Chronic Kidney Disease of Unknown Origin: interdisciplinary approaches to understanding a complex medical phenomenon

Over the past twenty years, across Low and Middle Income Countries (LMICs), there has been an unexplained increase and change in the causes of Chronic Kidney Disease (CKD). This new type of CKD is known as Chronic Kidney Disease of Unknown Origin (CKDu), today described as a new epidemic for countries in the global south, adding substantially to the burden of CKD globally. In Mexico, the focus of this application, the problem is critical given the high prevalence of CKD and inequalities in access to appropriate healthcare. CKDu is particularly problematic because it cannot be understood in conventional causal terms, meaning it is not an outcome of diabetes or hypertension, but is, instead, linked to social, cultural and environmental concerns. CKDu predominantly affects the young, is linked to informal work (e.g. the agri-industries and mining), as well as long term environmental harm and degradation.

Despite increasing concern, it is difficult to establish the percentage of CKD deaths that can actually be classified as CKDu due to the complex conditions it emerges from. In the absence of single causes or established risk factors, explanations have been driven by community, labour and environmental activists in addition to small groups of epidemiologists, public health researchers and toxicologists engaged in exploratory research. Our partnership team has, in addition, two current independent pilot projects, conducted by University of Guadalajara (CI Lozano) and the University of Liverpool (PI Kierans). These projects are documenting a multidimensional picture of CKDu emergence, focusing on the links between the structural conditions of poverty, political economy, environment and the everyday lives of poor communities in the state of Jalisco, focusing on the community of Poncitlán on the shores of lake Chapala. Lozano is identifying the multiple risk factors and social determinants of renal damage, while Kierans takes an anthropological approach mapping the cultural production of clinical and scientific knowledge on CKDu and documenting the cultural and social practices associated with its emergence.

CKDu is, therefore, a complex problem, an outcome of geographical, geological, historical, political, economic, social and biological processes. Establishing a collaborative, genuinely interdisciplinary partnership is critical for developing ways of understanding this condition and the responses needed for those living in poor and degraded environments. Existing research largely stems from clinical and scientific perspectives and priorities. Substantive contributions from the Arts and Humanities and Social Sciences are lacking, particularly those offering historically situated and culturally contextualised insights into the changing interrelationships between poverty work, health and environment. Taking a unique interdisciplinary approach, this partnership will make valuable contributions. It will integrate and expand our existing projects to include two further pilots: (1) a local community history pilot to document the changing experiences, explanations and challenges associated with CKD over time; (2) an environmental history project, to document land use and environmental relations over-time. By working in partnership, we will create dialogue, foster innovative methodological approaches and comprehensive understandings of CKDu. We will produce a research protocol for the study of CKDu to be applied within and beyond Mexico. We will work with a wide range of beneficiaries at community, state, federal and international to advance knowledge sharing, the co-production of health, welfare and environmental policies as well as strategies for intervention for the health and wellbeing needs of affected communities.

Working with community groups, healthcare professionals, government agencies and policy makers will help to develop and improve communication, knowledge translation and transfer with users/beneficiaries identifying solutions to the alleviation of sickness and harm and enabling more effective strategies to be developed at community, municipal and state level. By building a comprehensive understanding of the conditions through which CKDu emerges, this will, in turn, have an impact on poverty alleviation and development goals in the longer term.
Organisations that will benefit from the impact of this project include: Local Communities and Environmental Organisations: e.g. Foro Socio-Ambiental Guadalajara, Instituto de Derecho Ambiental, Comunidad Indigena Coca de Mexcala, the Communities of Agua Caliente, San Pedro Itizicán, Chalpicote, La Zapotera, Mezcala; Healthcare Providers: e.g. Hospitales Civiles de Guadalajara; State Level Policy Makers: e.g. Secretaria de Desarrollo e Integración Social de Jalisco, Secretaria de Medio Ambiente y Desarrollo Territorial de Jalisco Federal Level Policy Makers: e.g. Ministry of Health; International Advocates and Researchers: e.g. La Isla Foundation (Nicaragua) Consortium for the Epidemic of Nephropathy in Central America and Mexico (CENCAM). The partnership team has direct links to all of these organisations and more besides.
At the beginning of this partnership, we shall establish contact with all beneficiary organisations and introduce our strategy and ethos. Those that wish to attend our public engagement meetings will be invited to do so by CI Padilla at the start of the project. We will build up a database of contacts for the whole project group which will be a useful resource for both academics and non-academic participants. One of the outputs of our public engagement meetings will be a more developed strategy for the dissemination of our activities. This project is foundational aiming to establish a collaborative network in addition to generating a body of knowledge focused on the situated local conditions of CKD emergence. We intend that the knowledge produced through the project's four inter-connected pilots will provide a rich resource that will support a range of users: from local communities to healthcare professionals to policy makers and international global health researchers.
The specific impact this work will have includes: (1) the provision of comprehensive and contextualised knowledge/data; (2) a stronger scientific basis to understand the conditions of disease emergence and to develop co-working strategies for local change, e.g. through the generation of public policy on clean water; (3) the preservation of local knowledge and its integration in the development of public policy; (4) awareness raising and health promotion in relation to the health effects associated with environmental damage and working conditions; (5) data sharing to aid prevention, timely diagnosis and facilitate and target healthcare interventions at community level; (6) the promotion of access to appropriate healthcare; (7) contributions to social development programmes and co-production of targeted social and environmental policy; (8) the establishment of benchmarks to identify communities at risk of CKD and screening associated needs; (9) the creation of a formal research protocol to aid joined-up Global Health research and strategies for solution-building.