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

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.

Investigation of fluoride concentrations, water quality, and non-carcinogenic health risks of borehole water in bongo district, northern Ghana

Access to potable water is a significant concern due to the increasing global threat posed by fluoride contamination in groundwater sources. This study investigated the concentrations of fluoride (F-), the suitability of groundwater for human consumption, the physicochemical characteristics affecting the water quality, and non-carcinogenic adverse health risks to both children and adults in the Bongo district in Northern Ghana. The findings revealed that the groundwater had a mean pH, salinity, TDS, conductivity, and turbidity below the WHO guideline values with a mean fluoride concentration of 1.76 mg/L above the guideline limit of 1.5 mg/L. The study also found that there was no strong relationship between fluoride and the measured water parameters, which may be attributed to poor control of distribution, transport mechanisms, and sources. The WQI scores ranged from 42.62% to 70.72%, indicating that all borehole water samples were of good and excellent quality. The average chronic daily intake showed that children are often more exposed to the harmful impact of fluoride than adults. The average HQ > 1 indicates the probability of dental and skeletal fluorosis after continuous exposure over time in adults and children. The study recommends taking immediate action to mitigate high groundwater fluoride concentrations, implementing appropriate water management strategies, and raising public awareness of the health risks. These measures can guide future groundwater management practices and help policymakers address contamination and protect local communities.

Fluoride exposure and pediatric kidney health in dry, wet and intermediate climatic zone communities in Sri Lanka: Implications from urinary Cystatin-C, and albumin-creatinine ratio

BACKGROUND

High fluoride exposure is increasingly discussed attributing to kidney injury as a causative factor. Depending on geochemistry, differential fluoride levels in drinking water are identified in different regions in Sri Lanka. However, the levels of fluoride exposure, and associations with kidney health has not been adequately studied in Sri Lanka, particularly in pediatric communities. Hence, the present study aimed to assess fluoride exposure in selected pediatric communities in the dry, wet and intermediate climatic zones in Sri Lanka, along with an assessment of renal health using urinary Cystatin-C (uCys-C), and albumin-creatinine ratio (uACR).

METHODS

We conducted a cross-sectional study with school students in selected education zones representing dry (N = 331), wet (N = 152), and intermediate (N = 292) climatic zones in Sri Lanka. Fluoride contents in urine and drinking water were assessed as measures of fluoride exposure.

RESULTS

The median (interquartile distance) urinary fluoride levels of participants in the dry, wet and intermediate zones were 1.63(1.04-2.85), 1.29(0.85-2.21), and 1.07(0.61-1.98) mg/gCr while the fluoride contents of drinking water samples were 1.76(1.36-2.30), 0.25(0.18-0.37), and 0.43(0.26-0.63) ppm respectively with significant differences among the three groups. Median uCys-C level (ng/mgCr) of the participants in intermediate zone [30.26(8.49-71.44)] was significantly low (p < 0.05) compared to that of the participants in dry zone [56.19(7.08-211.8)], and wet zone [66.29(30.43-125.20)]. The incidences of elevated uCys-C levels above reference intervals in participants of dry zone (47.7%), and wet zone (50.0%) were significantly high (p < 0.001) compared to the intermediate zone (26.4%).

CONCLUSION

Relatively high fluoride exposure is likely in dry and wet zone communities compared to the intermediate zone along with significantly higher incidence of uCys-C levels above reference intervals in study groups with higher fluoride exposure. However, to conclude a clear link between fluoride exposure and kidney health we need in-depth studies.

A comprehensive review of human health risks of arsenic and fluoride contamination of groundwater in the South Asia region

The present study found that ∼80 million people in India, ∼60 million people in Pakistan, ∼70 million people in Bangladesh, and ∼3 million people in Nepal are exposed to arsenic groundwater contamination above 10 μg/L, while Sri Lanka remains moderately affected. In the case of fluoride contamination, ∼120 million in India, >2 million in Pakistan, and ∼0.5 million in Sri Lanka are exposed to the risk of fluoride above 1.5 mg/L, while Bangladesh and Nepal are mildly affected. The hazard quotient (HQ) for arsenic varied from 0 to 822 in India, 0 to 33 in Pakistan, 0 to 1,051 in Bangladesh, 0 to 582 in Nepal, and 0 to 89 in Sri Lanka. The cancer risk of arsenic varied from 0 to 1.64 × 1-1 in India, 0 to 1.07 × 10-1 in Pakistan, 0 to 2.10 × 10-1 in Bangladesh, 0 to 1.16 × 10-1 in Nepal, and 0 to 1.78 × 10-2 in Sri Lanka. In the case of fluoride, the HQ ranged from 0 to 21 in India, 0 to 33 in Pakistan, 0 to 18 in Bangladesh, 0 to 10 in Nepal, and 0 to 10 in Sri Lanka. Arsenic and fluoride have adverse effects on animals, resulting in chemical poisoning and skeletal fluorosis. Adsorption and membrane filtration have demonstrated outstanding treatment outcomes.

Nanocrystal-induced chronic tubular-nephropathy in tropical countries: diagnosis, mitigation, and eradication

In tropical countries, a mysterious tubulo-interstitial chronic renal disease (CKD), unrelated to diabetes, hypertension, and immunological causes, manifested four decades ago. Approximately 25,000 primarily middle-aged male farmers succumb annually to this crystal-tubular nephropathy (CTN). Without any known causative factors, it was identified as CKD of unknown aetiology (CKDu). Because multiple factors contribute to causing it later, was changed to CKD of multi-factorial (CKDmfo). Despite no evidence, it was hypothesised to cause by agrochemicals or heavy metals in food or drinking contaminated water. However, current data suggest that the CKD-CTN is due to natural geogenic water contamination. Consumption of concentrated stagnant groundwater from deep-dug wells and tube wells containing hard water and fluoride, overdecades is necessary for its clinical manifestations. In all affected countries have prolonged annual dry seasons that led to the evopo-concentration of ions and minerals in groundwater, making hard water even more unpalatable, thus, peasants consume lesser amounts of water. They develop chronic dehydration from daily exposure to hot climatic conditions aggravated by regular alcohol intake. These conditions provide a highly conducive environment-a perfect storm for calcium phosphate (CaPO₄) crystal formation in renal tissues. Our recent histological and preliminary electron microscopic data reveal deposition of CaPO₄ crystals and nano-tubes in kidneys. While CaPO₄ nano-minerals are unstable, the presence of fluoride ions stabilises and allows their growth. This new concept paves the path for highly cost-effective, straightforward local solutions to protect farm workers and eliminate the disease, without embarking on expensive medications, interventions, or building hospitals. Chronic dehydration-associated CKD-CTN is preventable by increased consumption of potable water. Increasing clean water consumption reduces CKD-CTN incidence, and associated morbidities and premature deaths. However, the damage becomes irreversible when the disease advances beyond CKD stage IIIB. The incidence of this deadly renal failure can be prevented by its education, lifestyle changes, and increased water consumption, not by treating the renal disease or expanding dialysis centres/hospitals, or transplantation services. Eradication of CKD-CTN cost significantly less than the current approach of treating affected persons and unnecessarily expanding health infrastructure. Since the manifestation of CKD-CTN is due to consuming naturally contaminated drinking water (with calcium containing hard water and fluoride), it is not difficult to remove these to prevent CKD-CTN: thus, international assistance is unwarranted for its eradication. The straightforward approaches described here will prevent CKD-CTN and save thousands of lives in affected farming communities.

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.

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

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

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

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

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.

Influence of climate on groundwater fluoride in different climatic domains in a hard rock terrain of Sri Lanka: implications to community health

Health risks associated with excessive intake of fluoride through drinking water are one of the geoenvironmental health problems observed in many parts of the world, mainly in countries of the humid tropical belt, including Sri Lanka. Fluoride-related health problems are widespread in the dry climatic region compared to the wet climatic zone of Sri Lanka. The potential health risks of fluoride for communities in a river basin which drains through two climatic zones, viz. wet and dry zones, were investigated in this study. Sixty-three groundwater samples were collected from wells in the Walawe river basin during pre- and post-monsoon periods. From collected samples, ten selected samples were analyzed for their tritium (³H) levels to find out the approximate resident time of groundwater. In the river basin, the dry zone segment is characterized by elevated levels of fluoride (> 1.0 mg/L) in groundwater. Groundwater fluoride in the region was primarily of geogenic origin. The tritium values showed older groundwater contained higher fluoride levels, showing a increased dissolution of fluoride-bearing minerals. The hazard quotient (HQ_fluoride) showed that about 45% of pre- and 55% of post-monsoon groundwater samples in the dry zone area were unsuitable for drinking purposes for school children who are vulnerable to non-carcinogenic risks and dental fluorosis. This study emphasizes the need for continuous water quality monitoring and mitigation measures to ensure the health of residents.

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

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

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

Abstract

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

Article highlights

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

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

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

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

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

Exposure Assessment of Fluoride Intake Through Commercially Available Black Tea (Camellia sinensis L.) from Areas with High Incidences of Chronic Kidney Disease with Undetermined Origin (CKDu) in Sri Lanka

Fluoride is a beneficial trace element for human health as its deficiency and excess levels can cause detrimental health effects. In Sri Lanka, dry zone regions can have excessive levels of fluoride in drinking water and can cause dental and skeletal fluorosis. In addition to drinking water, traditional habits of tea consumption can cause an additional intake of fluoride in the population. A total number of 39 locally blended black tea samples were collected from a village where chronic kidney disease with undetermined origin (CKDu) is prevalent. In addition, unblended tea samples were obtained from tea-producing factories. The fluoride contents in infusions of 2% weight per volume (w/v) were measured using calibrated ion-selective fluoride electrodes. The mean fluoride content was 2.68±1.03 mg/L in loose tea, 1.87±0.57mg/L in packed tea samples, and 1.14±0.55 mg/L in unblended tea. Repeated brewing of the same tea leaves showed that over 50% of fluoride leached into the solution in the first infusion. An estimate of the daily total average fluoride intake via tea consumption per person is 2.68 mg per day. With groundwater in many dry zone regions in Sri Lanka showing high fluoride levels that exceed 0.5 mg/L, the additional daily intake can rapidly exceed recommended thresholds of 2 mg/day. This can add to adverse health impacts that might also relate to CKDu.

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

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

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

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

Preliminary Data on Geochemical Characteristics of Major and Trace Elements in Typical Biominerals: From the Perspective of Human Kidney Stones

The chemical composition of biominerals is essential for understanding biomineral formation and is regarded as an attractive subject in bio-mineralogical research on human kidney stones (urinary calculi). In order to obtain more geochemically interpreted data on biogenic minerals, mineralogical compositions and major and trace element concentrations of sixty-six kidney stone samples derived from kidney stone removal surgeries were measured. Infrared spectroscopy results showed that calcium oxalate monohydrate (COM) and calcium oxalate dihydrate (COD) were the two main mineral components of kidney stones. Geochemical results indicated that major and trace element concentrations were present in the following order: Ca > Mg > Na > K > Zn > Fe > Pb > Ba > Cu > Ti > Mo > Cd > Cr. With the exception of Ca, Mg was the second-most abundant element. Zn exhibited higher concentrations relative to other trace elements, which suggests a potential substitution of calcium by metal ions with a similar charge and radius rather than by metals in kidney stone formation. Pb appeared in significantly higher concentrations than in previous studies, which indicates Pb enrichment in the environment. In order to discern multi-element relationships within kidney stones, principal component analysis was applied. Three principal components (PCs, eigenvalues >1) were extracted to explain 64.4% of the total variance. The first component exhibited positively correlated Na-Zn-Cr-Mo-Cd-Pb, while the second component exhibited more positively weighted Mg-K-Ba-Ti. Fe-Cu demonstrated a positive correlation in the third component. This study suggests that Ca exhibits a preference for uptake by oxalates during human urinary stone crystallization, while other alkali metals and alkaline earth metals precipitate with phosphate.

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.

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

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

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

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

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

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

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

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

Structure-Activity Relationship of Lanthanide-Incorporated Nano-Hydroxyapatite for the Adsorption of Fluoride and Lead

The growing demand for water purification provided the initial momentum to produce lanthanide-incorporated nano-hydroxyapatite (HAP) such as HAP·CeO2, HAP·CeO2·La(OH)3 (2:1), and HAP·CeO2·La(OH)3 (3:2). These materials open avenues to remove fluoride and lead ions from contaminated water bodies effectively. Composites of HAP containing CeO2 and La(OH)3 were prepared using in situ wet precipitation of HAP, followed by the addition of Ce(SO4)2 and La(NO3)3 into the same reaction mixture. The resultant solids were tested for the removal of fluoride and lead ions from contaminated water. It was found that the composite HAP·CeO2 shows fluoride and lead ion removal capacities of 185 and 416 mg/g, respectively. The fluoride removal capacity of the composite was improved when La(OH)3 was incorporated and it was observed that the composite HAP·CeO2·La(OH)3 (3:2) has the highest recorded fluoride removal capacity of 625 mg/g. The materials were characterized using scanning electron microscopy-energy-dispersive X-ray (SEM-EDX) spectrometry, Fourier transform infrared (FT-IR) spectrometry, X-ray powder diffractometry (XRD), X-ray photoelectron spectroscopy (XPS), and Brunauer-Emmett-Teller (BET) surface area analysis. Analysis of results showed that Ce and La are incorporated in the HAP matrix. Results of kinetic and leaching analyses indicated a chemisorptive behavior during fluoride and lead ion adsorption by the composites; meanwhile, the thermodynamic profile shows a high degree of feasibility for fluoride and lead adsorption.

Influence of regional climatic on the hydrogeochemistry of a tropical river basin-a study from the Walawe river basin of Sri Lanka

The Walawe river basin is one of the important watersheds in Sri Lanka subjected to water scarcity due to intensive exploitation for irrigation and domestic purposes. The groundwater resource in the basin is under-explored for its capacity to sustain a continuous supply of water for future demand while facing the growing climate change challenges. The objective of this study was to identify the behavior of groundwater in the Walawe river basin that flows through two major climatic zones in Sri Lanka. The study approach includes hydrogeochemical and stable isotope analysis in order to differentiate the geochemical evolution of groundwater in the basin with respect to climatic factors. Water samples from thirty-eight (38) deep wells (> 20 m), 25 shallow wells, and 14 surface water bodies were collected and measured for their major ions, and isotope ratios of δ²H and δ¹⁸O. The results indicated a clear difference in the geochemistry of groundwater between the two climatic zones of the basin. The dry zone area was characterized by a higher content of dissolved minerals as compared to that in the wet zone area. Silicate weathering, calcite dissolution, and ion exchange processes were found to be the main control of groundwater geochemistry in the basin. The Ca-HCO₃-type water was found to be the predominant water type. The isotope data suggested that the groundwater in the study area is recharged mainly from the northeast monsoon rain. Isotope characteristics also suggested that direct infiltration is prominent in the wet zone regions, whereas modifications of shallow groundwater by evaporation were dominated in the dry zone areas. The findings of the study suggest that water quality management in the dry zone areas of the basin is critical for the future sustainability of the water resource of the basin.

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

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

A Comparative Assessment of Trace Element Accumulation in Native and Improved Rice (Oryza sativa L.) Varieties Grown Under Different Conditions of Fertilizer Application

Rice (Oryza sativa L.) is the main food crop cultivated in Sri Lanka, and different varieties of rice are grown under different conditions of fertilizer application throughout the country. Since the consumption of rice is extremely high, it is considered as the major dietary source for macro- and micro-nutrients and also for toxic trace elements. The main objective of this study was to investigate and compare trace element levels in native and improved rice varieties that were grown under both organic and inorganic chemical fertilizers and also under unfertilized conditions. Rice grains were collected from a plot experiment with seven native and seven improved rice varieties that were treated with organic and inorganic fertilizers. Contents of macro-nutrients (Na, K, Ca and Mg) and trace elements (Cd, As, Pb, Cr, Mn, Co, Ni, Cu, Zn and Ba) in rice grains were measured by inductively coupled plasma mass spectrometry. The results indicated that rice cultivated using inorganic fertilizers showed the highest mean trace element contents while organic fertilizer-treated improved rice varieties showed the lowest Cd (0.10 mg/kg) which is lower than the maximum permissible level (0.2 μg g^-1). The highest mean value of Cd (0.32 mg/kg) was recorded in native rice varieties grown in plots with chemical fertilizer applications. However, the As content in rice samples collected from all treatment conditions indicated contents lower than the maximum permissible level. Rice cultivated in plots that were treated with chemical fertilizer showed the highest mean macro-nutrient contents.

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.

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.

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

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

Does fluoride cause the mysterious chronic kidney disease of multifactorial origin?

A chronic kidney disease of multifactorial origin (CKDmfo), also known as CKD of unknown origin, started to manifest during the past four decades in certain economically poor, peri-equatorial agricultural countries. CKDmfo is an environmentally induced, occupationally-mediated, chronic tubulointerstitial disease. Prolonged exposure to environmental nephrotoxic agents and extenuating conditions are prerequisites for its manifestation. More than 30 causative factors have been postulated, but none one has been properly scientifically tested, to be able to include or exclude. In recent years, fluoride has come to be considered a key contender as a causative agent of CKDmfo. Therefore, this review examines the pros and cons of that theory and the potential plausibility that fluoride causes CKDmfo. It also examines the potential interactions and additive or synergistic effects of certain geogenic factors, especially, the plausibility of CaPO₄^-3 apatite and fluorapatite crystals and nanotube formation in concentrated tubular filtrate and within tubular cells, in renal tubules. The information presented is based on published work and data collected over the past two decades in Sri Lanka. However, the evidence and concepts are applicable to all CKDmfo-affected countries. Thus, the presented content might facilitate scientists to narrowed down causative factors to just a few and government departments to implement effective programs for preventing this disease. The findings suggest that in addition to the geogenic components, disease manifestation requires (A) prolonged exposure to environmental nephrotoxins and factors, (B) interactions among elements (Ca²⁺, PO₄^-3 , F^-, and Mg²⁺), and (C) vulnerability of the person, such as chronic dehydration, and antioxidant and micronutrient deficiencies. In vivo precipitation of nanominerals in renal tubular tissues that arising over several years causes tubulointerstitial disease-CKDmfo. Inherent vulnerabilities and conditions, together with nanomineral precipitation, trigger renal tubular cell oxidative stresses, inflammation, and fibrosis, and eventually causing tubulointerstitial chronic renal failure-CKDmfo.

Renal bioaccumulation of trace elements in urban and rural Sri Lankan populations: A preliminary study based on post mortem tissue analysis

INTRODUCTION

Environmental pollution, especially by toxic trace elements, is a global health concern. Heavy metals such as Cadmium (Cd), Arsenic (As) and Lead (Pb) are associated with numerous disorders and are considered by some as an aetiological factor for the Chronic Kidney Disease (CKDu1) epidemic in Sri Lanka. This study explores patterns of bioaccumulation of six trace elements in kidneys obtained during forensic autopsies from urban and rural regions in Sri Lanka.

METHODS

Kidney samples obtained from one urban district (n = 13) and three rural districts (n = 18) were lyophilized, microwave digested and profiled by ICP-MS techniques.

RESULTS AND DISCUSSION

The mean age of the sampled population was 47.9 ± 11.3 yrs. Median (IQR) for Cd, As, Pb, Cr, Zn and Se were, 14.67(8.04-22.47) μg/g, 0.44(0.29-0.56) μg/g, 0.11(0.07-0.30) μg/g, 0.15(0.1096-0.3274), 25.55(17.24-39.35) μg/g and 0.52(0.37-0.84) μg/g, respectively. Cd, Zn and Se levels were significantly higher (p < 0.05) among the urban samples compared to that of the rural group. Zn and Se levels were higher among younger age groups. As, Pb and Cr did not show any significant differences between the two cohorts nor any correlations with age.

CONCLUSION

This population-specific baseline study provides an insight into the differences in exposure to toxic trace elements and essential elements between urban and rural populations. Residents in CKDu affected rural districts did not appear to be at risk of toxic heavy metal exposure, however their renal bioaccumulation of nephroprotective essential elements was lower than urban residents.

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

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

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

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

Experimental rat model for acute tubular injury induced by high water hardness and high water fluoride: efficacy of primary preventive intervention by distilled water administration

Background

High water hardness associated with high water fluoride and the geographical distribution of Chronic Kidney Disease of unknown etiology (CKDu) in Sri Lanka are well correlated. We undertook this study to observe the effects of high water hardness with high fluoride on kidney and liver in rats and efficacy of distilled water in reducing the effects.

Methods

Test water sample with high water hardness and high fluoride was collected from Mihinthale region and normal water samples were collected from Kandy region. Twenty-four rats were randomly divided into 8 groups and water samples were introduced as follows as daily water supply. Four groups received normal water for 60 (N1) and 90 (N2) days and test water for 60 (T1) and 90 (T2) days. Other four groups received normal (N3) and test (T3) water for 60 days and followed by distilled water for additional 60 days and normal (N4) and test (T4) water for 90 days followed by distilled water for another 90 days. The rats were sacrificed following treatment. Serum samples were subjected to biochemical tests; serum creatinine, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and elemental analysis. Histopathological examinations were carried out using kidney and liver samples.

Results

Test water treated groups were associated with acute tubular injury with loss of brush border and test water followed with distilled water treated groups maintained a better morphology with minimal loss of brush border. Serum creatinine levels in T1 and T2 groups and urea level in T2 group were significantly (p < 0.05) increased compared to control groups. After administration of distilled water, both parameters were significantly reduced in T4 group (p < 0.05) compared to T2. Serum AST activity was increased in T4 group (p < 0.05) compared to control group with no histopathological changes in liver tissues. The serum sodium levels were found to be much higher compared to the other electrolytes in test groups.

Conclusion

Hard water with high fluoride content resulted in acute tubular injury with a significant increase in serum levels of creatinine, urea and AST activity. These alterations were minimized by administering distilled water.

Ca2+ and SO42- interactions with dissolved organic matter: Implications of groundwater quality for CKDu incidence in Sri Lanka

It has recently been proposed that recalcitrant dissolved organic carbon (DOC) in groundwater plays a potent etiological role in the peculiar distribution of chronic kidney disease of unknown etiology (CKDu). This study aims to elucidate the interactions of Ca²⁺ and SO₄^2- with a model organic fraction of humic acid (SHA) to determine the possible relationship of CKDu incidence with the DOC in drinking water. XPS and FT-IR methods respectively determined the surface functional groups and chemical composition of protonated dissolved organic carbon (HDOC) in a CKDu high-risk zone (HR) of Sri Lanka and in SHA. Higher surface C composition (87.9%) and lower O (11.4%) were observed for HDOC from the HR region than for SHA (C: 73.8%, O: 24.7%). Aromatic C with less O-containing functional groups was observed in HDOC. The IR band at 1170 cm^-1 confirms the formation of organic sulfonate (C-SO₃^-) on SHA. A band at 1213 cm^-1 due to organic sulfonate in HDOC from the CKDu HR region was also identified. The IR band at 866 cm^-1 evidenced the formation of CaCO₃ on SHA above pH 7.4. XPS data confirmed the presence of sulfur oxidation states corresponding to SO₃^2- and SO₄^2- at 168.9 eV and 170.1 eV binding energies, respectively. The binding energies at 347 eV and 351 eV for Ca 2p_3/2 and Ca 2p_1/2 eV, respectively, confirmed the bidentate complexation of Ca²⁺ with COO^- and sulfonate groups on SHA. The organic sulfonate formed is postulated as a uremic toxicant.

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

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

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

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

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

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

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

This study investigated the water quality of the groundwater that was collected from the chronic kidney disease of unknown etiology (CKDu) prevailing areas in the dry zone of Sri Lanka to assess its suitability for drinking purposes, and for the first time a Water Quality Index (WQI) with emphasis on proposing appropriate drinking water treatment method was developed. A total of 88 groundwater samples were collected in dry (December 2016) and wet (May 2017) seasons; high concentrations of water hardness, fluoride, salinity, dissolved organic carbon (DOC), and the general alkaline nature of water were the main issues that were observed for disease incidence. The chemical weathering of the underlying bedrock, followed by ion exchange and precipitation processes, primarily controlled groundwater geochemistry. During the 1985–2017 period, the variations of the annual rainfall and temperature were minimal, which suggests no evidence for major climatic changes within the study areas. Almost all of the samples from the CKDu regions show a low alkali hazard and most of the samples show a medium to high salinity hazard. The DOC of the studied samples was mainly composed of the organic fractions in the following order, as fulvic acids > humic acids > aromatic protein II > soluble microbial by-products, and the molecular weights (MW) of these fractions ranged from 100–3000 Da. Based on the water quality index (WQI) calculations, it was found that only 3.8% in the wet season and 2.6% in the dry season of total water samples were categorized as the “excellent” type, and all other water sources require a further treatment before consumption. As there is an urgent need for establishing proper long-term drinking water treatment technology for the CKDu affected area, these findings can be used as benchmark of raw water quality in the design processes of treatment plants.

Heavy metal imaging in fibrotic human kidney tissue using the synchrotron X-ray fluorescence microprobe

Abnormally high exposure to heavy metals and their accumulation in some tissues are recognized as causes of many acute and chronic human diseases. Because of the roles many metals have in normal human physiology, proving cause and effect between exposure to heavy metals and pathogenesis of disease is problematic. Therefore, many illnesses that develop through occupational and environmental exposure are not considered directly related to heavy metal toxicity. The high sensitivity and spatial resolution of elements using the synchrotron X-ray fluorescence microprobe (XFM) may give a robust means to investigate spatial distribution of heavy metals in correlation with specific pathologies. For example, proven presence of different heavy metals may correlate spatially with kidney fibrosis, suggesting a mechanistic link between heavy metal-induced fibrosis and chronic kidney disease. One specific example that may benefit from such an analysis relates to a cluster of people with chronic kidney disease of unknown cause (CKDu), in a significant proportion of the population of the North Central Province of Sri Lanka. Here, it was postulated that heavy metal exposure, in particular of cadmium, in foods and agriculture may be one cause of end-stage kidney disease and premature death of patients with CKDu. Synchrotron methods had not been applied previously to this particular problem. This manuscript provides a brief review of the literature and reports some pilot data from an investigation of localization of kidney fibrosis in CKDu with selected heavy metals including cadmium.

Characterization of dissolved organic carbon in shallow groundwater of chronic kidney disease affected regions in Sri Lanka

Number of Chronic Kidney Disease patients with no identifiable cause (Chronic Kidney Disease Unknown Aetiology, CKDu) are escalating in the North Central Province (NCP) of Sri Lanka. This study examined distribution of dissolved organic carbon (DOC) in shallow groundwater of three CKDu risk zones (high risk, HR; low risk, LR and no risk, NR) and a control zone (CR) from wet to dry seasons. The interactions of DOC with calcium and magnesium ions and metabolites of selected pesticides were also examined. The lowest COD_MnDOC values of 0.60 ± 0.19, 0.58 ± 0.17 were reported in the DOC of the HR water in the wet and dry seasons, respectively, and this DOC fraction encompasses organic compounds with the lowest labile C with the highest aromaticity. Four distinct fluorescence DOC fractions in the HR water were identified with fulvic acid component associated as dominant non-labile C fraction. The essential building blocks of non-labile C were concentrated into molecular weight (MW) fraction II (900-1800 Da). The DOC source in all groundwater was identified as autochthonous (fluorescence index > 1.8). In the HR water, pentachlorophenol (PCP) was also detected in appreciable quantities. The factor loadings based on principal component analysis (PCA) showed a positive correlation between DOC and sulfate, calcium, total iron, PCP in the HR groundwater. Accordingly, it can be inferred that divalent cations (Ca²⁺, Mg²⁺) abundant in the HR groundwater interact with phenolate and carboxylate functional groups in DOC at alkaline pH.

The heterogeneous nature of water well fluoride levels in Sri Lanka: An opportunity to mitigate the dental fluorosis

OBJECTIVES

The study aimed to use Geographic Information Systems (GIS) to investigate the spatial distribution of the concentration of fluoride (F) in groundwater resources of Sri Lanka, and the geographic accessibility to an alternative water source having a low or safe F limit to mitigate dental fluorosis.

METHODS

The study used randomly collected (6107) groundwater samples from Sri Lanka and categorized them as "dentally optimal" and "unsafe" based on their F content. The minimum distance from an identified high F source (above dentally optimal level) to a safe groundwater source was determined using geospatial analysis.

RESULTS

Dentally optimal F sources (<1 and <1.5 mg/L) were identified among the high F groundwater sources (>2 mg/L), some even within a walking distance of 500 m. Results indicated that 26% of dentally unsafe groundwater sources (2.0 mg/L+ wells) had a low F source (<1.0 mg/L) available within a distance of 500 m. It was also evident that 39% of high F wells (2.0 mg/L+ wells) had a low F well (<1.5 mg/L) within a distance of 500 m, if the WHO guideline value for optimal F levels (1.5 mg/L) was assigned as the safe F limit.

CONCLUSION

The spatial approach demonstrated a reasonable access to alternative water sources with low or safe F limit in endemic fluorosis areas. Optimizing the use of accessible low F sources is highly recommended as the first-line option to mitigate dental fluorosis in Sri Lanka since the defluoridation methods introduced in past did not provide sustainable oral health solutions for the inhabitants in high-risk areas.

Improved nanocomposite of montmorillonite and hydroxyapatite for defluoridation of water

A novel hydroxyapatite montmorillonite (HAP-MMT) nanocomposite system was synthesized using a simple wet chemical in situ precipitation method. Neat nano hydroxyapatite (HAP) was also synthesized for comparison. The characterization of the materials was carried out using Fourier Transform Infrared Spectroscopy (FT-IR), Scanning Electron Microscopy (SEM), X-ray diffraction (XRD) and Brunauer–Emmett–Teller (BET) isotherms to study the functional groups, morphology, crystallinity and the surface area respectively. Batch adsorption studies and kinetic studies on fluoride adsorption were conducted for the HAP-MMT system and for neat HAP. The effect of parameters such as contact time, pH, initial concentration, temperature, and thermodynamic parameters and the effect of coexisting ions on fluoride adsorption by HAP-MMT were studied. Results of the isotherm experiments were fitted to four adsorption isotherm models namely Langmuir, Freundlich, Temkin and Dubinin Radushkevich. Fluoride adsorption over HAP-MMT fitted to the Freundlich adsorption isotherm model and showed more than two-fold improved adsorption capacity (16.7 mg g⁻¹) compared to neat HAP. The best-fitting kinetic model for both adsorbents was found to be pseudo second order. Calculated thermodynamic parameters indicated that the fluoride adsorption by HAP-MMT is more favorable compared to that on HAP within the temperature range of 27 °C–60 °C. Improved fluoride adsorption by HAP-MMT is attributed to the exfoliated nature of HAP-MMT. Gravity filtration studies carried out using a 1.5 ppm fluoride solution, which is closer to the ground water fluoride concentrations of Chronic Kidney Disease of unknown etiology (CKDu) affected areas in Sri Lanka, resulted in a 1600 ml g⁻¹ break through volume indicating the potential of HAP-MMT to be used in real applications.

A novel hydroxyapatite montmorillonite (HAP-MMT) nanocomposite was synthesized using a simple wet chemical in situ precipitation method. This nanocomposite showed improved adsorption properties towards fluoride ions in water.