Tropical Medicine expert Dr. Peter Hotezand colleagues from Baylor College of Medicine at Houston are sounding the alarm about a new hidden killer disease that disproportionately strikes young male Central American agricultural workers — primarily in the Pacific coastal regions of El Salvador and Nicaragua, but also in Guatemala and Costa Rica.
The recently named Mesoamerican nephropathy appears to be an emerging form of chronic kidney disease of unknown etiology. According to Correa-Rotter et al. the syndrome was first described in 2002 as a form of advanced chronic kidney disease at the Rosales Hospital, a referral hospital in the capital of El Salvador. The disease develops without the usual chronic risk factors such as diabetes and hypertension. Among its most common features, Mesoamerican nephropathy typically presents as a progressive tubulointerstitial form of renal disease and failure with no or low grade proteinuria. Histopathology findings from renal biopsies are unique – different from other causes of renal disease. It most commonly affects young men working in sugarcane plantations along the lowland Pacific Coast of Central America. Because this part of Central America is a resource-poor region, those affected often die prematurely due to inadequate access to renal dialysis.
A paper epublished ahead of print in the National Kidney Foundation’s American Journal of Kidney Disease, entitled: “CKD of Unknown Origin in Central America: The Case for a Mesoamerican Nephropathy” (Am J Kidney Dis. 2014 Jan 9. pii: S0272-6386(13)01568-0. doi: 10.1053/j.ajkd.2013.10.062), co-authored by R. Correa-Rotter of the Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, C . Wesseling of Program on Work, Environment and Health in Central America (SALTRA), Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica and R.J. Johnson of Division of Renal Diseases and Hypertension, University of Colorado, Denver, Colorado, notes that Mesoamerican nephropathy victimstypically have a history of manual labor under very hot conditions in agricultural fields, and that clinically, they usually present with normal or mildly elevated systemic blood pressure, asymptomatic yet progressive reduction in estimated glomerular filtration rate, low-grade non-nephrotic proteinuria, and often hyperuricemia and or hypokalemia.
The researchers note that diabetes is absent in this population, and kidney biopsies that have been performed show a chronic tubulointerstitial disease with associated secondary glomerulosclerosis and some signs of glomerular ischemia — causes unknown; Their article discusses and analyzes some of the etiologic possibilities currently under consideration, and note that it’s relevant to highlight that recurrent dehydration is suggested in multiple studies – a condition that possibly could be exacerbated in some cases by other conditions, including the use of nonsteroidal anti-inflammatory agents, but say that at present, Mesoamerican nephropathy is a medical enigma yet to be solved.
Another study, entitled: “End-stage renal disease among patients in a referral hospital in El Salvador,” (Rev Panam Salud Publica. 2002 Sep;12(3):202-6.) co-authored by R.G. Trabanino, R. Aguilar, C.R. Silva, M.O. Mercado, and R.L .Merino. – all of the Departamento de Medicina Interna, Hospital Nacional Rosales, San Salvador, El Salvador, notes that El Salvador is a country with high mortality from end-stage renal disease (ESRD), and that the objective of their study was to determine the epidemiological characteristics of a series of new cases of ESRD seen in a referral hospital in the country.
A cross-sectional study was conducted of all the new cases that initiated chronic dialysis between November 1999 and March 2000. Using a personal interview, data were obtained on the patients’ clinical, demographic, and occupational characteristics, among others.
The study abstract reports; “During the five months that the study lasted, 205 new cases of ESRD were observed. Among the 202 interviewees, two groups were clearly distinguished. One group, of 67 patients (33%), had known risk factors for ESRD, similar to those for developed countries (basically, diabetes mellitus, hypertension, and chronic consumption of non-steroidal anti-inflammatories). Another group of 135 patients (67%) had unusual characteristics that were not associated with the known risk factors. The majority of the patients in this second group were male, farmers, residents of coastal areas or areas next to rivers, and some years before had been exposed, without adequate protection, to agricultural insecticides or pesticides through their work.
They conclude that this group of patients with ESRD seem to lack a cause for their disease, but that their special characteristics make it possible to suspect a relationship with the occupational exposure to insecticides or pesticides, but that new studies are needed in order to confirm this hypothesis.
In a PLOS Neglected Tropical Diseases blog entry, Editor-in-Chief of PLOS Dr. Peter Hotez, Kristy O. Murray, Rojelio Mejia, Laila Woc-Colburn & Maria Elena Bottazzi — all professors in the Departments of Pediatrics and Medicine, National School of Tropical Medicine at Texas Children’s Hospital and Baylor College of Medicine in Houston — say some investigators believe Mesoamerican nephropathy is now the leading killer of young male sugarcane workers in Nicaragua, and possibly El Salvador as well.
Dr. Hotez observes that a number of theories have been advanced to explain the etiology of Mesoamerican nephropathy, including environmental exposures to various agrochemicals, heavy metals, and mycotoxins, as well as recurrent dehydration in the setting of Central America’s hot coastal climate. He and his colleagues at BCM are proponents of exploring potential infectious causes, especially zoonotic neglected tropical diseases from rodents that notoriously infest sugar cane plantations. He suggests that lead candidate infections might include leptospirosis, hantavirus, and Mansonella filarial infections, which are well known in Central and South America. Another possibility is West Nile virus infection shown recently by blog co-author Kristy O. Murray and her colleagues to produce a chronic and progressive renal disease leading to kidney failure notes Dr. Hotez, with WNV infection now a leading cause of renal disease in Texas, making it conceivable that this mosquito-transmitted disease may have emerged on Central America’s Pacific Coast.
Dr. Hotez et al. refer to a recently published research workshop highlighting the steps required to investigate this deadly outbreak going forward. Also published by the National Kidney Foundation’s American Journal of Kidney Disease, the paper is entitled: “Resolving the Enigma of the Mesoamerican Nephropathy: A Research Workshop Summary,” co-authored by C. Wesseling, J .Crowe, C. Hogstedt, K. Jakobsson, R. Lucas, and D.H. Wegman of the First International Research Workshop on Mesoamerican Nephropathy (MeN), Program on Work, Environment and Health in Central America (SALTRA), Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica, which met in Costa Rica in November 2012 to discuss how to establish the extent and degree of MeN, examine relevant causal hypotheses, and focus efforts to control or eliminate the disease burden.
The paper notes that MeN describes a devastating epidemic of chronic kidney disease of unknown origin predominantly observed among young male sugarcane cutters; that the cause of MeN remains uncertain; and suggests that the strongest hypothesis pursued to date is repeated episodes of occupational heat stress and water and solute loss, probably in combination with other potential risk factor(s), such as nonsteroidal anti-inflammatory drug and other nephrotoxic medication use, inorganic arsenic, leptospirosis, or pesticides.
At the research workshop, clinical and epidemiologic case definitions were proposed in order to facilitate both public health and research efforts. Recommendations emanating from the workshop included measuring workload, heat, and water and solute loss among workers; quantifying nephrotoxic agents in drinking water and food; using biomarkers of early kidney injury to explore potential causes of MeN; and characterizing social and working conditions together with methods for valid data collection of exposures and personal risk factors. Advantages and disadvantages of different population study designs were detailed.
To elucidate the etiology of MeN, multicountry studies with prospective cohort design, preferably integrating an ecosystem health approach, were considered the most promising. In addition, genetic, experimental, and mechanistic methods and designs were addressed, specifically the need for kidney biopsy analysis, studies in animal models, advances in biomarkers, genetic and epigenetic studies, a common registry and repository of biological and demographic data and/or specimens, and other areas of potential chronic kidney disease experimental research. Finally, in order to improve international collaboration on MeN, workshop participants agreed to establish a research consortium to link these Mesoamerican efforts to other efforts worldwide.
Dr. Hotez and his co-bloggers say they understand that the Pan American Health Organization – the World Health Organization regional office in the Americas – is now actively working with the US Centers for Disease Control and Prevention (CDC) together with health ministries in the disease affected countries to identify cases, establish case definitions, and conduct case-controlled studies. They note that there are also efforts to send blood and other tissue samples to reference laboratories, but that such efforts appear to be inadequately resourced given the alarming death rates and morbidities among some of Central America’s most productive young people. Consequently they stress an urgent need to mobilize financial and other resources to urgently address this deadly and frightening new illness.
Peter Hotez is Co-Editor in Chief of PLOS Neglected Tropical Diseases, Dean, National School of Tropical Medicine at Baylor College of Medicine, President, Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development, and Fellow in Disease and Poverty, James A. Baker III Institute for Public Policy at Rice University, Houston, Texas, United States of America. He is the author of Forgotten People, Forgotten Diseases (ASM Press), Second Edition. You can follow Prof. Hotez on Twitter @PeterHotez
PLOS Neglected Tropical Diseases; American Journal of Kidney Disease y Rev Panam Salud Publica.
The Board of Directors of ASOCHIVIDA is grateful for the massive presence of its members who responded to the call of the organization and were present on Friday, July 26, at the general meeting to defend our office at the sit-in, and on Tuesday, July 30, at the multi-purpose arena in the municipality of Chichigalpa to give its strong support to the efforts that are being made.
It is public knowledge that not even a week had passed after the death of our President Donald Cortez when a group of 50 people who do not belong to ASOCHIVIDA and are supported by a foreign organization called La Isla burst violently into our general meeting and offices on Thursday, July 25, and tried to destroy what has cost us so much to get. What baseness to dishonor the memory of someone who fought so much for the organization. They falsely accused the CAO, Boston University and the Board of Directors of deceiving people. They called for the end of the dialogue process with NSEL and said that nobody wants food provision and they will soon be paid compensation. The usual lies…
But in this dialogue process we have always worked with the truth and truth always prevails. The Board of Directors of ASOCHIVIDA rendered accounts to the members who gathered en masse on Tuesday. The financial balance of the organization detailing the expenses and income of the organization was presented.
All the benefits that have been received, such as food provision for more than 2200 members, loans that have benefited more than 500 families, 60 houses that were built and 40 that are under construction, the peritoneal dialysis project which already has 7 patients, school backpacks, clothes and zinc sheets, the poultry farm in Nindirí which generates revenues that are granted to the members for medical or funeral expenses, as well as to cover the expenses of the Association. Our next battle is to persuade the Ministry of Health to accept a donation of 330,000 dollars offered by the San Antonio sugar mill and the German Development Bank to build a renal clinic next to the new hospital. Almost two years have passed and we have not received a response from the MOH.
Our General Assembly did not allow to be fooled. It requested to the CAO to continue supporting the dialogue with NSEL and to obtain more benefits, it asked Boston University to speed up the studies, and reaffirmed its support to the Board of Directors and to the dialogue process. It also denounced Jason Glaser of the Foundation Island for interfering in the internal affairs of ASOCHIVIDA and his intention to sow discord between brothers that suffer this disease and destroy the benefits that we have achieved. This foreign organization, which has nothing to do here, is making us fight among ourselves so that nothing is resolved.
ASOCHIVIDA is an organization of peaceful struggle and does not want violence to exist between our brothers. We have been supporting the dialogue with NSEL and trying to get more benefits while serious scientific studies are carried out to determine the cause of this disease. Those who prefer to follow other strategies can form another group and do so, but do not need to come to fight with us.
ASOCHIVIDA does all its work legally and in accordance with its statutes. This Board of Directors will complete its term in office on October 28, 2014, when new elections will be held in a public and transparent way. Until then, the Vice-President will replace our deceased Donald Cortez as President.
ASOCHIVIDA thanks Commissioner Cárcamo of Chinandega for his support and hard work and efforts to prevent violence and to ensure the safety of our members and guests. It also thanks the Mayor for being present, for providing a place for the meeting, and for expressing his commitment to support our efforts for the construction of the clinic.
The Chichigalpa Association for Life (ASOCHIVIDA), the most representative organization of persons with chronic renal insufficiency (CKD) of the country, received, on November 14, the first 50 houses of a housing project consisting of 100 houses built for the benefit of its members, amounting to an investment of more than half a million dollars.
The project is the result of an agreement between ASOCHIVIDA and Nicaragua Sugar Estates Limited (NSEL), owner of Ingenio San Antonio, which in turn is owned by Grupo Pellas. This initiative has received the support of the Urban and Rural Housing Institute (INVUR), the municipal government of Chichigalpa, the Colmena Foundation and American Nicaraguan Foundation (ANF).
An exemplary Alliance
Chichigalpa Mayor, Victor Sevilla, described as exemplary this alliance between the private enterprise and the Government, which has responded to one of the most important needs raised by the members of ASOCHIVIDA.
“Blessed be God because today they have the key to their houses in their hands and we look forward to continuing this alliance, with this exemplary unity, coordinating efforts for the benefit of the community”, said Sevilla.
Engineer Neida Pereira, ANF’s project manager, announced that the total cost of the hundred houses amounts to 627 thousand dollars to be made in two phases. The first fifty homes delivered on this occasion represent an investment of 367,910 dollars. The second phase to complete the project will take place in land owned by the beneficiaries, which will be ready in the near future.
In this first phase, Nicaragua Sugar contributed 131,078 dollars for purchase of land, earth movement and full coverage of the counterpart funds to be provided by the beneficiaries in order to have access to a house.
For its part, INVUR and the municipality of Chichigalpa spent 100 thousand dollars, the Colmena Foundation contributed 13,500 dollars and ANF obtained from its donors the amount of 123,332 dollars, which amount, in addition to contributing to the construction of 50 houses already delivered, will be invested in the construction of latrines and wells to supply drinking water to the new neighborhood.
A crucial issue
The Administrative Director of Nicaragua Sugar, Doctor Álvaro Bermudez, expressed his satisfaction for this joint achievement in favor of ASOCHIVIDA and stated that the company he represents will support the completion of this housing project and other initiatives for the benefit of the community, in particular, research currently being conducted by Boston University to determine the causes of CKD in Nicaragua.
“The most important thing here is that we are trying to investigate the causes of this disease which has affected you, and for this, in conjunction with ASOCHIVIDA, we have selected Boston University to investigate the causes and determine why this disease is affecting not only Nicaragua, but also the entire Pacific coastal strip of Central America. I think that is paramount in this case”, he said.
“You can be sure that Nicaragua Sugar will be present, along with ASOCHIVIDA, in the future of each one of you, to the extent that the company is able to develop these projects,” he added.
ASOCHIVIDA DENOUNCES JASON GLASER AND LA ISLA FOUNDATION FOR SOWING DISCORD AMONG PEOPLE AFFECTED BY CKD AND CALLS FOR THEIR EXPULSION FROM NICARAGUA
Mr. Jason Glaser and La Isla Foundation have been dedicated during the past three years to deceive persons who are affected by CKD to get them fighting among each other and to prevent us from making progress in our struggle. Their actions have created violence in our community, jeopardizing the integrity of our people and our facilities, and we cannot tolerate that any longer.
Colleagues, do not be fooled by this man who says he wants to help the sick, but only does business with us and with our disease. It is time to unmask the true intentions of Glaser and his La Isla Foundation:
Glaser intimidates people who are sick. He burst into the general meeting of ASOCHIVIDA on July 28, 2012, shouting lies and carrying a camera. He says that he wants to talk with us, but then comes with microphones and threatens that he has recorded us. We have nothing to hide.
Glaser takes advantage of the sick. He films us in our sad agony in order to go out and get resources for his La Isla Foundation, and then uses those resources against us.
Glaser wants us to fight among ourselves and then appear as our savior. We must be united to fight this disease and not among ourselves.
Glaser does not respect our mourning. Our President Donald Cortez had just passed away and, instead of sending his condolences, he sent a group of people to violently disrupt our general meeting and destroy our offices.
Glaser has the arrogance to say that he speaks for our people. He sends emails to various institutions saying that he represents the interests of people who are sick, but never ever comes to meet with us on good terms. And the people he supports circulate press releases smearing the memory of our late President with vile and ruthless lies.
Glaser does not want to continue us to keep receiving food provisions and other benefits from NSEL nor wants us to continue the dialogue with the company. Who does this American think he is to come and tell us that this is the best for the sick? Does he have CKD? Does he suffer what we suffer?
Glaser falsely accuses us of corruption. He says we steal money from the sick. But our books show that our administration is transparent and that the few revenues we have are used to help our people with their medical or funeral expenses. Meanwhile, Glaser makes business with our disease, lives a life of luxury, and nobody makes him accountable. How unfair, colleagues.
Glaser deceives the sick with false promises. He supports a group of people who deceive people by saying they will pay a compensation of $140,000 to each claimant, but time passes and the lie falls under its own weight.
Glaser maniputes scientific reports. He tells people that Boston University studies have no validity and that he is preparing studies that are valid. ASOCHIVIDA chose Boston University and relies on its work. We want them to work faster, but we believe in them and not in the studies of Glaser that only serve to keep misleading us.
For all these reasons, ASOCHIVIDA denounces Jason Glaser and La Isla Foundation for interfering in the internal affairs of our organization, declares them unwelcome, and calls for their expulsion from the country and for the end of all their operations here. ASOCHIVIDA will not allow anyone to make us fight among ourselves and to arrogate the right to speak for us.