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Demographic and exposure definitions Demographic indicators were sex, age, education level, household poverty, zone (urban vs. Rural), neighborhood (Sutiava, Mantica or Perla) and source of drinking water. Drinking water source was categorized into four types: community source, indoor plumbing, own well, and other (includes people who obtain water from a river or stream, a neighbor, or purchased water in barrels or jugs). As participants could indicate more than one water source, these categories are not mutually exclusive. A household-level relative poverty indicator, based on the unsatisfied basic needs index score , was calculated using data collected through the demographic surveillance system (Additional file 1: Figure S1). This poverty indicator has been validated in the Nicaraguan setting.
Poverty data were unavailable for 247 participants from the Sutiava neighborhood. Education level was categorized into four levels: no schooling or illiterate, primary school, secondary school and university/professional school. Diabetes and hypertension diagnoses were self-reported (Yes/No).
Occupational and behavioral exposures evaluated included: number of years worked in agriculture, number of days per week consumed lija, number of cigarettes smoked per day; number of glasses of water consumed per day (ranked quartiles). To show the full range of the data, years of agricultural work was categorized into a 5-level variable (none, 0–4, 5–9, 10–14, and 15+); however, because the number of females in several of those categories was small, we also collapsed categories to create a 3-level categorical variable for agricultural work (.
Outcome definition Serum creatinine data were used to estimate glomerular filtration rate (GFR). The abbreviated modification of diet in renal disease (MDRD) equation for non-African Americans was chosen over the CKD-EPI equation to facilitate comparison of results between our study and other studies in the region. Markers of kidney damage and urinary abnormalities were not available; therefore the primary outcome of CKD was defined as an estimated GFR (eGFR) of. Descriptive analyses Prevalence proportions of three eGFR categories (. Logistic regression Variables significantly correlated with CKD in descriptive analyses were carried forward for review in factor analyses.
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A pairwise correlation matrix was evaluated with the plan of not controlling for both measures in statistical modeling when any two predictor variables attained correlations of 0.70 or greater. Bivariate logistic regression models were first fitted to evaluate the crude association between these factors and dichotomous CKD (eGFR. Comparison of MDRD and CKD-EPI equation The MDRD study equation is reasonably accurate at eGFRs of less than 60 mL/min per 1.73 m 2; however, its major limitations are imprecision and systematic underestimation of measured GFR at higher values, leading to overestimation of CKD prevalence. The CKD-EPI equation has less bias at high eGFRs and is more accurate for predicting adverse outcomes than is the MDRD equation.
To assess the extent of bias in CKD prevalence estimates, we calculated prevalence of eGFR. Sensitivity analysis: Cutpoint for CKD case definition EGFR 90 (with eGFR from 60 to 90 excluded). Analyses were performed with SAS version 9.2 (Cary, NC, USA). All significance testing was two-sided unless otherwise stated. Of the 3000 individuals initially selected to participate in this study, 2493 completed questionnaires, with 91% (n = 2275) also providing blood samples for analysis of serum creatinine.
Seven percent of those approached were not available for interview, the majority of whom had migrated, and less than 10% refused. A number of participant demographic characteristics were different compared to those of the surveillance system , which is why overall and sex-specific prevalence estimates were standardized to population-representative surveillance and census population data (see ). Few participants reported having a prior diabetes diagnosis (5%), and only 13% reported a prior diagnosis of high blood pressure. Thirteen percent of participants reported smoking ≥1 cigarette(s) per day, and 5% percent of participants reported drinking lija ≥1 time(s) per week, though only 2 of those were women. History of agricultural work was more common among men (64%) compared to women (30%) (data not shown). Forty-four percent of participants reported a history of agricultural work; of those, more than half reported working in agriculture for ≥10 years.
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The majority of participants (62%) reported drinking eight or fewer glasses of water per day. Prevalence of estimated Glomerular Filtration Rate (eGFR). Analysis of risk factors for CKD In bivariate analyses , older age, male sex, rural zone, lower education level, self-reported diagnosis of high blood pressure, self-reported diagnosis of diabetes, more years of agricultural work, lija consumption, and higher levels of average daily water consumption were significantly associated with CKD. All pair-wise correlations of variables studied were between zero and ±0.4 with only three exceptions, years in agriculture and zone (ρ = 0.59), zone and education (ρ = −0.45) and education and years in agriculture (ρ = −0.45), none of which reached our a priori correlation cut-point of 0.70 for modeling. In multivariable models controlling for age, sex, blood pressure and diabetes, all variables except for diabetes remained statistically significantly associated with prevalence of CKD at the alpha = 0.05 level.
Men had an adjusted odds of CKD more than 3 times that of women (POR = 3.47; 95% CI: 2.50, 4.80), and this estimate remained statistically significant even when we further controlled for other factors associated with CKD prevalence and moderately correlated with sex, including zone (rural vs. Urban), lija consumption, years of agricultural work, and water consumption (POR = 2.17; 95% CI: 1.49, 3.15, data not shown in ). Living in a rural zone was associated with significantly increased prevalence of CKD (POR = 2.10; 95% CI: 1.53, 2.89). The prevalence odds ratio for those reporting a diagnosis of high blood pressure was 2.07 (95% CI: 1.43, 3.02), compared to those who did not report a diagnosis. Those who reported drinking lija had a higher odds of CKD compared to those who did not (POR = 1.95; 95% CI: 1.13, 3.38).
More years of work in agriculture was associated with a significantly higher odds of CKD compared to never working in agriculture ( ), with prevalence odds ratios of 2.55 (95% CI: 1.50, 4.32) and 2.91 (95% CI: 1.94, 4.38) for those who reported working in agriculture for 10–14 years and ≥15 years, respectively. When limited to men, models revealed that years of agriculture remained highly important and conferred an increasing odds of CKD with increasing years of agricultural work as in the overall study data ( ). Among women, the odds of CKD was significantly elevated among those who worked in agriculture for ten or more years, though estimates were less precise (Additional file 2: Table S1). Of all models evaluated, the one limited to women showed the only impact of a self-reported history of diabetes with CKD (OR = 2.52, 95% CI: 1.23, 5.16 vs.
Model limited to men: OR = 0.78, 95% CI: 0.34, 1.79), adjusting for age, high blood pressure and years of agricultural work (data not shown in Additional file 2: Table S1). Sensitivity analysis results The magnitude of adjusted prevalence odds ratios and confidence limit ratios were similar when primary outcome results were compared to results using eGFR 90. Compared to the primary outcome categorization, effect estimates using an outcome categorization of eGFR 0–4 years of agricultural work vs. None (POR = 1.39; 95% CI: 1.03, 1.88), and 5–9 years of agricultural work vs. None (POR = 1.65; 95% CI: 1.23, 2.21). Inspection of the confidence limits revealed increased precision rather than substantial inflation of these estimates. Authors' contributions JFL conducted the statistical analyses, interpreted the results and drafted the manuscript.
EV, RP, SLS, REC, DRM and SLH conceived and designed the study and interpreted the results. EV, RP and EMP provided the leadership for the overall surveillance study and acquisition of data for this study. SLS and EC conducted and interpreted the calibration analyses of serum creatinine.
Download game cracks database management. All authors provided critical insights and editing on drafts and read and approved the final manuscript.
Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3–4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on ‘how to do it’. We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group.
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