Cooperation with developing countries:
the example of Nicaragua
A. Edefonti1, G. Marra1, F. Sereni1 ,
M. Sandoval2, Y. Silva Galàn2
1
2
UOC. Nefrologia e Dialisi Pediatrica, Clinica Pediatrica G e D. De Marchi, Milano, Italy
Departamento de Nefro-Urologia Pediatrica, Hospital Infantil de Nicaragua MJR, Managua, Nicaragua
42° Annual ESPN Meeting, Lyon, September 11-14, 2008
Introduction
• No specific pediatric workshop dedicated so
far to the initiatives of cooperation, but
increased awareness of the matter
• ISN organizing a COMGAN workshop during
WCN, Milan 2009
• Pediatric contributions in the literature about
the epidemiology of renal diseases in the
developing countries, but not about models
of cooperation
(Cont.)
• Pediatric Nephrologists always open to
educational matters (courses, stages for
doctors of developing countries)
• ESPN members regularly receiving trainees
from abroad and developing differents types
of projects
• No systematic documentation so far of the
initiatives of pediatric cooperation worldwide
– IPNA Fellowship Committee starting to require
feed-back and track doctors receiving educational
grants
A provocative question
Is cooperation with developing
countries only an educational
(teaching /training) issue?
The start of the cooperation with the
Pediatric Nephrology Unit of Managua
• 1997-1999
Stage in Milano of Dr. Mabel Sandoval Dìaz
• 1999-2000
Complain about lack of tools to properly
diagnose and treat renal diseases in the
Nicaraguan Hospitals
• 2000
Visit to Nicaragua of Italian pediatric
nephrologists and recognition of the
paucity of human, instrumental and
economic resources at Hospital Infantil MJR
• 2001
Start of the project of cooperation, financed
initially by the Associazione per il Bambino
Nefropatico, Milano
Topics
• Methodology of the project
• Results of the project
– Clinical activity
– Epidemiology
• Points of discussion
Nicaraguan demographic indicators
Total
Population
5 142 098
Child
Population
2 514 144
Child mortality
36/1000
Annual per
capita income
$ 730
Life expectancy
Male
67.0 years
Female 71.0 years
www.inec.gob.ni
Censo de Poblaciòn 2005.
Characteristics of the initial project
1.
Free of charge basic assistance for children with
renal diseases
•
Lab test, drugs, imaging (in the private system, whenever
necessary)
2.
Establishing shared nephrological protocols for the
main kidney and UT diseases (the 10 clinical
syndromes)
3.
Establishing a Pediatric Nephrology Unit in a public
Children University Hospital in Managua
•
•
Scaled training in Milano of the different components of the
team, (Pediatric Nephrologists, Urologists, Imaging
specialist, Pathologists, Dialysis Nurse)
Building a new Pediatric Nephrology ward
Characteristics of the initial project
4.
5.
Implementation of a database
•
to gather data on the epidemiology of renal diseases (with
special regard to CKD)
•
to record and monitor clinical activity
•
to make quality control of the diagnoses
Web connection between Milano and Managua for
clinical consultation
Expansion of the initial project
1.
Start of a RRT program (2 beds for HD, CAPD and 6
living donor Tx per year) for selected children with
ESRD
2.
Establishing a Pediatric Nephrology Network
including 5 District Hospitals covering about 55%
of the Nicaraguan population
-
to increase diagnostic and therapeutic power in each
hospital (supply of lab test, medications, imaging tools,
shared protocols)
-
to avoid patient and family unnecessary transfer to
Managua, whenever possible
Expansion of the initial project
3. Proposal of the model of cooperation to other Central
America countries
•
Sharing database with Guatemala
•
Conference on the Prevention and Management of CKD in five
Central America countries (29th of February 2008)
4. Extension of the project to a 6th District Hospital
where CKD prevalence is allegedly high (61% of
population covered)
5. Project of early diagnosis and treatment of kidney and
UT diseases in the peripheral “Unidades de Salud”
depending from the 6 District Hospitals
The Pediatric Nephrology Network in Nicaragua
at September 1 st 2008
León
Jinotega
Chinandega
Managua
Milano
Matagalpa
Masaya
Granada
Chronology of the project of cooperation
2001
Basic assistance
Protocols/guidelines
Team training
Database
Web connection MI – MA
Infrastructure
Dialysis and Renal Transplantation
Network of 5 District Hospitals
Database shared with Guatemala
Central America conference on CKD
Extension to a 6th District Hospitals
Extension to territorial “Unidades de Salud
2002
2003
2004
2005
2006
2007
2008
Funding of the cooperation
project (2001-2008)
Private Foundations
Public Grants
Associazione per il
Bambino Nefropatico,
Milano (2001-2008)
Health Ministry of Regione
Lombardia
(2004-2008)
Asociación para Niños
Nefropáticos, Managua
(2004-2008)
IPNA Educational Grant
(2008)
€ 600 000
€ 550 000
Funds from Nicaraguan Health Ministry
• Salaries for 4 Pediatric Nephrologists, 2 Urologists, 1
Pathologist, 11 Nurses, 1 part time Dietician and 1
Psychologist in Managua and 6 Pediatricians of
District Hospitals
• Costs of hospitalization, essential medications, lab
test and imaging
• Costs of Peritoneal Dialysis, (CAPD and APD) in
Managua
• Cost of immunosuppressive medications for renal
transplant in Managua since 2008
Topics
• Methodology of the project
• Results of the project
– Clinical activity
– Epidemiology
• Points of discussion
Clinical activity of the Pediatric Nephrology
Unit of HINMJR during the year 2007
Number of hospitalizations
Number of outpatient visits
– Nephrology
– Urology
Number of renal biopsies
Number of urodynamic tests
818
3096
1842
29
61
Clinical activity of the Pediatric Nephrology
Unit of HINMJR at 31 th of December 2007
Number of children with CRI/ESRD
Number of children treated with chronic HD
Number of children treated with PD
Number of transplanted children
• 2004 – 2007
• 2008
166
13
9
17
14
3
Cumulative number of children with kidney
and UT diseases entered in the database
Pediatric Nephrology Unit of HINMJR (2002 – 2007)
2019 patients
2500
2000
1500
1000
500
0
2
200
3
200
4
200
5
200
6
200
7
200
Cumulative number of children with kidney and UT
diseases entered in the database
District Hospitals (2005 – 2007) 858 patients
300
250
200
Granada
Jinotega
Masaya
Leon
Matagalpa
Managua
150
100
50
june-05 sept-05 dic-05
mar-05 june-06 sept-06 dic-06
mar-07 june-07 sept-07 dic-07
Main diagnoses of kidney and UT diseases
in Nicaragua
Pediatric Nephrology Unit of HINMJR (2002 – 2007) 2019 patients
500
450
400
350
300
250
200
150
100
50
0
P
A
N
SG
SS
S
N
ic
en
g
ro
eu
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at
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oh
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O
Main diagnoses of kidney and UT diseases in
Nicaragua
5 District Hospitals (2005 – 2007) 858 patients
400
350
300
250
200
150
100
50
In
s
sis
Lit
hia
uf
fic
ien
cy
Ur
op
Re
na
l
Ob
st .
s
op
at
ie
ep
hr
Ot
he
rn
ro
tic
sy
n
do
me
UT
I
Ne
ph
AP
SG
N
0
Epidemiology of CRI in Nicaragua
Nicaragua
Italy *
Point Prevalence
(patients/pmpp)
36,4
74,7
Incidence
(patients/pmpp)
9,8
12,1
Incidence in the period 2002 - 2007
16,0
14,0
12,0
10,0
8,0
6,0
4,0
2,0
0,0
2002
2003
2004
2005
2006
2007
* Ardissino GL. et al. Epidemiology of chronic renal failure in children data from ITALKID project (2003) Pediatrics 111;4:382-387
Primary renal diseases causing CRI
at HINJMR (2002 – 2007) 166 patients
500
450
400
350
GFR:≤90ml/min/1,73
300
250
200
150
100
50
rs
e
O
th
is
ri
t
h
us
p
Lu
yp
h
ey
n
id
N
ep
op
V
U
la
si
a
R
S
R
N
S
th
ia
si
s
N
D
ro
p
.U
st
O
b
Li
K
N
e
ur
og
en
ic
b
A
la
d
de
P
SG
r
N
0
Prevalence of CRI (patients/pmp) in the
Nicaraguan Districts
210
Districts inside the project
Districts outside the project
150
120
90
60
30
Nu
Se
go
vi
a
Ji
no
te
ga
ev
a
on
t
al
es
RS
J
Ch
Ri
va
s
in
an
de
ga
M
at
ag
al
pa
Ca
ra
zo
Ch
ac
o
Bo
A
ra
na
da
G
RA
M
as
ay
a
Es
te
lí
M
an
ag
ua
0
Le
ón
prevalencia pmp
180
Follow-up of patients with CRI
CRI
166
Deceased
67
* Without RRT
54
Lost to follow-up
41
CRI
32
On RRT
13
On follow-up
58
PD
5
HD
7
Tx
14
* Medical decision 27 %
Family decision 48 %
(socioeconomic reasons)
Deceased before the onset of the RRT program 25 %
Topics
• Methodology of the project
• Results of the project
– Clinical activity
– Epidemiology
• Points of discussion
Points of Discussion
• The problem of allocation of financial resources to
pediatric subspecialties by Health Ministries of
developing countries
- Low budget expected
- More for primary care than for tertiary care
• Top-down model (development of a central unit
prior to peripheral hospitals) preferable for pediatric
subspecialties?
• Financial feasibility of the assistance to CKD/ESRD
in a developing country and scaled transfer of the
costs to the government
Points of Discussion
• Need for fund-raising programs from private and
public institutions to finance a cooperation project
• Role of data-bases to assess and monitor the efficacy
of a project and to allocate financial resources
• Ethical issues, like allocation of financial resources to
dialysis/Tx vs prevention programs of CKD or
selection criteria for patients in need for RRT
• Extension of the cooperation model to other countries
(methodological aid instead of financial aid)
A provocative question
Is Cooperation with developing countries
only an educational (teaching/training) issue?
No. There’s something more to do than just
giving the instructions to catch the fish
You should provide also (at least one) fishing rod
What is the fishing rod?
• Experience in the development and
management of a Pediatric Nephrology Unit
and Pediatric Nephrology Network
• Financial resources, through fund-raising
programs, both in the developing and
industrialized countries
• Experience in scientific communication
What about scientific communication?
• Need for discussing models of cooperation and
confronting different experiences
• Need for spreading a culture of cooperation among
pediatric nephrologists
Dedicated workshops?
Publications in pediatric journals?
Internet?
Registry?
Life is calling. How far will you go?
Thanks