Thousands Are Dying of Chronic
Kidney Disease in Central America:
“The Malady of the Sugar Cane”
Presented by: Community Health International Medical
Projects for Sustainability (CHIMPS) – Salud Comunitaria
Internacional, Proyestos Médicos para Sostenibilidad
Mission : To cultivate sustainable public health interventions in partnership with underserved communities in developing countries through collaborative education

Deaths from Chronic Kidney Disease
Increased between 2005 and 2009
Deaths in 2009 and increase in mortality rate over 4 years from 2005-
09 Map/data from: http://www.publicintegrity.org/

El Salvador has highest mortality from
Chronic
Kidney
Disease (CKD) in world!
• Jesus Sosa Mancia, a CKD patient in Bajo Lempa, at home visit by a medical team from the national health ministry.
Sasha Chavkin/ICIJ
CKD 2 nd leading cause of death in men ages 20-60 in El Salvador

Social Cost is Enormous & Increasing
• Renal dialysis and transplant limited availability, costly
• Families left without financial support…”isla de viudas” in Nicaragua
• Loss of large portion of population in their most economically productive years

• Hard to prevent as symptoms do not develop until kidneys failing
• Generalized skin itching
• Weakness
• Fatigue and inability to carry out activities of daily living
• Blood & urine tests can detect it earlier

Damage is primarily to kidney tubules
Two main causes of kidney tubule damage:
• Decreased blood flow most commonly from dehydration
• Exposure to toxins
No evidence that this form of CKD is related to hypertension, obesity or diabetes as in the US

Limited Investigations Started in 2009
• Mainly found in sugar cane & cotton workers but also in construction, mining, shipping
• Associated with lower elevation communities
(cane workers at higher elevations without CKD)
• Similar disease in Sri
Lanka, India, Egypt
• Funeral in Costa Rica of sugar cane worker

Epidemic heavily focused in communities on Pacific side
From Brooks DR, Ramirez-Rubrio O, Amadar JJ. CKD in Central America:
A Hot Issue. Am J Kidney Dis 2012; 59:481-484.

Kidney Injury Associated with Years of Work
Peraza S et al, Decreased kidney function among agricultural workers in El Salvador
Am J Kidney Dis 2012; 59:531-540

Possible factors studied that are not single causes of this epidemic of CKD
• Heavy metals: lead, cadmium
• Arsenic (common in volcanic soil/cotton )
• Agrichemicals properly manufactured/applied
• Leptosporosis
• Medications: pain meds
(NSAIDs) and certain antibiotics
• Alcohol

Several Factors Combined May Cause
Chronic Kidney Disease
• Heat exposure and exhaustion – paid by weight of cane cut
• Pesticides
– Direct contact
– Water contamination
• Predisposition due to
– Intrauterine stress
– Acute kidney injury in childhood
– ? Genetic factors

Causes from Perspective of Workers and Central American Doctors
• Dr. Carlos Orantes.
“There are 3 factors: prohibited pesticides, combinations of pesticides and no protection from pesticides”
• Lack of any regulation for worker protection from chemicals
• Concern about water contamination by agrachemicals
Photo from: http://desinformemonos.org/2012/10/miles-de-muertes-en-nicaraguaa-causa-de-un-ingenio-azucarero/nicaragua-central-america-mystery-disease/

Prevention And Interventions
From Levey AS, Stevens LA, Coresh J. Conceptual Model of CKD: Applications and
And Implications. AJKD 2009; 53: S4-S16

What has been done to control this epidemic in effected countries?
• Sri Lankan gov’t & WHO conducting large study
• In CA, only 2 scientific conferences, one in
2005 and fall of 2012
• In ES, MOH focus on
PAHO to make major health concern;
Nefrolempa pilot study on coast
• MOH of El Salvador with El Salvador &
Cuban physicians reviewing pilot study results

Rise in Latino Immigrants in End Stage
Kidney Disease in US
• Increase in Latino immigrants needing dialysis in US
• University Medical Center in Las Vegas spent $24 million on emergency dialysis treatment for 80 patients in 2010…most undocumented and without medical insurance.

• 1/ 4 th of US sugar imported from CA
• Educate the public/members of your groups about the CKD epidemic
• Look at sources of sugar you buy. Urge
Puget Consumer Co-op, Trader Joe,
Whole Foods, Safeway, etc to find out
– Do growers have workers with CKD?
– Do workers have breaks & hydration?
– Are workers protected from pesticides?
• Put pressure on World Bank/IMF to force growers to change work conditions:
Compliance Advisor/Ombudsman Office
(http://www.cao-ombudsman.org/)

Demand Funding for Rigorous
Research to Find Main Causes
• Need a large and well designed case-control study
• Urge research and forums by:
– Pan American Health Organization
– World Health Organization
– CDC, NIH
• Support surveillance for kidney injury in workers and longitudinal studies
• Studies done to date funded by Cuba, Sweden

Conduct Education About Prevention with Latino Communities in US & CA
• Protection from agrichemicals when working
• Avoidance of medications that cause kidney injury
• Promote good hydration while working
• Avoidance of water and food contamination by chemicals that can harm kidneys

• http://www.guardian.co.uk/world/2012/oct/14/kidney-diseasekilling-sugar-cane-workers-central-america
• http://openchannel.nbcnews.com/_news/2012/10/16/13866856mystery-kidney-disease-decimates-central-america-sugarcaneworkers?lite
(video)
• Ramirez-Rubrio O, McClean MD, Amador JJ, Brooks DR. An epidemic of chronic kidney disease in Central American, an overview: J Epidemiol Community Health 2013; 67: 1-3
• Brooks DR, Ramirez-Rubrio O, Amadar JJ. CKD in Central America: A
Hot Issue. Am J Kidney Dis 2012; 59:481-484.
• Peraza S et al, Decreased kidney function among agricultural workers in El Salvador. Am J Kidney Dis 2012; 59:531-540
• Orantes CM et al. Chronic kidney disease and associated risk factors in the Bajo Lempa region of El Salvador: Nefrolempa study 2009.
MEDICC Review 2011, 14-22.