Chronic Kidney Disease in Ecuador: An Epidemiological and Health System Analysis of an Emerging Public Health Crisis

Background: The absence of a chronic kidney disease (CKD) registry in Ecuador makes it difficult to assess the burden of disease, but there is an anticipated increase in the incidence of end-stage kidney disease along with increasing diabetes, hypertension and population age. From 2008, augmented funding for renal replacement treatment expanded dialysis clinics and patient coverage. Methods: We conducted 73 in-depth interviews with healthcare providers in eight provinces. Findings were analyzed using qualitative methods and triangulated with quantitative data on patients with CKD diagnoses from six national-level databases between 2015 and 2018. We also reviewed grey and scientific literature on CKD and health systems in Ecuador. Results: Datasets show a total of 17 484 dialysis patients in 2018, or 567 patients per million population (pmp), with an annual cost exceeding 11% of Ecuador's public health budget. Each year, there were 139-162 pmp new dialysis patients, while doctors report waiting lists. The number of patients on peritoneal dialysis was stable; those on hemodialysis increased over time. Only 13 of 24 provinces have dialysis services, and nephrologists are in major cities, which limits access, delays medical attention, and adds a travel burden on patients. Prevention and screening programs are scarce, while hospitalization is an important reality of CKD patients. Conclusion: CKD is an emerging public health crisis that has increased dramatically over the last decade in Ecuador and is expected to continue, making coverage for all patients impossible and the current structure, unsustainable. A patient registry would permit to estimate the demand and progression of patients with consideration for comorbidities, requirements and costs, and mortality, and identify where to focus prevention efforts. Health policy should clearly state CKD definitions and required patient data, including cause, disease stage and follow-up statistics. Organized monitoring of patients would benefit from improvements in patient referral.