Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica

Chronic kidney disease (CKD) is a health problem worldwide and in Latin America (LA), which comprises 20 countries with a population of more than 620 million inhabitants, with great demographic, economic and health heterogeneity. The prevalence of CKD in LA is higher than worldwide, although it vari...

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Autores:: Obrador, Gregorio T.
Álvarez-Estévez, Guillermo
Bellorín, Ezequiel
Bonanno-Hidalgo, Carlos
Clavero, René
Correa-Rotter, Ricardo
Daza-Arnedo, Rodrigo
Dina-Batlle, Eliana
Morales, Luis
Orozco, Rodrigo
Ortiz, Fabián
Rosa-Díez, Guillermo
Sánchez-Polo, Vicente
Sola, Laura
Vázquez, Lourdes C.
Villavicencio, Vanessa
Rico-Fontalvo, Jorge

Tipo de recurso:

Fecha de publicación:: 2024

Institución:: Universidad Simón Bolívar

Repositorio:: Repositorio Digital USB

Idioma:: spa

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dc.title.spa.fl_str_mv	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
dc.title.translated.eng.fl_str_mv	Consensus document on new therapies to delay the progression of chronic kidney disease with emphasis on SGLT-2 inhibitors: implications for Latin America
title	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
spellingShingle	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica Enfermedad renal crónica Epidemiología Nefroprotección Inhibidores de SGLT-2 Implementación Políticas de salud Chronic kidney disease Epidemiology Nephroprotection SGLT-2 inhibitors Implementation Health policy
title_short	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
title_full	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
title_fullStr	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
title_full_unstemmed	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
title_sort	Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica
dc.creator.fl_str_mv	Obrador, Gregorio T. Álvarez-Estévez, Guillermo Bellorín, Ezequiel Bonanno-Hidalgo, Carlos Clavero, René Correa-Rotter, Ricardo Daza-Arnedo, Rodrigo Dina-Batlle, Eliana Morales, Luis Orozco, Rodrigo Ortiz, Fabián Rosa-Díez, Guillermo Sánchez-Polo, Vicente Sola, Laura Vázquez, Lourdes C. Villavicencio, Vanessa Rico-Fontalvo, Jorge
dc.contributor.author.none.fl_str_mv	Obrador, Gregorio T. Álvarez-Estévez, Guillermo Bellorín, Ezequiel Bonanno-Hidalgo, Carlos Clavero, René Correa-Rotter, Ricardo Daza-Arnedo, Rodrigo Dina-Batlle, Eliana Morales, Luis Orozco, Rodrigo Ortiz, Fabián Rosa-Díez, Guillermo Sánchez-Polo, Vicente Sola, Laura Vázquez, Lourdes C. Villavicencio, Vanessa Rico-Fontalvo, Jorge
dc.subject.spa.fl_str_mv	Enfermedad renal crónica Epidemiología Nefroprotección Inhibidores de SGLT-2 Implementación Políticas de salud
topic	Enfermedad renal crónica Epidemiología Nefroprotección Inhibidores de SGLT-2 Implementación Políticas de salud Chronic kidney disease Epidemiology Nephroprotection SGLT-2 inhibitors Implementation Health policy
dc.subject.keywords.eng.fl_str_mv	Chronic kidney disease Epidemiology Nephroprotection SGLT-2 inhibitors Implementation Health policy
description	Chronic kidney disease (CKD) is a health problem worldwide and in Latin America (LA), which comprises 20 countries with a population of more than 620 million inhabitants, with great demographic, economic and health heterogeneity. The prevalence of CKD in LA is higher than worldwide, although it varies within the region. The main cause of CKD is diabetes mellitus, although in some countries, especially in Central America, there is a high prevalence of CKD of non-traditional causes (Mesoamerican nephropathy). The main modality of replacement therapy is hemodialysis. The burden of CKD is very high, with great variation among LA countries with respect to public policies. Recently, there has been a very important advance in nephroprotective interventions, such as sodium-glucose transporter type 2 inhibitors. In this consensus, we present an evidence-based review of their indications in patients with CKD (diabetic and non-diabetic), proposing recommendations for their use, and describing the barriers for their implementation in LA. We conclude that prevention and early management of CKD should be promoted, which can be cost-effective to substantially mitigate the magnitude of the problem.
publishDate	2024
dc.date.accessioned.none.fl_str_mv	2024-06-28T15:13:06Z
dc.date.available.none.fl_str_mv	2024-06-28T15:13:06Z
dc.date.issued.none.fl_str_mv	2024
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dc.type.spa.none.fl_str_mv	Artículo científico
dc.identifier.issn.none.fl_str_mv	24449032 (Online)
dc.identifier.uri.none.fl_str_mv	https://hdl.handle.net/20.500.12442/14789
dc.identifier.doi.none.fl_str_mv	10.24875/NEFRO.M24000037
dc.identifier.url.none.fl_str_mv	https://www.nefrologialatinoamericana.com/?indice=20242192#JournalContents
identifier_str_mv	24449032 (Online) 10.24875/NEFRO.M24000037
url	https://hdl.handle.net/20.500.12442/14789 https://www.nefrologialatinoamericana.com/?indice=20242192#JournalContents
dc.language.iso.none.fl_str_mv	spa
language	spa
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dc.format.mimetype.none.fl_str_mv	pdf
dc.publisher.spa.fl_str_mv	Sociedad Latinoamericana de Nefrología e Hipertensión
dc.source.none.fl_str_mv	Vol. 21 No. 21,(2024) (Supl.)
dc.source.spa.fl_str_mv	Nefrología latinoamericana
dc.source.eng.fl_str_mv	Nefro Latinoam.
institution	Universidad Simón Bolívar
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spelling	Obrador, Gregorio T.2d21fa70-794b-4936-b799-8b437c8ae534-1Álvarez-Estévez, Guillermo722ab409-9e4f-48a9-892d-12383fb8200d-1Bellorín, Ezequiel3cdf24a0-d7a3-4332-8f3b-492d3f2a324e-1Bonanno-Hidalgo, Carlosd68f493a-bdb7-4dc7-8f04-e08ce7b8c063-1Clavero, René2c809608-a1c3-4059-befb-e0dcd95ef2b9-1Correa-Rotter, Ricardo77b63a97-9027-4286-bbeb-731aa57ed62d-1Daza-Arnedo, Rodrigo928bf6de-8e8b-40e4-9c34-3b53bd369dbf-1Dina-Batlle, Eliana72983ec9-f93b-4565-af34-49771b419a4b-1Morales, Luis8e5380e6-0319-46f9-a19b-0c7474d29353-1Orozco, Rodrigobb1ced4a-4e1e-4738-bcd4-033264290644-1Ortiz, Fabiáne911dcd2-dffc-4b81-8552-0cd720cf93b0-1Rosa-Díez, Guillermoa093e932-e1f3-4457-a99f-ee8a1c68abef-1Sánchez-Polo, Vicentec7418f8f-984e-4af5-9305-00656177f4c2-1Sola, Laura220258b4-e9bd-4a3e-b8f1-d642fd80bf1f-1Vázquez, Lourdes C.8add895f-82aa-42fd-a97a-60e19ad3ca67-1Villavicencio, Vanessa5195474c-152a-45f0-b310-80c50c179b6e-1Rico-Fontalvo, Jorgedb7fe1a8-5530-4479-a566-077a0266f60d-12024-06-28T15:13:06Z2024-06-28T15:13:06Z202424449032 (Online)https://hdl.handle.net/20.500.12442/1478910.24875/NEFRO.M24000037https://www.nefrologialatinoamericana.com/?indice=20242192#JournalContentsChronic kidney disease (CKD) is a health problem worldwide and in Latin America (LA), which comprises 20 countries with a population of more than 620 million inhabitants, with great demographic, economic and health heterogeneity. The prevalence of CKD in LA is higher than worldwide, although it varies within the region. The main cause of CKD is diabetes mellitus, although in some countries, especially in Central America, there is a high prevalence of CKD of non-traditional causes (Mesoamerican nephropathy). The main modality of replacement therapy is hemodialysis. The burden of CKD is very high, with great variation among LA countries with respect to public policies. Recently, there has been a very important advance in nephroprotective interventions, such as sodium-glucose transporter type 2 inhibitors. In this consensus, we present an evidence-based review of their indications in patients with CKD (diabetic and non-diabetic), proposing recommendations for their use, and describing the barriers for their implementation in LA. We conclude that prevention and early management of CKD should be promoted, which can be cost-effective to substantially mitigate the magnitude of the problem.La enfermedad renal crónica (ERC) es un problema de salud global y para América Latina (AL), la cual comprende 20 países con una población mayor a 620 millones de habitantes, con gran heterogeneidad demográfica, económica y de salud. La prevalencia de ERC en AL es más alta que la mundial, aunque varía dentro de la región. La principal causa de ERC es la diabetes mellitus, aunque en algunos países, sobre todo de América Central, existe alta prevalencia de ERC de causa no tradicional (nefropatía mesoamericana). La principal modalidad de terapia sustitutiva es la hemodiálisis. La carga de la ERC es muy alta, con gran variación entre los países de AL con respecto a las políticas públicas. En los últimos años ha habido un avance muy importante en intervenciones de nefroprotección, como los inhibidores del transportador sodio-glucosa tipo 2. En este consenso se presenta una revisión basada en la evidencia de sus indicaciones en pacientes con ERC (diabética y no diabética), se proponen recomendaciones para su uso y se describen las limitaciones para su implementación en AL. Concluimos que debe potencializarse la prevención y manejo temprano de la ERC, que puede resultar costo-efectiva para mitigar sustancialmente la magnitud del problema.pdfspaSociedad Latinoamericana de Nefrología e HipertensiónAttribution-NonCommercial-NoDerivs 3.0 United Stateshttp://creativecommons.org/licenses/by-nc-nd/3.0/us/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Vol. 21 No. 21,(2024) (Supl.)Nefrología latinoamericanaNefro Latinoam.Enfermedad renal crónicaEpidemiologíaNefroprotecciónInhibidores de SGLT-2ImplementaciónPolíticas de saludChronic kidney diseaseEpidemiologyNephroprotectionSGLT-2 inhibitorsImplementationHealth policyDocumento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para LatinoaméricaConsensus document on new therapies to delay the progression of chronic kidney disease with emphasis on SGLT-2 inhibitors: implications for Latin Americainfo:eu-repo/semantics/articleArtículo científicohttp://purl.org/coar/version/c_970fb48d4fbd8a85http://purl.org/coar/resource_type/c_2df8fbb1Bello AK, Okpechi IG, Levin A, Ye F, Saad S, Zaidi D, et al. ISN-Global Kidney Health Atlas. A report by the International Society of Nephrology: An assessment of Global Kidney Health Care Status focusing on capacity, availability, accessibility, affordability and outcomes of kidney disease [Internet]. Bruselas, Bélgica: International Society of Nephrology; 2023. Disponible en: https://www. theisn.org/wp-content/uploads/media/ISN%20Atlas_2023%20Digital.pdfLuxardo R, Ceretta L, Gonzalez-Bedat M, Ferreiro A, Rosa-Diez G. The Latin American Dialysis and Renal Transplantation Registry: report 2019. Clin Kidney J. 2022;15(3):425-31.Correa-Rotter R, Méndez Durán A, Vallejos A, Rico-Fontalvo J, Cusumano AM, Rosa-Diez GJ, et al. Unmet Needs of CKD in Latin America: A Review from Expert Virtual Working Group. Kidney Int Rep. 2023;8(5):954-67.Figueroa-Lara A, Gonzalez-Block MA, Alarcon-Irigoyen J. Medical expenditure for chronic diseases in Mexico: the case of selected diagnoses treated by the largest care providers. PLoS One. 2016;11(1):e0145177.Correa-Rotter R, García-Trabanino R. Mesoamerican nephropathy. Semin Nephrol. 2019;39(3):263-71.Fernandez-Fernandez B, Sarafidis P, Soler MJ, Ortiz A. EMPA-KIDNEY: expanding the range of kidney protection by SGLT2 inhibitors. Clin Kidney J. 2023;16(8):1187-98Naaman SC, Bakris GL. Diabetic nephropathy: update on pillars of therapy slowing progression. Diabetes Care. 2023;46(9):1574-86Mark PB, Sarafidis P, Ekart R, Ferro CJ, Balafa O, Fernandez-Fernandez B, et al. SGLT2i for evidence based cardiorenal protection in diabetic and non-diabetic chronic kidney disease: a comprehensive review by EURECA-m and ERBP working groups of ERA. Nephrol Dial Transplant. 2023;38(11):2444-55.Marso SP, Bain SC, Consoli A, Eliaschewitz FG, Jodar E, Leiter LA, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(19):1834-44Marso SP, Daniels GH, Brown-Frandsen K, Kristensen P, Mann JF, Nauck MA, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311-22Sattar N, Lee MMY, Kristensen SL, Branch KRH, Del Prato S, Khurmi NS, et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of randomised trials. Lancet Diabetes Endocrinol. 2021;9(10):653-62.Agarwal R, Filippatos G, Pitt B, Anker SD, Rossing P, Joseph A, et al. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J. 2022;43(6):474-84Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, et al. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-29Pitt B, Filippatos G, Agarwal R, Anker SD, Bakris GL, Rossing P, et al. Cardiovascular events with finerenone in kidney disease and type 2 diabetes. N Engl J Med. 2021;385(24):2252-63Gragnano F, De Sio V, Calabro P. FLOW trial stopped early due to evidence of renal protection with semaglutide. Eur Heart J Cardiovasc Pharmacother. 2024;10(1):7-9.Aviles-Santa ML, Monroig-Rivera A, Soto-Soto A, Lindberg NM. Current state of diabetes mellitus prevalence, awareness, treatment, and control in Latin America: challenges and innovative solutions to improve health outcomes across the continent. Curr Diab Rep. 2020;20(11):62.Sanchez Polo V, Garcia-Trabanino R, Rodriguez G, Madero M. Mesoamerican Nephropathy (MeN): what we know so far. Int J Nephrol Renovasc Dis. 2020;13:261-72Jain AK, Blake P, Cordy P, Garg AX. Global trends in rates of peritoneal dialysis. J Am Soc Nephrol. 2012;23(3):533-44.Karopadi AN, Mason G, Rettore E, Ronco C. Cost of peritoneal dialysis and haemodialysis across the world. Nephrol Dial Transplant. 2013;28(10):2553-69Mendez-Duran A. Evolution of renal replacement therapy in Mexico in the last 10 years. Nefrologia (Engl Ed). 2021;41(1):82-3.Garcia P, Sanchez-Polo V. Global dialysis perspective: Guatemala. Kidney360. 2020;1(11):1300-5.Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993;329(20):1456-62.Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving H-H, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861-9.Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851-60Tuttle KR, McGill JB, Haney DJ, Lin TE, Anderson PW, Pkc-Drs PD, et al. Kidney outcomes in long-term studies of ruboxistaurin for diabetic eye disease. Clin J Am Soc Nephrol. 2007;2(4):631-6.Mann JF, Green D, Jamerson K, Ruilope LM, Kuranoff SJ, Littke T, et al. Avosentan for overt diabetic nephropathy. J Am Soc Nephrol. 2010;21(3):527-35.Sharma K, Ix JH, Mathew AV, Cho M, Pflueger A, Dunn SR, et al. Pirfenidone for diabetic nephropathy. J Am Soc Nephrol. 2011;22(6):1144-51.Parving HH, Brenner BM, McMurray JJV, de Zeeuw D, Haffner SM, Solomon SD, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med. 2012;367(23):2204-13Packham DK, Wolfe R, Reutens AT, Berl T, Heerspink HL, Rohde R, et al. Sulodexide fails to demonstrate renoprotection in overt type 2 diabetic nephropathy. J Am Soc Nephrol. 2012;23(1):123-30.Fried LF, Emanuele N, Zhang JH, Brophy M, Conner TA, Duckworth W, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369(20):1892-903.de Zeeuw D, Akizawa T, Audhya P, Bakris GL, Chin M, Christ-Schmidt H, et al. Bardoxolone methyl in type 2 diabetes and stage 4 chronic kidney disease. N Engl J Med. 2013;369(26):2492-503Wiviott SD, Raz I, Bonaca MP, Mosenzon O, Kato ET, Cahn A, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2018;380(4):347-57Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117-28.Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377(7):644-57.Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, Charytan DM, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295-306Heerspink HJL, Stefansson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-46Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, Emberson JR, et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-27Gerstein HC, Sattar N, Rosenstock J, Ramasundarahettige C, Pratley R, Lopes RD, et al. Cardiovascular and renal outcomes with efpeglenatide in type 2 diabetes. N Engl J Med. 2021;385(10):896-907.Rossing P, Baeres FMM, Bakris G, Bosch-Traberg H, Gislum M, Gough SCL, et al. The rationale, design and baseline data of FLOW, a kidney outcomes trial with once-weekly semaglutide in people with type 2 diabetes and chronic kidney disease. Nephrol Dial Transplant. 2023;38(9): 2041-51Vallon V, Platt KA, Cunard R, Schroth J, Whaley J, Thomson SC, et al. SGLT2 mediates glucose reabsorption in the early proximal tubule. J Am Soc Nephrol. 2011;22(1):104-12Vallon V, Thomson SC. Targeting renal glucose reabsorption to treat hyperglycaemia: the pleiotropic effects of SGLT2 inhibition. Diabetologia. 2017;60(2):215-25Cherney DZI, Cooper ME, Tikkanen I, Pfarr E, Johansen OE, Woerle HJ, et al. Pooled analysis of Phase III trials indicate contrasting influences of renal function on blood pressure, body weight, and HbA1c reductions with empagliflozin. Kidney Int. 2018;93(1):231-44.Ferrannini E. Sodium-glucose co-transporters and their inhibition: clinical physiology. Cell Metab. 2017;26(1):27-38.Yau K, Dharia A, Alrowiyti I, Cherney DZI. Prescribing SGLT2 inhibitors in patients with CKD: Expanding indications and practical considerations. Kidney Int Rep. 2022;7(7):1463-76.Lee PC, Ganguly S, Goh SY. Weight loss associated with sodium-glucose cotransporter-2 inhibition: a review of evidence and underlying mechanisms. Obes Rev. 2018;19(12):1630-41Nuffield Department of Population Health Renal Studies G, Consortium SiM-AC-RT. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet. 2022;400(10365):1788-801Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.Rossing P, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K, et al. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102(5):S1-S127UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease [Internet]. Reino Unido: UK Kidney Association [consultado en marzo de 2024]. Disponible en: https://ukkidney.org/renal-association/news/sglt-2-inhibition-adults-kidney-diseaseNyirjesy P, Sobel JD. Genital mycotic infections in patients with diabetes. Postgrad Med. 2013;125(3):33-46.Nyirjesy P, Sobel JD, Fung A, Mayer C, Capuano G, Ways K, et al. Genital mycotic infections with canagliflozin, a sodium glucose co-transporter 2 inhibitor, in patients with type 2 diabetes mellitus: a pooled analysis of clinical studies. Curr Med Res Opin. 2014;30(6):1109-19.St Peter WL, Meaney CJ. Extending SGLT2 inhibitor use for people undergoing dialysis? Clin J Am Soc Nephrol. 2023;18(8):991-3.Heerspink HJL, Berger S, Gansevoort RT; Renal Life Cycle Trial I. Will SGLT2 inhibitors be effective and safe in patients with severe CKD, dialysis, or kidney transplantation. Clin J Am Soc Nephrol. 2023;18(11):1500-2.Ujjawal A, Schreiber B, Verma A. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) in kidney transplant recipients: what is the evidence? Ther Adv Endocrinol Metab. 2022;13:20420188221090001.McCoy RG, Dykhoff HJ, Sangaralingham L, Ross JS, Karaca-Mandic P, Montori VM, et al. 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Documento de consenso sobre nuevas terapias para retrasar la progresión de la enfermedad renal crónica con énfasis en los iSGLT-2: implicaciones para Latinoamérica

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