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
