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Cooperation with developing countries: the example of Nicaragua A. Edefonti 1, G. Marra 1, F. Sereni 1, M. Sandoval 2, Y. Silva Galàn 2 1 UOC. Nefrologia.

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Presentation on theme: "Cooperation with developing countries: the example of Nicaragua A. Edefonti 1, G. Marra 1, F. Sereni 1, M. Sandoval 2, Y. Silva Galàn 2 1 UOC. Nefrologia."— Presentation transcript:

1 Cooperation with developing countries: the example of Nicaragua A. Edefonti 1, G. Marra 1, F. Sereni 1, M. Sandoval 2, Y. Silva Galàn 2 1 UOC. Nefrologia e Dialisi Pediatrica, Clinica Pediatrica G e D. De Marchi, Milano, Italy 2 Departamento de Nefro-Urologia Pediatrica, Hospital Infantil de Nicaragua MJR, Managua, Nicaragua 42° Annual ESPN Meeting, Lyon, September 11-14, 2008

2 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

3 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 (Cont.)

4 Is cooperation with developing countries only an educational (teaching /training) issue? A provocative question

5 The start of the cooperation with the Pediatric Nephrology Unit of Managua 1997-1999Stage in Milano of Dr. Mabel Sandoval Dìaz 1999-2000Complain about lack of tools to properly diagnose and treat renal diseases in the Nicaraguan Hospitals 2000Visit to Nicaragua of Italian pediatric nephrologists and recognition of the paucity of human, instrumental and economic resources at Hospital Infantil MJR 2001Start of the project of cooperation, financed initially by the Associazione per il Bambino Nefropatico, Milano

6 Methodology of the project Results of the project –Clinical activity –Epidemiology Points of discussion Topics

7 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.

8 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

9 Characteristics of the initial project 4.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 5.Web connection between Milano and Managua for clinical consultation

10 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

11 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

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13 Managua Milano Chinandega Granada Jinotega León Masaya Matagalpa The Pediatric Nephrology Network in Nicaragua at September 1 st 2008

14 20012002200320042005200620072008 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 Chronology of the project of cooperation

15 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

16 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

17 Methodology of the project Results of the project –Clinical activity –Epidemiology Points of discussion Topics

18 Clinical activity of the Pediatric Nephrology Unit of HINMJR during the year 2007 Number of hospitalizations 818 Number of outpatient visits –Nephrology 3096 –Urology 1842 Number of renal biopsies 29 Number of urodynamic tests 61

19 Clinical activity of the Pediatric Nephrology Unit of HINMJR at 31 th of December 2007 Number of children with CRI/ESRD166 Number of children treated with chronic HD13 Number of children treated with PD9 Number of transplanted children 17 2004 – 2007 14 20083

20 Cumulative number of children with kidney and UT diseases entered in the database Pediatric Nephrology Unit of HINMJR (2002 – 2007) 2019 patients

21 50 100 150 200 250 300 june-05sept-05dic-05mar-05june-06sept-06dic-06mar-07june-07sept-07dic-07 Granada Jinotega Masaya Leon Matagalpa Cumulative number of children with kidney and UT diseases entered in the database District Hospitals (2005 – 2007) 858 patients Managua

22 Main diagnoses of kidney and UT diseases in Nicaragua Pediatric Nephrology Unit of HINMJR (2002 – 2007) 2019 patients

23 Main diagnoses of kidney and UT diseases in Nicaragua 5 District Hospitals (2005 – 2007) 858 patients

24 Epidemiology of CRI in Nicaragua * Ardissino GL. et al. Epidemiology of chronic renal failure in children data from ITALKID project (2003) Pediatrics 111;4:382-387 Nicaragua Italy * Point Prevalence (patients/pmpp) 36,474,7 Incidence (patients/pmpp) 9,812,1

25 Primary renal diseases causing CRI at HINJMR (2002 – 2007) 166 patients GFR:90ml/min/1,73

26 Prevalence of CRI (patients/pmp) in the Nicaraguan Districts Districts inside the project Districts outside the project

27 Follow-up of patients with CRI CRI 166 Deceased 67 On RRT 13 * Without RRT 54 Lost to follow- up 41 On follow-up 58 HD 7 Tx 14 CRI 32 PD 5 * Medical decision 27 % Family decision 48 % (socioeconomic reasons) Deceased before the onset of the RRT program 25 %

28 Methodology of the project Results of the project –Clinical activity –Epidemiology Points of discussion Topics

29 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

30 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)

31 Is Cooperation with developing countries only an educational (teaching/training) issue? A provocative question No. Theres something more to do than just giving the instructions to catch the fish You should provide also (at least one) fishing rod

32 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

33 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?

34 Life is calling. How far will you go?

35 Thanks


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