CKDu, CINAC, KDUCAL; A Nephropathy looking for a name....

Written by Meguid El Nahas on Friday, 31 March 2017. Posted in OLA Blog

CKDu, CINAC, KDUCAL; A Nephropathy looking for a name....


Am J Kidney Dis. 2017 Apr;69(4):552. doi: 10.1053/j.ajkd.2016.09.029.

Kidney Disease of Unknown Cause in Agricultural Laborers (KDUCAL) Is a Better Term to Describe Regional and Endemic Kidney Diseases Such as Uddanam Nephropathy.

Subramanian SJavaid MM1

MesoAmerican Nephropathy (MAN)
Chronic Kidney Disease of Unknown Etiology (CKDu)
chronic interstitial nephritis in agricultural communities (CINAC)
https://www.ncbi.nlm.nih.gov/pubmed/?term=sri+lanka%2C+CKD%2C+De+Broe
 
Now KDUCAL...
 
Are we looking for a name for renal insufficiency that affects labourers in extreme heat conditions...?!
 
Perhaps, we should call it...
CKDh (Chronic Kidney Disease heat induced...)
or even
CKDd (Chronic Kidney Disease dehydration induced...)
 
all these nephropathies observed amongst agricultural workers exposed to extreme heat conditions and who are chronically wasted and dehydrated include those noted amongst:
Sugar cane and other crop labourers in Central America
MesoAmerican Nephropathy
 
Including that observed in agricultural workers in India; Uddanam
https://www.ncbi.nlm.nih.gov/pubmed/27209444
 
In Cuba, Columbia, India, Sri Lanka, Egypt and elsewhere, those workers suffering form CKD may simply suffer from chronic dehydration in people exposed to long period of heat and related stress:
https://www.ncbi.nlm.nih.gov/pubmed/24717833
 
However, additional agricultural related factors have been raised by some, such as my good friend Prof Marc De Broe, who wrote:
https://www.ncbi.nlm.nih.gov/pubmed/?term=sri+lanka%2C+CKD%2C+De+Broe
 
"The heat stress and dehydration hypothesis, however, cannot explain: why the incidence of CINAC went up along with increasing mechanization of paddy farming in the 1990s; the non-existence of CINAC in hotter northern Sri Lanka, Cuba and Myanmar where agrochemicals are sparsely used; the mosaic geographical pattern in CINAC endemic areas; the presence of CINAC among women, children and adolescents who are not exposed to the harsh working conditions; and the observed extra renal manifestations of CINAC. This indicates that heat stress and dehydration may be a contributory or even a necessary risk factor, but which is not able to cause CINAC by itself."
 
In Sri Lanka, heavy metals, and trace elements including cadmium, strontium, etc... contamination of foodstuff has been raised:
https://www.ncbi.nlm.nih.gov/pubmed/26701260
as well as excessive high fluoride water content:
https://www.ncbi.nlm.nih.gov/pubmed/20853020
 
In the meanwhile...and until the etiology is settled....nephrologists will continue to look for a name...
 
same story as many decades ago when Balkan Nephropathy...was atributed to mycotoxins and ochratoxin...and it  became known as Aristolochic Acid Nephropathy (AAN)...
or is it?...
https://www.ncbi.nlm.nih.gov/pubmed/27871899
 
 
 
 
 
 
Meguid El Nahas

Professor Meguid El Nahas PhD, FRCP

Chief Editor, OLA Director

Professor El Nahas was born in Cairo, Egypt and undertook his undergraduate medical education in...
Posted: 3 weeks 2 days ago by arif.khwaja #21400
arif.khwaja's Avatar
Are we really seeing an epidemic.... is the rise in CKD simply a testing and recognition issue... back in the 1990s there was little systematic monitoring of kidney function in high income countries never mind lower GDP countries... perhaps there is more testing now in these countries and this is leading to increased identification of CKD amongst the lower socioeconomic groups with perhaps poorer access to healthcare than those living in urban environments....I don't know but just wonder
Posted: 3 weeks 2 days ago by elnahas #21401
elnahas's Avatar
I am sure you are right...and most have hemoconcentration during to severe dehydration...and raised serum creatinine...

if you go round and screen:

Outdoor workers in tropical countries they are most likely to have raised sCr, until they get rehydrated!

Steel workers next to hot furnisses etc....they will also be dehydrated and have raised serum creatinine: Steel workers nephropathy...?!

and a convincing argument there is that the same cotton and sugar cane farmers in Columbia who work at altitude where the climate is milder dont have the Mesoamerican Nephropathy....I suspect the other variable including pesticides, chemicals etc....are the same! Only difference low altitude extreme heat...high altitude cooler temperature!
Posted: 3 weeks 2 days ago by tukaram #21402
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Increased detection may have contributed to CKD epidemic in urban population. However I disagree that CKDu is reflection of just increased testing. This entity exists in at least 2 pockets in India (Chennai, and northern Maharashtra). There is definite clustering of cases in young adults, without obvious CKD risk factors, and severe (often symptomatic), hyponatremia and hypokalemia is present at detection. Many of such patients are on dialysis.

Clearly lot of work is needed to elucidate this further.
Posted: 3 weeks 21 hours ago by elnahas #21403
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Very interesting!

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