race and economic status—can be important predicters of ESRD. The lack of specific and comprehensive information on the impact of occupational and environmental nephrotoxicants on diseases of the kidney and urinary tract is troublesome. The possible correlations between the development of clinically significant renal disease and race, economic status, and exposure to occupational and environmental nephrotoxicants suggest the need for epidemiologic studies.

Recommendation

For patients entering programs for treatment of ESRD, details of occupational history or other factors that would show the impact of patients' environments on their condition should be obtained. As a first step, available information in relevant databases should be examined. Studies should be undertaken to determine whether the higher incidences of ESRD among minority groups and the economically disadvantaged are related to occupational or environmental exposure to nephrotoxicants. Epidemiologic studies need to focus on the various populations at risk; this focus should include not only the identification of the populations but their continued monitoring.

Conclusion

Some susceptible populations in the United States have anatomic or physiologic differences in the kidneys at birth that might help to explain their propensity for renal damage. As a result, they are less tolerant of various stresses, including exposure to environmental or occupational nephrotoxicants. Although emphasis has been placed on the toxicity of environmental and occupational nephrotoxicants, as well as diagnostic and therapeutic agents, a less well-defined problem is the frequency and severity of renal injury that results from recreational-drug use. Understanding the spectrum of urologic and renal diseases that might be produced by occupational or environmental agents requires integration of studies of the anatomy, biochemistry, and physiology of the kidney in conjunction with knowledge of the mechanisms of injury and disease.

Recommendation

Studies should be performed to determine whether an association between anatomic or physiologic differences of the kidney at birth and the later response to environmental or occupational nephrotoxicants leads to susceptibility to disease or to progression once disease occurs.

Data should be collected on the incidence of renal abnormalities among recreational-drug users to determine the influence of those substances on the rate of progression of renal disease due to other causes.

Basic studies are needed to deter-



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