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

在过去的二十年中，在低收入和中等收入国家（LMICs）中，慢性肾脏疾病（CKD）的病因出现了不明原因的增加和变化。这种新型的CKD被称为未知来源的慢性肾脏疾病（CKDu），今天被描述为全球南方国家的一种新的流行病，大大增加了全球CKD的负担。在墨西哥，这一应用的重点是，鉴于慢性肾病的高患病率和获得适当医疗保健的不平等，这个问题至关重要。CKDu的问题特别大，因为它不能用传统的因果关系来理解，这意味着它不是糖尿病或高血压的结果，而是与社会、文化和环境问题有关。CKDu主要影响年轻人，与非正式工作（如农业和采矿业）以及长期的环境危害和退化有关。尽管越来越多的人关注，但由于CKD产生的复杂情况，很难确定CKD死亡中实际可归类为CKDu的百分比。在没有单一原因或确定的风险因素的情况下，除了从事探索性研究的流行病学家、公共卫生研究人员和毒理学家小团体之外，社区、劳工和环境活动人士也提出了解释。此外，我们的合作团队目前还有两个独立的试点项目，分别由瓜达拉哈拉大学（CI Lozano）和利物浦大学（PI Kierans）进行。这些项目记录了CKDu出现的多维图景，重点关注哈利斯科州贫困结构条件、政治经济、环境与贫困社区日常生活之间的联系，重点关注查帕拉湖岸边的Poncitlán社区。Lozano正在确定肾脏损害的多种风险因素和社会决定因素，而Kierans则采用人类学方法绘制CKDu临床和科学知识的文化生产，并记录与CKDu出现相关的文化和社会实践。因此，CKDu是一个复杂的问题，是地理、地质、历史、政治、经济、社会和生物过程的结果。建立一种协作的、真正跨学科的伙伴关系对于制定理解这种情况的方法以及为生活在贫穷和退化环境中的人们所需的反应至关重要。现有的研究主要源于临床和科学的观点和优先事项。缺乏艺术、人文和社会科学方面的实质性贡献，特别是那些对贫困、工作、健康和环境之间不断变化的相互关系提供历史背景和文化背景见解的贡献。采用独特的跨学科方法，这种伙伴关系将作出宝贵的贡献。它将整合和扩展我们现有的项目，包括另外两个试点项目：(1)当地社区历史试点项目，记录与慢性肾病相关的不断变化的经验、解释和挑战；(2)环境史项目，记录土地利用与环境的长期关系。通过合作，我们将建立对话，促进创新的方法方法和对CKDu的全面理解。我们将为CKDu研究制定一项研究方案，以便在墨西哥境内外应用。我们将与社区、州、联邦和国际上的广泛受益者合作，促进知识共享，共同制定卫生、福利和环境政策，以及为满足受影响社区的卫生和福利需求而采取干预措施的战略。

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.