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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 e Dialisi Pediatrica, Clinica Pediatrica G e D. De Marchi, Milano, Italy

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Cooperation with developing countries the example of nicaragua l.jpg

Cooperation with developing countries: the example of Nicaragua

A. Edefonti1, G. Marra1, F. Sereni1 , M. Sandoval2, Y. Silva Galàn2

1UOC. 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


Introduction l.jpg
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 literatureabout the epidemiology of renal diseases in the developing countries, but not about models of cooperation


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(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


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Is cooperation with developing countries only an educational (teaching /training) issue?

A provocative question


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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 l.jpg
Topics Unit of Managua

  • Methodology of the project

  • Results of the project

    • Clinical activity

    • Epidemiology

  • Points of discussion


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Nicaraguan demographic indicators Unit of Managua

www.inec.gob.ni

Censo de Poblaciòn 2005.


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Characteristics of the initial project Unit of Managua

  • Free of charge basic assistance for children with renal diseases

    • Lab test, drugs, imaging (in the private system, whenever necessary)

  • Establishing shared nephrologicalprotocols for the main kidney and UT diseases (the 10 clinical syndromes)

  • 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


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Characteristics of the initial project Unit of Managua

  • 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


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Expansion of the initial project Unit of Managua

  • Start of a RRT program (2 beds for HD, CAPD and 6 living donor Tx per year) for selected children with ESRD

  • 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


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Expansion of the initial project Unit of Managua

  • 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)

  • Extension of the project to a 6th District Hospital where CKD prevalence is allegedly high (61% of population covered)

  • 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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León Unit of Managua

Jinotega

Chinandega

Milano

Managua

Matagalpa

Masaya

Granada

The Pediatric Nephrology Network in Nicaragua

at September 1 st 2008




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Funds from Nicaraguan Health Ministry Unit of Managua

  • 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


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Topics Unit of Managua

  • Methodology of the project

  • Results of the project

    • Clinical activity

    • Epidemiology

  • Points of discussion


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Clinical activity of the Pediatric Nephrology Unit of HINMJR during the year 2007

Number of hospitalizations 818

Number of outpatient visits

  • Nephrology3096

  • Urology 1842

    Number of renal biopsies 29

    Number of urodynamic tests 61


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Clinical activity of the Pediatric Nephrology Unit of HINMJR at 31 th of December 2007

Number of children with CRI/ESRD 166

Number of children treated with chronic HD 13

Number of children treated with PD 9

Number of transplanted children 17

  • 2004 – 2007 14

  • 2008 3


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Cumulative number of children with kidney and UT diseases entered in the database

Pediatric Nephrology Unit of HINMJR (2002 – 2007)

2019 patients


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300 entered in the database

Granada

Jinotega

Masaya

250

Leon

Matagalpa

200

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

Cumulative number of children with kidney and UT diseases entered in the database

District Hospitals (2005 – 2007) 858 patients

Managua


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Main diagnoses of kidney and UT diseases in Nicaragua entered in the database

Pediatric Nephrology Unit of HINMJR (2002 – 2007) 2019 patients


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Main diagnoses of kidney and UT diseases in Nicaragua entered in the database

5 District Hospitals (2005 – 2007) 858 patients


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Epidemiology of CRI in Nicaragua entered in the database

* Ardissino GL. et al. Epidemiology of chronic renal failure in children data from ITALKID project (2003) Pediatrics 111;4:382-387


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Primary renal diseases causing CRI entered in the database

at HINJMR (2002 – 2007) 166 patients

GFR:≤90ml/min/1,73


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Prevalence of CRI (patients/pmp) in the entered in the database

Nicaraguan Districts

Districts inside the project

Districts outside the project


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Follow-up of patients with CRI entered in the database

* Medical decision 27 %

Family decision 48 %

(socioeconomic reasons)

Deceased before the onset of the RRT program 25 %


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Topics entered in the database

  • Methodology of the project

  • Results of the project

    • Clinical activity

    • Epidemiology

  • Points of discussion


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Points of Discussion entered in the database

  • 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


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Points of Discussion entered in the database

  • 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)


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Is Cooperation with developing countries only an educational (teaching/training) issue?

A provocative question

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


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What is the fishing rod? (teaching/training) issue?

  • 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


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What about scientific communication? (teaching/training) issue?

  • 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?


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Life is calling. How far will you go? (teaching/training) issue?


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Thanks (teaching/training) issue?


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