{"id":4747,"date":"2016-06-07T00:00:00","date_gmt":"2016-06-07T06:00:00","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/2016\/06\/07\/floods-fires-droughts-kidney-disease\/"},"modified":"2021-09-07T17:50:02","modified_gmt":"2021-09-07T23:50:02","slug":"floods-fires-droughts-kidney-disease","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/floods-fires-droughts-kidney-disease\/","title":{"rendered":"Floods, fires, droughts, kidney disease"},"content":{"rendered":"
<\/div>

A medical resident in El Salvador\u2019s suspicion that \u201cnormal\u201d was anything but has led to what researchers believe to be an epidemic of heat-related kidney disease, one that kills thousands of people each year, and one that climate change could make far more lethal. University of Colorado School of Medicine researchers have played a key role in turning a young doctor\u2019s hunch into a global research effort to understand and address the disease.<\/p>\n

\"Richard
Richard Johnson, MD, who leads the University of Colorado School of Medicine\u2019s Department of Nephrology, has pursued the climate-kidney connection since 2012.<\/figcaption><\/figure>\n

Richard Johnson, MD<\/a>, who chairs the CU Department of Nephrology, is at the hub of the effort, which recently produced a paper<\/a> that found evidence of heat-stress-related chronic kidney disease (CKD) manifesting in Central America, Southeast Asia, India and elsewhere. If Johnson and colleagues are right, their findings mark a watershed moment in our understanding of the health impacts of climate change.<\/p>\n

Not only may vector-borne diseases like malaria, dengue and Zika creep out of the tropics with the poleward migration of the mosquitoes hosting them. Not only may more frequent heat waves contribute to spiking death rates among the ill and infirm as happened in Europe<\/a> in 2003. But in the case of CKD, the heat and higher temperatures and the resulting dehydration may debilitate and ultimately kill otherwise healthy people.<\/p>\n

‘Even in the kitchen’<\/strong><\/p>\n

The story began in 1998. Ramon Garcia-Trabanino, the medical resident, noted outsized numbers of rural patients with kidney disease coming through the doors of San Salvador’s Hospital Nacional Rosales, El Salvador\u2019s premier hospital. Patients with failing kidneys seemed to be everywhere.<\/p>\n

\u201cI used to say metaphorically that renal patients were even in the kitchen. They were overwhelming the hospital,\u201d Garcia-Trabanino said.<\/p>\n

When he asked around, the usual answer was, \u201cThis is the way it has always been,\u201d he said.<\/p>\n

He led a small study to understand who these patients with failing kidneys were and where they came from. That study, published in 2000, found that two-thirds of them showed no signs of diabetes, hypertension or any other typical cause of CKD. Eighty-seven percent were men, and most worked in agriculture or did manual labor outdoors.<\/p>\n

The paper won a national prize for medical research. That brought local and regional attention, which led to additional studies with collaborators in Central America and Mexico. By 2005, the disease had a name: Mesoamerican nephropathy, described as chronic kidney disease of unknown origin, or CKDu for short. The unknowns centered on the root causes of the disease: Was it pesticides? Something in the diet? Dehydration? Some combination? Something else entirely?<\/p>\n

The effort to understand what was causing CKD moved forward slowly due to a lack of money and lab expertise. That changed in late 2012, in no small part because Johnson attended a conference<\/a> in San Jose, Costa Rica.<\/p>\n

In the lab<\/strong><\/p>\n

Among many other areas, Johnson\u2019s research team had for years focused on understanding the kidney\u2019s role in sugar metabolism and, by extension, obesity (his book, The Fat Switch, was part of a wave of research that has implicated fructose and other sugars \u2013 as opposed to fatty foods \u2013 as the principal villain in the obesity epidemic.) Johnson had been doing mouse-model research to understand the connection between dehydration and fructose metabolism. He and his team had found dehydrated animals to have suffered kidney damage similar to what Garcia-Trabanino and colleagues were seeing among sugarcane field workers and others in El Salvador, Nicaragua, Costa Rica, and Mexico.<\/p>\n

As Garcia-Trabanino described it, Johnson \u201cstarted assisting our little poor local research because we never had proper funding.\u201d With Johnson\u2019s interest and his CU lab now involved, \u201csuddenly we had a big lab, one properly equipped to analyze blood samples and urine samples, and we had a great nephrologist with his experience and expertise.\u201d<\/p>\n

The aim was to understand the biology underlying CKD. While there\u2019s still no definitive answer, Johnson and colleagues believe the kidney damage is a result of a dehydration-triggered chain of events involving the hormone vasopressin, which makes the body want to hold onto water. In the short term, it\u2019s an effective survival tactic. Over time, the adaptation damages the kidneys and ultimately, without dialysis or transplant \u2013 neither of which are easy to come by in the places men work cane fields \u2013 kills you.<\/p>\n

Global warming<\/strong><\/p>\n

\"Ramon
Ramon Garcia-Trabanino, MD, was the first to research chronic kidney disease of unknown origin in his native El Salvador.<\/figcaption><\/figure>\n

The potential global-warming link came about through an insight of Johnson\u2019s in May 2013. He and Carlos Roncal, a researcher in the Johnson Lab, got interested in whether heat might produce uric acid crystals in urine, which they had recently linked<\/a> to CKD. They typically found about 20 percent of the Nicaraguan sugarcane workers being tested had the crystals in their urine \u2013 as compared to perhaps 1 percent among a typical population. After a particularly hot day in May, though, all the samples that came in had uric acid crystals. Johnson was convinced that heat stress had to be the cause.<\/p>\n

He reached out to colleagues around the world via the International Society of Nephrology; they compared heat maps to CKD cases. They found overlap.<\/p>\n

\u201cWhere the hottest days of the year are, that\u2019s where the epidemics are,\u201d Johnson said.<\/p>\n

Johnson brought in other experts, including Jay Lemery, MD<\/a>, a CU School of Medicine associate professor of Emergency Medicine and the department\u2019s chief for wilderness and environmental medicine. Lemery wrote the book on climate change and health.<\/p>\n

The result of the work, published<\/a> in May, was \u201cClimate Change and the Emergent Epidemic of CKD from Heat Stress in Rural Communities: The Case for Heat Stress Nephropathy.\u201d<\/p>\n

Lemery described his role as being \u201cpart of the group that pulled the story together, pulled the data together and wrote the narrative in a much larger context.\u201d<\/p>\n

That narrative makes a compelling case that heat-related CKD is not merely a Mesoamerican phenomenon, but rather a global phenomenon. What\u2019s more, the heat waves that climate scientists consider<\/a> to be an inevitable result of climate change are only going to make the problem worse.<\/p>\n

\u201cIn our paper, whether it\u2019s in Sri Lanka or El Salvador, the ultimate morbidity\/mortality is kidney failure,\u201d Lemery said. \u201cBut it\u2019s really not. It\u2019s chronic exposure to extreme heat events in combination with a paucity of potable water.\u201d<\/p>\n

The same idea applies to, say, heart failure patients who die during heat waves, he added.<\/p>\n

\u201cThe take-home message is that it\u2019s really important to articulate the clinical impact of climate change, because unless you\u2019re teasing that out, it just may not show up in the data,\u201d Lemery said.<\/p>\n

Changing habits<\/strong><\/p>\n

These men with CKD \u2013 and for now, they\u2019re mostly men \u2013 continue to toil through the heat in the fields or on construction sites or in open-air mines. They may or may not be drinking enough water, and they aren\u2019t likely to adhere to U.S. Occupational Safety and Health Administration<\/a> guidelines saying that one should rest in the shade for 15 minutes for each hour of humidity-adjusted temperatures over 79 degrees and take breaks of 45 minutes per hour if it\u2019s hotter than 86 degrees.<\/p>\n

\u201cThey have to work,\u201d said Garcia-Trabanino. \u201cSo we teach them to drink enough water; to measure their level of hydration by looking at the color of their urine; and to take rests in the shade if they work in the sun.\u201d<\/p>\n

\"Jay
Jay Lemery, MD, a CU School of Medicine associate professor of emergency medicine, says schronic kidney disease of unknown origin is an example of how climate-related health impacts can be difficult to discern from underlying conditions or other causes.<\/figcaption><\/figure>\n

Garcia-Trabanino, now a nephrologist leading a San Salvador dialysis clinic his father founded, continues to research and publish<\/a> on CKD. He says patients diagnosed early can also benefit from certain drugs.<\/p>\n

\u201cI still have patients alive we diagnosed in 2004-2005,\u201d he said. \u201cThey still have CKD but we have slowed down the progression.\u201d<\/p>\n

The Johnson Lab at CU\u2019s Anschutz Medical Campus has stayed on the CKD case, too. Other recent efforts include a closer look at the connection between the body\u2019s reaction to dehydration and the kidney-damaging effects of Western diets high in fructose, salt and uric acid-producing purines. His team has also shown<\/a> that rats exposed to 97-degree heat for an hour have much worse kidney damage if they rehydrate with a soft-drink-like solution than if they drink water or water with a sugar substitute. The work has major on-the-ground relevance: In places where the local population doesn\u2019t trust the water (often because of suspicion that pesticides in the water are causing CKD), sugary drinks have become a substitute of choice.<\/p>\n

The bottom line is that climate change impacts are about more than forest fires, floods and drought, Johnson said.<\/p>\n

\u201cWe have not focused on the effects of water shortage and heat stress on the body itself,\u201d he said. \u201cThe kidney is the great regulator. It can only do so much.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

A medical resident in El Salvador\u2019s suspicion that \u201cnormal\u201d was anything but has led to what researchers believe to be an epidemic of heat-related kidney disease, one that kills thousands of people each year, and one that climate change could make far more lethal. University of Colorado School of Medicine researchers have played a key […]<\/p>\n","protected":false},"author":23,"featured_media":2782,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[134,280,179],"class_list":["post-4747","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-kidney-care","tag-kidney-disease-hypertension","tag-nephrology"],"acf":[],"yoast_head":"\nFloods, fires, droughts, kidney disease - UCHealth Today<\/title>\n<meta name=\"description\" content=\"A medical resident in El Salvador\u2019s suspicion that \u201cnormal\u201d was anything but has led to what researchers believe to be an epidemic of heat-related kidney disease, one that kills thousands of people each year, and one that climate change could make far more lethal. 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