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 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
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
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
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 México. 2009 * Sanabria L, et al: unpublished data.
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
Garcia G et al; Semin Nephrol 2010;30:3-7 Garcia G et al; Kidney Int 2005;Suppl 97: 58-61
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
Garcia G et al; Semin Nephrol 2010;30:3-7 Garcia G et al; Kidney Int 2005;Suppl 97: 58-61
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.
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 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
Kidney International Supplements (2013) 3, 250–253
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
Kidney International Supplements (2013) 3, 250–253
Addictions prevalence: Homeless vs General Population
Kidney International Supplements (2013) 3, 250–253
HIV, Hepatitis B and C Prevalence:Homeless vs General Population
Kidney International Supplements (2013) 3, 250–253
ENSA 2000 = National Health Survey 2000
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
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.