There has been a high suspicion that pesticides may play a role in large outbreaks of chronic kidney disease (CKD) in some international regions such as El Salvador, Sri Lanka and Nicaragua. Studies have also previously reported an increased incidence of kidney disease in agricultural workers. Pesticides used on many farms can be used for non-agricultural purposes and are even available to the average consumer without an application license. Previous studies on factors contributing to the development of end-stage renal disease (ESRD) have focused on diabetes and hypertension, with few studies focusing on the role of occupational and environmental factors in its development. Professor Sandler from the North Carolina Institute of Environmental Health and Sciences focused on farmers as occupational pesticide applicators and reported the findings in Medscape. Combining data from the Agricultural Health Study (AHS) and the United States Renal Disease Data System (USRDS), Professor Sandler’s team enabled the researchers to identify pesticide users with ESRD in North Carolina and Iowa from 1993-1997 through 2011 from the registry. Of the more than 55,000 registrants enrolled, 320 developed ESRD after nearly 16 years of follow-up, for an incidence rate of 36.6/100,000 people/year. Of those registrants who completed the take-home questionnaire, 136 developed ESRD (incidence rate of 35.1/100,000/year). Factors found to be associated with increased risk of ESRD included obesity, low education, history of diabetes, history of hypertension, and history of kidney disease. Hospitalization due to pesticide use and more than 1 visit to a physician for the same reason predicted a higher risk of ESRD. Insecticides and herbicides, ipratropium, paraquat, ipratropium, atrazine, and alachlor showed trends in exposure response. This study showed an increased risk of kidney failure in occupational pesticide applicators chronically exposed to a pesticide. Both short-term acute accidental exposure leading to medical visit behavior and chronic low-level exposure to the same pesticides may increase the risk of developing kidney disease. This study adds to the evidence that pesticides may play a role in the development and progression of CKD to ESRD. While diabetes and obesity are major contributors to ESRD in the United States, not everyone with this condition will develop kidney failure.