A small crowd of villagers waiting in a concrete school building low Pedda Srirampuram, a village in the southern Indian state of Andhra Pradesh. The morning air is crisp and the men and women dressed in light shawls and sweaters. Each holds two bags with a plastic medical records, the other with a transparent plastic container of urine. They are lining up to be seen by one of the four young men with two large wooden tables.
A researcher named Srinivas Rao is sitting at the first table. "What is your name?" He asks, a short stiff man who is next in line. "RE. Kesava Rao," the man replies, put his medical records. Rao, the researcher, leafs through the pages, noting details. "His kidneys are not working at all," notes Rao. "Both his kidneys."
This is a disease that has a significant mortality. People who [otherwise] work, raise a family are dying. It is quite extraordinary.
Kesava Rao, 45, has chronic kidney disease of unknown etiology (CKDU) and depends on dialysis to survive. "Every week, I undergo dialysis, 4 weeks a month," says Rao. a man with a soft voice with a ready smile, Rao worked all his life on construction sites or in coconut farms. he lived a healthy life and almost never seen a doctor, he said, until the fever has led to an examination and diagnosis Rao. did not have diabetes or until her kidneys failed, hypertension, the two leading causes of chronic kidney disease in the world. No more than most other villagers who gathered here, all patients with chronic kidney disease, waiting to get a free blood test for creatinine, a metabolite and a proxy for kidney function, and give samples of urine and blood for research.
The Andhra Pradesh coastal region is at the heart of what doctors and local media called a CKDU epidemic. There is little data on the prevalence rigorous, but unpublished studies by Gangadhar Taduri, nephrologist at the Nizam Institute of Medical Sciences in Hyderabad, in the neighboring state of Telangana, suggest the disease affects 15% to 18% of the population in this agricultural region, known for rice, cashew and coconut. Unlike the most common type of CKD, especially seen in the elderly in urban areas, CKDU seems a rural disease, affecting agricultural workers, the men of the majority of them between their 30 and 50. "It is a problem of the poor, "said Taduri, who leads the team of researchers in the village.
chronic kidney disease affects mainly rural laborers, such as coconut husking men in southern India the sun.
© Tom Laffay
a rash of similar outbreaks in other countries stressed that it is a global problem. Some rice-growing areas of Sri Lanka have their own epidemic and endemic in the producing areas of sugar from Mexico and Central America (Science, 11 April 2014 , p. 143). It has also been reported in Egypt. Everywhere, prevalence figures are scarce and uncertain, but "there is a lot of concern," said Virginia Weaver, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health University in Baltimore, Maryland. "This is a disease that has a significant mortality. People who [otherwise] work, raise a family, are dying. It is quite extraordinary."
experts and public health researchers are alarmed and confused. In Central America, which was the most affected, the main hypothesis is that this is an occupational disease caused by chronic exposure to heat and dehydration in the cane fields. Here, in Andhra Pradesh, Taduri and his colleagues believe that natural toxins in lithium drinking water, for example, could help. Using samples of blood and urine of Pedda Srirampuram, "we will evaluate if [trace elements] are really present in the body or not," says C. Prabhakar Reddy, one of the researchers who collect the samples.
But in India, Sri Lanka and Central America, researchers attempt to explain CKDU pursue a wide range of ideas, including the excessive use of over the counter pain medication and exposure to pesticides . Nephrologist Ajay Singh of Harvard Medical School in Boston found high levels of silica, found in some pesticides in drinking water in the region, and thinks he could be responsible. "There is a smoking gun" he says, but he concedes.. "I do not know if smoking gun is responsible"
As global disease becomes clear, the search for answers is accelerating beginnings an international scientific network to study CKDU take shape, and researchers are working on a simple and accurate diagnosis so they can map the incidence in the world and try to correlate with possible causes.
Like most places CKDU is endemic, India does not have a good idea how many people have the disease (also known as CKDnT for nontraditional causes). But anecdotal evidence from Andhra Pradesh is disappointing. We have "almost 126 widows" of men who died of CKD, Rajni Kumar said time limit, the village chief of Balliputtuga. The total population of the village is 3270, which means that almost 4% of its people died of the disease.
By screening the villagers in a van equipped with an ultrasound machine and other diagnostic equipment, Taduri and his colleagues came up with their estimated incidence of 15% or more in this region. Most people diagnosed with CKDU "did not have complaints that suggested a kidney problem," says Taduri. "But ... their creatinine was high." Sonographic examinations revealed that they had kidney "narrowed."
in the village of Pedda Srirampuram, a mobile test team villagers interviews and collecting samples of blood and urine to test their kidneys.
© Ed Kashi / VII
CKDU is so deadly in part because it is difficult to detect. "It is a silent killer," says AK Chakravarthy, nephrologist Nellore, Andhra Pradesh. In the early stages of the disease, people have no symptoms. "By the time they discover it is too late," he said. Their kidneys are already beyond repair, leading to high blood pressure, weakness, and other symptoms. Access to dialysis here remains limited, although the state government of Andhra Pradesh has added facilities in recent years. for many patients, death comes not long after their diagnosis.
Those lucky enough for dialysis survive for several years, but are unable to earn a living, pushing families deeper into poverty. its strength and stamina undermined by disease and dialysis, Kesava Rao can no longer provide for his family of five. his eldest son, now 20, had to take the place of his father. "He finished high school, then stopped studying," Rao said. "It is the main breadwinner of the family now."
In India, several research groups are on the trail of a cause. But every team used its own methods and tools, often in isolation, making it difficult to compare results. Taduri and Singh, for instance, both worked in Andhra Pradesh for years, and both have pursued the hypothesis that high levels of silica in drinking water might be responsible. Silica dust is known to damage the lungs and kidneys if inhaled, but we do not know what he does when ingested.
However, the two researchers had never met until recently. "I did not even know that this work was going on," Singh said on the work Taduri. While Singh thinks silica comes from pesticides, Taduri considers it leached into groundwater of bedrock. Singh admits researchers have benefited from collaboration. "We need to develop a coordinated approach."
This is true beyond India. as scientists and public health experts are finding that CKDU is a global disease or group of diseases, they cast a wider net for possible causes. "We have to look at this from a global perspective," says Weaver.
Some scientists 30 doctors and Indian and international public health experts are seated at a round table in any conference room at the Institute of Energy and Resources in New Delhi. The group is here for a workshop led by the CKD La Isla Foundation, a nonprofit group working with affected communities in Central America. The purpose of the January meeting: creating a global network of scientists studying the disease.
The first task for the network is to determine the prevalence, said Ben Caplin, nephrologist at University College London who works in Nicaragua. "We need to know where hotspots CKDnT," he said. "Are there environmental factors, professional and common social shared CKDnT hot spots?"
But participants differ . how to define the disease Caplin offers a working definition: "any alternative cause of CKD diagnosed by a medical professional, no diabetes, no high blood pressure." But Singh said the state could well be a collection diseases caused by different factors in different places. by insisting on a single definition, we "are already beginning to have a bias as to what the causes may be."
Neil Pearce of the London School of hygiene & Tropical Medicine, the only epidemiologist in the room, said screening for renal function can be done without making assumptions about the causes. "We try to find populations with high prevalence and low prevalence. This says nothing about the individual. "
Get a handle on prevalence will require a standard screening test, however. Caplin, Pearce and colleagues are developing a protocol that can be adapted for different populations: a blood test for kidney function, a urine test and a background questionnaire recording age, sex, occupation and income the participant. The team tries to keep things simple and inexpensive, Caplin said. "We do not want to put too complicated and people."
The team hopes to publish the protocol in peer review, so that scientists from any country can use to screen local or regional populations with their own funds. "I think the use of a simple protocol that will be affordable in different contexts would really shed light on the extent and global distribution of the disease," says Catharina Wesseling, a expert in occupational health and the environment at the Karolinska Institute in Stockholm.
Wesseling CKDnT studies in Central America, where it takes an even heavier toll in India. "Just look at mortality figures," said Jason Glaser La Isla. In Chichigalpa, Nicaragua, for example, "46% of all deaths in men are due to CKD," he said. "Sixty -Fifteen percent of men between 35 and 55 deaths are due to CKD. " By some estimates, the disease has killed at least 20,000 people in the region.
If the disease is the same striking India, research in Central America could narrow the search for a cause. Recent studies have reinforced the hypothesis that CKDU results of long hours in the heat of drinking water too little, leading to chronic dehydration. Last year, for example, a study by Wesseling and colleagues showed that the disease exists in Costa Rica, at least since the 1970s, but the mortality rate in Guanacaste province has climbed 4.4 to 100,000 men between 1970 and 1972 to 38.5 in 08 to 2012 with the expansion of sugarcane farms on an industrial scale. In another study, the same group showed that renal function cane cutters in a Nicaraguan community decreased by a single harvest period. "These people have a very frightening deterioration in renal function during the harvest period," says Wesseling.
the mysterious new form of chronic kidney disease strikes, agricultural areas mainly poor in tropical regions. It takes more toll in Central America, but it has now been reported in other regions.
G. Grullón / Science
a pilot study she and colleagues did last year hinted at how chronic dehydration done its damage. They found high levels of uric acid crystals in the urine of cane cutters, particularly at the ends their shifts. These crystals can hurt the kidneys, the researchers suggested. "This is an important mechanism that we had not thought of," said Richard Johnson, a nephrologist at the University of Colorado Denver and author of the study.
But the case is far from be closed. "I absolutely do not think the heat stress and dehydration are the only part of the story," Glaser said. "You see the different severity [of the disease] in different places." Like him, the most scientists are not yet rule out other factors.
Even before scientists know for sure what causes the disease, said Taduri communities can take action to reduce risks. Provide clean surface water sources for drinking, urging people to drink more water to work, and advising them to stay away from killers bread- will improve their health anyway, he says. In El Salvador, Glaser and his colleagues are working to develop a pilot study called the health efficiency program and workers, which requires frequent rest and hydration for workers.
Meanwhile, in CKDU affected communities in southern India, fear and frustration are on the rise. Now Taduri said, villagers in Andhra Pradesh refuse to come for screening, fearing stigmatization. When a man is diagnosed with kidney disease, "his family will feel it as a burden," said time limit, the village chief of Balliputtuga.
On a nearby farm, a group of men stand a peeling circle coconut. most are sweating in the sun by mid morning. Each stands on a blade longer than his forearm, his wooden handle firmly planted in the soil. They gather nuts coco a pile and each quickly pull on the blade, peeling away the thick hard crust, brown inner shell.
men talk as they work, and the conversation turns to their creatinine levels. "mine is 1.4," said a young man in his 30s. "mine is 1.3," another said. "One point nine." "Two." For half the men, the levels are either borderline or elevated. All work long hours under the sun, too little water to drink. Their legs and back hurt often when they go home at night, and they turn to painkillers or alcohol, even if they both know are bad for their kidneys.
men understand that they are at risk of disease chronic kidney, but believe they can not prevent it from progressing. the rest is not an option, it is said. "We have the disease, but we still have to work for a living."
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