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We conducted a case\u2013control study among women in Sri Lanka, identifying 15 cases, who experienced progressive kidney disease in a prospective study in a CKDu-endemic region. We selected age-matched controls from the same endemic and neighboring non-endemic region. We then assessed differences in self-reported exposures, and analyzed water samples for inorganic and organic chemicals. Women who reported heat exhaustion (OR = 19.3; p = 0.017) and pesticide handling (OR = 12.6; p = 0.011) were more likely cases. Women who used natural fertilizer in home gardens were more likely controls (OR = 0.05; p = 0.008). Cases' water had higher fluoride, sulfate, calcium, and vanadium, and more often contained pesticides at &amp;gt;1 ppb, particularly diazinon, compared with controls from endemic and non-endemic regions. Our study supports prior data linking heat exposure to CKDu and identifies differences in home gardening, pesticide use, and water content among CKDu-affected women.<\/jats:p>","DOI":"10.2166\/wh.2026.175","type":"journal-article","created":{"date-parts":[[2026,2,14]],"date-time":"2026-02-14T08:25:02Z","timestamp":1771057502000},"page":"160-175","update-policy":"https:\/\/doi.org\/10.2166\/iwapcrossmarkpolicypage","source":"Crossref","is-referenced-by-count":2,"title":["Case-control study of water and agricultural exposures among women in CKDu-endemic Sri Lanka"],"prefix":"10.2166","volume":"24","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-3809-0801","authenticated-orcid":false,"given":"Marimar","family":"Contreras Nieves","sequence":"first","affiliation":[{"name":"a Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Santhushya","family":"Hewapathiranage","sequence":"additional","affiliation":[{"name":"b Kandy Kidney Protection Society, National Teaching Hospital, Kandy, Sri Lanka"},{"name":"c Center for Research, National Hospital, Kandy, Sri Lanka"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"F. Quin","family":"Zabel","sequence":"additional","affiliation":[{"name":"d Department of Marine Sciences, University of Connecticut, Groton, CT, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dhananjalee","family":"Mahalekam","sequence":"additional","affiliation":[{"name":"e Department of Geology, University of Peradeniya, Peradeniya, Sri Lanka"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xue","family":"Yu","sequence":"additional","affiliation":[{"name":"a Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiran","family":"Weerakoon","sequence":"additional","affiliation":[{"name":"b Kandy Kidney Protection Society, National Teaching Hospital, Kandy, Sri Lanka"},{"name":"c Center for Research, National Hospital, Kandy, Sri 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Hospital, Kandy, Sri Lanka"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nilantha","family":"Pushpakuamra","sequence":"additional","affiliation":[{"name":"b Kandy Kidney Protection Society, National Teaching Hospital, Kandy, Sri Lanka"},{"name":"c Center for Research, National Hospital, Kandy, Sri Lanka"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eddie","family":"Lee","sequence":"additional","affiliation":[{"name":"a Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kyla","family":"Baron","sequence":"additional","affiliation":[{"name":"f Department of Medicine, Howard University College of Medicine, Washington, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vivek","family":"Bhalla","sequence":"additional","affiliation":[{"name":"a Division of Nephrology, Department of 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