J.Univ.

Ruhuna 2014 2:1-3

EDITORIAL

Chronic kidney disease of unknown etiology: Mystery unsolved

New form of chronic kidney disease (CKD) that renal failure (Abeysekera, 1996). Chandrajith et al.,
cannot be attributed to diabetes, hypertension, (2011) reported that higher fluoride levels are
primary glomerular nephrities or other known common in drinking water not only in disease
etiologies has encountered in the predominantly prevalent areas but also in other areas unaffected by
agricultural areas in the Northern Central Province of the disease, nevertheless they have observed greater
Sri Lanka. It has reached epidemic proportions with incidence of the disease in areas where calcium
ever increasing numbers of patients and deaths, thus carbonate hardness in groundwater is high.
becoming a new and emerging health issue Chandrajith et al., (2010) have also shown that
(Athuraliya et al., 2003, 2006; Chandrajith, et al., nephrotoxic metals such as Cd, U and Al could be
2009, 2011; Jayasumana et al., 2011) that would eliminated as causative agents on account of their
eventually inflict adverse consequences on national very low presence in water. Hypothesis that
food security, merely for the fact that affected microcystis, the toxin produced by certain species of
populations constitute major rice farming freshwater cyanobacteria present in reservoir waters,
communities in Sri Lanka. This disease exclusively is the causative agent of CKDu was not supported as
occurs in settlements where groundwater is the main no evidence was available for their abundant
source of drinking water and it is more common presence in well water, the source of drinking water
among members of lower socio-economic strata, for majority of CKDu patients. On the contrary,
particularly the farmers. Due to its unique inhabitants in disease endemic areas who use
geographical distribution and histopathological reservoir water for drinking were not affected with
evidence, causality has been speculated to be an the disease. Evidence is emerging that the potential
environmentally induced problem (Chandrajith et al., causative agent of CKDu in Mahawilachchiya and
2011; Wanigasuriya et al., 2007), that is observed Padaviya areas may be the presence of arsenic (As) in
not only in Sri Lanka but also in most other groundwater (100-200 μg/L) as arsenic poisoning
developing countries where agriculture is the primary symptoms, i.e. hyper-pigmentation and keratosis in
means of income (Nahas and Belle, 2005). palms and soles, presence of high As content in hair
(3-10 mg/kg) and body parts of deceased CKDu
Etiology of this disease has since been attributed to a patients have been reported (Jayasumana, 2011;
range of causes, including presence of the heavy Jayasumana et al., 2012).
metal cadmium in water that would potentially have
introduced to water from inorganic fertilizer used in These preliminary investigations have also revealed
paddy fields (Bandara et al., 2010, 2008), presence of high mercury (Hg) levels in groundwater (10-30
excessive amounts of fluoride in drinking water and μg/L). As- content in rice produced in the endemic
prevalent use of low quality aluminum utensils areas have been detected to be as high as 100-500
(Herath et al., 2005), presence of toxins produced by μg/kg (Chandrajith et al., 2010; Jayasumana, 2011)
microorganisms such as cyanobacteria in water and and this could be another potential means through
presence of radionuclides introduced by inorganic which As enters human body, as reported in
fertilizer (Chandrajith et al., 2011). Despite the said Bangladesh where the highest number of As-
research efforts over the last decade, none of these poisoning cases due to consumption of As-polluted
hypotheses have been supported with adequate groundwater and rice has been found (Naha & Belle,
evidence. Therefore, causative factors and etiology of 2005). It has also been observed that the number of
this chronic kidney disease is still considered CKDu patients recorded had a marked positive
uncertain or unknown and abbreviated as CKDu. As relationship with the extent of ground water hardness
there is no cure available in the system of western and soil type that presumed to have high heavy metal
medicine for CKDu, prevention is of utmost retention capacity due to their unique chemical
importance. Prevention or/and cure in turn, is property, high cation exchange capacity
impossible a task without adequate knowledge on (Amarasinghe, 2004; Jayasumana, 2011; Fonseka et
causality of the disease and mechanisms leading to al., 2012).

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Above observations suggest the potential causative agents such as nephrotoxic agrochemicals, arsenic
factors for the unique distribution of CKDu, i.e. and cadmium and their effects may be similar.
effect of groundwater hardness, presence of arsenic However, it is clear that affected farming
in water and type of soil on human health and also communities have no direct access to the clean water.
their socio-economic status need further Water may be an important carrier of the causative
investigations to produce data from other parts of agent and therefore, clean water supply in the disease
CKDu endemic areas. No studies are reported on prevalent areas should be given the priority. In
effect of climate and its envisaged change on addition, short, medium and long term strategies
catchment hydrology, groundwater quality and proposed by the WHO report in 2013 should be given
movement as well as factors affecting pollutant due recognition and implementation of
distribution within water tables. Besides, some recommendations should commence without further
studies have shown that the presence of arsenic in delay. It is speculated that the mystery of the disease
pesticides and fertilizer imported to Sri Lanka and its etiology will remain unsolved for decades, but
(Paranagama et al., 2012; Jayasumana et al., 2012) precautions and strategies to prevent CKDu is
despite importation of As and Hg containing prerequisite.
pesticides is illegal according to the Pesticides
Control Act of 1981. Fertilizers contain considerable References
amounts of As and other heavy metals as impurities.
The most recent evidence on the etiology of CKDu is 1. Abeysekera D.T.D.J., Kaiyoom S.A.A. and
contained in the interim reports and final report of the Dissanayake S.U. (1996). Place of peritoneal
investigations carried out in Padaviya area in dialysis in the management of renal failure
Anuradhapura District by the WHO (2013) and it patients admitted to General Hospital Kandy.
states that nephrotoxic agrochemicals, arsenic and Kandy Society of Medicine 18th Annual
cadmium are the most potential causative agents of Academic Conference.
CKDu as they have found above normal levels of 2. Amarasinghe M.D., Liyanage J.and Nirbadha
arsenic and cadmium levels in hair, nails and urine of K.G.S. (2004). Presence of heavy metals in
the CKDu patients. Recent studies show that plants of a tropical wetland in Sri Lanka, as an
cadmium exposure through rice in Sri Lanka is indicator of their phytoremediation potential.
remarkably high compared to the other Asian rice Proc. World Conference on Environmental
producing nations (Meherg et al., 2013). New Management. Universiti Kebangsaan Malaysia.
hypothesis of Glyphosate and nephrotoxic metals 3. Athuraliya T.N.C., Abeysekera D.T.D.J.,
forming complexes with hard water is emerging Amerasinghe P.H., Kumarasiri P.V.R. and
(Jayasumana et al., 2014) and backed by the WHO Dissanayake V. (2009). Prevalence of chronic
report where residues of glyphosates and its kidney disease in two tertiary care hospitals:
degradation products were recorded in urine samples. high proportion of cases with uncertain etiology.
Ceylon Medical Journal, 54(1): 23-25.
CKDu is slowly progressive and starting second 4. Athuraliya T.N.C, Abeysekera.T,
decade of life in other parts of the country. It should AmerasingheP.H., Kumarasiri R., Abeysekera
be noted that it was asymptomatic until it reach C., Gooneratna A. and Bandara P. (2003). A
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emerging within farming communities in Southern Report.
and adjacent lower part of the Uva province. 5. Bandara J.M., Senevirathna D.M., Dasanayake
Increasing number of patients has been reported in D.M., Herath V., Bandara J.M., Abeysekara T.
Wellawaya, Thelulla and Thanamalwila in Uva and Rajapaksha K.H. (2008). Chronic renal
provinve and Thissamaharamaya and failure among farmer families in cascade
Lunugamwehera in Southern province. Biogeography irrigation systems in Sri Lanka associated with
and environmental variables of Southern and Uva elevated dietary cadmium levels in rice and
provinces may significantly differ from the North freshwater fish (Tilapia). Environ Geochem
Central province, nevertheless potential causative Health 30(5):465-78.

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6. Chandrajith R., Dissanayake C.B., Ariyarathna 10. Meharg, A.A., Norton G., Deacon C., Williams
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(2011). Dose-dependent Na and Ca in fluoride- F., McGrath S., Villada A., Sommella A.,
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chronic renal failure in tropical arid regions. Dasgupta T., and Islam M.R. (2013). Variation
Science of the Total Environment 409: 671–675. in rice cadmium related to human Exposure.
7. Chandrajith R., Senevirathne S., Environ. Sci. Technol. 47: 5613-5618.
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metals: Are they the culprits behind the epidemic chronic kidney disease of uncertain etiology in
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P. Mangala C. S. De Silva
Department of Zoology
Faculty of Science, University of Ruhuna,
Matara, Sri Lanka.
Correspondence: [email protected]