title: Mesoamerican nephropathy: geographical distribution and time trends of chronic kidney disease mortality between 1970 and 2012 in Costa Rica.
abstract: OBJECTIVE
  Mesoamerican nephropathy is an epidemic of chronic kidney disease (CKD) unrelated to traditional causes, mostly observed in sugarcane workers. We analysed CKD mortality in Costa Rica to explore when and where the epidemic emerged, sex and age patterns, and relationship with altitude, climate and sugarcane production.
  
  
  METHODS
  SMRs for CKD deaths (1970-2012) among population aged ≥20 were computed for 7 provinces and 81 counties over 4 time periods. Time trends were assessed with age-standardised mortality rates. We qualitatively examined relations between mortality and data on altitude, climate and sugarcane production.
  
  
  RESULTS
  During 1970-2012, age-adjusted mortality rates in the Guanacaste province increased among men from 4.4 to 38.5 per 100,000 vs. 3.6-8.4 in the rest of Costa Rica, and among women from 2.3 to 10.7 per 100,000 vs. 2.6-5.0 in the rest of Costa Rica. A significant moderate excess mortality was observed among men in Guanacaste already in the mid-1970s, steeply increasing thereafter; a similar female excess mortality appeared a decade later, remaining stable. Male age-specific rates were high in Guanacaste for age categories ≥30, and since the late 1990s also for age range 20-29. The male spatiotemporal patterns roughly followed sugarcane expansion in hot, dry lowlands with manual harvesting.
  
  
  CONCLUSIONS
  Excess CKD mortality occurs primarily in Guanacaste lowlands and was already present 4 decades ago. The increasing rates among Guanacaste men in hot, dry lowland counties with sugarcane are consistent with an occupational component. Stable moderate increases among women, and among men in counties without sugarcane, suggest coexisting environmental risk factors.
authors.affiliation: Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Catharina
authors.initials: C
authors.lastname: Wesseling
authors.affiliation: Program on Work, Environment and Health in Central America (SALTRA), Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica.
authors.forename: Berna
authors.initials: B
authors.lastname: van Wendel de Joode
authors.affiliation: Program on Work, Environment and Health in Central America (SALTRA), Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Crowe
authors.affiliation: Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
authors.forename: Ralf
authors.initials: R
authors.lastname: Rittner
authors.affiliation: Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
authors.forename: Negin A
authors.initials: NA
authors.lastname: Sanati
authors.affiliation: Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Christer
authors.initials: C
authors.lastname: Hogstedt
authors.affiliation: Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Jakobsson
mesh_terms: D000328:Adult; D017677:Age Distribution; D000382:Agricultural Workers' Diseases / Q000401:mortality*; D002423:Cause of Death; D015331:Cohort Studies; D003364:Costa Rica / Q000453:epidemiology; D016208:Databases, Factual; D003906:Developing Countries; D005260:Female; D005843:Geography; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016273:Occupational Exposure / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000401:mortality* / Q000473:pathology; D012189:Retrospective Studies; D018570:Risk Assessment; D031786:Saccharum; D017678:Sex Distribution; D016019:Survival Analysis; D015996:Survival Rate; D055815:Young Adult