A Global but Underrecognized Problem

In the past two decades, younger adults without any of the usual risk factors have begun suffering irreversible kidney damage. In the U.S., kidney disease typically disproportionately affects poor communities in urban areas. However, this “chronic kidney disease of unknown origin,” or CKDu, is most common in hot, low-lying agricultural regions across the world. It primarily impacts young and middle-aged males whose livelihoods involve strenuous agricultural and manual labor.

The progressive disease is often not diagnosed until the patient has reached the final stage – at which point their kidneys are so damaged, they require costly, time-consuming dialysis or a kidney transplant for survival. 

In recent years, analyses from the U.S. Renal Data System have revealed unusually high rates of end-stage kidney disease in Central California. While this region and Sri Lanka are separated by nearly 9,000 miles, they share similar geographic features and high temperatures. 

Two Hot Spots, Two Approaches

In Sri Lanka, Anand and community researchers have been following healthy people over time to identify risk factors and exposures in those who eventually fall ill. Anand is also helping communities build their local capacity for research, including blood testing, gathering environmental samples, and testing interventions, such as filtering drinking water for potential contaminants. This work has been supported by the Stanford Center for Innovation in Global Health through Global Health Seed Grants, an NIH/Fogarty Global Health Equity Scholarship, and mentorship from Michele Barry, MD, the center’s director. 

A team of faculty at Stanford are collaborating to tackle the disease locally and in Sri Lanka, including Vivek Bhalla, MD, associate professor of nephrology; Kurella Tamura, MD, professor of nephrology; Neeraja Kambham, MD, professor of pathology; Andrew Fire, PhD, professor of pathology and genetics; and Maria Montez-Rath, PhD, senior research engineer.

Yet Central California requires a different approach, since those most impacted – farmworkers – move frequently, are hard to reach, may not trust the healthcare system, and usually aren’t aware of the illness. Anand and Contreras realized they needed to start with patients in the end stage of the disease and work backward to fully understand the relationship between a patient’s work, environmental exposure, residential history, and CKDu. The Stanford Woods Institute for the Environment has funded recent work in the Central Valley through an Environmental Venture Project grant.

“The base for this project is gathering information from patients and understanding their stories,” Contreras says. They’ve established strong relationships with local nephrologists serving patients in Central California, including Krishna, and begun interviewing dialysis patients. They’ve also collaborated with Clovis Community College, near Fresno, to identify young, bilingual research assistants from the community to interview patients.

Research Assistant Esteban Banda remembers the first time he entered a quiet Salinas dialysis clinic in the early morning, hesitant to disturb the sleeping patients’ rest and unsure whether they’d want to talk with him. Yet he was quickly surprised by how eager they were to discuss their lives and contribute information.

A Model for Future Educational Collaboration

A third participating Stanford resident, Nick Zehner, MD, MS, sees this collaboration as a scalable model for global education. “It takes advantage of technology that wasn’t as widespread before the pandemic, so we are on the cutting edge of a new way to transfer knowledge and education,” he says. He hopes this program can help in the development of best practices to replicate it all over the globe.

He also appreciates its nonpaternalistic approach. “One of the liabilities of global health is this colonial legacy of the haves giving to the have-nots,” he says. “But we probably get as much out of these sessions as the students. It takes so much dedication for the Ethiopian students to reach the point of becoming medical students. These students are on top of things. … I think that makes us better educators.”

Renault is effusive in her praise of the residents working with her. “It’s incredible to see how the rewards of this initiative have prompted our residents to reflect on what they ultimately want to do and the impact they could have in their careers,” she says.

In return, Renault’s Stanford residents cannot say enough good things about her leadership or the NAGHMC initiative. In July of 2024, Renault returned to Ethiopia to advance the initiative by meeting with the leadership and the students, familiarizing herself with the curriculum, and teaching in-person classes in infectious diseases for medical students and NAGHMC faculty.