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Holliday MW, Majeti RN, Sheikh-Hamad D. Chronic Interstitial Nephritis in Agricultural Communities: Observational and Mechanistic Evidence Supporting the Role of Nephrotoxic Agrochemicals. Clin J Am Soc Nephrol 2024; 19:538-545. [PMID: 37678249 PMCID: PMC11020436 DOI: 10.2215/cjn.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
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.
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Affiliation(s)
- Michael W. Holliday
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
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Goldfarb DS. Nephrologists should talk to their patients about climate change. Curr Opin Nephrol Hypertens 2024; 33:170-173. [PMID: 38240262 DOI: 10.1097/mnh.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- David S Goldfarb
- Nephrology Division, NYU Grossman School of Medicine and Nephrology Section, NY Harbor VA Healthcare System, New York, New York, USA
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Strasma A, Reyes ÁM, Aragón A, López I, Park LP, Hogan SL, Thielman N, Wyatt C, González-Quiroz M. Kidney disease characteristics, prevalence, and risk factors in León, Nicaragua: a population-based study. BMC Nephrol 2023; 24:335. [PMID: 37953252 PMCID: PMC10641961 DOI: 10.1186/s12882-023-03381-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/28/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND CKD of unknown etiology (CKDu) disproportionately affects young people in Central America who lack traditional CKD risk factors (diabetes and hypertension) and has instead been variably linked to heat stress, occupational and environmental exposures, nephrotoxic medications, and/or genetic susceptibility. This study aimed to estimate the prevalence of CKD and identify risk factors for traditional CKD and CKDu in Nicaragua. METHODS Surveys and assessment for CKD markers in urine and serum were performed in 15-59 year olds in households of the León municipality of Nicaragua. The survey included questions on demographics, health behaviors, occupation, and medical history. Participants with CKD were subdivided into traditional CKD and suspected CKDu based on history of diabetes, hypertension, or other specified conditions. A multinomial logistic regression model was used to identify factors associated with traditional CKD and suspected CKDu, compared to the non-CKD reference group. RESULTS In 1795 study participants, CKD prevalence was 8.6%. Prevalence in males was twofold higher than females (12% vs 6%). Of those with CKD, 35% had suspected CKDu. Both traditional CKD and CKDu were associated with male sex and increasing age. Traditional CKD was associated with a family history of CKD, history of urinary tract infections, and lower socioeconomic status, while CKDu was associated with drinking well water and a lower body mass index. CONCLUSIONS Both traditional CKD and CKDu are significant burdens in this region. Our study supports previous hypotheses of CKDu etiology and emphasizes the importance of CKD screening.
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Affiliation(s)
- Anna Strasma
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Ángel Mejía Reyes
- Bioanalysis and Immunology Research Group, National Autonomous University of Honduras, Tegucigalpa, Honduras
| | - Aurora Aragón
- WUQU' KAWOQ, Maya Health Alliance, Chimaltenango, Guatemala
| | - Indiana López
- WUQU' KAWOQ, Maya Health Alliance, Chimaltenango, Guatemala
| | - Lawrence P Park
- Duke Global Health Institute, Durham, NC, USA
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Susan L Hogan
- Department of Medicine, Division of Nephrology and Hypertension and the UNC Kidney Center, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Nathan Thielman
- Duke Global Health Institute, Durham, NC, USA
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Marvin González-Quiroz
- WUQU' KAWOQ, Maya Health Alliance, Chimaltenango, Guatemala
- Department of Renal Medicine, University College London, London, UK
- School of Medicine, Universidad Nacional de Chimborazo, Riobamba, Ecuador
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Wijkström J, Annadata KC, Elinder CG, Kolla PK, Sarvepalli NR, Ring A, Swaminathan R, Gunabooshanam B, Söderberg M, Venugopal V, Wernerson A. Clinical findings and kidney morphology in chronic kidney disease of unknown cause in India. J Intern Med 2023; 294:492-505. [PMID: 37400986 DOI: 10.1111/joim.13690] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Chronic kidney disease of unknown cause (CKDu) is an emerging health problem in India and other countries worldwide. However, clinical descriptions, including kidney pathology, are scarce. METHODS This is a descriptive case series of patients with CKDu from an endemic region in India, with a focus on clinical and biochemical characteristics, kidney biopsy findings, and environmental exposure. Patients with suspected CKDu, aged 20-65, and eGFR 30-80 mL/min/1.73 m2 from rural areas with endemic prevalence of CKDu were included. The exclusion criteria were diabetes mellitus, uncontrolled hypertension, proteinuria >1 g/24 h, or other known kidney diseases. The participants underwent kidney biopsies, and blood and urine samples were collected. RESULTS Fourteen participants (3 females, 11 males) with a mean eGFR of 53 (range 29-78) mL/min/1.73 m2 were included. Kidney biopsies showed a combination of chronic tubulointerstitial damage, glomerulosclerosis, and glomerular hypertrophy, with varying degrees of interstitial inflammation. Eight participants had polyuria (diuresis ≥ 3 L/day). The urinary sediments were bland, with no haematuria. Serum potassium and sodium levels were, in most cases, normal but within the lower reference interval. CONCLUSION The kidney morphology and clinical characteristics in patients with CKDu in India were similar to those described for CKDu in Central America and Sri Lanka.
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Affiliation(s)
- Julia Wijkström
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | | | - Carl-Gustaf Elinder
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | | | | | - Anneli Ring
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Rajendiran Swaminathan
- Department of Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Barathi Gunabooshanam
- Department of Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Magnus Söderberg
- Clinical Pharmacology and Safety Sciences, AstraZeneca R&D, Gothenburg, Sweden
| | - Vidhya Venugopal
- Department of Environmental Health Engineering, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Annika Wernerson
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW In the 1990s, a type of chronic kidney disease with unknown cause (CKDu) was identified in Central America and Sri Lanka. Patients lacked hypertension, diabetes, glomerulonephritis, or other usual causes of kidney failure. Affected patients are predominantly male agricultural workers aged 20-60 years, living in economically disadvantaged areas with poor access to medical care. Patients typically present late and progress to end-stage kidney disease within 5 years, resulting in social and economic hardship for families, regions, and countries. This review covers the current state of knowledge for this disease. RECENT FINDINGS The prevalence of CKDu is increasing in known endemic regions and across the globe, reaching epidemic proportions. There is primary tubulointerstitial injury with secondary glomerular and vascular sclerosis. No definitive etiologic factors have been identified, and these may vary or overlap in different geographic locations. The leading hypotheses include exposure to agrochemicals, heavy metals and trace elements, and kidney injury from dehydration/heat stress. Infections and lifestyle factors may play a role, but are likely not key. Genetic and epigenetic factors are beginning to be explored. SUMMARY CKDu is a leading cause of premature death in young-to-middle-aged adults in endemic regions and has become a public health crisis. Studies are underway to investigate clinical, exposome, and omics factors, and hopefully will provide insights into pathogenetic mechanisms resulting in biomarker discovery, preventive measures, and therapeutics.
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Affiliation(s)
- Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Garcia P, Anand S. Unraveling the Mysteries of CKD of Uncertain Etiology. Clin J Am Soc Nephrol 2022; 17:1269-1271. [PMID: 35944912 PMCID: PMC9625095 DOI: 10.2215/cjn.08430722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Pablo Garcia
- Department of Medicine (Nephrology), Stanford University, Palo Alto, California
| | - Shuchi Anand
- Department of Medicine (Nephrology), Stanford University, Palo Alto, California
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