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

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

8. 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

9. 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

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

11. 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

13. 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

14. 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

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

16. 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

17. 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/exphistory/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/preview/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.

18. Contact Information Erica Peppers, M.P.H. Permanent Address: 211 Northbrook Court Davenport, IA 52806 Email: peppers.erica@gmail.com Contact number: (205)356-3855