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. 2026 Feb;24(2):160-175.
doi: 10.2166/wh.2026.175. Epub 2026 Jan 30.

Case-control study of water and agricultural exposures among women in CKDu-endemic Sri Lanka

Marimar Contreras Nieves #  1 , Santhushya Hewapathiranage  2   3 , F Quin Zabel  4 , Dhananjalee Mahalekam  5 , Xue Yu  1 , Chiran Weerakoon  2   3 , Manoj Bandara  2   3 , Isuru Bandara  2   3 , Ishan Maduwantha  2   3 , Dulanjalee Hearth  2   3 , Ishara Athauda  5 , Bhagya Rathnayake  5 , Naduni Erandika  2   3 , Nilantha Pushpakuamra  2   3 , Eddie Lee  1 , Kyla Baron  6 , Vivek Bhalla  1 , Karen L Artiles  7 , Andrew Fire  7 , Stephen L Schensul  8 , Rohana Chandrajith  5   9 , Penny Vlahos #  4   9 , Maria Montez-Rath #  1   9 , Shuchi Anand #  10   9 , Nishantha Nanayakkara #  2   3   9
Affiliations

Case-control study of water and agricultural exposures among women in CKDu-endemic Sri Lanka

Marimar Contreras Nieves et al. J Water Health. 2026 Feb.

Abstract

Chronic kidney disease of unknown etiology (CKDu) disproportionately affects men in agricultural regions; few studies parse exposures among affected and unaffected women. We conducted a case-control study among women in Sri Lanka, identifying 15 cases, who experienced progressive kidney disease in a prospective study in a CKDu-endemic region. We selected age-matched controls from the same endemic and neighboring non-endemic region. We then assessed differences in self-reported exposures, and analyzed water samples for inorganic and organic chemicals. Women who reported heat exhaustion (OR = 19.3; p = 0.017) and pesticide handling (OR = 12.6; p = 0.011) were more likely cases. Women who used natural fertilizer in home gardens were more likely controls (OR = 0.05; p = 0.008). Cases' water had higher fluoride, sulfate, calcium, and vanadium, and more often contained pesticides at >1 ppb, particularly diazinon, compared with controls from endemic and non-endemic regions. Our study supports prior data linking heat exposure to CKDu and identifies differences in home gardening, pesticide use, and water content among CKDu-affected women.

Keywords: CKDu; agriculture; fluoride; groundwater contamination; pesticides.

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Conflict of interest statement

The authors declare there is no conflict.

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