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Clinical e-News Blog - August

Written by Professor Karen Dwyer, Nephrologist, Clinical Director, Kidney Health Australia

Is there a role for environmental factors in chronic kidney disease?

Chronic kidney disease (CKD) poses a significant health burden to the Australian population, with a prevalence of 1:10 amongst non-Indigenous Australians and 1:5 amongst Indigenous Australians (1). The prevalence of kidney disease in Indigenous Australians increases exponentially with degree of remoteness (1) and in some regions is considered endemic (2). Further, there are several areas outside of Indigenous communities where the prevalence of CKD is greater than for the state as a whole, many of which are in agricultural communities.

Agricultural (3) and Indigenous (4) communities in Australia have an increased prevalence of hypertension, diabetes and obesity, all of which are risk factors for CKD. It is not clear if these risk factors alone account for the upsurge in kidney disease in these communities and unidentified nephrotoxins as contributing factors is an area of intense interest. Historically lead poisoning was implicated in a spike of deaths in 1930’s due to “nephritis” in Queensland (reviewed in (5)). More recently data demonstrated that the drinking water in Aboriginal communities in Western Australia, in which CKD is endemic with a prevalence of 22.8% (1, 2), were contaminated with the putative nephrotoxins nitrate and uranium (2). Further, a number of Australian towns have been affected by water contamination with Perfluoroalkyl substances (PFAS) and Perfluorooctyl Sulfonate (PFOS), which have been linked with altered kidney function (6). The issues faced by towns across Australia, some of which have attracted intense media coverage, include Katherine (NT) (7, 8); Oakey (Queensland) (9); Williamtown (NSW) (10) and Penshurst (Victoria) (11).

Many regions in Australia are dependent on agriculture as the primary industry. As the push for higher and consistent agricultural production has continued so has pesticide and fertiliser use in Australia. A Deloitte report estimated more than A$20.6 billion of Australian crop production was attributed to Crop Protection Products in 2015-16 (12). Crop Protection Products are natural and synthetic chemicals used to control insects, disease and weeds in food crops and plants with herbicides, insecticides and fungicides making up 85% of the product sales (12). This increased use, whilst increasing production, has led to pollution of water courses and underground water aquifers (13).

A study undertaken of 1454 wells in Northeastern Australia reported 3% of well water above the permissible limit for drinking water, however in three specific areas 14-21% of wells showed elevated nitrate concentrations and these corresponded to higher intensive agricultural areas (14). According to the Australian Bureau of Statistics, 5.3million tonnes of fertiliser were applied to 49.1 million hectares of agricultural land in 2014-15. The most common were nitrogen-based fertilisers accounting for 66%, with urea and ammonium phosphate the most common (15). According to Gourley et al (16), even if action were taken to reduce nutrient surpluses, there will be a lag in water-quality improvement as accumulated nitrogen and phosphorus continue to provide a source of nutrients. Practically, this means that degraded water quality will continue to occur despite land-based improvements.

Accurate figures for pesticide usage is difficult to obtain as although the Australian Pesticides and Veterinary Medicines Authority (17) publishes a list of the total number of products, the actual volume used is not stated. Furthermore, although an Australian Agricultural Chemicals Usage Database (18) contains information on the agricultural chemicals used in Australia from 1997 to 2006 by broadacre farmers, data beyond these dates are not available.

The traditional risk factors of diabetes, obesity, and hypertension account for much of the burden of CKD. However, increasingly additional factors operational in local environments such as water contamination and use of agrochemicals require attention. It is likely that no one single factor is responsible for the increased prevalence of kidney disease observed within pockets in Australia, rather multiple factors act in a synergistic fashion in an at-risk population.

1. Ludlow M. State of the Nation. 2016 Kidney Health Week. Chronic Kidney Disease Hot Spots. 2016.
2. Rajapakse J, Rainer-Smith S, Millar GJ, Grace P, Hutton A, Hoy W, et al. Unsafe drinking water quality in remote Western Australian Aboriginal communities. Geographical Research. 2018.
3. Brumby S, Chandrasekara A, McCoombe S, Kremer P, Lewandowski P. Cardiovascular risk factors and psychological distress in Australian farming communities. Aust J Rural Health. 2012;20(3):131-7.
4. Hoy WE, Hughson MD, Singh GR, Douglas-Denton R, Bertram JF. Reduced nephron number and glomerulomegaly in Australian Aborigines: a group at high risk for renal disease and hypertension. Kidney Int. 2006;70(1):104-10.
5. Weaver VM, Fadrowski JJ, Jaar BG. Global dimensions of chronic kidney disease of unknown etiology (CKDu): a modern era environmental and/or occupational nephropathy? BMC Nephrol. 2015;16:145.
6. Blake BE, Pinney SM, Hines EP, Fenton SE, Ferguson KK. Associations between longitudinal serum perfluoroalkyl substance (PFAS) levels and measures of thyroid hormone, kidney function, and body mass index in the Fernald Community Cohort. Environ Pollut. 2018;242(Pt A):894-904.
7. Zillman S. Katherine residents say Defence was negligent, caused economic loss with PFAS contamination: ABC news; 2018 [Available from:
8. Lansbury Hall N, Mott S, Hoy W. Getting clean drinking water into remote Indigenous communities means overcoming city thinking 2018 [Available from:
9. Bradfield E, Phillip A. Defence tells Oakey residents toxic pollutants no health risk, just don't eat the local produce 2017 [Available from:
10. Page D. Williamtown Red zone residents outraged after study finds contamination zone not fit for animals or plants 2018 [Available from:
11. Sullivan K. Penshurst on bottled water amid PFOS contamination fears 2015 [Available from:
12. Economics DA. Economic activity attributable to crop protection products. CropLife Australia. 2018.
13. Herath G. Agrochemical use and the environment in Australia: A resource economics perspective. Int J Soc Economics. 1998;25(2/3/4):283-301.
14. Thorburn PJ, Biggs JS, Weier KL, Keathing BA. Nitrate in groundwaters of intensive agricultural areas in coastal Northeastern Australia. Agriculture, Ecosystems and Environment. 2003;94:49-58.
15. Australian Bureau of Statistics. Land Management and Farming in Australia, 2014-15 2016 [Available from:
16. Gourley CJP, Weaver DM. Nutrient surpluses in Australian grazing systems: management practices, policy approaches, and difficult choices to improve water quality. Crop & Pasture Science. 2012;63:805-18.
17. Australian Government. Pesticides and Veterinary Medicines Product Sales 2014 [Available from:
18. Australian Government Department of Education and Environment. Agricultural Chemical Usage Database 2006 [Available from:

    See previous blog posts here