Identifying Potential Contributory Occupational, Environmental, and Pharmacologic Exposures in Dialysis Patients

1
Identifying Potential Contributory
Occupational, Environmental, and Pharmacologic
Exposures in Dialysis Patients
U.S.-Mexico Border Environmental Health
Fellowship Program Summer and Fall 2008

• Erica Peppers, M.P.H.
• University of Alabama at Birmingham (U.A.B.)
• Mentors Claudia Miller, M.D., M.S.,
• Beatriz Tapia, M.D., M.P.H.,
• U.T. Health Science Center San Antonio

2
Background/Project Importance

• Kidney Disease is the 9th leading cause of death
  in the United States
• 80,000 patients diagnosed with chronic kidney
  failure each year
• 4,000 new cases without clear understanding of
  etiology

3
Background/Project Importance cont.

• Studies report
• Physicians have a strong interest and value the
  need to consider environmental exposures
• A low self-efficacy in environmental history
  taking

4
Importance of Taking an Environmental Exposure
History

• Symptoms of environmentally related illnesses
  often manifest as common medical problems
  (headache, general malaise, etc.)
• Plethora of harmful agents present in everyday
  life
• Time limit within the clinical setting
• Need for a systematic, organized, and concise
  approach to obtaining this valuable information.

5
Project Activities

• Questionnaire Development (Evidence Based)
• Literature Review
• - Identified the Top 10 Occupational,
  Environmental, and Pharmacologic Exposures
• - Agency for Toxic Substances and Disease
  Registry (ATSDR)
• - The College of Family Physicians of Canada
• Project submission and approval from UT Health
  Science Center S.A. Institutional Review Board
• Meetings with nephrologists in Harlingen
• and San Antonio

6
Methods

• Convenience Sample Valley Baptist Dialysis
• 28 patients approached
• 22 patients interviewed
• Inclusion criteria
• No exclusion criteria

7
Methods

• Nurse designated approachable participants
• Interviews administered in both Spanish and
  English, preference indicated by participant
• Approximately 15-20 minutes per interview

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Findings

• 12 reported being diagnosed with diabetes
• 10 reported no diagnosis of diabetes
• Data from patients without diabetes was further
  assessed for potential environmental exposures

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Findings cont.

• Common occupations among Spanish speaking
  patients Labor industries, agriculture
• Varying degrees of occupational exposures among
  English speaking patients
• Common household exposures lead and pesticides

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Case Report

• 39 year old female
• Agricultural worker 10 years
• - seasonal labor, tomatoes, chilies cucumbers,
  pumpkins
• No other major illnesses reported

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Case Report

• Renal failure diagnosed 13 months prior
• Reported exposures pesticides, asbestos,
  arsenic, radiation, unknown green chemical
  (tomato fields)

12
Case Report

• Personal Protective Equipment Gloves
• Symptoms Lower back/waist pain only
• Repetitive movements vs. manifestation of renal
  disease
• Clinically trained physician needed to further
  assess potential association
• Additional information needed
• - Name of unknown green chemical
• - Potential harmful ingredients and toxicity

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Implications for Practice

• Teaching tool for medical students, physicians in
  training, and healthcare providers
• Future development for use in a variety clinical
  settings
• Environmental exposures are a preventable cause
  of renal impairment in most cases

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Implications for Practice cont.

• Additional research needed to clarify and
  strengthen existing associations
• Primary and Secondary Prevention
• Ultimate goal Prevention of environmentally
  related causes of renal disease and costly
  treatments such as dialysis

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Additional Enriching Activities

• STEER
• - Harlingen (June) and Laredo (July)
• Operation Lone Star (August 4-August 8)
• Seminars
• -Public Health Grand Rounds
• -Pediatric Grand Rounds

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Acknowledgements

• Dr. Claudia Miller
• Dr. Beatriz Tapia
• Patsy Bortoni
• Dr. Noe Garza
• Roger Perales
• Sylvia Arellano
• Dr. Bertram Roberts
• Dr. Oladayo Sanusi
• Tatjana Walker
• U.T. Health Science Center S.A., RAHC Faculty and
  Staff

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References

• Agency for Toxic Substances and Disease Registry
  (ATSDR). Case studies in environmental medicine
  (CSEM) Taking an exposure history. Retrieved
  July 8, 2008 from http//www.atsdr.cdc.gov/csem/e
  xphistory/ehcover_page.html
•  
• Center for Disease Control and Prevention (CDC)
  CDC MMWR State Specific Trends in Chronic Kidney
  Failure (2004), 53(39) 918-920. Retrieved
  September 18, 2008 from http//www.cdc.gov/mmwr/p
  review/mmwrhtml/mm5339a3.htm
•  
• Kilpatrick, N., Frumkin, H., Trowbridge, J.,
  Escoffery, C.,Geller, R., Rubin, L.,Teague, G.,
  and Nodvin, J. (2002). The environmental history
  in pediatric practice A study of
• pediatricians attitudes, beliefs, and
  practices. Electronic Version. Environmental
• Health Perspectives, 110(8) 823-827.
•  
• Ladou, Joseph. (2004). Current Occupational and
  Environmental Medicine, third ed. pp. 375-385,
  pp. 667-682.
•  
• Marshall, L., Weir, E., Abelsohn, A. Sanborn,
  M.D. (2002). Identifying and managing adverse
  environmental health effects 1. Taking an
  exposure history. Electronic
• Version. CMAJ, 166(8)1049-1055.

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Contact Information

• Erica Peppers, M.P.H.
• Permanent Address
• 211 Northbrook Court
• Davenport, IA 52806
• Email peppers.erica_at_gmail.com
• Contact number [phone]