The Importance of an Occupational History: Chronic Kidney Disease vs Chronic Kidney Disease of Non-Traditional Etiology

Climate change is one of the most pressing issues affecting human health in the 21st century and is thought to have led to the development of chronic kidney disease of non-traditional etiology (CKDnt). The disease has been identified in outdoor workers in the region previously known as Mesoamerica (i.e., Western & Southern Mexico, Guatemala, Belize, El Salvador, and the western coasts of Honduras, Nicaragua, and Costa Rica), but there is increasing evidence of the disease in outdoor workers within the United States (Chapman et al., 2021). In comparison to “traditional” kidney disease, CKDnt develops in the absence of hypertension, diabetes, or known use of nephrotoxic substances (e.g., homemade alcohol, ibuprofen, and so on) but is associated with heat stress, leading to extracellular volume depletion, hyperosmolarity, hyperthermia, and low-grade rhabdomyolysis, causing repeated acute kidney injury and, ultimately, chronic interstitial fibrosis of the kidney (Glaser et al., 2016).

Within the United States, occupations of concern include both outdoor workers, such as farmworkers, construction workers, and landscapers, and indoor workers such as firefighters, manufacturing, and utility workers (Chapman et al., 2021). However, of particular concern are low-income, often undocumented workers, in sectors such as farming, construction, and landscaping (Smith et al., 2022). These workers often do not receive the same protections as native-born workers and do not have the same level of control over their working environment. Furthermore, in states that have not expanded Medicaid, once an undocumented individual develops kidney disease, they often do not receive the gold standard of thrice-weekly planned hemodialysis (Cervantes et al., 2018). Instead, they receive sporadic dialysis through the emergency department (Smith et al., 2022), which has been associated with increased mortality and healthcare utilization (Cervantes et al., 2018).

To fully understand the development of kidney disease in occupations susceptible to heat stress, occupational health nurses and other occupational health clinicians working with patients with kidney disease in multiple settings should routinely collect patients’ occupational history data. Ideally, the collection of occupational history data happens on a continuous basis and is seen as a fluid part of a patient’s health status. For a full occupational history, the Occupational/Environmental History Form can collect job-specific information, such as availability and use of personal protective equipment and known/perceived workplace hazards and exposures (“Taking the Occupational History,” 1983). However, at a minimum, the occupational history should include job title, occupation sector, and approximate dates of employment. The occupational health clinician must approach the process delicately when dealing with persons who may be undocumented due to fear around disclosing occupational history. Nonetheless, we have made the routine collection of past medical, family, and surgical history a standard in health care. Why not past occupational history as well?