What is Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )?
Chronic interstitial nephritis in agricultural communities (CINAC) is a unique type of chronic kidney disease (CKD) that is not linked to common causes like diabetes, high blood pressure, or certain kidney diseases. It’s noteworthy that this disease has become widespread, especially affecting young men, with some cases in women and adolescents, in various countries, including Central American nations like El Salvador, Guatemala, Nicaragua, and Costa Rica, Egypt in Africa, and Sri Lanka and India in Asia.
This distinct CKD, also known by other names such as Central American nephropathy, Salvadoran agricultural nephropathy, and others, has been reported worldwide and shows similar patterns among the affected people. It’s typically found in people working in the farming industry in these regions, famously known as CINAC endemic areas.
The presence of this disease is influenced by various factors like poverty, use of harmful agricultural chemicals, and hot tropical climates. It often affects men more commonly but also impacts women, children, and teenagers living in these farming communities. This can even be found in those who don’t work in farming in these areas.
According to a report from The Pan American Health Organization, the CKD-related death rates in Nicaragua and El Salvador are four times higher compared to other countries. In El Salvador, the disease is the second most leading cause of death among young men, affecting men three times more than women.
What Causes Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )?
The cause of a type of chronic kidney disease in farming communities is not yet known. This form of kidney disease is surprisingly common in such communities, particularly affecting male farmers at a young age as well as some non-farming women and adolescents. Children too show signs of kidney damage, suggesting environmental and job-related factors in these communities may be the cause.
People in these communities face the same health risks as the rest of the world. However, their work exposes them to harmful substances, many of which are banned in other countries. They work long hours around these chemicals, often without protection in high temperatures and performing strenuous physical activity.
Some experts think the disease might be linked to environmental toxins, present in the air, soil, water, or food, from both natural and man-made sources. These toxins might be inhaled, swallowed, or absorbed through the skin. This exposure can vary, from repeated high-level exposure for farmers, to lower levels of chronic exposure for the general population. In both situations, an individual’s genetic makeup might influence how they’re affected, although this aspect hasn’t been studied yet.
One complication is that the toxins in the bloodstream should be removed by the kidneys, but this process can be disrupted if farmers are frequently dehydrated. Some research suggests that high levels of certain metals in the environment might be contributing to the problem.
Some believe the toxins directly damage the cells in the kidneys. Additional kidney damage can occur due to changes in blood flow caused by environmental factors. Other things that increase the risk of kidney damage in farming communities include low birth weight, diseases like malaria, health conditions like diabetes and obesity, lifestyle factors like smoking and excessive drinking, use of certain drugs, dehydration, and the use of herbal remedies known to be harmful to the kidneys.
Another theory is that the disease could be caused by repeated dehydration. However, areas with similar hot climates but without the use of harmful chemicals don’t show the same prevalence of this kidney disease. Lab experiments with rats have also shown that dehydration and heat stress alone do not cause the kidney abnormalities seen in this disease.
Further studies are needed, but current observations suggest that the disease may be the body’s response to exposure to toxins.
Risk Factors and Frequency for Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
Chronic Interstitial Nephritis in Agricultural Communities (CINAC) is a significant health issue that started being reported 20 years ago. It has been particularly problematic in Central America and Sri Lanka. For instance, Sri Lanka’s North Central Province is estimated to have over 60,000 cases and more than 20,000 deaths per year. Hospital records also show an increase in CINAC cases from the year 2000 to 2015. The cause of kidney failure was not determined in 82% of Chronic Kidney Disease (CKD) cases seen at a teaching hospital in Anuradhapura between 2000 and 2002. Although there is a slightly higher prevalence of CINAC in women according to a World Health Organization (WHO) study, more severe forms of the disease commonly occur in men.
Many studies have found CKD to be common in farming communities. Less than half of those affected have diabetes or high blood pressure. Men are primarily affected, and kidney damage usually starts early in life. However, other group members, including women, children, and adolescents, are also affected, regardless of whether or not they work on the farms. This increased prevalence of CKD in farming communities occurs in both highland and lowland areas. Additionally, research has shown that pesticides and heavy metals like cadmium and arsenic are present in well water, household floors, and farmlands, especially concentrated in crop areas. Pesticides also contaminate farmers’ clothes, providing an additional exposure risk for family members, particularly women who wash these clothes. In the United States, a study involving 55,580 male licensed pesticide applicators showed a significant link between chronic pesticide exposure and the risk for CKD.
- An outbreak of CKD not associated with typical risk factors has been found in India, Japan, Central America, and Sri Lanka.
- In India, numerous cases have been diagnosed among coconut and paddy farmers.
- In Central America, increased numbers of CKD cases and mortalities have been reported over the past two decades, especially in El Salvador and Nicaragua.
The Pan American Health Organization reported CKD-specific mortality rates (per 100,000 population) as follows:
- Nicaragua: 42.8
- Guatemala: 13.6
- El Salvador: 41.9
- Panama: 12.3
Signs and Symptoms of Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
Chronic Interstitial Nephritis in Agricultural Communities (CINAC) is a slowly developing condition that’s often associated with exposure to farm chemicals, herbicides, or polluted water. Initially, many people with CINAC may not notice any symptoms. However, some might experience joint pain, fatigue, muscle cramps, lower sexual drive, or faintness. Protein in the urine (proteinuria) is sometimes seen, but it’s usually not severe. Lab tests may show several abnormalities in their urine, such as increased levels of phosphate, magnesium, sodium, potassium, and calcium.
As CINAC advances, often from stage 2 of Chronic Kidney Disease (CKD) onwards, the frequency and intensity of symptoms increases. Some urinary symptoms from the start can include:
- Increased nighttime urination (Nocturia)
- Painful urination (Dysuria)
- Leaking after urination (Post-void dribbling)
- Difficulty starting to urinate (Hesitancy)
- Foamy urine
Aside from the kidney issues, some patients may also experience problems in other body systems, while others may show no signs of external damage. For example:
- Cardiovascular system: Normal or slightly high blood pressure, mostly normal heart tests, but there might be slight issues with heart’s ability to relax between beats. Patients in El Salvador showed minor changes in their main and neck arteries but significant changes in their leg arteries.
- Peripheral arteries: Ultrasound tests showed the main damage in the leg arteries, with the primary issue being irregularities in the artery walls.
- Nervous system: Abnormalities in nerve reflexes are seen early with potential hearing loss over time due to exposure to heavy metals and organic solvents.
- Eyes: Most patients have normal eye tests, indicating they do not have significant small blood vessel damage as seen in diabetes or high blood pressure-related eye diseases.
Testing for Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
To diagnose chronic interstitial nephritis, which is common in farming communities, various tests are necessary. Here’s what you need to know:
Starting with laboratory tests, your doctor may order a complete blood count (CBC) and a comprehensive metabolic panel (CMP). Furthermore, tests for magnesium levels, total urine protein, levels of sodium, potassium, and magnesium in your urine, as well as a 24-hour urine test and a urine protein-creatinine ratio test are usually conducted. In the early stages, you might notice electrolyte loss, mild protein in your urine, and high levels of a substance called beta 2 microglobulin. Interestingly, they often don’t find significant changes or oddly shaped red blood cells in the urine.
Next, they’ll look at your electrolyte levels. If they’re low for substances such as sodium, potassium, chlorine, and magnesium, it could indicate this condition. On the other hand, the measure of different solutes in your blood, known as blood osmolality, typically stays normal.
Another factor they’ll investigate is your body’s acid-base balance – whether you have too much acid or alkali in your blood. In this case, metabolic alkalosis tends to take over, notably as early as stage 2 of chronic kidney disease (CKD).
Besides laboratory tests, imaging like kidney ultrasounds can provide helpful clues. They might show an increase in echogenicity (how much the kidney reflects sound waves), a decrease in the relation between the kidney cortex and medulla, and irregular edges. A special type of ultrasound called a Doppler might reveal that blood flow in the kidney and its smaller vessels is still intact. The ultrasound of the bladder and prostate typically doesn’t show any unusual findings.
Other potential evaluations are an electrocardiogram, echocardiogram, or ultrasounds of the leg and the neck vessels, depending on your specific condition.
Your kidney function might also need to be tested through renal function tests or a biopsy. For a more definitive diagnosis, they might use immunofluorescence, electron microscopy, or light microscopy to look at your kidney tissue under a microscope.
Lastly, if you’re having any issues with your nerves, you might need to undergo an electromyography or nerve conduction studies.
Treatment Options for Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
The best way to deal with chronic kidney inflammation in farming communities is to catch it early and stop it from getting worse. The first step is to make sure the person no longer comes into contact with farm chemicals. Other early-stage treatments include ensuring the person stays well-hydrated and receives care to manage fluid and electrolyte levels. Once chronic kidney disease sets in, it’s often treated the same way as kidney disease caused by other factors. In the final stage of the disease, the person may need kidney replacement therapy.
Recent research has identified cell changes that may provide new treatment options to slow or stop kidney damage. In particular, antioxidants like vitamins C and E may help, as they’re thought to manage oxidative stress, which plays a key role in the disease.
Preventing kidney inflammation in farming communities could involve installing water purifying systems that use reverse osmosis. This would reduce exposure to harmful chemicals present in the drinking water. It’s equally crucial to raise awareness about health safety, especially how farmers handle agricultural chemicals. Improving farming practices and lifestyle changes could prevent this disease.
What else can Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures ) be?
When a patient shows signs that could hint at a condition called chronic interstitial nephritis, particularly in farming areas, several other conditions should also be thought about. These include:
- Nephropathy caused by long-term use of painkillers
- Nephropathy due to Aristolochic acid, a compound found in some natural remedies
- Endemic nephropathy, a kidney disease that occurs in specific regions of the Balkans
- Poisoning from Lithium, a medication often used for bipolar disorder
- Poisoning from lead or cadmium, which are heavy metals
- High levels of uric acid in the blood causing kidney disease
- Kidney disease caused by a condition called sarcoidosis, which causes inflammation in various parts of the body
- Kidney disease caused by calcineurin inhibitors, a type of drug used to prevent organ rejection after a transplant
It’s important to pinpoint the correct cause in order to provide effective treatment.
What to expect with Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
The future health outcomes for people with chronic interstitial nephritis, a kidney disorder common in farming communities, are influenced by several things. These include how well the kidneys are working at the time of diagnosis, the options available to manage the underlying cause of the illness, the person’s overall health status, and past medical history.
This kidney condition tends to worsen quickly, often leading to the final stage of kidney disease within a 4 to 10 year period. Research has found a high number of deaths due to chronic kidney disease in Guanacaste lowlands, a region known for its sugarcane fields. The increasing rates in hot and dry lowland regions suggest a link to occupational exposure.
Possible Complications When Diagnosed with Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
In agricultural communities, older individuals with chronic interstitial nephritis (an inflammation of the kidney’s spaces) are more at risk for complications. If diagnosis or treatment is delayed, this can make their condition much worse. Kidney insufficiency, or poor functioning of the kidneys, is common and can get worse until it results in end-stage kidney disease. This happens when inflammation leads to fibrosis (the creation of excessive fibrous connective tissue), and severe damage of tubular cells in the kidney causes irreversible kidney damage. As a result, the patient may need early kidney dialysis or a kidney transplant.
Some complications brought by this illness can affect the nervous system (causing changes in reflexes during the early stages), hearing (hearing loss), and result in vascular lesions in the lower limbs.
Here are some common complications:
- Neurological changes (reflex modifications in early stages)
- Hearing loss
- Vascular lesions in the lower limbs
Preventing Chronic Interstitial Nephritis in Agricultural Communities (CINAC) (Kidney Disease Due to Toxic Agricultural Exposures )
It’s crucial for those living in agricultural communities and suffering from a chronic kidney disease called interstitial nephritis to receive proper health education. A team of occupational health professionals can help these communities understand and manage the risk of kidney diseases related to their work. They can guide on prevention methods, which could involve following government rules on pesticide use, wearing personal protective equipment (PPE), and taking steps to avoid heat stress and dehydration like taking breaks, finding shade, and having enough water supply.
Health professionals should also look at the work environment and the type of work the patient does. They can provide guidance on how to manage pain without relying heavily on over-the-counter drugs like NSAIDs, inform them about the dangers of self-treating urinary symptoms with antibiotics without professional supervision, and encourage them to seek medical assistance to mitigate the threat of acute kidney injury.
For those at high risk of chronic kidney disease, screening is key. Their medical history and job history, specifically if they’ve worked as farmers, the kind of crops they’ve handled, their experience with pesticide use, and if they’ve worked in sugar cane cutting, are all important details that could help identify high-risk patients.