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

Health burden of sugarcane burning on agricultural workers and nearby communities

Sugarcane is the most widely cultivated crop in the world, with equatorial developing nations performing most of this agriculture. Burning sugarcane is a common practice to facilitate harvest, producing extremely high volumes of respirable particulate matter in the process. These emissions are known to have deleterious effects on agricultural workers and nearby communities, but the extent of this exposure and potential toxicity remain poorly characterized. As the epidemicof chronic kidney disease of an unknown etiology (CKDu) and its associated mortality continue to increase along with respiratory distress, there is an urgent need to investigate the causes, determine viable interventions to mitigate disease andimprove outcomes for groups experiencing disproportionate impact. The goal of this review is to establish the state of available literature, summarize what is known in terms of human health risk, and provide recommendations for what areas should be prioritized in research.

Metabolome evidence of CKDu risks after chronic exposure to simulated Sri Lanka drinking water in zebrafish

It is still a serious public health issue that chronic kidney disease of uncertain etiology (CKDu) in Sri Lanka poses challenges in identification, prevention, and treatment. What environmental factors in drinking water cause kidney damage remains unclear. This study aimed to investigate the risks of various environmental factors that may induce CKDu, including water hardness, fluoride (HF), heavy metals (HM), microcystin-LR (MC-LR), and their combined exposure (HFMM). The research focused on comprehensive metabolome analysis, and correlation with transcriptomic and gut microbiota changes. Results revealed that chronic exposure led to kidney damage and pancreatic toxicity in adult zebrafish. Metabolomics profiling showed significant alterations in biochemical processes, with enriched metabolic pathways of oxidative phosphorylation, folate biosynthesis, arachidonic acid metabolism, FoxO signaling pathway, lysosome, pyruvate metabolism, and purine metabolism. The network analysis revealed significant changes in metabolites associated with renal function and diseases, including 20-Hydroxy-LTE4, PS(18:0/22:2(13Z,16Z)), Neuromedin N, 20-Oxo-Leukotriene E4, and phenol sulfate, which are involved in the fatty acyls and glycerophospholipids class. These metabolites were closely associated with the disrupted gut bacteria of g_ZOR0006, g_Pseudomonas, g_Tsukamurella, g_Cetobacterium, g_Flavobacterium, which belonged to dominant phyla of Firmicutes and Proteobacteria, etc., and differentially expressed genes (DEGs) such as egln3, ca2, jun, slc2a1b, and gls2b in zebrafish. Exploratory omics analyses revealed the shared significantly changed pathways in transcriptome and metabolome like calcium signaling and necroptosis, suggesting potential biomarkers for assessing kidney disease.

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.

Sugarcane ash and sugarcane ash-derived silica nanoparticles alter cellular metabolism in human proximal tubular kidney cells

Multiple epidemics of chronic kidney disease of an unknown etiology (CKDu) have emerged in agricultural communities around the world. Many factors have been posited as potential contributors, but a primary cause has yet to be identified and the disease is considered likely multifactorial. Sugarcane workers are largely impacted by disease leading to the hypothesis that exposure to sugarcane ash produced during the burning and harvest of sugarcane could contribute to CKDu. Estimated exposure levels of particles under 10 μm (PM10) have been found to be exceptionally high during this process, exceeding 100 μg/m3 during sugarcane cutting and averaging ∼1800 μg/m3 during pre-harvest burns. Sugarcane stalks consist of ∼80% amorphous silica and generate nano-sized silica particles (∼200 nm) following burning. A human proximal convoluted tubule (PCT) cell line was subjected to treatments ranging in concentration from 0.025 μg/mL to 25 μg/mL of sugarcane ash, desilicated sugarcane ash, sugarcane ash-derived silica nanoparticles (SAD SiNPs) or manufactured pristine 200 nm silica nanoparticles. The combination of heat stress and sugarcane ash exposure on PCT cell responses was also assessed. Following 6-48 h of exposure, mitochondrial activity and viability were found to be significantly reduced when exposed to SAD SiNPs at concentrations 2.5 μg/mL or higher. Oxygen consumption rate (OCR) and pH changes suggested significant alteration to cellular metabolism across treatments as early as 6 h following exposure. SAD SiNPs were found to inhibit mitochondrial function, reduce ATP generation, increase reliance on glycolysis, and reduce glycolytic reserve. Metabolomic analysis revealed several cellular energetics pathways (e.g., fatty acid metabolism, glycolysis, and TCA cycle) are significantly altered across ash-based treatments. Heat stress did not influence these responses. Such changes indicate that exposure to sugarcane ash and its derivatives can promote mitochondrial dysfunction and disrupt metabolic activity of human PCT cells.

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.

Elucidating environmental factors and their combined effects on CKDu in Sri Lanka using zebrafish

Chronic kidney disease with uncertain etiology (CKDu) in Sri Lanka has attracted much attention as a global health issue. However, how environmental factors in local drinking water induce kidney damage in organisms is still elusive. We investigated multiple environmental factors including water hardness and fluoride (HF), heavy metals (HM), microcystin-LR (MC-LR), and their combined exposure (HFMM) to elucidate their toxic effects on CKDu risk in zebrafish. Acute exposure affected renal development and inhibited the fluorescence of Na, K-ATPase alpha1A4:GFP zebrafish kidney. Chronic exposure influenced the body weight of both genders of adult fish and induced kidney damage by histopathological analyses. Furthermore, the exposure significantly disturbed differential expression genes (DEGs), diversity and richness of gut microbiota, and critical metabolites related to renal functions. The transcriptomic analysis revealed that kidney-related DEGs were linked with renal cell carcinoma, proximal tubule bicarbonate reclamation, calcium signaling pathway, and HIF-1 signaling pathway. The significantly disrupted intestinal microbiota was closely related to the environmental factors and H&E score, which demonstrated the mechanisms of kidney risks. Notably, the Spearman correlation analysis indicated that the changed bacteria such as Pseudomonas, Paracoccus, and ZOR0006, etc were significantly connected to the DEGs and metabolites. Therefore, the assessment of multiple environmental factors provided new insights on "bio-markers" as potential therapies of the target signaling pathways, metabolites, and gut bacteria to monitor or protect residents from CKDu.

Fluorescence characteristics and source analysis of DOM in groundwater during the wet season in the CKDu zone of North Central Province, Sri Lanka

The dissolved organic matter (DOM) should be purified for safe drinking water due to disinfection by-products (DBPs) produced by disinfectants reaction with DOM. Current research on groundwater in the chronic kidney disease with unknown etiology (CKDu) zone of the North Central Province (NCP) in Sri Lanka has focused mainly on aquatic chemistry, with limited attention paid to the spatial distribution, compositional sources and factors of DOM. Therefore, the structure, composition, source and spatial distribution of the DOM of two kinds of groundwater samples collected from dug well and tube well in the NCP during the wet season were determined, compared and analyzed by analytical tools such as parallel factor analysis (PARAFAC). Results show that the average concentrations of TOC in these two groundwater samples are generally higher than 5.0 mg/L, and the concentration of TOC in the groundwater of the shallow weathered aquifer is higher than that of the deep hard rock aquifer, while its distribution of the two aquifers are on contrary. The DOM in the dug well has three types and four components, including humus-like component C1 (33.36%) and C2 (38.60%), protein-like component C3 (13.09%) and heterogeneous organic component C4 (14.95%). In the tube well, two types and two components of the DOM are determined, including humus-like component CⅠ (69.80%) widely existing in natural water and soluble microbial by-product CⅡ (30.20%) produced by microbial community activities. In the dug well, DOM is mainly exogenous input, the higher ion concentration in water affected the fluorescence intensity of humus and protein components. And in the tube well, DOM has obvious endogenous characteristics, and higher pH value may inhibit the production of protein like fluorescent substances to a certain extent.

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.

Comprehensive Groundwater Quality Analysis in Chronic Kidney Disease of Unknown Etiology (CKDu) Prevalence Areas of Sri Lanka to Investigate the Responsible Culprit

Chronic kidney disease of unknown etiology (CKDu) is a serious health problem in Sri Lanka especially among agricultural communities in dry zone since 19th century. In the present study, several water quality parameters were studied in well water samples and only four parameters, namely, hardness, cadmium level, fluoride level, and strontium level have shown a relationship with the CKDu prevalence. Higher percentage of well water samples collected from CKDu prevalent area in both pre and postmonsoon seasons have exceeded the WHO recommended levels of hardness. Further, water samples collected in postmonsoon seasons had significantly higher hardness than the well water samples collected in premonsoon season ( $P<0.05$ ). This may be due to the dissolution of calcium carbonate by water recharge. Moreover, cadmium and fluoride contents have exceeded the recommended levels in high-risk area during the premonsoon period. Furthermore, according to principal component analysis (PCA), four clusters were identified depending on the different levels of fluoride, cadmium, hardness, and strontium contents. The control area (Am) fell in to separate cluster with low contents of fluoride, cadmium, hardness, and strontium than in CKDu prevalent area. Since it has been found that the above species are directly involved in renal damage, it can be concluded that a synergetic effect of cadmium, fluoride, hardness, and strontium in well water may be a main cause for CKDu in Sri Lanka.

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.

Seasonal Variations in Groundwater Quality and Hydrogeochemistry in the Endemic Areas of Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka

Groundwater quality and geochemical processes were investigated in the endemic areas of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka. Representative groundwater samples (n = 60) were collected from 30 dug wells located in the Anuradhapura district, over the dry and wet seasons. The samples were analyzed for pH, electrical conductivity (EC), total dissolved solids (TDS), alkalinity, major cations and major anions. Calcium-magnesium-bicarbonate ion combinations are predominant in this groundwater, and the simultaneous occurrence of high hardness (382–394 mg/L as CaCO3), alkalinity (364–379 mg/L as CaCO3) and ionicity is a salient characteristic. Alkalinity, TDS, hardness, and magnesium exceeded the safe limits for drinking in over half of the samples, regardless of the season. The major ion chemistry (Ca2+, Mg2+, Na+ and HCO3−) is primarily governed by the weathering of carbonate and silicate minerals, ion exchange, and evaporation which is accelerated by the semi-arid climate. Fluoride and chloride inputs are regulated by dissolution of fluoride-bearing minerals and anthropogenic causes, respectively. Saturation indices suggested supersaturation of carbonates and silicates, and undersaturation of evaporites and fluorite. Persistent high ionicity, and hardness of groundwater that is seldom impacted by seasonal variations might be playing a vital role in the genesis of CKDu.