Pesticide exposures and chronic kidney disease of unknown etiology: an epidemiologic review

Longitudinal Renal Function Degradation Among Florida Agricultural Workers

OBJECTIVE

This longitudinal study evaluated renal function and acute kidney injury (AKI) over time in US agricultural workers.

METHODS

We followed Florida agricultural workers from January 2020 to August 2022, collecting blood and urine preworkday and postworkday during five visits.

RESULTS

Preworkday estimated glomerular filtration rate function in all participants was lower in summers but relatively consistent over time. In participants who worked almost exclusively in fernery operations (piece-rate compensation), we observed a high incidence of postworkday AKI in 2020 (21%) that increased to 43% by the end of the study. In comparison, 11% of nursery workers (hourly compensation) had AKI, and this rate was fairly stable.

CONCLUSION

AKI risk over time differs according to the type of agricultural work. Piece rate workers who are incentivized to forgo rest breaks and hydration to earn higher wages demonstrate steadily increasing rates of AKI.

Emerging Roles of Xanthine Oxidoreductase in Chronic Kidney Disease

Xanthine Oxidoreductase (XOR) is a ubiquitous, essential enzyme responsible for the terminal steps of purine catabolism, ultimately producing uric acid that is eliminated by the kidneys. XOR is also a physiological source of superoxide ion, hydrogen peroxide, and nitric oxide, which can function as second messengers in the activation of various physiological pathways, as well as contribute to the development and the progression of chronic conditions including kidney diseases, which are increasing in prevalence worldwide. XOR activity can promote oxidative distress, endothelial dysfunction, and inflammation through the biological effects of reactive oxygen species; nitric oxide and uric acid are the major products of XOR activity. However, the complex relationship of these reactions in disease settings has long been debated, and the environmental influences and genetics remain largely unknown. In this review, we give an overview of the biochemistry, biology, environmental, and current clinical impact of XOR in the kidney. Finally, we highlight recent genetic studies linking XOR and risk for kidney disease, igniting enthusiasm for future biomarker development and novel therapeutic approaches targeting XOR.

Structure-specific variation in per- and polyfluoroalkyl substances toxicity among genetically diverse Caenorhabditis elegans strains

Background

There are >14,500 structurally diverse per- and polyfluoroalkyl substances (PFAS). Despite knowledge that these "forever chemicals" are in 99% of humans, mechanisms of toxicity and adverse health effects are incompletely known. Furthermore, the contribution of genetic variation to PFAS susceptibility and health consequences is unknown.

Objectives

We determined the toxicity of a structurally distinct set of PFAS in twelve genetically diverse strains of the genetic model system Caenorhabditis elegans.

Methods

Dose-response curves for four perfluoroalkyl carboxylic acids (PFNA, PFOA, PFPeA, and PFBA), two perfluoroalkyl sulfonic acids (PFOS and PFBS), two perfluoroalkyl sulfonamides (PFOSA and PFBSA), two fluoroether carboxylic acids (GenX and PFMOAA), one fluoroether sulfonic acid (PFEESA), and two fluorotelomers (6:2 FCA and 6:2 FTS) were determined in the C. elegans laboratory reference strain, N2, and eleven genetically diverse wild strains. Body length was quantified by image analysis at each dose after 48 hr of developmental exposure of L1 arrest-synchronized larvae to estimate effective concentration values (EC50).

Results

There was a significant range in toxicity among PFAS: PFOSA > PFBSA ≈ PFOS ≈ PFNA > PFOA > GenX ≈ PFEESA > PFBS ≈ PFPeA ≈ PFBA. Long-chain PFAS had greater toxicity than short-chain, and fluorosulfonamides were more toxic than carboxylic and sulfonic acids. Genetic variation explained variation in susceptibility to PFBSA, PFOS, PFBA, PFOA, GenX, PFEESA, PFPeA, and PFBA. There was significant variation in toxicity among C. elegans strains due to chain length, functional group, and between legacy and emerging PFAS.

Conclusion

C. elegans respond to legacy and emerging PFAS of diverse structures, and this depends on specific structures and genetic variation. Harnessing the natural genetic diversity of C. elegans and the structural complexity of PFAS is a powerful New Approach Methodology (NAM) to investigate structure-activity relationships and mechanisms of toxicity which may inform regulation of other PFAS to improve human and environmental health.

Glyphosate: Hepatotoxicity, Nephrotoxicity, Hemotoxicity, Carcinogenicity, and Clinical Cases of Endocrine, Reproductive, Cardiovascular, and Pulmonary System Intoxication

Glyphosate (GLP) is an active agent of GLP-based herbicides (GBHs), i.e., broad-spectrum and postemergent weedkillers, commercialized by Monsanto as, e.g., Roundup and RangerPro formulants. The GBH crop spraying, dedicated to genetically engineered GLP-resistant crops, has revolutionized modern agriculture by increasing the production yield. However, abusively administered GBHs' ingredients, e.g., GLP, polyoxyethyleneamine, and heavy metals, have polluted environmental and industrial areas far beyond farmlands, causing global contamination and life-threatening risk, which has led to the recent local bans of GBH use. Moreover, preclinical and clinical reports have demonstrated harmful impacts of GLP and other GBH ingredients on the gut microbiome, gastrointestinal tract, liver, kidney, and endocrine, as well as reproductive, and cardiopulmonary systems, whereas carcinogenicity of these herbicides remains controversial. Occupational exposure to GBH dysregulates the hypothalamic-pituitary-adrenal axis, responsible for steroidogenesis and endocrinal secretion, thus affecting hormonal homeostasis, functions of reproductive organs, and fertility. On the other hand, acute intoxication with GBH, characterized by dehydration, oliguria, paralytic ileus, as well as hypovolemic and cardiogenic shock, pulmonary edema, hyperkalemia, and metabolic acidosis, may occur fatally. As no antidote has been developed for GBH poisoning so far, the detoxification is mainly symptomatic and supportive and requires intensive care based on gastric lavage, extracorporeal blood filtering, and intravenous lipid emulsion infusion. The current review comprehensively discusses the molecular and physiological basics of the GLP- and/or GBH-induced diseases of the endocrine and reproductive systems, and cardiopulmonary-, nephro-, and hepatotoxicities, presented in recent preclinical studies and case reports on the accidental or intentional ingestions with the most popular GBHs. Finally, they briefly describe modern and future healthcare methods and tools for GLP detection, determination, and detoxification. Future electronically powered, decision-making, and user-friendly devices targeting major GLP/GBH's modes of actions, i.e., dysbiosis and the inhibition of AChE, shall enable self-handled or point-of-care professional-assisted evaluation of the harm followed with rapid capturing GBH xenobiotics in the body and precise determining the GBH pathology-associated biomarkers levels.

Exposome and Metabolome Analysis of Sugarcane Workers Reveals Predictors of Kidney Injury

Introduction

Sugarcane workers are exposed to potentially hazardous agrochemicals, including pesticides, heavy metals, and silica. Such occupational exposures present health risks and have been implicated in a high rate of kidney disease seen in these workers.

Methods

To investigate potential biomarkers and mechanisms that could explain chronic kidney disease (CKD) among this worker population, paired urine samples were collected from sugarcane cutters at the beginning and end of a harvest season in Guatemala. Workers were then separated into 2 groups, namely those with or without kidney function decline (KFD) across the harvest season. Urine samples from these 2 groups underwent elemental analysis and untargeted metabolomics.

Results

Urine profiles demonstrated increases in silicon, certain pesticides, and phosphorus levels in all workers, whereas heavy metals remained low. The KFD group had a reduction in estimated glomerular filtration rate (eGFR) across the harvest season; however, kidney injury marker 1 did not significantly change. Cross-harvest metabolomic analysis found trends of fatty acid accumulation, perturbed amino acid metabolism, presence of pesticides, and other known signs of impaired kidney function.

Conclusion

Silica and certain pesticides were significantly elevated in the urine of sugarcane workers with or without KFD. Future work should determine whether long-term occupational exposure to silica and pesticides across multiple seasons contributes to CKD in these workers. Overall, these results confirmed that multiple exposures are occurring in sugarcane workers and may provide insight into early warning signs of kidney injury and may help explain the increased incidence of CKD among agricultural workers.

Occupational risks associated with chronic kidney disease of non-traditional origin (CKDnt) in Brazil: it is time to dig deeper into a neglected problem

In the past decades, an epidemic of chronic kidney disease (CKD) has been associated with environmental and occupational factors (heat stress from high workloads in hot temperatures and exposure to chemicals, such as pesticides and metals), which has been termed CKD of non-traditional origin (CKDnt). This descriptive review aims to present recent evidence about heat stress, pesticides, and metals as possible causes of CKDnt and provide an overview of the related Brazilian regulation, enforcement, and health surveillance strategies. Brazilian workers are commonly exposed to extreme heat conditions and other CKDnt risk factors, including increasing exposure to pesticides and metals. Furthermore, there is a lack of adequate regulation (and enforcement), public policies, and strategies to protect the kidney health of workers, considering the main risk factors. CKDnt is likely to be a significant cause of CKD in Brazil, since CKD's etiology is unknown in many patients and several conditions for its development are present in the country. Further epidemiological studies may be conducted to explore causal associations and estimate the impact of heat, pesticides, and metals on CKDnt in Brazil. Moreover, public policies should prioritize reducing workers´ exposure and promoting their health and safety.

Chronic Interstitial Nephritis in Agricultural Communities: Observational and Mechanistic Evidence Supporting the Role of Nephrotoxic Agrochemicals

Chronic interstitial nephritis in agricultural communities (CINAC) is an epidemic of kidney disease affecting specific tropical and subtropical regions worldwide and is characterized by progressive CKD in the absence of traditional risk factors, such as hypertension and diabetes. CINAC prevalence is higher among young, male agricultural workers, but it also affects women, children, and nonagricultural workers in affected areas. Biopsies from patients with CINAC across regions commonly demonstrate tubular injury with lysosomal aggregates, tubulointerstitial inflammation, and fibrosis and variable glomerular changes. Each endemic area holds environmental risk factors and patient/genetic milieus, resulting in uncertainty about the cause(s) of the disease. Currently, there is no specific treatment available for CINAC. We highlight survey findings of Houston-based migrant workers with CINAC and draw similarities between kidney injury phenotype of patients with CINAC and mice treated chronically with paraquat, an herbicide used worldwide. We propose potential pathways and mechanisms for kidney injury in patients with CINAC, which may offer clues for potential therapies.

Association of urine glyphosate levels with renal injury biomarkers in children living close to major vegetable-producing regions in China

Glyphosate (GLY)-based herbicides exposure contributes to renal dysfunction in experimental conditions, but the effects on humans are rarely reported. Biomonitoring is practically relevant for evaluating the association of urine GLY levels and renal damage in children living close to vegetable-cultivating regions. In this study, we collected the first-morning void urine samples of 239 healthy children (aged 3-12, 48.12 % boys) living near major vegetable-producing regions in March-May and August 2023 in Shandong Province, China. Urine levels of GLY and kidney injury-associated biomarkers were determined using ELISA kits to assess their correlation. GLY was detected in 92.05 % of urine samples (220 out of 239 participants) and the geometric concentration (GM) was 7.429 μg/L (range: 0.625 to 38.267 μg/L). Binary logistic regression and multivariate regression analysis revealed GLY detectability and levels positively correlated with home ventilation and self-producing vegetable intake of the subjects, as well as sampling periods. Moreover, a statistically significant concentration association with urine GLY was found for kidney injury-associated biomarkers (NGAL and KIM-1) (R2 = 0.923 and 0.855, respectively). Additionally, risk assessment revealed that the maximum value of probable daily intake was 0.150 mg/kg bw/day, accounting for 30.1 % of the established Acceptable Daily Intake of GLY. This study unveils a positive correlation between continuous GLY-based herbicide exposure and renal injury biomarkers of children. A large-scale epidemiological study is warranted for comprehensively assessing the effects of GLY-based herbicides on kidney function of the entire public.

Social deprivation and kidney failure due to an undiagnosed nephropathy

BACKGROUND

In France, kidney diseases of undetermined origin account for 5%-20% of all causes of end-stage kidney disease. We investigated the impact of social disadvantage on the lack of aetiological diagnosis of nephropathies.

METHODS

Data from patients who started dialysis in France between 1 January 2017 and 30 June 2018 were extracted from the French Renal Epidemiology and Information Network registry. The social deprivation of each individual was estimated by the European Deprivation Index (EDI) defined by the patient's address. Logistic regression was used to perform mediation analysis to study the potential association between social deprivation and unknown nephropathy.

RESULTS

Of the 7218 patients included, 1263 (17.5%) had unknown kidney disease. A total of 394 (31.4%) patients in the unknown kidney disease belonged to the most deprived quintile of the EDI [fifth quintile (Q5)], vs 1636 (27.5%) patients in the known kidney disease group. In the multivariate analysis, unknown kidney disease was associated with Q5 (odds ratio 1.40, 95% confidence interval 1.12-1.74, P = .003). Mediation analysis did not identify any variables (e.g. obesity, initiation of dialysis in emergency, number of visits to the general practitioner and nephrologist before initiation of dialysis, date of first nephrology consultation) that mediated the association between social deprivation and nephropathy of unknown origin.

CONCLUSIONS

Our results show that, compared with nondeprived subjects, individuals experiencing social deprivation have a higher risk of unknown nephropathy at dialysis initiation. However, mediation analysis did not identify any variables that explained the association between social deprivation and nephropathy of unknown origin.

Chronic dehydration induces injury pathways in rats, but does not mimic histopathology of chronic interstitial nephritis in agricultural communities

CINAC-patients present renal proximal tubular cell lysosomal lesions which are also observed in patients experiencing calcineurin inhibitor (CNI) nephrotoxicity, suggesting that CINAC is a toxin-induced nephropathy. An alternative hypothesis advocates chronic dehydration as a major etiological factor for CINAC. Here, we evaluated histological and molecular changes in dehydrated versus toxin exposed rats. Wistar rats were divided in 3 groups. Group 1 (n = 6) had free access to drinking water (control group). Group 2 (n = 8) was water deprived for 10 h per 24 h, 5 days/week and placed in an incubator (37 °C) for 30 min/h during water deprivation. Group 3 (n = 8) underwent daily oral gavage with cyclosporine (40 mg/kg body weight). After 28 days, renal function, histopathology and proteomic signatures were analysed. Cyclosporine-treated rats developed focal regions of atrophic proximal tubules with associated tubulo-interstitial fibrosis. PASM staining revealed enlarged argyrophilic granules in affected proximal tubules, identified as lysosomes by immunofluorescent staining. Electron microscopy confirmed the enlarged and dysmorphic phenotype of the lysosomes. Overall, these kidney lesions resemble those that have been previously documented in farmers with CINAC. Dehydration resulted in none of the above histopathological features. Proteomic analysis revealed that dehydration and cyclosporine both induce injury pathways, yet of a clear distinct nature with a signature of toxicity only for the cyclosporine group. In conclusion, both cyclosporine and dehydration are injurious to the kidney. However, dehydration alone does not result in kidney histopathology as observed in CINAC patients, whereas cyclosporine administration does. The histopathological analogy between CINAC and calcineurin inhibitor nephrotoxicity in rats and humans supports the involvement of an as-yet-unidentified environmental toxin in CINAC etiology.

Prevalence of chronic kidney disease in Kazakhstan: evidence from a national cross-sectional study

To date, there have been no large-scale national studies of the prevalence of chronic kidney disease in Kazakhstan. It includes the research based on the analysis of the estimated glomerular filtration rate (eGFR). The aim of this study was to investigate the population prevalence of CKD and associated risk factors in Kazakhstan. The cross-sectional study consisted of a nationally representative sample of n = 6 720 adults aged 18 to 69 from 14 regions and 3 major cities in Kazakhstan. The study covered the period from October 2021 to May 2022. The WHO STEPS questionnaire was used for the survey. For the diagnosis of CKD, creatinine levels in collected blood samples were measured to assess eGFR. Demographic characteristics were collected and studied. The total and adjusted prevalence of factors associated with the presence of CKD were calculated and analysed using logistic regression. 73.5% (n = 4940) of participants had normal eGFR, while 25.2% (n = 1695) had mild CKD (eGFR = 60-89 mL/min/1.7 m2). The overall prevalence of CKD with eGFR < 60 ml/min/1.7 m2 was 1.3% (n = 85), of which 0.2% (n = 15) had eGFR < 45 ml/min/1.7 m2. A mild degree of CKD was most often determined in residents of the East Kazakhstan region in 10.4%, and in 7.8-8.0% of cases. The majority of CKD patients was detected in the East Kazakhstan region and Almaty city, 15.3% and 10.6% of cases respectively. In mild and CKD with GFR < 60 ml/min/1.7 m2, the age of participants was 50-69 years in 61.5% and 78.8% of cases, respectively (p < 0.001). In addition to the association with the place of residence, a statistically significant relationship was found between the risk of developing CKD and underweight (OR 1.43, 95% CI (1.09-1.88), p < 0.001), as well as the presence of obesity (OR 1.24, 95% CI (0.99-1.53), p = 0.04). We observed the prevalence of CKD with eGFR < 60 ml/min/1.7 m2 at the level of 1.3%. However, a fairly large part of study participants had a mild CKD (25.2%). The results of this study can be used for the optimization of the doctors workload and the timely provision of care to patients with CKD.

The Hematological and Biochemical Effects from Pesticide Exposure on Thai Vegetable Farmers

Pesticide-related health concerns are a global public health issue. Few studies in Thailand have explored the hematological and biochemical effects of occupational pesticide exposure. The goal of this study was to investigate the effects of pesticides on the hematology, hepatic, and renal function of Thai vegetable farmers. A cross-sectional study was carried out in Chiang Mai, northern Thailand. A total of 124 apparently healthy vegetable farmers were interviewed about their lifetime exposure to agricultural pesticides. Blood samples were collected via venipuncture to be tested for complete blood count (CBC), liver function, and kidney function. Approximately 46% of the farmers were pesticide users who reported a history of pesticide use for their crops, while 54% were non-pesticide users. In the male farmers, the activities of aspartate aminotransferase (AST), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were significantly higher in the pesticide users compared to the non-pesticide users, while the estimated glomerular filtration rate (eGFR), hematocrit (HCT), and red blood cells (RBC) were significantly lower (p < 0.05). In the females, the pesticide users had significantly higher levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), and MCHC than the non-pesticide users (p < 0.05). Pesticide use among Thai vegetable farmers may cause hematological alterations and increase the risk of hepatic and renal dysfunction. Some hematological and biochemical parameters may be used for monitoring to protect them from the adverse health effects of occupational exposure to pesticides.

Urinary Metabolomic Profile of Youth at Risk of Chronic Kidney Disease in Nicaragua

Key Points

Urinary concentrations of glycine, a molecule associated with thermoregulation, were elevated among youth from a high-risk region for chronic kidney disease of non-traditional etiology (CKDnt). Urinary concentrations of pyruvate, citric acid, and inosine were lower among youth at higher risk of CKDnt, suggesting renal stress. Metabolomic analyses may shed light on early disease processes or profiles or risk in the context of CKDnt.

Background

CKD of a nontraditional etiology (CKDnt) is responsible for high mortality in Central America, although its causes remain unclear. Evidence of kidney dysfunction has been observed among youth, suggesting that early kidney damage contributing to CKDnt may initiate in childhood.

Methods

Urine specimens of young Nicaraguan participants 12–23 years without CKDnt (n =136) were analyzed by proton nuclear magnetic resonance spectroscopy for 50 metabolites associated with kidney dysfunction. Urinary metabolite levels were compared by, regional CKDnt prevalence, sex, age, and family history of CKDnt using supervised statistical methods and pathway analysis in MetaboAnalyst. Magnitude of associations and changes over time were assessed through multivariable linear regression.

Results

In adjusted analyses, glycine concentrations were higher among youth from high-risk regions (β =0.82, [95% confidence interval, 0.16 to 1.85]; P = 0.01). Pyruvate concentrations were lower among youth with low eGFR (β = −0.36 [95% confidence interval, −0.57 to −0.04]; P = 0.03), and concentrations of other citric acid cycle metabolites differed by key risk factors. Over four years, participants with low eGFR experienced greater declines in 1-methylnicotinamide and 2-oxoglutarate and greater increases in citrate and guanidinoacetate concentrations.

Conclusion

Urinary concentration of glycine, a molecule associated with thermoregulation and kidney function preservation, was higher among youth in high-risk CKDnt regions, suggestive of greater heat exposure or renal stress. Lower pyruvate concentrations were associated with low eGFR, and citric acid cycle metabolites, such as pyruvate, likely relate to mitochondrial respiration rates in the kidneys. Participants with low eGFR experienced longitudinal declines in concentrations of 1-methylnicotinamide, an anti-inflammatory metabolite associated with anti-fibrosis in tubule cells. These findings merit further consideration in research on the origins of CKDnt.

Anthropological perspectives on CKDnt in Mexico: time for a paradigm shift on the social determinants of health

In Mexico, the kidneys of individuals in poor and marginalized communities are failing with little warning and no explanation. Commonly referred to as chronic kidney disease of non-traditional origin (CKDnt), this new variant of kidney disease cannot be accounted for by conventional or discrete etiological explanations, but is instead understood to be a consequence of economic development, environmental degradation and precarious working and living conditions. Drawing on two interconnected ethnographic studies, and the intertwining problems of causation and care, this paper will (1) document the social conditions of disease emergence around Lake Chapala, Central Mexico, and (2) follow the haphazard routes kidney patients take to access resource-intensive biotechnical treatments. Its aim is to both challenge and reconceptualize social determinants as social relations in order to fully account for the profoundly contextual, temporal, and dynamic character of this condition, and to rethink opportunities for care and intervention.

Prevalence and predictors of chronic kidney disease of undetermined causes (CKDu) in Western Kenya's "sugar belt": a cross-sectional study

BACKGROUND

Epidemics of chronic kidney disease of undetermined causes (CKDu) among young male agricultural workers have been observed in many tropical regions. Western Kenya has similar climatic and occupational characteristics as many of those areas. The study objectives were to characterize prevalence and predictors of CKDu, such as, HIV, a known cause of CKD, in a sugarcane growing region of Kenya; and to estimate prevalence of CKDu across occupational categories and evaluate if physically demanding work or sugarcane work are associated with reduced eGFR.

METHODS

The Disadvantaged Populations eGFR Epidemiology Study (DEGREE) protocol was followed in a cross-sectional study conducted in Kisumu County, Western Kenya. Multivariate logistic regression was performed to identify predictors of reduced eGFR.

RESULTS

Among 782 adults the prevalence of eGFR < 90 was 9.85%. Among the 612 participants without diabetes, hypertension, and heavy proteinuria the prevalence of eGFR < 90 was 8.99% (95%CI 6.8%, 11.5%) and 0.33% (95%CI 0.04%, 1.2%) had eGFR < 60. Among the 508 participants without known risk factors for reduced eGFR (including HIV), the prevalence of eGFR < 90 was 5.12% (95%CI 3.4%, 7.4%); none had eGFR < 60. Significant risk factors for reduced eGFR were sublocation, age, body mass index, and HIV. No association was found between reduced eGFR and work in the sugarcane industry, as a cane cutter, or in physically demanding occupations.

CONCLUSION

CKDu is not a common public health problem in this population, and possibly this region. We recommend that future studies should consider HIV to be a known cause of reduced eGFR. Factors other than equatorial climate and work in agriculture may be important determinants of CKDu epidemics.

Chronic Kidney Disease of Unknown Origin: Think Beyond Common Etiologies

Chronic kidney disease has an increased health impact on a global scale, with the most common etiologies being hypertension and diabetes. It is most frequently linked to noncommunicable conditions, including diabetes and hypertension, among high-income nations. However, it has a couple of new potential etiologies in low- and middle-income countries, many of which are yet unknown, including viral infections and environmental toxins. The phrase "CKD of unknown etiology" (CKDu) has been used to refer to CKD that is not caused by a typical risk factor such as diabetes, high blood pressure, or HIV. Environmental variables have been investigated as potential contributors to CKDu, including heavy metal exposure, elevated seasonal temperatures, pesticide use, mycotoxins, contamination of water supplies, and snake bites. Furthermore, the underlying causes have not been definitively established in the majority of areas and identifying serious health consequences across different international contexts and populations may be crucial for comprehending and avoiding CKDu.

Exposure of patients with chronic kidney disease on dialysis to pesticides

INTRODUCTION

Pesticides can trigger kidney disease.

OBJECTIVE

To describe the exposure to pesticides of patients with chronic kidney disease on dialysis.

METHODS

Quantitative and descriptive field research, with 90 patients with chronic kidney disease on dialysis in two hemodialysis units in the state of Santa Catarina, through the application of a structured questionnaire. Participants were divided into two groups: with and without exposure to pesticides. The questionnaire was applied in hemodialysis clinics during treatment. Laboratory test values were collected from clinical records. Data were analyzed using descriptive statistics and association using the chi-square test. For laboratory test data, a comparison of means was performed using the unpaired Student's t-test between the groups.

RESULTS

The mean age of exposed participants was 58 years (±13.7; minimum = 23; maximum = 75) and that of non-exposed participants was 64 years old (±13.9; minimum = 35; maximum = 96). Of the 90 patients, 30% were exposed to pesticides. The mean exposure time was 6.7 ± 3.8 hours/day. There was a statistically significant association between the preparation of the mixture with pesticides and diabetes (p ≤ 0.048). There was no statistically significant difference between the results of laboratory tests in the exposed and non-exposed groups.

CONCLUSION

This study shows that pesticides can be triggering factors for chronic kidney disease (CKD); however, we must expand research in this field to prove the relationship between exposure to pesticides and CKD.

Endosulfan induced kidney cell injury by modulating ACE2 through up-regulating miR-429 in HK-2 cells

Endosulfan, a typical organochlorine pesticide, is widely used in agricultural countries and was detected in blood samples from the general population. Studies have shown a positive correlation between chronic kidney disease of unknown aetiology (CKDu) and endosulfan. CKDu has become endemic in agricultural countries, with clinical manifestations of tubulointerstitial fibrosis.The goal of this study was to investigate the effects of endosulfan in kidney cell injury in human renal tubular epithelial cells (HK-2), focusing on apoptosis, inflammatory response, and epithelial-mesenchymal transition (EMT). We found that endosulfan induced apoptosis in HK-2 cells by up-regulating the expression of BAX, APAF-1, Caspase-3 and mitochondrial Cytochrome c was released into the cytosol. Endosulfan caused an inflammatory response, showing the increase in the secretion and mRNA expression levels of IL-6/IL-8. Endosulfan triggered EMT, characterized by downregulation of E-cadherin and upregulation of Vimentin. Western blot results showed that p-Smad3 and Smad3 protein expression were elevated while the expression of Smad7 were decreased in endosulfan-exposed groups. Dual luciferase reporter assay confirmed the potential binding capacity of miR-429 to 3'-UTR of ACE2. Endosulfan causes upregulation of miR-429 and downregulation of ACE2 in HK-2 cells. Overexpression of miR-429 or silencing of ACE2 in HK-2 cells caused apoptosis, inflammation and EMT through TGF signaling pathway. These findings suggest that endosulfan can lead to kidney cell injury by modulating ACE2 through up-regulating miR-429, providing new evidence for the pathogenesis of CKDu.

Determinants of Consumers' Behavior in Reducing Pesticide Residues in Vegetables and Fruits, Northern Thailand

Pesticide residues in vegetables in northern Thailand exceed the maximum residue limits established by the European Union. Therefore, improved knowledge and behavior in reducing pesticide residues in vegetables and fruits (VF) would reduce the risk of exposure to pesticides. This study aims to investigate the contributing factors of consumers' behavior in reducing pesticide residues in VF. The differences in knowledge, attitude, and behavior in reducing pesticide residues in VF between consumers living in rural and urban communities of Chiang Mai, Thailand were also investigated. The cross-sectional study was carried out during August and October 2021 with 456 participants. Data was collected from participants using a Google form questionnaire. The results indicated that pesticide-free was the top-ranked consideration for VF purchasing. Linear regression analysis found that factors associated with consumers' behavior in reducing pesticide residues in VF were total knowledge scores (Beta (β) ± standard error (SE.) = 1.15 ± 0.18, 95%CI = 0.79, 1.51), total attitude scores (β ± SE. = 1.30 ± 0.49, 95%CI = 3.87, 10.40), having co-morbidity (β ± SE. = 3.2 ± 1.37, 95%CI = 0.52, 5.90), type of VF purchasing (β ± SE. = 1.98 ± 0.57, 95%CI = 0.85, 3.11), frequency of VF purchasing (β ± SE. = 3.81 ± 1.18, 95%CI = 1.49, 6.13), price of VF products (β ± SE. = -2.23 ± 1.13, 95%CI = -4.45, -0.02), and getting information from the broadcasting tower in the village (β ± SE. = 7.13 ± 1.66, 95%CI = 0.32, 2.27).

Exposição de pacientes com doença renal crônica em tratamento dialítico aos agrotóxicos

Resumo Introdução: O uso de agrotóxicos pode desencadear doença renal. Objetivo: Descrever a exposição a agrotóxicos de pacientes com doença renal crônica em tratamento dialítico. Métodos: Pesquisa de campo, quantitativa e descritiva, com 90 portadores de doença renal crônica em tratamento dialítico em duas unidades de hemodiálise no estado de Santa Catarina, por meio da aplicação de um questionário estruturado. Os participantes foram divididos em dois grupos: sem e com exposição a agrotóxicos. O questionário foi aplicado nas clínicas de hemodiálise durante o tratamento. Foram coletados valores de exames laboratoriais dos prontuários clínicos. Os dados foram analisados pela estatística descritiva e associação pelo teste qui-quadrado. Para os dados dos exames laboratoriais, foi realizada comparação de médias pelo teste t de Student não pareado entre os grupos. Resultados: A idade média dos participantes expostos foi de 58 anos (±13,7; mínimo = 23; máximo = 75) e a dos não expostos, de 64 anos (±13,9; mínimo = 35; máximo = 96). Dos 90 pacientes, 30% foram expostos a agrotóxicos. O tempo médio de exposição foi de 6,7 ± 3,8 horas/dia. Houve associação estatística significativa entre o preparo da calda com agrotóxicos e a presença de diabetes (p ≤ 0,048). Não houve diferença estatística significativa entre os resultados dos exames laboratoriais do grupo exposto e do não exposto. Conclusão Esta pesquisa evidencia que os agrotóxicos podem ser fatores desencadeadores da doença renal crônica (DRC), entretanto sugere-se ampliar pesquisas na área que possam comprovar a relação entre exposição a agrotóxicos e DRC.

Chronic kidney disease among greenhouse workers and field workers in China

BACKGROUND

Agricultural workers are at increased risk of developing chronic kidney disease of non-traditional etiology (CKDnt). The environment in solar greenhouse has high-intensity agricultural hazard factors. However, the association between solar greenhouse work and CKDnt remains unknown.

OBJECTIVES

We aimed to evaluate the relationship among solar greenhouse work, field work, and CKDnt risk, and to explore gender differences in CKDnt risk among solar greenhouse workers.

METHODS

Solar greenhouse workers and field workers were selected as the greenhouse worker and field worker groups in a cross-sectional study. Individuals with an estimated glomerular filtration rate (eGFR) of <60 ml/min per 1.73 m² were defined as CKDnt patients. Binary logistic regression and generalized linear regression models were used to estimate the association among solar greenhouse workers, field workers and CKDnt. Furthermore, gender differences in CKDnt were also analyzed.

RESULTS

A total of 638 solar greenhouse workers and 231 field workers were included. The prevalence of CKDnt was 2.8% in the solar greenhouse workers and 0.4% in the field workers, and the prevalence of CKDnt was higher in female solar greenhouse workers than in males. The eGFR reduced by 20.0% (19.74 ml/min per 1.73 m²) in the greenhouse worker group compared with that in the field worker group (p < 0.05). Generalized linear analysis showed that the level of eGFR was lower in women than that in men after adjusting for parameters (β = -10.99 [-12.79, -9.10]).

CONCLUSION

Solar greenhouse workers may be at an increased risk of CKDnt, and women are more vulnerable.

Enzymatic Laser-Induced Graphene Biosensor for Electrochemical Sensing of the Herbicide Glyphosate

Glyphosate is a globally applied herbicide yet it has been relatively undetectable in-field samples outside of gold-standard techniques. Its presumed nontoxicity toward humans has been contested by the International Agency for Research on Cancer, while it has been detected in farmers' urine, surface waters and crop residues. Rapid, on-site detection of glyphosate is hindered by lack of field-deployable and easy-to-use sensors that circumvent sample transportation to limited laboratories that possess the equipment needed for detection. Herein, the flavoenzyme, glycine oxidase, immobilized on platinum-decorated laser-induced graphene (LIG) is used for selective detection of glyphosate as it is a substrate for GlyOx. The LIG platform provides a scaffold for enzyme attachment while maintaining the electronic and surface properties of graphene. The sensor exhibits a linear range of 10-260 µ m, detection limit of 3.03 µ m, and sensitivity of 0.991 nA µ m -1. The sensor shows minimal interference from the commonly used herbicides and insecticides: atrazine, 2,4-dichlorophenoxyacetic acid, dicamba, parathion-methyl, paraoxon-methyl, malathion, chlorpyrifos, thiamethoxam, clothianidin, and imidacloprid. Sensor function is further tested in complex river water and crop residue fluids, which validate this platform as a scalable, direct-write, and selective method of glyphosate detection for herbicide mapping and food analysis.

High prevalence of chronic kidney disease of unknown etiology among workers in the Mesoamerican Nephropathy Occupational Study

BACKGROUND

Mortality from chronic kidney disease of unknown etiology (CKDu) is extremely high along the Pacific coast of Central America, particularly among sugarcane workers. The Mesoamerican Nephropathy Occupational Study (MANOS) is a prospective cohort study of CKDu among agricultural and non-agricultural workers in El Salvador and Nicaragua. The objective of this manuscript is to describe the MANOS cohort recruitment, baseline data collection, and CKDu prevalence after two rounds.

METHODS

Workers with no known diabetes, hypertension, or CKD were recruited from sugarcane, corn, plantain, brickmaking, and road construction industries (n = 569). Investigators administered questionnaires, collected biological samples, and observed workers for three consecutive workdays at the worksite. Serum specimens were analyzed for kidney function parameters, and used to calculate estimated glomerular filtration rate (eGFR). At six months, serum was collected again prior to the work shift. CKD at baseline is defined as eGFR ≤ 60 ml/min/1.73m2 at both timepoints. Age-standardized prevalence was calculated by industry, country, and demographic measures. Kidney function parameters were compared by CKD status.

RESULTS

Prevalence of CKD at baseline was 7.4% (n = 42). Age-standardized prevalence was highest in Salvadoran sugarcane (14.1%), followed by Salvadoran corn (11.6%), and Nicaraguan brickmaking (8.1%). Nicaraguan sugarcane had the lowest prevalence, likely due to kidney function screenings prior to employment.

CONCLUSION

Despite efforts to enroll participants without CKD, our identification of prevalent CKD among agricultural and non-agricultural workers in the MANOS cohort indicates notable kidney disease in the region, particularly among sugarcane workers.

Metals and Metallothionein Expression in Relation to Progression of Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka

Chronic kidney disease of unknown etiology was investigated for metal relations in an endemic area by a cross-sectional study with CKD stages G1, G2, G3a, G3b, G4, G5 (ESRD), and endemic and nonendemic controls (EC and NEC) as groups. Subjects with the medical diagnosis were classified into groups by eGFR (SCr, CKD-EPI) and UACR of the study. It determined 24 metals/metalloids in plasma (ICPMS) and metallothionein (MT) mRNA in blood (RT-PCR). MT1A at G3b and MT2A throughout G2−G5 showed increased transcription compared to NEC (ANOVA, p < 0.01). Both MT1A and MT2A remained metal-responsive as associations emerged between MT2A and human MT inducer Cr (in EC: r = 0.54, p < 0.05, n = 14), and between MT1A and MT2A (in EC pooled with G1−G5: r = 0.58, p < 0.001, n = 110). Human MT (hMT)-inducers, namely Zn, Cu, As, Pb, and Ni; Σ hMT-inducers; 14 more non-inducer metals; and Σ MT-binding metals remained higher (p < 0.05) in EC as compared to NEC. Declining eGFR or CKD progression increased the burden of Be, Mg, Al, V, Co, Ni, Rb, Cs, Ba, Mn, Zn, Sr, Σ hMT-inducers, and Σ MT-binding metals in plasma, suggesting an MT role in the disease. MT1A/2A mRNA followed UACR (PCA, Dendrogram: similarity, 57.7%). The study provides evidence that proteinuric chronic renal failure may increase plasma metal levels where blood MT2A could be a marker.

Urinary Levels of Sirtuin-1, π-Glutathione S-Transferase, and Mitochondrial DNA in Maize Farmer Occupationally Exposed to Herbicide

Epidemiologic studies have suggested an association between agrochemical exposure and risk of renal injury. Farmers face great risks to developing adverse effects. The most appropriate biomarker related to renal injury needs to be developed to encounter earlier detection. We aim to study the association between early renal biomarker and occupational herbicide exposure in maize farmers, Thailand. Sixty-four farmers were recruited and interviewed concerning demographic data, herbicide usage, and protective behavior. Two spot urines before (pre-work task) and after (post-work task) herbicide spraying were collected. To estimate the intensity of exposure, the cumulative herbicide exposure intensity index (cumulative EII) was also calculated from activities on the farm, type of personal protective equipment (PPE) use, as well as duration and frequency of exposure. Four candidate renal biomarkers including π-GST, sirtuin-1, mitochondrial DNA (mtDNA) were measured. Most subjects were male and mostly sprayed three herbicides including glyphosate-based herbicides (GBH), paraquat, and 2,4-dichlorophenoxyacetic acid (2,4-D). A type of activity in farm was mixing and spraying herbicide. Our finding demonstrated no statistical significance of all biomarker levels between pre- and post-work task urine. To compare between single and cocktail use of herbicide, there was no statistical difference in all biomarker levels between pre- and post-work task urine. However, the urinary mtDNA seems to be increased in post-work task urine. Moreover, the cumulative EII was strongly associated with change in mtDNA content in both ND-1 and COX-3 gene. The possibility of urinary mtDNA as a valuable biomarker was promising as a noninvasive benchmark for early detection of the risk of developing renal injury from herbicide exposure.

A review of molecular mechanisms linked to potential renal injury agents in tropical rural farming communities

The chronic kidney disease of unknown etiology (CKDu) is a global health concern primarily impacting tropical farming communities. Although the precise etiology is debated, CKDu is associated with environmental exposures including heat stress and chemical contaminants such as fluoride, heavy metals, and herbicide glyphosate. However, a comprehensive synthesis is lacking on molecular networks underpinning renal damage induced by these factors. Addressing this gap, here we present key molecular events associated with heat and chemical exposures. We identified that caspase activation and lipid peroxidation are common endpoints of glyphosate exposure, while vasopressin and polyol pathways are associated with heat stress and dehydration. Heavy metal exposure is shown to induce lipid peroxidation and endoplasmic reticulum stress from ROS activated MAPK, NFĸB, and caspase. Collectively, we identify that environmental exposure induced increased cellular oxidative stress as a common mechanism mediating renal cell inflammation, apoptosis, and necrosis, likely contributing to CKDu initiation and progression.

Flavin-Containing Monooxygenase 3 (FMO3) Is Critical for Dioxin-Induced Reorganization of the Gut Microbiome and Host Insulin Sensitivity

Exposure to some environmental pollutants can have potent endocrine-disrupting effects, thereby promoting hormone imbalance and cardiometabolic diseases such as non-alcoholic fatty liver disease (NAFLD), diabetes, and cardiorenal diseases. Recent evidence also suggests that many environmental pollutants can reorganize the gut microbiome to potentially impact these diverse human diseases. 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is among the most potent endocrine-disrupting dioxin pollutants, yet our understanding of how TCDD impacts the gut microbiome and systemic metabolism is incompletely understood. Here, we show that TCDD exposure in mice profoundly stimulates the hepatic expression of flavin-containing monooxygenase 3 (Fmo3), which is a hepatic xenobiotic metabolizing enzyme that is also responsible for the production of the gut microbiome-associated metabolite trimethylamine N-oxide (TMAO). Interestingly, an enzymatic product of FMO3 (TMAO) has been associated with the same cardiometabolic diseases that these environmental pollutants promote. Therefore, here, we examined TCDD-induced alterations in the gut microbiome, host liver transcriptome, and glucose tolerance in Fmo3+/+ and Fmo3-/- mice. Our results show that Fmo3 is a critical component of the transcriptional response to TCDD, impacting the gut microbiome, host liver transcriptome, and systemic glucose tolerance. Collectively, this work uncovers a previously underappreciated role for Fmo3 in integrating diet-pollutant-microbe-host interactions.

Impacts of Climate Change and Heat Stress on Farmworkers' Health: A Scoping Review

Due to the continuous rise of global temperatures and heatwaves worldwide as a result of climate change, concerns for the health and safety of working populations have increased. Workers in the food production chain, particularly farmworkers, are especially vulnerable to heat stress due to the strenuous nature of their work, which is performed primarily outdoors under poor working conditions. At the cross-section of climate change and farmworkers' health, a scoping review was undertaken to summarize the existing knowledge regarding the health impacts associated with climate change and heat stress, guide future research toward better understanding current and future climate change risks, and inform policies to protect the health and safety of agricultural workers. A systematic search of 5 electronic databases and gray literature websites was conducted to identify relevant literature published up until December 2021. A total of 9045 records were retrieved from the searches, of which 92 articles were included in the final review. The majority of the reviewed articles focused on heat-related illnesses (n = 57) and kidney diseases (n = 28). The risk factors identified in the reviewed studies included gender, dehydration, heat strain, wearing inappropriate clothing, workload, piece-rate payment, job decision latitude, and hot environmental conditions. On the other hand, various protective and preventive factors were identified including drinking water, changing work hours and schedule of activities, wearing appropriate clothing, reducing soda consumption, taking breaks in shaded or air-conditioned areas, and increasing electrolyte consumption in addition to improving access to medical care. This review also identified various factors that are unique to vulnerable agricultural populations, including migrant and child farmworkers. Our findings call for an urgent need to expand future research on vulnerable agricultural communities including migrant workers so as to develop effective policies and interventions that can protect these communities from the effects of heat stress.

Epidemiology of hospitalizations due to pesticide intoxication-associated acute kidney injury in China

BACKGROUND

There is a paucity of epidemiological data regarding pesticide intoxication-associated acute kidney injury (AKI). Therefore, the aim of this study was to identify the epidemiological features, risk factors, and adverse outcomes of AKI in this population.

METHODS

The data used in this multi-center, hospitalized population-based, retrospective study were retrieved from electronic medical records. AKI was defined as an acute increase in serum creatinine according to the criteria of Kidney Disease: Improving Global Outcomes. The Charlson Comorbidity Index was used to evaluate the burden of in-hospital mortality.

RESULTS

Of 3,371 adult patients in 11 hospitals, 398 (11.8%) were diagnosed with AKI (grade 1, 218 [6.5%]; grade 2, 89 [2.6%]; grade 3, 91 [2.7%]). Herbicide intoxication was associated with the highest incidence of AKI (53.5%) and higher grades of AKI. After multivariable adjustment, pesticide categories and moderate or severe renal disease were independently associated with AKI. As compared with the referred category, insecticide and herbicide intoxications were associated with a 1.3-fold (95% CI 1.688-3.245) and 3.8-fold (95% CI 3.537-6.586) greater risk of AKI. Regardless of the pesticide category, AKI was independently associated with in-hospital mortality, with odds ratios of 3.433 (95% CI 1.436-8.203) for insecticides, 2.153 (95% CI 1.377-3.367) for herbicides, and 4.524 (95% CI 1.230-16.632) for unclassified or other pesticides.

CONCLUSION

AKI is common in pesticide intoxication and associated with an increased in-hospital mortality. Herbicides pose the greatest risks of AKI and death.

Exposure to Sub-Lethal Doses of Permethrin Is Associated with Neurotoxicity: Changes in Bioenergetics, Redox Markers, Neuroinflammation and Morphology

Permethrin (PERM) is a member of the class I family of synthetic pyrethroids. Human use has shown that it affects different systems, with wide health dysfunctions. Our aim was to determine bioenergetics, neuroinflammation and morphology changes, as redox markers after subacute exposure to PERM in rats. We used MDA determination, protein carbonyl assay, mitochondrial O₂ consumption, expression of pro-inflammatory cytokines and a deep histopathological analysis of the hippocampus. PERM (150 mg/kg and 300 mg/kg body weight/day, o.v.) increased lipoperoxidation and carbonylated proteins in a dose-dependent manner in the brain regions. The activities of antioxidant enzymes glutathione peroxidase, reductase, S-transferase, catalase, and superoxide dismutase showed an increase in all the different brain areas, with dose-dependent effects in the cerebellum. Cytokine profiles (IL-1β, IL-6 and TNF-α) increased in a dose-dependent manner in different brain tissues. Exposure to 150 mg/kg of permethrin induced degenerated and/or dead neurons in the rat hippocampus and induced mitochondrial uncoupling and reduction of oxidative phosphorylation and significantly decreased the respiratory parameters state 3-associated respiration in complex I and II. PERM exposure at low doses induces reactive oxygen species production and imbalance in the enzymatic antioxidant system, increases gene expression of pro-inflammatory interleukins, and could lead to cell damage mediated by mitochondrial functional impairment.

Urinary concentrations of neonicotinoid insecticides were related to renal tubular dysfunction and neuropsychological complaints in Dry-zone of Sri Lanka

Neonicotinoids are systemic insecticides used since the 1990’s , that possess renal tubular toxicity. We conducted a field-based descriptive study in the North Central Dry-zone of Sri Lanka, where chronic kidney disease (CKD) of unknown etiology has been increasing since the 1990’s. To elucidate the relationship between renal tubular dysfunctions and urinary neonicotinoids concentrations, we collected spot urine samples from15 CKD patients, 15 family members, and 62 neighbors in 2015, analyzed two renal tubular biomarkers, Cystatin-C and L-FABP, quantified seven neonicotinoids and a metabolite N-desmethyl-acetamiprid by LC–MS/MS; and we investigated their symptoms using a questionnaire. Cystatin-C and L-FABP had a positive correlation (p < 0.001). N-Desmethyl-acetamiprid was detected in 92.4% of the urine samples, followed by dinotefuran (17.4%), thiamethoxam (17.4%), clothianidin (9.8%), thiacloprid and imidacloprid. Dinotefuran and thiacloprid have never been registered in Sri Lanka. In High Cystatin-C group (> 70 μg/gCre, n = 7), higher urinary concentration of dinotefuran (p = 0.009), and in Zero Cystatin-C group (< LOQ, n = 7), higher N-desmethyl-acetamiprid (p = 0.013), dinotefuran (p = 0.049), and thiacloprid (p = 0.035), and more complaints of chest pains, stomachache, skin eruption and diarrhea (p < 0.05) were found than in Normal Cystatin-C group (n = 78). Urinary neonicotinoids may be one of the potential risk factors for renal tubular dysfunction in this area.

In silico approaches in organ toxicity hazard assessment: Current status and future needs for predicting heart, kidney and lung toxicities

The kidneys, heart and lungs are vital organ systems evaluated as part of acute or chronic toxicity assessments. New methodologies are being developed to predict these adverse effects based on in vitro and in silico approaches. This paper reviews the current state of the art in predicting these organ toxicities. It outlines the biological basis, processes and endpoints for kidney toxicity, pulmonary toxicity, respiratory irritation and sensitization as well as functional and structural cardiac toxicities. The review also covers current experimental approaches, including off-target panels from secondary pharmacology batteries. Current in silico approaches for prediction of these effects and mechanisms are described as well as obstacles to the use of in silico methods. Ultimately, a commonly accepted protocol for performing such assessment would be a valuable resource to expand the use of such approaches across different regulatory and industrial applications. However, a number of factors impede their widespread deployment including a lack of a comprehensive mechanistic understanding, limited in vitro testing approaches and limited in vivo databases suitable for modeling, a limited understanding of how to incorporate absorption, distribution, metabolism, and excretion (ADME) considerations into the overall process, a lack of in silico models designed to predict a safe dose and an accepted framework for organizing the key characteristics of these organ toxicants.

Mesoamerican nephropathy: A not so unknown chronic kidney disease

From 2000, Mesoamerican region has reached an important rate of chronic kidney disease of unknown etiology. Under the name of Meroamerican Nephropathy (MeN) several hypotheses (including dehydration, heat stress, environmental or toxic exposure or even infections) have tried to explain the etiology this new disease. MeN affects young men, agricultural workers exposed to high temperatures. MeN courses with unspecific symptoms as low-grade fever and dysuria and progressive kidney disease with impaired renal function and hydroelectrolyte disturbances. The diagnosis requires kidney biopsy showing tubule-interstitial nephritis (usually at chronic stage). Although MeN conditions a high morbi-mortality in endemic regions, there is a lack of specific treatment and only preventive measures have demonstrated some effect of prognosis (avoid heat stress, constant hydration). In this review we aim to summarize the available information of MeN, illustrating the information in a case report.

Women and other risk factors for chronic kidney disease of unknown etiology in Thailand: National Health Examination V Survey

There are limited data on chronic kidney disease of unknown etiology (CKDu) from Southeast Asia. Initially described in working age men, a common approach to detect CKDu that includes all adults has recently been proposed. We determined the prevalence, and risk factors for CKDu using data from a cross-sectional, nationally representative survey of the adult population of Thailand. We used a proxy for CKDu as age < 70 with impaired kidney function (eGFR < 60) in the absence of diabetes and hypertension (CKDu1) and heavy proteinuria (CKDu2). Prevalence estimates were probability-weighted for the Thai population. The associations between risk factors and CKDu or elderly subjects with eGFR < 60 without traditional causes were assessed by multivariable logistic regression. Of 17,329 subjects, the prevalence were: eGFR < 60, 5.3%; CKDu1 0.78%; CKDu2, 0.75%. CKDu differed by 4.3-folds between regions. Women, farmers/laborers, older age, gout, painkillers, rural area, and stones were independent risk factors for CKDu. Women, age, rural, gout, painkillers were significant risk factors for both CKDu and elderly subjects. These data collected using standardized methodology showed that the prevalence of CKDu in Thailand was low overall, although some regions had higher risk. Unlike other countries, Thai women had a two-fold higher risk of CKDu.

Non-occupational exposure to pesticides and health markers in general population in Northern Finland: Differences between sexes

BACKGROUND

Occupational exposure to pesticides has been reported among general population worldwide. However, little is known about the associations between non-occupational exposure to pesticides, and biological markers of health and their response by sex.

OBJECTIVES

We aimed to assess the associations between non-occupational overall pesticide exposure, length of exposure and specific pesticides reported with 35 biological markers of health representing cardiometabolic, haematological, lung function, sex hormones, liver and kidney function profiles, and vitamin D in Finnish cohort.

METHODS

31-year cross-sectional examination of the Northern Finland Birth Cohort 1966 provided blood samples for biomarker measurements in 1997-1998. Number of subjects varied between 2361 and 5037 for given exposures and certain outcome associations. Multivariable regression analyses were performed to examine associations between overall pesticide exposure (OPE), length of pesticide exposure in months (PEM), in years (PEY), and specific pesticides use (PEU) or not with cardiometabolic [SBP, DBP, TC, LDL, HDL, triglycerides, fasting glucose, insulin, HOMA-IR, HOMA-B, HOMA-S, hs-CRP], hematological [WBC, RBC, Hb, HCT, MCV, MCH, MCHC, platelets], lung function (FVC, FEV1), sex hormones [luteinizing hormone (LH), testosterone (TT), sex-hormone binding globulin (SHBG)], liver and kidney function profiles [total protein, albumin, globulin, ALP, ALT, GGT, urea, creatinine], and vitamin D adjusting for sex, BMI, socioeconomic position (SEP) and season of pesticide use.

RESULTS

This cohort study on up to 5037 adults with non-occupational OPE, PEM, PEY and PEU differed by sex and SEP. In regression analyses, all the exposures were positively associated with total cholesterol and low-density lipoprotein cholesterol, and PEU was negatively associated with high-density lipoprotein cholesterol in females. OPE and PEM were positively associated with haematocrit in females and PEU with platelets in males. PEU was negatively associated with mean corpuscular haemoglobin. OPE and PEM were positively associated with LH in males. OPE was negatively associated with total protein and albumin in males.

DISCUSSION

In Finnish young adults, non-occupational overall pesticide exposure, length of exposure and specific pesticides were associated with multiple biological markers of health. The biological markers seem to be indicative of adverse effects of pesticides and warrant for further studies to replicate the findings and determine the underlying mechanisms.

Environment and chronic kidney disease in farmers

The prevalence of chronic kidney disease (CKD) has been on the rise worldwide. Epidemiological studies performed primarily in Central America and South Asia have reported high prevalence of CKD among young and middle-aged men working in agricultural communities. The clinical features do not appear linked to any classical CKD risk factors, such as hypertension, diabetes, or chronic nephritis. The disease develops and progresses as interstitial nephritis, without showing noticeable symptoms or high levels of proteinuria. Pathologically, the disease essentially represents chronic interstitial nephritis and is termed chronic interstitial nephritis in agricultural communities (CINAC). The potential causes of CINAC include: (1) heat stress-related factors associated with increased ambient temperatures resulting from global warming; and (2) factors connected with exposure to agrochemicals and/or pesticides. Global warming and environmental pollution will undoubtedly pose a significant health risk to farmers, and heat stress during farm work could easily result in the development and progression of CKD. Japanese agricultural regions evidently will not be spared from global environmental changes. For future epidemiological studies, researchers should establish a more comprehensive analytical method that can incorporate additional risk-factor variables, such as occupational history (including agricultural work) and ambient temperature.

Organophosphate pesticides and progression of chronic kidney disease among children: A prospective cohort study

BACKGROUND

Growing evidence suggests that exposure to environmental chemicals, such as pesticides, impacts renal function and chronic kidney disease (CKD). However, it is not clear if pesticides may affect CKD progression and no studies exist in children.

OBJECTIVES

The objective of this study was to examine associations between serially measured urinary OP pesticide metabolites and clinical and laboratory measures of kidney function over time among children with CKD.

METHODS

This study used data on 618 participants enrolled in the CKD in Children study (CKiD), a cohort study of pediatric CKD patients from the US and Canada. Children were followed over an average of 3.0 years (standard deviation (SD) = 1.6) between 2005 and 2015. In serially collected urine samples over time, six nonspecific dialkyl phosphate (DAP) metabolites of OP pesticides were measured. Biomarkers of tubular injury (kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL)) and oxidant stress (8-hydroxy-2'-deoxyguanosine (8-OHdG) and F2-isoprostane) were determined in the same specimens. Estimated glomerular filtration rate (eGFR), proteinuria, and blood pressure were assessed annually.

RESULTS

DAPs were associated with increased KIM-1 and 8-OHdG throughout follow-up. A standard deviation increase in ∑diethyl metabolites was associated with increases of 11.9% (95% Confidence Interval (CI): 4.8%, 19.4%) and 13.2% (95% CI: 9.3%, 17.2%) in KIM-1 and 8-OHdG over time, respectively. DAPs were associated with lower eGFR at baseline and higher eGFR over subsequent years.

CONCLUSIONS

These findings provide preliminary evidence suggesting that urinary DAP metabolites are associated with subclinical kidney injury among children with CKD, which may signal the potential for clinical events to manifest in the future. The results from this study are significant from both a clinical and public health perspective, given that OP pesticide exposure is a modifiable risk factor.

Xenoestrogen exposure and kidney function in the general population: Results of a community-based study by laboratory tests and questionnaire-based interviewing

BACKGROUND

Chronic kidney disease (CKD) is a growing concern worldwide. Exposure to xenoestrogens (XEs), such as phthalates, parabens, and phenols, lead to CKD. However, kidney function and its complex relationship with XEs, lifestyle, and dietary habits are not well understood.

METHODS

In the present cross-sectional community-based cohort study, we enrolled 887 subjects for a questionnaire-based interview and laboratory tests. XE exposure concerning lifestyle/dietary habits were evaluated using questionnaires. Urinary levels of 17XE metabolites were measured in 60 subjects with high exposure risk scores and 60 subjects with low exposure risk scores.

RESULTS

Univariate and multivariate linear regression showed that a high exposure score (β ± SE: 4.226 ± 1.830, P = 0.021) was independently negatively associated with eGFR in 887 subjects. Univariate and multivariate linear regression to urinary XEs and urine albumin creatinine excretion ratio (UACR) in 120 subjects indicated that ethylparaben (EP) (β: 1.934, 95% CI: 0.135-3.733, P = 0.035) was significantly associated with increased UACR. Multivariate regression analyses of the CKD subgroup (n = 38), after adjusting for age, showed that higher levels of mono-(2-ethylhexyl) phthalate (MEHP), EP, nonylphenol (NP), and benzophenone-3 (BP-3) were significantly associated with lower estimated glomerular filtration rate (eGFR). Higher urinary levels of MEHP (OR: 3.037, 95% CI: 1.274-7.241) were more likely associated with high exposure scores (>5 points), after adjusting for diabetes, gender, eGFR, age, Na, Ca, albumin, vitamin D, systolic blood pressure (SBP), white blood cell count, total bilirubin, aspartate transaminase, and heart rate. MEHP (β ± SE: 0.033 ± 0.009, P < 0.001) was also significantly positively associated with total exposure scores after applying multivariate linear regression analyses.

CONCLUSION

XE exposure scores obtained from the questionnaires were negatively associated with kidney function. Urinary metabolites of XEs, including EP, NP, BP-3, and MEHP, are potential risk factors for microalbuminuria and decline in kidney function. MEHP seemed to have the strongest correlation with high exposure scores and decline in kidney function.

Environmental risk factors for reduced kidney function due to undetermined cause in India: an environmental epidemiologic analysis

BACKGROUND

An epidemic of chronic kidney disease is occurring in rural communities in low-income and middle-income countries that do not share common kidney disease risk factors such as diabetes and hypertension. This chronic kidney disease of unknown etiology occurs primarily in agricultural communities in Central America and South Asia. Consequently, environmental risk factors including heat stress, heavy metals exposure, and low altitude have been hypothesized as risk factors. We conducted an environmental epidemiological analysis investigating these exposures in India which reports the disease.

METHODS

We used a random sample population in rural and urban sites in Northern and Southern India in 2010, 2011, and 2014 (n = 11,119). We investigated associations of the heat index, altitude, and vicinity to cropland with estimated glomerular filtration rate (eGFR) using satellite-derived data assigned to residential coordinates. We modeled these exposures with eGFR using logistic regression to estimate the risk of low eGFR, and linear mixed models (LMMs) to analyze site-specific eGFR-environment associations.

RESULTS

Being over 55 years of age, male, and living in proximity to cropland was associated with increased risk of low eGFR [odds ratio (OR) (95% confidence interval (CI) = 2.24 (1.43, 3.56), 2.32 (1.39, 3.88), and 1.47 (1.16, 2.36)], respectively. In LMMs, vicinity to cropland was associated with low eGFR [-0.80 (-0.44, -0.14)]. No associations were observed with temperature or altitude.

CONCLUSIONS

Older age, being male, and living in proximity to cropland were negatively associated with eGFR. These analyses are important in identifying subcommunities at higher risk and can help direct future environmental investigations.

Mesoamerican nephropathy: A not so unknown chronic kidney disease

From 2000, Mesoamerican region has reached an important rate of chronic kidney disease of unknown etiology. Under the name of Meroamerican Nephropathy (MeN) several hypotheses (including dehydration, heat stress, environmental or toxic exposure or even infections) have tried to explain the etiology this new disease. MeN affects young men, agricultural workers exposed to high temperatures. MeN courses with unspecific symptoms as low-grade fever and dysuria and progressive kidney disease with impaired renal function and hydroelectrolyte disturbances. The diagnosis requires kidney biopsy showing tubule-interstitial nephritis (usually at chronic stage). Although MeN conditions a high morbi-mortality in endemic regions, there is a lack of specific treatment and only preventive measures have demonstrated some effect of prognosis (avoid heat stress, constant hydration). In this review we aim to summarize the available information of MeN, illustrating the information in a case report.

Epidemiology of chronic kidney disease of undetermined aetiology in Taiwanese farmers: a cross-sectional study from Changhua Community-based Integrated Screening programme

OBJECTIVES

Chronic kidney disease of undetermined or non-traditional aetiology (CKDu or CKDnT) has been reported in Mesoamerica among farmers under heat stress. Epidemiological evidence was lacking in Asian countries with similar climatic conditions. The objective of this study was to investigate the prevalence of CKDu and possible risk factors.

METHODS

We used the data from the Changhua Community-based Integrated Screening programme from 2005 to 2014, which is the annual screening for chronic diseases in Taiwan's largest rice-farming county since 2005. Our study population included farmers and non-farmers aged 15-60 years. CKDu was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m² at age under 60 years without hypertension, diabetes, proteinuria, haematuria or using Chinese herbal medicine. We estimated the adjusted prevalence OR (POR) of CKDu by farmers, age, sex, education, urbanisation, smoking, body mass index, hyperuricaemia, hyperlipidaemia, heart disease and chronic liver disease.

RESULTS

5555 farmers and 35 761 non-farmers were included in this study. CKDu accounted for 48.9% of all CKD cases. The prevalence of CKDu was 2.3% in the farmers and 0.9% in the non-farmers. The crude POR of CKDu in farmers compared with non-farmers was 2.73 (2.13-3.50), and the adjusted POR was 1.45 (1.10-1.90). Dehydration (blood urea nitrogen-to-creatinine ratio >20) was found in 22% of the farmers and 14% of the non-farmers.

CONCLUSIONS

Farmers in subtropical Asian countries are at increased risk of CKDu. Governments should take the CKDu epidemics seriously and provide farmers with occupational health education programmes on thermal hazards.

Adverse Health Effects in Women Farmers Indirectly Exposed to Pesticides

Farmers are among the most vulnerable populations because of the exposure to low levels of pesticides. Acetylcholinesterase and butyrylcholinesterase activities are considered as biomarkers of pesticides poisoning. However, biomarkers of oxidative stress are also playing an important role in toxicity of these contaminants. Further, increased activities of gamma-glutamyltransferase, alanine aminotransferase, urea and creatinine have been linked with hepatic and nephrotoxic cell damage, respectively. The aim of this study was to ascertain if the indirect exposure to pesticides leads to some biochemical parameter changes. Thus, cholinesterase activities, oxidative stress status (lipid and protein oxidation), hepatic function (AST and ALT levels), hormonal function (TSH, T4, FSH, LH and AMH), renal function (serum creatinine and urea), as well as possible subclinical kidney damage (urinary proteins and biomarkers of early kidney damage) were evaluated in farmer women who collect fruits and vegetables comparing with a group of women non-occupational exposed to pesticides but living in the same rural environment. Samples were taken periodically along one year to relate the observed effects to a chronic exposure. Our main results showed for the first time a subclinical kidney damage in a rural setting with indirect chronic exposure to pesticides.

Inflammation-Related Factors Identified as Biomarkers of Dehydration and Subsequent Acute Kidney Injury in Agricultural Workers

Globally, there is increasing recognition that agricultural workers are at risk for chronic kidney disease of unknown etiology (CKDu). Recurrent heat exposure, physical exertion, dehydration, muscle damage, and inflammation are hypothesized to contribute to the development of CKDu, but the relative importance of these processes and the interactions among them remain unclear. Moreover, there is a need to identify biomarkers that could distinguish individuals who are at greatest risk for kidney damage to target preventative interventions for CKDu. In this study, we evaluated dehydration and markers of inflammation, muscle damage, and renal function in agricultural workers at a non-workday baseline assessment. Urine specific gravity and kidney function were measured before and after work shifts on three subsequent days, and heat index, core body temperature, and heart rate were monitored during the work shifts. A combination of direct comparisons and machine learning algorithms revealed that reduced levels of uromodulin and sodium in urine and increased levels of interleukin-6 and C-reactive protein in serum were indicative of dehydration at baseline, and that dehydration, high body mass index, reduced urine uromodulin, and increased serum interleukin-6, C-reactive protein, and lipopolysaccharide-binding protein at baseline were predictive of acute kidney injury on subsequent workdays. Our findings suggest a method for identifying agricultural workers at greatest risk for kidney injury and reveal potential mechanisms responsible for this process, including pathways overlapping in dehydration and kidney injury. These results will guide future studies confirming these mechanisms and introducing interventions to protect kidney health in this vulnerable population.

Ambient air pollution exposure and risk of chronic kidney disease: A systematic review of the literature and meta-analysis

Ambient air pollution has been identified as one of the leading causes of global burden of disease. The relationship between ambient air pollution exposure and risk of chronic kidney disease (CKD) has stimulated increasing scientific interest in the past few years. However, evidence from human epidemiological studies is still limited and inconsistent. We performed an updated systematic review and meta-analysis to clarify the potential association comprehensively. Selected electronic databases were searched for related English language studies until March 1, 2020 with a final follow-up in December 31, 2020. Risk of bias assessment for individual studies were assessed using the OHAT (Office of Health Assessment and Translation) risk-of-bias rating tool. Confidence rating and level-of-evidence conclusions were developed for bodies of evidence for a given ambient air pollutant. Summary effect estimates were calculated using random-effects meta-analyses when three or more studies are identified for the same air pollutant-CKD combination. A total of 13 studies were finally identified in our study. The meta-analytic estimates (ORs) for risk of CKD were 1.15 (95% CI: 1.07, 1.24) for each 10 μg/m³ increase in PM_2.5, 1.25 (95% CI: 1.11, 1.40) for each 10 μg/m³ increase in PM₁₀, 1.10 (95% CI: 1.03, 1.17) for each 10 ppb increase in NO₂, 1.06 (95% CI: 0.98, 1.15) for each 1 ppb increase in SO₂ and 1.04 (95% CI: 1.00, 1.08) for each 0.1 ppm increase in CO, respectively. The level of evidence was appraised as moderate for four of the five tested air pollutant-CKD combinations using an adaptation of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool. In conclusion, this study suggests that certain ambient air pollutant exposure was significantly associated with an increased risk of CKD. Given the limitations, the results of this study should be interpreted with caution, and further well-designed epidemiological studies are needed to draw a definite evidence of a causal relationship.

A pilot case-control study using a one health approach to evaluate behavioral, environmental, and occupational risk factors for chronic kidney disease of unknown etiology in Sri Lanka

BACKGROUND

Chronic kidney disease of unknown etiology (CKDu) was first recognized in Sri Lanka in the early 1990s, and since then it has reached epidemic levels in the North Central Province of the country. The prevalence of CKDu is reportedly highest among communities that engage in chena and paddy farming, which is most often practiced in the dry zone including the North Central and East Central Provinces of Sri Lanka. Previous studies have suggested varied hypotheses for the etiology of CKDu; however, there is not yet a consensus on the primary risk factors, possibly due to disparate study designs, sample populations, and methodologies.

METHODS

The goal of this pilot case-control study was to evaluate the relationships between key demographic, cultural, and occupational variables as risk factors for CKDu, with a primary interest in pesticide exposure both occupationally and through its potential use as an ingredient in brewed kasippu alcohol. An extensive one health focused survey was developed with in cooperation with the Centre for Research, Education, and Training on Kidney Diseases of Sri Lanka.

RESULTS

A total of 56 CKDu cases and 54 control individuals were surveyed using a proctored, self-reported questionnaire. Occupational pesticide exposure and alcohol consumption were not found to be significant risk factors for CKDu. However, a statistically significant association with CKDu was observed with chewing betel (adjusted odds ratio [aOR]: 6.11, 95% confidence interval [CI]: 1.93, 19.35), age (aOR: 1.07, 95% CI: 1.02, 1.13), owning a pet dog (aOR: 3.74, 95% CI: 1.38, 10.11), water treatment (aOR: 3.68, 95% CI: 1.09, 12.43) and pests in the house (aOR: 5.81, 95% CI: 1.56, 21.60).

CONCLUSIONS

The findings of this study suggest future research should focus on practices associated with chewing betel, potential animal interactions including pests in the home and pets, and risk factors associated with water.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s42522-020-00034-3.

CKD and CKDu in northern Peru: a cross-sectional analysis under the DEGREE protocol

BACKGROUND

This study estimated the prevalence and risk factors for decreased estimated glomerular filtration rate (eGFR) in those without known hypertension, type 2 diabetes mellitus, or heavy proteinuria as a surrogate marker for chronic kidney disease of unknown cause (CKDu) among adults in the North of Peru.

METHODS

A cross-sectional study was conducted following the Disadvantaged Populations eGFR Epidemiology (DEGREE) Study protocol. Low eGFR was defined based on a single eGFR ≤60 mL/min/1.7m² estimated using the CKD-EPI equation. Environmental conditions related to CKDu (i.e., work in agriculture or sugarcane, water source, heat intolerance, and pesticide exposure) were evaluated, in addition to traditional risk factors for CKD (i.e., smoking, heavy drinking, physical activity, hypertension, type 2 diabetes mellitus, urolithiasis, among others).

RESULTS

A total of 1514 subjects were included in the study, mean age 45.1 (SD: 16.4), and 55.2% were females. Overall, only 26 cases (1.7%; 95%CI: 1.1-2.5%) had an eGFR < 60 mL/min/1.7m² compatible with CKD definition; when those with hypertension and type-2 diabetes or heavy proteinuria were excluded, according to the DEGREE protocol, the estimate fell to 0.9% (95%CI: 0.4-1.5%). Low physical activity levels (OR = 1.99; 95%CI: 1.18-3.34), hypertension (OR = 2.07; 1.26-3.41), and urolithiasis (OR = 1.97; 95%CI: 1.18-3.27) were factors associated with low eGFR.

CONCLUSIONS

A low population-based prevalence of low eGFR (as a surrogate for CKDu), both in rural and urban settings areas, in the Northern Peru, was found. Low physical activity levels, hypertension and urolithiasis were factors associated with low eGFR. Interventions to prevent CKD cases may be focused on well-known CV risk factors and urolithiasis.

A comparative review: Chronic Kidney Disease of unknown etiology (CKDu) research conducted in Latin America versus Asia

INTRODUCTION

The incidence of chronic kidney disease of unknown or uncertain etiology (CKDu) is recognized as a global non-communicable health crisis. The goal of this work is to compare the types of research studies in Latin America and Asia, two regions with increasing CKDu incidence.

METHODS

A comparative literature review was conducted to evaluate the CKDu research design for peer-reviewed articles published from 2015 to 2019. Full texts were reviewed to identify study location, study type, study design, risk factors evaluated, and if applicable, sample type and number.

RESULTS

In Asia and Latin America, 82 and 65 articles were identified in total, respectively, with 55 field studies in Asia versus 34 in Latin America. In Asia, research was focused on drinking water (34), heavy metals (20), and agrochemical product usage (19) as potential risk factors. In Latin America, research focused mostly on heat stress/dehydration (36) and agrochemical product usage (18) as potential CKDu risk factors. Biological samples were collected more frequently than environmental samples, especially in Latin America.

DISCUSSION

Research to pinpoint the risk factors associated with CKDu to date is not standardized and typically limited in geographical scope. The emphasis of CKDu research varies by geographic region, with a greater priority placed on water quality and chemical exposure in Asia, versus dehydration and heat stress in Latin America. Using a harmonized approach to CKDu research would yield improved understanding of the risk factors associated with CKDu and how they compare across affected regions.

Renal tubular injury induced by glyphosate combined with hard water: the role of cytosolic phospholipase A2

Background

The combined effects of glyphosate and hard water on chronic kidney disease of unknown etiology (CDKu) have attracted much interest, but the mechanisms remain unknown. Cytoplasmic phospholipase A₂ (cPLA₂) plays a key role in the acute and chronic inflammatory reactions. This study explored the effect of glyphosate combined with hard water on renal tubules and the possible targets and mechanisms involved.

Methods

In vivo experiments were conducted to investigate the synergistic effects and potential mechanisms of glyphosate and hard water on renal tubular injury in mice.

Results

Administration of glyphosate in mice resulted in elevated levels of β2-microglobulin (β₂-MG), albumin (ALB), and serum creatinine (SCr) compared to control mice. This increase was more pronounce when glyphosate was combined with hard water. In the glyphosate-treated mice, small areas of the kidney revealed fibroblast proliferation and vacuolar degeneration, particularly at the higher dose of 400 mg/kg glyphosate. However, the combination of glyphosate and hard water induced an even greater degree of pathological changes in the kidney. Immunofluorescence and western blot analyses showed that glyphosate and hard water had a coordinated effect on calcium ions (Ca²⁺)-activated phospholipase A₂ and the activation may play a key role in inflammation and renal tubular injury. Exposure to glyphosate alone or glyphosate plus hard water increased the levels of oxidative stress markers and inflammatory biomarkers, namely, thromboxane A₂ (TX-A₂), leukotriene B₄ (LTB₄), prostaglandin E₂ (PGE₂), nitric oxide synthase (NOS), and nitric oxide (NO). Parameters of oxidative stress, including the levels of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) were decreased. Further analysis showed that the levels of these biomarkers were significantly different between the mice treated with glyphosate plus hard water and the mice treated with glyphosate alone.

Conclusions

These findings suggested that hard water combined with glyphosate can induce renal tubular injury in mice, and this may involve mitogen-activated protein kinases (MAPK)/cytosolic phospholipase A₂ (cPLA₂)/arachidonic acid (AA) and its downstream factors.

Purposeful Review to Identify Risk Factors, Epidemiology, Clinical Features, Treatment and Prevention of Chronic Kidney Disease of Unknown Etiology

The global burden of chronic kidney disease (CKD) has risen, and chronic kidney disease of unknown etiology (CKDu) contributes considerably to the national burden of CKD. It is characterized by irreversible, slowly advancing disease, and symptoms often appear in the late stages of the disease. It is a serious, novel cause of kidney failure and leads to premature deaths. Many hypotheses have emerged; however, the etiology of CKDu continues to be elusive and debatable and it is claimed that the etiology is multifactorial, encompassing environmental, genetic, occupational, and social factors. The dominant histopathological feature is chronic tubulointerstitial nephritis. It predominantly affects individuals with low socio-economic status, of working age, largely without chronic comorbidities, who perform strenuous labor in extreme conditions in various tropical areas of the world. It is often fatal due to fast progression and limited access to dialysis or transplant options in the involved geographic areas. Early recognition and appropriate interventions at the earliest possible stage are imperative for decreasing its associated morbidity and mortality. In this review, I tried to summarize available evidence on the risk factors, epidemiology, clinical features, treatment, and prevention of CKDu. The literature search for this review was conducted comprehensively by using different electronic databases and by using appropriate search terms.

Workplace Screening Identifies Clinically Significant and Potentially Reversible Kidney Injury in Heat-Exposed Sugarcane Workers

An epidemic of chronic kidney disease of unknown origin (CKDu) has emerged in the past two decades in agricultural communities, characterized by progressive renal failure with a dearth of early clinical symptoms. The aim of this study is to improve understanding of the natural history of this disease and to evaluate the impact of an educational and behavioral intervention on the trajectories of renal decline among a cohort of Guatemalan sugarcane workers. We identified groups of workers based on their kidney function during a longitudinal parent study conducted among sugarcane workers during the 2016–2017 harvest season. At the study’s first time point in February 2017, workers who developed abnormal kidney function (AKF) (estimated glomerular filtration rate, eGFR, <60 mL/min per 1.73 m²) were placed in the AKF group, workers with reduced kidney function (RKF) (eGFR 60–89) were placed in the RKF group, and workers who maintained normal kidney function (NKF) (eGFR ≥ 90) were placed in the NKF group. As part of the study, a health promotion, behavioral and educational intervention centered on water, electrolytes, rest, and shade (WERS) was provided to all study participants. We then prospectively analyzed renal function at the three study time points in February, March, and April. Additional data collected from previous harvests allowed for retrospective analysis and we compared the rate of change in eGFR over the previous five years (2012 to 2016) for each identified group. Mixed effects linear regression with random intercepts for the workers was used to investigate the difference in rates of change for the three groups and to assess the impact of the intervention study on rate of change of kidney function during the study compared to each group’s prior trajectory, utilizing the retrospective data collected during the five years prior to the study intervention. Between 2012 and 2016, eGFR declined at a rate of 0.18 mL/min per 1.73 m² per year for the NKF group (95% CI: −0.66, 0.29, p = 0.45), 2.02 per year for the RKF group (95% CI: 1.00, 3.03, p = 0.0001) and 7.52 per year for the AKF group (95% CI: 6.01, 9.04, p < 0.0001). All study groups stabilized or improved their trajectory of decline during the intervention. This study supports the need to institute WERS interventions and to include mid-harvest screening protocols and longitudinal tracking of kidney function among sugarcane workers at high risk of CKDu. Early detection of rapid kidney function decline combined with appropriate interventions hold promise for stopping or slowing progression of renal insufficiency among these workers.