The main causes of chronic kidney disease (CKD) globally are diabetes and hypertension but epidemics of chronic kidney disease of unknown etiology (CKDu) occur in Central America, Sri Lanka, India and beyond. Althoug also being observed in women, CKDu concentrates among men in agricultural sectors. Therefore, suspicions fell initially on pesticide exposure, but currently chronic heat stress and dehydration are considered key etiologic factors. Responding to persistent community and scientific concerns about the role of pesticides, we performed a systematic review of epidemiologic studies that addressed associations between any indicator of pesticide exposure and any outcome measure of CKD. Of the 21 analytical studies we identified, seven were categorized as with low, ten with medium and four with relatively high explanation value. Thirteen (62%) studies reported one or more positive associations, but four had a low explanation value and three presented equivocal results. The main limitations of both positive and negative studies were unspecific and unquantified exposure measurement (‘pesticides’), the cross-sectional nature of most studies, confounding and selection bias. The four studies with stronger designs and better exposure assessment (from Sri Lanka, India and USA) all showed exposure-responses or clear associations, but for different pesticides in each study, and three of these studies were conducted in areas without CKDu epidemics. No study investigated interactions between pesticides and other concommittant exposures in agricultural occupations, in particular heat stress and dehydration. In conclusion, existing studies provide scarce evidence for an association between pesticides and regional CKDu epidemics but, given the poor pesticide exposure assessment in the majority, a role of nephrotoxic agrochemicals cannot be conclusively discarded. Future research should procure assessment of lifetime exposures to relevant specific pesticides and enough power to look into interactions with other major risk factors, in particular heat stress.Electronic supplementary materialThe online version of this article (doi:10.1186/s12940-017-0254-0) contains supplementary material, which is available to authorized users.

A paradigm change in the management of environmental health issues has been observed in recent years: instead of managing specific risks individually, a holistic vision of environmental problems would assure sustainable solutions. However, concrete actions that could help translate these recommendations into interventions are lacking. This review presents the relevance of using an integrated indoor air quality management approach to ensure occupant health and comfort. At the nexus of three basic concepts (reducing contaminants at the source, improving ventilation, and, when relevant, purifying the indoor air), this approach can help maintain and improve indoor air quality and limit exposure to several contaminants. Its application is particularly relevant in a climate change context since the evolving outdoor conditions have to be taken into account during building construction and renovation. The measures presented through this approach target public health players, building managers, owners, occupants, and professionals involved in building design, construction, renovation, and maintenance. The findings of this review will help the various stakeholders initiate a strategic reflection on the importance of indoor air quality and climate change issues for existing and future buildings. Several new avenues and recommendations are presented to set the path for future research activities.

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