This document discusses the epidemic of chronic kidney disease of unknown etiology (CKDu) affecting agricultural workers along the Pacific coast of Central America. It provides evidence that the disease has an occupational etiology related to heat stress and dehydration experienced by sugarcane and other field workers. Studies show physiological changes in workers consistent with heat stress and dehydration across work shifts. Longitudinal studies find declines in kidney function over harvest seasons among heat-exposed occupations. Intervention studies reducing heat stress through water, rest, and shade have shown reduced declines in kidney function. While some non-occupational factors may also contribute, the evidence strongly suggests that prolonged occupational heat stress is a primary driver of the CKDu epidemic.
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
The importance of sex and gender in medical researchCoda Change
The importance of sex and gender in medical research.
For many years it was widely assumed that the occurrence and outcome of disease was the same for women and men.
Our understanding was that studies involving only men would be equally relevant for women. In the last two decades however, it has been shown that this assumption is highly prejudice and can have a detrimental impact on the health of women.
It is, therefore, really important to incorporate a sex and gender research lens in to medical research.
First, Kelly makes the important distinction between sex and gender and how this can impact medical diagnosis, treatment and outcomes.
Then, she identifies how the incorporation of sex and gender into research has allowed for advancements across healthcare. Improved accuracy, avoiding misinterpretation, reduced unintentional bias and greater social equity to name a few.
In this presentation, Kelly Thompson refers to case studies to examine the differences in the interpretation of health data when examining through a sex and gender research lens.
The severity of disease, risk factors and treatment effectiveness are just a few of the reasons why this is so important.
Kelly encourages researchers to ensure gender diversity in the research team and to explain how sex and gender are accounted for in research applications moving forward.
From CodaZero Live, tune into this fascinating discussion on the importance of sex and gender in medical research by Kelly Thompson.
Early diagnosis of diabetes by near infrared spectroscopy with aquaphotomics ...PoojaSoni132
Using near infrared spectroscopy, diagnosis of diabetes type 2 melitus in early stages has become feasible.
Use of aquaphotomics and machine learning (SVM) model can increase the specificity and accuracy of this procedure.
A description of changes in climate we have seen and how those have and are affecting our daily lives. The talk is oriented more for South Florida but is applicable anywhere
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Health effects of climate change initiatives in Bangladesh
Health effects of climate change initiatives in Bangladesh
Health effects of climate change initiatives in Bangladesh
Health effects of climate change initiatives in Bangladesh
Climate change, health, and an introduction to epidemiologic methods. This lecture was held in the researcher training sessions which are part of the Adapting to Climate Change in China II project. http://www.ccadaptation.org.cn/
Objectives for the call:
Provide an overview of why glucose control is important in surgical patient outcomes
.Demonstrate an understanding of how anesthetics and surgery can impact the body's ability to remain within glycemic boundaries
.Outline the optimal surgical patient glycemic goal range
.To identify the effectiveness of tight glycemic control on mortality and morbidity of adult patients during the intra and post-operative period
.To discuss possible change ideas to implement glucose control
WATCH: http://goo.gl/3vGq2B
Assessment of Toxicant Exposure and Renal Damage During a Sugarcane Harvest S...Arthur Stem
Chronic kidney disease of unknown etiology
(CKDu) is highly prevalent among low-income
agricultural communities, specifically in equatorial
regions. Acute interstitial nephritis is characteristic
of CKDu, indicating inflamed proximal convoluted
tubules (PCTs). Unfortunately, affected individuals
do not have access to dialysis or kidney replacement
therapy, resulting in a high mortality rate.
Long-term exposure to heat and dehydration are risk
factors associated with CKDu. However, various
treatments of heat-related conditions do not prevent
the progression of CKDu, suggesting the role of an
agricultural toxicant.
We analyzed renal damage in Guatemalan sugarcane
workers across one harvest season. We measured
KIM-1 (kidney injury molecule 1) and NGAL
(neutrophil gelatinase-associated lipocalin) as
biomarkers for acute cortical injury. We quantified
the amounts of metals in urine samples to determine
toxicant exposure.
The importance of sex and gender in medical researchCoda Change
The importance of sex and gender in medical research.
For many years it was widely assumed that the occurrence and outcome of disease was the same for women and men.
Our understanding was that studies involving only men would be equally relevant for women. In the last two decades however, it has been shown that this assumption is highly prejudice and can have a detrimental impact on the health of women.
It is, therefore, really important to incorporate a sex and gender research lens in to medical research.
First, Kelly makes the important distinction between sex and gender and how this can impact medical diagnosis, treatment and outcomes.
Then, she identifies how the incorporation of sex and gender into research has allowed for advancements across healthcare. Improved accuracy, avoiding misinterpretation, reduced unintentional bias and greater social equity to name a few.
In this presentation, Kelly Thompson refers to case studies to examine the differences in the interpretation of health data when examining through a sex and gender research lens.
The severity of disease, risk factors and treatment effectiveness are just a few of the reasons why this is so important.
Kelly encourages researchers to ensure gender diversity in the research team and to explain how sex and gender are accounted for in research applications moving forward.
From CodaZero Live, tune into this fascinating discussion on the importance of sex and gender in medical research by Kelly Thompson.
Early diagnosis of diabetes by near infrared spectroscopy with aquaphotomics ...PoojaSoni132
Using near infrared spectroscopy, diagnosis of diabetes type 2 melitus in early stages has become feasible.
Use of aquaphotomics and machine learning (SVM) model can increase the specificity and accuracy of this procedure.
A description of changes in climate we have seen and how those have and are affecting our daily lives. The talk is oriented more for South Florida but is applicable anywhere
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Health effects of climate change initiatives in Bangladesh
Health effects of climate change initiatives in Bangladesh
Health effects of climate change initiatives in Bangladesh
Health effects of climate change initiatives in Bangladesh
Climate change, health, and an introduction to epidemiologic methods. This lecture was held in the researcher training sessions which are part of the Adapting to Climate Change in China II project. http://www.ccadaptation.org.cn/
Objectives for the call:
Provide an overview of why glucose control is important in surgical patient outcomes
.Demonstrate an understanding of how anesthetics and surgery can impact the body's ability to remain within glycemic boundaries
.Outline the optimal surgical patient glycemic goal range
.To identify the effectiveness of tight glycemic control on mortality and morbidity of adult patients during the intra and post-operative period
.To discuss possible change ideas to implement glucose control
WATCH: http://goo.gl/3vGq2B
Assessment of Toxicant Exposure and Renal Damage During a Sugarcane Harvest S...Arthur Stem
Chronic kidney disease of unknown etiology
(CKDu) is highly prevalent among low-income
agricultural communities, specifically in equatorial
regions. Acute interstitial nephritis is characteristic
of CKDu, indicating inflamed proximal convoluted
tubules (PCTs). Unfortunately, affected individuals
do not have access to dialysis or kidney replacement
therapy, resulting in a high mortality rate.
Long-term exposure to heat and dehydration are risk
factors associated with CKDu. However, various
treatments of heat-related conditions do not prevent
the progression of CKDu, suggesting the role of an
agricultural toxicant.
We analyzed renal damage in Guatemalan sugarcane
workers across one harvest season. We measured
KIM-1 (kidney injury molecule 1) and NGAL
(neutrophil gelatinase-associated lipocalin) as
biomarkers for acute cortical injury. We quantified
the amounts of metals in urine samples to determine
toxicant exposure.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
Anatomy and Physiology Chapter-16_Digestive-System.pptx
Presentation_Wesseling - Private Public Partnerships and CKDu
1. CKDu epidemic in Mesoamerica:
an occupational disease
Catharina (Ineke) Wesseling
IMM, Karolinska Institutet, Sweden
La Isla Network, Washington D.C., USA
2. Mesoamerican nephropathy (MeN)
• A severe CKD epidemic unrelated
to hypertension, diabetes or
obesity
• Tropical lowlands along the Pacific
coast from Mexico to Panama
• One estimate of 20,000 deaths by
2012
• Main hypotheses:
• Toxins: pesticides, metals
• Heat stress and chronic dehydration
• Unknown ------ Multifactorial
Along the Pacific coast, in the lowlands
3. Disentanglement of a multifactorial etiology is of crucial
importance for effective interventions in those causal components
that are identified
Let us keep in mind
We are in the presence of an epidemic with tens of thousands
of premature deaths
Even in the presence of multiple causes, there must be a
very STRONG driver
4. Early evidence
• Mid 1990s: The occupational nature of the disease was noted by clinicians and workers
• Costa Rica: “Nefropatía del cañero / sugarcane worker nephropathy”
• El Salvador: Hospital case series showed hundreds of young, male agricultural workers with
kidney failure without known cause
• Nicaragua: Vital and health statistics showed large male / female differences, especially in
sugarcane areas
0
10
20
30
40
Guanacaste
Costa Rica…
Men
0
10
20
30
40
Women
Time trend CKD
mortality in CKDu
area in Costa Rica
vs rest of the
country
(Wesseling et al, 2016)
Green revolution
Global warming
Plantation agriculture
Migration
Informal work
5. Outbreak study by company physician at sugarcane enterprise
Nicaragua (Zelaya, 2001)
• In 1999 the number of job applicants with high SCr became alarming:
‘outbreak study’ during zafra 2000-2001 …
• Conclusions
• Exhausting physical work in high environmental temperatures without a
proper hydration program predisposes to heat fatigue syndrome (insolation),
which is an important factor that leads to CKD
• Awkward positions for cane cutters during long workdays with poor hydration
lead to excessive intake of NSAIDs
6. Prevalence studies followed with data indicating occupational etiology
• Men much more affected than women in the general population
• Women similarly affected within occupational categories
• Not all agricultural worker populations reported with high prevalences of kidney dysfunction:
• High prevalence: sugarcane cutters and other sugarcane field workers, any agricultural field workers,
cotton workers, banana workers, and rice and corn farmers
• No excess: subsistence farmers in high risk areas without history of plantation work:
control over working conditions, work in cooler hours, self-pacing
• Also non-agricultural worker populations moderate to high prevalence of kidney dysfunction:
• Fishermen 7%, shrimp farmers 10%, construction workers 5-15%, miners 6-16%; port workers with heavy
labor 8%, and brick makers 12%
Common characteristic: hot occupations
HIGH WORKLOAD COUPLED TO ENVIRONMENTAL HEAT
7. 0
5
10
15
20
25
30
Triglycerides >200 mg
/dL
Blood pressure
>140/90
BMI >30 kg/m2 SCr >1.20 mg/dL eGFR CKD-EPI <80
ml/min/1.73m2
Proteinuria >30
mg/dL
Cane cutting Construction work Farming
%
Nicaraguan sugarcane cutters compared to construction workers and
farmers, age 18 – 39, León, Nicaragua, 2013 (n=194)
Cutters better general health
(Wesseling et al, BMJ Open, 2016)
Cutters with worse kidney function
8. Pesticide and metal studies negative
• Review on pesticides and CKD:
• Scarce or no evidence for pesticides as an important etiology, but poor exposure assessment (Valcke et al, 2017)
• Two following studies with good exposure assessment negative
• 2,4-D and glyphosate exposure in work environment in sugarcane workers of the WE Program was very low (Curwin et al, 2016,
NIOSH study)
• No associations with kidney decline for 12 common pesticides and 12 metals in a nested case-control study of the Nicaraguan
community cohort (Smpokou et al, 2019)
• Metals negative
• Low serum levels of cadmium, arsenic, lead, urenium and other metals in the WE Program participants in El Salvador (Jakobsson et
al, manuscript)
• No associations with kidney dysfunction in Nicaragua among sugarcane workers, construction workers, miners and port workers
with heavy labor (McClean et al, 2012)
• In general: TOXIN levels in affected regions, both measured in environmental and human samples are
below international tolerances and below levels that would produce other evident health effects.
• Conclusion: Toxins may contribute but are not the strong drivers of the epidemic of CKDu in
Mesoamerica
9. Cross-shift observations in sugarcane workers
Study Setting Findings / conclusion pro-occupational
etiology
Crowe et al,
2014
Costa Rica
Cane cutters (n=56)
3 x 1 week, midharvest
Urine, dipstick and microscopy
-Clear evidence of dehydration and kidney
injury among heat stress exposed workers.
-Overnight recovery was insufficient
García-
Trabanino et
al, 2015
El Salvador
Cane cutters (n=189)
End of harvest
Phys exam, urine, blood
Changes for blood pressure and kidney-
related serum and urine biomarkers involved
in maintaining water and electrolyte balance
were associated with heat and workload
Wesseling et
al, 2016
Nicaragua
Cane cutters (n= 29), D1, D6, Wk 9
Administrative referents (n=25), start and
end of harvest
Phys exam, urine, blood
Dehydration cross-shift among cutters is
clear and repeated among cutters and not
among administrative workers
Wegman et
al, 2018
El Salvador
Cane cutters (n=40)
Pre- and post intervention (midharvest)
and end of harvest
Phys exam, urine, blood
-Cases of AKI developed
-Cross-shift decline in eGFR related to heat
and workload
-Positive effect intervention on reducing
cross-shift kidney function decline.
Sorensen et
al, 2018
Guatemala
Sugarcane field workers (n=105)
1/mth, 3 x towards end harvest
Urine, blood
High prevalence of acute decline in eGFR in
well-hydrated workers
Without exception,
studies concluded that
cross-shift physiologic
and biomarker changes
were compatible with
heat stress and
dehydration
10. Longitudinal observations in workers
Study Setting Findings / conclusion pro-
occupational etiology
Laws et al, 2015
Laws et al, 2016
Nicaragua
Cross-harvest cohort in five job
categories of sugarcane field
workers and two categories of
non-field workers (n=284)
-eGFR decline and increase in markers of
injury acute tubular differed by job category
-Findings in accordance to heat stress in the
job categories
-Protective effect from electrolytes
Wesseling et al,
2016
Nicaragua
Cutters (n= 29), Day 1, Day 6,
Week 9
Administrative workers (n=25),
start - end of harvest
Marked decline in kidney function among
cutters but not in the referent population
Butler-Dawson et
al, 2017
Guatemala
Cross-harvest cohort of 330
cutters
-Decline in eGFR in 37% of young male
cutters (6% with a decline in eGFR > 20%)
-3% declined over the harvest to eGFR <60
ml/min/1.73m2
Gallo-Ruiz et al,
2019
Nicaragua
Brick makers (n= 257),
4-month follow-up
-High prevalence of CKD (twice eGFR<60
ml/min/1.73m2, ≥ 3 months apart)
-Risk higher among highest heat exposed
(ovens)
- Low water intake and longest work week
associated with decline in eGFR over the
follow-up
Without exception,
studies found decline in
eGFR over the follow-up
among heat exposed job
categories, more severe
in workers with the
highest heat exposures
11. Community cohort in Nicaragua with 2-year follow-up
Decline in Kidney Function among Apparently Healthy Young Adults at Risk of
Mesoamerican Nephropathy (Gonzalez-Quiroz et al, 2018)
020406080100120140160
Estimatedglomerularfiltrationrate(mL/min/1.73m
2
)
0 0.5 1 1.5 2
Time in study (years)
Stable kidney function
(n = 213, I = 113.3, S = -0.3)
020406080100120140160
Estimatedglomerularfiltrationrate(mL/min/1.73m
2
)
0 0.5 1 1.5 2
Time in study (years)
Rapid decline in kidney function
(n = 25, I = 109.5, S = -9.1)
020406080100120140160
Estimatedglomerularfiltrationrate(mL/min/1.73m
2
)
0 0.5 1 1.5 2
Time in study (years)
Renal dysfunction at baseline
(n = 25, I = 55.6, S = -1.9)
Rapid decline in 10% of healthy men at
baseline and 3% of women
Associations with rapid decline:
• Agricultural work, outdoor work and lack
of shade
Sensitivity analyses:
• Cane and seed cutting and fever in the last
6 months
No association with general questions on
perceived heat exposures
No pesticide associations
Conclusion: Besides occupational factors also
non-occupational factors may contribute
12. Evidence for non-occupational etiology
• Some reports of women with MeN, who were not occupationally active
• Limited evidence of early kidney injury in children in vulnerable agricultural
communities
• Associations with non-occupational risk factors
• Most frequently age
• Smoking, alcohol intake, diabetes, hypertension, kidney stones, NSAIDs mostly negative or
inconsistent across studies.
Non-occupational risk factors did not emerge as suspects for being a
primary driver of the occurrence of MeN in any of the studies
conducted to date
13. Therefore: LIN started intervention studies
to prevent heat stress
• Two intervention studies in the region
• WE Program in El Salvador
• Adelante Initiative in Nicaragua
• Intervention studies are complex
o Effectiveness of the different components to prevent heat exposure
physical work load, work tools, water, rest, shade, sanitation at work, work
organization, payment scheme (piece work)
o Feasibility
o Adequacy of implementation
o Simultaneously study etiology
14. 88
92
96
100
104
5-8 Nov 7-9 Jan 18 Fbr 8-10 Apr
Mean eGFR (as percentage of baseline
value) over the course of the Harvest
Inland Coastland
WE-Program in El Salvador: Water - Rest - Shade and Efficiency
intervention for sugarcane cutters (Bodin et al, 2016; Wegman et al 2018)
With intervention
N=40
Without intervention
N=40
15. Adelante Initiative in Nicaragua
WRS in sugarcane field workers (n=530), first year assessment
Incident Kidney Injury (IKI) across harvest: overall 12%
8% in those who finished harvest and 32% in drop outs
The same environmental heat for the different job categories
Job category Physical
activity
Only harvest finishers Including drop-outs Adjusted
Incidence Ratio
(95% CI)
#
N=427
IKI measured
%
#
N=530
IKI measured+
reported
%
Burned cane cutters Very high 128 21 158 27 11.9 (4.0 – 35.8)
Seed cutters High 148 3 190 8 3.5 (1.2 – 10.7)
Irrigation repair workers Intermediate 109 0 128 2
1
Field support staff Low 42 0 54 2
Current preventive measures are insufficient for categories with highest physical workload
16. Conclusions
• In Central America, sugarcane cutters have provided the bulk of the data to understand
CKDu related to heat stress
• Sentinel occupational population, showing the tip of the iceberg of what occurs in other
populations less visibly
• Non-occupational causal factors certainly must contribute but:
• For an epidemic as devastating as MeN there must be a strong driver
All hard evidence points to
a work-related disease caused by occupational heat stress
Chronic kidney disease increasing in the entire world due to HT, DM and being fat
This is a different phenomenon
In 2011, researchers of the Boston University School of Public Health made an estimate that more than 20,000 deaths had occurred in Central America due to the Mesoamerican nephropathy.
2005-SALTRA Workshop on CKD in Central America (Cuadra et al 2006)
Dr. Zelaya justified his study:
Disease is endemic (as commented by local population)
Increasing numbers of cases of elevated SCr at pre-employment screenings during the 1990s
Pre-employment screening of kidney function of seasonal workers started in 1996
Sugarcane cutters are more athletic but with worse kidney function than construction work and farmers. Among farmers there was no CKD.