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In reply to: “Should we consider renaming ‘Mesoamerican Nephropathy’ as Nephropathy of Unknown Cause in Agricultural Labourers (NUCAL)?”
  1. Ramón García-Trabanino1,2,
  2. Kristina Jakobsson3,
  3. Carolina Guzmán Quilo4,
  4. Daniel R Brooks5,
  5. Jennifer Crowe6,
  6. Joaquín Barnoya7,8,
  7. Magdalena Madero9,
  8. Marvin González Quiroz10,11,
  9. Catharina Wesseling12,
  10. David H Wegman13,
  11. Ricardo Correa-Rotter14
  1. 1 Centro de Hemodiálisis, San Salvador, El Salvador
  2. 2 Emergency Social Fund for Health of Tierra Blanca, Tierra Blanca, El Salvador
  3. 3 Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
  4. 4 Faculty of Chemistry and Pharmacy, Universidad de San Carlos, Guatemala, Guatemala
  5. 5 Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
  6. 6 Regional Institute for Studies on Toxic Substances (IRET), Program on Health, Work and Environment (SALTRA), Universidad Nacional, Heredia, Costa Rica
  7. 7 Research Department, Cardiovascular Surgery Unit, Guatemala, Guatemala
  8. 8 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
  9. 9 Division of Nephrology, Department of Medicine, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico city, Mexico
  10. 10 Research Center on Health, Work and Environment (CISTA), National Autonomous University of Nicaragua at León (UNAN-León), León, Nicaragua
  11. 11 Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  12. 12 Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
  13. 13 Department of Work Environment, University of Massachusetts Lowell, Lowell, Massachusetts, USA
  14. 14 Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico city, Mexico
  1. Correspondence to Dr Ramón García-Trabanino, Calle Gabriela Mistral 211, 1101, San Salvador, El Salvador; rgt{at}

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We, from the Consortium on the Epidemic of Nephropathy in Central America and Mexico (CENCAM), read with interest Drs Subramanian and Javaid's letter,1 regarding Mesoamerican Nephropathy (MeN), a name assigned to a type of chronic kidney disease (CKD) not related to classic risk factors and also referred to as CKD of unknown (CKDu) or non-traditional causes. MeN is highly prevalent in Central America and a major health problem.2

We agree with the authors that it is important to focus attention on the occupational component of this disease, and therefore on its preventable nature. Nevertheless, we consider it premature and inappropriate to rename MeN and other regional nephropathies as Nephropathy of Unknown Cause in Agricultural Labourers (NUCAL). First, this would imply that there is enough evidence to confirm that what is being described in Mesoamerica and other CKDu epidemics in developing nations (ie, Sri Lanka, India, Egypt) are manifestations of a single worldwide or multiregional disease. Moreover, the demographics reported in Mesoamerica and Sri Lanka are different. As an example, MeN is not limited to agricultural labourers only,3 ,4 as the proposed name implies. In addition, histopathology in kidney biopsies from Mesoamerica and Sri Lanka, while having important similarities, suggest a predominantly tubulointerstitial type of disease with glomerulosclerosis, a non-specific histological pattern that does not provide at present significant information in relation to causality or prove a single entity.5

We believe that population-based, epidemiological, clinical and histopathology studies comparing between regions are urgently needed. While the exact pathogenesis of MeN is still uncertain and could be multifactorial, there is increasing evidence that strenuous occupational physical activity in hot environments without appropriate rest and rehydration may be playing an important role.6

Beyond any name discussion, we join the authors' plea for global awareness, and emphasise the urge for international action against this epidemic. There is limited access to proper renal replacement therapy in most of the affected nations. Progression to end stage renal disease is common among those suffering from MeN, and mortality is high.3 Endemic pockets of CKDu have become a true humanitarian crisis. Collaboration globally among researchers, clinicians and other stakeholders will surely advance understanding. Funding and support for studies wherever CKDu is endemic is needed now, to clarify the disease's aetiology, in order to enable evidence-based prevention, and to combat its toll.2


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  • Contributors RG-T conceived and proposed the first draft. RC-R, KJ, CW and DHW improved the letter. CGQ, DRB, JC, JB, MM and MGQ contributed relevant input to the final text. All authors have read and approved the submitted response letter.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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