Chronic kidney disease of unknown aetiology and ground-water ionicity: study based on Sri Lanka

Seasonal sensitivity of groundwater dissolved organic matter in recognition of chronic kidney disease of unknown etiology: Optical and molecular perspectives

Chronic kidney disease of unknown etiology (CKDu) has aroused a great concern due to its widespread prevalence in many developing countries. Dissolved organic matter (DOM) has been proved to be associated with CKDu in groundwater. However, the responses of their association to abiotic influencing factors like seasonal variation are not carefully disclosed. Herein, we revealed the seasonal variation of DOM in CKDu related groundwater (CKDu groundwater) and control group (non-CKDu groundwater) collected from Sri Lanka during the dry and wet seasons by excitation-emission matrix spectroscopy and Fourier transform ion cyclotron resonance mass spectrometry. In both CKDu and non-CKDu groundwaters, the input of exogenous DOM during wet season improved the degree of humification and molecular weight of DOM, while oxidative processes during the dry season increased the ratios of oxygen to carbon (O/C). Furthermore, compared with non-CKDu groundwater, more DOM with high O/C enriched in CKDu groundwater during the dry season, indicating stronger oxidative processes in CKDu groundwater. It may result in the enrichment of carboxyl group and induce the enhanced leaching of CKDu-related Si and F-. The receiver operating characteristic (ROC) analysis showed that the CKDu-recognition ability of most optical and molecular indicators was susceptible to seasonal factors and their recognition abilities were stronger in the wet season. The linkage between DOM and CKDu was affected by seasonal factors through the occurrence, mobility, degradation, and toxicity of typical organic molecules (e.g., C17H18O10S). The study provides a new insight into screening pathogenic factors of other endemic diseases related to organic molecules.

Ingested nitrate and nitrite and end-stage renal disease in licensed pesticide applicators and spouses in the Agricultural Health Study

BACKGROUND

Nitrate and nitrite ingestion has been linked to kidney cancer, possibly via the endogenous formation of carcinogenic N-nitroso compounds. These exposures might also contribute to end-stage renal disease (ESRD).

OBJECTIVES

We investigated associations of drinking water nitrate and dietary nitrate and nitrite intakes (total and by food type) with incident ESRD in the Agricultural Health Study. We also explored modifying effects of vitamin C and heme iron intake, which may affect endogenous nitrosation.

METHODS

We performed complete case analyses among private pesticide applicators and their spouses. We obtained water nitrate estimates for participants whose primary drinking water source at enrollment (1993-1997) was public water supplies (PWS) or private wells (N = 59,632). Average nitrate concentrations were computed from historical data for PWS users and predicted from random forest models for private well users. Analysis of dietary nitrate and nitrite was restricted to the 30,177 participants who completed the NCI Dietary History Questionnaire during follow-up (1999-2003). Incident ESRD through 2018 was ascertained through linkage with the U.S. Renal Data System. We estimated adjusted hazard ratios (HRs) and 95%CI for associations of tertiles (T) of exposure with ESRD overall and explored effects in strata of vitamin C and heme iron intake.

RESULTS

We identified 469 incident ESRD cases (206 for dietary analysis). Water nitrate and total dietary nitrate/nitrite were not associated with ESRD, but increased ESRD was associated with nitrate and nitrite from processed meats. We found apparent associations between nitrite and ESRD only among participants with vitamin C

SIGNIFICANCE

ESRD incidence was associated with dietary nitrate/nitrite from processed meat among all study participants and with total dietary nitrite among participants with lower vitamin C or higher heme iron intake.

IMPACT STATEMENT

There are few well-established environmental risk factors for end-stage renal disease (ESRD), a worldwide public health challenge. Ingestion of nitrate and nitrite, which may lead to endogenous formation of carcinogenic N-nitroso compounds, has been linked to some cancers and chronic diseases. We investigated these exposures in relation to ESRD in an agricultural cohort. ESRD incidence was associated with dietary nitrate/nitrite from processed meat and with total dietary nitrite among subgroups with lower vitamin C or higher heme iron intake. This study provides preliminary evidence that points to dietary nitrite and possibly dietary nitrate intake as a potential contributor to ESRD.

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Key Words

• Chronic kidney disease
• End-stage renal disease
• Nitrate
• Nitrite
• Processed meat
• Water pollution

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MESH Headings

• Humans
• Nitrates/analysis
• Kidney Failure, Chronic/epidemiology
• Kidney Failure, Chronic/chemically induced
• Male
• Nitrites/analysis
• Nitrites/adverse effects
• Female
• Middle Aged
• Spouses/statistics & numerical data
• Adult
• Pesticides
• Occupational Exposure/adverse effects
• Occupational Exposure/analysis
• Aged
• Drinking Water/chemistry
• Drinking Water/analysis
• Incidence
• Agriculture
• Diet/statistics & numerical data
• Farmers/statistics & numerical data
• Ascorbic Acid

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Affiliation(s)

Dazhe Chen Epidemiology Branch, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, NC, USA
Christine G Parks Epidemiology Branch, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, NC, USA
Laura E Beane Freeman Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
Jonathan N Hofmann Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
Rashmi Sinha Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
Jessica M Madrigal Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
Mary H Ward Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
Dale P Sandler Epidemiology Branch, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, NC, USA.

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Food-mediated exposure of Hofmeister ions in Oryza sativa (Rice) from selected CKDu endemic regions in Sri Lanka

The objectives of this study were to determine selected Hofmeister anions and cations that are important for kidney health, in raw rice samples from selected Chronic Kidney Disease of unknown etiology (CKDu) endemic and non-endemic areas in Sri Lanka and their intake. The anions and cations were analyzed by Ion Chromatography and Microwave Plasma Atomic Emission Spectrometry (MP-AES), respectively, after alkaline and acid digestion in thirty raw rice samples each from CKDu endemic and non-endemic areas, and the dietary intake was estimated. The mean concentrations of fluoride (F-), chloride (Cl-), phosphate (PO43-), sulfate (SO42-), sodium (Na+), magnesium (Mg2+), potassium (K+), and calcium (Ca2+) in raw rice in CKDu endemic areas were 53.317, 1515.3, 2799.6, 2704.9, 30.603, 300.76, 1001.3, and 90.075 mg/kg, respectively. The mean concentration of the anions and cations in raw rice from CKDu non-endemic areas were 22.850, 947.52, 4418.7, 6080.2, 23.862, 364.45, 955.78, and 96.780 mg/kg, respectively. Significantly higher differences (p < 0.05) were reported in the mean concentration of F-, Cl-, and Na+ in raw rice from CKDu endemic areas in comparison with the samples from non-endemic areas. The aggregated estimated daily intake (EDI) and cumulative EDI of F- via consumption of cooked non-traditional samba rice from CKDu endemic areas for adults were the highest (0.155 and 0.172 mg/kg bw/d, respectively), which were higher than the recommended tolerable upper intake value (0.15-0.2 mg/kg bw/d). In contrast, the traditional rice from CKDu non-endemic areas for adolescents, reported the lowest values (0.0210 and 0.0470 mg/kg bw/d, respectively). Adults who consume non-traditional samba rice from CKDu endemic areas were at health risk, while children were the most vulnerable group due to their low body weight. These results indicate that the consumption of rice rich in Hofmeister ions may contribute to the total intake and act as risk factors to negatively affect weak kidneys in CKDu endemic areas. Further research to analyze Hofmeister ions in cooked rice and rice from different countries is recommended.

Hydrogeochemical characterization of groundwater with a focus on Hofmeister ions and water quality status in CKDu endemic and CKDu non‒endemic areas, Sri Lanka

Hydro-geochemistry of drinking water was characterized in chronic kidney disease of unknown etiology (CKDu) endemic areas in Girandurukotte (GK) and Dehiattakandiya (DH) and non-endemic areas in GK, DH, and Sewanagala (SW) in Sri Lanka to comprehend any potential risk factors for CKDu. Groundwater (n = 142) and surface water (n = 08) were sampled during wet and dry seasons and analyzed for major anions, cations and stable isotopes of hydrogen and oxygen (δ²H and δ¹⁸O). Besides the typical water quality analysis, the water quality status was determined using the weighted arithmetic water quality index (WQI) and Hofmeister ion exposure levels. The measured average groundwater F^- level was higher than the permissible level assigned by regulatory agencies for tropical countries at CKDu locations in GK, DH and non-CKDu locations in DH and SW. Significant differences in the content of total hardness (p = 0.017) and total dissolved solids (p = 0.003) were observed between CKDu and non-CKDu locations whereas the differences were insignificant for F^- (p = 0.985) and alkalinity (p = 0.203). Weathering of silicate and carbonate minerals was found to be the main governing factor of groundwater compositions in both CKDu and non-CKDu areas, while recharging of groundwater is mainly determined by the rainfall than the surface water inputs. Higher ionic strength of groundwater in non-CKDu areas suggested that the potential environmental CKDu risk factors might be suppressed from dissolution into groundwater. The WQI calculations revealed that the both CKDu and non-CKDu locations were frequently presented with poor water quality. This study highlights the water quality status of the CKDu and non-CKDu locations and signifies the potential health risks that could arise even in non-CKDu areas due to the consumption of poor quality water. Accordingly, regular monitoring of water quality and assessment of Hofmeister ions exposure from food and beverages are highly warranted.

Hydrogeochemical factors controlling the occurrence of chronic kidney disease of unknown etiology (CKDu)

Chronic kidney disease of unknown etiology (CKDu) has posed a serious threat to human health around the world. The link between the prevalence of CKDu and groundwater geochemistry is not well understood. To identify the potential geogenic risk factors, we collected 52 groundwater samples related to CKDu (CKDu groundwater) and 18 groundwater samples related to non-CKDu (non-CKDu groundwater) from the typical CKDu prevailing areas in Sri Lanka. Results demonstrated that CKDu groundwater had significantly higher Si (average 30.1 mg/L, p < 0.05) and F^- (average 0.80 mg/L, p < 0.05) concentrations than those of non-CKDu groundwater (average 21.0 and 0.45 mg/L, respectively), indicating that Si and F^- were the potential risk factors causing CKDu. The principal hydrogeochemical process controlling local groundwater chemistry was chemical weathering of silicates in Precambrian metamorphic rocks. Groundwater samples were mostly undersaturated with respect to amorphous silica and clay minerals such as talc and sepiolite, which was conducive to silicate weathering and elevated Si concentrations in groundwater. Decreased Ca²⁺ being facilitated by calcite precipitation and cation exchange between Ca²⁺ and Na⁺ favored fluorite dissolution and thus led to high groundwater F^- concentrations. Competitive adsorption between [Formula: see text] and F^- also enhanced the release of F^- from solid surfaces. This study highlights the CKDu potential risk factors regarding groundwater geochemistry and their enrichment factors, which helps in preventing the prevalence of CKDu.

The blending effect of natural polysaccharides with nano-zirconia towards the removal of fluoride and arsenate from water

Nano-zirconia (ZO) was synthesized using a microwave-assisted one-pot precipitation route. Two biopolymers, chitosan (CTS) and carboxymethyl cellulose were blended with ZO at different w/w ratios. The formulation with 30% w/w chitosan (ZO-CTS) was found to give enhanced uptake of F^- and As(V). ZO and the most effective ZO-CTS system were characterized using Fourier transform infrared spectroscopy, scanning electron microscopy, X-ray diffraction and X-ray photoelectron spectroscopy. These confirmed the formation of a composite system containing nanoparticles of 50 nm in size, in which ZO was present in the amorphous form. It was observed that the combination of ZO with CTS improved the F^- and As(V) adsorption capacity most notably at pH 5.5. Fluoride adsorption by ZO-CTS followed the Freundlich isotherm model, with an adsorption capacity of 120 mg g^-1. Adsorption of As(V) by ZO-CTS could be fitted with both the Langmuir and Freundlich isotherm models and was found to have a capacity of 14.8 mg g^-1. Gravity filtration studies conducted for groundwater levels indicated the effectiveness of ZO-CTS in adsorbing As(V) and F^- at a pH of 5.5. The ability of the ZO-CTS in removing Cd(II) and Pb(II) was also investigated, and no such enhancement was observed, and found the neat ZO was the most potent sorbent here.

Intake of fluoride and other Hofmeister ions from black tea consumption in CKDu prevalent areas, Sri Lanka

Dietary exposure of selected Hofmeister ions-fluoride, chloride, sulfate, phosphate, sodium, potassium, magnesium, and calcium from black tea consumption in chronic kidney disease of unknown etiology (CKDu) prevalent areas in Sri Lanka-were assessed in order to understand exposure and risk. Black tea samples (n = 25) were collected from CKDu prevalent areas and control areas (n = 15). Total fluoride content in alkali fused digested black tea samples was determined. The available Hofmeister ions in tea infusions prepared using deionized water and the groundwater collected by CKDu endemic areas were compared. Dietary exposure was calculated by chronic daily intake data. Total fluoride concentrations ranged from 80 to 269 mg/kg in tea collected from the CKDu endemic regions and 62.5-123.5 mg/kg in non-endemic regions. The fluoride content in infusions ranged from 1.45 to 2.04 mg/L in CKDu endemic areas and 1.11-1.38 mg/L in control samples. The infusions prepared with local groundwater from the CKDu endemic areas showed an elevated level of fluoride 95% than that of the infusion prepared using same tea with deionized water. Aggregated chronic daily intake value from tea and groundwater exceeds the estimated adequate daily intake value of fluoride. The hazard quotient (HQ) values of fluoride in 5 min and 120 min tea infusions were 1.60 and 2.20, respectively, and indicate an adverse health risk. Potassium content in tea infusions collected from CKDu endemic areas is higher than in the control. Even though these values are less than the adequate intake, it may pose an impairment on a weak kidney. Chronic daily intake of Hofmeister ions, i.e., fluoride and potassium from black tea consumed in CKDu endemic areas may induce a risk for CKDu.

Randomized control trial of prednisolone and doxycycline in patients with acute interstitial nephritis of unknown aetiology

BACKGROUND

Patients presenting with acute interstitial nephritis (AIN) of unknown aetiology, probably the earliest presentation of chronic kidney disease of unknown aetiology (CKDu), have been treated with oral prednisolone and doxycycline by physicians in Sri Lanka. This trial assessed the effectiveness of prednisolone and doxycycline based on eGFR changes at 6 months in patients with AIN of unknown aetiology.

METHOD

A randomized clinical trial with a 2 × 2 factorial design for patients presenting with AIN of unknown aetiology (n = 59) was enacted to compare treatments with; A-prednisolone, B-doxycycline, C-both treatments together, and D-neither. The primary outcome was a recovery of patients' presenting renal function to eGFR categories: 61-90 ml/min/1.73m² (complete remission- CR) to 31-60 ml/min/1.73m² (partial remission- PR) and 0-30 ml/min/1.73m² no remission (NR) by 6 months. A secondary outcome was progression-free survival (not reaching < 30 ml/min/1.73m² eGFR), by 6-36 months. Analysis was by intention to treat.

RESULTS

Seventy patients compatible with a clinical diagnosis of AIN were biopsied for eligibility; 59 AIN of unknown aetiology were enrolled, A = 15, B = 15, C = 14 and D = 15 randomly allocated to each group. Baseline characteristics were similar between groups. The number of patients with CR, PR and NR, respectively, by 6 months, in group A 3:8:2, group B 2:8:3 and group C 8:5:0 was compared with group D 8:6:1. There were no significant differences found between groups A vs. D (p = 0.2), B vs. D (p = 0.1) and C vs. D (p = 0.4). In an exploratory analysis, progression-free survival in prednisolone-treated (A + C) arms was 0/29 (100%) in comparison to 25/30 (83%) in those not so treated (B + D) arms, and the log-rank test was p = 0.02, whereas no such difference found (p = 0.60) between doxycycline-treated (B + C) arms 27/29 (93%) vs those not so treated (A + D) arms 27/30 (90%).

CONCLUSION

Prednisolone and doxycycline were not beneficial for the earliest presentation of CKDu at 6 months. However, there is a potential benefit of prednisolone on the long-term outcome of CKDu. An adequately powered steroid trial using patients reaching < 30 ml/min/1.73m² eGFR by 3 years, as an outcome is warranted for AIN of unknown aetiology.

TRIAL REGISTRATION

Sri Lanka Clinical Trial Registry SLCTR/2014/007, Registered on the 31st of March 2014.

Exposure to Sri Lanka's local groundwater in a CKDu prevalent area causes kidney damage in zebrafish

How local groundwater induces chronic kidney disease of unknown etiology (CKDu) in Sri Lanka is still elusive. This study aims to elucidate the impacts of Sri Lanka's local groundwater in a CKDu prevalent area and reveal the possible pathogenic mechanism of CKDu using zebrafish models. The drinking water from the local underground well in Vavuniya was sampled and the water quality parameters including Na⁺, Mg²⁺, K⁺, Ca²⁺, Cl^-, NO^3-, SO₄^2-, and F^- were analyzed. Then, local groundwater exposure to zebrafish larvae and 293T cells was performed, and water with high hardness and fluoride was prepared as parallel groups. Our result showed that exposure to Sri Lanka's local groundwater caused developmental toxicity, kidney damage, and pronephric duct obstruction as well as abnormal behavior in zebrafish. Similar results were also found after exposure to water with high hardness and fluoride in zebrafish. Further, the expression levels of marker genes related to renal development and functions (foxj1a, dync2h1, pkd2, gata3, and slc20a1) were significantly altered, which is also confirmed in the 293T cells. Taken together, those results indicated that Sri Lanka's local groundwater in a CKDu prevalent area could cause kidney damage, implying that high water hardness and fluorine might be the inducible environmental factors for the etiological cause of CKDu.

The position of geochemical variables as causal co-factors of diseases of unknown aetiology

Abstract

The term diseases of unknown aetiology (DUA) or idiopathic diseases is used to describe diseases that are of uncertain or unknown cause or origin. Among plausible geoenvironmental co-factors in causation of DUA, this article focusses on the entry of trace elements, including metals and metalloids into humans, and their involvement in humoral and cellular immune responses, representing potentially toxic agents with implications as co-factors for certain DUA. Several trace elements/metals/metalloids (micronutrients) play vital roles as co-factors for essential enzymes and antioxidant molecules, thus, conferring protection against disease. However, inborn errors of trace element/metal/metalloid metabolisms can occur to produce toxicity, such as when there are basic defects in the element transport mechanism. Ultimately, it is the amount of trace element, metal or metalloid that is taken up, its mode of accumulation in human tissues, and related geomedical attributes such as the chemical form and bioavailability that decisively determine whether the exerted effects are toxic or beneficial. Several case descriptions of DUA that are common worldwide are given to illustrate our knowledge so far of how trace element/metal/metalloid interactions in the immune system may engender its dysregulation and be implicated as causal co-factors of DUA.

Article highlights

The importance of a proper understanding of geochemical perturbations in human metabolisms is emphasisedIt is proferred that such an understanding would aid greatly in the decipherment of diseases of unknown aetiology (DUA)The thesis presented may pave the way towards better diagnosis and therapy of DUA.

Groundwater-Based Drinking Water Supply in Sri Lanka: Status and Perspectives

Drinking water is largely from groundwater in Sri Lanka, so quality management is of great concern. In order to achieve the 6th goal of United Nations (UN) Sustainable Development Goals (SDG), more efforts are being undertaken to secure drinking water quality. In this paper, the current status, challenges and opportunities of groundwater quality management and improvement in Sri Lanka were reviewed and discussed, based on previous studies. There are Ca-HCO3 type, Ca–Mg-HCO3 type and Na–SO4–Cl type groundwater dominated in the wet zone, intermediate and the dry zone, respectively. Elevated levels of hardness, fluoride, DOC, and alkalinity, and salinity are reported in the groundwater in the dry zone controlled by geology and arid climate. Although groundwater in some regions contain significant levels of nitrates, arsenic, cadmium and lead, the majority remain at acceptable levels for drinking purposes. As for treatment technologies, existing membrane-based drinking water treatment technologies such as RO (Reverse Osmosis) stations can produce safe and clean drinking water to the community, but this has still a limited coverage. To achieve a safe drinking water supply for all, especially in rural communities of Sri Lanka under the 6th goal of the UN SDG, more efforts in building up the infrastructure and man power are needed to monitor and assess groundwater quality regularly so as to develop management strategies. Research and development can be directed towards more cost-effective water treatment technologies. Protection of groundwater from being polluted, and educational and awareness programs for the stakeholders are also essential tasks in the future.

Chronic kidney disease of unknown etiology in India: a comparative study with Mesoamerican and Sri Lankan nephropathy

Chronic kidney disease of unknown etiology [CKDu] is a condition characterized by decline in kidney function and is not associated with diabetic nephropathy or hypertensive nephropathy. In this review, we have done a detailed literature analysis on CKDu in India, and then had a comparison with that of Mesoamerica and Sri Lanka. In India, CKDu became the second most common type of CKD after diabetic nephropathy. Silica was seen in the groundwater of both India and Sri Lanka, whereas in Mesoamerica silica exposure through particulate matter was seen among CKDu communities. DDE is a common agrochemical seen in both India and Sri Lanka. The risk factors vary from region to region and it is important to categorize CKDu population based on the risk factors to avoid misinterpretation of the condition as non-CKDu category and to evade further complications. More studies have to be conducted to reveal the detailed pathophysiological mechanisms and its relation with irrational exploitation of environmental resources.

Chronic Kidney Disease of Uncertain Etiology in Sri Lanka: Curing between Medicine and Traditional Culture

Chronic Kidney Disease of unknown origin (CKDu) has appeared across Sri Lanka’s North Central Province (NCP) since the 1990s as an epidemic, unexplained by conventional associated risk factors. During the past few decades, a large number of studies attempted to determine the unknown etiology of CKDu. Despite these investigations, no concrete conclusions were developed, though a number of contradictory hypotheses emerged. The present ethnographic study was carried out in two endemic areas, labelled as “CKDu hotspots”, and illuminates how curing takes place between biomedicine and traditional cultural practices. Our ethnographic study thoroughly scrutinized three decades of lived experience, lay-perceptions and local discourses on CKDu. We used a qualitative study design with a transcendental phenomenological approach and employed a mixture of ethnographic methods. Data collection techniques included participant observation, in-depth interviews, focus group discussions and key informant interviews. Data was analysed by using an interpretive thematic analysis model. Findings revealed that lay people have constructed a popular discourse on CKDu, and we explored their views on the origin, etiology and prevalence of CKDu in their locality over the past few decades. Patients’ narratives revealed that there were currently a number of gaps in service delivery. These were mainly due to distant relationships between healthcare providers and CKDu patients. Lay people in affected communities were marginalized throughout the investigation process to determine the unknown etiology, their involvement marginalized to merely acting as objects for scientific instigation. The affected communities strongly believed that CKDu was a recent phenomenon resulting from the mismanagement of the natural environment due to social and lifestyle changes. These findings highlight local dynamics of healthcare seeking behaviours which demand complementary medicine system, particularly given the number of limitations in the biomedical system. Empirical evidence generated from this study suggests a conceptual shift to an ethno-medical model to address CKDu. Improving cultural competency and communication skills among healthcare providers in public health are crucial in order to apply a “bio-psychosocial perspective” in healthcare delivery system and bridging the gap between hospital and the community.

Significance of Mg-hardness and fluoride in drinking water on chronic kidney disease of unknown etiology in Monaragala, Sri Lanka

The epidemic of chronic kidney disease of unknown etiology (CKDu) that contributes significantly to morbidity and mortality rates among dry-zonal farming communities has become a public health priority in Sri Lanka. Though a large number of hypotheses were introduced as causative factors, none of them have been confirmed so far. As drinking water quality is among the most suspected causative factors for the emergence of CKDu, a detailed hydro-geochemical investigation was carried out concurrently with the population screening in the Monaragala district of Sri Lanka where high incidences of CKDu are reported. A population screening was performed selecting 46,754 people using both dipstick proteinuria test and Albumin-Creatinine Ratio (ACR). The results revealed that the disease prevalence is about 6.7 % in the district. A total of 60 groundwater samples, 30 each, were collected from CKDu-prevalent locations and control locations where there are no CKDu cases reported. The samples were analyzed to identify any possible linkage between water quality and disease prevalence. Concentrations of hardness, F^-, Na^+, and Mg²⁺ in groundwater revealed a statistically significant difference between CKDu and control wells at a confident level of p = 0.05. The study revealed that alkali (Na⁺+K⁺) and alkaline earth cations (Mg²⁺, Ca²⁺, Sr²⁺, Ba²⁺) were relatively higher in drinking water sources used by CKDu patients, compared to the well waters used by healthy individuals. Nearly 87 % of the wells used by CKDu cases showed higher fluoride levels that exceed the threshold level (1.0 mg L^-1). Contents of nephrotoxic trace elements such as As, Cd, and Pb were found to be comparable in both types of wells and were well below the WHO permissible levels, thus negating their prime influence on the CKDu prevalence. It is obtrusive that the elevated fluoride levels together with water hardness associated with higher Mg²⁺ levels have a possible relation with CKDu and may influence the disease progression.

Multi-pronged research on endemic chronic kidney disease of unknown etiology in Sri Lanka: a systematic review

Increasing prevalence of endemic chronic kidney disease of unknown etiology (CKDu) in Sri Lanka is a major health problem since the 1990s. Despite numerous studies on CKDu, research groups have been unable to develop a comprehensive approach to mitigate the disorder, and thereby to identify research gaps. We conducted a systematic literature review of 119 publications on CKDu in Sri Lanka from Pubmed, Google Scholar, and Scopus, published until end September 2020. A higher CKDu prevalence in the working population of the North Central Province was reported with recent studies indicating patients from non-endemic regions as well. A majority were etiological studies that recorded conflicting and inconclusive evidence on CKDu etiology. Studies on clinico-pathological, diagnostic, biochemical, and molecular biological aspects of CKDu, studies analyzing CKDu symptom burden, anthropological, and behavioral impacts of CKDu, were reviewed as well. A dearth of research exists on nutritional, demographical, immunological, and microbial aspects of CKDu. The overview of the reviewed literature indicated the absence of a comprehensive plan of action to mitigate this situation. Hence, we propose the "One Health" approach with a systems dynamics model as a potential way forward to alleviate the CKDu epidemic in Sri Lanka. This enables the representation of multiple causative agents (and interactions thereof) among environmental, animal, and human systems, in concert with the "exposome" that provides the totality of exposure the individual has undergone since birth.

Risk factors for endemic chronic kidney disease of unknown etiology in Sri Lanka: Retrospect of water security in the dry zone

The prevalence of chronic kidney disease of unknown etiology (CKDu) is receiving considerable attention due to the serious threat to human health throughout the world. However, the roles of geo-socio-environmental factors in the prevalence of the CKDu endemic areas are still unknown. Sri Lanka is one of the countries most seriously affected by CKDu, where 10 out of 25 districts have been identified as the areas with the high prevalence of CKDu (10-20%). This review summarizes the geographical distribution of CKDu and its probable geochemical, behavioral, sociological, and environmental risk factors based on research related to hydrogeochemical influences on CKDu in Sri Lanka. More than 98% of CKDu patients have consumed groundwater as their primary water source in daily life, indicating the interactions of geogenic contaminants (such as F^-, total dissolved solids, Hofmeister ions) in groundwater is responsible for the disease. Apart from the hydrogeochemical factors, mycotoxins, cyanotoxins, use of some herbal medicines, dehydration, and exposure to agrochemicals were alleged as risk factors. Sociological factors, including poverty, living habits and anthropogenic activities, may also provoke the emergence of CKDu. Therefore, the interaction of geo-socio environmental risk factors should be sociologically and scientifically considered to prevent the prevalence of CKDu. Future in-depth studies are required to reveal the individual role of each of the postulated etiological factors, possibly using machine learning and advanced statistics.

The Groundwater Geochemistry and the Human Health Risk Assessment of Drinking Water in an Area with a High Prevalence of Chronic Kidney Disease of Unknown Etiology (CKDu), Sri Lanka

Chronic kidney disease of unknown etiology (CKDu) has become an alarming health issue in Sri Lanka. The disease is more notable among farming communities and people who consume groundwater as their main source of drinking water. To assess the possible links between drinking water chemistry and expansion of CKDu, the study was compared with hydrogeochemical data of drinking water sources in a CKDu prevalent area (Girandurukotte GND, Badulla District) and a reference area (Dambethalawa GND, Ampara District) in Sri Lanka. Based on the results, nephrotoxic heavy metal (Cd, Cr, Pb, and As) concentrations were significantly higher in the CKDu prevalent site than the reference area, compromised the harmful consequences to the people in the CKDu hotspot. Results of the inverse distance weighted (IDW) interpolation tool indicated the nephrotoxic heavy metals contents including Cd, Pb, As, and Cr in CKDu hotspot were changed in the ranges of 9.78–187.25 μg/L, 0.08–0.66 μg/L, 20.76–103.30 μg/L, and 0.03–0.34 μg/L. The random distribution patterns were shown by the result in Moran’s index values. Noteworthy, the results have emphasized a strong association between fluoride and water hardness. The frequency of occurrence above the threshold limit of fluoride was 28% in non-CKDu water samples, while 81% in CKDu prevalent sites. The hardness values in the CKDu prevalent site indicated “moderately hard water,” while the non-CKDu area indicated the “soft water.” Furthermore, this paper quantified overall water quality and heavy metal contamination and assessed the human health risks associated with drinking water. According to the results of the water quality index, 90% of the samples in the CKDu prevalent area were classified as “poor water” and “very poor water” for drinking purposes, while 73.33% of the samples in the non-CKDu area were “good” and “excellent” for drinking usage. Calculated chronic daily intake (CDIoral) and hazard quotient (HQoral) of nephrotoxicants were higher in CKDu hotspot than the non-CKDu site. Besides, the hazard index (HI) values obtained for the CKDu prevalent area exceeding the acceptable limit (HI = 1) indicated potential health risks to the people in those areas. This study suggests that long-term exposure to nephrotoxic heavy metals, water hardness, and fluoride present in drinking water may threaten human health and affect kidney functions. Therefore, regular monitoring and better management of water supplies in CKDu prevalent areas are essential to determine the contamination load and reduce the health impacts due to excessive and long-term exposure to the nephrotoxicants.

Natural and Anthropogenic Controls of Groundwater Quality in Sri Lanka: Implications for Chronic Kidney Disease of Unknown Etiology (CKDu)

Poor groundwater quality in household wells is hypothesized as being a potential contributor to chronic kidney disease of unknown etiology (CKDu) in Sri Lanka. However, the influencing factors of groundwater quality in Sri Lanka are rarely investigated at a national scale. Here, the spatial characteristics of groundwater geochemistry in Sri Lanka were described. The relationships of groundwater quality parameters with environmental factors, including lithology, land use, and climatic conditions, were further examined to identify the natural and anthropogenic controlling factors of groundwater quality in Sri Lanka. The results showed that groundwater geochemistry in Sri Lanka exhibited significant spatial heterogeneity. The high concentrations of NO3− were found in the districts that have a higher percentage of agricultural lands, especially in the regions in the coastal zone. Higher hardness and fluoride in groundwater were mainly observed in the dry zone. The concentrations of trace elements such as Cd, Pb, Cu, and Cr of all the samples were lower than the World Health Organization guideline values, while some the samples had higher As and Al concentrations above the guideline values. Principal component analysis identified four components that explained 73.2% of the total data variance, and the first component with high loadings of NO3−, hardness, As, and Cr suggested the effects of agricultural activities, while other components were primarily attributed to natural sources and processes. Further analyses found that water hardness, fluoride and As concentration had positive correlations with precipitation and negative correlations with air temperature. The concentration of NO3− and water hardness were positively correlated with agricultural lands, while As concentration was positively correlated with unconsolidated sediments. The environmental factors can account for 58% of the spatial variation in the overall groundwater geochemistry indicated by the results of redundancy analysis. The groundwater quality data in this study cannot identify whether groundwater quality is related to the occurrence of CKDu. However, these findings identify the coupled controls of lithology, land use, and climate on groundwater quality in Sri Lanka. Future research should be effectively designed to clarify the synergistic effect of different chemical constituents on CKDu.

Groundwater as a potential cause of Chronic Kidney Disease of unknown etiology (CKDu) in Sri Lanka: a review

The cause of Chronic Kidney Disease of unknown etiology (CKDu) in the rural dry zone of Sri Lanka remains unidentified, despite vast research efforts that brought about an extensive list of potential risk factors. Among these, the long-term exposure to various nephrotoxic elements through drinking groundwater was widely suspected owing to the unique geographical distribution of the disease. This review focuses on such well-known hypotheses suspecting the relations with fluoride, hardness, major ions, heavy metals, metalloids, organic matter, agrochemical residues, pathogens, and bacterial toxins in the groundwaters of the CKDu-endemic region. It was comprehensively discussed why each of these constituents was considered a risk factor of CKDu, how could they possibly trigger the pathogenesis of the disease, what was the evidence that supported or failed each hypothesis, and whether providing safe drinking water had been effective at mitigating the progression of the disease. Although plenty of circumstantial evidence supported an etiology related to groundwater for CKDu, it was impossible to elucidate the cause-effect relationships between drinking impaired groundwater and the occurrence of the disease. Future research should be effectively designed to clarify the role of groundwater in the onset of CKDu by taking into account the gaps in past research.

A Systematic Review of Renal Pathology in Chronic Kidney Disease of Uncertain Etiology

INTRODUCTION

Despite much research on chronic kidney disease of uncertain etiology (CKDu) in Sri Lanka and the Mesoamerican nephropathy, the etiology and pathogenesis of this disease remains elusive. The pathology has broadly been described as chronic tubulointerstitial nephritis and no specific signature lesions have been identified.

METHODS

A scoping review was conducted through MEDLINE and Google Scholar databases for peer-reviewed publications on biopsy studies related to CKDu - Sri Lanka and Mesoamerican nephropathy to develop a comparative and critical analysis of the renal pathology found in these patients.

RESULTS

Thirteen studies met the selection criteria. Interstitial fibrosis was the predominant lesion in all the studies. Tubulointerstitial and glomerular abnormalities showed a more variable distribution. No characteristic histopathological feature was reported other than a proximal tubular lysosomal inclusion body which was claimed to indicate a toxic etiology. Three main pathogenetic mechanisms were postulated: repeated acute insults leading to scarring, low-grade chronic insults leading to non-inflammatory fibrosis, and tubulointerstitial damage in combination with glomerular injury. The main limitations in the interpretation and comparative analysis of these studies were the heterogeneity in case selection and biopsy reporting.

CONCLUSIONS

Although no characteristic histopathological feature could be found in CKDu-Sri Lanka or Mesoamerican nephropathy, there are noticeable differences between these two groups in the frequency and severity of the glomerular and tubulointerstitial changes which warrant more explorative studies preferably on kidneys in early stages of the disease. Future strategies should ensure that more uniform selection criteria and reporting methods are used.

Evaluation of Performance of Existing RO Drinking Water Stations in the North Central Province, Sri Lanka

Reverse osmosis (RO) drinking water stations have been introduced to provide safe drinking water for areas with prevailing chronic kidney disease with unknown (CKDu) etiology in the dry zone of Sri Lanka. In this investigation, RO drinking water stations established by community-based organizations (CBO) in the North Central Province (NCP) were examined. Water samples were collected from source, permeate, and concentrate in each station to determine water quality and performance. Furthermore, the operators of the systems were interviewed to evaluate operational and maintenance practices to identify major issues related to the RO systems. Results show that the majority (>93%) of RO systems had higher salt rejection rates (>92%), while water recovery varied from 19.4% to 64%. The removal efficiencies of hardness and alkalinity were averaged at 95.8% and 86.6%, respectively. Most dominant ions such as Ca²⁺, Mg²⁺, K⁺, Na⁺, Ba²⁺, Sr²⁺ Cl⁻, F⁻, and SO₄²⁻ showed higher rejections at averaged values of 93.5%, 97.4%, 86.6%, 90.8%, 95.4%, 96.3%, 95.7%, 96.6%, and 99.0%, respectively. Low recovery rates, lower fluoride levels in product water, and membrane fouling were the main challenges. Lack of knowledge and training were the major issues that could shorten the lifespan of RO systems.

Biopolymer-Based Nanohydroxyapatite Composites for the Removal of Fluoride, Lead, Cadmium, and Arsenic from Water

In this study, hydroxyapatite (HAP) nanocomposites were prepared with chitosan (HAP-CTS), carboxymethyl cellulose (HAP-CMC), alginate (HAP-ALG), and gelatin (HAP-GEL) using a simple wet chemical in situ precipitation method. The synthesized materials were characterized using scanning electron microscopy, Fourier transform infrared spectroscopy, X-ray diffraction, Brunauer-Emmett-Teller surface area analysis, and thermogravimetric analysis. This revealed the successful synthesis of composites with varied morphologies. The adsorption abilities of the materials toward Pb(II), Cd(II), F-, and As(V) were explored, and HAP-CTS was found to have versatile adsorption properties for all of the ions, across a wide range of concentrations and pH values, and in the presence of common ions found in groundwater. Additionally, X-ray photoelectron spectroscopy and energy-dispersive X-ray spectroscopy confirmed the affinity of HAP-CTS toward multi-ion mixture containing all four ions. HAP-CTS was hence engineered into a more user-friendly form, which can be used to form filters through its combination with cotton and granular activated carbon. A gravity filtration study indicates that the powder form of HAP-CTS is the best sorbent, with the highest breakthrough capacity of 3000, 3000, 2600, and 2000 mL/g for Pb(II), Cd(II), As(V), and F-, respectively. Hence, we propose that HAP-CTS could be a versatile sorbent material for use in water purification.

Balkan Endemic Nephropathy: An Autopsy Case Report

Balkan endemic nephropathy (BEN) is a form of interstitial nephritis seen only in certain geographical areas in the Balkan peninsula. Herein we describe the gross and histological changes in a diseased 42-year-old male Caucasian patient with BEN. All the changes fit the classically described alterations, with copper hue discoloration of the skin of the torso and orange discoloration of the soles and palms. Grossly, the kidneys were atrophic, with the left one weighing 31 grams and the right one 32 grams. Their surface was predominantly smooth with areas of fine granulations and cystic transformations. Histology revealed hyalinization of the glomeruli, predominantly in the external part of the cortex, severe vascular changes, interstitial fibrosis, and scant inflammatory cell infiltrate. The renal pelvis and ureters revealed multiple urothelial papillomas and atypical urothelial hyperplasia. BEN is only one geographical variant of interstitial nephritis caused by exposure to aristolochic acid. Other forms of this condition include Chinese herb nephropathy/aristolochic acid nephropathy, as well as several similar endemic conditions with a yet unestablished link to aristolochic acid.

Progression of potential etiologies of the chronic kidney disease of unknown etiology in Sri Lanka

Chronic kidney disease of unknown etiology (CKDu) is a major health issue in agricultural areas in Sri Lanka. Despite many attempts to identifying causative factors of CKDu, the real cause/s remain/s elusive to date. Understanding the progression of potential etiologies may provide valuable insight into this quest. Literature relevant to CKDu addresses several etiologies, including quality of drinking water in the affected areas including hardness, fluoride, ionicity, agrochemical and heavy metal contaminations, consumption of contaminated food, and the genetic makeup of vulnerable populations. Progression of the etiologies revealed persistent interest in heavy metals of multiple origins: waterborne, foodborne, or soilborne. Secondary factors, such as water hardness, fluoride, and ionicity appear to act synergistically, aggravating the role of heavy metals on the onset, and the progression of CKDu. Demographical factors, such as male sex, over 50 years of age, agriculture-related occupation, and the consumption of contaminated water and food are intricately related with the disease progression while other minor risk factors such as smoking, alcohol consumption, etc. exasperate the disease condition. Since, none of these etiologies are examined adequately, conducting laboratory exposure studies under in-vivo and in-vitro settings to understand their role in CKDu is crucial.

Evaluation of groundwater quality and reverse osmosis water treatment plants in the endemic areas of Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka

Community-based reverse osmosis (RO) water treatment plants are employed as an interim solution for producing safe drinking water for the endemic areas of Chronic Kidney Disease of Unknown Etiology (CKDu) in the rural dry zone of Sri Lanka. It is recognized that RO-treated groundwater diminishes the progression of CKDu; thus, proper maintenance of these RO plants would be indispensable to protect public health. The present study broadly investigated the quality of groundwater in CKDu-endemic areas, and the performance, operations, and maintenance of the RO plants which purified this groundwater. The feedwater (i.e., groundwater) and treated water from 32 RO plants in Anuradhapura District, comprising 27 in the CKDu high-risk (HR) region and 5 in the low-risk (LR) region, were analyzed for major chemical and biological water quality parameters. Alkalinity, hardness, and microbiological parameters in groundwaters exceeded the maximum allowable levels (MALs) for drinking in all study areas. Additionally, TDS and magnesium exceeded the MALs, exclusively in the HR areas. Elevated occurrence of magnesium-predominant hardness and ionicity in groundwater showed significant relations with the incidence of CKDu. All RO plants achieved high removal rates (>95%) for excessive chemical constituents in groundwater, but the recovery rates were fairly low (~46%). The current disinfection practices in RO plants were insufficient to ensure the microbial safety of the product water. Low demand for product water, scarcity of groundwater, lack of technical capacity of the local communities, poor maintenance practices and unplanned brine removal were the key issues related to RO plant O&M. Unless properly handled, the lack of rules and regulations for RO water treatment in the CKDu-endemic region could lead to numerous environmental and public health issues in the future.

Using water quality and isotope studies to inform research in chronic kidney disease of unknown aetiology endemic areas in Sri Lanka

Chronic Kidney Disease of unknown aetiology (CKDu) is a major public health concern in dry climatic, agricultural regions of Sri Lanka. The chemistry of groundwater (the main source of drinking water) in the area has been studied extensively, in relation to the occurrence of CKDu. This paper investigates water quality studies published in CKDu affected areas of Sri Lanka and also presents a new data set of 27 hydrochemical and isotopic samples collected from groundwater wells in selected CKDu endemic areas in Sri Lanka. The study outcomes do not provide evidence of pollutants such as heavy metals in groundwater. However, the study identifies elevated concentrations of silica which requires further investigation. Two groups of groundwater have been identified based on the isotopic results suggesting different sources or origins. The available water quality data, including the data from this study, is not sufficient to answer questions on whether the chemistry of groundwater is related to the CKDu occurrence. However, this study identifies the importance of detailed investigation into degradation products of agrochemicals, the organic matter content and the influence of elevate silica concentration in groundwater. The study also provides research directions in the form of isotopic tracers and the frequency of sampling that is needed to capture potential pollutants in future groundwater quality studies in CKDu endemic areas in Sri Lanka.

Exploring the Root Cause for Chronic Kidney Disease of Unknown Etiology (CKDu) via Analysis of Metal Ion and Counterion Contaminants in Drinking Water: A Study in Sri Lanka

The introduction of elevated amounts of foreign ions into the blood may lead to impairment of the filtration membrane of kidneys and chronic kidney damage. In order to assess the risk of consumption of drinking water (dug well water) in chronic kidney disease of unknown etiology (CKDu), affected areas in Sri Lanka, trace metals, and other counterions in water samples obtained from dug wells were analyzed and compared with a reference area. Drinking water could be the major source that is responsible for entering nephrotoxic ion contaminants into the human body. To achieve the objective, drinking water samples were collected from dug wells in two CKDu endemic areas and a reference area where no CKDu patients were found in a dry season. In the Wewelketiya area (one of the endemic areas), Cd concentrations in 60% of water samples and Pb concentrations in 40% of water samples have exceeded the maximum limit given by Sri Lanka water quality standards. Fluoride concentrations also have exceeded the permissible limits of more than 80% of collected water samples in both CKDu endemic areas. However, none of the water samples in reference areas has reported that Cd, Pb, and fluoride are beyond their maximum permissible limits. Hence, people in the particular CKDu endemic areas are at risk of kidney tissue damage due to long-term exposure to drinking water with elevated levels of some metal ions and counterions.

Serum and urine fluoride levels in populations of high environmental fluoride exposure with endemic CKDu: a case-control study from Sri Lanka

Chronic kidney disease of uncertain etiology (CKDu) is a common health issue among farming communities in the dry zone of Sri Lanka where groundwater fluoride is known to be higher than recommended levels. Excessive environmental ingestion of fluoride is widely considered as a possible factor for the onset of CKDu. This study was carried out to evaluate the serum and urine fluoride levels in biopsy-proven, non-dialysis CKDu patients. Control subjects were selected from the same area without any deteriorated kidney functions. Serum and urine fluoride levels were determined by ion-selective electrode method. Higher content of serum and urine fluoride levels were observed in patients with chronic renal failures. In CKDu cases, the serum fluoride concentrations ranged between 0.47 and 9.58 mg/L (mean 1.39 ± 1.1 mg/L), while urine levels were varied between 0.45 and 6.92 mg/L (mean 1.53 ± 0.8 mg/L). In patients, urine fluoride levels showed a significant difference with the CKDu stage; however, no difference was obtained between genders and age. In endemic controls, serum and urine fluoride levels ranged between 0.51 and 1.92 mg/L (mean = 1.07 ± 0.3 mg/L) and 0.36 and 3.80 mg/L (mean = 1.26 ± 0.6 mg/L), respectively. Significantly higher fluoride in serum and urine was noted in CKDu patients compared to endemic control groups. Higher fluoride exposure via drinking water is possibly the reason for higher fluoride in serum, while excessive urinary excretion would be due to deterioration of the kidney, suggesting a possible nephrotoxic role of environmental fluoride exposure.

Chronic kidney disease and household behaviors in Sri Lanka: Historical choices of drinking water and agrochemical use

This paper examines whether there are systematic differences in the historical behaviors of households that are affected and unaffected by chronic kidney disease (CKD) in Sri Lanka pertaining to their water source choices, water treatment practices, and agrochemical use. This analysis is motivated by the Sri Lankan government's largest policy response to this epidemic - to encourage communities to switch from untreated well water to publicly provided alternatives. We use recall methods to elicit information on the drinking water source and treatment choices of households over an 18-year period from 2000-2017. Our analysis is based on a survey of 1497 rural ground-water dependent households in the most CKD-affected areas of the 10 districts of Sri Lanka with the highest prevalence of CKD. Our main findings are that (a) households that have ever used a pump to extract (typically deep) drinking water from a household well are more likely to be affected by CKD; (b) we fail to find a relationship between disease status and households' use of buckets to extract (typically shallow) groundwater from their wells; and (c) those who have ever treated their shallow well water by boiling it are less likely to be affected by CKD. We also find that a greater share of CKD affected households historically used agrochemicals, used wells that were geographically removed from surface water sources, and displayed lower proxies of wealth. The implications of these findings are fourfold. First, since the systematic differences in the historical patterns of water sources and treatments used by CKD affected and non-affected households are modest, the sources of water and the treatment practices themselves may not be the sole risk factors in developing CKD. Second, although we find a negative association between boiling water and the probability of CKD, it is not obvious that a public policy campaign to promote boiling water is an appropriate response. Third, the hydrochemistry of deep and shallow well water needs to be better understood in order to shed light on the positive relationship between deep well water and disease status, and on why boiling shallow but not deep well water is associated with a lower probability of CKD. Fourth, there is a need for a deeper understanding of other risk factors and of the efficacy of preventative programs that provide alternative sources of household drinking water.

Chronic Interstitial Nephritis in Agricultural Communities (CINAC) in Sri Lanka

A significant increase in cases of chronic kidney disease has been observed in the dry zone of Sri Lanka. This unusual chronic kidney disease was first reported in the early 1990s among middle-aged paddy farmers. Considering epidemiologic and histopathologic findings, the disease recently was named chronic interstitial nephritis in agricultural communities (CINAC). Twenty-five years after the first report, CINAC is the most significant public health issue in the paddy farming areas with more than 70,000 estimated patients and many deaths. Histopathologically, this disease is a tubular interstitial nephritis associated with glomerular sclerosis and mild vascular changes. Morphologic and biochemical characteristics of CINAC in Sri Lanka share many similarities with Mesoamerican nephropathy. Certain natural and man-made toxins, heat stress with repeated volume and salt depletion, infections such as hantavirus and leptospirosis, and a genetic origin have been proposed and investigated as possible etiologies, and an association between CINAC and herbicides is widely discussed. Several preventive measures already have been implemented by health authorities in Sri Lanka to minimize nephrotoxin exposure and well hydrate the inhabitants in the disease-endemic region. The impact of these interventions will be watched with anticipation.

Chronic kidney disease of unknown etiology (CKDu): Using a system dynamics model to conceptualize the multiple environmental causative pathways of the epidemic

A chronic kidney disease of unknown etiology is devastating agricultural communities of Sri Lanka, Central America, areas of India, and Egypt. Researchers are yet to agree on its etio-pathogenesis despite many cross-sectional, case-control and cohort studies done in these countries. These approaches are broadly based on a reductionist approach. We propose a complementary paradigm based on complexity science to deepen our understanding of the disease. Complexity science views a population as system that has several dynamically interacting and inter-dependent sub-systems and is 'open' to the 'outer' environment. Health outcomes or epidemics are viewed as 'emergent' properties of the population. Using available literature from Sri Lanka, the paper presents a system dynamics model incorporating exposures from pesticides and heavy metals, drinking hard water with high levels of fluoride, poverty, low birth weight, micronutrient deficiencies and heat stress. This approach can be used to model the epidemic, understand the impacts of different factors, predict potential populations at risk, and formulate multi-pronged prevention strategies that target leverage points of the system.

Factors Affecting the Environmentally Induced, Chronic Kidney Disease of Unknown Aetiology in Dry Zonal Regions in Tropical Countries—Novel Findings

A new form of chronic tubulointerstitial kidney disease (CKD) not related to diabetes or hypertension appeared during the past four decades in several peri-equatorial and predominantly agricultural countries. Commonalities include underground stagnation of drinking water with prolonged contact with rocks, harsh climatic conditions with protracted dry seasons, and rampant poverty and malnutrition. In general, the cause is unknown, and the disease is therefore named CKD of unknown aetiology (CKDu). Since it is likely caused by a combination of factors, a better term would be CKD of multifactorial origin (CKDmfo). Middle-aged malnourished men with more than 10 years of exposure to environmental hazards are the most vulnerable. Over 30 factors have been proposed as causative, including agrochemicals and heavy metals, but none has been properly tested nor proven as causative, and unlikely to be the cause of CKDmfo/CKDu. Conditions such as, having favourable climatic patterns, adequate hydration, and less poverty and malnutrition seem to prevent the disease. With the right in vivo conditions, chemical species such as calcium, phosphate, oxalate, and fluoride form intra-renal nanomineral particles initiating the CKDmfo. This article examines the key potential chemical components causing CKDmfo together with the risk factors and vulnerabilities predisposing individuals to this disease. Research findings suggest that in addition to drinking water from stagnant sources that contain high ionic components, more than 10 years of exposure to environmental nephrotoxins and micronutrient malnutrition are needed to contract this fatal disease.

Prevalence of chronic kidney disease in Sri Lanka: A profile of affected districts reliant on groundwater

This analysis provides new estimates of chronic kidney disease (CKD) prevalence - including CKD of unknown etiology (CKDu) - across ten districts most affected by CKD in Sri Lanka, including an examination of rural households' historical reliance on groundwater consumption. A carefully designed household survey provides information on whether these households self-reported having a member in the decade prior to 2018, who had been clinically diagnosed with CKD. Households were classified according to whether or not they had used groundwater (from household wells, agro-wells or springs) as their primary source for drinking or cooking for at least five years between 1999 and 2018. More than 98% of households reported having consumed groundwater as their primary source of drinking or cooking water for at least five of those years and >15% of households reported having at least one CKD-affected member in the ten-year period up to 2018, but these numbers varied across and within districts. The reported characteristics of symptomatic individuals reveal that the incidence of CKD was significantly higher among females (62%) than males (38%). In addition to CKD, about 63% of symptomatic individuals had hypertension and about one-third of them also had diabetes. About 33% of the symptomatic individuals had neither diabetes nor hypertension, where this group most closely fits commonly used definitions of CKDu. With a survey response of over 8000 households comprising as many as 30,000 individuals, these data illustrate the scale of CKD in the most-affected districts of Sri Lanka on an aggregate basis as well as revealing differences across districts and at the sub-district level.

Drinking-Water Supply for CKDu Affected Areas of Sri Lanka, Using Nanofiltration Membrane Technology: From Laboratory to Practice

Installation of decentralized water-treatment plants is an ideal option to supply safe drinking water for rural communities. Presently in Sri Lanka, over 3.6 million villagers face acute water-quality problems, and chronic kidney disease of unknown etiology (CKDu) is also prevalent among this community. Most of the drinking water in these villages is unpalatable due to high hardness and salinity. As an interim measure, reverse-osmosis (RO) water-treatment plants are introduced to provide safe water. However, due to deficient electrolytes, RO-treated water tastes unpleasant to some consumers; hence, people refuse it after prolonged use. The operation, maintenance, and management of RO plants are other major problems. Aimed at providing safe drinking water to the rural sector in a cost-effective manner, in this study, we fabricated an automated drinking-water purification system based on nanofiltration (NF) membrane technology, which can remove divalent cations, dissolved organic carbon (DOC) and pathogens efficiently, and monovalent ions partially, and thus keep electrolytes to some degree. Ten commercial NF membranes were tested in a laboratory, for solute and DOC removal efficiency and robustness. The DF-90 membrane showed the highest removal of DOC and hardness, and it was therefore selected, to design a pilot NF drinking-water treatment plant. The adhered DOC by the membrane can be cleaned by NaOH solution (pH = 12). The pilot NF drinking-water treatment plant has been in use since September 2018, and it shows excellent performance of removing DOC, TDS, hardness, fluoride, and pathogens in groundwater, and the permeate water of the NF plant has been well-accepted by the stakeholders of the society. The dominant genus of source water, and throughout the two processes (NF and RO), is Pseudomonas, and their difference is significant in the concentrates of the NF and RO processes.

Public health interventions for chronic diseases: cost-benefit modelizations for eradicating chronic kidney disease of multifactorial origin (CKDmfo/ CKDu) from tropical countries

Background

In the mid-1970s, an unusual chronic kidney disease of multifactorial origin (CKDmfo), also known as CKD of unknown aetiology (CKDu), began to manifest in several economically poor, tropical, agricultural countries. This preventable, environmentally induced, occupational disease affects several peri-equatorial countries; it first manifested in Sri Lanka in the mid-1990s. The study goal was to estimate the costs of eradicating CKDmfo and the resulting cost savings, using CKDmfo in Sri Lanka as an example. This chronic disease model is applicable to CKDu and few other chronic diseases in other countries.

Methodology

Eight cost-effective, key interventions were identified that are essential to eradicate CKDmfo. A systematic assessment was performed on these interventions (including providing clean water, behavioural and lifestyle changes, alleviating malnutrition, reducing irresponsible and overuse of agrochemicals, and cost-effective treatment options), the cost of prevention, and the resultant cost savings. A cost–benefit analysis was based on the data collected during the past 20 years of work in Sri Lanka.

Findings

The yearly cost required to eradicate the disease was approximately one-tenth of the current annual operating and opportunity costs due to CKDmfo. Analysis indicates that implementation of a focussed chronic disease-prevention plan using essential multiple interventions, CKDmfo can be eradicated within 15 years. This includes provision of potable water; real-time disease surveillance program; public and professional education; prevention of environmental pollution; alleviation of poverty and associated malnutrition; sustainable self-sufficiency in food, clean water, energy, and security; diversification of economy and job opportunities; sustainable economic development; regionwide programs of effective screening, early diagnosis and intervention to reverse the disease progression at earliest possible; and effective treatment of CKDmfo.

Interpretation

This analysis is based on multiple population-level, chronic disease-eradication strategies that include an interdisciplinary, geographic information system (GIS)-based, regionwide, long-term research and intervention program; economic diversification; and environmental, socioeconomic, and behavioural improvements. Such an approach will facilitate identification of root causes and key risk factors, enabling implementation of cost-effective longer-term interventions to eradicate chronic diseases, applicable to other countries as well.

Chronic kidney disease of unknown aetiology in Sri Lanka and the exposure to environmental chemicals: a review of literature

Chronic kidney disease of unknown aetiology (CKDu) has emerged as a serious health issue in Sri Lanka. The disease has been recorded in the North Central Province of the country. While studies have elicited many hypotheses concerning the pathogenicity of CKDu, none adequately explains the cause of CKDu and the measures needed to minimise its occurrence. Nephrotoxic heavy metal (oid)s such as cadmium, arsenic, lead, and chromium are present in biological samples of people from endemic areas. This review appraises evidence on the effects of long-term exposure to low concentration of nephrotoxic heavy metals, which could be the principal cause of CKDu. Although a considerable variation exists in metal concentrations in patients' blood and urine, higher levels of heavy metals were consistently observed in affected areas. This review finds that the populations in the endemic areas are exposed to heavy metal (oid)s at low concentrations, which are considered as safe levels; nevertheless, it influences the incidence of CKDu. Recent global studies on chronic kidney disease (CKD) revealed a low concentration of heavy metals in diseased patients. Research findings indicated that CKDu patients in Sri Lanka demonstrated similar blood levels of Cd, Pb, and higher concentrations of Cr than that have been reported globally. Further studies on the influence of combinations of nephrotoxic heavy metals at low concentrations on reduced glomerular filtration rate and other renal biomarkers could explain CKDu pathogenicity.

Glyphosate's Synergistic Toxicity in Combination with Other Factors as a Cause of Chronic Kidney Disease of Unknown Origin

Chronic kidney disease of unknown etiology (CKDu) is a global epidemic. Sri Lanka has experienced a doubling of the disease every 4 or 5 years since it was first identified in the North Central province in the mid-1990s. The disease primarily affects people in agricultural regions who are missing the commonly known risk factors for CKD. Sri Lanka is not alone: health workers have reported prevalence of CKDu in Mexico, Nicaragua, El Salvador, and the state of Andhra Pradesh in India. A global search for the cause of CKDu has not identified a single factor, but rather many factors that may contribute to the etiology of the disease. Some of these factors include heat stroke leading to dehydration, toxic metals such as cadmium and arsenic, fluoride, low selenium, toxigenic cyanobacteria, nutritionally deficient diet and mycotoxins from mold exposure. Furthermore, exposure to agrichemicals, particularly glyphosate and paraquat, are likely compounding factors, and may be the primary factors. Here, we argue that glyphosate in particular is working synergistically with most of the other factors to increase toxic effects. We propose, further, that glyphosate causes insidious harm through its action as an amino acid analogue of glycine, and that this interferes with natural protective mechanisms against other exposures. Glyphosate's synergistic health effects in combination with exposure to other pollutants, in particular paraquat, and physical labor in the ubiquitous high temperatures of lowland tropical regions, could result in renal damage consistent with CKDu in Sri Lanka.

A Review of Chronic Kidney Disease of Unknown Etiology in Sri Lanka, 2001-2015

An increase in the prevalence of chronic kidney disease of unknown etiology (CKDu) was observed in several countries of the world since the early 2000s. We reviewed the literature to summarize the existing knowledge regarding epidemiology, clinical features, and risk factors for CKDu in Sri Lanka. We reviewed published literature from PubMed and unpublished literature from literature repository of CKDu published by the World Health Organization. We identified 36 articles based on various inclusion/exclusion criteria and reviewed the full text of all selected articles. The prevalence of CKDu was approximately 5% in endemic areas based on the surveillance data. CKDu accounted for 70% of CKD cases in endemic areas. Clustering of cases was observed in select divisions and districts in the dry region of the country. Low body mass index, normal blood pressure, scanty proteinuria, and tubulointerstitial pathology were characteristics of early stages of a disease. Genetic susceptibility, farmer as occupation, heavy metals (cadmium and arsenic), and drinking well water were identified as risk factors. Data were limited on the association with agrochemical use and heat stress/dehydration. Community- and facility-based surveillance needs to be strengthened to document the burden of disease and trends over time.

Fertilizer usage and cadmium in soils, crops and food

Phosphate fertilizers were first implicated by Schroeder and Balassa (Science 140(3568):819-820, 1963) for increasing the Cd concentration in cultivated soils and crops. This suggestion has become a part of the accepted paradigm on soil toxicity. Consequently, stringent fertilizer control programs to monitor Cd have been launched. Attempts to link Cd toxicity and fertilizers to chronic diseases, sometimes with good evidence, but mostly on less certain data are frequent. A re-assessment of this "accepted" paradigm is timely, given the larger body of data available today. The data show that both the input and output of Cd per hectare from fertilizers are negligibly small compared to the total amount of Cd/hectare usually present in the soil itself. Calculations based on current agricultural practices are used to show that it will take centuries to double the ambient soil Cd level, even after neglecting leaching and other removal effects. The concern of long-term agriculture should be the depletion of available phosphate fertilizers, rather than the negligible contamination of the soil by trace metals from fertilizer inputs. This conclusion is confirmed by showing that the claimed correlations between fertilizer input and Cd accumulation in crops are not robust. Alternative scenarios that explain the data are presented. Thus, soil acidulation on fertilizer loading and the effect of Mg, Zn and F ions contained in fertilizers are considered using recent [Formula: see text], [Formula: see text] and [Formula: see text] ion-association theories. The protective role of ions like Zn, Se, Fe is emphasized, and the question of Cd toxicity in the presence of other ions is considered. These help to clarify difficulties in the standard point of view. This analysis does not modify the accepted views on Cd contamination by airborne delivery, smoking, and industrial activity, or algal blooms caused by phosphates.

Glyphosate and AMPA of agricultural soil, surface water, groundwater and sediments in areas prevalent with chronic kidney disease of unknown etiology, Sri Lanka

Glyphosate, which is commercially available as Roundup®, was the widely used herbicide in Sri Lanka until 2015 and is suspected to be one of the causal factors for Chronic Kidney Disease of unknown etiology (CKDu). This research, therefore, aims at studying the presence of glyphosate and Aminomethylphosphonic acid (AMPA) in different environmental matrices in CKDu prevalent areas. Topsoil samples from agricultural fields, water samples from nearby shallow wells and lakes, and sediment samples from lakes were collected and analyzed for glyphosate and AMPA using the LC/MS. Glyphosate (270-690 µg/kg) and AMPA (2-8 µg/kg) were detected in all soil samples. Amorphous iron oxides and organic matter content of topsoil showed a strong and a moderate positive linear relationship with glyphosate. The glyphosate and inorganic phosphate levels in topsoil had a strong negative significant linear relationship. Presence of high valence cations such as Fe3+ and Al3+ in topsoil resulted in the formation of glyphosate-metal complexes, thus strong retention of glyphosate in soil. Lower levels of AMPA than the corresponding glyphosate levels in topsoil could be attributed to factors such as the strong adsorption capacity of glyphosate to soil and higher LOQ in the quantification of AMPA. The glyphosate levels of lakes were between 28 to 45 µg/L; no AMPA was detected. While trace levels of glyphosate (1-4 µg/L) were detected in all groundwater samples, AMPA (2-11µg/L) was detected only in four out of nine samples. Glyphosate was detected in all sediment samples (85-1000 µg/kg), and a strong linear relationship with the organic matter content was observed. AMPA was detected (1-15 µg/kg) in seven out of nine sediment samples. It could be inferred that the impact on CKDu by the levels of glyphosate and AMPA detected in the study area is marginal when compared with the MCL of the USEPA (700 µg/L).

Geochemical and isotopic evidences from groundwater and surface water for understanding of natural contamination in chronic kidney disease of unknown etiology (CKDu) endemic zones in Sri Lanka

Chronic kidney disease of unknown etiology (CKDu) is the main health issue in the dry zone of Sri Lanka. Despite many studies carried out, causative factors have not been identified yet clearly. According to the multidisciplinary researches carried out so far, potable water is considered as the main causative factor for CKDu. Hence, the present study was carried out with combined isotopic and chemical methods to understand possible relationships between groundwater; the main drinking water source, and CKDu in four endemic areas in the dry zone. Different water sources were evaluated isotopically (²H, ³H and ¹⁸O) and chemically from 2013 to 2015. Results revealed that prevalence of CKDu is significantly low with the groundwater replenished by surface water inputs. It is significantly high with the groundwater stagnated as well as groundwater recharged from regional flow paths. Thus, the origin, recharge mechanism and flow pattern of groundwater, as well as geological conditions which would be responsible for natural contamination of groundwater appear as the main causative factors for CKDu. Therefore, detailed investigations should be made in order to identify the element(s) in groundwater contributing to CKDu. The study recommends providing drinking water to the affected zones using water sources associated with surface waters.

Transcriptome analysis supports viral infection and fluoride toxicity as contributors to chronic kidney disease of unknown etiology (CKDu) in Sri Lanka

PURPOSE

Chronic kidney disease of unknown etiology (CKDu), having epidemic characteristics, is being diagnosed increasingly in certain tropical regions of the world, mainly Latin America and Sri Lanka. They have been observed primarily in farming communities and current hypotheses point toward many environmental and occupational triggers. CKDu does not have common etiologies of chronic kidney disease (CKD) such as hypertension, diabetes, or autoimmune disease. We aimed to understand the molecular processes underlying CKDu in Sri Lanka using transcriptome analysis.

METHODS

RNA extracted from whole blood was reverse transcribed and used for microarray analysis using the Human HT-12 v.4 array (Illumina). Pathway analysis was carried out using ingenuity pathway analysis (IPA-Qiagen). Microarray results were validated using real-time PCR of five selected genes.

RESULTS

Pathways related to innate immune response, including interferon signaling, inflammasome signaling and TREM1 signaling had the most significant positive activation z scores, where as EIF2 signaling and mTOR signaling had the most significant negative activation z scores. Pathways previously linked to fluoride toxicity; G-protein activation, Cdc42 signaling, Rac signaling and RhoA signaling were activated in CKDu patients. The most significantly activated biological functions were cell death, cell movement and antimicrobial response. Significant toxicological functions were mitochondrial dysfunction, oxidative stress and apoptosis.

CONCLUSIONS

Based on the molecular pathway analysis in CKDu patients and review of literature, viral infections and fluoride toxicity appear to be contributing to the molecular mechanisms underlying CKDu.

Chronic kidney disease of unknown etiology and the effect of multiple-ion interactions

High incidence of chronic kidney disease of unknown etiology (CKDU) prevalent in many countries (e.g., Sri Lanka, equatorial America) is reviewed in the context of recent experimental work and using our understanding of the hydration of ions and proteins. Qualitative considerations based on Hofmeister-type action of these ions, as well as quantitative electrochemical models for the Gibbs free energy change for ionpair formation, are used to explain why (1) fluoride and water hardness due to magnesium ions (but not due to calcium ions) and similarly (2) cadmium ions in the presence of suitable pairing ions can be expected to be more nephrotoxic, while arsenite in the presence of fluoride and hardness may be expected to be less nephrotoxic. No synergy of arsenic with calcium hardness is found. The analysis is applied to a variety of ionic species that may be found in typical water sources to predict their likely combined electrochemical action. These results clarify the origins of chronic kidney disease that has reached epidemic proportions in the North Central Province of Sri Lanka as being most likely due to the joint presence of fluoride and magnesium ions in drinking water. The conclusion is further strengthened by a study of the dietary load of Cd and other toxins in the affected regions and in the healthy regions where the dietary toxin loads and lifestyles are similar, and found to be safe especially when the mitigating effects of micronutrient ionic forms of Zn, Se, as well as corrections for bioavailability are taken into account. The resulting etiological picture is consistent with the views of most workers in the field who have suspected that fluoride and other ions found in the hard water stagnant in shallow household wells were the major causative factors of the disease. Similar incidence of CKDu found in other hot tropical climates is likely to have similar origins.

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

Chronic kidney disease of unknown aetiologies (CKDu) is increasingly recognized in tropical regions and is now considered a global health problem. A detailed hydrogeochemical investigation has been performed in three CKDu hotspots in Sri Lanka to assess the geo-environmental aetiological factors influencing this disease. A total of 71 ground- and 26 surface water samples were collected from Girandurukotte, Wilgamuwa and Nikawewa regions and analysed for major constituents and trace elements. The affected regions are dominated by Ca-Mg-HCO₃ facies groundwater that is mainly controlled by silicate weathering. Higher levels of fluoride associated with higher hardness is the main feature of groundwater from CKDu regions compared to non-CKDu regions. Results showed that 65% of the wells in the affected regions exceeded the fluoride concentration of 0.5mg/L. Environmental isotopes of groundwater in the CKDu regions are represented by the regression line of δ²H=5.42δ¹⁸O-3.59 (r²=0.916) with a clear isotopic differentiation between local precipitation and groundwater. None of the trace elements exceeded the recommended scales and in most cases levels are negligible in both surface and groundwater in study areas. Therefore, the involvement of trace elements such as Cd, As and Pb can be ignored as causative factors for CKDu. This study highlights the synergistic influence of fluoride and hardness that could enhance the disease, and thereby refute earlier theories that attribute trace elements as causative factors for CKDu. Higher hardness in drinking water also restricts sufficient water uptake, particularly by farmers and which affects the physiological, biochemical and nutritional requirements.

Biochar-based constructed wetlands to treat reverse osmosis rejected concentrates in chronic kidney disease endemic areas in Sri Lanka

The objectives were to investigate the potential remedial measures for reverse osmosis (RO) rejected water through constructed wetlands (CWs) with low-cost materials in the media established in chronic kidney disease of unknown etiology (CKDu) prevalent area in Sri Lanka. A pilot-scale surface and subsurface water CWs were established at the Medawachchiya community-based RO water supply unit. Locally available soil, calicut tile and biochar were used in proportions of 81, 16.5 and 2.5% (w/w), respectively, as filter materials in the subsurface. Vetiver grass and Scirpus grossus were selected for subsurface wetland while water lettuce and water hyacinth were chosen for free water surface CWs. Results showed that the CKDu sensitive parameters; total dissolved solids, hardness, total alkalinity and fluoride were reduced considerably (20-85%) and most met desirable levels of stipulated ambient standards. Biochar seemed to play a major role in removing fluoride from the system which may be due to the existing and adsorbed K⁺, Ca⁺², Mg⁺², etc. on the biochar surface via chemisorption. The least reduction was observed for alkalinity. This study indicated potential purification of aforesaid ions in water which are considerably present in RO rejection. Therefore, the invented bio-geo constructed wetland can be considered as a sustainable, economical and effective option for reducing high concentrations of CKDu sensitive parameters in RO rejected water before discharging into the inland waters.

Endemic Nephropathy Around the World

There have been several global epidemics of chronic kidney disease of unknown etiology (CKDu). Some, such as Itai-Itai disease in Japan and Balkan endemic nephropathy, have been explained, whereas the etiology of others remains unclear. In countries such as Sri Lanka, El Salvador, Nicaragua, and India, CKDu is a major public health problem and causes significant morbidity and mortality. Despite their geographical separation, however, there are striking similarities between these endemic nephropathies. Young male agricultural workers who perform strenuous labor in extreme conditions are the worst affected. Patients remain asymptomatic until end-stage renal failure. Biomarkers of tubular injury are raised, and kidney biopsy shows chronic interstitial nephritis with associated tubular atrophy. In many of these places access to dialysis and transplantation is limited, leaving few treatment options. In this review we briefly describe the major historic endemic nephropathies. We then summarize the epidemiology, clinical features, histology and clinical course of CKDu in Mesoamerica, Sri Lanka, India, Egypt, and Tunisia. We draw comparisons between the proposed etiologies and supporting research. Recognition of the similarities may reinforce the international drive to establish causality and to effect prevention.

Medical geology in the framework of the sustainable development goals

Exposure to geogenic contaminants (GCs) such as metal(loid)s, radioactive metals and isotopes as well as transuraniums occurring naturally in geogenic sources (rocks, minerals) can negatively impact on environmental and human health. The GCs are released into the environment by natural biogeochemical processes within the near-surface environments and/or by anthropogenic activities such as mining and hydrocarbon exploitation as well as exploitation of geothermal resources. They can contaminate soil, water, air and biota and subsequently enter the food chain with often serious health impacts which are mostly underestimated and poorly recognized. Global population explosion and economic growth and the associated increase in demand for water, energy, food, and mineral resources result in accelerated release of GCs globally. The emerging science of "medical geology" assesses the complex relationships between geo-environmental factors and their impacts on humans and environments and is related to the majority of the 17 Sustainable Development Goals in the 2030 Agenda of the United Nations for Sustainable Development. In this paper, we identify multiple lines of evidence for the role of GCs in the incidence of diseases with as yet unknown etiology (causation). Integrated medical geology promises a more holistic understanding of the occurrence, mobility, bioavailability, bio-accessibility, exposure and transfer mechanisms of GCs to the food-chain and humans, and the related ecotoxicological impacts and health effects. Scientific evidence based on this approach will support adaptive solutions for prevention, preparedness and response regarding human and environmental health impacts originating from exposure to GCs.

Upregulation of Oxidative Stress Related Genes in a Chronic Kidney Disease Attributed to Specific Geographical Locations of Sri Lanka

Objective. To infer the influence of internal and external oxidative stress in chronic kidney disease patients of unknown etiology (CKDu) in Sri Lanka, by analyzing expression of genes related directly or indirectly to oxidative stress: glutamate-cysteine ligase catalytic subunit (GCLC), glutathione S-transferase mu 1 (GSTM1), glucose-6-phosphate dehydrogenase (G6PD), fibroblast growth factor-23 (FGF23), and NLR family pyrin domain containing 3 (NLRP3). Methods. Reverse transcription quantitative polymerase chain reaction (RT-qPCR) was carried out for the selected populations: CKDu patients (n = 43), chronic kidney disease patients (CKD; n = 14), healthy individuals from a CKDu endemic area (GHI; n = 9), and nonendemic area (KHI; n = 16). Fold changes were quantified relative to KHI. Results. GCLC had greater than threefold upregulation in all three study groups, with a maximum of 7.27-fold upregulation in GHI (p = 0.000). GSTM1 was not expressed in 25.6% of CKDu and 42.9% of CKD patients, but CKDu patients expressing GSTM1 showed upregulation of 2.60-fold (p < 0.05). Upregulation of FGF23 and NLRP3 genes in CKD and CKDu was observed (p < 0.01), with greater fold changes in CKD. Conclusion. Results suggest higher influence of external sources of oxidative stress in CKDu, possibly owing to environmental conditions.