The leading hypothesis is chronic agrochemical exposure combined with hard water and genetic susceptibility, but after two decades, a definitive single cause remains elusive because research is fragmented and underfunded, failing to move from correlation to causation. In my corporate unit, I see farmers from these regions too late, their kidneys already granular and shrunken, a pattern distinct from typical diabetic nephropathy. My own research proposals to prospectively study the water and soil get rejected for lacking 'commercial value' unlike dialysis equipment tenders. So, it's unknown because a preventable environmental disease offers less profit than a lifelong treatment protocol.
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