Guatemala is situated in Central America, south-west of Mexico and has a population of approximate 15 million people of which 60% are younger than 20 years of age and 37% (5 millions) younger than twelve years of age (1). As any other developing country, Guatemala struggled with limited economical resources devoted to treat non communicable diseases. This is especially true for ESRD due to the fact that renal replacement therapy competes with other urgent needs of the population, such as treatment of diarrhea and respiratory infections.

In 2010, FUNDANIER (Foundation for Children with Kidney Diseases) signed a cooperative agreement with the Ministry of Health, through Roosevelt Hospital, one of two tertiary level hospitals in the national network. The goal of the agreement was to create, within the National Health System, a comprehensive pediatric nephrology program, by facilitating the infrastructure, promoting administrative changes, and building capacity with health-care providers (2, 3). This program provides free access to renal replacement therapy to Guatemalan children.

In Guatemala, the pediatric ESRD incidence rate was calculated in 4.6 per million inhabitants under the age of 20 (4.7 for girls and 4.5 for boys). Of the 432 patients with CRF on our data base, 193 patients had CKD stage 5 (ESRD). The majority received peritoneal dialysis (40.4%), followed by hemodialysis (26.4%), transplant (12.4%), and no renal replacement therapy (conservative management; 17.6%) (4).

One of limitations for the kidney transplant is the high cost, which avoids transplant for the majority of patients. Many efforts had been made to decrease the transplant maintenance cost. The first one was replacement the micofenolate for aziatropina in our protocol (5). The other one was to reduce the tacrolimus dose using ketoconazole. Partial results of these efforts are presented in the following abstract.

Material and Methods

A group of 18 patients was evaluated to compare the tacrolimus dose used three months before and three months after the introduction of a daily dose of ketoconazole. As security measures were compare: Levels of tracrolimus, number of rejection graft and level of transaminases before and after the dose of ketoconazole. This information was collected from medical registers.

The Results and Discussion

Eighteen medical records were reviewed; seven patients were male and eleven patients were female, with an average age of 11.5 years. The average transplant time was three years.

The average Tacrolimus amount given to each patient per day for the three months prior to the use of ketoconazole was 4.4 mg / day (average dose 0.15 mg/Kg/day).  The average Tacrolimus amount given to each patient per day for the three months after the use of ketoconazole was 2.7 mg/day (average dose 0.06 mg/Kg/day).  The average dose of ketoconazole was 1.3 mg / kg / day. To keep an average tacrolimus blood level of 5-7 ng/ml.

One patient had an increase in transaminases (2X) during the use of ketoconazole. This complication resolved after the ketoconazole was suspended. No rejection event was reported during the period of ketoconazole use.

To conclude: the administration of ketoconazole reduced the amount of tacrolimus given to the patients without finding a relevant variation in the tacrolimus levels, number rejection graft or significant liver toxicity. This allowed the reduction of the cost used for maintenance of the anti-rejection medication.