Oliver Ileperuma,1 Stanley Weeraratne,2 Sunil J Wimalawansa

We read with interest the article titled above on the chronic kidney disease (CKD).1 We agree with authors’ conclu-sions that the available data and the mortality pattern presented suggest addi-tional factors beyond those hypothe-sised, including heat stress–dehydration as possible causation of chronic kidney disease of unknown aetiology (CKDu).2

Almost all data to date point towards (1) multifactorial aetiology of CKDu that encompasses broader environmental and occupational components3 and (2) water as the vehicle for disseminating this disease. However, more research is needed before making conclusions on what causes this deadly disease that affect those who live in economically poor, tropical countries. However, we disagree with the researchers’ conclusion that the CKDu is confined to agricultural communities.

The use of unproven and unvalidated termi-nology, ‘Chronic Interstitial Nephritis of Agricultural Communities’ (CINAC), will also misdirect funding organisations and mislead the public and scientific commu-nity.

These will have a detrimental effect on the focus of the research, thus, finding cause(s) and solutions to eliminate it. In addition, ‘CINAC’ does not necessarily mean ‘Chronic Interstitial Nephritis of Agricultural Communities’.

There are multiple utilities and definitions of CINAC that have been used going back many years (eg, internet), none of which are related to CKD. Examples include but not limited to
https://www. edge. org/ response- detail/ 11257;
https:// acronyms. thefreed-ictionary. com/ CINAC;
http:// noisesociety. com/ nicklaslundblad. se/? p= 888.

Several research teams have pointed out before, the inappropriateness of the term CINAC,4–6 which is neither a proven nor an appropriate term for CKDu. While the proposed name indirectly implies that CKDu is caused by agrochemicals, this is not the case.2 7

There are no cred-ible scientific data worldwide that CKDu is caused by agrochemicals. Moreover, CKDu has affected a significant number of people who do not live in agricultural communities or have worked in agricul-ture or ever exposed to agrochemicals. In fact, in some regions, CKDu is present predominantly in non-agricultural areas which contradicts the use of CINAC, a false terminology.

Moreover, approximately a third of CKD conditions affecting those who live in agricultural communities have other forms of CKDu (eg, secondary to diabetes, hypertension, snake bites and so on). While many of the affected people may live in agricultural communities or work in agribusiness, it does not even exceed 75% of the affected, in many communities.8 Therefore, labelling CKDu as a disease of ‘agricultural community’ or ‘agrochemical nephropathy’ is clearly misleading and levy unwarranted stigma on those poor communities who are already suffering.

While there could be an association between the CKDu in those who live in agricultural communities, there is no scientific evidence that engagement in agriculture causes CKDu.

Many scien-tists and analysts have pointed out that, ‘correlations or associations, are not causation’. We agree with the authors that there are many commonalities of CKDu affecting countries, particularly those located in periequatorial regions,7 including Meso-american Nephropathy (MeN; CKDu).

Similarities and differences between MeN and CKDu have been reported previously.8 CINAC, if used, fails to capture thousands of people who suffer from CKDu but do not live in agricultural communities or do not engage in agriculture; thus, it is erro-neous and an injustice to them. This is also applicable to Sri Lanka and other affected tropical countries, where many persons with CKDu (a lesser degree than in MeN) do not engage in agricultural practices or even live in agricultural areas.8 10

In addition, the term CINAC does neither explain the disease or its pathology11 nor the cause.4–8 The use of it introduces a misleading concept to the public and the legislators. In fact, such false propaganda has led to making wrongful policies, as in the case of banning of glyphosate in Sri Lanka in absence of valid, reproducible scientific data.3 7 8 In the case of Sri Lanka, the harm is already done and continuing.

This inappropriate ban of glyphosate imposed in 2016 has no effect at all in reducing the incidence of CKDu. Instead, it has negatively affected the income and the livelihood of thousands of farmers in various agricultural sectors (conse-quently, increased the suicidal rate) and owners of small-scale tea estates across the country. Each year since this short-sighted banning, the country is losing more than 18 billion rupees and the loss is escalating.12 This is a classic example of imposing a politically motivated policy, causing major negative economic consequences in a country.

Evidence suggests that CKDu is caused by multiple factors with the consump-tion of water serving as the carrier; these factors are common to all CKDu affected countries. Based on the data available to date, a more accurate terminology for both research concepts and for practical purposes is ‘CKD of multifactorial origin’ (CKDmfo).3 7 8 Such multiple factors that are contributing to the genesis of CKDu include poverty and micronutrient-mal-nutrition, environmental pollution, geogenic factors, unhealthy behaviour and others3 7 8 (https://www. youtube. com/ watch? v= xMn0-_ xS6JA& t= 1s).

Therefore, we assert that for the benefit of research and the dignity of those who suffer from CKDu, and the economy of the country, the misleading term CINAC or analogue terms should not be used. It will do further harm by delaying identification of real cause(s) of CKDu and adopting and implementing effective preventa-tive measures, thereby prolonging the suffering of the affected and their families. To date, there is no convincing scientific data to support that CKDu is caused by agrochemicals or it is confined to agri-cultural workers. Attempts to change the current, globally accepted term CKDu with inappropriate terms such as CINAC, ACN, KDUCAL or NUCAL and so on4–6 is erroneous and misleading.

Oliver Ileperuma, University of Peradeniya, Peradeniya, Sri Lanka 1 Stanley Weeraratne Soils and water resources, University of Rajarata, Anuradhapura, Sri Lanka ,2 Sunil J Wimalawansa Chemistry, 23Medicine, North Brunswick, New Jersey, USA

Correspondence to Professor Oliver Ileperuma, Chemistry, University of Peradeniya, Peradeniya, Sri Lanka; oliveri@pdn.ac.lk

Contributors All three authors contributed equally tothe Letter to the Editor.Competing interests None declared.Patient consent Not required.Provenance and peer review internally peer reviewed.© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.To cite: IleperumaO, WeeraratneS, WimalawansaSJ.J. Epidemiol Community Health 2018;72:967–968.Received 29 April 2018PostScript on 11 September 2018 by guest. Protected by copyright.http://jech.bmj.com/J Epidemiol Community Health: first published as 10.1136/jech-2018-210959 on 17 July 2018.