Dehydration, Medication Potential Factors in CKD Epidemic in Nicaragua.
In their search for causes of an epidemic of chronic kidney disease in Nicaragua, a BUSPH-led team gathered insights from local health workers, who cited heat stress, insufficient water intake — and medical treatment that may further damage kidneys.
In a study published in the journal BMC Public Health, the research team interviewed 10 physicians and nine pharmacists in northwest Nicaragua, where chronic kidney disease (CKD) has claimed the lives of a disproportionate number of agricultural workers, most of them young adult men. BUSPH researchers have been working in northwestern Nicaragua since 2009, as part of a mediation process that includes the management of a major sugar producer in northwestern Nicaragua and a group of about 2,000 former sugarcane workers and community members who are affected by CKD.
Madeleine Kangsen ScammellThe health professionals interviewed said they perceived CKD as a serious and increasing problem in the region. All of them regarded exposure to sun and heat, as well as dehydration, as critical factors associated with the occurrence of CKD. They indicated that reluctance among workers to hydrate might be influenced by perceptions of water contamination.
The physicians and pharmacists also said that symptoms related to dehydration often were treated with non-steroidal anti-inflammatory drugs (NSAIDs), diuretics and antibiotics – medications that may contribute to CKD.
“These interviews have highlighted several potential contributors to CKD in Nicaragua, including heat stress and use of potential nephrotoxic medications, supporting the plausibility of a multi-factorial cause of CKD,” the researchers said. They recommended increased education for pharmacists and doctors on the diagnosis and treatment of heat-exposure symptoms and urinary tract infections, as well as greater oversight of “self-medication” for dysuria-related symptoms.
“Despite the media attention given to the potential role of agrichemicals in causing CKD, physicians and pharmacists were much more likely to cite exposure to heat, physical work and dehydration as key factors responsible for CKD — a common combination of exposures among men in this region and in Central America,” the research team said. Those insights are consistent with regional studies, which have found that CKD appears more common among occupations in which strenuous work is undertaken at high ambient temperatures.
Dan Brooks“Although not a recognized cause of CKD, heat stress is associated with volume depletion and may also be associated with muscle damage (rhabdomyolysis), both of which may predispose individuals to AKI (acute kidney injury), particularly in the presence of nephrotoxic medications,” the study says. “Critically, there is a growing body of literature that suggests that AKI, even if mild or if the serum creatinine recovers to baseline, may result in residual structural damage and ultimately progress to clinically recognized CKD.”
The authors of the study include: Madeleine Kangsen Scammell, assistant professor of environmental health at BUSPH; Dan Brooks, associate professor of epidemiology at BUSPH; Dr. Oriana Ramirez-Rubio, a preventive medicine and public health specialist pursuing her PhD at Universidad Autonoma de Madrid, Spain, and an international research scholar at BUSPH; Dr. Juan Jose Amador, an epidemiologist from Nicaragua who leads the BU field research team; Dr. James S. Kaufman, formerly a professor of medicine and staff nephrologist at the VA Boston Healthcare System and BU School of Medicine who is currently with the VA New York Harbor Healthcare System; and Dr. Daniel E. Weiner, assistant professor of medicine at Tufts University School of Medicine and a nephrologist at Tufts Medical Center.
Submitted by: Lisa Chedekel Chedekel@bu.edu