Chronic kidney disease in Nicaragua: a qualitative analysis of semi-structured interviews with physicians and pharmacists

Oriana Ramirez-Rubio Daniel R Brooks Juan Jose Amador James S Kaufman Daniel E Weiner Madeleine Kangsen Scammell 0 0 Department of Environmental Health, Boston University School of Public Health , 715 Albany St. T4W, Boston, MA 02118 , USA Background: Northwestern Nicaragua has a high prevalence of chronic kidney disease (CKD) of unknown cause among young adult men. In addition, frequent occurrence of urinary tract infections (UTI) among men and a dysuria syndrome described by sugarcane workers as chistata are both reported. This study examines health professionals perceptions regarding etiology of these conditions and their treatment approaches, including use of potentially nephrotoxic medications. Methods: Nineteen in-person semi-structured interviews were conducted in November 2010 among ten physicians and nine pharmacists practicing in the region. Results: Health professionals perceived CKD as a serious and increasing problem in the region, primarily affecting young men working as manual laborers. All interviewees regarded occupational and environmental exposure to sun and heat, and dehydration as critical factors associated with the occurrence of CKD. These factors were also considered to play a role in the occurrence of chistata in the region. Health professionals indicated that reluctance among workers to hydrate might be influenced by perceptions of water contamination. Symptoms often were treated with non-steroidal antiinflammatory drugs (NSAIDs), diuretics and antibiotics. Physicians acknowledged that the diagnosis of UTI usually was not based on microbial culture and opined that the use of potentially nephrotoxic medications may be contributing to CKD. Conclusions: Interviews provided evidence suggesting that medications such as diuretics, antibiotics and NSAIDs are widely used and sold over the counter for symptoms that may be related to dehydration and volume depletion. These factors, alone or in combination, may be possible contributors to kidney damage. Acute kidney damage coupled with volume depletion and exposures including medications and infectious agents should be further evaluated as causal factors for CKD in this region. - Background Chronic kidney disease (CKD) is a serious and increasing global health problem. Treatment for its most severe form, end stage renal disease, with dialysis or transplant is currently not available in many parts of the world [1,2]. Major known risk factors for CKD include diabetes and hypertension [3,4]. However, in lower income countries CKD may be associated with chronic glomerulonephritis and interstitial nephritis, which are generally ascribed to infectious and parasitic agents [5]. In Central America, case reports and government statistics document high mortality due to CKD, particularly among younger men and in certain regions of the Pacific coast [6-8]. Community prevalence studies in Nicaragua and El Salvador are consistent with these mortality data and have attempted to assess associations with pharmaceutical, behavioral, environmental and occupational exposures [9-15]. However, the causes of the high prevalence of CKD remain unknown. Our team has been working in northwestern Nicaragua since 2009 as part of a mediation process (termed the Dialogue Table) including the management of Nicaragua Sugar Estates Limited (NSEL), a major sugar producer in northwestern Nicaragua that operates the Ingenio San Antonio located in the town of Chichigalpa, and the Association of Chichigalpans for Life (ASOCHIVIDA), a group of approximately 2000 former NSEL workers and community members who are affected by CKD. The Dialogue Table was established in 2008 after ASOCHIVIDA filed a complaint with the Compliance Advisor Ombudsman (CAO), the independent office that handles complaints from communities against the World Bank Groups private sector arm which had provided funding to NSEL. CAO formed the Dialogue Table in response to the complaint, and the participants determined that they wanted an outside scientific group to make an independent assessment of the epidemic. Our team led by the Boston University School of Public Health was selected by Dialogue Table participants. Our research occurred in stages, beginning with a scoping study summarizing the available information on CKD in the region, identifying data gaps, and recommending research activities to address those gaps [16]. During the process of conducting the scoping study we learned from members of the Dialogue Table and from informal discussions with area physicians of the frequent occurrence of a set of symptoms referred to locally as chistata, characterized by painful urination and often accompanied by kidney and/or back pain, and the common diagnosis of urinary tract infections (UTIs) among young men. Our final list of potential causes was extensive [16]. We identified several feasible activities that would provide more information to evaluate these hypotheses [16,17]. Among the subsequent research activities, we conducted qualitative interviews in Chinandega and Leon (regions with the highest CKD mortality rates in Nicaragua) both with physicians who are likely to diagnose or treat chistata, UTI, and/or CKD and with retail pharmacists who are likely to fill prescriptions or sell medications to treat these conditions. Medication use was on our list of hypotheses because members of the Dialogue Table reported that use of analgesics, and potentially nephrotoxic antibiotics that would require prescriptions in many higher income countries, were common in Nicaragua and could be obtained without a prescription. Medications are a common cause of acute kidney injury and may be associated with CKD [18]. For example, non-steroidal antiinflammatory drugs (NSAIDs) are a frequent cause or contributor to acute kidney failure in the setting of severe volume depletion or other nephrotoxins. Aminoglycosides (a class of broad spectrum antibiotics) also are common causes of acute kidney failure, with risk factors including preexisting kidney disease, concomitant nephrotoxic medication use, and dehydration/volume depletion. Study aims While there had been a great deal of media and activism focused on CKD and potential causes in Nicaragua, we did not know the general knowledge, opinion or practice of physicians and pharmacists in the region. Our aims in this study were to: (1) increase our understanding of health professionals perceptions regarding CKD in the region (characteristics of the affected population, causal hypotheses, symptoms, diagnostic tools, treatment and prognosis); (2) determine whether further study of the relationship among hydration practices, diagnosis of UTI/chistata and use of medications is warranted; and (3) explore potential opportunities for public health interventions related to the CKD epidemic aimed at physicians and pharmacists. This was the first effort known of by our team to engage physicians and pharmacists in Nicaragua in a formal assessment of th (...truncated)