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

Transcription

1 CKD Screening in Developing Countries. The case of Jalisco, Mexico. Hospital Civil de Guadalajara. Hospitales Civiles de Guadalajara Foundation University of Alberta, Edmonton, CA

2 Jalisco, Mexico.

3 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

4 CKD is frequent: ESRD Incidence & Prevalence in Jalisco is rising. per mliion population Incidence Prevalence year USRDS, 2013

5 Percent distribution of dialysis patients, by modality & year. % HD PD year USRDS, 2013

6 Etiology of ESRD. Incident Patients Unknown 31% Diabetes 58% Other 3% Hypertension 4% Chronic GN 6% REDTJAL, 2005

7 CKD is harmful: ESRD is among the 10 leading causes of death. Cardiovascular Diabetes Malignacies Accidental Liver Cirrhosis CVA COPD Pneumonia ESRD Rate per 100,000 population

8 DM Prevalence in Mexico. % Rull JA. Arch Med Res 2005; 36: , NSCD 1993, NHS 2000.

9 Hypertension Prevalence in Mexico % Rodriguez J. Arch Cardiol Mex 1998;68:

10 Obesity Prevalence in Mexico. % NHS 1993, 2000, 2006, 2012

11 CKD is Harmful: Survival on PD in Jalisco. Mortality rate: 19.2 in Jalisco vs 5.9 per 100 patients-years in the US Garcia GG, et al. JASN 18: , 2007

12 Survival on Dialysis Garcia GG, et al. JASN 18: , 2007

13 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, CAPD 37,423 14,947.00* APD 8,215 16,874.00* Sub-Total 64, Cervantes M et al; Estudio de Insuficiencia Renal Crónica y Tratamiento Mediante Terapia de Substitución. Secretaria de Salud. México * Sanabria L, et al: unpublished data.

14 Mexican Health System 2000 Frenk J; Lancet 2003; 362:

15 Health Care in Mexico Distribution by Health Care System UNINSURED 34.9 IMSS 31.4 PRIVATE INSURANCE OTHER ISSSTE 5.5 SEGURO POPULAR

16 Limited Access to RRT: Acceptance rates are lower among the uninsured 500 Acceptance rates PMP Garcia G et al; Semin Nephrol 2010;30:3-7 Garcia G et al; Kidney Int 2005;Suppl 97: 58-61

17 Unequal Access to RRT: ESRD prevalence is lower among the uninsured Prevalence rate 1211 PMP Garcia G et al; Semin Nephrol 2010;30:3-7 Garcia G et al; Kidney Int 2005;Suppl 97: 58-61

18 Unequal access to Renal Transplantation: Transplant rates are lower among uninsured ESRD paients Transplant Rate 122 PMP Garcia G et al; Semin Nephrol 2010;30:3-7 Garcia G et al; Kidney Int 2005;Suppl 97: 58-61

19 CKD FREQUENT + HARMFUL + EXPENSIVE + UNEQUAL ACCESS TO RRT = PREVENTION

20 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!!!!

21 ! In operation since 1999 Diabetes Hypertension CA of Cervix HIV-AIDS Cataracts Mobile Clinics Screening Programs

22 Mobile Clinics CKD Screening Program begins September, 2006! Mexico s Secretary of Health, Dr. Jose Cordova Villalobos, launches the CKD Screening Program. March, 2007

23 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

24 Clinical and Lab exams! CBC Blood Glucose, Creatinine, Urea Pap smear Eye examination Serum Lipids Urianalysis Estimated GFR (MDRD) BMI Blood Pressure

25 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)

26 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.

27 Published Results Am J Kidney Dis 2010; 55:

28 Location of the Mobile Clinics Am J Kidney Dis 2010; 55:

29 Population-based Screening Am J Kidney Dis 2010; 55:

30 CKD Screening Initiatives.!! TARGETED SCREENING! -KEEP Mexico. Pilot Study.!

31 KEEP Jalisco Kidney International (2010) 77 (Suppl 116), S2 S8

32 KEEP Jalisco Participant Characteristics N= % 74% 60% 53 ± 13 56% 40% 20% 10% 0% Mean Age Women > High School Medical Insurance

33 Risk Factors 50% 44% 49% Participants (%) 38% 25% 13% 17% 23% 0% DM HTN DM + HTN Family Hx DM/HTN/CKD

34 Prevalence of Dipstick Proteinuria and egfr <60 KEEP Jalisco 40% 30% 31% 20% 10% 10% 0% PROTEINURIA egfr < 60 ml/min

35 Overall CKD Prevalence 40% 33% CKD Prevalence (%) 30% 20% 10% 7% 16% 10% 0% Overall Stage 1 Stage 2 Stage 3 Stages 4-5 1%

36 CKD Prevalence KEEP Jalisco versus KEEP US KEEP Jalisco KEEP US 40% CKD Prevalence (%) 30% 20% 10% 0% 33% 26% 16% 17% 10% 7% 5% 3% 1% 1% Overall Stage 1 Stage 2 Stage 3 Stages 4-5 * *

37 CKD Awareness 100% 91% 75% 50% 25% 0% 0% Aware of CKD Visited a MD in the previous year

38 CKD Screening Initiatives.!! TARGETED SCREENING! -Homeless Individuals!

39 CKD in Homeless Individuals Kidney International Supplements (2013) 3,

40 CKD in Homeless Homeless n= 269 NHS* n= 45,300 Age (y) ± ± Male (%) Known or New Diabetic (%) Known or new Hypertensive (%) egfr < 60 ml/ min/1.73 m p *NHS: National Health Survey 2000 Kidney International Supplements (2013) 3,

41 CKD in Homeless Persons Percentage Homeless Population-Based Stage 3 Stage 4Kidney International Stage 5 Supplements (2013) 3,

42 Addictions prevalence: Homeless vs General Population Kidney International Supplements (2013) 3,

43 HIV, Hepatitis B and C Prevalence: Homeless vs General Population ENSA 2000 = National Health Survey 2000 Kidney International Supplements (2013) 3,

44 CKD Screening Initiatives.!! TARGETED SCREENING! -High Risk Populations!

45 Targeting High-Risk Populations Archives of Medical Research 44 (2013)

46 Targeting High Risk Populations High Risk n= 9,619 NHS 2006* n= 33,366 Age (y) 55.5 ± ± Self-reported diabetes (%) 4,027 (41.9) 2,449 (7.34) Diabetes (%) 5,340 (56.1) 4,812 (14.42) Self-reported hypertension (%) SBP 140 or DBP 90 mmhg 4,956 (51.6) 5,505 (16.5) ,035 (52.5) 4,414 (43.2) BMI 30 kg/m 4,028 (42.8) 9,776 (29.3) p * NHS= National Health Survey 2006 Archives of Medical Research 44 (2013)

47 Targeting High Risk Populations 40 Percentage High Risk KEEP USA CKD Stage 1 Archives of Medical Research 44 (2013) Stage 2 Stage 3 Stage 4-5

48 CKD Screening Initiatives.!! OPORTUNISTIC SCREENING! -CKD screening on World Kidney Day!

49 CKD screening in WKD

50 Results egfr < 60 ml/min/1.73 m2 prevalence ranges between 1.7% in children and 6.4% in adults.

51 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.

52 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.

53 THANKS!