Global Dialysis Perspective: Nicaragua

Country Profile

Nicaragua is a Central American country with a population of approximately 6.7 million.¹ It is the second poorest country in the Western Hemisphere after Haiti and is classified as a lower-middle–income country.^2,3 Approximately 40% of the population live in rural areas.¹ The economy is based on agriculture with coffee, peanuts, sugar, gold, and livestock being the top exports.⁴ Most workers are employed in agriculture (32%) and the service industry (45%).⁴ Over 60% of employees work in the informal economy and are not eligible for health coverage by the Nicaraguan Social Security Institute.⁵ The literacy rate in urban areas is 86% but is much lower (63%) in rural areas.⁶ The health system includes public, social security, and private sectors. The Ministry of Health (MINSA) provides free medical care to 65% of the population, while the Nicaraguan Social Security Institute (INSS) covers 18% of the population.⁷ Health expenditures accounted for 8.4% of the total gross domestic product in 2019.²

Kidney Disease in Nicaragua

Kidney disease is the second leading cause of death in Nicaragua, second only to ischemic heart disease.⁸ The age-standardized mortality rate for CKD in Nicaragua is 73 per 100,000 population compared with 13 in the United States.⁹ This mortality rate increased by 60% from 2000 to 2019.⁹ There is no national CKD surveillance system, so the prevalence is unknown; however, it seems to be rising.

This rise in CKD prevalence is partly attributed to a new form of CKD called Mesoamerican Nephropathy (also termed CKD of unknown etiology, or CKDu), a tubulointerstitial nephritis that disproportionally affects young, male, and agricultural workers who lack traditional CKD risk factors.¹⁰ Studies have found that up to 26% of adult men in agricultural areas have elevated serum creatinine compared to 9.1% of adult men in an urban area.^11,12 A study in nine Nicaraguan agricultural communities found that 10% of young, healthy men experienced a rapid decline in kidney function in just two years.¹³ However, other studies have reported a high prevalence of Mesoamerican Nephropathy in the nonagricultural sector.¹⁴ This disease is an important contributor to the growing burden of CKD and ESRD in Nicaragua.

Dialysis Delivery

These data were collected by interviewing medical directors of dialysis units. This is not an official report by the Ministry of Health, but rather an article sharing the knowledge and perspectives of its authors.

Prevalence of RRT

According to the Registro Latinoamericano de Dialisis y Trasplante Renal's (RLDTR) most recent report in 2018, Nicaragua has an estimated 520 per million population (pmp) on RRT.¹⁵ We estimate the current prevalence is higher at approximately 700 pmp (Table 1). Almost all the patients are on some form of dialysis because transplants are rare (two pmp).¹⁵ A total of 154 kidney transplants (150 living and four deceased donors) have been performed in Nicaragua in the referral children's hospital and two private hospitals in Managua. The average age of MINSA and INSS dialysis patients is 49.9 years. The 3-year survival rate for patients initiated on hemodialysis (HD) is 52%, and increased age and comorbidities are associated with poorer survival.

Table 1.

Characteristics of patients on dialysis in Nicaragua

Characteristics	Value
Number of dialysis patients	4640 total; 700 pmp
Patients on home dialysis, %
Total	11
CAPD	100
Mean age, yr	49.9
Total number of dialysis units	21
Dialysis unit situation
Free standing	2
Hospital based	19
Dialysis unit profit designation	All the private system units are profit
Reimbursement per dialysis session
Social security system reimbursement to private unit	$75–100 USD per HD session
Direct cost to patient in private unit	$140 USD per HD session
Dialysis delivery staff	Only dialysis nurses
Typical patient/nurse ratio in the dialysis units	4–5:1
Average length of a dialysis session, hr	3.5–4
Times per month patients seen by a nephrologist during dialysis sessions	1
HD accessa
MINSA Nicaragua	53% AVF, 47% CVC
INSS	59% AVF, 41% CVC
Private system	Unknown
Total number of kidney transplants performed in Nicaragua (n)	154

Pmp, per million people; CAPD, continuous ambulatory peritoneal dialysis; MINSA, Nicaragua, Ministerio de Salud Nicaragua (Nicaragua Ministry of Health); INSS, Instituto Nicaragüense de Seguridad Social (Nicaraguan Institute of Social Security); CVC, central venous catheter; AVF, arteriovenous fistula.

^aNo arteriovenous grafts are used.

Overall, there are limited data on dialysis in Nicaragua. There is no national registry for dialysis, and data from RLDTR are incomplete and collected directly from nephrologists. In addition, Nicaragua is notably absent from the International Society of Nephrology (ISN) Global Kidney Health Atlas.¹⁶ This article is lacking patient data from the private system.

Health System

Dialysis can be performed by the private, public, and social security systems (Table 2). The private system provides HD to only approximately 100 patients (2% of the total dialysis population). This system has seven private dialysis units where patients undergo dialysis three times per week, costing the patient approximately $140 US dollars (USD) per session. The cost is prohibitively expensive for most of the population, which has an average income of $306 USD per month.⁴

Table 2.

Distribution of dialysis care across systems in Nicaragua

System	Approximate Total Patients, n (%)	Number of Dialysis Units	Percentage of Patients on PD	Weekly Number of HD Sessions	Payment	Number of Nephrologists
Public (MINSA)	840 (18%)	10	60%	2	No cost to patient, covered by the ministry of health	10 (5 pediatric)
Social security (INSS)	3700 (80%)	Eight (six private, one army hospital, one police hospital)	0% PD unavailable	3	No cost to patient, social security system pays dialysis unit $75–$100 USD	24 (1 pediatric)
Private	100 (2%)	Seven (four also serve social security patients)	0% PD unavailable	3	Out of pocket for patient, approximately $140 USD per HD session	1
Overall	4640 (700 pmp)	21	11%			35

MINSA, Ministerio de Salud Nicaragua (Nicaragua Ministry of Health); INSS, Instituto Nicaragüense de Seguridad Social (Nicaraguan Institute of Social Security); pmp, per million population; PD, peritoneal dialysis; HD, hemodialysis; USD, US dollar.

The INSS covers workers who have insurance through their employers, those with pensions, and workers with occupational diseases (including Mesoamerican Nephropathy).¹⁷ Approximately 3700 patients receive dialysis in six private dialysis units, one military hospital, and one police hospital (Table 2). INSS pays the unit for its service with no direct cost to the patients. Patients in INSS and private systems attend clinics that offer HD three times weekly. Transplant and associated care, including immunosuppressive drugs, are covered by MINSA and INSS.

Finally, 840 patients receive treatments through MINSA at 10 dialysis units where HD is offered twice weekly because of limited resources (Table 2). Dialysis in the public sector is at no cost to the patient and is funded by the health national budget. The distribution of funds is determined at the national level, and payment is not directly linked to clinical outcomes.¹⁷ In both the private and public sectors, each dialysis unit has its own standards and protocols while following generally accepted guidelines. MINSA provides pediatric patients with peritoneal dialysis (PD), HD, and renal transplantation through a referral children's hospital in Managua, which started its dialysis program in 2005.

There is no complete registry of dialysis units or patients in Nicaragua. A map of the total 21 dialysis units identified through our research is shown in Figure 1. In the public sector, patients are referred from their primary care clinics to dialysis clinics. Dialysis clinics are only located in urban areas. This limits options for those residing in rural areas, which tend to be the areas most affected by Mesoamerican Nephropathy.

Figure 1.

Map of dialysis unit locations in Nicaragua by department.

Modality and Dialysis Access

The decision on dialysis modality is based on the available resources and recommendation of the patient's physician. PD is only offered in the public sector through MINSA. According to RLDTR, in 2018, approximately 29% of total dialysis patients were on PD.¹⁵ On the basis of our current data, approximately 60% of patients in the public sector are on PD, but this only accounts for 11% of the total dialysis population (Table 1). A challenge with PD in Nicaragua is the need for a sanitary space to perform exchanges, so some families must construct “clean rooms” dedicated only to PD, which is a financial burden. In addition, there is limited training offered to patients on how to perform PD, which is particularly important for those who are illiterate or lack formal education. There is also a widespread fear of death from peritonitis with this modality.

Vascular access is a challenge largely because of workforce shortage. With only 1.5 vascular surgeons pmp, it is difficult to obtain an arteriovenous fistula.¹⁸ In 2020, a structured training program supported by the ISN for two general surgeons was performed with good results.¹⁸ Currently, 53% of patients on HD have vascular access in MINSA, and 59% in INSS (Table 1).

Dialysis Workforce

Lack of trained staff limits the growth of dialysis services. HD is performed by dialysis nurses with a ratio of four to five patients per nurse (Table 1). There are currently 35 nephrologists in Nicaragua, of whom 32 were trained in this specialty outside of the country. In response to the population's needs, the government initiated a nephrology fellowship training program in 2021.¹⁹ This fellowship has a goal of increasing the workforce by training four adult and four pediatric nephrologists annually.¹⁹

Future Directions

The startling rise in ESRD in Nicaragua combined with limited resources leads to an incredibly challenging situation. MINSA has responded appropriately by increasing nephrology training and dialysis capabilities. As Nicaragua's kidney disease infrastructure grows, consideration should be given to further development of the kidney transplantation program.

There should also be a renewed focus on kidney disease prevention. Importantly, 40% of the Nicaraguan population resides in rural areas where access to health care, especially specialty care, is a major challenge. We recommend increased funding and education for the prevention of CKD by primary care physicians in rural areas who can detect early signs of kidney disease. These clinics should have the support to perform appropriate testing, preventative interventions, and timely referral to specialists.

Attention should also be paid to optimizing current dialysis care. Patients in rural areas who develop ESRD have limited options because all dialysis units are in urban areas with a high concentration in the capital (Figure 1). Patients requiring HD in rural areas must finance their own transportation. The time commitment of transportation and treatment can lead to difficulty maintaining employment. The use of PD instead of HD could alleviate some of these challenges. One consideration could be the creation of a PD program that promotes, finances, and facilitates PD, especially in rural areas. This program could provide education and training on PD, which is currently a major barrier in the uptake of this modality. This kind of program has been effective in Guatemala, which currently has one of the highest rates of PD in the world.²⁰ More information is also needed on dialysis delivery, including a registry of dialysis patients, to implement system-level innovations that could improve patient care and optimize resource usage.

One of the most essential tools for improving the lives of those with kidney disease in Nicaragua is research. Clinical and epidemiological research is essential to identify the etiology and risk factors for CKD in Nicaragua, especially Mesoamerican Nephropathy. In addition, understanding the effect of social, cultural, educational, and occupational factors on health and health care access is needed so that appropriate preventative interventions can be implemented.

In conclusion, kidney care in Nicaragua can be improved through disease prevention and can focus on care delivery to rural populations and continued research.

Disclosures

A.K. Strasma reports the following: Employer: Duke University School of Medicine; and Other Interests or Relationships: National Kidney Foundation—North Carolina Fellow Member of Medical Advisory Board; long-term volunteer and previous donor to an NGO in Nicaragua, Amigos for Christ. A family member is employed by this NGO. The remaining authors have nothing to disclose.

Funding

None.

Author Contributions

A.K. Strasma conceptualized the study and was responsible for methodology; C.L. Cajina-Aguirre and A.K. Strasma were responsible for data curation and formal analysis, and wrote the original draft; R.J. Álvarez-Novoa provided supervision and was responsible for validation; and all the authors were responsible for investigation and reviewed and edited the manuscript.