GoKawiilSome staggered through the hospital’s doors, arriving at all hours of day and night. Others were wheeled in on gurneys, their bodies having given out before they could reach the emergency department. Many had collapsed at work—while painting houses, stapling shingles, or paving roads. All had been born in Mexico or Central America, and most complained of a crushing fatigue they could no longer ignore.
Routine blood analyses revealed the cause: kidney failure. They would need dialysis three times per week just to stay alive. What puzzled doctors most was that they didn’t resemble typical dialysis patients, who are older and have long histories of obesity, diabetes, or hypertension. These were otherwise healthy young men.
For more than a decade, the plight of these patients has haunted Ricardo Nuila, an internist at Houston’s Ben Taub Hospital. He saw them almost daily, greeting them with the warm smile that lends his dark eyes their inner glow. The smile hid his quiet grief. He feared that these men would die far too early, their kidneys having given out for reasons no physician can ascertain.
Nuila wasn’t alone in his concern. Doctors at Harris County’s other safety-net hospitals reported seeing much the same. But Nuila got a hint about what might be happening while visiting El Salvador, where he’d spent his childhood summers with family. The country was dealing with a deadly epidemic that affects vast numbers of sugarcane cutters on plantations throughout Central America. It’s known as chronic kidney disease of unknown origin—CKDu—or as Mesoamerican nephropathy. Kidney diseases are among the leading causes of death in El Salvador, where dialysis is not widely available.
Researchers had found signs of CKDu outside Central America, including in Sri Lanka, India, and Nepal. But it had never been documented in the United States. If the men arriving at Ben Taub were experiencing CKDu, Nuila worried that he might have been witnessing the first wave of a coming tsunami of kidney failure and death—with Texas at the center.
Epidemiologists disagree on exactly what causes CKDu, although studies have consistently identified physical labor in extreme heat as a contributor. A 2019 article in The New England Journal of Medicine called it “a sentinel disease in the era of climate change.” But studies of CKDu have been especially challenging to execute because the disease primarily affects marginalized populations.
The possibility that CKDu had arrived in Texas was unnerving, but there was one potential upside. It could offer an opportunity to harness the cutting-edge medical research available in Houston to solve the mystery of CKDu’s origins.
That might prevent young men from being debilitated in the prime of their lives.
Dr. Ricardo Nuila in the ambulance bay outside Ben Taub Hospital, in Houston, on April 23, 2026. Photograph by Meridith Kohut
Rebecca Fischer looked up from a half-dissected rodent to take in the dense greenery of Nicaragua’s sugarcane fields. She was struck by the beauty of her surroundings—the dark soil, the verdant plant life, the chain of brooding volcanoes standing sentry over it all. The area’s landscape, depicted on the label of the country’s flagship Toña beer, is iconic. Yet alongside this natural splendor existed an unsettling prevalence of death and disease.
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