Central American Institute for Studies on Toxic Substances (IRET-UNA) Program on Work, Environment and Health in Central America (SALTRA) 10 1 Serie SALUD, TRABAJO Y AMBIENTE MESOAMERICAN NEPHROPATHY Report from the First International Research Workshop on MeN Programa Financiado por la Unión Europea MESOAMERICAN NEPHROPATHY Report from the First International Research Workshop on MeN 616.61 I61m International Research Workshop (1ª : 2012 : San José, C.R.) Mesoamerican nephropathy: report / ed. Catharina Wesseling...[et. al.]. – 1 ed. – Heredia, C.R.: SALTRA / IRET-UNA, 2013. 240 p. : il.; 25 cm. -- (Salud trabajo y ambiente ; n°10). ISBN 978-9968-924-06-1 1. RIÑONES. 2.ENFERMEDADES. 3. NEFROLOGIA. 4. MESOAMÉRICA. I. Título. II. Wesseling, Catharina, ed. III. SALTRA. IV. IRET-UNA. V. Serie. Program on Work, Environment and Health in Central America (SALTRA) (+)506-2263-6375 Central American Institute for Studies on Toxic Substances (IRET) (+)506-2277-3584 www.una.ac.cr/iret Editors: Catharina Wesseling Jennifer Crowe Christer Hogstedt Kristina Jakobsson Rebekah Lucas David Wegman © Saltra SALTRA and the editors of this report invite you to reproduce and otherwise use the material in this report to inform research, healthcare, prevention and policy efforts to lessen the effects of chronic kidney disease of unknown origin. There is no charge and you do not need permission. However, we ask that you please cite both the report as well as the individual authors of any part of the report you use. Correpondence to: Jennifer Crowe IRET-SALTRA-UNA Email: [email protected] (+) 506-2277-3584 This publication has been created with assistance from the European Union. Its content is the exclusive responsability of the SALTRA program and in no case should be considered to reflect the views of the European Union. MESOAMERICAN NEPHROPATHY Report from the First International Research Workshop on MeN Bringing together knowledge, research questions, and initiatives related to Chronic Kidney Disease of unknown origin in Mesoamerica NOVEMBER 28-30, 2012 HOTEL BARCELÓ PALMA REAL, SAN JOSÉ, COSTA RICA Organized by Editors Central American Program for Work, Environment and Health - SALTRA- Catharina Wesseling Central American Institute for Studies on Toxic Substances (IRET) Jennifer Crowe Universidad Nacional (UNA), Costa Rica Christer Hogstedt Kristina Jakobsson Technical Series SALTRA Rebekah Lucas Program for Work, Environment and Health in Central America (SALTRA) David Wegman (+506) 2263-6375 / www.salta.una.ac.cr MAIN MESSAGE There is an epidemic of chronic kidney disease of unknown etiology (CKDu) in several parts of Mesoamerica. This public health problem is of such magni- tude and severity that urgent, exhaustive and collaborative actions must be put into place to elucidate the cause(s), act on available information to prevent further disease and find permanent solutions for prevention and mitigation. The general consensus of the workshop was that the strongest causal hy- pothesis for the epidemic is repeated episodes of heat stress and dehydration during heavy work in hot climates. Co-factors to consider interacting with heat stress or influencing the progression of CKDu, include excess use of non- steroidal anti-inflammatory drugs (NSAIDs) and fructose consumption in rehydration fluids. Contributing factors for the epidemic could include inor- ganic arsenic, leptospirosis, pesticides, or hard water. Interventions to reduce heat stress and improve hydration with controlled trials are recommended. The need for well-designed, interdisciplinary collaborative research is em- phasized, with priority attention on biopsy studies to elucidate pathophysi- ology, prevalence studies to further measure magnitude and identify new population groups at risk, and prospective cohort studies to advance etiologic research. Attention to treatment of existing CKD is also a priority. A Declaration was signed by workshop participants emphasizing the public health problem and the immediate need for prevention. Support is of- fered to governments to act now on existing knowledge and to local research- ers and multisector actors to advance research through collaborative efforts. An international research consortium of investigators was established. DECLARACIÓN M N M N DECLARATION DECLARACIÓN MeN MeN DECLARATION 30 noviembre, 2012 November 30, 2012 San José, Costa Rica San José, Costa Rica Reconociendo que la enfermedad renal crónica está de- Recognizing that chronic kidney disease is devas- vastando trabajadores y sus familias en múltiples partes de tating to workers and families in many parts of Cen- Centroa mérica, tral America, and Apoyando la declaración de COMISCA del 2011, “Unidos Supporting COMISCA’s 2011 declaration “Uni- para Detener La Epidemia de Las Enfermedades Crónicas No dos para Detener Ia Epidemia de Ias Enfermedades Transmisibles (ECNT) en Centroamérica y la República Do- Crónicas No Transmisibles (ECNT) en Centroamérica minicana”, la cual incluye la enfermedad renal crónica como y la República Dominicana”, which includes chronic prioridad entre la enfermedades no-transmisibles sujetos a kidney disease as a priority among the non-transmit- vigilancia, table chronic diseases subject to surveillance Nosotros, los participantes en el taller de la Nefropatía We, the participants in the Mesoamerican Ne- Mesoamericana (MeN) organizado por SALTRA, del 28 al phropathy (MeN) workshop organized by SALTRA, 30 de noviembre del 2012, declaramos que existe prueba November 28-30, 2012, declare that there is suffi- de una enfermedad renal crónica de origen no-determina- cient proof of a chronic kidney disease of undeter- do (MeNu) afectando a Mesoamérica. mined origin (MeNu) affecting Mesoamerica. Esta es una enfermedad silenciosa que está sobresatu- This is a silent disease that is overwhelming public rando a los sistemas de salud y resulta en muertes prematu- health systems, leading to premature deaths. There- ras. Por eso, acciones de prevención y promoción de la salud fore, prevention and health promotion are essential. son de primordial importancia. Los participantes de esta The participants of this meeting have provided sub- reunión han suministrado evidencia basada en sus investi- stantial evidence describing the prob lem and are ac- gaciones y están activamente buscando la etiología de esta tively seeking the etiology of the disease. Global and enfermedad. Es fundamental realizar acciones interdisci- local interdisciplinary action and research are essen- plinarias, al nivel global y local, con el fin de dar respuesta a tial to address this urgent and tragic public health este problema urgente y trágico de salud pública. problem. Considerando lo anterior, ofrecemos nuestro apoyo a As such, we offer our support to governments los gobiernos para asistirles en reconocer esta enfermedad to aid them in recognizing the disease in Central en América Central y para colaborar con investigadores lo- America and to collaborate with local researchers cales y con actores multisectoriales para: and multi-sector actors to: 1. enfrentar este problema uniendo recursos y utilizando 1. address this issue by pooling resources and using evidencia científica existente existing scientific evidence, 2. prevenir muertes prematuras en las poblaciones más 2. prevent premature deaths in the most affected afectadas mediante intervenciones ahí donde sea posible. populations by intervening where possible. Alejandro Riefkohl Alejandro Riefkohl Andrés Robles Andrés Robles Annika Östman-Wer nerson Annika Östman-Wer nerson Aurora Aragón Aurora Aragón Carl-Gustaf Elinder Carl-Gustaf Elinder Carlos Manuel Orantes Carlos Manuel Orantes Carolina Guzmán Carolina Guzmán Catharina Wesseling Catharina Wesseling Channa Jayasumana Channa Jayasumana Christer Hogstedt Christer Hogstedt Cinthya Bonilla Cinthya Bonilla Clemens Ruepert Clemens Ruepert Daniel Brooks Daniel Brooks David Friedman David Friedman David Wegman David Wegman Donna Mergler Donna Mergler Douglas Barraza Douglas Barraza Eugenio Vilanova Eugenio Vilanova Hildaura Acosta Hildaura Acosta Ilana Weiss Ilana Weiss Ingvar Lundberg Ingvar Lundberg James Kaufman James Kaufman Jennifer Crowe Jennifer Crowe Joe Yracheta Joe Yracheta Juan José Amador Juan José Amador Kristina Jakobsson Kristina Jakobsson Laura Gabriela Sánchez Lozada Laura Gabriela Sánchez Lozada Lino Carmenate Lino Carmenate Luisa Castillo Luisa Castillo Manuel Cerdas Manuel Cerdas Maria Ethel Trejos Maria Ethel Trejos Marvin González Marvin González Michael McClean Michael McClean Nathan Raines Nathan Raines Olaf Chresten Jensen Olaf Chresten Jensen Oriana Ramírez Oriana Ramírez Pedro Vinda Pedro Vinda Pim de Voogt Pim de Voogt Rafael Porras Rafael Porras Ramón Antonio García Trabanino Ramón Antonio García Trabanino Ramón Vanegas Ramón Vanegas Rebecca Laws Rebecca Laws Rebekah Lucas Rebekah Lucas Ricardo Correa-Rotter Ricardo Correa-Rotter Ricardo Leiva Ricardo Leiva Richard Johnson Richard Johnson Roberto Antonio Ruiz Roberto Antonio Ruiz Roy Wong Roy Wong Sandra Peraza Sandra Peraza Y-Vonne Hutchinson Y-Vonne Hutchinson Zulma Cruz de Trujillo Zulma Cruz de Trujillo INAUGURAción INAUGURATION M.Sc. Marianela Rojas Garbanzo, Regional Coordinator, Program Work, Environment and Health in Central America (SALTRA) M.Sc. Tomás Marino Herrera, Vice-Dean Faculty of Land and Marine Sciences Dr. Florian Luëtticken, Delegate European Union Lic. Sandra León Coto, Rector, Universidad Nacional Dr. Luisa Castillo, Director Central American Institute for Studies on Toxic Substances