The epidemic of chronic kidney disease in Central America
Authors: Pedro Ordunez, Carla Saenz, Ramón Martinez, Evelina Chapman, Ludovic Reveiz, Francisco Becerra
Journal: The Lancet Global Health (2014)

Immediate and coordinated action is needed to address the epidemic of chronic kidney disease sweeping across Central America. The disorder, known as CKDnT, is not related to traditional causes such as hypertension and diabetes, and mainly affects young male agricultural workers, the highest mortality being in El Salvador1Orantes CM Herrera R Almaguer M et al.Chronic kidney disease and associated risk factors in the Bajo Lempa region of El Salvador: Nefrolempa study, 2009.MEDICC Rev. 2011; 13: 14-22Crossref PubMed Google Scholar and Nicaragua (figure).2Torres C Aragón A González M et al.Decreased kidney function of unknown cause in Nicaragua: a community-based survey.Am J Kidney Dis. 2010; 55: 485-496Summary Full Text Full Text PDF PubMed Scopus (173) Google Scholar, 3PAHOChronic kidney disease in agricultural communities in Central America, concept paper. Pan American Health Organization, Washington, DC2013Google Scholar However, CKDnT also affects women and non-agricultural workers living in farming communities. Mortality estimates from the Pan American Health Organization (PAHO) show that chronic kidney disease coded as N18 in WHO's International Classification of Diseases revision 10—a proxy for CKDnT—in men younger than 60 years has been responsible for thousands of deaths in the past decade in Central America. CKDnT is characterised by a tubulointerstitial nephropathy with low-grade proteinuria, which has a long subclinical period that tends to progress to end-stage renal disease in a short period of time.4Correa-Rotter R Wesseling C Johnson RJ CKD of unknown origin in Central America: the case for a Mesoamerican nephropathy.Am J Kidney Dis. 2014; 63: 506-520Summary Full Text Full Text PDF PubMed Scopus (240) Google Scholar The scarcity of coverage and access to health services might contribute to the clinical course and high mortality rates of CKDnT. Health authorities, for example in El Salvador, responded to this poor coverage by increasing access to health services; however, the large number of patients and absence of adequate infrastructure and trained personnel led to overloaded hospitals. Similar epidemiological and clinical patterns of CKDnT have been reported in other countries, such as Sri Lanka.5Athuraliya NT Abeysekera TD Amerasinghe PH et al.Uncertain etiologies of proteinuric chronic kidney disease in rural Sri Lanka.Kidney Int. 2011; 80: 1212-1221Summary Full Text Full Text PDF PubMed Scopus (158) Google Scholar Causes of the CKDnT epidemic are not clear, although a consensus exists among researchers on its multifactorial character and relation to social, environmental, and economic determinants. Most commonly postulated causes include exposure to pesticides,3PAHOChronic kidney disease in agricultural communities in Central America, concept paper. Pan American Health Organization, Washington, DC2013Google Scholar, 5Athuraliya NT Abeysekera TD Amerasinghe PH et al.Uncertain etiologies of proteinuric chronic kidney disease in rural Sri Lanka.Kidney Int. 2011; 80: 1212-1221Summary Full Text Full Text PDF PubMed Scopus (158) Google Scholar heat stress with recurrent dehydration,6Crowe J Wesseling C Solano BR et al.Heat exposure in sugarcane harvesters in Costa Rica.Am J Ind Med. 2013; 56: 1157-1164Crossref PubMed Scopus (92) Google Scholar and an excessive intake of high-sugar drinks.7Jimenez CAR Ishimoto T Lanaspa MA et al.Fructokinase activity mediates dehydration-induced renal injury.Kidney Int. 2013; (published online Dec 11.)https://doi.org/10.1038/ki.2013.492Summary Full Text Full Text PDF Scopus (177) Google Scholar Exposure to heavy metals, use of non-steroidal anti-inflammatory drugs and alcohol, and infectious diseases have similarly been postulated as causes for the CKDnT epidemic.4Correa-Rotter R Wesseling C Johnson RJ CKD of unknown origin in Central America: the case for a Mesoamerican nephropathy.Am J Kidney Dis. 2014; 63: 506-520Summary Full Text Full Text PDF PubMed Scopus (240) Google Scholar Research to identify determinants of the epidemic is necessary, but the moral duty to address an epidemic cannot be postponed until its causes are identified. A coordinated response from the public health sector and other related sectors is urgently needed. In addition to health services required to treat affected people, public health bodies need to consider environmental and occupational health measures. The two main hypotheses for the high incidence and excess mortality—ie, the use of pesticides and heat stress along with dehydration—are strongly related to the absence of a regulatory system to control agrochemical use and the poor compliance with rules and standards to protect the labour force's health. Almost all Central American countries are signatories to the Stockholm Convention on Persistent Organic Pollutants8Stockholm ConventionProtecting human health and the environment from persistent organic pollutants.http://chm.pops.int/Countries/StatusofRatifications/PartiesandSignatories/tabid/252/Default.aspxGoogle Scholar and the Rotterdam Convention on Prior Informed Consent. Compliance, however, is far from effective. The Central American Institute for Studies on Toxic Substances reported that, between 2000 and 2004, Central America imported 33 million kg of active ingredients per year, including high volumes of hazardous pesticides, most of which are tightly regulated by international treaties.9Bravo V Rodriguez T Van Wendel de Joode B et al.Monitoring pesticide use and associated health hazards in Central America.Int J Occup Environ Health. 2011; 17: 258-269Crossref PubMed Scopus (37) Google Scholar Central American populations are thus at high risk of the acute and chronic toxic effects of pesticides irrespective of the causes of the CKDnT epidemic. Compliance with relevant international treaties, existing laws, and regulations needs to be secured immediately to protect the health and rights of workers. Present compliance with regulations on workplace health is very poor, as shown in a 2013 report10Hutchinson YV Patel P Sickly sweet. Human rights conditions for sugar cane workers in western Nicaragua.https://apha.confex.com/apha/141am/webprogram/Paper293114.htmlGoogle Scholar that extensively documents the deficient working conditions in western Nicaragua, one of the most affected communities, and proposes interventions to mitigate the situation. In 2013, in response to a request from the Minister of Health of El Salvador to the PAHO Directing Council, Member States recognised the CKDnT epidemic in Central America as a serious public health problem and approved a resolution for ethically imperative urgent action, even if the causes of CKDnT have not been established.3PAHOChronic kidney disease in agricultural communities in Central America, concept paper. Pan American Health Organization, Washington, DC2013Google Scholar Awareness of the epidemic among policy makers and the general public is critical to advance global health actions in response to CKDnT. The opinions expressed herein are those of the authors and do not necessarily reflect the views of Pan American Health Organization. We declare no competing interests.