Environmental change and kidney health

Abstract

The threat to human health from environmental change is inevitable as extreme weather events are being reported increasingly and as temperate zones are getting warmer. Besides increasing the risk of lung and heart diseases, environmental change greatly impacts kidney health. Recurrent kidney injury from dehydration in people working under unfavourable hot environments is one of the strongest links between environmental change and kidney disease. Rising temperatures have been linked with increased rates of hospitalisation for a range of kidney diseases. Climate change is also contributing to declining biodiversity around the globe with adverse impact on the geographic spread and severity of vector-borne diseases, many of which are associated with kidney injury. Certain section of the community such as women, children, the elderly, indigenous communities and people with pre-existing kidney diseases, are particularly vulnerable to the effects of environmental change on kidney health. Access to healthcare, especially dialysis, is impacted due to extreme weather events. The healthcare system, such as dialysis services contributes to about three-fourth of all carbon gas emissions in kidney services. Creating awareness among healthcare professionals about the influence of healthcare on environmental change is the first step towards tackling the effects of environmental change. We discuss a number of adaptation and mitigation activities to blunt the impact of environmental change on kidney health. Implementation of green dialysis universally is crucial towards achieving the goal of reducing adverse impact of environmental change on kidney healthcare.

Main article text

Introduction

Human health is linked to the ecosystem. Climate or environmental change, commonly referred to as Global Warming, affects at least 80% of the land mass globally. Most of the 7.7 billion people in the world are affected by environmental change and is being perceived as the biggest and most immediate existential threat modern humans have ever faced. Extreme weather events, linked to global warming, are increasingly reported worldwide and have affected at least 85% of the global population.(1)

The current global warming is anthropogenic, i.e. mostly due to human activities, hence potentially modifiable. Activities after the industrial era (about 1750s), such as construction, heating and cooling, fossil fuel use in transportation, cement manufacture, and activities related to agriculture, have caused a large increase in long-lived greenhouse gas emissions with a sharp spurt in the last few decades.(2) While all domains of human life are directly or indirectly affected by environmental change, human health is the most immediate domain threatened by it. A World Health Organization (WHO) report in 2016 showed 23% of global deaths to be attributable to modifiable environmental factors.(3) Environmental change also influences healthcare accessibility as it forces displacement of populations and increases job, food and housing insecurity. The burden is undoubtedly the highest in the lower income countries.(3) While lung and heart diseases are commonly known to be associated with environmental change, kidney health impact of environmental change is less familiar to the world, including to health professionals. Kidney disease affects about 850 million people globally. As per latest evidence, chronic kidney disease is the 12th leading cause of death globally, and projected to become the 5th most common cause of death by 2040. The process of providing care to patients with kidney disease (e.g. through dialysis) also contributes to environmental change. In this narrative review, we discuss the bidirectional link between environmental change and kidney health and explore how the healthcare community could take the initiative to combat the threat of environmental change.

What are the effects of environmental change on kidney health?

Compelling evidence continues to emerge suggesting that kidney health is affected by environmental change (4) (Figure 1). Heat stress and changing patterns of infections causing kidney damage are familiar factors arising from the changing environment. Chronic kidney disease of unknown origin (CKDu) and metabolic diseases are also being linked to environmental change.

Fig 1

 Four different consequences of environmental change causing and/or complicating kidney diseases: (i) Heat stress leading to repeated dehydration cause kidney tubule damage, and predispose to kidney stones. (ii) Changing pattern of vector-borne infections reflect expanded geographical distribution and increased frequency of outbreaks in endemic areas. Vector-borne infections such as leptospirosis, dengue fever, malaria, schistosomiasis, are known to cause kidney injury. (iii) Heavy metal toxicity from water contaminated with cadmium, arsenic, lead, mercury are known to cause kidney diseases like acute kidney injury, chronic kidney disease, and nephrotic syndrome. Water scarcity in certain areas of the world and during/after natural disasters cause disruption in hemodialysis treatment and complicate management of kidney disease. (iv) Increasing metabolic diseases like obesity and diabetes mellitus are linked to environmental change as heat stress and water scarcity alter fructose and vasopressin metabolism to store water and fat. Kidney involvement is common in the background of diabetes mellitus and obesity

Heat stress-related kidney diseases linked to environmental change are being increasingly identified globally

A rise of 0.8°C–0.9°C in global average temperature is leading to increasing frequency and severity of extreme heat events worldwide. Increasing ambient temperature has been linked to a range of kidney diseases (Figure 2). In a study conducted in South Australia which involved recording of daily temperature over warm seasons for a period of 10 years, hospital admissions for kidney diseases like AKI, CKD, kidney stones went up with increases in daily temperature.(5)

Fig 2

 Heat stress, a consequence of environmental change, is an important cause of kidney injury. Incidence of heat stress nephropathy around the world gained attention after around 1990s when Earth's annual mean temperatures started hiking up. An animal model showed development of tubular injury and tubulointerstitial nephritis in response to recurrent dehydration under hot condition, commonly being referred to as heat stress nephropathy model

Among outdoor workers of El Salvador, Guatemala, Nicaragua, and Costa Rica people with poor living conditions and occupational exposure to prolonged heat have been documented to have an increased incidence of CKD-related mortality, of the nature of an epidemic in the last two decades.(6) Fuelled by this epidemic, CKD is now the fifth commonest cause of death in El Salvador, particularly among adult males.(7) An overall CKD prevalence of 15%–21% has been described in this population. This condition has been commonly referred to as Mesoamerican Nephropathy. Indeed, a substantial proportion (>40%) of sugarcane workers in certain parts of Nicaragua, El Salvador, and Costa Rica, were noted to have high serum creatinine (>1.5 mg/dl) after 10 years of work.(8) Most affected individuals are typically asymptomatic until they reach terminal stages of kidney failure. While the exact pathogenic mechanisms have not yet been elucidated, it is believed that cyclical dehydration is the root cause of CKD among these agricultural workers. In experimental studies, mice subjected to recurrent dehydration show renal histological changes of chronic tubulointerstitial nephritis, as noted in patients with Mesoamerican nephropathy.(9,10) Recurrent dehydration activates aldose reductase in the proximal tubule which converts glucose to fructose which is further metabolized by fructokinase in the proximal tubule, causing release of oxidants.(11) Repeated acute insults lead to CKD.(12) Vasopressin has also been shown to accelerate experimental CKD.(13) Hyperuricemia, and rhabdomyolysis are other factors postulated to cause heat stress nephropathy.(14)

Heat stress is also associated with acute kidney injury (AKI) and electrolyte disorders. In a report from southern China, 44% of heat stroke patients developed AKI associated with raised muscle damage biomarker creatine kinase.(15) The California heat wave in 2006 resulted in increased hospitalisations from AKI.(16) A Brazilian study has noted a 0.9% increased risk of hospitalisation for kidney diseases with every 1⁰C rise in temperature.(17) Sugarcane workers with elevated serum creatinine from Nicaragua had non-hyaline urine casts, leukocyturia, haematuria, and proteinuria, and kidney biopsy showed acute interstitial nephritis.(18) Urinary neutrophil gelatinase-associated lipocalin (NGAL) and interleukin 18 (IL-18) were noted to increase during harvest season, likely associated with excessive heat exposure. These workers with high urinary biomarkers were also noted to have a decline in GFR of 3.1-4.6 ml/min/1.73m².(18) Elevated levels of urinary markers of AKI such as NGAL and kidney injury molecule (KIM-1), have been demonstrated among agricultural workers reporting heat stress symptoms in Sri Lanka.(19) Mild AKI has been also reported in endurance cyclists exposed to heat.(S1)

Kidney stones are precipitated in the presence of dehydration as the latter causes concentrated urine and low urine pH. A well-known association exists between high daily temperatures and prevalence of kidney stones.(20) The “stone belt”, named due to a high prevalence (10%–15%) of kidney stones, extends from Southeast America and Central America (prevalence: 12%–15%), North Africa, Middle east and South-east Asia (prevalence: 10%–15%), and Europe (prevalence: 5%–9%).(21) Prediction models indicate rising prevalence of kidney stones (up to 30% rise) with increasing global warming.(S2) Humidity impairs thermoregulation as more water is lost through skin irrespective of the temperature. In line with this, in a study from California, higher precipitation in hot climate zones has been observed to be more predictive of kidney stone formation than just a hot climate.(S3)

Extreme heat waves also indirectly influence human health through their impact on food systems. High temperatures kill heat-sensitive cereals such as wheat and rice reducing overall crop yields, leading to malnutrition. This acts as a threat multiplier to worsening morbidities in those with pre-existing kidney disease. Drying up of wells can increase the concentration of heavy metals and/or toxins in drinking water. The combination of heat exhaustion and intake of pain medications pushes vulnerable patients towards kidney disease. Water scarcity compromises hemodialysis capacity of healthcare systems increasing morbidity and mortality of kidney patients.(4)

Biodiversity loss is linked to environmental change

Biodiversity reflects the variety of biological species in a given area. Global warming has caused a shift of many species of terrestrial organisms to higher latitudes (which were cooler earlier) as a warm environment is favourable for vectors, parasites, and reservoir hosts. This has led to an increased incidence of endemic infections in previously cold temperate zones that were hitherto free from such infections.(S4) Biodiversity loss has been linked to the emergence of new vector-borne diseases and infections (e.g. COVID-19).(22)

Infections are an important cause of kidney diseases in tropical regions. The relationship between infections and acute kidney injury (AKI) is firmly established, but their association with chronic kidney disease is less explored. Acute malarial nephropathy is a complication of falciparum malarial infection, while leptospirosis causes kidney injury in up to 40%–60% of cases. Dengue hemorrhagic fever is complicated by AKI in up to 5% cases.(S5) Many of these infections are expanding their geographic footprint, with populations living in colder temperate areas also becoming vulnerable. Enlargement of geographic areas affected by malaria and dengue is evident by the rising incidence of malarial disease in temperate zones (23,S6,S7) and increased frequency of dengue outbreaks.(S7). Westward movement of migratory birds due to environmental change has been linked to emergence of West Nile Virus encephalitis in the western North America.(S8) Flooding and heavy rain falls have been associated with outbreaks of leptospirosis in parts of Southeast Asia.(S9,S10) Growing urbanization and urban heat-island effect have been reported to increase leptospirosis outbreaks in endemic regions of South and Southeast Asia and predicted to cause leptospirosis outbreaks in cities of developed countries like Japan, and the USA.(24) Diarrheal illnesses increase the risk of AKI, especially in children, and often occur due to lack of clean water supply, which is being threatened by environmental change. Environmental change is affecting schistosomiasis transmission in sub-Saharan Africa as global temperature rises above critical thermal maximum for freshwater snails, the intermediate hosts for Schistosoma species.(25)

Extreme environmental events linked to environmental change reduce access to healthcare for those with kidney diseases

Extreme environmental events and natural disasters, besides increasing the risk of AKI, also lead to population displacement, transport disruptions and damage to essential infrastructure and medical equipment. This reduces access to healthcare, and can have dire consequence for patients on dialysis. People who are already disadvantaged (the poor, the elderly, children, those without health insurance) are the worst affected. Issues with healthcare accessibility lasted for a year after the 2011 Tsunami in Japan.(26) Disaster induced sympathetic activation is known to induce hypertension among survivors. Long-term follow-up of survivors of the 2011 Japan earthquake and tsunami showed increased incident CKD rates in evacuees (100.2/1000 person-years) as compared to non-evacuees (80.8/1000 person-years) living in the same area.(S11) Evacuation causing disaster induced stress was hypothesized to be a risk factor for CKD in the evacuees.

Chronic Kidney Disease of unknown origin is linked to environmental change

Over the last quarter century, an endemic type of kidney disease has been increasingly identified in young male outdoor workers in certain geographic areas. Akin to chronic interstitial nephritis in presentation, this condition has been dubbed chronic kidney disease of unknown aetiology (CKDu). Initially described from the central American countries of Nicaragua, El Salvador, Costa Rica, this was dubbed Mesoamerican Nephropathy. Clusters have been reported from other parts of the world such as Sri Lanka, India, Egypt, Tunisian and Brazil.(S12) This condition is characterized by distinct clinicopathological characteristics. The Central American reports highlight the predominance of young males who work in extreme heat in the agriculture sector, such as sugarcane fields (Figure 3). Other reports have proposed roles for environmental toxins, including heavy metals (cadmium, silica, lead, uranium, arsenic, mercury, lithium) (S13) and pesticides (2-4-dichlorophenoxyacetic acid, carbofuran, dicrotophos, glyphosate).(S14) Mine workers from the Jinzu river basin in Toyama, Japan were the first to be recognized as suffering from cadmium nephropathy, locally named “Itai-Itai” disease; the probable source of exposure was polluted water and rice paddies.(S13) Mesoamerican nephropathy has emerged as a leading cause of CKD in low-altitude coastal areas of Nicaragua and El Salvador, with additional foci in Costa Rica and Guatemala. In addition to sugarcane cutters, port workers, miners, and cotton and construction workers have also been affected. The potential risk factors reported from Sri Lanka include field work >6 hours a day, self-reported heat exposure, low consumption of water per day and drinking from shallow wells, and a history of malaria.(S15,S16)

Fig 3

 Chronic kidney disease of unknown origin (CKDu)- risk factors and proposed mechanisms of kidney injury. CKDu patient population across the globe has common and risk factors for kidney injury such as prolonged intense labor under hot conditions, environmental toxins from occupational exposure and unsafe drinking water, and poor living conditions. A multitude of mechanisms, mostly mediated via tubular injury, are proposed to cause CKDu, shown in the right end of the figure

The linkage between anthropogenic air pollution and kidney diseases

Air pollution is now firmly established as a risk factor for a range of non-communicable diseases.(S17) According to the Global Burden of Disease Study 2015, 4.2% of all global DALYs were attributable to air pollution.(S18) An association between the ambient PM_2.5 concentration (indicative of presence of particulate matter <2.5 µM in diameter) and CKD has been shown in epidemiological studies from USA and China.(S19,27) Long-term exposure to PM_2.5 has also been shown to be associated with the rising prevalence of membranous nephropathy.(S20) While these epidemiological studies suggest a possible link, more studies are needed to establish causality and explore mechanistic pathways. Such information will help find ways to adapt to environmental pollution until large scale mitigation strategies tackle air pollution.

Metabolic diseases predisposing to kidney diseases are linked to environmental change

Rapid, often unplanned urbanization has limited the space available for outdoor physical activities and reliance on automobiles. Changing food habits, e.g. increasing consumption of packaged and frozen calorie-dense preserved foods, increase the risk of metabolic diseases. These are further perpetuated by the food industry influencing behaviour change through advertisements in mass media and through influencers like sportspersons and movie stars. Data from many parts of the world show lack of food diversity such as reduced intake of fruit and vegetables and heavy reliance on cereals and sugar-sweetened beverages, all of which contribute to increased risk of cardio-metabolic diseases.(S21) Emerging reports highlight the salutary effects of plant-based diets on CKD.(S22) Diabetes mellitus and obesity are widely prevalent metabolic diseases associated with kidney diseases and have a theoretical link to environmental change as proposed by Johnson and his colleagues (S23) using a comparative physiology approach evaluating the relation between water shortage and metabolic profile in the past and the present.

Who are the most vulnerable to adverse kidney health effects of environmental change?

Indigenous communities, children (especially less than <4 years of age), women, elderly (especially >60 years), people living in areas prone to extremes of climate, those engaged in work that requires exposure to extreme heat and reduced access to hydration such as agricultural and construction workers, and economically disadvantaged regions are most vulnerable to environmental change.(S24) The least developed countries, especially in the tropics, are likely to bear the major negative impacts of environmental change as they depend heavily on natural resources (agriculture, fisheries) for livelihoods and have limited economic resources to respond to calamities. Environmental change affects women more than men compounding the issue of gender inequality. Identifying vulnerable groups and providing solutions is crucial to mitigate threats from environmental change.

Care delivery to patients with kidney disease contributes to environmental change

Amongst the various human activities that contribute to the emission of greenhouse gases, healthcare sector is an important one. The amount of greenhouse house gases comprised of carbon dioxide and other carbon compounds emitted due to the consumption of fossil fuels by a particular unit is called the carbon footprint. The healthcare sector contributes to about 3%–10% of the global carbon footprint and therefore, contributes to global warming.(S25) The variations in the carbon footprint of healthcare on the national greenhouse gas emissions depends on the country, the mix of the services and specialties and the intensity of technological use. The main contributors to the carbon footprint include the building, consumption of electricity/natural gas, and travel. Overall, developed nations have higher per capita healthcare emissions than most developing countries.

Renal services carry a substantial footprint, mainly related to dialysis services.(S26) According to one study in 2010, a renal service in the UK had a carbon footprint of 3006 tonnes carbon dioxide equivalents (CO2 Eq) per annum, with dialysis services contributing 62.5% of all carbon gas emissions.(28) Data from developed countries like Australia, United Kingdom and France have shown carbon emissions to be ~3.8-ton CO2 Eq/year to 10.2-ton CO2 Eq/year from haemodialysis (HD) services, more than most other healthcare sectors. Indeed, water and electricity energy consumption are much higher with HD on a recurrent per capita basis than any other healthcare service.(S26,S27) In a French study on HD sustainability, power consumption was ~20 kilowatt per HD session.(29) Although lesser than HD, peritoneal dialysis is also associated with significant carbon emissions, owing largely to the use of plastics and transportation of fluids.

Each session of HD requires ~500 litres (L) of high-quality water for dialysate production, priming and rinsing of the HD circuit. The reverse osmosis system used for water treatment in HD typically rejects two-thirds of the supply water, which goes to waste. For example, a typical patient receiving twice-a-week HD will consume about 52,000 L of water annually. Cumulatively, the 150,000 patient currently on dialysis in India (30) will consume about 7.8 billion L of water every year. Extreme weather events and water scarcity are wake-up calls to rapidly implement ways to make dialysis services more sustainable and environment-friendly. Frequent occurrence of extreme weather events also interrupt dialysis services.(S28) With the prediction that water scarcity is likely to affect more than two-thirds of the world population by 2050, it is imperative to combat healthcare-related water wastage. Dialysis is associated with a vast amount of waste generation, mostly from procedures involving vascular access. Waste segregation can help in reducing carbon emission associated with waste treatment and identify recyclable products.

How can kidney healthcare professionals help combat this threat?

The system level response to environment change can be divided into two categories: mitigation and adaptation. Mitigation refers to efforts to reduce or prevent emission of greenhouse gases (by using new technologies, renewable energy sources, changing human behaviour or making system-level changes in the way we live and conduct business) while adaptation involves taking actions that will reduce the impact of environment change on human health. Some actions can provide dual benefits by reducing greenhouse gas emissions and reducing impact on health. For example, going “retro” by using bicycles and walking, instead of using motorised transport, reduces emission and also reduces kidney disease risk through increased physical activity. Similarly, reducing consumption of processed food and meat-based diet and promoting dietary diversity by increasing the intake of locally grown food items including fruits and vegetables helps decrease carbon emission while at the same time cutting down on risk of non-communicable diseases. Other actions with similar dual benefit include using rural ways of air cooling and retrofitting of a storage tank to water treatment systems for reverse osmosis of reject water.

Public awareness is crucial to combat the threat of environmental change as the impact of one's action is on the whole of the human race. Along with other professionals, healthcare workers need to understand the urgency of the consequences of environmental change and encourage change in behaviour associated with healthcare delivery. These include improved understanding of the carbon footprint of daily activities such as printing papers, computer use, education, patient care, etc. Environmental change and its link with health should be incorporated in training of all healthcare professionals. All healthcare facilities should strive to adopt environment-friendly policies including investing in eco-friendly infrastructure such as solar panel powered hospital units, creation of green corridors, environmental-friendly instruments and replacing paper products with effective electronic record systems. For kidney care professionals, changing the methods of kidney care delivery to make it more sustainable is the way to go.(S26) Sustainable practices are economically beneficial too.

Together, the implementation of such initiatives is the first step towards achieving the goal of reducing the adverse impact of kidney healthcare on the environment. The attributes of ‘green dialysis’ have been enunciated by several groups, almost exclusively from developing countries.(28,29,S26,S27) There has been little or no awareness of this urgency in developing countries where dialysis is growing rapidly and there is an opportunity to incorporate these attributes right at the beginning. This way the kidney health community can contribute to mitigation strategies, making it a truly sustainable service. Ecological performance indicators of dialysis such as energy consumption, carbon footprint, amount and type of waste generation, and water consumption should be used to monitor dialysis treatment.(29) The carbon footprint should be tracked on an ongoing basis using a validated tool such as the one developed by the Agha Khan University (https://www.aku.edu/news/Pages/NewsDetails.aspx?nid=NEWS-002741).

Finally, we would like to emphasize that the best way kidney health professionals can reduce the carbon impact of kidney diseases is by preventing the need for carbon-intensive hospital care including dialysis by early identification and prevention of progressive kidney disease. We also strongly promote integrated care delivery targeting common risk factors rather than kidney health activities as an independent vertical. To the extent possible, these activities should be conducted close to where the subject lives, ideally at home, as enunciated in the WHO model of primary healthcare delivery. In addition to reducing carbon footprint of hospital services, the best way nephrologists can mitigate environmental change is by promoting prevention of kidney disease. These include education regarding adequate hydration in warm climates, reduced use of painkillers, reduced pesticide use, and early screening of communities at risk of CKD due to climate change, all of which will ultimately reduce the need for hospital care thereby reducing the environment costs.

Encouraging research on the effects of environmental change on kidney health is important for data generation and planning focussed actions. Innovations focussing on energy-efficient dialysis machines and waste water use need to be prioritised. Research on the feasibility of converting single-use consumables to reusable ones are needed. Research on ecological performance indicators of dialysis such as energy consumption, carbon footprint, amount and type of waste generation, and water consumption are already being implemented in centers in Australia, UK, Netherlands and France.(28,29) One promising initiative is the Affordable Dialysis Machine being developed in response to a prize instituted by the George Institute for Global health and the International Society of Nephrology. It promises to drastically reduce the need for water and the reliance on expensive hospital-based services. Investments by local and national governments in the fight against environmental change is the need of the hour. The Climate Change Health Protection and Promotion Act in the US is an example. It is established to support healthcare professionals to respond to environmental change appropriately. More countries, have committed to bring national and international reforms towards “net-zero” emissions in coming decades.(S29) Developed countries supporting developing countries in tackling consequences of environmental change need to be escalated. Professional societies including national and international nephrology societies should collaborate with government bodies to improve awareness, research and funding to widely implement eco-friendly practices.

Conclusions

Environmental change is an existential threat to human race which needs to be addressed urgently. Kidney health is frequently affected by changing environmental patterns. In turn, kidney health care, such as dialysis, contributes to emission of toxic greenhouse gases. Disparity (between the poor and rich; men and women; youth and elderly), and vulnerability (of the diseased population) are only going to increase if environmental change is not addressed immediately. Healthcare professionals, governments, policy makers can and should clearly champion this fight against environmental change.

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