***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objectives Experimental studies suggest a relationship between pesticide exposure and renal impairment , but epidemiological evidence is limited . We evaluated the association between exposure to 39 specific pesticides and  end-stage renal disease ( ESRD )  incidence in the Agricultural Health Study , a prospect i ve cohort study of licensed pesticide applicators in Iowa and North Carolina . Methods Via linkage to the US Renal Data System , we identified 320 ESRD cases diagnosed between enrolment ( 1993–1997 ) and December 2011 among 55 580 male licensed pesticide applicators . Participants provided information on use of pesticides via self-administered question naires . Lifetime pesticide use was defined as the product of duration and frequency of use and then modified by an intensity factor to account for differences in pesticide application practice s. Cox proportional hazards models , adjusted for age and state , were used to estimate associations between ESRD and : ( 1 ) ordinal categories of intensity-weighted lifetime use of 39 pesticides , ( 2 ) poisoning and high-level pesticide exposures and ( 3 ) pesticide exposure result ing in a medical visit or hospitalisation . Results Positive exposure-response trends were observed for the herbicides alachlor , atrazine , metolachlor , paraquat , and pendimethalin , and the insecticide permethrin . More than one medical visit due to pesticide use ( HR=2.13 ; 95 % CI 1.17 to 3.89 ) and hospitalisation due to pesticide use ( HR=3.05 ; 95 % CI 1.67 to 5.58 ) were significantly associated with ESRD . Conclusions Our findings support an association between ESRD and chronic exposure to specific pesticides , and suggest pesticide exposures result ing in medical visits may increase the risk of ESRD . Clinical trial registration Clinical trials.gov NCT00352924 Background Epidemics of chronic kidney disease ( CKD ) not due to diabetes mellitus ( DM ) or hypertension have been observed among individuals working in hot environments in several areas of the world . Experimental models have documented that recurrent heat stress and water restriction can lead to CKD , and the mechanism may be mediated by hyperosmolarity that activates pathways ( vasopressin , aldose reductase-fructokinase ) that induce renal injury . Here we tested the hypothesis that elevated serum sodium , which reflects serum osmolality , may be an independent risk factor for the development of CKD . Methods This study was a large-scale , single-center , retrospective 5-year cohort study at Center for Preventive Medicine , St. Luke ’s International Hospital , Tokyo , Japan , between 2004 and 2009 . We analyzed 13,201 subjects who underwent annual medical examination of which 12,041 subjects ( age 35 to 85 ) without DM and /or CKD were enrolled . This analysis evaluated age , sex , body mass index , abdominal circumference , hypertension , dyslipidemia , hyperuricemia , fasting glucose , BUN , serum sodium , potassium , chloride and calculated serum osmolarity . Results Elevated serum sodium was an independent risk factor for development of CKD ( OR : 1.03 , 95 % CI , 1.00–1.07 ) after adjusted regression analysis with an 18 percent increased risk for every 5 mmol/L change in serum sodium . Calculated serum osmolarity was also an independent risk factor for CKD ( OR : 1.04 ; 95 % CI , 1.03–1.05 ) as was BUN ( OR : 1.08 ; 95 % CI , 1.06–1.10 ) ( independent of serum creatinine ) . Conclusions Elevated serum sodium and calculated serum osmolarity are independent risk factors for developing CKD . This finding supports the role of limiting salt intake and preventing dehydration to reduce risk of CKD Background Cadmium ( Cd ) , lead ( Pb ) , and mercury ( Hg ) cause toxicological renal effects , but the clinical relevance at low-level exposures in general population s is unclear . The objective of this study is to assess the risk of developing end-stage renal disease in relation to Cd , Pb , and Hg exposure . Methods A total of 118 cases who later in life developed end-stage renal disease , and 378 matched ( sex , age , area , and time of blood sampling ) referents were identified among participants in two population -based prospect i ve cohorts ( 130,000 individuals ) .  Cd , Pb , and Hg concentrations were determined in prospect ively collected sample s. Results Erythrocyte lead was associated with an increased risk of developing end-stage renal disease ( mean in cases 76 μg/L ; odds ratio ( OR ) 1.54 for an interquartile range increase , 95 % confidence interval ( CI ) 1.18 - 2.00 ) , while erythrocyte mercury was negatively associated ( 2.4 μg/L ; OR 0.75 for an interquartile range increase , CI 0.56 - 0.99 ) . For erythrocyte cadmium , the OR of developing end-stage renal disease was 1.15 for an interquartile range increase ( CI 0.99 - 1.34 ; mean Ery-Cd among cases : 1.3 μg/L ) . The associations for erythrocyte lead and erythrocyte mercury , but not for erythrocyte cadmium , remained after adjusting for the other two metals , smoking , BMI , diabetes , and hypertension . Gender-specific analyses showed that men carried almost all of the erythrocyte lead and erythrocyte cadmium associated risks . Conclusions Erythrocyte lead is associated with end-stage renal disease but further studies are needed to evaluate causality . Gender-specific analyses suggest potential differences in susceptibility or in exposure biomarker reliability In epidemiologic studies , high arsenic exposure has been associated with adverse kidney disease outcomes . We performed a systematic review of the epidemiologic evidence of the association between arsenic and various kidney disease outcomes . The search period was January 1966 through January 2014 . Twenty-five papers ( comprising 24 studies ) meeting the search criteria were identified and included in this review . In most studies , arsenic exposure was assessed by measurement of urine concentrations or with an ecological indicator . There was a generally positive association between arsenic and albuminuria and proteinuria outcomes . There was mixed evidence of an association between arsenic exposure and chronic kidney disease ( CKD ) , β-2-microglobulin ( β2MG ) , and N-acetyl-β-D-glucosaminidase ( NAG ) outcomes . There was evidence of a positive association between arsenic exposure and kidney disease mortality . Assessment of a small number of studies with three or more categories showed a clear dose-response association between arsenic and prevalent albuminuria and proteinuria , but not with CKD outcomes . Eight studies lacked adjustment for possible confounders , and two had small study population s. The evaluation of the causality of the association between arsenic exposure and kidney disease outcomes is limited by the small number of studies , lack of study quality , and limited prospect i ve evidence . Because of the high prevalence of arsenic exposure worldwide , there is a need for additional well- design ed epidemiologic and mechanistic studies of arsenic and kidney disease outcomes Background The rising prevalence of chronic kidney disease ( CKD ) and subsequent end stage renal failure necessitating renal replacement therapy has profound consequences for affected individuals and health care re sources . This community based study was conducted to identify potential predictors of microalbuminuria in a r and omly selected sample of adults from the North Central Province ( NCP ) of Sri Lanka , where the burden of CKD is pronounced and the underlying cause still unknown . Methods Exposures to possible risk factors were determined in r and omly recruited subjects ( 425 females and 461 males ) from selected areas of the NCP of Sri Lanka using an interviewer administered question naire .  Sulphosalicylic acid and the Light Dependent Resister microalbumin gel filtration method was used for initial screening for microalbuminuria and reconfirmed by the Micral strip test . Results Microalbumnuria was detected in 6.1 % of the females and 8.5 % of the males . Smoking ( p < 0.001 ) , alcohol use ( p = 0.003 ) , hypertension ( p < 0.001 ) , diabetes ( p < 0.001 ) , urinary tract infection ( UTI ) ( p = 0.034 ) and consumption of water from wells in the fields ( p = 0.025 ) were associated with microalbuminuria . In the binary logistic regression analysis , hypertension , diabetes mellitus , UTI , drinking well water in the fields , smoking and pesticide spraying were found to be significant predictors of microalbuminuria . Conclusions Hypertension , diabetes mellitus , UTI , and smoking are known risk factors for microalbuminuria . The association between microalbuminuria and consumption of well water suggests an environmental aetiology to CKD in NCP . The causative agent is yet to be identified . Investigations for cadmium as a potential causative agent needs to be initiated BACKGROUND Long-term arsenic exposure is a major global health problem . However , few epidemiologic studies have evaluated the association of arsenic with kidney measures . Our objective was to evaluate the cross-sectional association between inorganic arsenic exposure and albuminuria in American Indian adults from rural areas of Arizona , Oklahoma , and North and South Dakota . STUDY DESIGN Cross-sectional . SETTING & PARTIPANTS : Strong Heart Study locations in Arizona , Oklahoma , and North and South Dakota . 3,821 American Indian men and women aged 45 - 74 years with urine arsenic and albumin measurements . PREDICTOR Urine arsenic . OUTCOMES Urine albumin-creatinine ratio and albuminuria status . MEASUREMENTS Arsenic exposure was estimated by measuring total urine arsenic and urine arsenic species using inductively coupled plasma mass spectrometry ( ICPMS ) and high-performance liquid chromatography-ICPMS , respectively . Urine albumin was measured by automated nephelometric immunochemistry . RESULTS The prevalence of albuminuria ( albumin-creatinine ratio ≥30 mg/g ) was 30 % . Median value for the sum of inorganic and methylated arsenic species was 9.7 ( IQR , 5.8 - 15.6 ) μg per gram of creatinine . Multivariable-adjusted prevalence ratios of albuminuria ( albumin-creatinine ratio ≥30 mg/g ) comparing the 3 highest to lowest quartiles of the sum of inorganic and methylated arsenic species were 1.16 ( 95 % CI , 1.00 - 1.34 ) , 1.24 ( 95 % CI , 1.07 - 1.43 ) , and 1.55 ( 95 % CI , 1.35 - 1.78 ) , respectively ( P for trend < 0.001 ) . The association between urine arsenic and albuminuria was observed across all participant subgroups evaluated and was evident for both micro- and macroalbuminuria . LIMITATIONS The cross-sectional design can not rule out reverse causation . CONCLUSIONS Increasing urine arsenic concentrations were cross-sectionally associated with increased albuminuria in a rural US population with a high burden of diabetes and obesity . Prospect i ve epidemiologic and mechanistic evidence is needed to underst and the role of arsenic as a kidney disease risk factor Background In sub-Saharan Africa , kidney failure has a high morbidity and mortality . Despite this , population -based estimates of prevalence , potential etiologies , and awareness are not available . Methods Between January and June 2014 , we conducted a household survey of r and omly-selected adults in Northern Tanzania . To estimate prevalence we screened for CKD , which was defined as an estimated glomerular filtration rate ≤ 60 ml/min/1.73m2 and /or persistent albuminuria . We also screened for human immunodeficiency virus ( HIV ) , diabetes , hypertension , obesity , and lifestyle practice s including alcohol , tobacco , and traditional medicine use . Awareness was defined as a self-reported disease history and subsequently testing positive . We used population -based age- and gender-weights in estimating prevalence , and we used generalized linear models to explore potential risk factors associated with CKD , including living in an urban environment . Results We enrolled 481 adults from 346 households with a median age of 45 years .  The community-based prevalence of CKD was 7.0 % ( 95 % CI 3.8 - 12.3 ) , and awareness was low at 10.5 % ( 4.7 - 22.0 ) . The urban prevalence of CKD was 15.2 % ( 9.6 - 23.3 ) while the rural prevalence was 2.0 % ( 0.5 - 6.9 ) . Half of the cases of CKD ( 49.1 % ) were not associated with any of the measured risk factors of hypertension , diabetes , or HIV . Living in an urban environment had the strongest crude ( 5.40 ; 95 % CI 2.05 - 14.2 ) and adjusted prevalence risk ratio ( 4.80 ; 1.70 - 
    Output:
    
Results of the meta- analysis suggest that exposure to agrochemicals and working in agriculture increase the risk of CKDnT , but this only reached significance for working in agriculture .
When cross-sectional studies were excluded , agrochemical exposure became significant .