The three leading causes of mortality and DALYs in LA, particularly in Central America and the Caribbean, were diabetes, arterial hypertension, and obesity, with an annual increase rate change in all-age DALYs from 2010 to 2019 between 1.6% and 5.0%.

Diabetes is by far the leading cause (36%) of treated end-stage kidney disease (ESKD), representing 67%, 58%, and 48% of incident dialysis patients in Puerto Rico, Mexico, and Paraguay, respectively, followed by hypertension and chronic glomerular disease. On average, the prevalence of diabetes in LA countries was 9.7%. Mexico was the country that experienced the largest increase in diabetes prevalence, of 4.40 percentage points, while the prevalence in Venezuela and Uruguay decreased around 6 percentage points in the 2010–2019 period. The burden of diabetes and kidney diseases is particularly high compared with the global average, equivalent to 2560 DALYs per 100,000 population compared with a global average of 1460 DALYs per 100,000 population.

Hypertension is the most important risk factor contributing to the burden of cardiovascular disease and the leading cause of death in all LA countries. Close to 22% of the adult LA population is estimated to be affected by hypertension, below the global average of 30%. Peru and Panama have the highest prevalence of 25%, while the lowest prevalence was observed in the Dominican Republic (17.9%) and Paraguay, the only country below 15%. Between 2005 and 2015, most LA countries reduced the prevalence of raised blood pressure with an average of-8%. Changes in risk factors and improvements in detection and treatment of raised blood pressure have, at least partly, contributed to these general reductions. ^,

Overweight and obesity are major public health concerns in the region. Obesity is an established risk factor for hypertension, diabetes, and cardiovascular disease. In LA countries, 63% of women and 53% of men are overweight (overweight + obesity). Between 2010 and 2016, the overweight population increased 6% in women and 9% in men. In LA countries, obesity is higher among women (29%) than men (18%). Social determinants of health such as poverty, inadequate water and sanitation, and inequitable access to education and health services underlie the epidemic of obesity and diabetes in the region. A key driver is a changing food environment, in which nutrient-poor and energy-dense processed foods are being aggressively marketed.

An endemic type of CKD of unknown origin (also known as “Mesoamerican Nephropathy” [MeN]) has been described in the region, particularly in El Salvador, Guatemala, Honduras, Nicaragua, Mexico, and Paraguay. ^, This form of CKD has been most consistently reported among agricultural workers, ^, has a higher prevalence in men, favors regions at lower altitudes, and particularly affects workers in sugar cane plantations. This form of CKD of unknown cause, named MeN, is endemic to Pacific coastal communities in Central America. ^20.

The clinical presentation of MeN is characterized by an elevation of serum creatinine level and non-nephrotic proteinuria, predominantly in young men without evidence of any known risk factors for CKD such as hypertension or diabetes, raising the possibility of a tubulointerstitial kidney disease due to an unknown environmental or occupational hazard. Various hypotheses have been described including ischemic injury as a result of the heavy physical work in a hot climate leading to repeated episodes of chronic dehydration with AKI after working hours. The temperature in Mesoamerica has increased significantly, and recent evidence has shown that kidney tubules can be damaged by heat stress. Nonetheless, it is likely that multiple “hits” are necessary. In kidney biopsies from eight male sugarcane workers (aged 22−57 years) from a rural area of El Salvador who had presented with impaired kidney function (estimated glomerular filtration rate (GFR) between 27 and 77 mL/min/1.73 m ² ), inactive urinary sediment, and non-nephrotic proteinuria, ^, the morphologic picture was similar in all patients, showing chronic tubulointerstitial injury with tubular atrophy and interstitial fibrosis, and a surprising finding was the presence of relatively extensive glomerular sclerosis. These findings suggest primary tubulointerstitial disease.

Other authors have also described acute interstitial nephritis in young people without other comorbidities who had abnormalities in kidney function markers.

Kidney tubular injury may also be induced by pesticides used in agriculture, which induce proximal tubular injury similar to that observed with calcineurin inhibitors. The pesticide paraquat has been shown to be strongly associated with the progression of CKD in exposed individuals in regions of Central America. Acute heavy metal exposure has also been implicated in Central American communities, especially in a town in Mexico called Poncitlan, where its inhabitants have one of the highest prevalence of CKD of undetermined etiology in the world. Another of the most commented hypotheses are those derived from fructose. ^, It is likely that there is also a genetic predisposition for MeN. In a municipality in Mexico where MeN is highly prevalent, genetic variants of ATP6V0A2 were identified in more than 30% of the affected population. ATP6V0A2 encodes the ATPase pump of the lysosomal H+ transporter in the kidney tubule. Thus it is possible that MeN may be a kidney disease due to a combination of genetic predisposition, with chronic dehydration leading to tubulointerstitial injury ^, and toxins (e.g., pesticides) or heavy metals contributing as second hits in the development of the disease. Although originally reported in Central America, MeN could represent a larger entity, explaining CKD epidemics seen in countries such as Sri Lanka, Bangladesh, and central Australia.

Heat stress is a syndrome that can occur in hot environments during the summer months. ^, When heat waves persist for consecutive days, the risk of AKI and CKD increases. Dehydration, a common condition among workers in agriculture, construction, firefighters, and miners, is a significant risk factor for nephropathy. Recurrent dehydration increases serum osmolarity and activates the polyol pathway in the kidney, leading to increased conversion of glucose to sorbitol and fructose. Fructose in turn can be metabolized by the fructokinase that is constitutively present, resulting in the generation of uric acid, oxidants, and chemokines, which can cause local tubulointerstitial injury. Mice with knockout of fructokinase are protected from CKD when subjected to repeated dehydration. Heat stress and strenuous physical work can also lead to rhabdomyolysis. Continuous episodes of rhabdomyolysis are associated with elevated uric acid levels. This episode of environmentally associated AKI could be related to unknown CKD (CKDu) or MeN as discussed earlier. ^,

Kidney transplantation in LA started in Argentina in 1957, followed by Mexico (1963), Brazil (1964), Chile, and Colombia (1966). Kidney transplantation is available in 17 (94%) countries, with a regional median of 0.5 transplant centers pmp, above the global median of 0.42 pmp. Mexico and Argentina have the highest capacity for transplantation (2.16 and 1.39 transplant centers pmp, respectively ^, ). All countries with transplant capacity perform a combination of deceased and living-donor kidney transplants, except for El Salvador, which has capacity for living-donor kidney transplants only. The kidney transplant rate has doubled over the past 2 decades, from 11 transplants pmp in 2000 to 22 transplants pmp in 2019 ( Fig. 74.6 ). The country-specific deceased organ transplantation rate is heterogenous, with Uruguay, Brazil, and Argentina reporting the higher rates of deceased-donor kidney transplantation in the region (33.8, 20.8, and 16.0 pmp, respectively), and >70% of their transplants were from deceased donors. Most countries (63%) with kidney transplantation available had national transplant waitlists, whereas the rest had regional lists only. ^{, ,}

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