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Original article
Pesticide use and risk of end-stage renal disease among licensed pesticide applicators in the Agricultural Health Study
  1. Jill F Lebov1,
  2. Lawrence S Engel1,
  3. David Richardson1,
  4. Susan L Hogan2,
  5. Jane A Hoppin3,
  6. Dale P Sandler4
  1. 1Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
  2. 2Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, USA
  3. 3Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina, USA
  4. 4Epidemiology Branch/Chronic Disease Epidemiology Group, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
  1. Correspondence to Dr Dale P Sandler, Epidemiology Branch/Chronic Disease Epidemiology Group, National Institute of Environmental Health Sciences, P.O. Box 12233, MD A3-05, 111 T.W. Alexander Drive, Research Triangle Park, NC 27709, USA; sandler{at}


Objectives Experimental studies suggest a relationship between pesticide exposure and renal impairment, but epidemiological evidence is limited. We evaluated the association between exposure to 39 specific pesticides and end-stage renal disease (ESRD) incidence in the Agricultural Health Study, a prospective cohort study of licensed pesticide applicators in Iowa and North Carolina.

Methods Via linkage to the US Renal Data System, we identified 320 ESRD cases diagnosed between enrolment (1993–1997) and December 2011 among 55 580 male licensed pesticide applicators. Participants provided information on use of pesticides via self-administered questionnaires. Lifetime pesticide use was defined as the product of duration and frequency of use and then modified by an intensity factor to account for differences in pesticide application practices. Cox proportional hazards models, adjusted for age and state, were used to estimate associations between ESRD and: (1) ordinal categories of intensity-weighted lifetime use of 39 pesticides, (2) poisoning and high-level pesticide exposures and (3) pesticide exposure resulting in a medical visit or hospitalisation.

Results Positive exposure-response trends were observed for the herbicides alachlor, atrazine, metolachlor, paraquat, and pendimethalin, and the insecticide permethrin. More than one medical visit due to pesticide use (HR=2.13; 95% CI 1.17 to 3.89) and hospitalisation due to pesticide use (HR=3.05; 95% CI 1.67 to 5.58) were significantly associated with ESRD.

Conclusions Our findings support an association between ESRD and chronic exposure to specific pesticides, and suggest pesticide exposures resulting in medical visits may increase the risk of ESRD.

Clinical trial registration NCT00352924.

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