Valcke Mathieu, Levasseur Marie-Eve, Soares da Silva Agnes, Wesseling Catharina
WHO-PAHO Collaborating Centre on Environmental and Occupational Health Impact Assessment and Surveillance INSPQ-CHUQ-DSPQ, 945, Avenue Wolfe, Québec, G1V 5B3, Canada.
Department of Environmental and Occupational Health, School of Public Health, Université de Montréal, C.P. 6128 Succursale Centre-Ville, Montreal, H3C 3J7, Canada.
Environ Health. 2017 May 23;16(1):49. doi: 10.1186/s12940-017-0254-0.
The main causes of chronic kidney disease (CKD) globally are diabetes and hypertension but epidemics of chronic kidney disease of unknown etiology (CKDu) occur in Central America, Sri Lanka, India and beyond. Althoug also being observed in women, CKDu concentrates among men in agricultural sectors. Therefore, suspicions fell initially on pesticide exposure, but currently chronic heat stress and dehydration are considered key etiologic factors. Responding to persistent community and scientific concerns about the role of pesticides, we performed a systematic review of epidemiologic studies that addressed associations between any indicator of pesticide exposure and any outcome measure of CKD. Of the 21 analytical studies we identified, seven were categorized as with low, ten with medium and four with relatively high explanation value. Thirteen (62%) studies reported one or more positive associations, but four had a low explanation value and three presented equivocal results. The main limitations of both positive and negative studies were unspecific and unquantified exposure measurement ('pesticides'), the cross-sectional nature of most studies, confounding and selection bias. The four studies with stronger designs and better exposure assessment (from Sri Lanka, India and USA) all showed exposure-responses or clear associations, but for different pesticides in each study, and three of these studies were conducted in areas without CKDu epidemics. No study investigated interactions between pesticides and other concommittant exposures in agricultural occupations, in particular heat stress and dehydration. In conclusion, existing studies provide scarce evidence for an association between pesticides and regional CKDu epidemics but, given the poor pesticide exposure assessment in the majority, a role of nephrotoxic agrochemicals cannot be conclusively discarded. Future research should procure assessment of lifetime exposures to relevant specific pesticides and enough power to look into interactions with other major risk factors, in particular heat stress.
全球慢性肾脏病（CKD）的主要病因是糖尿病和高血压，但中美洲、斯里兰卡、印度及其他地区出现了病因不明的慢性肾脏病（CKDu）流行情况。虽然在女性中也观察到CKDu，但CKDu在农业部门的男性中更为集中。因此，最初怀疑是接触农药所致，但目前慢性热应激和脱水被认为是关键病因。为回应社区和科学界对农药作用的持续关注，我们对流行病学研究进行了系统综述，这些研究探讨了农药接触的任何指标与CKD的任何结局指标之间的关联。在我们确定的21项分析研究中，7项被归类为解释价值低，10项为中等，4项为解释价值相对较高。13项（62%）研究报告了一个或多个阳性关联，但4项解释价值低，3项结果不明确。阳性和阴性研究的主要局限性在于接触测量不具体且未量化（“农药”）、大多数研究的横断面性质、混杂因素和选择偏倚。设计更强、接触评估更好的4项研究（来自斯里兰卡、印度和美国）均显示了接触反应或明确关联，但每项研究针对的是不同农药，其中3项研究是在没有CKDu流行的地区进行的。没有研究调查农药与农业职业中其他伴随接触因素之间的相互作用，特别是热应激和脱水。总之，现有研究几乎没有提供农药与地区性CKDu流行之间存在关联的证据，但鉴于大多数研究中农药接触评估不佳，不能完全排除肾毒性农用化学品的作用。未来的研究应进行终生接触相关特定农药的评估，并具备足够的效力来研究与其他主要风险因素的相互作用，特别是热应激。
