RESUMEN
Over the last 20 years, many reports have described an excess of cases of chronic kidney disease (CKD) in the Pacific coastal area of Central America, mainly affecting male farmworkers and signaling a serious public health problem. Most of these cases are not associated with traditional risk factors for CKD, such as aging, diabetes mellitus, and hypertension. This CKD of nontraditional causes (CKDnT) might be linked to environmental and/or occupational exposure or working conditions, limited access to health services, and poverty. In response to a resolution approved by the Directing Council of the Pan American Health Organization (PAHO) in 2013, PAHO, the U.S. Centers for Disease Control and Prevention, and the Latin American Society of Nephrology and Hypertension (SLANH) organized a consultation process in order to expand knowledge on the epidemic of CKDnT and to develop appropriate surveillance instruments. The Clinical Working Group from SLANH was put in charge of finding a consensus definition of a confirmed clinical case of CKDnT. The resulting definition establishes mandatory criteria and exclusion criteria necessary for classifying a case of CKDnT. The definition includes a combination of universally accepted definitions of CKD and the main clinical manifestations of CKDnT. Based on the best available evidence, the Clinical Working Group also formulated general recommendations about clinical management that apply to any patient with CKDnT. Adhering to the definition of a confirmed clinical case of CKDnT and implementing it appropriately is expected to be a powerful instrument for understanding the prevalence of the epidemic, evaluating the results of interventions, and promoting appropriate advocacy and planning efforts
En los 20 últimos años, en muchos informes se ha descrito un número inusual de casos de enfermedad renal crónica (ERC) en la costa del Pacífico de Centroamérica, que afecta principalmente a trabajadores agrícolas varones y señala un grave problema de salud pública. La mayoría de estos casos no se asocia con los factores de riesgo tradicionales de ERC, como envejecimiento, diabetes mellitus e hipertensión. Esta ERC de causas no tradicionales (ERCnT) podría estar vinculada con la exposición laboral o ambiental o las condiciones de trabajo, el escaso acceso a los servicios de salud y la pobreza. En respuesta a una resolución aprobada por el Consejo Directivo de la Organización Panamericana de la Salud (OPS) en el 2013, la OPS, los Centros para el Control y la Prevención de Enfermedades de los Estados Unidos y la Sociedad Latinoamericana de Nefrología e Hipertensión (SLANH) organizaron un proceso de consulta para ampliar los conocimientos sobre la epidemia de ERCnT y elaborar instrumentos apropiados para la vigilancia. El Grupo Clínico de Trabajo de la SLANH tuvo la responsabilidad de consensuar una definición de caso clínico confirmado de ERCnT. En la definición resultante se establecen criterios obligatorios y criterios de exclusión necesarios para clasificar un caso como de ERCnT. La definición incluye una combinación de definiciones de ERC universalmente aceptadas y las principales manifestaciones clínicas de ERCnT. Sobre la base de los mejores datos científicos disponibles, el Grupo Clínico de Trabajo también formuló recomendaciones generales acerca del manejo clínico, que se aplican a cualquier paciente con ERCnT. Se espera que la adopción de la definición de caso confirmado de ERCnT y su aplicación adecuada sean una herramienta poderosa para conocer la prevalencia de la epidemia, evaluar los resultados de las intervenciones y promover acciones apropiadas de sensibilización y planificación.
Asunto(s)
Insuficiencia Renal Crónica , Enfermedades de los Trabajadores Agrícolas , Epidemiología , Conferencia de Consenso , América Central , Insuficiencia Renal Crónica , Enfermedades de los Trabajadores Agrícolas , Epidemiología , Conferencia de Consenso , América CentralRESUMEN
BACKGROUND: The widely recognized clinical and epidemiological relevance of the socioeconomic determinants of health-disease conditions is expected to be specifically critical in terms of chronic diseases in fragile populations in low-income countries. However, in the literature, there is a substantial gap between the attention directed towards the medical components of these problems and the actual adoption of strategies aimed at providing solutions for the associated socioeconomic determinants, especially in pediatric populations. We report a prospective outcome study on the independent contribution and reciprocal interaction of the medical and socioeconomic factors to the hard end-point of mortality in a cohort of children with chronic kidney disease in Nicaragua. METHODS AND FINDINGS: Every child (n = 309) diagnosed with chronic kidney disease (CKD) and referred to the tertiary unit of Pediatric Nephrology in Managua (Nicaragua) from a network of nine hospitals serving 80% of the country's pediatric population was registered between January 2005 and December 2013. The three main socioeconomic determinants evaluated were family income, living conditions and the family's level of education. Further potential determinants of the outcomes included duration of exposure to disease, CKD stage at the first visit as suggested by the KDOQI guidelines in children, the time it took the patients to reach the reference centre and rural or urban context of life. Well-defined and systematically collected medical and socioeconomic data were available for 257 children over a mean follow-up period of 2.5±2.5 years. Mortality and lost to follow-up were considered as outcome end-points both independently and in combination, because of the inevitably progressive nature of the disease. A high proportion (55%) of children presented in the advanced stages of CKD (CKD stage IV and V) at the first visit. At the end of follow-up, 145 (57%) of the 257 cohort children were alive, 47 (18%) were lost to follow-up and 65 (25%) had died. Cox regression analysis showed an independent contribution to mortality of CKD stage at diagnosis and of level of education, with overlapping HR values (HR and 95%CI: 2.66; 1.93-3.66 and 2.72; 1.71-4.33, respectively). CONCLUSIONS: The unfavourable socioeconomic and cultural background of the pediatric study cohort and the severity of kidney damage at diagnosis were the key determinants of the clinical risk conditions at baseline and of the mortality outcome. Long-term structural interventions on such backgrounds must be adopted to assure effectiveness of medical care and to assure an earlier diagnosis of CKD in these patients. The translation-extension of our results is currently underway with an agenda which includes: 1) better integration of chronic pediatric conditions into primary care strategies to promote prevention and early timely referral; 2) the consideration of socioeconomic conditions as a mandatory component of the packages of best-care; 3) the formulation and flexible adaptation of guidelines and educational programs, based on the information generated by a context-specific, epidemiological monitoring of needs and outcomes, guaranteed by an effective database.
Asunto(s)
Mortalidad del Niño , Países en Desarrollo/economía , Renta , Insuficiencia Renal Crónica/epidemiología , Insuficiencia Renal Crónica/mortalidad , Niño , Femenino , Humanos , Perdida de Seguimiento , Masculino , Nicaragua , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Factores Socioeconómicos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Over the last 20 years, many reports have described an excess of cases of chronic kidney disease (CKD) in the Pacific coastal area of Central America, mainly affecting male farmworkers and signaling a serious public health problem. Most of these cases are not associated with traditional risk factors for CKD, such as aging, diabetes mellitus, and hypertension. This CKD of nontraditional causes (CKDnT) might be linked to environmental and/or occupational exposure or working conditions, limited access to health services, and poverty. In response to a resolution approved by the Directing Council of the Pan American Health Organization (PAHO) in 2013, PAHO, the U.S. Centers for Disease Control and Prevention, and the Latin American Society of Nephrology and Hypertension (SLANH) organized a consultation process in order to expand knowledge on the epidemic of CKDnT and to develop appropriate surveillance instruments. The Clinical Working Group from SLANH was put in charge of finding a consensus definition of a confirmed clinical case of CKDnT. The resulting definition establishes mandatory criteria and exclusion criteria necessary for classifying a case of CKDnT. The definition includes a combination of universally accepted definitions of CKD and the main clinical manifestations of CKDnT. Based on the best available evidence, the Clinical Working Group also formulated general recommendations about clinical management that apply to any patient with CKDnT. Adhering to the definition of a confirmed clinical case of CKDnT and implementing it appropriately is expected to be a powerful instrument for understanding the prevalence of the epidemic, evaluating the results of interventions, and promoting appropriate advocacy and planning efforts.