An analysis of the gap between available healthcare services and deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua

Mireille Levy-Culminating Experience
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Boston University School of Public Health
Department of Global Health and Development
Culminating Experience Cover Page
Name: Mireille Levy
CE Advisor: James Wolff
Culminating Experience Paper Title: An analysis of the gap between available healthcare services and
deficiencies in care and treatment among patients with Chronic Kidney Disease in Chinandega and León,
Nicaragua
Abstract
Currently, there is an epidemic of Chronic Disease of unknown causes (CKDu) in the farming
communities of Chinandega and León, Nicaragua. An increase in the incidence rate of CKDu over the past decade
have resulted in increases in patient demand for specific services and treatment beyond what the government is
able to sufficiently provide. El Ministerio de Salud (MINSA) in Nicaragua has responded by developing the
Norma y Protocolo Para El Abordaje De La Enfermedad Renal Crónica, a medical provider protocol guideline
for early detection, treatment and management of patients with CKD/u1
and by building sub-clinics that
specializes in CKD/u in high impact areas. However, quality and access to care and treatment for CKD/u is
compromised by a set of systemic issues arising from resource shortages, lack of programming and poor
implementation of key initiatives by MINSA and sub agencies. This paper discusses systemic issues that
undermine the quality of patient care, the economic impact of CKDu on Nicaragua’s healthcare system, medical
resource shortages and patient barriers to care in areas most affected.
To address these issues, I suggest that MINSA create a CKDu Task Force that collaboratively provides
recommendations to improve dissemination, training and provider education on the CKD protocol guideline and
to address areas of unmet needs and service gaps that improve the quality of care and health outcomes among
patients with CKD/u.
1
CKD/u is used in instances where the context applies to both CKD and CKDu patients.

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TABLE OF CONTENTS
Section PAGE
Glossary ........................................................................................................................................................ 3
Introduction................................................................................................................................................... 4
Chronic Kidney Disease (CKD ................................................................................................................. 4
Standard Methods of Diagnosis.................................................................................................................... 5
Blood Tests....................................................................................................................................... 5
Urine Tests....................................................................................................................................... 5
Epidemiology................................................................................................................................................ 6
Identified Risk Factors for CKDu................................................................................................................. 6
Occupational Risk Factors .............................................................................................................. 6
Environmental Risk Factors ............................................................................................................ 7
Pharmaceutical Risk Factors........................................................................................................... 7
Behavioral Risk Factors .................................................................................................................. 8
Healthcare System Structure in Chichigalpa, Chinandega ........................................................................... 8
Systemic Issues That Compromise Quality of Patient Care ......................................................................... 9
Physician Protocols for CKD/u Diagnosis and Treatment.............................................................. 9
Absence of Provider Education: A departure from standard methods of diagnosis and patient education10
Barriers to Patient Care............................................................................................................................... 11
Transportation Barriers................................................................................................................. 11
Renal Replacement Therapy Barriers............................................................................................ 11
Medical Services Capacity at the JD Health Center ................................................................................... 13
Infrastructure................................................................................................................................. 13
Organization of Health Service ..................................................................................................... 13
Equipment and Supplies................................................................................................................. 15
The CKD Task Force.................................................................................................................................. 15
CKD Task Force Staff Support ...................................................................................................... 16
Task Force Members...................................................................................................................... 16
The Division of General Health Services....................................................................................... 17
The Division of Financial Administration ..................................................................................... 17
The Division of General Medical Supplies .................................................................................... 17
The Division of Procurement for Medicines.................................................................................. 18
The National Diagnostic and Reference Center ............................................................................ 18
The Division of Teaching and Research ........................................................................................ 18
Hospital Directors ......................................................................................................................... 18
Clinic Managers ............................................................................................................................ 19
SME’s............................................................................................................................................. 19
Preliminary Planning..................................................................................................................... 19
Initial Meeting and planning ......................................................................................................... 19
Moving Forward............................................................................................................................ 20
Conclusion .................................................................................................................................................. 20
Bibliography ............................................................................................................................................... 21

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GLOSSARY
1. ADP - Automatic Peritoneal Dialysis
2. ANF - The American-Nicaraguan Foundation
3. CAPD - Continuous Ambulatory Peritoneal Dialysis
4. CAO - The Office of the Compliance Advisor/Ombudsman
5. CKD – Chronic Kidney Disease
6. CKDu – Chronic Kidney Disease of Unknown Causes
7. CKD/u – Chronic Kidney Disease and Chronic Kidney Disease of Unknown Causes2
8. DGFA - The Division of General Financial Administration
9. DGHS - The Division of General Health Services
10. DGMS - The Division of General Medical Supplies
11. DPM - The Division of Procurement for Medicines
12. DTR - The Division of Teaching and Research
13. GFR - Glomerular Filtration Rate
14. HD - Hemodialysis
15. HEODRA - Hospital Escuela Oscar Danilo Rosales Argüello
16. IFC - the International Financial Corporation
17. JD - The Julio Duran Health Center
18. MIGA - Multilateral Investment Guarantee Agency
19. MINSA – El Ministerio de Salud
20. MOH – Ministry of Health
21. NDRC - The National Diagnostic and Reference Center
22. NSAIDs - non-steroidal anti-inflammatory drugs
23. PD – Peritoneal Dialysis
24. SMEs – Subject Matter Experts
2
CKD/u is used in instances where the context applies to both CKD and CKDu patients.

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Date : November 28th, 2016
To :El Ministerio de Salud (MINSA), Nicaragua
From : Mireille Levy
Boston University School of Public Health MPH Candidate
RE : An analysis of the gap between available healthcare services and deficiencies in care and treatment
among patients with Chronic Kidney Disease in Chinandega and León, Nicaragua
Introduction
A rise in the incidence rate of Chronic Kidney Disease of unknown causes (CKDu) in Chinandega,
Nicaragua over the past decade have resulted in increases in patient demand for specific services and treatment
beyond what the government is able to sufficiently provide thus undermining the quality and accessibility to care
and treatment for patients with CKDu. Key initiatives by Nicaragua’s ministry of health (MOH), MINSA, to
address this issue, such as the development of the Norma y Protocolo Para El Abordaje De La Enfermedad Renal
Crónica, a medical provider protocol document for early detection, treatment and management for patients with
CKD/u and by building sub-clinics that specializes in CKD/u in high impact areas have fallen short of meeting
patient demand for care and treatment and ensuring that patients are receiving quality care in Chinandega and
León. Reasons for this is primarily due to resource shortages, lack of programming and poor implementation
strategies by MINSA and sub agencies.
The purpose of this paper is to discuss systemic issues that compromise the quality of patient care, the
economic impact of CKDu on Nicaragua’s healthcare system, medical resource shortages and patient barriers to
care in the most affected areas. Additionally, a policy recommendation is provided to offer an approach to address
these areas of concerns as a Public Health community in the departments of Chinandega and Léon, Nicaragua.
Information used to write this paper is from a literature review, an in-depth interview with a medical doctor
employed at the Hospital Escuela Oscar Danilo Rosales Argüello (HEODRA), multiple needs assessment reports,
and government documents published by the Nicaraguan Ministry of Health (MOH), MINSA.
Chronic Kidney Disease (CKD)
CKD is progressive loss of kidney function over time. The primary function of the kidneys are to remove
waste product from the blood. Urine created during this process is collected in the kidney, transported to the
bladder and excreted from the body [13]. Each kidney has several renal pyramids which contain a renal medulla
composed of about a million nephrons. Each nephron includes a glomerulus which is a microscopic blood filter.

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Damage to the glomerulus results in a lower filtration rate [15]. The National Kidney Disease Foundation defines
chronic kidney disease as either Glomerular Filtration Rate (GFR) <60 mL/min/1.73 m2
for ≥ 3 months [15].
Standard Methods of CKD Diagnosis
Bio-markers of kidney damage can be identified through blood tests, urine tests, diagnostic imaging or
kidney biopsy [13]. Calculating a patient’s GFR is the standard method for diagnosing a patient with CKD
however other tests should be conducted and compared to detect CKD.
Blood tests
A rapid creatinine test is normally conducted to determine kidney function because it is used to calculate
GFR. When damaged the kidneys cannot remove the body’s load of creatinine from the blood and the level in the
blood rises. Normal creatinine levels range from .5-1.21, this includes ranges for both males and females. A
creatinine test result higher than 1.21 may indicate kidney disease, acute kidney failure or other conditions such
as dehydration, low blood volume, or a meat heavy diet. Elevated creatinine levels should be confirmed either by
a repeated rapid test or a lab test. If results continue to show an elevated level of creatinine, then other tests should
be conducted to confirm the diagnosis of kidney disease.[16].
A BUN test is another way to check how well the kidneys are functioning by measuring the amount of
urea nitrogen in the blood. Healthy adults have a BUN result between 7-20 mg/dL, higher levels of urea nitrogen
in blood may suggest that the kidneys are not working properly [18].
Urine tests
Another efficient method for diagnosing individuals with kidney disease in a low resource setting, like
Nicaragua, is by a multi-reagent dipstick urine test to examine uric acid and albumin. Uric acid is produced from
broken-down cells and other purines and passes from the body during urination. Normal values range from 250
to 750 mg per 24 hours and low levels may indicate that the kidneys are unable to filter uric acid from the body
causing the substance to be retained in the blood stream.
Additionally, albumin can detect kidney disease. An excess amount of albumin in urine is called
albuminuria and indicates that the kidneys are leaking large molecules into urine, however albuminuria also
occurs in individuals with long-standing diabetes, usually type I, hypertension or a recent episode of high level
activity, such as labor intensive work common among young men in rural Nicaragua [22].

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Based on recommendations by the Clinic Reference Laboratory and the National Kidney Foundation, creatinine,
BUN, albumin and uric acid results should be compared and if each result is abnormal, then there is a high
probability that kidney function is impaired [14]. Additionally, it is recommended that an ultrasound be conducted
for differential diagnosis and to assess disease progression, if present, as a supplement to a patient’s GFR.
Epidemiology
Several case reports and published research studies over the past two decades indicate that an epidemic of
CKDu is occurring among agriculture communities in Nicaragua [1,3-11,23-24]. Information generated from
these studies suggest that patients share common demographic characteristics; this condition primarily affects
young males working in agriculture and who live along the pacific coast [1-5,7-9, 23-24] A community prevalence
study conducted among males working in pacific coastal areas in Nicaragua found an estimated CKDu prevalence
of 13.8% [5].
CKDu community prevalence studies have largely been focused in the department of Léon and Chinandega; the
areas with the highest CKDu prevalence in Nicaragua [3, 5-6]. The mortality rate among males age 35-55 years
in Chichigalpa, Chinandega is about five times as high as the national mortality rate [23]. La Isla Foundation, a
non-profit policy and research group reported that between 2002-2012, 75% of deaths among males age 35-55
years in Chichigalpa, Chinandega was due to CKDu [23]. In 2007, the mortality rate of CKD was 5.3 and 5.2 per
10,000 residents in Léon and Chinandega respectively [3]. Between 2004 and 2010 the total number of newly
registered CKD/u cases in the same community rose from 799 to 2,073 cases indicating an average increase of
212 new cases per year [3]. Among the 2,073 registered patients, 9% (183) are stage 0, 16% (332) are stage 1,
21% (428) are stage 2, 35% (726) are stage 3, 14% (291) are stage 4, and 4% (85) are in stage 5 [3].
Identified Risk Factors for CKDu
Several assessment studies conducted in Chinandega and Léon suggest an association between the
development of CKDu with behavioral, environmental, pharmaceutical and occupational exposures [1-4,6-13];
though the true cause of CKDu remains unknown there are several hypothesized risk factors by exposure category.
Occupational risk factors
Mortality data and community prevalence studies found that CKDu occurs primarily among young men
who work in farming. Prolonged exposure to heat and a heavy workload in combination with excess volume

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depletion and dehydration among agriculture workers are considered to be risk factors for CKDu [9]. Sugar cane
workers comprise the majority of patients with CKDu, although cases have been reported among miners,
construction workers and bricklayers [4, 9, 23-24].The departments of Chinandega and Léon, those with the
highest prevalence and mortality rate of CKDu, also host the country’s largest sugar cane plantation and are the
area’s largest employer [1,3,5-6, 23]. Individuals employed to either plant seeds or apply agrichemicals are also
at an increased risk for developing CKDu compared to workers who drive trucks or sort harvested crops on the
same farm [24]. One report found that nearly 70% of sugarcane workers in Chinandega developed CKDu [24]. A
study conducted by Raines et al. assessed potential risk factors associated with agricultural work. Age and sex
adjusted binomial logistic regression analysis of reduced GFR, measured as <60 mL/min/1.73 m2 found that the
odds of developing CKDu among men who indicated >365 lifetime days of harvesting crops were 431% more
than among men who reported less than 365 lifetime days of harvesting crops. (OR 4.31, 95% Cl 1.76-10.52).
Moreover, the odds of developing CKDu among men who reported any lifetime history cutting sugarcane during
the dry season were 586% higher than men who have never cut sugarcane during the dry season (OR 5.86, 95%
Cl 2.45-14.01).
Environmental risk factors
Exposure to heavy metals through contaminated surface dirt and drinking water, pesticides and
agrichemicals have been investigated in several studies. Exposure to pesticides when harvesting personal crops
for consumption and resale is also common among residents in rural communities [1, 8, 24]. A study conducted
by Raines et al assessed exposures to CKDu as potential causal mechanisms found that men who reported inhaling
pesticides from either work or personal use have a 331% higher odds of developing CKDu compared to men who
are not exposed to pesticides in the form of aerosols (OR 3.31, 95% Cl 1.32-8.31).
Pharmaceutical
Chronic and over prescribed use of non-steroidal anti-inflammatory drugs (NSAIDs) are included in the
list of hypothesized risk factors for CKDu [9, 11]. 19 Semi-structured interviews conducted with physicians and
retail pharmacies found that farm workers often suffer from chronic back and muscle pain. These workers
regularly visit their local pharmacy to purchase medications for pain relief. Prescriptions for NSAIDs are not
required in Nicaragua and these medicines are considered to be affordable by residents. A review of median
prices for two frequently consumed NSAIDs in Nicaragua from a WHO/HAI survey conducted in 2008 (adjusted

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for 2016 inflation) reported private sector consumer prices for both Ibuprofen 400mg cap/tab and Diclofenac
50mg cap/tab to be 0.11 USD. Even with a salary of 3-5 USD per day, NSAIDS to treat pain as a result of
strenuous working conditions is considered to be affordable to local residents and may be subject to abuse. In the
public sector, patients at health facilities receive NSAIDS at no charge.
Behavioral risk factors
Alcohol consumption and fructose intake are additional risk factors that have been investigated in multiple
research studies that relate to behavioral exposures [10, 11].A study conducted by Raines et al. assessed potential
risk factors associated with sugar consumption and traditional risk factors for renal failure among individuals with
an occupational history in agriculture. Age and sex adjusted binomial logistic regression analysis of reduced GFR,
measured as <60 mL/min/1.73 m2, found that participants who identified as being a male (OR 6.1, 95% Cl 2.34-
18.74), indicated current or past alcohol consumption (OR 3.25, 95% CI 1.36-7.85) and/or cane chewing (OR
3.24, 95% Cl 1.39-7.58 ), had a significantly higher odds of being diagnosed with CKDu compared to participants
who did not share these characteristics. CKDu is considered to be an unknown type of renal failure primarily
because it does not share the same etiological factors as patients with reduced GFR in developed countries such
as the United States.
In traditional CKD, males and females have similar odds of developing this disease and individuals are
more likely to be diagnosed as they grow older. Further, renal diseases tend to occur in patients who present with
hypertension and diabetes mellitus type II. However, Raines et al. measured hypertension and diabetes among
their participants as an independent variable and found both these characteristics to be an insignificant contributor
to CKDu among the participants in their study [8].
Healthcare System Structure in Chichigalpa, Chinandega
Primary and secondary services for care and treatment of CKD/u are provided free of charge to patients
by MINSA [3]. Chichigalpa is the largest town in Chinandega with a total population of about 46,455, of which
26% live in rural areas. A total of 10 health centers serve about 8,166 people while the rest are served at health
posts.
The Julio Duran (JD) Health Center in Chichigalpa provides primary care services for CKD patients while
secondary medical services are available at Hospital España in Chinandega and at HEODRA in Léon. Local
residents account for 90% of registered cases while the remaining resides in other departments.

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Systemic Issues that Compromise Quality of Patient Care
Physician Protocols for CKD/u Diagnosis and Treatment
A major issue that clinicians continue to face is a lack of protocols for evaluating, diagnosing, and
monitoring patients with CKD/u. Several reports and discussions with medical providers prior to 2009 mentioned
that until a set of treatment guidelines are published by MINSA, patients will continue to be managed based on
different criteria determined by individual general physicians [3]. In 2009, MINSA published their first rules and
protocol guidelines for clinicians on the prevention, collection, and management of patients with CKD. This
guideline essentially acknowledges CKD as a serious public health issue, outlines the epidemiology of this disease
in Nicaragua, and standardizes medical definitions, formulas for calculating GFR, and test result ranges related
to CKD/u. Also included are protocol compliance indicators for data collection, prevention and management of
CKD, standardized forms to record patient information and tests results, and formal protocols for diagnosing
patients with CKD/u. The guideline also provides guidance on determining disease stage, standardized follow-up
periods, including a detailed plan of action for each follow up appointment by disease stage, and CKD risk factors
depending on the patient’s health status [6].
Despite their criticism of a lack of coordinated effort to integrate a CKD protocol into their healthcare
system, providers are not using MINSA’s protocol guideline to diagnose, treat and monitor patients with CKD/u.
The main reasons for poor compliance among medical providers are due to a lack of awareness that a protocol is
available, deficiencies in education for medical providers about diagnostics methods, patient monitoring and care
coordination for patients with CKD, geographical displacement, poor compliance monitoring by MINSA, and a
primarily older physician population3
.
Specifically, providers are not aware that a protocol has been published because the protocol guideline is
only available online and must be downloaded and printed in order to disseminate it around a health clinic and
MINSA has not distributed the protocols to medical providers at clinics that serve patients with CKD4
. This is a
barrier to providing quality care because most healthcare centers do not have a computer and printer on site and
the number of people who have laptops or desktop computers at home remains low in Nicaragua; consequently,
access to electronic information continues to be an issue.
3
Results from an IDI conducted with a medical doctor employed at HEODRA in León, Nicaragua
4

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In terms of geographical displacement, providers who care for CKD/u patients in rural areas don’t have
access to reliable or new information related to CKD5
. One major reason is because medical doctors in rural areas
tend to be older and do not have the technical capacity to visit the protocol online and are unwilling to change the
processes that they have been using to diagnose and monitor patients with CKD/u in their respective health clinic6
.
Absence of provider education: A departure from standard methods of diagnosis and patient education
Medical providers in the areas most affected, prevalence >10% in the Department of Chinandega, are not
receiving training specifically for CKD/u or on the protocol guideline resulting in a departure from standard
methods of diagnosing patients with CKD and deficiencies in patient education for personal care and treatment7
.
In Nicaragua, blood and urine tests are primarily used to diagnose patients with CKD because it is less
costly than diagnostic imaging or a biopsy. Providers in primary care clinics containing a sub-clinic specifically
serving CKD patients are relying on two rapid creatinine tests taken at two points in time to determine if a patient
presents with CKD. Additionally, some providers are not measuring and comparing other indicators of CKD such
as BUN or Albumin nor calculating GFR8
. Some medical providers are also unaware that they have to monitor
patients who either have an elevated creatinine level or a GFR between 60-90mL/min/1.73 m29
. The major
problem with this type of diagnosing method is that creatinine levels may change for a variety of reasons other
than kidney failure, such as strenuous labor which is common among male farmers in Nicaragua. The standard
definition for CKD, including staging of the disease is based on a patient’s GFR. Therefore, patients who present
with elevated levels of creatinine may be misdiagnosed with CKD if their GFR is not calculated or/and if the
physician does not conduct other tests that indicate CKD. Additionally, without calculating a patient’s GFR or
using diagnostic imaging, it’s unlikely that a physician will know the stage of disease progression.
Additionally, the lack of CKD training to medical providers undermines the quality of care and treatment
education to their patients. Education provided to diagnosed patients generally consist of a few general tips such
as to reduce salt intake and to drink cool liquids.10
The absence of education specificity during consultation and
supplemental materials to take home contributes to a patient’s lack of awareness about their condition and
5
Rural clinics rarely have internet connection and therefore rely on MOH outreach and provider-to-provider updates on published
information
6
7
8
9
10

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compromises their ability to appropriately care for themselves to reduce disease staging. For instance, some
patients diagnosed with stage 5 renal failure do not enroll into dialysis because they are unaware of the severity
of their condition and do not perceive that their need for renal dialysis to be urgent11
.
Barriers to patient care
Patients are only referred to a hospital when they are diagnosed with stage 5 kidney failure and require
dialysis therapy in order to survive. The cost of dialysis is covered entirely by MINSA 12
[4], however patients
often do not receive dialysis treatment because of transportation barriers, medical supply shortages at the hospital,
and lack of information provided to them about their condition.
Transportation barriers
As of 2011, Hospital España has already reached their capacity to provide dialysis, so the remaining
patients must visit HEODRA in León [3]. Taxi services from Chichigalpa to HEODRA in León cost about $800
Córdoba or $26 USD round trip. By bus the trip requires four buses for a total of $70 Córdoba or $2.50 round
trip. Bearing in mind that an average daily income for a farmer in this area is between $2-$5 USD, cost of
transportation is a barrier to treatment, especially if they are required to receive dialysis 3 times a week13
.
Renal replacement Therapy barriers
A medical needs assessment report of the Chichigalpa health center was conducted in 2010 that identified
poor and limited infrastructure, lack of trained personnel, shortage of dialysis supplies, lack of functioning
equipment, and insufficient funding sources from the government to pay for patient’s treatment costs to be the
primary barriers to patient access to dialysis. Peritoneal dialysis (PD) is the most common type of dialysis
treatment in Nicaragua because it is the least expensive option, though not necessarily affordable for the
government to cover.
For patients diagnosed with stage 5 renal failure, either a kidney transplant procedure or renal replacement
therapy, such as peritoneal or hemodialysis is required for the patient to survive.
11
12
13
This information was obtained from 2 farmers in Chinandega and the MD employed at HEODRA

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The cost of PD treatment is very costly for the government to cover [4]. In 2010, the initial cost of PD
catheters were US$600 plus US$900 a month per patient for treatment supplies and equipment totaling at about
$11,400 USD annually in a country that budgets to spend $445 on healthcare services and medication per capita
a year. Lastly, unpredictable shortages of essential supplies such as functioning equipment, dialysis fluid, and
other materials commonly occur within the Chichigalpa healthcare network, which contribute to patient barriers
to life saving treatment [3].
In contrast, HEODRA is able to provide nearly unlimited PD services to patients because they have a
contract with Baxter, a private international dialysis supply company. Moreover, Baxter trains nurses and doctors
at HEODRA on how to appropriately care for CKD patients and operate PD machines; this agreement is strictly
between Baxter and HEODRA, not with the Ministry of Health. Additionally, HEODRA also receives dialysis
supplies from The American-Nicaraguan Foundation (ANF). The problem is that these agreements do not service
the overall Public Health issue of CKDu, which are occurring among low-income and rural male farmers. For
instance, in 2010, HEODRA was providing PD treatment to 50 patients but only 10 were farmers while the
remaining were urban dwelling diabetic women [3]. Further, HEODRA is located in the city of Léon, about 1.5
hours from Chichigalpa by car and nearly twice as long by public transportation, further alienating those who
reside in Chinandega and need treatment the most.
Hemodialysis (HD) is another treatment option for individuals with stage 5 renal failure. It removes waste
products and free water from the blood and requires advance medical equipment, costly reagents, an outpatient
facility, specialized nursing and technical staff in order to provide quality treatment to patients and to ensure that
machines are calibrated. Patients with CKD stage 5 require 3-4 hour sessions 3 times a week. The cost of HD is
about $9,000 per patient annually in HEODRA and thus prohibitively costly for the government to cover based
on the national budget for health expenditure. Moreover in 2008 Hospital España, in Chichigalpa, received a
donation of 8 new HD machines but this health facility is not equipped with a cold storage room for supplies nor
an outpatient facility, therefore they are unable to provide any HD treatment to their patients [3].
Based on the results from a needs assessment report, it would make more sense from a financial
perspective for hospitals to cease PD dialysis and switch to HD dialysis therapy. The primary advantage, is that
Nicaragua’s healthcare system may save an average of $2,400 USD per patient annually when services with HD
dialysis compared to PD dialysis.

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Medical Services Capacity at the JD Health Center:
The Office of the Compliance Advisor/Ombudsman (CAO) is a group committed to responding and
resolving complaints by individuals, groups of people or organizations affected by projects conducted by the
International Financial Corporation (IFC) and Multilateral Investment Guarantee Agency (MIGA); essentially the
CAO promotes social and environmental accountability of IFC and MIGA. A medical needs assessment report
conducted by CAO evaluated the infrastructure, organization of health services, equipment and supplies related
to the ability to treat and monitor CKD/u patients in the department of Chinandega. The majority of CKD/u
patients in Chichigalpa receives their primary medical services form the Julio Duran Health Center; publically
funded by MINSA. As of 2010, the health center in Chichigalpa did not have sufficient amount of space, supplies,
equipment or personnel to meet the medical demands of their community residents including CKD/u patients.
Medical providers from this health center mentioned that a hygienic, comfortable, staffed and spacious
environment is necessary to deliver safe and quality medical care [1, 3].
Infrastructure
The JD health center consists of a small waiting room and two modest consultation rooms staffed by two
physicians. The waiting room was built to accommodate 15 patients, however there are usually about 40 patients
waiting to receive services at any point in time. The waiting room is not air conditioned, which may cause
discomfort for patients and pose additional risks for CKD/u patients. Patients, including those with CKD/u, are
examined and treated openly in front of other patients, compromising privacy and patient confidentiality. In
regards to unstable CKD/u patients, the JD health center has a small observation room but consists of only two
beds. Additionally, the clinic lacks a room to conduct care coordination services, health education discussions
for patients with chronic illnesses, and provider training and education sessions [4].
Organization of health service
CKD is a progressively fatal disease that requires early detection, monitoring, health education, and
medical treatment to prolong and improve the quality of life for a patient. In order to achieve this goal, the health
clinic needs to have a sufficient number of trained personnel, a feedback system for monitoring and evaluating
the quality of services, ancillary services, a stocked pharmacy, patient counseling services and other informational
resources [3].

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As of 2010, the JD consisted of a small CKD clinic staffed by a single nephrologist and an internal
medicine physician whom are responsible for providing treatment and monitoring services for about 2,073 known
registered CKD patients. The CKD clinic provides services from 8:00 am - 3:00 pm Monday-Friday which
includes 1 hour dedicated only to administrative responsibilities. Together these physicians consult about 700
CKD/u patients per month or 40-50 CKD/u patients per day [3]. Consequently, each patient only spends a few
minutes with a physician, an insufficient amount of time for a complex chronic disease that requires consultation
on medication and nutrition, blood and urine tests for monitoring disease progression, discussion of associated
signs and/or symptoms and a primary physical. Moreover, dietary and other type of counseling services such as
health education are necessary for CKD patients, especially for those who are in the later stages of the disease.
The JD Health Center does not have a nutritionist or a social workers on site; therefore CKD patients must seek
ancillary services at Hospital España in Chinandega. Patient appointments are scheduled based on creatinine
levels and care is limited after normal operating hours which is especially dangerous for CKD/u patients who are
either unstable or at the later stages of the disease. Some medical doctors disagree with this mechanism for
organizing medical appointments because several other factors can influence the result of a rapid creatinine test,
such as recent use of medication, high level activity or dehydration, which is common among residents of rural
communities [3].
Additionally, the availability of palliative services for CKD patients, especially those who are in stage 5,
is also concerning as the JD Health Center and most health facilities in Nicaragua completely lack a palliative
care program. Palliative programs are essential for the continuum of care as it providers physical and emotional
support to alleviate pain and suffering for both the patients and their families through the dying process. Currently,
the demand for palliative programs is low among patients and medical providers primarily because other priorities
have been set, lack of patient awareness about the disease and the meaning of palliative care remains low in
Nicaragua [3].
Another essential feature for evaluating the organization and quality of healthcare services are feedback
systems. Feedback systems monitor and evaluate the capacity of the healthcare facility, health staff availability
and quality of care provided to the patient by the provider. It can also identify problems in the delivery of care in
order to take effective corrective action. Feedback systems guided by a set of protocols, such as those produced
by MINSA in 2009, are useful to reduce medical complications, improve health outcomes, and increase the quality
of healthcare services while minimizing costs. In regards to CKD, a clinical feedback system can address
problems that patients have specifically mentioned such as scheduling availability, short appointment times,

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medication and reagent shortages, and low patient satisfaction based on the quality of care they receive. To the
knowledge of both the medical doctor that was interviewed and the assessment reports that were reviewed,
MINSA has not implemented a feedback system between rural clinics, community health centers and hospitals to
monitor and refer CKD/u patients to other health facilities.
Equipment and supplies
The JD Health Center medical needs assessment conducted by CAO also analyzed equipment and
materials required to properly treat CKD/u patients. Although the JD Health Center is sufficiently supplied with
staffing and administrative materials, the report indicated a serious shortage of medical supplies and equipment
required to monitor patients or test those that present with symptoms and characteristics of CKD/u. For instance,
diagnostic reagents and a small refrigerator to store urine and blood samples were missing. Reagents are a
component to diagnosing patients with CKD while blood and urine samples must be stored in a refrigerator unless
they are processed within an hour14
, else the samples will be compromised and will likely yield incorrect test
results.
Another issue the health center faces is the inability to provide emergency treatment for CKD/u patients
if necessary. According to the needs assessment report, the health center needs an EKG machine, an oxygen
delivery system, respirator, manometer, and a separate stock of emergency medications to provide emergency
services to unstable patients. These supplies are not available at this clinic and the pharmacy closes at 4:00 pm
during the week and is closed on weekends [3]. Therefore, unstable CKD patients who require emergency
attention must travel to either Hospital España or HEODRA and may be charged for ambulance fuel expenses,
which is an additional barrier to care and illegal15
.
The CKD Task Force
To improve provider compliance of the CKD protocol guideline and to recognize and work to address areas
of unmet healthcare need among patients with CKD/u, I recommend that MINSA create a stakeholder task force
to plan, organize and monitor the following initiatives in Chinandega and León:
14
Urine should be processed within an hour if not stored at 39o
F. Time to process blood if not sored in a refrigerator depends on
blood type.
15
Fuel expenses charged to the patient was mentioned in the needs assessment report and confirmed by MD that was interviewed
for this paper.

Page 16
1. Disseminate, train and improve compliance of the protocol guideline Norma y Protocolo Para El
Abordaje De La Enfermedad Renal Crónica or the Rules and Protocols for Approaching Chronic Renal
Disease in Chinandega, the area with the highest prevalence, incidence and death rate of CKDu.
2. Identify areas of unmet need, such as those mentioned above, and provide recommendations that
addresses those needs to improve the quality of care among patients with CKD/u.
The CKD task force’s intended primary outcomes include an increase in early detection rates, a reduction
in death rates of CKD through improved patient monitoring methods, provider compliance on the CKD protocol
guideline to achieve standard diagnostic methods across providers in high prevalence areas, and recognition of
major and minor medical and non-medical areas of unmet needs among patients with CKD and CKDu. These
objectives should be executed through the provision of informed recommendations to MINSA by the Task Force
members, or stake holders, and subject matter experts (SMEs).
CKD Task Force Staff Support
Implementing the task force requires administrative staff support to organize meeting locations, manage
updates, audio record the meetings, draft meeting minute notes, and supply administrative materials to task force
members and SMEs (agendas, writing utensils, and reports). Reports from respective members should be given
to the Task Force Staff Support team to manage and send out to other members. Ultimately, the task force staff
support is responsible for coordinating and managing the task force meetings, administrative materials and
correspondences among members. This team is critical to ensuring that the Task Force is well organized and able
to properly operate under changing circumstances among several stakeholders. Failure to properly organize a task
force and manage its cohesiveness through logistical and administrative planning can cause the initiative to
collapse early on and waste valuable resources in an already low-resource setting like Nicaragua.
Task force members
I recommend that MINSA officials draft a preliminary list of task force members to represent stakeholders
of this epidemic and SMEs to provide expert knowledge or technical assistance that facilitates informed
recommendations by members in Chinandega and León.

Page 17
MINSA can draft a stakeholder and a SME member list to contact and invite them to be a member of the
task force. I recommend that the following agencies should have representation on the task force, but to not limit
the number of agencies on the taskforce. 16
The Division of General Health Services (DGHS)
The DGHS is responsible for conducting needs assessment reports, collecting and presenting data to
stake holders, and developing strategy reports and protocol guidelines for health clinics [25]. A member from
this division can serve to help strategize how the protocol guideline is implemented to both urban and rural
health clinics.
The Division of Financial Administration (DGFA)
The DGFA is responsible for developing Nicaragua’s annual healthcare budget, allocating funds to health
facilities and monitoring health expenditures, among other duties [25]. Representation from the DGFA will help
direct the type of recommendations made based on available funds and willingness to change budget allocations
where needed by the DGFA.
1. Lic. Sergio Guerrero – Director
The Division of General Medical Supplies (DGMS)
The DGMS is responsible for managing the supply chain system for medical supplies in Nicaragua.
Their primary responsibilities are managing logistics and overseeing rational use of medical supplies. They
gather supply consumption information from health units to analyze the prescription, dispensing and use of
medical supplies. Further, they work to identify opportunities for improvement to implement recommendations
that optimize the use of medical supplies [25]. This paper mentions dialysis and other medical supply shortages
at specific clinics in Chinandega as a gap in medical care for CKD patients. Representation from this division
raises awareness to this issue and members can provide directed input for recommendations made to address
this issue.
16
Task force member names were obtained from the official Nicaragua Ministry of Health website at
http://www.minsa.gob.ni/index.php/directorio

Page 18
The Division of Procurement for Medicines (DPM)
MINSA works with the Division of General Procurements for Medicines who works with the Division
of Planning and Tracking Contracts and the Contracting Division to negotiate prices and purchase medicines
[25]. Medicine supply shortages data provided from medical needs assessment reports, health clinics and the
DGHS can be delivered to members of the DPM to encourage additional procurement of medicines for patients
with CKD as needed.
The National Diagnostic and Reference Center17 (NDRC)
The NDRC is responsible for handling confirmatory lab requests by smaller health clinics, to educate
health authorities, and guide laboratory directors and technicians to identify responsibilities and functions of
laboratory services. Further, they take into account priorities, needs and the local capacity of a health clinic to
conduct laboratory testing [25]. Representation by the NDRC will help to facilitate logistical planning and
implementing the portion of the CKD Protocol Guide that covers standardized diagnostic methods.
The Division of Teaching and Research (DTR)
The DTR is responsible for providing continuing education for providers, hospital management
education and social services for patients [25]. The division has published a series of continuing education
modules for providers but CKD is not among them. Representation from this division will assist in strategizing
how to implement continuing education on CKD for general physicians working at clinics in Chinandega and
León.
Hospital Directors
Patients who require dialysis services and treatment for disease complications are referred to a hospital for
care [3]. Needs assessment and other reports have indicated a dialysis supply shortage, a treatment necessary for
survival among patients with stage 5 CKD [3]. Hospital directors or their representatives are an important
stakeholder in regards to addressing treatment shortages as a care gap for patients with CKD. Their presence
will help the task force committee plan recommendations to address these issues that incorporate the needs and
perspectives of hospital directors or managers who have the authority to implement recommendations. Further,

Page 19
buy-in from hospital directors will be crucial for implementing a continuous training program on the CKD
protocol guidelines for providers in large hospitals. Below is the list of hospital directors.
1. Gaviota Sandoval Rodríguez - Hospital España
2. Dr. Ricardo Cuadra Solórzano – Oscar Danilo Rosales
3. Dra. Vera Mercedes Orozco Iglesias – Rosario Lacayo
Clinic Managers
Clinic administrators or managers from clinics that serve a large number of CKD patients in Chinandega
and León should be members of the task force as they are the front line care givers for patients with CKD. Input
from this group will facilitate the development of realistic recommendations and improve the likelihood that a
recommendation is successfully implemented in their respective clinics.
SME’s
SMEs serve the role of providing technical assistance and help inform recommendations to the task
force. An Epidemiologist specializing in kidney or Chronic diseases, a Nephrologist, and a health educator
should be included in the task force, but additional SMEs can be included depending on the need of the task
force. These members can be appointed by MINSA and asked to present at the first meeting.
Preliminary Planning
MINSA members should meet to discuss task force objectives and to develop a flexible timeline for the
taskforce (i.e. beginning to approx. end date). Task force member selection from each stakeholder group to be
the representative to the task force should also take place during this planning phase. Ideally, several members
from each stakeholder group are given the task force’s purpose, objectives and a formal invitation to participate
with the understanding that a number of invitees will decline the request.
Initial Meeting and Planning
Ideally, The CKD Task Force’s initial meeting should be attended by influential members of MINSA to
encourage awareness about the task force and demonstrate a sense of urgency towards the CKD epidemic in
Chinandega and León. Additionally, it would be ideal to have all meetings open to the public including a brief Q
& A session to allow members of the affected community or other individuals to softly participate. The initial

Page 20
meeting can be an introduction to the purpose and objectives of the task force and include presentations from
SMEs and MINSA about the epidemic to further familiarize stakeholders about the issue at hand and where they
fit in terms of addressing those objectives. Additionally, documents outlining specific objectives by MINSA to
address the two major objectives should be given to members of the task force.
Moving Forward
The remaining taskforce meetings should primarily be recommendation and implementation meetings.
Stakeholders should discuss their role and level of contribution to either or both objectives of the Task Force.
Planning meetings between staff support and MINSA should be conducted between The CKD Task Force
member meetings to review meetings minutes, delegate data and other type of requests between members, and
handle other logistical aspects of the CKD Task Force to improve the efficiency of each member meeting.
Conclusion
Over the past 6 years, the MOH, INSS and other health organizations such as non-profits and academic
institutions have responded to the increasing epidemic of CKD, both known and unknown causes, along the
pacific coastal regions of Nicaragua. Nicaragua has nearly doubled their per capita health expenditure from $232
USD in 2010 to $455 USD in 2016 and they have developed and released protocol guidelines for the detection,
treatment and monitoring of chronic kidney disease. However, there continues to be areas of weakness regarding
protocol implementation and provider compliance, equipment and supply shortages, medical provider education,
and patient awareness about chronic kidney disease. Several non-profit organizations have donated medical
equipment and supplies to healthcare facilities, such as the 8 HD machines to Hospital España, but this facility
lacks additional materials needed to expand their capacity to deliver renal replacement treatment. Additionally,
health clinics in general often experience shortages in reagents, other supplies and fuel for transportation.
Academic institutions, such as Boston University, have worked with several other groups to conduct
epidemiological studies, both cross sectional and longitudinal, to better understand the development of this
particular type of kidney disease and to offer technical assistance to MINSA, CAO and other organizations in
Nicaragua.
Medical provider non-compliance to a CKD protocol guideline, gaps in medical need and health
disparities among CKD patients is largely a systemic problem coupled with resource shortages in Nicaragua’s

Page 21
healthcare system. Addressing these issues require a collaborative and organized effort among MINSA agencies,
SME’s and members of the affected community. A CKD Task Force comprised of MINSA sub agency members,
SMEs, and members of the affected community is likely to raise awareness to the issues at hand. Moreover,
concerted efforts by staff support, MINSA, members and SME’s may generate realistic recommendations on how
to disseminate, train and improve compliance of the CKD protocol guideline to providers and address identified
areas of unmet need among patients with CKD/u.
Bibliography
1. Brooks D. Executive Summary Scoping Study Epidemiology of Chronic Kidney Disease in Nicaragua
Prepared for the CAO-Convened Dialogue Process on Chronic Renal Insufficiency.; 2009.
2. Gracia-Trabanino R, Domínguez J, Jansà JM, Oliver a. Proteinuria and chronic renal failure in the coast of El
Salvador: detection with low cost methods and associated factors. Nefrologia. 2005;25(1):31-38.
3. Jiron N, Amador JJ, Pastora M, Silver D, Gongora I. MEDICAL NEEDS ASSESSMENT OF THE
CHICHIGALPA COMMUNITY HEALTH CENTER DIALYSIS OPTIONS for.; 20
4. Laux TS, Bert PJ, Ruiz GMB, et al. Nicaragua revisited: Evidence of lower prevalence of chronic kidney
disease in a high-altitude, coffee-growing village. J Nephrol. 2012;25(4):533-540. doi:10.5301/jn.5000028.
5. Lebov JF, Valladares E, Pena R, et al. A population-based study of prevalence and risk factors of chronic
kidney disease in Leon, Nicaragua. Can J Kidney Heal Dis. 2015;2:6. doi:10.1186/s40697-015-0041-1.
6. Nicaragua EM de S de. Ministerio de Salud: Norma Y Protocolo Para El Aboradaje de La Enfermedad Renal
Cronica. Vol 2009.; 2009.
7. O’Donnell JK, Tobey M, Weiner DE, et al. Prevalence of and risk factors for chronic kidney disease in rural
Nicaragua. Nephrol Dial Transplant. 2011;26(9):2798-2805. doi:10.1093/ndt/gfq385.
8. Raines N, González Quiroz M, Wyatt C, et al. Risk factors for reduced glomerular filtration rate in a
nicaraguan community affected by mesoamerican nephropathy. MEDICC Rev. 2014;16(2):16-2.
9. Ramirez-Rubio O, McClean MD, Amador JJ, Brooks DR. An epidemic of chronic kidney disease in Central
America: an overview. J Epidemiol Community Heal. 2012;67(1):1-3. doi:10.1136/jech-2012-201141.
10. Ramírez-Rubio O, Amador JJ, Kaufman JS, et al. Urine biomarkers of kidney injury among adolescents in
Nicaragua, a region affected by an epidemic of chronic kidney disease of unknown aetiology. Nephrol Dial
Transplant. 2015:gfv292. doi:10.1093/ndt/gfv292.
11. Ramirez-Rubio O, Brooks DR, Amador JJ, Kaufman JS, Weiner DE, Scammell MK. Chronic Kidney Disease
in Nicaragua: A Qualitative Analysis of Semi-Structured Interviews with Physicians and Pharmacists. Vol 13.;
2013. doi:10.1186/1471-2458-13-350.
12. The World Health Organization. Nicaragua. http://www.who.int/countries/nic/en/.
13. WebMD. Incontinence and Overactive Bladder. http://www.webmd.com/urinary-incontinence-oab/picture-of-
the-kidneys. Accessed November 16, 2016.
14. Uric Acid - Serum. https://www.crlcorp.com/test/uric-acid-serum/. Accessed November 16, 2016.
15. National Kidney Foundation. (n.d.). Glomerular Filtration Rate (GFR). Retrieved November 10, 2016, from
https://www.kidney.org/atoz/content/gfr

Page 22
16. Net, M. (n.d.). Creatinine Blood Test. Retrieved November 12, 2016, from
http://www.medicinenet.com/creatinine_blood_test/article.htm
17. Clinic, the M. (n.d.). Blood Urea nitrogen (BUN) test. Retrieved November 12, 2016, from
http://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/details/results/rsc-20211280
18. Foundation, T. N. K. (n.d.). Albuminuria. Retrieved November 13, 2016, from
https://www.kidney.org/atoz/content/albuminuria
19. Health Action International (October 2008) Median Prices Nicaragua, October 2008. Retrieved December 1,
2016 from http://www.haiweb.org/MedPriceDatabase/median_price_by_medicine.php?SRV_ID=456
20. Trading International (October 2016) Nicaragua Inflation Rate. Retrieved December 1, 2016, from
http://www.tradingeconomics.com/nicaragua/inflation-cpi
21. Trading International (October 2016) Nicaragua Consumer Price Index (CPI). Retrieved December 1,2016,
from
http://www.tradingeconomics.com/nicaragua/consumer-price-index-cpi
22. Wikipedia. (n.d.). Economy of Nicaragua. Retrieved November 28, 2016, from
https://en.wikipedia.org/wiki/Economy_of_Nicaragua.
23. La Isla Foundation (n.d) The Epidemic. Retrieved November 25th
, 2016, from
https://laislafoundation.org/epidemic/
24. Foundation LI, Disease CK. Ingenio San Antonio Field Visits.; 2014.
25. MINSA (n.d) Dirección Superior. Retreived December 05, 2016, from
http://www.minsa.gob.ni/index.php/institucion/dir-superior

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