Zuni Health Initiative

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1 ZUNI JEWELRY Zuni Health Initiative Raj Shah-University of New Mexico Do' tse'mak i:k'oshudu, elek'yanna!!! May you feel better, everything will be alright!!!

2 OBJECTIVES Describe the Epidemiology of chronic disease Discuss the Epidemiology Chronic Kidney disease (CKD) economic impact Discuss the Epidemiology of CKD in Zuni Discuss the occupational exposure and CKD in Zuni Describe the Reason for Home base health care in Zuni

3 Chronic Disease Chronic diseases (>98 million in US) such as: heart disease cancer diabetes are the leading causes of death and disability in the US. These diseases account for: 7 of every 10 deaths 90 million Americans have their quality of life affected. IDF data-dm in to 230 in 2000 and will be 350 million by China 49, India 40 and US 31 million. One person dying every 10 seconds with DM related cause -UN

4 Chronic Kidney Disease in the United States

5 Kidney Failure Is a Rapidly Growing Problem

6 157 Kidney Failure Compared to Cancer Deaths in the U.S. in 2000* (in Thousands) *SEER, Lung Cancer Kidney Failure Colon Cancer Breast Cancer Prostate Cancer

7 Prevalence of Renal Insufficiency in U.S. GFR (ml/min/1.73 m 2 ) < 15 Number of People 7.6 Million 360,000 > 300,000 More than 8 million Americans have substantial kidney impairment and 10 million more have albuminuria. Coresh, Levey, et al Chronic Kidney Disease on the Rise By Michael Smith, MedPage Today, Published: October 10, 2008 The prevalence of CKD in the U.S. has increased by between 20% and 25% over the past decade, according to a new NIH report. But the trend among older Americans has been much higher -- doubling between 1992 and 2002, and increasing another 65% between 2002 and 2006, according to Allan Collins, M.D., director of the U.S. Renal Data System (USRDS), and colleagues.

8 Chronic Kidney Disease on the Rise The extrapolation of survey data from 1999 through 2006 suggests that about 16% of Americans have some form of chronic kidney disease. The increase in overall prevalence means chronic kidney disease affects about 31 million Americans and accounts for more than a quarter of all Medicare costs. The NHANES data for that period, however, show a prevalence of 44.2% among participants 65 or older -- a figure that is much higher than the 6.4% shown by Medicare diagnosis codes in The discrepancy may imply that milder forms of the disease are not being picked up by ICD-9 diagnosis codes, the investigators suggested. In 2006, costs for Medicare patients with chronic kidney disease exceeded $49 billion, almost five times greater than costs in 1993, the researchers said. During the same period, overall Medicare expenditures about doubled.

9 ESRD CKD

10 The researchers found that CVD is highly associated with stage and age % percent of participants age 60 and older in stages four and five have cardiovascular disease. Among other findings: All-cause hospitalization rates were sharply higher among Medicare patients with the condition per 1,000 patient-years, compared with 341 for those without kidney disease. Compared with Medicare patients without CKD, those with the condition had a relative risk of all-cause mortality of 2.97 (CI: 2.83 to 3.12, P<0.0001). If patients also had congestive heart failure, the odds ratio jumped to 5.94 (CI: 5.69 to 6.20, P<0.0001). Adding diabetes into the mix caused another increase in risk, to 7.15 (CI: 6.84 to 7.48, P<0.0001).

11 Incident Rates by Primary Diagnosis (per million population, unadjusted) USRDS, 2000

12 Incidence of Kidney Failure per million population, 1990, by HSA, unadjusted

13 Incidence of Kidney Failure per million population, 2000, by HSA, unadjusted

14 Early Treatment Makes a Difference

15 Treatment To Prevent Progression of CKD to Kidney Failure Intensive glycemic control lessens progression from microalbuminuria in type 1 diabetes (DCCT, 1993) Antihypertensive therapy with ACE Inhibitors lessens proteinuria and progression - Giatras, et al., Psait, et al., Jafar, et al., 2001 Low protein diets lessen progression - Fouque, et al., Pedrini, et al., Kasiske, et al., 1998 Meta-Analyses Meta-Analyses

16 CKD Is Not Being Recognized or Treated Only 10% of Medicare beneficiaries with diabetes receive annual urine albumin tests Patients are referred late to a nephrologist, especially African American men Less than 1/3 of people with identified CKD get an ACE Inhibitor McClellan, et al., 2000 Kinchen, 2002 McClellan et al.,1997

17 Who To Test for Chronic Kidney Disease Regular testing of people at risk Diabetes Hypertension Relative with kidney failure

18 How To Test for Chronic Kidney Disease Spot urine albumin to creatinine ratio Estimate GFR from serum creatinine using the MDRD prediction equation Note: 24 hour urine collections are NOT needed Diabetics: should be tested once a year. Others at risk: less frequently as long as normal.

19 Who Should Be Treated for Chronic Kidney Disease Diabetics with urine albumin/creatinine ratios more than 30mg albumin/1 gram creatinine Non-diabetics with urine albumin/creatinine ratios more than 300mg albumin/1 gram creatinine or Non-diabetics with estimated GFR less than 60 ml/min/1.73m 2

20 How To Treat for Chronic Kidney Disease Maintain blood pressure less than 130/80 mm Hg Use an ACE Inhibitor or ARB More than one drug is usually required and a diuretic should be part of the regimen

21 How To Treat for Chronic Kidney Disease (continued) Refer to dietician for a reduced protein diet Consult a nephrologist early Team with the nephrologist for care if GFR is less than 30 ml/min/1.73m 2 Monitor hemoglobin and phosphorous with treatment as needed Treat cardiovascular risk, especially smoking and hypercholesterolemia

22 PCP Must Be Engaged 1) 7.6 million people with GFR ml/min/1.73m 2 2) About 4,500 full-time nephrologists 3) Nearly 2,000 new patients per nephrologist Therefore, 7 new patients per day per nephrologist

23 What Can Primary Care Providers Do? Recognize who is at risk Provide testing and treatment Encourage labs to provide and report estimated GFR and spot urine albumin/ creatinine ratios

24 Zuni Kidney Project Zuni Pueblo Indian Health Service UNMHSC GCRC NIEHS Dialysis Clinics Inc. NIDDK

25 American Indians in the US US Census 2000: AI: 2.6M (0.9%); 1,6M (0.6%) reported AI plus another race During last decade AI (26%) increased at twice rate of general (13%) population AI birth rate is 25.7 vs 15.5/1000 for general population Median age: 28.0 yrs for AI vs 35.3 yrs for general population

26 Socio-economics American Indians* US general population** High school (%) 65.3 (Z=61.2) 75.2 College (%) 8.9 (Z=7.8) 20.3 Unemployed (%) 16.4 M 13.2 F 6.4 M 6.2 F Median household income ($) 19,897 (Z=16,121) 30,095 Poverty (%) 31.6 (Z=34.7) 13.1 * Indian Health Service ** National Center for Health Statistics

27 Health Issues American Indians US general population Life expectancy (yrs) 71.1* 75.8** Diabetes (%)*** ESRD (pmp)**** 3,089 1,212 CVD mortality (per 100,000 pop) 156.0* 138.0** *Indian Health Service; ** National Center for Health Statistics (NCHS); *** Diabetes Care 23:1786, 2000; **** USRDS 2001

28 ESRD among Zuni Indians (per 1,000 pop, age and gender adjusted ) Zuni Indians 3.1 American Indians 0.9 European Americans 3.9 African Americans 1.2 US Population USRDS 2000; Stidley CA et al, AJKD 2002

29 Stages of Kidney Disease in the Zuni Indians Prevalence (%) US population Zuni Indians Stages of kidney disease Among the Zuni Indians CKD is 2.5 times more common than in the US population. In Zuni 80% of kidney disease is early stages (stages 1 and 2) compared to 58% in the US.

30 # of participants Current Participants-GKDZI n= % 34% 17% 28% 24%

31 # of participants Participants with Kidney Disease 84% 67% 43% 36%

32 # of participants How Kidney Disease is Expressed 59% 26% 10% 6%

33 -Environmental Study

34 INTRODUCTION Home-based jewelry making (JM) is of great cultural and economical importance to the Zuni Pueblo Home-based jewelry making is associated with chronic exposure to heavy metals There is increased epidemic of diabetic and non-diabetic kidney disease among the Zuni Indians

35 METHODS 40 Zuni Households 18 JM homes 22 Non-JM homes Environmental samples collected from workspace and living areas (715 cm 2 )

36 METHODS Home metal burden (HMB 30) is defined as dust samples containing >30 heavy metals with swipe concentration in the top 50th percentile Home metal burden (HMB 20) is defined as dust samples containing >20 heavy metals with swipe concentration in the top 50th percentile Generalized estimating equations (GEE) used to construct models with and without diabetes mellitus (DM) We used UACR>0.03 as outcome and HM burden as primary exposure. We used DM, living in JM or non-jm homes, age, gender as covariates.

37 Concentration, geometric mean (ug/sample) 100 Metals in Surface Dust in JM and Non-JM Homes 10 Non-Jewelry Living Area Jewelry Living Area Jewelry Work Area Silver Copper Zinc Boron Nickle Tin Lead Antimony Cadmium Mercury

41 Lead 0.68 Antimony 0.02 Cadmium 0.61 Mercury 0.02 Metal p-value Silver 0.001 Copper <0.

39 Differences in Metal Concentrations Living areas: JM vs. non-jm Homes JM Homes: Work vs. living areas Metal p-value Silver <0.001 Copper <0.001 Tin 0.37 Boron 0.11 Nickel 0.02 Zinc 0.41 Lead 0.68 Antimony 0.02 Cadmium 0.61 Mercury 0.02 Metal p-value Silver Copper <0.001 Tin Boron Nickel Zinc Lead 0.04 Antimony 0.22 Cadmium Mercury 0.08

40 Odds Ratio [95% CI] for Albuminuria Variables HMB30 Living in JM home Diabetes HMB30 Model-I 6.45 [1.94, 21,44]* 0.79 [0.26, 2.44] 2.33 [0.66, 8.27] Model-II 5.75 [1.79, 18.50]* 0.80 [0.26, 2.42] Variables HMB20 Living in JM home Diabetes HMB20 Model-I 3.71 [1.16, 1.91]* 0.66 [0.22, 2.09] 2.05 [0.64, 6.60] Model-II 3.54 [1.13, 11.10]* 0.67 [0.21, 2.11] *p<0.01, Model I and II are with and without DM in the model respectively.

41 Urine TGF- /Creatinine Ratios by Metal GLM Adjusted for Diabetes and Albuminuria (Urinary TGF- / Urinary Creatinine)x 10-5 * * * * * * p<0.05 w/ metal w/o metal Cadmium Copper Iron Nickel Silica

42 Home base health care Why??? Costs of Kidney Failure Are High (in $billions for 2000) Kidney Failure Care 19.3 Kidney Failure Accounts for 6% of Medicare Payments Total NIH Budget 17.8 Lost Income for Patients Is $2-4 Billion/Yr

43 Home base health care Why??? Medicare Kidney Program -$23 billion Transplant payment -$106,000/Transplant $17,000/yr anti-rejection cost Dialysis treatment -$71K -120K/patient/yr Barriers to health care in Zuni- Unique combination of historical, economic and cultural barriers, which limit health care utilization thereby increasing health disparities.

44 ZHI -Specific Aims Hold focus groups to inform the design of a culturally sensitive chronic care model that when implemented will decrease the burden of chronic disease. Develop a culturally sensitive education curriculum for community, family and individuals to teach healthy life styles, chronic disease prevention and improved health care utilization. Recruit 100 participants from 1 extended families. Work with IHS to Implement nationally recognized screening and treatment guidelines for hypertension, diabetes, obesity, hyperlipidemia, and kidney disease.

47 Acknowledgments Zuni Tribal Council Philip Zager Arlene Bobelu - coordinator Zuni Staff Thomas Welty Andrew Narva David Kessler Ama hon ansam'ona dobinde tse'makwinn ashanna, demla a:hoi hon yansatdunap'du. Let s have a vision to help all human beings!!!!

TREAT THE KIDNEY TO SAVE THE HEART. Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd, 2009

TREAT THE KIDNEY TO SAVE THE HEART Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd, 2009 1 ESRD Prevalent Rates in 1996 per million population December