ckd screening in developing countries. the case of jalisco,...

CKD Screening in Developing Countries. The case of Jalisco, Mexico.

Hospital Civil de Guadalajara. Hospitales Civiles de Guadalajara Foundation

University of Alberta, Edmonton, CA e-mail: [email protected]

Jalisco, Mexico.

Jalisco in numbers

GDP (million) $ US 68,373

Annual Income per capita $ US 14,651

Population (m) 7.35

Life expectancy at birth (y) 75.6

HDI 0.82

Fertility rate 2.37

Population with medical insurance (m) 4.7

Illiteracy (%) 4.4

CKD is frequent: ESRD Incidence & Prevalence

in Jalisco is rising.

0

350

700

1050

1400

2003

2005

2006

2007

2008

2009

2010

IncidencePrevalence

per m

liion

pop

ulat

ion

USRDS, 2013year

Percent distribution of dialysis patients, by modality & year.

PDHD

%

USRDS, 2013year

Diabetes 58%Unknown 31%

Chronic GN 6%Hypertension 4%

Other 3%

Etiology of ESRD. Incident Patients

REDTJAL, 2005

CKD is harmful:ESRD is among the 10 leading causes of death.

Cardiovascular

Diabetes

Malignacies

Accidental

Liver Cirrhosis

CVA

COPD

Pneumonia

ESRD

0 22.5 45 67.5 90

www.inegi.gob.mx

Rate per 100,000 population

DM Prevalence in Mexico.

%

≤

Rull JA. Arch Med Res 2005; 36:188-1996, NSCD 1993, NHS 2000.

Hypertension Prevalence in Mexico. 1930-2000

%

Rodriguez J. Arch Cardiol Mex 1998;68:130-139

Obesity Prevalence in Mexico.

1993200020062012

%

≥ ≥

NHS 1993, 2000, 2006, 2012

CKD is Harmful: Survival on PD in Jalisco.

Garcia GG, et al. JASN 18:1922-27, 2007

● Mortality rate: 19.2 in Jalisco vs 5.9 per 100 patients-years in the US

Survival on Dialysis

Garcia GG, et al. JASN 18:1922-27, 2007

CKD is Expensive: 1 billion dollars spent on 65,000 dialysis patients

Patients (n)

Annual cost per patient (USD)

Estmated annual cost USD (millions)

Hemodialysis 19,097 13,989.00¶ 268.03

CAPD 37,423 14,947.00* 559.36

APD 8,215 16,874.00* 138.65

Sub-Total 64,735 966.04

¶Cervantes M et al; Estudio de Insuficiencia Renal Crónica y Tratamiento Mediante Terapia de Substitución. Secretaria de Salud. México. 2009 * Sanabria L, et al: unpublished data.

Mexican Health System 2000

Frenk J; Lancet 2003; 362: 1667-1671

Health Care in Mexico 2010. Distribution by Health Care System

UNINSURED 34.9

PRIVATE INSURANCE 1.8OTHER

3.2ISSSTE 5.5 SEGURO POPULAR

IMSS 31.4

www.censo2010.org.mx

Limited Access to RRT:

Acceptance rates are lower among the uninsured

Acceptance rates

PMP

0

125

250

375

500

2000 2010

99

231

327

478

Garcia G et al; Semin Nephrol 2010;30:3-7 Garcia G et al; Kidney Int 2005;Suppl 97: 58-61

Unequal Access to RRT: ESRD prevalence is lower among

the uninsured

Prevalence ratePM

P

0

350

700

1050

1400

2000 2010

166286

939

1211


Unequal access to Renal Transplantation: Transplant rates

are lower among uninsured ESRD paients

Transplant RatePM

P

0

35

70

105

140

2000 2010

9 12

72

122


FREQUENT +

HARMFUL +

EXPENSIVE + UNEQUAL ACCESS TO RRT =

PREVENTION

CKD

CKD Screening and Prevention Initiatives in Jalisco.

!● Population-based screening ● Targeted Screening -CKD screening program using mobile clinics ● Oportunistic Screening - CKD Screening on WKD !● MDC Prevention Clinic ! !!! ! !

Mobile Clinics Screening Programs

!▪ In operation since 1999 ▪ Diabetes ▪ Hypertension ▪ CA of Cervix ▪ HIV-AIDS ▪ Cataracts

Mobile Clinics CKD Screening Program begins September, 2006

!▪ Mexico’s Secretary of

Health, Dr. Jose Cordova Villalobos, launches the CKD Screening Program. March, 2007

Equipment and Staff

!● 4 mobile units ● 4 Physicians ● 4 Nurses ● 4 Lab Technicians ● Undergraduate students

from the University of Guadalajara Schools of Medicine, Nursing, and Nutrition

Clinical and Lab exams

!● CBC ● Blood Glucose, Creatinine,

Urea ● Pap smear ● Eye examination ● Serum Lipids ● Urianalysis ● Estimated GFR (MDRD) ● BMI ● Blood Pressure

How does it work?

● Community leaders organize the screening program at their communities.

- location of the van - estimated population - number of days of screening. ● Advertising campaign to alert for risk factors for

kidney and CV disease and the benefits of early detection (flyers, radio and pulpit announcements during Sunday mass, mobile loudspeakers in public places, or door-to-door visits by local volunteers)

Follow-up of Findings During Screening

● Individuals found to have hypertension, proteinuria, diabetes or reduced eGFR are informed of the findings.

● They are advised for: A) follow up with their own physician B) Those without phisicians are referred to our subsidized, protocol-driven, multidisciplinary prevention clinic.

Published Results

Am J Kidney Dis 2010; 55:474-484

Location of the Mobile Clinics

Am J Kidney Dis 2010; 55:474-484

Population-based Screening

Am J Kidney Dis 2010; 55:474-484

CKD Screening Initiatives.

!! ● TARGETED SCREENING ! -KEEP Mexico. Pilot Study. !

KEEP Jalisco

Kidney International (2010) 77 (Suppl 116), S2–S8

KEEP Jalisco Participant CharacteristicsN= 2020

0%

20%

40%

60%

80%

Mean Age Women > High School Medical Insurance

53 ± 13

74%

10%

56%

Risk Factors Pa

rtic

ipan

ts (%

)

0%

13%

25%

38%

50%

DM HTN DM + HTN Family Hx DM/HTN/CKD

23%17%

49%44%

Prevalence of Dipstick Proteinuria and eGFR <60

0%

10%

20%

30%

40%

PROTEINURIA eGFR < 60 ml/min

10%

31%

KEEP Jalisco

Overall CKD PrevalenceC

KD

Pre

vale

nce

(%)

0%

10%

20%

30%

40%

Overall Stage 1 Stage 2 Stage 3 Stages 4-5

1%

10%

16%

7%

33%

CKD PrevalenceKEEP Jalisco versus KEEP US

CK

D P

reva

lenc

e (%

)

0%

10%

20%

30%

40%

Overall Stage 1 Stage 2 Stage 3 Stages 4-5

1%

17%

5%3%

26%

1%

10%

16%

7%

33%

KEEP Jalisco KEEP US

*

*

CKD Awareness

0%

25%

50%

75%

100%

Aware of CKD Visited a MD in the previous year

91%

0%


!! ● TARGETED SCREENING ! -Homeless Individuals !

CKD in Homeless Individuals

Kidney International Supplements (2013) 3, 250–253

CKD in Homeless

Homeless n= 269

NHS* n= 45,300

p

Age (y) 50.75 ± 17-93 39.0 ± 13.0 0.0001Male (%) 74.29 49.7 0.0001Known or New Diabetic (%)

24.7 10.6 0.0001

Known or new Hypertensive (%)

34.5 30.1 0.001

eGFR < 60 ml/min/1.73 m

22.4 10.9 0.0001

*NHS: National Health Survey 2000


CKD in Homeless Persons

0

4.5

9

13.5

18

Stage 3 Stage 4 Stage 5

0.40.8

14.6

1.2

4.3

16.5

HomelessPopulation-Based

Perc

enta

ge


Addictions prevalence: Homeless vs General Population


HIV, Hepatitis B and C Prevalence:Homeless vs General Population


ENSA 2000 = National Health Survey 2000


!! ● TARGETED SCREENING ! -High Risk Populations !

Targeting High-Risk Populations

Archives of Medical Research 44 (2013) 623-627

Targeting High Risk Populations

High Risk n= 9,619

NHS 2006* n= 33,366

p

Age (y) 55.5 ± 0.14 42.5 ± 0.25 0.0001

Self-reported diabetes (%)

4,027 (41.9) 2,449 (7.34) 0.0001

Diabetes (%) 5,340 (56.1) 4,812 (14.42) 0.0001

Self-reported hypertension (%)

4,956 (51.6) 5,505 (16.5) 0.0001

SBP ≥ 140 or DBP ≥ 90 mmHg

5,035 (52.5) 4,414 (43.2) 0.0001

BMI ≥ 30 kg/m 4,028 (42.8) 9,776 (29.3) 0.0001

Archives of Medical Research 44 (2013) 623-627* NHS= National Health Survey 2006

Targeting High Risk Populations

0

10

20

30

40

CKD Stage 1 Stage 2 Stage 3 Stage 4-5

1

17

53

26

1.2

16.1

10.2

3.8

31.3

High RiskKEEP USA

Perc

enta

ge

Archives of Medical Research 44 (2013) 623-627


!! ● OPORTUNISTIC SCREENING ! -CKD screening on World Kidney Day !

CKD screening in WKD

Results

● eGFR < 60 ml/min/1.73 m2 prevalence ranges between 1.7% in children and 6.4% in adults.

Conclusions

● Impaired kidney function is frequently detected when mobile units are used to perform screening in Jalisco, Mexico.

● Our data indicate that oportunistic screening on World Kidney Day may be useful for identifying individuals with CKD

" KEEP is an effective CKD screening program for high-risk individuals, an CKD is severely under diagnosed and under recognized.

Conclusions

● CKD and its risk factors are highly prevalent among homeless persons in Jalisco, Mexico. Lack of awareness of having CKD, diabetes, and hypertension is highly common.

● Impaired kidney function, proteinuria, and cardiovascular risk factors are frequently detected when targeting a high-risk population.

● This suggests that trials of case-finding and intervention are feasible and warranted in Mexico and other low income settings.

THANKS!

ckd screening in developing countries. the case of jalisco,...

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