Pro: Heat stress as a potential etiology of Mesoamerican and Sri Lankan nephropathy: a late night consult with Sherlock Holmes.

Epidemics of chronic kidney disease are now recognized in Central America, Mexico, India and Sri Lanka, and there is also some evidence that similar epidemics may be occurring in the USA, Thailand and elsewhere. A common denominator for each location is manually working outside in extremely hot environments. Here we review the evidence that the primary etiology may be heat stress related to repeated subclinical or clinical acute kidney injury that eventually manifests as chronic kidney disease. In some aspects, the disease may manifest as subclinical heat stroke, subclinical rhabdomyolysis or a subclinical tumor lysis syndrome. While toxins could be involved, it would be difficult to attribute this as a main mechanism, given the wide range of occupations and geographic regions manifesting this disease. While some of the epidemics may be due to better reporting, we believe the most important reasons are increasing heat extremes (heat waves) coupled with hydration with sugary or, less commonly, alcoholic beverages.