Thousands Are Dying of Chronic Kidney Disease in Central

Thousands Are Dying of Chronic
Kidney Disease in Central America:
“The Malady of the Sugar Cane”
Presented by: Community Health International Medical
Projects for Sustainability (CHIMPS) – Salud Comunitaria
Internacional, Proyestos Médicos para Sostenibilidad
Mission : To cultivate sustainable public health
interventions in partnership with underserved communities
in developing countries through collaborative education
Reuter’s Video
Deaths from Chronic Kidney Disease
Increased between 2005 and 2009
Deaths in 2009 and increase in mortality rate over 4 years from 200509 Map/data from:
El Salvador
has highest
mortality from
Disease (CKD)
in world!
CKD 2nd leading
cause of death in
men ages 20-60
in El Salvador
• Jesus Sosa Mancia, a CKD
patient in Bajo Lempa, at home
visit by a medical team from
the national health ministry.
Sasha Chavkin/ICIJ
Social Cost is Enormous & Increasing
• Renal dialysis and
transplant limited
availability, costly
• Families left without
financial support…”isla
de viudas” in Nicaragua
• Loss of large portion of
population in their most
productive years
Silent Disease Until Kidneys Fail
• Hard to prevent as
symptoms do not develop
until kidneys failing
• Generalized skin itching
• Weakness
• Fatigue and inability to
carry out activities of
daily living
• Blood & urine tests can
detect it earlier
Damage is primarily to kidney tubules
Two main causes of kidney
tubule damage:
• Decreased blood flow
most commonly from
• Exposure to toxins
No evidence that this form
of CKD is related to
hypertension, obesity or
diabetes as in the US
Limited Investigations Started in 2009
• Mainly found in sugar
cane & cotton workers
but also in construction,
mining, shipping
• Associated with lower
elevation communities
(cane workers at higher
elevations without CKD)
• Similar disease in Sri
Lanka, India, Egypt
• Funeral in Costa Rica of
sugar cane worker
Epidemic heavily focused in
communities on Pacific side
From Brooks DR, Ramirez-Rubrio O, Amadar JJ. CKD in Central America:
A Hot Issue. Am J Kidney Dis 2012; 59:481-484.
Kidney Injury Associated with Years of Work
Peraza S et al, Decreased kidney function among agricultural workers in El Salvador
Am J Kidney Dis 2012; 59:531-540
Possible factors studied that are not
single causes of this epidemic of CKD
• Heavy metals: lead,
• Arsenic (common in
volcanic soil/cotton )
• Agrichemicals properly
• Leptosporosis
• Medications: pain meds
(NSAIDs) and certain
• Alcohol
Several Factors Combined May Cause
Chronic Kidney Disease
• Heat exposure and
exhaustion – paid by
weight of cane cut
• Pesticides
– Direct contact
– Water contamination
• Predisposition due to
– Intrauterine stress
– Acute kidney injury in
– ? Genetic factors
Causes from Perspective of Workers
and Central American Doctors
• Dr. Carlos Orantes.
“There are 3 factors:
prohibited pesticides,
combinations of
pesticides and no
protection from
• Lack of any regulation for
worker protection from
• Concern about water
contamination by agrachemicals
Photo from:
Prevention And Interventions
From Levey AS, Stevens LA, Coresh J. Conceptual Model of CKD: Applications and
And Implications. AJKD 2009; 53: S4-S16
What has been done to control this
epidemic in effected countries?
• Sri Lankan gov’t & WHO
conducting large study
• In CA, only 2 scientific
conferences, one in
2005 and fall of 2012
• In ES, MOH focus on
PAHO to make major
health concern;
Nefrolempa pilot study
on coast
• MOH of El Salvador
with El Salvador &
Cuban physicians
reviewing pilot study
Rise in Latino Immigrants in End Stage
Kidney Disease in US
• Increase in Latino
immigrants needing
dialysis in US
• University Medical Center
in Las Vegas spent $24
million on emergency
dialysis treatment for 80
patients in 2010…most
undocumented and
without medical
What can we do from US?
• 1/4th of US sugar imported from CA
• Educate the public/members of your
groups about the CKD epidemic
• Look at sources of sugar you buy. Urge
Puget Consumer Co-op, Trader Joe,
Whole Foods, Safeway, etc to find out
– Do growers have workers with CKD?
– Do workers have breaks & hydration?
– Are workers protected from pesticides?
• Put pressure on World Bank/IMF to force
growers to change work conditions:
Compliance Advisor/Ombudsman Office
Demand Funding for Rigorous
Research to Find Main Causes
• Need a large and well designed case-control
• Urge research and forums by:
– Pan American Health Organization
– World Health Organization
• Support surveillance for kidney injury in
workers and longitudinal studies
• Studies done to date funded by Cuba, Sweden
Conduct Education About Prevention
with Latino Communities in US & CA
• Protection from
agrichemicals when
• Avoidance of medications
that cause kidney injury
• Promote good hydration
while working
• Avoidance of water and
food contamination by
chemicals that can harm
Sources of more information
• (video)
• Ramirez-Rubrio O, McClean MD, Amador JJ, Brooks DR. An
epidemic of chronic kidney disease in Central American, an
overview: J Epidemiol Community Health 2013; 67: 1-3
• Brooks DR, Ramirez-Rubrio O, Amadar JJ. CKD in Central America: A
Hot Issue. Am J Kidney Dis 2012; 59:481-484.
• Peraza S et al, Decreased kidney function among agricultural
workers in El Salvador. Am J Kidney Dis 2012; 59:531-540
• Orantes CM et al. Chronic kidney disease and associated risk factors
in the Bajo Lempa region of El Salvador: Nefrolempa study 2009.
MEDICC Review 2011, 14-22.

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