Chair, National Nephrology Experts’ Group; Coordinator, National Program for Chronic Renal Diseases, Dialysis and Transplantation; Full Professor of Nephrology, Higher Institute of Medical Sciences of Havana; Senior Member, Cuban Academy of Sciences.