Air pollution and the kidney—implications for control of non-communicable diseases
Authors: Philip J Landrigan
Journal: The Lancet Planetary Health (2017)

Air pollution is a massive threat to planetary health. It is responsible for an estimated 6·5 million deaths per year,1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4081) Google Scholar, 2Pruss-Ustun A Wolf J Corvalan C Bos R Neira M Preventing disease through healthy environments. World Health Organization, Geneva2016Google Scholar, 3Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet (in press).Google Scholar which is more deaths than AIDS, tuberculosis, and malaria combined, endangers the stability of the earth's support systems, and is intimately linked to global climate change.4McMichael AJ Climate change and the health of nations: famines, fevers, and the fate of populations. Oxford University Press, London2017Crossref Google Scholar Thanks to the introduction of cleaner cookstoves, non-polluting energy sources, new vaccines, and improved paediatric treatment protocols, deaths due to household air pollution have come down over the past four decades.3Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet (in press).Google Scholar But ambient air pollution is on the rise, and the number of deaths due to ambient pollution increased from 3·5 million in 1990 to 4·2 million in 2015, an increase of 20%.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4081) Google Scholar The main drivers are the uncontrolled growth of cities, increasing demands for energy, the growing use of gasoline-powered and diesel-powered vehicles, and the globalisation of industry against the backdrop of an expanding, ageing global population. As is noted in the State of Global Air 2017 report, the largest increases in pollution-related deaths are seen in rapidly industrialising low-income and middle-income countries (LMICs), notably India and Bangladesh. In the absence of aggressive intervention, the numbers of these deaths are projected to increase by more than 50% by 2050.5Lelieveld J Evans JS Fnais M Giannadaki D Pozzer A The contribution of outdoor air pollution sources to premature mortality on a global scale.Nature. 2015; 525: 367-371Crossref PubMed Scopus (3221) Google Scholar The list of diseases associated with air pollution has expanded greatly. Prospective epidemiological studies6Pope CA Respiratory disease associated with community air pollution and a steel mill, Utah Valley.Am J Public Health. 1989; 79: 623-628Crossref PubMed Google Scholar, 7Dockery DW Pope CA Xu X et al.An association between air pollution and mortality in six U.S. cities.N Engl J Med. 1993; 329: 1753-1759Crossref PubMed Scopus (6393) Google Scholar have linked particulate pollution to asthma, cancer, neurodevelopmental disorders, and birth defects in children, and to heart disease, stroke, chronic obstructive pulmonary disease, and cancer in adults. Emerging evidence indicates that particulate pollution might also be linked to diabetes,8Cosselman KE Navas-Acien A Kaufman JD Environmental factors in cardiovascular disease.Nat Rev Cardiol. 2015; 12: 627-642Crossref PubMed Scopus (306) Google Scholar preterm birth,9Malley CS Kuylenstierna JCI Vallack HW Henze DK Blencowe H Ashmore MR Preterm birth associated with maternal fine particulate matter exposure: a global, regional and national assessment.Environ Int. 2017; 101: 173-182Crossref PubMed Scopus (152) Google Scholar autism,10Weisskopf MG Kioumourtzoglou MA Roberts AL Air pollution and autism spectrum disorders: causal or confounded?.Curr Environ Health Rep. 2015; 2: 430-439Crossref PubMed Scopus (78) Google Scholar and dementia.11Heusinkveld HJ Wahle T Campbell A et al.Neurodegenerative and neurological disorders by small inhaled particles.Neurotoxicology. 2016; 56: 94-106Crossref PubMed Scopus (212) Google Scholar Pollution is now estimated to be responsible for more than 20% of all deaths from non-communicable diseases (NCDs), a fraction that will be likely to increase as new data become available.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4081) Google Scholar, 3Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet (in press).Google Scholar In The Lancet Planetary Health, Benjamin Bowe and colleagues12Bowe B Xie Y Li T Yan Y Xian H Al-Aly Z Associations of ambient coarse particulate matter, nitrogen dioxide, and carbon monoxide with the risk of kidney disease: a cohort study.Lancet Planet Health. 2017; 1: e267-e276Summary Full Text Full Text PDF Scopus (103) Google Scholar suggest an association between ambient air pollution and yet another NCD—chronic kidney disease. They built a cohort of 2·2 million military veterans with no previous history of kidney disease using records from the US Department of Veterans Affairs and linked data on place of residence with data on ambient concentrations of airborne coarse particulates (PM10), nitrogen dioxide, and carbon monoxide pollution. Over a median follow-up of 8·52 years, the authors found significant, positive associations between annual mean concentrations of each of these pollutants and increased incidence of eGFR less than 60mL/min per 1·73 m2, eGFR decline of 30% or more, chronic kidney disease, and end-stage renal disease. To assess the significance of these findings for public health, the authors calculated the fraction of kidney disease in the American population attributable to air pollution. They found that PM10 pollution is responsible for 10·14% of incident eGFR of less than 60 mL/min per 1·73 m2, 9·97% of chronic kidney disease, 11·62% of eGFR decline of 30% or more, and 12·73% of end-stage renal disease. These rates translate to around 765 000 new cases of eGFR less than 60 mL/min per 1·73 m2 and to nearly 30 000 new cases of end-stage renal disease attributable each year in the USA to ambient air pollution. Although these observations will need to be corroborated by future studies, they underscore the importance of the connections between ambient air pollution and NCDs. However, pollution-related NCDs are surprisingly neglected in both the international development and global health agendas.3Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet (in press).Google Scholar Development funding from international agencies and donor countries for prevention of disease caused by ambient air pollution and other forms of modern industrial chemical and automotive pollution in LMICs is meagre. Private philanthropy is also lacking. Despite the fact that more than 70% of the diseases caused by pollution are NCDs, interventions against pollution are barely mentioned in WHO's Global Action Plan for the Prevention and Control of Non-Communicable Diseases.13WHOGlobal action plan for the prevention and control of non-communicable diseases 2013–2020.http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1Google Scholar The forthcoming Lancet Commission3Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet (in press).Google Scholar on pollution and health calls on individual countries and the international community to do better. Pollution-related NCDs are a growing global threat that can no longer be ignored. International agencies and the donor community must substantially increase the amount of funding and technical assistance that they direct to prevention of NCDs caused by pollution by the industrial, transport, chemical, and mining sectors in LMICs. Data systems must be strengthened. Vested interests must be confronted. WHO must accelerate their efforts to make interventions against pollution core components of the Global Action Plan for the Prevention and Control of Non-Communicable Diseases and translate this global strategy into health and pollution action plans for individual countries.14WHOPreventing noncommunicable diseases (NCDs) by reducing environmental risk factors.http://apps.who.int/iris/bitstream/10665/258796/1/WHO-FWC-EPE-17.01-eng.pdf?ua=1Google Scholar Fortunately, many of the tools needed to control pollution and to prevent pollution-related disease have already been developed. These strategies have been field-tested in high-income and middle-income countries, proven successful, and found to be highly cost-effective. They are based in law, policy, regulation, and technology; are based on the polluter-pays principle; and eliminate government subsidies for polluting industries. They include mandated reductions in emissions, strictly enforced air-quality standards, incentivised transitions to non-polluting, renewable sources of energy and to non-polluting production technologies, and they encourage public transportation. These strategies are available to be adopted globally. Their application can enable LMICs to advance over the health and ecological disasters that have previously plagued industrial development. Pollution is not the unavoidable consequence of development. Control of pollution-related NCDs is a winnable battle. I declare no competing interests. Associations of ambient coarse particulate matter, nitrogen dioxide, and carbon monoxide with the risk of kidney disease: a cohort studyEnvironmental exposure to higher concentrations of PM10, NO2, and CO is associated with increased risk of incident chronic kidney disease, eGFR decline, and end-stage renal disease. Full-Text PDF Open Access