Table 5.
Recommendations for an action plan to improve the understanding of environmental factors of chronic kidney disease hotspots
| Goals | Activities | Category |
Partners | Special aspects in LMICs | Milestones | Timeline | |||
|---|---|---|---|---|---|---|---|---|---|
| Research | Clinical care | Education | Advocacy | ||||||
| 1.Characterize CDK hotspots and CKDu | |||||||||
| Agree on a definition of CDK hotspots and CKDu | x | ISN, CENCAM, WHO, PAHO, universities | PAHO, CDC, and SLANH recently convened a working group to define CKDu in agricultural communities | Publications and reports | 1 yr | ||||
| Develop a registry and an interactive map of CKD hotspots and CKDu with data on CKD prevalence, incidence, and potential risk factors | x | ISN, CENCAM, WHO, PAHO, MOH, public health schools | Will require funding | Publications, reports, and the Internet | 2 yr | ||||
| 2.Improve research methods | |||||||||
| Search for the cause of CKDu | Perform studies with a lifecycle approach that considers factors such as genetic predisposition, prenatal exposures, parents’ health status, working age, and social determinants of health | x | CENCAM, ISN, WHO, PAHO, public health schools, MOH | Particularly relevant in LMICs due to the potential role of genetic, developmental, and socioeconomic factors | Publications and reports | 5–10 yr | |||
| Perform epidemiologic studies to continuously assess CKD prevalence and risk factors | x | CENCAM, ISN, WHO, PAHO, public health schools, MOH, NGOs | Particularly relevant in LMICs due to the potential role of genetic, developmental, and socioeconomic factors | Publications and reports | 5–10 yr | ||||
| Perform interventional studies when risk factors are reasonably well established | x | CENCAM, ISN, WHO, PAHO, public health schools, MOH, NGOs | Potential risk factors can be suspected but not necessarily confirmed | Publications and reports | 5–10 yr | ||||
| Standardize data collection tools in different studies in different countries to facilitate comparison of research results and accelerate progress | x | ISN, CENCAM, WHO, PAHO, public health schools | Should include global as well as local risk factors for CKD | Reports | 1 yr | ||||
| Promote international and multidisciplinary collaboration through a research consortium to link efforts around the globe | x | x | ISN, CENCAM, WHO, PAHO, public health schools, MOH, NGOs | LMICs may benefit from such international collaborations | Publications, reports, and the Internet homepage |
2 yr | |||
| Develop biomarkers for detecting early kidney disease and identifying exposure | x | Basic scientists, clinical researchers | Synergies between HICs and LMICs may be required | Publications and reports | 5–10 yr | ||||
| Perform genetic and epigenetic studies to evaluate genetic susceptibility of specific populations to different environmental factors | x | Genetic epidemiologists | Synergies between HICs and LMICs may be required | Publications and reports | 5–10 yr | ||||
| Develop a biorepository with urine samples, serum samples, and DNA to enable future analysis with advanced techniques and understanding | x | ISN, CENCAM, WHO, PAHO, public health schools | Synergies between HICs and LMICs may be required | Biorepository | 5–10 yr | ||||
| 3.Prevent CKD | |||||||||
| Implement preventive interventions | Evaluate local factors and implement preventive interventions based on confirmed or presumed risk factors for CKD, including children and adolescents if appropriate | x | WHO, PAHO, MOH, local health care authorities | Basic public health and occupational interventions may have significant impact and be relatively inexpensive | Assess CKD incidence trends | 5 yr | |||
| Develop local ongoing surveillance systems | x | CENCAM, MOH, NGOs | Essential to assess the efficacy of interventions | Publications and reports, and the Internet | 5 yr | ||||
| Reduce environmental exposure | Agrochemical and industrial chemical control | x | MOH, Ministries of Labor, corporations | Although evidence that agrochemicals cause nephrotoxicity is very limited, it causes CKD | Reports | 5–10 yr | |||
| Access to safe drinking water | x | Government, MOH | Basic human right | Reports | 5–10 yr | ||||
| Regulate herbal and other traditional medicines | x | Government, MOH | Herbal medicine use is very common in LMICs | Reports | 5–10 yr | ||||
| Reduce or eliminate exposure to heavy metals | x | Government, MOH, corporations | Prioritize by the level of exposure and risk of nephrotoxicity | Reports | 5–10 yr | ||||
| Regulate exposure to organic contaminations, including ongoing surveillance programs | x | Government, MOH, corporations | Prioritize by the level of exposure and risk of nephrotoxicity | Reports | 5–10 yr | ||||
| Eradicate infections potentially related to CKD | Access to safe drinking water | x | Government, MOH, WHO, PAHO | Basic human right | Reports | 5–10 yr | |||
| Sanitation control | x | Government, MOH, local health care authorities | Prioritize based on local epidemiology | Reports | 5–10 yr | ||||
| Vector control | x | MOH, local health care authorities | Prioritize based on local epidemiology | Reports | 5–10 yr | ||||
| Implement vaccination | x | MOH, local health care authorities | Prioritize based on local epidemiology | Reports | 5–10 yr | ||||
| Assess the potential role of infections and develop an action plan with infectious disease specialists and health care authorities for mass treatment programs | x | ISN, CENCAM, WHO, PAHO, MHO, public health schools | Particularly important in some LMICs | Publications and reports | 5 yr | ||||
| Improve working conditions in poor agricultural communities | Develop a legal framework for workers’ protection | x | Government, international agencies, corporations, human rights organizations | Importance of involving nonmedical parties | Reports | 2–5 yr | |||
| Enforce compliance with existing rules and regulations | x | Government, international agencies, corporations, NGOs | Importance of involving nonmedical parties | Reports | 2–5 yr | ||||
| Break the cycle of poverty, malnutrition, and death | x | x | Government, international agencies, corporations, NGOs | Importance of involving nonmedical parties | Reports | >10 yr | |||
| 4.Offer affordable CKD treatment options to affected individuals | |||||||||
| Implement CKD screening programs based on local risk factors | x | MOH, local health care authorities | Both case finding and opportunistic CKD screening | Assess CKD incidence | 5 yr | ||||
| Increase access to affordable and quality CKD care | x | ISN, MOH, local health care authorities | Will require more funding for infrastructure | Publications and reports | 5–10 yr | ||||
| Improve access to nephroprotective medications | x | WHO, PAHO, ISN, MOH, local health care authorities, industries | Use bioequivalent generic medications | Reports | 5–10 yr | ||||
| Improve access to RRT if possible | x | Government, MOH, ISN, ASN, NGOs, industries | Peritoneal dialysis may be a cheaper option | Reports | 5–10 yr | ||||
| 5.Increase funding and advocacy | |||||||||
| Support research and channel aid money to research related to prevention | x | ISN, CENCAM, WHO, PAHO, MOH, NGOs, corporations, industries | Essential to continuously search for the cause of CKDu in many regions and to know trends | Reports of research funds | 2 yr | ||||
| Develop synergies to strengthen fund raising efforts and collaborate with other parties interested in chronic conditions | x | ISN, CENCAM, WHO, PAHO, NGOs, MOH, corporations | LMICs will require national and international support | Reports | 2 yr | ||||
| 6.Improve education and awareness | |||||||||
| Improve the education of health care professionals (mainly PCPs) regarding the prevention and treatment of CKD | x | ISN, regional and local nephrology societies, NGOs | Partnerships with local renal societies may be helpful | Reports | 5 yr | ||||
| Build workforce capacity by training nephrologists | x | ISN, regional and local renal societies, hospitals | ISN may continue to play an important role by training nephrologists of developing countries | Reports | 5 yr | ||||
| Educate workers about potential preventive measures at work (i.e., hydration, etc.) | x | Government, MOH, NGOs | Basic public health and occupational interventions may have significant impact and be relatively inexpensive | Reports | 5 yr | ||||
| Educate the general population to increase the awareness about risk of herbal medicines and other nephrotoxins | x | Government, MOH, NGOs | Herbal medicine and NSAID use is very common in LMICs | Reports | 5 yr | ||||
CDC, Centers for Disease Control and Prevention; CENCAM, Consortium for the Epidemic of Nephropathy in Central America and Mexico; CKD, chronic kidney disease; CKDu, chronic kidney disease of unknown etiology; HICs, high-income countries; ISN, International Society of Nephrology; LMIC, low- and middle-income country; MOH, Ministry of Health; NGOs:, non-profit organizations; NSAID, nonsteroidal antiinflammatory drug; PAHO, Pan American Health Organization; PCPs, primary care physicians; RRT, renal replacement therapy; SLANH, Society of Latin American Nephrology and Hypertension; WHO, World Health Organization.