Pesticides and the epidemic of CKD in Central America.

To the Editor: In a recently published article in AJKD, Dr Correa-Rotter and colleagues attempt to disentangle the causes of an epidemic of chronic kidney disease (CKD) of unknown origin that is devastating farming communities in Central America, reviewing potential risk factors and causes and summarizing evidence for and against each. We believe the method used to assess the evidence was flawed; consequently, the authors’ proposed priorities for future research are misguided. Specifically, the authors conclude that heat stress likely is a leading risk factor in this CKD epidemic and should be a high priority for future research. However, they also state that “[a]n etiologic role of pesticides in MeN [Mesoamerican nephropathy] is not likely but cannot be completely ruled out.” We contend that heat stress cannot explain cases of CKD found in non– sugarcane workers and women. Moreover, CKD of unknown origin, which has been documented in Sri Lanka and Central America, is virtually absent in other countries with similar weather conditions and long traditions of sugarcane cultivation. Unfortunately, Central America has a long-standing and welldocumented history of agrochemical misuse. The mere fact that some pesticides used regularly in Central America are clearly nephrotoxic should be sufficient reason to take them into account in the research agenda for this epidemic. Underestimating the role of pesticides in this epidemic could seriously undermine efforts to develop effective—and urgently needed— public health interventions for the CKD epidemic in Central America and other health problems that could be related to pesticide misuse.