Environmental Pollution & Environmental Pollution &

Chronic Kidney Disease of Chronic Kidney Disease of

“Multi Factorial Origin”“Multi Factorial Origin”

in in Sri LankaSri Lanka

Sunil J. Wimalawansa, MD, PhD, MBA, DSc

Professor of Medicine

Endocrinology Metabolism & Nutrition

Outline

• Water, sanitation, pollution and diseases

• Definition of Chronic Kidney Disease (CKD)-

of multi factorial origin (CKD-mfo)

• What causes CKD-mfo

• Engineering solutions for CKD: Clean water

• Reverse osmosis method to overcome CKD

• Sustainable solutions to overcome the

problem

90% of these deaths

occur in economically

poor countries

Why this disparity? 120 Children are

Dead

How Does Water Get

Polluted?

• Domestic: disposals, chemicals...

• Industries: agriculture, manufacturing..

• Production: gasoline, chemicals, etc..

Natural Disasters are Destructive and Lead to Water Pollution

Post-Tsunami environmental and water pollution

Floods Lead to Water Contamination

Flood Causes Water pollution

Main Causes of Water Polution

“Microbial” contaminants ― bacteria and viruses:

– Contamination via sewage and septic systems

– Agriculture, livestock operations, and wildlife

“Inorganic” contaminants ― salts and metals:

– Can be naturally occurring, or

– Agrochemicals; storm water runoff

– Industrial or domestic wastewater

– Oil and gas production, mining, and farming

Preventable

Water Pollution

Poor Sanitation and

Water Pollution

Toxins & Chemicals Affect The

Whole Body

• Brain

• Cardiovascular system

• Intestine

• Skin and eye/sensory system

• Immune system

• Liver and Kidneys

Consequences of Drinking

Contaminated Water

• Acute illnesses

–Water-borne diseases

–Diarrheal diseases

–Dehydration and death

• Chronic illnesses

–Fluorosis

–Chronic liver diseases

–Chronic kidney disease

• High morbidity and mortality

Chronic Kidney Disease

Anatomy & the Functions of The Kidney

Preferred Terminology for CKD

• CKD of Multi-Factorial Origin (CKD-mfo)

(the term, I have been using since 2007)

• CKD-mfo is an “Environmental” Disease

that cause by - several factors

• When the “conditions” are unfavorable

to kidneys, it begin to fail

• It causes tubulo-interstitial sclerosis;

Thus, it is irreversible

• Prevention is the only cure

Rajarata Kidney Disease: Causes?

• No one is certain what is going on

• Too much speculations: Inadequate research

data to make meaningful conclusions

• Multiple interactions escalate toxic effects

• Unregulated / illicit medicine and alcohol

• Role of NSAID, leptospirosis, smoking, and

others―totally neglected

• Unforeseen, unpredicted, or neglected reasons

• Combination of various unhealthful issues

Prevalence of Chronic

Kidney Diseases in NCR

• In certain villages in NCP, the

prevalence of CKD is between

8 – 10 %, of the population

• Region-wide, the average

prevalence is ~ 5%

Geographical

Distribution of CKD

in Sri Lanka

CKD-mfo:

Endemic Areas

Predominantly Affected Districts:

• Anuradhapura

• Polonnaruwa

• Badulla

• Hambantota

Distribution of CKD in SL

Also now in: Southern

Wellawaya,

Thanamalvila,

Lunugamvehera,

Tissamaharama, etc.

Occupational Distribution of CKD Pts.

Category Number %

Farmers (male) 174 56 [71%]

House wife 29 9.4

Labors 15 4.9

Businessmen 05 1.6

Carpenters 05 1.6

Postman 03 1.0

Gramasewaka 02 0.6

Others 13 3.9

Missing data's 63 20

Age Distribution

AGE / YEARS NO %

0-10 00 00.0

11-20 04 01.3

21-30 29 09.4

31-40 57 17.4

41-50 73 23.6

51-60 73 23.6

61-70 51 16.5

71-80 10 03.2

Missing data's 12 03.9

Total 309 100.0

63%

Multiple Aetiologies Leads to

Development of Chronic Renal Failure

Potential Culprits:

Lack of adequate hydration (chronic

dehydration) – GI absorption issue

Heavy Metals: Cadmium /Arsenic /Lead

Fluoride / aluminium / hard water

Pesticides / herbicides / Nitrates

NSAID / leptospirosis /illicit alcohol & drugs

Unidentified toxins

Agrochemicals

Cadmium

Hard water

Petrochemicals

Arsenic Fluoride

Algae ionocity

Leptospirosis and others

Tobacco,

alcohol

NSAIDs

Others

Causes of CKD-mfo

Combination of some of these are

more likely to cause CKD-mfo

Rajarata CKD Epidemic

• Pathological feature of CKD-mfo is

“interstitial nephritis”

• The aetiology of it is unclear

• CKD-mfo is not an immune, congenital,

genetic, or an infectious disease

• It is a disease that is acquired by

“environmental” exposure

• Real time bio-surveillance is necessary

Probable Causes for CKD-mfo

Algae/ ionocity

Hard water

Cadmium

Fluoride

Agrochemicals Petrochemicals

Arsenic

CKD-mfo

Excusive use of NSAIDs

Leptospirosis and others

Use of locally grown tobacco

Illegal drugs Illegal alcohol

Potential Water Pollutants

in NCP that Cause CKD

Heavy Metals

Agro-Chemicals

Fluoride

Heavy Metal Toxicity

Cadmium

Arsenic

Lead Mercury

Evidence on Toxins

from Algae as a Cause

of CKD?

War-related

pollution and

bio-terrorism in

previously

endangered

villages are

NOT causes of

Rajarata kidney

disease

Water Hardness is Unlikely a

Major Source for CKD

• Hardness of water is mostly caused due to

presence of cations, Ca2+ and Mg2+ ,

prevailing across the island for hundreds of

years.

• It may be interact with Fluoride, Cadmium

or Arsenic; but unlikely to be a cause for

the epidemic of CKD.

• The natural ground water hardness does

NOT correlates with CKD distribution

Distribution of

Ground Water

Hardness

Distribution of

CKD Patients

Role of Pesticides and Others

Agrochemicals Causing CKD

Role of Pesticides and Others

Agrochemicals Causing CKD

Agricultural Fields Are A key Source of

Water Contamination in NCP

Synthetic fertilizers

Pesticides, Weedicides

& Fungicides

Excessive and

Indiscriminate Uses of

Agricultural Fields Are A key Source of

Water Contamination in NCP

Artificial fertilizers

Pesticides, weedicides

& Fungicides

Excessive uses of Government subsidy:

Miss information;

Advertisements; Fashion /

Desires!

Water Pollution CKD

Annual Chemical Fertilizer Consumption

in South Asian Region 2012

Country Fertilizer consumption

(Kg/hectare of arable land)

Sri Lanka 284.3

Bangladesh 164.5

Pakistan 163.3

India 153.5

Bhutan 9.0

Nepal 7.7 Source :http://data.worldbank.org/indicator/AG.CON.FERT.ZS

We Can Control Pests Without Toxins

Ways of Purifying Water

Ways of Purifying Water Need to develop an affordable

methodology to purify water applicable to:

• Domestic use: for less fortunate

communities

• Community-based small local plants

• Filtration vs. chemical purification

• Predictable, easy to operate & maintain

• Household vs. larger scale purification

What Works in the Field?

• The use of charcoal, sand, and brick

(individually or in combination) do not

meaningfully remove heavy metal or

fluoride.

• Anything given free, people will

consider worthless; hence some

nominal amount should be charged to

make them feel responsible and taking

the ownership.

We Have Tasted Several Commercial Water

Purification Filters for Efficiency in the Lab

Efficacy of the Locally available

Filters in Removing Heavy

Metals, Fluoride, Agro-

chemicals, and Bacteria

None of the filter material we tested

in the laboratories was efficient or

useful in removing potentially

serious water contaminants in NCP

region. We need a New Method.

CKD -mfo

Interactions of multiple factors

Inadequate consumption of water, dehydration, pollution

Changing lifestyles, food, and farming habits

Deviation form well-established healthy ancient agricultural and

food habits

CKD-mfo ― Causation Pyramid

Real World Water Solutions (in order of long-term cost-effectiveness)

• Natural spring water

• Rainwater harvesting

• Wells, and deed tube wells

• Provision of pipe-borne water

• Water transportation

• Boiled, cooled water

• Desalination

• Bottled water (the most expensive)

Reverse osmosis: The most applicable

What is Happening Now

• Every month, over 400 people are dying of CKD-mfo

• i.e., Approximately 13 deaths per day!

• Should we continue neglecting those who are affected, suffering and dying form the CKD?

Do We Really Need to Confirm Causative

Factors Before Taking an Action?

• Over 10 years of CKD-related

investigations, failed to come to a

conclusion of the cause of CKD.

• No substantial actions have been

taken.

• Yet people are dying every day.

We Need Long-Term Solutions

• Intense public awareness

• Effective water purification methods

• Prevention of water contamination

– (agriculture, waste, and sewage disposal)

• Use of environmentally friendly agricultural practices

• Reverse osmosis methodology

• Provision of centrally purified pipe-borne water supply to every one

Educational Posters

Educational Posters

Water is Everybody’s Business

Water

Government

Local Governments

Municipalities Departments

Private sector Public sector

Central Government

Ministries

Authorities

NGOs / CBOs

We Must Provide Clean Water for All

Dialysis Units are not the

Answer to Solve this Issue

Setting up Large-Scale Dialysis

Units is NOT the Answer to This

Ongoing Problem:

We Must Take Preventative

Actions:

Actions Needed to Prevent

Healthy People Acquiring CKD

Prevention of CKD

in The NCP Region

Functions and Failure of the Kidney

• Recognition of the impact of different

environmental conditions

• (In)appropiate continued spending on

authorities like Mahaweli (and others)?

• Re-allocation of resources to:

– Restoration of cascade of ancient tank

system, and

– Village-level activities to re-vitalize the

rural societies

Focus Should Be on Prevention and

Sensible Reallocation of Resources

Solution to CKD Problem Must Include

Science &

Research Medical

Engineering Environmental

Think of

Conservations,

and not

destruction

Provision of Reverse Osmosis Would

• Prevent new occurrence of CKD in healthy

farmers

• Also decrease other chronic diseases that

prevalent in the region

• Clean water consumption should reverse

the trend of sicknesses, and thus, enhance

productive lives

• Installation of Reverse Osmosis plants are

the best way to achieve these goals

Focus Should Be on Preservation,

Improve Access, and Prevention of

Water Pollution

• Preservation of waterways, canals,

underground water, and tanks

• Regulation and maintenance of the

quality of the water in tanks, wells

and tube-wells

• Prevention of water pollution and

alleviation of its adverse effects

Practical Steps to Be Taken

• Explore alternative water

conservation methods

• Empowerment of women & youth

• Rainwater harvesting

• Attention to sanitation

• Provision of sustainable

drinking water and toilets in public

places, schools, and workplaces

Current Priorities:

Commitments and Raising Funds

• Regional and country-wide awareness

programs on prevention of water and

environment pollution.

• Provision of clean, safe drinking water to

all CKD-affected villages in Sri Lanka.

• Region-wide, geo-water-health study.

• Obtaining funds, and corporation from

all stake-holders to rapidly implement

this worthwhile project.

What We Need to Do ?

• SLGo to categorically authorize the CCPO, The Consortium to carry our region wide:

– Education on prevention of water and the environmental contamination

– Provision of clean water to all villages

– Carryout region-wide geo-water study

– Allocate funds for the project

• In parallel, individuals, organizations, and

corporations should raise funds for the project

• CCPO is READY to implement the project

Overcoming The CKD Issue in NCP

• Never doubt what a committed group of

people can do for the country

• When resources and expertise are

inadequate, evolve & adapt to the situation

• Need to provide an economic viability to

the region

• Change the fundamental

• Need unbiaed leadership and investments

to overcome poverty and diseases

Thank you………

Questions

and

discussion

Conserve Our Precious Water Recycle All Material

Preserve Our Environment