Increase in the prevalence of chronic kidney disease (CKD) is observed in Central America, Sri Lanka and other tropical countries. It is named chronic interstitial nephritis in agricultural communities (CINAC). CINAC is defined as a form of CKD that affects mainly young men, occasionally women. Its aetiology is not linked to diabetes, hypertension, glomerulopathies or other known causes. CINAC patients live and work in poor agricultural communities located in CINAC endemic areas with a hot tropical climate, and are exposed to toxic agrochemicals through work, by ingestion of contaminated food and water, or by inhalation. The disease is characterized by low or absent proteinuria, small kidneys with irregular contours in CKD stages 3–4 presenting tubulo-interstitial lesions and glomerulosclerosis at renal biopsy. Although the aetiology of CINAC is unclear, it appears to be multifactorial. Two hypotheses emphasizing different primary triggers have been proposed: one related to toxic exposures in the agricultural communities, the other related to heat stress with repeated episodes of dehydration heath stress and dehydration. Existing evidence supports occupational and environmental toxins as the primary trigger. The heat stress and dehydration hypothesis, however, cannot explain: why the incidence of CINAC went up along with increasing mechanization of paddy farming in the 1990s; the non-existence of CINAC in hotter northern Sri Lanka, Cuba and Myanmar where agrochemicals are sparsely used; the mosaic geographical pattern in CINAC endemic areas; the presence of CINAC among women, children and adolescents who are not exposed to the harsh working conditions; and the observed extra renal manifestations of CINAC. This indicates that heat stress and dehydration may be a contributory or even a necessary risk factor, but which is not able to cause CINAC by itself.

Chronic interstitial nephritis in agricultural communities: a worldwide epidemic with social, occupational and environmental determinants.

CKD, with its high prevalence, morbidity and mortality, is an important public health problem With <3% of land mass, India hosts 17% of the Earth’s population Large numbers of patients below the poverty line, low gross domestic product, and low monetary allocations for health care have led to

Chronic Kidney Disease in India A Clarion Call for Change

Tracing environmental aetiological factors of chronic kidney diseases in the dry zone of Sri Lanka-A hydrogeochemical and isotope approach.

Since at least two decades, Chronic Kidney Disease of Uncertain Etiology (CKDu) has become an increasingly discussed health issue in Sri Lanka and as well as in other tropical regions. Areas that are particularly affected with the disease are mostly located in the dry zone of Sri Lanka. The disease is more prominent among communities that consume groundwater as their main source of drinking water. Hydrogeochemical investigations were carried out in the Ginnoruwa area, a known hotspot of CKDu. It revealed possible links between drinking water chemistry and the spreading of the disease. This work compares hydrogeochemical data of drinking water sources of wells whose consumers are affected by CKDu and other nearby wells whose consumers were not affected by the disease. A total of 63 groundwater samples were collected from selected wells. About one-third of these samples (i.e., 19) were collected from wells used by CKDu patients. Significantly higher values of pH, total hardness, electrical conductivity, Ca2+, Mg2+, F−, Cl−, PO43−, and SO42− were found in wells that were used by CKDu patients. Mean contents of Na+, Ca2+, and Mg2+ in CKDu affected wells were 33.8 mg/L, 30.1 mg/L, and 14.9 mg/L, respectively, compared to 23.1 mg/L, 26.7 mg/L, and 9.65 mg/L in non-CKDu wells. Differences in major ion geochemistry in groundwaters are possibly governed by variable time periods of water storage in fractured hard rock aquifers in this region. Hydrogeochemical parameters were statistically compared by a Mann–Whitney U test and indicated significant differences in total dissolved solids (TDS) (p = 0.016), SO42− (p = 0.005), PO43− (p = 0.030), F− (p = 0.048), Na+ (p = 0.008), and Mg2+(p = 0.008) between non-CKDu and CKDu wells at p = 0.050 level. Other suspected solutes such as nephrotoxic trace elements including As, Cd, and Pb were similar in both types of wells. They were also lower than the accepted guideline limits of the World Health Organization (WHO). Results of this study suggest that fluoride in drinking water in combination with water hardness may be one of the responsible factors for kidney damage and progression of the disease. This may be particularly the case when elevated amounts of Mg2+ are present in hard groundwater.

Possible links between groundwater geochemistry and chronic kidney disease of unknown etiology (CKDu): an investigation from the Ginnoruwa region in Sri Lanka

This study investigated the water quality of the groundwater that was collected from the chronic kidney disease of unknown etiology (CKDu) prevailing areas in the dry zone of Sri Lanka to assess its suitability for drinking purposes, and for the first time a Water Quality Index (WQI) with emphasis on proposing appropriate drinking water treatment method was developed. A total of 88 groundwater samples were collected in dry (December 2016) and wet (May 2017) seasons; high concentrations of water hardness, fluoride, salinity, dissolved organic carbon (DOC), and the general alkaline nature of water were the main issues that were observed for disease incidence. The chemical weathering of the underlying bedrock, followed by ion exchange and precipitation processes, primarily controlled groundwater geochemistry. During the 1985-2017 period, the variations of the annual rainfall and temperature were minimal, which suggests no evidence for major climatic changes within the study areas. Almost all of the samples from the CKDu regions show a low alkali hazard and most of the samples show a medium to high salinity hazard. The DOC of the studied samples was mainly composed of the organic fractions in the following order, as fulvic acids > humic acids > aromatic protein II > soluble microbial by-products, and the molecular weights (MW) of these fractions ranged from 100-3000 Da. Based on the water quality index (WQI) calculations, it was found that only 3.8% in the wet season and 2.6% in the dry season of total water samples were categorized as the "excellent" type, and all other water sources require a further treatment before consumption. As there is an urgent need for establishing proper long-term drinking water treatment technology for the CKDu affected area, these findings can be used as benchmark of raw water quality in the design processes of treatment plants.

https://www.mdpi.com/1660-4601/16/10/1698/pdf

Assessment of Groundwater Quality in CKDu Affected Areas of Sri Lanka: Implications for Drinking Water Treatment.

https://www.jstage.jst.go.jp/article/jea/advpub/0/advpub_JE20140074/_pdf

Epidemiology of chronic kidney disease, with special emphasis on chronic kidney disease of uncertain etiology, in the north central region of Sri Lanka.

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Epidemiology of chronic kidney disease, with special emphasis on chronic kidney disease of uncertain etiology, in the north central region of Sri Lanka.