Chronic Kidney Disease of Unknown Etiology: Hotspots in India and Other Asian Countries

https://doi.org/10.1016/j.semnephrol.2019.02.005Get rights and content

Summary: There has been increased reporting of chronic kidney disease of unknown etiology (CKDu) in certain agricultural communities in the world. In India, an increased prevalence of CKDu has been observed in the states of Andhra Pradesh, Odisha, Goa, and Maharashtra. Although no single causative factor has been proved, several have been proposed: water-borne agrochemicals, silica, chemical flavors in betel nuts, and pesticides. The renal biopsy findings have been similar to those seen in Sri Lanka and Mesoamerican nephropathy in that the predominant findings have been tubular atrophy and interstitial fibrosis with little or no involvement of the glomerular and vascular compartments. Because most of the affected communities belong to the lower socioeconomic group including farmers, a multipronged approach is required for addressing this CKDu epidemic with an emphasis on awareness, prevention, screening, surveillance, provision of renal replacement therapy, increased government spending on health care, and systematic research.

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POPULATIONS AFFECTED

Most of the regions affected in India are rural areas with scarce nephrology care.5 CKDu is a major public health problem in the Uddanam region in the north-central districts of Andhra Pradesh, consisting of the mandals (subdistricts) of Kaviti, Sompeta, Kanchili, Ithapuram, Palasa, and Vajrapukkoturu, accounting for more than 100 villages and a population of approximately 150,000.6 The name Uddanam (derived from the Sanskrit word “Udhyanam,” meaning garden) is given because the area is close

ETIOLOGIC FACTORS

There are a paucity of robust data on the etiologic factors. A systematic search has failed to provide a consensus on a single causative agent, and thus several factors have been proposed, as shown in Table 1. In Mesoamerican nephropathy, heat stress, heavy physical activity, and severe dehydration may have led to multiple episodes of subclinical acute kidney injury,10 generation of reactive oxidants, and tubular injury. Other proposed mechanisms include hyperuricemia, rhabdomyolysis, and

MANAGEMENT OF CKDu

Management of the CKDu epidemic should involve the following components.

  • 1.

    Awareness, screening, and surveillance of the affected community;

  • 2.

    Identification of the affected population in the geographic areas and categorization into CKD stages;

  • 3.

    Lifestyle modification, such as avoidance of smoking and chemically flavored betel nut chewing;

  • 4.

    Safe drinking water supply;

  • 5.

    Avoidance of nephrotoxic agents, such as nonsteroidal anti-inflammatory drugs and alternative therapy;

  • 6.

    Dietary advice regarding

SCREENING

Screening for early detection of kidney impairment should be instituted in these areas with serum creatinine concentration, fasting blood glucose level, blood pressure measurement, body mass index, and a urine dipstick for albuminuria. The average cost of kidney disease–related laboratory screening per person in India is approximately Indian Rupees 200 (approximately US $3). The lack of frank albuminuria poses a challenge to early detection of CKDu. Community ultrasound screening per person for

INTERVENTIONS IN AFFECTED PEOPLE

Use of clean water for drinking and cooking purposes, avoidance of nephrotoxic agents and alternative medicines, and avoidance of exposure to pesticides and agrochemicals are important measures that need to be instituted in these hotspots to address factors that may contribute to the progression of CKDu. For this to happen, efficient government machinery with public-private partnership is needed. For people affected with CKDu, anemia correction, skilled dietary advice, and regular follow-up

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    The current literature on solar greenhouse work and CKDnt has not been reported. The available studies have been primarily conducted in farmers with low-intensity agricultural risk factors; these results show that farmers are at an increased risk of developing CKDnt compared with the general population, while the prevalence varies greatly between different regions and lines of latitude (Abraham et al., 2019; Chang and Yang, 2021; Fitria et al., 2020; Hansson et al., 2020; Johnson et al., 2019; Nanayakkara et al., 2020; Valcke et al., 2017). The prevalence of CKDnt was reported 15%–21% in E1 Salvador in Central America (Orantes-Navarro et al., 2017), meanwhile a study on Indonesian rice farmers reported a prevalence of 18.4% (Fitria et al., 2020).

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