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Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL).

BACKGROUND
End-stage renal disease represents a serious public health problem in Jalisco, Mexico. It is reported among the 10 leading causes of death, with an annual mortality rate of 12 deaths per 100,000 population. The state population is 6.3 million, and more than half do not have medical insurance. In this study, we report the population's access to renal replacement therapy (RRT).


METHODS
Patients > or =15 years of age, who started RRT between January 1998 and December 2000 at social security or health secretariat medical facilities, were included. Nine facilities participated in the study. At the start of treatment, the patient's facility, age, gender, cause of renal failure, and initial treatment modality were registered.


RESULTS
Within the study period, 2456 started RRT, 1767 (72%) at social security facilities and 687 (28%) at health secretariat facilities, for an annual incidence rate of 195 per million population (pmp). The main cause of renal failure was diabetes mellitus (51% of patients). There were significant differences between the 2 populations. Patients with social security were older (53.1 +/- 17 vs. 45.1 +/- 20 years, P= 0.001) and had more diabetes (54% vs. 42%, P= 0.001) than those without social security. They had higher acceptance (327 pmp vs. 99 pmp, P= 0.001) and prevalence rates (939 pmp vs. 166 pmp, P= 0.001) than patients without medical insurance. Dialysis use was similar in both populations. Eighty-five percent of patients were on continuous ambulatory peritoneal dialysis and 15% on hemodialysis. Kidney transplant rate was higher among insured patients (72 pmp vs. 7.5 pmp, P= 0.001). The number of dialysis programs and nephrologists that offered renal care also differed. There were 10 dialysis programs in social security and 3 in health secretariat facilities. Fourteen nephrologists looked after the insured population, whereas 5 cared for the uninsured (7.7 pmp vs. 2.1 pmp, P= 0.001). The latter had access to 8 hemodialysis stations compared with 34 for the insured population (3.4 pmp vs. 18.8 pmp, P= 0.001).


CONCLUSIONS
Access to RRT is unequal in our state. Although it is universal for the insured population, it is severely restricted for the poor. Social and economical factors, as well as the limited number of understaffed, centralized dialysis facilities, could explain these differences.