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

Chemical characteristics and water stability evaluation of groundwater in the CKDu Zone of Sri Lanka

Groundwater is the main source of drinking water for the rural population in the chronic kidney disease of unknown etiology (CKDu) zone of the North Central Province (NCP) in Sri Lanka. In this study, a total of 334 groundwater samples (311 dug wells, 21 tube wells and 2 springs) during the wet season from two aquifers in the NCP were collected, and investigated their chemical characteristics and evaluate their water quality, including groundwater chemistry, main ion sources, the corrosion and scaling potential of groundwater. The results showed that the two hydrochemical types of groundwater in the NCP were mainly of the Ca-HCO3, Na·Ca-HCO3 types, with the main HCO3-, Na+ and Ca2+ ions in both types of groundwater originating from silicate and evaporite salt dissolution and influenced by alternating cation adsorption, while the presence of NO3- was mainly anthropogenic. Evaluation of water stability using namely Langelier saturation index (LSI), Ryznar stability index (RSI), Puckorius scaling index (PSI) and Larson-Skold index (LS), indicated that most groundwater presents corrosion potential and has corrosion behavior tendency of metals to some degrees. The water quality of Polonnaruwa was better than that of Anuradhapura in the NCP, and when the groundwater was worse than the "good" grade, which must be properly treated before it is used as drinking water.

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.

Decreasing incidence of hospital diagnosed CKD/CKDu in North Central Province of Sri Lanka: is it related to provision of drinking water reverse osmosis plants?

BACKGROUND

We assessed the possible impact of provision of reverse osmosis (RO) water on the incidence of hospital diagnosed CKD/CKDu in North Central Province (NCP) of Sri Lanka.

METHODS

An ecological study was conducted on data from 2010-2020 on the incidence of hospital diagnosed CKD/CKDu, CKD/CKDu screening and provision of drinking water RO plants in NCP. Analysis was conducted using descriptive statistics, ANOVA and chi-square test.

RESULTS

The annual incidence of hospital diagnosed CKD/CKDu (per 100 000 population) in 2010-2013, 2014-2016 and 2017-2020 periods in Anuradhapura district were 129.07, 331.06 and 185.57 (p = 0.002) while in Polonnaruwa district these were 149.29, 326.12 and 296.73 (p = 0.04) respectively. In NCP provision of RO plants commenced after 2011 and the decline in the incidence of hospital diagnosed CKD/CKDu was seen in 25 of the 29 Divisional Secretary Divisions when more than 20% of the families received access to drinking RO water projects.

CONCLUSIONS

The annual incidence of hospital diagnosed CKD/CKDu increased in NCP from 2010 to 2016 and continuously decreased thereafter. Continuous declining of CKD/CKDu incidence was seen after more than 20% of the families received access to drinking water RO plants.

Multi-omics reveal mechanisms underlying chronic kidney disease of unknown etiology (CKDu) pathogenesis using zebrafish

Chronic kidney disease of unknown etiology (CKDu) is an endemic disease in the dry zone of farming communities, Sri Lanka. The drinking water in a CKDu prevalent area contains a high concentration of F-, hardness and other environmental pollutants, including heavy metals and microcystin, which are considered possible etiology of CKDu in these areas. Here, multi-omics data with host transcriptome, metabolome and gut microbiomes were obtained using simulated local drinking water of Sri Lanka after their exposure to adult zebrafish. Based on an integrated multi-omics analysis in the context of host physiology in the kidney injury samples with different pathologic grades, two common pathways necroptosis and purine metabolism were identified as potentially important pathways that affect kidney injury. The key metabolite acetyl adenylate in the purine metabolism pathway was significantly positively correlated with Comamonas (rho = 0.72) and significantly negatively correlated with Plesiomonas (rho = -0.58). This crucial metabolite and two key gut bacteria genera may not only be potential markers but also potential therapeutic targets in the uric acid metabolic pathway, which is an important factor in the pathogenesis of acute kidney injury (AKI) in general, as well as of chronic kidney disease (CKD). Based on this, we revealed the urea metabolism pathway of kidney injury in zebrafish and provided a new avenue for the treatment of CKDu in Sri Lanka.

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.

Rising of a global silent killer: critical analysis of chronic kidney disease of uncertain aetiology (CKDu) worldwide and mitigation steps

Chronic kidney disease of uncertain aetiology (CKDu) is an advanced version of chronic kidney disease (CKD) which bears a high burden on the world health economy. More than 200 articles were analysed to understand the disease responsible for more than 30,000 deaths per year. CKDu is a non-communicable occupational disease that has a progressive deterioration of the kidney in the absence of CKD risk factors such as hypertension, diabetes and glomerulonephritis, while the diagnosis is only possible at the later stages when kidney function is no longer effective. Published evidence for the existence of CKDu was found for around 35 countries. This is a growing health issue in Asia, Central America, Africa and Middle East with identified hot spots. Despite many research studies over decades, the exact root causes are still uncertain. Six main suspected causative factors are identified. Those are heat stress, strenuous labour, dehydration, use of agrochemicals, exposure to heavy metals and the use of polluted water and agricultural lands. This review summarizes four key areas which are CKDu and its general medical background, worldwide prevalence, suspected causative factors and potential circumventing steps to mitigate against CKDu. The importance of further studies addressing early detection and surveillance methods, contribution of nephrotoxins in environmental health, soil chemistry on transporting nephrotoxins, geological parameters which influence the prevalence of the disease and other related sectors to overcome the mysterious nature is highlighted. Mitigation steps to lessen the burden of CKDu are also identified.

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.

Factors Associated with Symptom Burden in Adults with Chronic Kidney Disease Undergoing Hemodialysis: A Prospective Study

People with end stage renal disease and undergoing hemodialysis experience a high symptom burden that impairs quality of life. This study aimed to assess the prevalence, dynamicity and determinants of symptom burden among middle-aged and older adult hemodialysis patients. A descriptive cross-sectional study together with a longitudinal assessment was used. A total of 118 and 102 hemodialysis patients were assessed at baseline and at a 6-month follow-up. Validated questionnaires were used to assess the symptom burden, stress, illness perception and social support. Multiple linear regression analysis was used to determine the factors associated with symptom burden. The median number of symptoms experienced was 21 (Interquartile Range (IQR); 18−23) and 19 (IQR; 13−22) at baseline and 6 months, respectively. Having elevated stress (β = 0.65, p ≤ 0.005) and illness perception (β = 0.21, p = 0.02) were significantly predicted symptom burden at baseline (F (4, 112) = 55.29, p < 0.005, R2 = 0.664). Stress (β = 0.28, p = 0.003), illness perception (β = 0.2, p = 0.03), poor social support (β = −0.22, p = 0.01) and low body weight (β = −0.19, p = 0.03) were the determinants for symptom burden at 6 months (F (5, 93) = 4.85, p ≤ 0.005, R2 = 0.24). Elevated stress, illness perception level, poor social support and low post-dialysis body weight were found to be determinants for symptom burden. Attention should be given to psychosocial factors of hemodialysis patients while conducting assessment and delivering care to patients.

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.

Spatial and physicochemical assessment of groundwater quality in the urban coastal region of Sri Lanka

Rising sea levels, groundwater exploitation, and urbanization were the primary causes of seawater intrusion, exerting pressure on coastal aquifers. In Sri Lanka's urban coastal region, a comprehensive physicochemical description of groundwater has yet to be identified. Therefore, the objectives of this research were to (a) use a Geographic Information System (GIS) to designate spatial distribution of various water physicochemical characteristics, (b) detect "suitable" groundwater zones for drinking, and (c) estimate groundwater quality by developing a groundwater quality index (GWQI) in Sri Lanka's urban coastal region. The physiochemical parameters of 18 groundwater samples [pH, electrical conductivity (EC), turbidity, total dissolved solids (TDS), Na⁺, K⁺, Ca²⁺, Mg²⁺, Cl^-, and HCO₃^-] were studied in terms of their spatial and temporal variation. According to the World Health Organization (WHO) and Sri Lankan Standard Institution (SLS), EC levels in 11% of samples were above the acceptable range, while turbidity levels in 22% of samples were above the acceptable range. Water was consumable in 77.78% of the locations and unsatisfactory in 22.22%. The main hydrochemical facies detected in groundwater samples were Na⁺- Cl^- and the mixed Ca²⁺- Mg²⁺- Cl^- face, which indicated carbonate dissolution and weathering of silicate minerals and the main mechanism controlling the water chemistry in the study area is water-rock interaction. Based on daily water consumption, it was discovered that the HQ is greater than one, in 61% of males, 78% of females, and 89% of children, indicating a health hazard. Furthermore, groundwater quality in the study region is deteriorating due to significant coastal erosion, making it critical to maintain a comprehensive groundwater management strategy to promote sustainable water consumption.

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.

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.

Two decades of chronic kidney disease of unknown aetiology (CKDu) research: Existing evidence and persistent gaps from epidemiological studies in Sri Lanka

BACKGROUND

Chronic Kidney Disease of unknown origin (CKDu) excludes known primary renal conditions or systemic disease (such as diabetes mellitus or hypertension). Prominence of CKDu has been noted for some decades in Sri Lanka, especially among men in particular rural areas, prompting many studies directed towards environmental causation. This article critically reviews relevant primary studies.

METHODS

Articles for this literature review (n = 86) were found by searching Medline, Embase, Global Health and ProQuest databases over 2000-2020 utilizing a standard algorithm. Articles were critiqued according to criteria for diagnosis of CKDu, aetiological agents investigated, analytic methods employed and findings.

RESULTS

Criteria for diagnosis of CKDu varied significantly, including pre-selection by proteinuria, eGFR and biopsy proven interstitial nephritis. Prevalence studies have been largely conducted in the North Central Province, with recent studies demonstrating the presence of CKDu in other regions. Aetiological factors investigated in primary studies included water source, use of agrochemicals, agricultural work, heavy metals, snake bites, ayurvedic medication, heat stress, infectious diseases and usage of tobacco and betel leaf. There is no conclusive evidence for any one aetiological agent despite consistent evidence of distal factors such as male sex, rural residence and farming.

CONCLUSIONS

The current body of evidence for any aetiological agent as the cause of CKDu in Sri Lanka is limited. Further research with stronger study designs is necessary to increase knowledge of aetiology of CKDu in Sri Lanka to identify and eliminate exposure to possible causative agent(s) prior to concluding that the disease is multifactorial.

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.

Involvement of mitochondrial fission in renal tubular pyroptosis in mice exposed to high and environmental levels of glyphosate combined with hard water

Chronic interstitial nephritis in agricultural communities (CINAC) has reached epidemic proportions. The combination of glyphosate and hard water has been postulated to play a potent aetiological role in CINAC. Therefore, dynamin-related protein 1 (Drp1)-mediated aberrant mitochondrial fission and subsequent activation of the nucleotide-binding oligomerization domain (NOD)-like receptor protein 3 (Nlrp3)/caspase1 pathway may be involved in the pathogenesis of nephropathy. In the present study, mice were sub-chronically exposed to high doses and environmental levels of glyphosate (100 mg/kg body weight (mg/kg·bw) glyphosate in Roundup and 0.7 mg/L pure glyphosate, respectively) and hard water (2500 mg/L CaCO3 and 250 mg/L Ca2+, respectively) in drinking water. Moreover, Mdivi-1 (Md-1, 10 mg/kg·bw) was intraperitoneally injected to inhibit Drp1 on the basis of the high-dose experiment. Histopathological examination, biochemical analysis, ELISA, western blotting and fluorescent staining were used to analyse renal structure, renal tubular pyroptosis and mitochondrial fission/fusion alterations. The results showed dramatic proximal tubular injury, particularly in the combined groups. Moreover, significant increases in the protein expression levels of calmodulin (CaM), calmodulin-dependent protein kinase II (CaMKII), Drp1/p-Drp1-Ser616 and the Txnip/Nlrp3/caspase1 signalling pathway, and alterations in oxidative stress were observed in the combined groups, and these effects were attenuated by the Drp1 inhibitor Md-1. Intriguingly, there may be a synergistic effect of glyphosate and hard water on renal injury. Taken together, these results suggest that the combination of glyphosate and hard water, even at environmental exposure levels, enhances pyroptosis and ongoing tubulointerstitial inflammation through excessive Drp1-mediated mitochondrial fission.

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.

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.

Profiles of antibiotic resistome and microbial community in groundwater of CKDu prevalence zones in Sri Lanka

The chronic kidney disease of unknown etiology (CKDu) prevalent in certain regions of Sri Lanka poses a serious threat to human health. Previous epidemiological studies focused on the search of causative agents for CKDu etiology from the viewpoint of groundwater composition, but how CKDu prevalence affected the groundwater microbial composition, especially the antibiotic resistome, has never been illuminated. This study investigated the response of microbial community and antibiotic resistome to CKDu prevalence in the groundwater through the high throughput sequencing and qPCR (HT-qPCR), respectively. Results showed that CKDu prevalence significantly influenced the distribution of antibiotic resistome and microbial community composition. The mexF dominated in all the groundwater samples and could be considered as an intrinsic ARG, and the β-lactamase cphA was specially enriched and closely associated with the antibiotics used for CKDu patients. The Acinetobacter was a potential human pathogen common in the groundwater of CKDu affected regions, while CKDu prevalence specially enriched the Aeromonas. Statistical analysis indicated that CKDu prevalence impacted antibiotic resistome through the microbial community as a whole, and MGEs contributed to the occurrence of mexF, while the enrichment of cphA could be attributed to the increase of Aeromonas.

A comparative review: Chronic Kidney Disease of unknown etiology (CKDu) research conducted in Latin America versus Asia

INTRODUCTION

The incidence of chronic kidney disease of unknown or uncertain etiology (CKDu) is recognized as a global non-communicable health crisis. The goal of this work is to compare the types of research studies in Latin America and Asia, two regions with increasing CKDu incidence.

METHODS

A comparative literature review was conducted to evaluate the CKDu research design for peer-reviewed articles published from 2015 to 2019. Full texts were reviewed to identify study location, study type, study design, risk factors evaluated, and if applicable, sample type and number.

RESULTS

In Asia and Latin America, 82 and 65 articles were identified in total, respectively, with 55 field studies in Asia versus 34 in Latin America. In Asia, research was focused on drinking water (34), heavy metals (20), and agrochemical product usage (19) as potential risk factors. In Latin America, research focused mostly on heat stress/dehydration (36) and agrochemical product usage (18) as potential CKDu risk factors. Biological samples were collected more frequently than environmental samples, especially in Latin America.

DISCUSSION

Research to pinpoint the risk factors associated with CKDu to date is not standardized and typically limited in geographical scope. The emphasis of CKDu research varies by geographic region, with a greater priority placed on water quality and chemical exposure in Asia, versus dehydration and heat stress in Latin America. Using a harmonized approach to CKDu research would yield improved understanding of the risk factors associated with CKDu and how they compare across affected regions.

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.

Impact of water quality on Chronic Kidney Disease of unknown etiology (CKDu) in Thunukkai Division in Mullaitivu District, Sri Lanka

Background

Increase in the number of cases in Chronic Kidney Disease of Unknown etiology (CKDu) in Sri Lanka has become a health issue of national concern. Even though, Northern Province is not identified as a high-risk province, there is an increasing trend of CKDu after the end of civil war in the Northern Province.

Methods

The present study was conducted in Thunukkai Division in Mullaitivu District to investigate the socio demographic and clinical pattern of CKDu patients and to evaluate the quality of their water sources. The samples were selected by using stratified purposive random sampling method which represented 29% of total CKDu patients in Thunukkai Division. Pretested structured questionnaire was administered to collect the data from the CKDu patients. The association between serum creatinine excreted by CKDu patients and the water quality parameters were determined by using linear regression model.

Results

Among the patients, 80% were male with over 68% falling in the age range of 50–70. Majority (90%) were involved in agriculture related occupation. Smoking and alcohol consumption were detected as common habits among 40% of the patients. Secondarily developed, hypertension (60%) and diabetes (34%) were reported as common diseases in the area. Dug wells served as the commonest source of drinking water in the area (90% households) together with few tube wells. Physicochemistry of more than 50% of the water samples revealed higher electric conductivity, salinity, total dissolved solids, total hardness and Na levels compared to drinking water standards in Sri Lanka.

Conclusions

Serum creatinine levels of the CKDu patients were significantly and negatively correlated with phosphate while positively correlated with total dissolved solids (TDS) and arsenic content of the drinking water. Geospatial mapping of TDS and arsenic in drinking water with the occurrence of higher serum creatinine levels confirmed the same trend. Thus, the total dissolved solids and arsenic in drinking water may have positive correlation with the occurrence of CKDu in Thunukkai region in the Mullaitivu District of Sri Lanka.

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.

Kidney developmental effects of metal-herbicide mixtures: Implications for chronic kidney disease of unknown etiology

Chronic kidney disease of unknown etiology (CKDu) is an emerging global concern affecting several agricultural communities in the Americas and South Asia. Environmental contaminants such as heavy metals (e.g., Cd, As, Pb, and V) and organic pesticides (e.g., glyphosate) in the drinking water have been hypothesized to play a role in childhood onset and progression of this disease. However, a comprehensive analysis of chemical contaminants in the drinking water and effects of these compounds and their mixtures on kidney development and function remains unknown. Here, we conducted targeted and non-targeted chemical analyses of sediment and drinking water in CKDu affected regions in Sri Lanka, one of the most affected countries. Using zebrafish Danio rerio, a toxicology and kidney disease model, we then examined kidney developmental effects of exposure to (i) environmentally derived samples from CKDu endemic and non-endemic regions and (ii) Cd, As, V, Pb, and glyphosate as individual compounds and in mixtures. We found that drinking water is contaminated with various organic chemicals including nephrotoxic compounds as well as heavy metals, but at levels considered safe for drinking. Histological studies and gene expression analyses examining markers of kidney development (pax2a) and kidney injury (kim1) showed novel metal and glyphosate-metal mixture specific effects on kidney development. Mitochondrial dysfunction is directly linked to kidney failure, and examination of mixture specific mitochondrial toxicity showed altered mitochondrial function following treatment with environmental samples from endemic regions. Collectively, we show that metals in drinking water, even at safe levels, can impede kidney development at an early age, potentiating increased susceptibility to other agrochemicals such as glyphosate. Drinking water contaminant effects on mitochondria can further contribute to progression of kidney dysfunction and our mitochondrial assay may help identify regions at risk of CKDu.

The water chemistry and microbiome of household wells in Medawachchiya, Sri Lanka, an area with high prevalence of chronic kidney disease of unknown origin (CKDu)

Chronic kidney disease (CKD) of unknown etiology (CKDu) mostly affects agricultural communities in Central America, South Asia, Africa, but likely also in North America and Australia. One such area with increased CKDu prevalence is the Medawachchiya District Secretariat Division of the Anuradhapura District in the North Central Province of Sri Lanka. Recent research has focused on the presence of various microbial pathogens in drinking water as potential causal or contributing factors to CKDu, yet no study to date has performed a more comprehensive microbial and water chemistry assessment of household wells used for domestic water supply in areas of high CKDu prevalence. In this study, we describe the chemical composition and total microbial content in 30 domestic household wells in the Medawachchiya District Secretariat Division. While the chemical composition in the tested wells mostly lies within standard drinking water limits, except for high levels of fluoride (F), magnesium (Mg), sodium (Na), chloride (Cl) and calcium (Ca) in some samples, we find a frequent presence of cyanotoxin-producing Microcystis, confirming earlier studies in Sri Lanka. Since the total microbial content of drinking water also directly influences the composition of the human gut microbiome, it can be considered an important determinant of health. Several bacterial phyla were previously reported in the gut microbiome of patients with CKD. Using these bacteria phyla to define operational taxonomic units, we found that these bacteria also occur in the microbiome of the sampled well water. Based on available environmental data, our study demonstrates associations between the abundances of these bacteria with geographical distribution, well water temperature and likely fertilizer use in the local surface water catchment area of the individual household wells. Our results reinforce the recommendation that household wells with stagnant or infrequently used water should be purged prior to use for drinking water, bathing and irrigation. The latter is suggested because of the reported potential accumulation of bacterial toxins by agricultural crops. The observation that bacteria previously found in chronic kidney disease patients are also present in household wells requires a more detailed systematic study of both the human gut and drinking water microbiomes in CKDu patients, in relation to disease prevalence and progression.

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.

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.