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Aoun M, Chelala D. Where do you live and what do you do? Two questions that might impact your kidney health. FRONTIERS IN NEPHROLOGY 2022; 2:1011964. [PMID: 37675017 PMCID: PMC10479685 DOI: 10.3389/fneph.2022.1011964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/13/2022] [Indexed: 09/08/2023]
Abstract
In many cases the social determinants of health need to be assessed through their interaction with environmental factors. This review looks at the impact of physical location and occupation of individuals on their kidney health. It examines the effect of living at high altitude on kidney function and the relationship between extreme cold or hot temperatures and the incidence of kidney injury. It reviews as well the many occupations that have been linked to kidney disease in high-income and low-and-middle-income countries. As a conclusion, this overview proposes preventive recommendations that could be individualized based on weather, altitude, socio-economic level of the country and occupation of the individual.
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Affiliation(s)
- Mabel Aoun
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
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2
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Lou-Meda R, Alvarez-Elías AC, Bonilla-Félix M. Mesoamerican Endemic Nephropathy (MeN): A Disease Reported in Adults That May Start Since Childhood? Semin Nephrol 2022; 42:151337. [PMID: 37028147 DOI: 10.1016/j.semnephrol.2023.151337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Mesoamerican endemic nephropathy (MeN) is a type of chronic kidney disease (CKD) of uncertain etiology that occurs along the Pacific coast of the southern part of Mexico and Central America. During the past 20 years MeN has become a leading cause of death in the region, clamming close to 50,000 lives, with 40% of these deaths occurring in young people. The cause remains unknown, but most researchers believe in a multifactorial etiology that includes social determinants of poverty. Existing evidence suggests that subclinical kidney injury begins early in life and leads to a higher than expected prevalence of CKD among children in Central America. Access to health services in the region, specifically kidney replacement therapy, remains limited. We proposed a strategy to address the perceived needs and urge coordinated efforts of governments, academic organizations, and international bodies to develop a comprehensive plan of action to mitigate this situation among the vulnerable and economically disadvantaged population.
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Affiliation(s)
- Randall Lou-Meda
- Pediatric Nephrology Unit, Fundacion Para el Niño Enfermo Renal (FUNDANIER), Guatemala City, Guatemala; Department of Pediatrics, Hospital Roosevelt, Guatemala City, Guatemala.
| | - Ana Catalina Alvarez-Elías
- Nephrology Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Institute of Health Policy and Management, University of Toronto, Ontario, Canada; Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - Melvin Bonilla-Félix
- Pediatric Nephrology Division, Hospital Pediátrico Universitario, San Juan, Puerto Rico; Universidad de Puerto Rico, San Juan, Puerto Rico
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Yan T, Yang S, Zhou X, Zhang C, Zhu X, Ma W, Tang S, Li J. Chronic kidney disease among greenhouse workers and field workers in China. CHEMOSPHERE 2022; 302:134905. [PMID: 35561762 DOI: 10.1016/j.chemosphere.2022.134905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/07/2022] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Tenglong Yan
- Beijing Institute of Occupational Disease Prevention and Treatment, Beijing 100093, China
| | - Siwen Yang
- National Center for Occupational Safety and Health, National Health Commission of the People's Republic of China, Beijing 102308, China
| | - Xingfan Zhou
- Beijing Key Laboratory of Occupational Safety and Health, Institute of Urban Safety and Environmental Science, Beijing Academy of Science and Technology, Beijing 100054, China
| | - Chuyi Zhang
- Beijing Key Laboratory of Occupational Safety and Health, Institute of Urban Safety and Environmental Science, Beijing Academy of Science and Technology, Beijing 100054, China
| | - Xiaojun Zhu
- National Center for Occupational Safety and Health, National Health Commission of the People's Republic of China, Beijing 102308, China.
| | - Wenjun Ma
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing 100191, China
| | - Shichuan Tang
- Beijing Key Laboratory of Occupational Safety and Health, Institute of Urban Safety and Environmental Science, Beijing Academy of Science and Technology, Beijing 100054, China
| | - Jue Li
- Beijing Institute of Occupational Disease Prevention and Treatment, Beijing 100093, China
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He L, Xue B, Wang B, Liu C, Gimeno Ruiz de Porras D, Delclos GL, Hu M, Luo B, Zhang K. Impact of high, low, and non-optimum temperatures on chronic kidney disease in a changing climate, 1990-2019: A global analysis. ENVIRONMENTAL RESEARCH 2022; 212:113172. [PMID: 35346653 PMCID: PMC9907637 DOI: 10.1016/j.envres.2022.113172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 05/07/2023]
Abstract
BACKGROUND Although a few studies have reported the relationship between high and low temperatures and chronic kidney disease (CKD), the global burden of CKD attributable to extreme heat and cold in recent decades remains unknown. METHODS Based on the Global Burden of Disease Study (GBD) 2019, we obtained data on age-standardized mortality rates (ASMR) and age-standardized rates of disability-adjusted life years (ASDR) per 100 000 population of the CKD attributable to non-optimum temperatures from 1990 to 2019. The annual mean temperature of each country was used to divide each country into five climate zones (tropical, subtropical, warm-temperate, cool-temperate, and boreal). The locally weighted regression model was used to estimate the burden for different climate zones and Socio-demographic index (SDI) regions. RESULTS In 1990, the ASMR and ASDR due to high temperature estimated -0.01 (95% UI, -0.74 to 0.44) and -0.32 (-21.66 to 12.66) per 100 000 population, respectively. In 2019, the ASMR and ASDR reached 0.10 (-0.28 to 0.38) and 2.71 (-8.07 to 10.46), respectively. The high-temperature burden increased most rapidly in tropical and low SDI regions. There were 0.99 (0.59 to 1.39) ASMR attributable to low-temperature in 1990, which increased to 1.05 (0.61-1.49) in 2019. While the ASDR due to low temperature declined from 22.03 (12.66 to 30.64) in 1990 to 20.43 (11.30 to 29.26) in 2019. Overall, the burden of CKD attributable to non-optimal temperatures has increased from 1990 to 2019. CKD due to hypertension and diabetes mellitus were the primary causes of CKD death attributable to non-optimum temperatures in 2019 with males and older adults being more susceptible to these temperatures. CONCLUSIONS The CKD burden due to high, low, and non-optimum temperatures varies considerably by regions and countries. The burden of CKD attributable to high temperature has been increasing since 1990.
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Affiliation(s)
- Li He
- Institute of Occupational Health and Environmental Health, School of Public Health, Lanzhou University, Lanzhou, Gansu, 730000, People's Republic of China
| | - Baode Xue
- Institute of Occupational Health and Environmental Health, School of Public Health, Lanzhou University, Lanzhou, Gansu, 730000, People's Republic of China
| | - Bo Wang
- Institute of Occupational Health and Environmental Health, School of Public Health, Lanzhou University, Lanzhou, Gansu, 730000, People's Republic of China
| | - Ce Liu
- Institute of Occupational Health and Environmental Health, School of Public Health, Lanzhou University, Lanzhou, Gansu, 730000, People's Republic of China
| | - David Gimeno Ruiz de Porras
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA; Southwest Center for Occupational and Environmental Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - George L Delclos
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA; Southwest Center for Occupational and Environmental Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Ming Hu
- School of Architecture, Planning and Preservation, University of Maryland, College Park, MD, 20742, USA
| | - Bin Luo
- Institute of Occupational Health and Environmental Health, School of Public Health, Lanzhou University, Lanzhou, Gansu, 730000, People's Republic of China.
| | - Kai Zhang
- Department of Environmental Health Sciences, School of Public Health, University at Albany, State University of New York, One University Place, Rensselaer, NY, 12144, USA.
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5
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Urinary biomarkers indicate pediatric renal injury among rural farming communities in Sri Lanka. Sci Rep 2022; 12:8040. [PMID: 35577796 PMCID: PMC9110366 DOI: 10.1038/s41598-022-10874-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/13/2022] [Indexed: 01/11/2023] Open
Abstract
Pediatric renal injury is an emerging health concern in communities affected by chronic kidney disease of uncertain etiology (CKDu). Early detection of susceptibilities through highly sensitive and specific biomarkers can lead to effective therapeutic and preventive interventions against renal diseases. Here, we aimed to investigate the utility of kidney injury molecule (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) in early detection of renal abnormalities in selected pediatric communities in Sri Lanka. The study areas were stratified as CKDu endemic, emerging, and non-endemic based on the prevalence of CKDu, and a total of 804 school students (10–18 years of age) participated in the study. The median (IQR) urinary KIM-1 levels of the participants were 0.193 (0.026–0.338), 0.082 (0.001–0.220) and 0.040 (0.003–0.242) ng/mgCr for CKDu endemic, emerging and non-endemic regions respectively. Participants from CKDu endemic regions reported elevated (p < 0.0001) urinary KIM-1 expression compared to those from the other regions. The median (IQR) NGAL levels in participants from CKDu endemic (2.969; 1.833–5.641), emerging (3.374; 1.766–6.103), and non-endemic (3.345; 1.742–5.128 ng/mgCr) regions showed no significant difference. Also, urinary albumin-creatinine ratio (UACR) showed no significant differences across gender or residency. The prevalence of albuminuria was 1–2% in the locations irrespective of CKDu burden. Albuminuric participants reported higher (p < 0.05) urinary KIM-1 levels in comparison to normoalbuminuric participants. Significantly elevated urinary KIM-1 expression in a pediatric population from CKDu affected regions, especially in the presence of albuminuria, may indicate low-grade early renal damage supporting the utility of KIM-1 as a quantifiable biomarker.
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El Khayat M, Halwani DA, Hneiny L, Alameddine I, Haidar MA, Habib RR. Impacts of Climate Change and Heat Stress on Farmworkers' Health: A Scoping Review. Front Public Health 2022; 10:782811. [PMID: 35211437 PMCID: PMC8861180 DOI: 10.3389/fpubh.2022.782811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 01/10/2022] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Moussa El Khayat
- Department of Environmental Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Dana A. Halwani
- Department of Environmental Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Layal Hneiny
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Ibrahim Alameddine
- Department of Civil and Environmental Engineering, Maroun Semaan Faculty of Engineering and Architecture, American University of Beirut, Beirut, Lebanon
| | - Mustapha A. Haidar
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima R. Habib
- Department of Environmental Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Smith DJ, Mac V, Thompson LM, Plantinga L, Kasper L, Hertzberg VS. Using Occupational Histories to Assess Heat Exposure in Undocumented Workers Receiving Emergent Renal Dialysis in Georgia. Workplace Health Saf 2022; 70:251-258. [PMID: 35112607 DOI: 10.1177/21650799211060695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immigrants often work in jobs that are known as dirty, demanding, and dangerous. Globally, the agricultural occupations have been associated with the emergence of chronic kidney disease of unknown etiology (CKDu) primarily in outdoor worker populations. The disease has also been reported in immigrants in the United States who work in agricultural occupations, but little research has been done outside of agricultural workers to determine whether immigrants who work other occupations are at risk for developing CKDu. METHODS This study assessed the self-reported occupational histories of undocumented immigrants receiving frequent, emergent-only dialysis in Atlanta, GA. We assessed demographics, employment status, and work history, using the Grady Dialysis Questionnaire and the Occupational/Environmental Health History Form. RESULTS Fifty undocumented immigrants receiving frequent, emergent-only hemodialysis were recruited for this study. The average age was 49.5 years (SD ± 11.5), and the majority (52%) were female and originated from Mexico (66%). A majority (74%) reported having worked in the past 5 years and 28% reported currently working. A total of 68 unique jobs were reported. In decreasing order of frequency, our sample worked in occupations with documented renal toxicant exposures, such as applying pesticides in landscaping, heat exposure in agriculture, construction, landscaping, and dry cleaning, and lead paint fumes in construction. DISCUSSION Occupational histories provide a greater understanding of the exposures and working conditions of those receiving frequent, emergent-only hemodialysis. This exploratory study suggests that further research is needed to investigate and assess whether renal toxicants are associated with occupations with high numbers of undocumented workers. APPLICATION TO PRACTICE A detailed and thorough occupational history should be conducted from those receiving frequent, emergent-only hemodialysis. Developing continuing education for nursing and medical staff in dialysis centers on taking an occupational history, mandatory State reporting requirements, and hazard communication training for workers should be considered. Collaborations between occupational health professionals, public health authorities, employers, dialysis providers, and clinicians who see undocumented workers is required to understand and develop appropriate prevention measures for this population.
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Affiliation(s)
- Daniel J Smith
- Emory University Nell Hodgson Woodruff School of Nursing
| | - Valerie Mac
- Emory University Nell Hodgson Woodruff School of Nursing
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Arambegedara D, Jayasinghe S, Udagama P. Multi-pronged research on endemic chronic kidney disease of unknown etiology in Sri Lanka: a systematic review. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:4893-4910. [PMID: 34799798 PMCID: PMC8604553 DOI: 10.1007/s11356-021-17316-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/27/2021] [Indexed: 05/08/2023]
Abstract
Increasing prevalence of endemic chronic kidney disease of unknown etiology (CKDu) in Sri Lanka is a major health problem since the 1990s. Despite numerous studies on CKDu, research groups have been unable to develop a comprehensive approach to mitigate the disorder, and thereby to identify research gaps. We conducted a systematic literature review of 119 publications on CKDu in Sri Lanka from Pubmed, Google Scholar, and Scopus, published until end September 2020. A higher CKDu prevalence in the working population of the North Central Province was reported with recent studies indicating patients from non-endemic regions as well. A majority were etiological studies that recorded conflicting and inconclusive evidence on CKDu etiology. Studies on clinico-pathological, diagnostic, biochemical, and molecular biological aspects of CKDu, studies analyzing CKDu symptom burden, anthropological, and behavioral impacts of CKDu, were reviewed as well. A dearth of research exists on nutritional, demographical, immunological, and microbial aspects of CKDu. The overview of the reviewed literature indicated the absence of a comprehensive plan of action to mitigate this situation. Hence, we propose the "One Health" approach with a systems dynamics model as a potential way forward to alleviate the CKDu epidemic in Sri Lanka. This enables the representation of multiple causative agents (and interactions thereof) among environmental, animal, and human systems, in concert with the "exposome" that provides the totality of exposure the individual has undergone since birth.
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Affiliation(s)
- Dinushi Arambegedara
- Department of Zoology and Environment Sciences, Faculty of Science, University of Colombo, Colombo, 3, Sri Lanka
| | - Saroj Jayasinghe
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, 8, Sri Lanka
| | - Preethi Udagama
- Department of Zoology and Environment Sciences, Faculty of Science, University of Colombo, Colombo, 3, Sri Lanka.
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9
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Adverse Health Effects in Women Farmers Indirectly Exposed to Pesticides. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115909. [PMID: 34072924 PMCID: PMC8198255 DOI: 10.3390/ijerph18115909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/11/2021] [Accepted: 05/27/2021] [Indexed: 12/20/2022]
Abstract
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.
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Houser MC, Mac V, Smith DJ, Chicas RC, Xiuhtecutli N, Flocks JD, Elon L, Tansey MG, Sands JM, McCauley L, Hertzberg VS. Inflammation-Related Factors Identified as Biomarkers of Dehydration and Subsequent Acute Kidney Injury in Agricultural Workers. Biol Res Nurs 2021; 23:676-688. [PMID: 34018403 DOI: 10.1177/10998004211016070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Madelyn C Houser
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Valerie Mac
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Daniel J Smith
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Roxana C Chicas
- Renal Division, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Nezahualcoyotl Xiuhtecutli
- Farmworker Association of Florida, Apopka, FL, USA.,Department of Anthropology, Tulane University, New Orleans, LA, USA
| | - Joan D Flocks
- Social Policy Division, Center for Governmental Responsibility, Levin College of Law, University of Florida, Gainesville, FL, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | | | - Jeff M Sands
- Renal Division, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Linda McCauley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Vicki S Hertzberg
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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11
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Fox J, Macaluso F, Moore C, Mesenbring E, Johnson RJ, Hamman RF, James KA. Urine tungsten and chronic kidney disease in rural Colorado. ENVIRONMENTAL RESEARCH 2021; 195:110710. [PMID: 33460634 PMCID: PMC7987874 DOI: 10.1016/j.envres.2021.110710] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/23/2020] [Accepted: 12/31/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a cause of global morbidity and mortality in agricultural communities. The San Luis Valley (SLV) is a rural agricultural community in southern Colorado with geographic and sociodemographic risk factors for CKD, including a water supply contaminated by heavy metals. METHODS We obtained pre-existing sociodemographic, clinical, and urine trace metal data for 1659 subjects from the San Luis Valley Diabetes Study, a prospective cohort study. We assessed prospective associations between urine tungsten (W) and time-to-CKD using accelerated failure time models (n = 1659). Additionally, logistic models were used to assess relationships between urine W and renal injury markers (NGAL, KIM1) using Tobit regression (n = 816), as well as epidemiologically-defined CKD of unknown origin (CKDu) using multiple logistic regression (n = 620). RESULTS Elevated urine W was strongly associated with decreased time-to-CKD, even after controlling for hypertension and diabetes. Depending on how CKD was defined, a doubling of urine W was associated with a 27% (95% CI 11%, 46%) to 31% (14%, 51%) higher odds of developing CKD within 5 years. The relationship between urine W and select renal injury markers was not significant, although urine NGAL was modified by diabetes status. Elevated (>95%ile) urinary W was significantly associated with CKDu (OR 5.93, 1.83, 19.21) while adjusting for known CKD risk factors. CONCLUSIONS Our data suggest that increased exposure to W is associated with decreased time-to-CKD and may be associated with CKDu. Given persistence of associations after controlling for diabetes and hypertension, W may exert a primary effect on the kidney, although this needs to be evaluated further in future studies.
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Affiliation(s)
- Jacob Fox
- Colorado School of Public Health, Departments of Environmental & Occupational Health and Epidemiology, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, B119, Aurora, CO, 80045, USA.
| | - Francesca Macaluso
- Colorado School of Public Health, Departments of Environmental & Occupational Health and Epidemiology, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, B119, Aurora, CO, 80045, USA.
| | - Camille Moore
- Colorado School of Public Health, Departments of Environmental & Occupational Health and Epidemiology, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, B119, Aurora, CO, 80045, USA; Center for Genes, Environment and Health, National Jewish Health, Smith Building; A647, 1400 Jackson Street, Denver, CO, 80206, USA.
| | - Elise Mesenbring
- Colorado School of Public Health, Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, B119, Aurora, CO, 80045, USA.
| | - Richard J Johnson
- School of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor 13001 E. 17th Place, B119, Aurora, CO, 80045, USA.
| | - Richard F Hamman
- Colorado School of Public Health, Departments of Environmental & Occupational Health and Epidemiology, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, B119, Aurora, CO, 80045, USA.
| | - Katherine A James
- Colorado School of Public Health, Departments of Environmental & Occupational Health and Epidemiology, University of Colorado Anschutz Medical Campus, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, B119, Aurora, CO, 80045, USA.
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12
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Smith DJ, Pius LM, Plantinga LC, Thompson LM, Mac V, Hertzberg VS. Heat Stress and Kidney Function in Farmworkers in the US: A Scoping Review. J Agromedicine 2021; 27:183-192. [PMID: 33691597 DOI: 10.1080/1059924x.2021.1893883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronic kidney disease of unknown etiology (CKDu) has been well described in farmworkers in Latin America. Agricultural workers in the United States (US) are exposed to similar hot and humid working conditions, but CKDu in the US is under-described. This review aims to better understand the current literature describing the connection between heat stress and kidney function in farmworkers in the United States. Utilizing a scoping review methodology, we searched CINAHL, Embase, PubMed, and Web of Science databases to better understand the current state of the heat stress and kidney function research in farmworkers within the United States. In this review, 229 pieces of literature were screened. Ultimately, 4 articles were chosen to be included in the scoping review. Common themes within the articles were variations in study protocol lengths and type of heat stress measurement. Additionally, the majority of the work completed was quantitative to date, with only one study providing a critical social lens for analysis of CKDu in the United States. We found evidence that more work is needed within the US to understand the relationship between working in the heat and kidney function in agricultural and other workers who experience high heat conditions at work and are susceptible to the deleterious effects of working in said conditions.
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Affiliation(s)
- Daniel J Smith
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Lisa M Pius
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Laura C Plantinga
- Division of Geriatrics and Gerontology, School of Medicine, Emory University, Atlanta, GA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Valerie Mac
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Vicki S Hertzberg
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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13
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Cerón A, Ramay BM, Méndez-Alburez LP, Lou-Meda R. Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. Rev Panam Salud Publica 2021; 45:e24. [PMID: 33727908 PMCID: PMC7954194 DOI: 10.26633/rpsp.2021.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/18/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. METHODS A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER's pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis. RESULTS The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother's education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables. CONCLUSIONS Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother's level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.
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Affiliation(s)
- Alejandro Cerón
- University of DenverDenver, COUnited States of AmericaUniversity of Denver, Denver, CO, United States of America
| | - Brooke M. Ramay
- Universidad del Valle de GuatemalaGuatemala CityGuatemalaUniversidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Luis Pablo Méndez-Alburez
- Universidad Maya KaqchikelChimaltenangoGuatemalaUniversidad Maya Kaqchikel, Chimaltenango, Guatemala
| | - Randall Lou-Meda
- Fundación para el Niño Enfermo Renal—FUNDANIERGuatemala CityGuatemalaFundación para el Niño Enfermo Renal—FUNDANIER, Guatemala City, Guatemala
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14
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Cerón A, Ramay BM, Méndez-Alburez LP, Randall R. Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. Rev Panam Salud Publica 2021. [DOI: 10.26633/rpsp.2020.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala.
Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER’s pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis.
Results. The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother’s education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables.
Conclusions. Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother’s level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.
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Affiliation(s)
| | - Brooke M. Ramay
- Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | | | - Randall Randall
- Fundación para el Niño Enfermo Renal—FUNDANIER, Guatemala City, Guatemala
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Miller AC, Tuiz E, Shaw L, Flood D, Garcia P, Dhaenens E, Thomson DR, Barnoya J, Montano CM, Rohloff P. Population Estimates of GFR and Risk Factors for CKD in Guatemala. Kidney Int Rep 2021; 6:796-805. [PMID: 33732994 PMCID: PMC7938058 DOI: 10.1016/j.ekir.2020.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 12/15/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is an emerging public health priority in Central America. However, data on the prevalence of CKD in Guatemala, Central America's most populous country, are limited, especially for rural communities. METHODS We conducted a population-representative survey of 2 rural agricultural municipalities in Guatemala. We collected anthropometric data, blood pressure, serum and urine creatinine, glycosylated hemoglobin, and urine albumin. Sociodemographic, health, and exposure data were self-reported. RESULTS We enrolled 807 individuals (63% of all eligible, 35% male, mean age 39.5 years). An estimated 4.0% (95% confidence interval [CI] 2.4-6.6) had CKD, defined as an estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m2. Most individuals with an eGFR below 60 ml/min per 1.73 m2 had diabetes or hypertension. In multivariable analysis, the important factors associated with risk for an eGFR less than 60 ml/min per 1.73 m2 included a history of diabetes or hypertension (adjusted odds ratio [aOR] 11.21; 95% CI 3.28-38.24), underweight (body mass index [BMI] <18.5) (aOR 21.09; 95% CI 2.05-217.0), and an interaction between sugar cane agriculture and poverty (aOR 1.10; 95% CI 1.01-1.19). CONCLUSIONS In this population-based survey, most observed CKD was associated with diabetes and hypertension. These results emphasize the urgent public health need to address the emerging epidemic of diabetes, hypertension, and CKD in rural Guatemala. In addition, the association between CKD and sugar cane in individuals living in poverty provides some circumstantial evidence for existence of CKD of unknown etiology in the study communities, which requires further investigation.
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Affiliation(s)
- Ann C. Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Eva Tuiz
- Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, Tecpán, Guatemala
| | - Leah Shaw
- Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, Tecpán, Guatemala
| | - David Flood
- Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, Tecpán, Guatemala
| | - Pablo Garcia
- Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, Tecpán, Guatemala
| | - Eloin Dhaenens
- Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, Tecpán, Guatemala
| | - Dana R. Thomson
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | | | | | - Peter Rohloff
- Centro de Investigación en la Salud Indígena, Wuqu’ Kawoq, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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16
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Leibler JH, Ramirez-Rubio O, Velázquez JJA, Pilarte DL, Obeid W, Parikh CR, Gadupudi S, Scammell MK, Friedman DJ, Brooks DR. Biomarkers of kidney injury among children in a high-risk region for chronic kidney disease of uncertain etiology. Pediatr Nephrol 2021; 36:387-396. [PMID: 32504218 DOI: 10.1007/s00467-020-04595-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 04/09/2020] [Accepted: 04/28/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Mesoamerican Nephropathy (MeN), a form of chronic kidney disease of uncertain etiology, is a leading cause of death in Central America. The disease often presents in young adult male agricultural workers and progresses rapidly. Given the young age at presentation, we hypothesized that children in Central America experience subclinical kidney injury prior to working life. METHODS We assessed specimens from a cross-sectional study of youth, aged 7-17 years, predominantly residing in a high-risk region of Nicaragua (n = 210). We evaluated urinary concentrations and risk factors for kidney injury biomarkers neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), interleukin-18 (IL-18), monocyte chemoattractant protein 1 (MCP-1), and chitinase-3-like protein 1 (YKL-40). We evaluated the association between biomarkers and contemporaneous eGFR and compared biomarker concentrations with reference values from healthy children in other countries. RESULTS Median uNGAL, uIL-18, and uKIM-1 concentrations exceeded healthy reference values. A one-year increase in age was associated with 40% increase in odds of being in the highest quartile of uNGAL (OR 1.4; (95%CI 1.2, 1.5); p < 0.0001). Youth who reported ever experiencing dysuria had 2.5 times the odds of having uNGAL concentrations in the top quartile (OR 2.5; (95%CI 1.4, 4.6); p = 0.003). Girls had significantly higher concentrations of all biomarkers than boys. Nine percent of children demonstrated low eGFR (≤ 100 ml/min/1.73 m2), while 29% showed evidence of hyperfiltration (eGFR ≥ 160 ml/min/1.73 m2), both potentially indicative of renal dysfunction. CONCLUSIONS Children residing in regions of Nicaragua at high risk for MeN may experience subclinical kidney injury prior to occupational exposures.
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Affiliation(s)
- Jessica H Leibler
- Department of Environmental Health, Boston University School of Public Health, 715 Albany St., 430W, Boston, MA, 02118, USA.
| | - Oriana Ramirez-Rubio
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Damaris López Pilarte
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Wassim Obeid
- Division of Nephrology, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Salini Gadupudi
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Madeleine K Scammell
- Department of Environmental Health, Boston University School of Public Health, 715 Albany St., 430W, Boston, MA, 02118, USA
| | - David J Friedman
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel R Brooks
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Anastario M, Arias Rodas MG, Escobar Arteaga MA, Villanueva C, Chacón Serrano F, Ferdowsian H. Genitourinary Systems Entangled with Shifting Environments in a Salvadoran Subsistence Farming Community. Med Anthropol Q 2020; 35:246-265. [PMID: 33035383 DOI: 10.1111/maq.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Abstract
Diseases of the genitourinary system are the leading cause of hospital deaths in El Salvador, and chronic kidney disease of unknown origin has been gaining attention as a public health problem among farmers in particular. Epidemiological studies point, in part, to environmental risk factors, which have shifted over time with the deployment of modern agricultural science and ongoing climate change. We examined how diseases of the genitourinary system were situated at several margins of an epidemic in one rural Salvadoran municipality where these environmental and epidemiological changes are occurring, albeit relatively slow. By using this approach to study diseases of the genitourinary system, we illustrate one way in which shifting human/environment entanglements can be experimentally "known" in the context of human diseases associated with them. Our approach offers a unique perspective in thinking with ethnographic data to compliment ongoing epidemiological investigations of kidney disease in El Salvador.
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Affiliation(s)
- Mike Anastario
- Robert Stempel College of Public Health & Social Work, Florida International University
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18
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Hamilton SA, Nakanga WP, Prynn JE, Crampin AC, Fecht D, Vineis P, Caplin B, Pearce N, Nyirenda MJ. Prevalence and risk factors for chronic kidney disease of unknown cause in Malawi: a cross-sectional analysis in a rural and urban population. BMC Nephrol 2020; 21:387. [PMID: 32894093 PMCID: PMC7487679 DOI: 10.1186/s12882-020-02034-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/20/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND An epidemic of chronic kidney disease of unknown cause (CKDu) is occurring in rural communities in tropical regions of low-and middle-income countries in South America and India. Little information is available from Southern African countries which have similar climatic and occupational characteristics to CKDu-endemic countries. We investigated whether CKDu is prevalent in Malawi and identified its potential risk factors in this setting. METHODS We conducted a cross-sectional study from January-August 2018 collecting bio samples and anthropometric data in two Malawian populations. The sample comprised adults > 18 years (n = 821) without diabetes, hypertension, and proteinuria. Estimates of glomerular filtration rate (eGFR) were calculated using the CKD-EPI equation. Linear and logistic regression models were applied with potential risk factors, to estimate risk of reduced eGFR. RESULTS The mean eGFR was 117.1 ± 16.0 ml/min per 1.73m2 and the mean participant age was 33.5 ± 12.7 years. The prevalence of eGFR< 60 was 0.2% (95% confidence interval (95% CI) 0.1, 0.9); the prevalence of eGFR< 90 was 5% (95% CI =3.2, 6.3). We observed a higher prevalence in the rural population (5% (3.6, 7.8)), versus urban (3% (1.4, 6.7)). Age and BMI were associated with reduced eGFR< 90 [Odds ratio (OR) (95%CI) =3.59 (2.58, 5.21) per ten-year increment]; [OR (95%CI) =2.01 (1.27, 3.43) per 5 kg/m2 increment] respectively. No increased risk of eGFR < 90 was observed for rural participants [OR (95%CI) =1.75 (0.50, 6.30)]. CONCLUSIONS Reduced kidney function consistent with the definition of CKDu is not common in the areas of Malawi sampled, compared to that observed in other tropical or sub-tropical countries in Central America and South Asia. Reduced eGFR< 90 was related to age, BMI, and was more common in rural areas. These findings are important as they contradict some current hypothesis that CKDu is endemic across tropical and sub-tropical countries. This study has enabled standardized comparisons of impaired kidney function between and within tropical/subtropical regions of the world and will help form the basis for further etiological research, surveillance strategies, and the implementation and evaluation of interventions.
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Affiliation(s)
- Sophie A Hamilton
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
- MRC Centre for Environment and Health, Imperial College London, London, UK.
- Imperial College London, School of Public Health, London, UK.
| | - Wisdom P Nakanga
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Josephine E Prynn
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Institute of Cardiovascular Science, University College London, London, UK
| | - Amelia C Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Departments of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniela Fecht
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
- MRC Centre for Environment and Health, Imperial College London, London, UK
| | - Paolo Vineis
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
- MRC Centre for Environment and Health, Imperial College London, London, UK
| | - Ben Caplin
- Centre for Nephrology, Division of Medicine, University College London, London, UK
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
- Centre for Global NCDs, London School of Hygiene and Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Departments of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Jayasinghe S, Zhu YG. Chronic kidney disease of unknown etiology (CKDu): Using a system dynamics model to conceptualize the multiple environmental causative pathways of the epidemic. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 705:135766. [PMID: 31841920 DOI: 10.1016/j.scitotenv.2019.135766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/24/2019] [Accepted: 11/24/2019] [Indexed: 06/10/2023]
Abstract
A chronic kidney disease of unknown etiology is devastating agricultural communities of Sri Lanka, Central America, areas of India, and Egypt. Researchers are yet to agree on its etio-pathogenesis despite many cross-sectional, case-control and cohort studies done in these countries. These approaches are broadly based on a reductionist approach. We propose a complementary paradigm based on complexity science to deepen our understanding of the disease. Complexity science views a population as system that has several dynamically interacting and inter-dependent sub-systems and is 'open' to the 'outer' environment. Health outcomes or epidemics are viewed as 'emergent' properties of the population. Using available literature from Sri Lanka, the paper presents a system dynamics model incorporating exposures from pesticides and heavy metals, drinking hard water with high levels of fluoride, poverty, low birth weight, micronutrient deficiencies and heat stress. This approach can be used to model the epidemic, understand the impacts of different factors, predict potential populations at risk, and formulate multi-pronged prevention strategies that target leverage points of the system.
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Affiliation(s)
- Saroj Jayasinghe
- Department of Clinical Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Yong-Guan Zhu
- Environmental Soil Science and Biogeochemistry, Institute of Urban Environment, Chinese Academy of Sciences, Xiamen, China
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Wesseling C, Glaser J, Rodríguez-Guzmán J, Weiss I, Lucas R, Peraza S, da Silva AS, Hansson E, Johnson RJ, Hogstedt C, Wegman DH, Jakobsson K. Chronic kidney disease of non-traditional origin in Mesoamerica: a disease primarily driven by occupational heat stress. Rev Panam Salud Publica 2020; 44:e15. [PMID: 31998376 PMCID: PMC6984407 DOI: 10.26633/rpsp.2020.15] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/09/2020] [Indexed: 12/30/2022] Open
Abstract
The death toll of the epidemic of chronic kidney disease of nontraditional origin (CKDnt) in Mesoamerica runs into the tens of thousands, affecting mostly young men. There is no consensus on the etiology. Anecdotal evidence from the 1990s pointed to work in sugarcane; pesticides and heat stress were suspected. Subsequent population-based surveys supported an occupational origin with overall high male-female ratios in high-risk lowlands, but small sex differences within occupational categories, and low prevalence in non-workers. CKDnt was reported in sugarcane and other high-intensity agriculture, and in non-agricultural occupations with heavy manual labor in hot environments, but not among subsistence farmers. Recent studies with stronger designs have shown cross-shift changes in kidney function and hydration biomarkers and cross-harvest kidney function declines related to heat and workload. The implementation of a water-rest-shade intervention midharvest in El Salvador appeared to halt declining kidney function among cane cutters. In Nicaragua a water-rest-shade program appeared sufficient to prevent kidney damage among cane workers with low-moderate workload but not among cutters with heaviest workload. Studies on pesticides and infectious risk factors have been largely negative. Non-occupational risk factors do not explain the observed epidemiologic patterns. In conclusion, work is the main driver of the CKDnt epidemic in Mesoamerica, with occupational heat stress being the single uniting factor shown to lead to kidney dysfunction in affected populations. Sugarcane cutters with extreme heat stress could be viewed as a sentinel occupational population. Occupational heat stress prevention is critical, even more so in view of climate change.
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Affiliation(s)
- Catharina Wesseling
- La Isla NetworkLa Isla NetworkWashington DCUnited States of AmericaLa Isla Network, Washington DC, United States of America.
- Karolinska InstitutetKarolinska InstitutetStockholmSwedenKarolinska Institutet, Stockholm, Sweden
| | - Jason Glaser
- La Isla NetworkLa Isla NetworkWashington DCUnited States of AmericaLa Isla Network, Washington DC, United States of America.
| | - Julieta Rodríguez-Guzmán
- Pan-American Health OrganizationPan-American Health OrganizationWashington DCUnited States of AmericaPan-American Health Organization, Washington DC, United States of America
| | - Ilana Weiss
- La Isla NetworkLa Isla NetworkWashington DCUnited States of AmericaLa Isla Network, Washington DC, United States of America.
| | - Rebekah Lucas
- University of BirminghamUniversity of BirminghamBirminghamUnited KingdomUniversity of Birmingham, Birmingham, United Kingdom
| | - Sandra Peraza
- University of El SalvadorUniversity of El SalvadorSan SalvadorEl SalvadorUniversity of El Salvador, San Salvador, El Salvador
| | - Agnes Soares da Silva
- Pan-American Health OrganizationPan-American Health OrganizationWashington DCUnited States of AmericaPan-American Health Organization, Washington DC, United States of America
| | - Erik Hansson
- University of GothenburgUniversity of GothenburgGothenburgSwedenUniversity of Gothenburg, Gothenburg, Sweden
| | - Richard J. Johnson
- University of Colorado at DenverUniversity of Colorado at DenverAuroraUnited States of AmericaUniversity of Colorado at Denver, Aurora, United States of America
| | - Christer Hogstedt
- Karolinska InstitutetKarolinska InstitutetStockholmSwedenKarolinska Institutet, Stockholm, Sweden
| | - David H. Wegman
- University of Massachusetts LowellUniversity of Massachusetts LowellLowellUnited States of AmericaUniversity of Massachusetts Lowell, Lowell, United States of America
| | - Kristina Jakobsson
- University of GothenburgUniversity of GothenburgGothenburgSwedenUniversity of Gothenburg, Gothenburg, Sweden
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Abstract
Objectives: To characterize kidney function of sugarcane workers in Guatemala over the 6-month harvest and identify risk factors associated with changes in kidney function. Methods: Demographic and biological data were collected for 330 sugarcane cutters at the beginning and end of the harvest. Multivariable regression analyses were used to assess factors related to kidney function. Results: A decline in kidney function across the harvest was observed in 36% of the participants. Risk factors associated with this decline included working at a particular plantation mill, local area workers compared with highland workers, and current smokers. Conclusion: Results showed both occupational and behavioral factors play significant roles in declines in kidney function. These results underline the need for a comprehensive approach to the epidemic as well as further investigation of risk factors to guide research and interventions.
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Johnson RJ, Wesseling C, Newman LS. Chronic Kidney Disease of Unknown Cause in Agricultural Communities. N Engl J Med 2019; 380:1843-1852. [PMID: 31067373 DOI: 10.1056/nejmra1813869] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Richard J Johnson
- From the Division of Renal Diseases and Hypertension (R.J.J.), the Colorado Consortium on Climate Change and Health (R.J.J., L.S.N.), the Center for Health, Work & Environment, and the Departments of Environmental and Occupational Health and Epidemiology, Colorado School of Public Health (L.S.N.), and the Division of Pulmonary Sciences and Critical Care Medicine (L.S.N.), University of Colorado Anschutz Medical Campus, and the Division of Nephrology, Rocky Mountain Regional Veterans Health Administration Hospital, Department of Veterans Affairs (R.J.J.) - all in Aurora; the Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm (C.W.); and La Isla Network, Washington, DC (C.W.)
| | - Catharina Wesseling
- From the Division of Renal Diseases and Hypertension (R.J.J.), the Colorado Consortium on Climate Change and Health (R.J.J., L.S.N.), the Center for Health, Work & Environment, and the Departments of Environmental and Occupational Health and Epidemiology, Colorado School of Public Health (L.S.N.), and the Division of Pulmonary Sciences and Critical Care Medicine (L.S.N.), University of Colorado Anschutz Medical Campus, and the Division of Nephrology, Rocky Mountain Regional Veterans Health Administration Hospital, Department of Veterans Affairs (R.J.J.) - all in Aurora; the Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm (C.W.); and La Isla Network, Washington, DC (C.W.)
| | - Lee S Newman
- From the Division of Renal Diseases and Hypertension (R.J.J.), the Colorado Consortium on Climate Change and Health (R.J.J., L.S.N.), the Center for Health, Work & Environment, and the Departments of Environmental and Occupational Health and Epidemiology, Colorado School of Public Health (L.S.N.), and the Division of Pulmonary Sciences and Critical Care Medicine (L.S.N.), University of Colorado Anschutz Medical Campus, and the Division of Nephrology, Rocky Mountain Regional Veterans Health Administration Hospital, Department of Veterans Affairs (R.J.J.) - all in Aurora; the Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm (C.W.); and La Isla Network, Washington, DC (C.W.)
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Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. Estimates of the 2016 global burden of kidney disease attributable to ambient fine particulate matter air pollution. BMJ Open 2019; 9:e022450. [PMID: 31072847 PMCID: PMC6528010 DOI: 10.1136/bmjopen-2018-022450] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To quantitate the 2016 global and national burden of chronic kidney disease (CKD) attributable to ambient fine particulate matter air pollution ≤ 2.5 μm in aerodynamic diameter (PM2.5). DESIGN We used the Global Burden of Disease (GBD) study data and methodologies to estimate the 2016 burden of CKD attributable to PM2.5 in 194 countries and territories. Population-weighted PM2.5 levels and incident rates of CKD for each country were curated from the GBD study publicly available data sources. SETTING GBD global and national data on PM2.5 and CKD. PARTICIPANTS 194 countries and territories. MAIN OUTCOME MEASURES We estimated the attributable burden of disease (ABD), years living with disability (YLD), years of life lost (YLL) and disability-adjusted life-years (DALYs). RESULTS The 2016 global burden of incident CKD attributable to PM2.5 was 6 950 514 (95% uncertainty interval: 5 061 533-8 914 745). Global YLD, YLL and DALYs of CKD attributable to PM2.5 were 2 849 311 (1 875 219-3 983 941), 8 587 735 (6 355 784-10 772 239) and 11 445 397 (8 380 246-14 554 091), respectively. Age-standardised ABD, YLL, YLD and DALY rates varied substantially among geographies. Populations in Mesoamerica, Northern Africa, several countries in the Eastern Mediterranean region, Afghanistan, Pakistan, India and several countries in Southeast Asia were among those with highest age-standardised DALY rates. For example, age-standardised DALYs per 100 000 were 543.35 (391.16-707.96) in El Salvador, 455.29 (332.51-577.97) in Mexico, 408.41 (283.82-551.84) in Guatemala, 238.25 (173.90-303.98) in India and 178.26 (125.31-238.47) in Sri Lanka, compared with 5.52 (0.82-11.48) in Sweden, 6.46 (0.00-14.49) in Australia and 12.13 (4.95-21.82) in Canada. Frontier analyses showed that Mesoamerican countries had significantly higher CKD DALY rates relative to other countries with comparable sociodemographic development. CONCLUSIONS Our results demonstrate that the global toll of CKD attributable to ambient air pollution is significant and identify several endemic geographies where air pollution may be a significant driver of CKD burden. Air pollution may need to be considered in the discussion of the global epidemiology of CKD.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
- Nephrology Section, Medicine Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA
- Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri, USA
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Agampodi SB, Amarasinghe GS, Naotunna PGCR, Jayasumana CS, Siribaddana SH. Early renal damage among children living in the region of highest burden of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka. BMC Nephrol 2018; 19:115. [PMID: 29769043 PMCID: PMC5956963 DOI: 10.1186/s12882-018-0911-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/30/2018] [Indexed: 12/31/2022] Open
Abstract
Background Chronic kidney disease of unknown origin (CKDu) in Sri Lanka is grouped with several other epidemics of similar nature across the world as Chronic Interstitial Nephritis in Agricultural Communities (CINAC). In CKDu endemic countries, the focus has mainly been on adults. We hypothesized that studying distribution and factors associated with elevated urine albumin to creatinine ratio (UACR), an early marker of kidney injury, among children living in a CKDu endemic area may provide important clues about the onset and progression of the disease. Methods This cross sectional study was performed in rural primary schools in North Central Province of Sri Lnaka, a CKDu high endemic region. Total of 2880 students aging 5 to 11 years from 67 schools were enrolled for urinalysis in a random spot urine sample. Bedside Schwartz formula was used to measure estimated glomerular filtration rate (eGFR) on all children with UACR > 30 mg/g in Polonnaruwa district and a group of age matched controls. A standard multiple linear regression using log transformed UACR as the dependent variable was performed. Mean eGFR were compared between UACR elevated group and controls using independent sample t test. Results Median UACR was 10.3 mg/g. Sex, ethnicity, history of having a chronic disease and age uniquely contributed to the multiple regression model which only explained 2.8% of the variance in the log of the UACR (p < 0.001). Only 15 (0.5%) had UACR> 300 mg/g while 8.2% (n = 236) had UACR between 30 to 300 mg/g and 89.8% (n = 203) of them did not have a chronic disease (Chi square 2.21, p = 0.091). Mean eGFR was significantly lower in the group with elevated UACR (88.9 mg/dl/1.73 m2, 95% CI for mean 86.4- 91.3) compared to group with normal UACR (93.7 mg/dl/1.73 m2,95% CI 91.1- 96.3) (t 2.7, p 0.007). Three out of the four students with eGFR less than 60 mg/dl/1.73 m2 had moderately elevated UACR. Conclusion This study provides evidence to suggest that children in CKDu endemic regions are having an early renal damage. This observation needs to be investigated further in order to understand the worldwide epidemic of CKDu.
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Affiliation(s)
- S B Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - G S Amarasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka.
| | - P G C R Naotunna
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - C S Jayasumana
- Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - S H Siribaddana
- Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
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Reveiz L, Pinzón-Flórez C, Glujovsky D, Elias V, Ordunez P. [Establishing research priorities for chronic kidney disease of non-traditional causes in Central AmericaDeterminação de prioridades em pesquisa da doença renal crônica associada a causas não tradicionais na América Central]. Rev Panam Salud Publica 2018; 42:e13. [PMID: 31093042 PMCID: PMC6385632 DOI: 10.26633/rpsp.2018.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 11/07/2017] [Indexed: 12/24/2022] Open
Abstract
Introducción En 2013, los Estados Miembros de la OPS reconocieron la epidemia de enfermedad renal crónica de causas no tradicionales (ERCnT) como un grave problema de salud pública. Este artículo describe el establecimiento de prioridades de investigación para abordar de manera integral la ERCnT en Centroamérica. Métodos Se estructuró una encuesta virtual utilizando la metodología Delphi mediante una búsqueda de estudios de investigación efectuados en Centroamérica y de agendas de investigación previas sobre la ERC. Los encuestados se identificaron en diversas fuentes. La primera ronda buscó refinar y añadir tópicos de investigación y priorizar los más relevantes. La segunda ronda priorizó los tópicos más relevantes. Se realizó un análisis por fuzzy sets para estimar umbrales de decisión y puntajes por tópico. Resultados La encuesta se envió a 83 personas de habla hispana y 38 de habla inglesa y respondió 46,2%. Para la segunda ronda, se envió la encuesta a 56 personas en español y 16 en inglés que habían contestado a la la primera. Se priorizaron 18 tópicos de investigación enmarcados en 10 áreas: políticas públicas, determinantes, etiología, diagnóstico y tratamiento de la ERC, prevención primaria, prestación de servicios, recursos humanos, sistemas de información y financiamiento. Se comprobó que la investigación en ERCnT es escasa y está restringida a ciertos tópicos. Conclusiones Además de los factores etiológicos, se dio gran relevancia a aspectos relacionados con la respuesta de los sistemas de salud, incluidos el abordaje de la prestación de servicios, los recursos humanos, el financiamiento y aspectos ocupacionales y ambientales.
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Affiliation(s)
- Ludovic Reveiz
- Organización Panamericana de la Salud, Washington, DC, Estados Unidos de América
| | - Carlos Pinzón-Flórez
- Grupo de Investigación en Salud, Facultad de Medicina, Universidad de La Sabana, Chía, Colombia
| | - Demián Glujovsky
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Vanessa Elias
- Organización Panamericana de la Salud, Washington, DC, Estados Unidos de América
| | - Pedro Ordunez
- Organización Panamericana de la Salud, Washington, DC, Estados Unidos de América
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Survey of Heavy Metal Contamination in Water Sources in the Municipality of Torola, El Salvador, through In Situ Sorbent Extraction. WATER 2017. [DOI: 10.3390/w9110877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Valcke M, Levasseur ME, Soares da Silva A, Wesseling C. Pesticide exposures and chronic kidney disease of unknown etiology: an epidemiologic review. Environ Health 2017; 16:49. [PMID: 28535811 PMCID: PMC5442867 DOI: 10.1186/s12940-017-0254-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/08/2017] [Indexed: 05/20/2023]
Abstract
The main causes of chronic kidney disease (CKD) globally are diabetes and hypertension but epidemics of chronic kidney disease of unknown etiology (CKDu) occur in Central America, Sri Lanka, India and beyond. Althoug also being observed in women, CKDu concentrates among men in agricultural sectors. Therefore, suspicions fell initially on pesticide exposure, but currently chronic heat stress and dehydration are considered key etiologic factors. Responding to persistent community and scientific concerns about the role of pesticides, we performed a systematic review of epidemiologic studies that addressed associations between any indicator of pesticide exposure and any outcome measure of CKD. Of the 21 analytical studies we identified, seven were categorized as with low, ten with medium and four with relatively high explanation value. Thirteen (62%) studies reported one or more positive associations, but four had a low explanation value and three presented equivocal results. The main limitations of both positive and negative studies were unspecific and unquantified exposure measurement ('pesticides'), the cross-sectional nature of most studies, confounding and selection bias. The four studies with stronger designs and better exposure assessment (from Sri Lanka, India and USA) all showed exposure-responses or clear associations, but for different pesticides in each study, and three of these studies were conducted in areas without CKDu epidemics. No study investigated interactions between pesticides and other concommittant exposures in agricultural occupations, in particular heat stress and dehydration. In conclusion, existing studies provide scarce evidence for an association between pesticides and regional CKDu epidemics but, given the poor pesticide exposure assessment in the majority, a role of nephrotoxic agrochemicals cannot be conclusively discarded. Future research should procure assessment of lifetime exposures to relevant specific pesticides and enough power to look into interactions with other major risk factors, in particular heat stress.
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Affiliation(s)
- Mathieu Valcke
- WHO-PAHO Collaborating Centre on Environmental and Occupational Health Impact Assessment and Surveillance INSPQ-CHUQ-DSPQ, 945, Avenue Wolfe, Québec, G1V 5B3 Canada
- Department of Environmental and Occupational Health, School of Public Health, Université de Montréal, C.P. 6128 Succursale Centre-Ville, Montreal, H3C 3J7 Canada
| | - Marie-Eve Levasseur
- WHO-PAHO Collaborating Centre on Environmental and Occupational Health Impact Assessment and Surveillance INSPQ-CHUQ-DSPQ, 945, Avenue Wolfe, Québec, G1V 5B3 Canada
| | - Agnes Soares da Silva
- Pan American Health Organization (PAHO), 525 Twenty-third Street, N.W, Washington DC, 20037 USA
| | - Catharina Wesseling
- Department of Occupational Medicine, Institute of Environmental Medicine (IMM), Karolinska Institutet, 171 77 Stockholm, SE Sweden
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