Chronic Kidney Disease: Food as a cause challenged
A Chronic Kidney Disease, also called Chronic Renal Failure (CRF) has been reported to occur in several areas of Sri Lanka since 1990s. The causal factors of this kidney disease are not known. Hence this disease is called Chronic Kidney Disease of unknown etiology (CKDu).
According to the article by Kamal Gammampila ( KG) on Chronic Kidney Disease, ( presumably CKDu) published in Sunday
Times of Feb 1, 2015, this disease is confined to North Central Province ( NCP) and there are about 400,000 people in this province affected by this disease. This data is incorrect. CKD is reported to occur not only in NCP, but also in the following provinces - North Western, Uva, Eastern and Central. According to MOH data, in 2010, there were 20,336 confirmed CKDu patients in Sri Lanka. Official statistics on the number of people affected by CKDU after 2010 appear to be unavailable.
KG attributes CKDu to cadmium, arsenic and lead in food consumed by the people. If this is correct people in other parts of the country such as Colombo, Gampaha, Kandy and other places should also be affected by CKDu, because a considerable amount of rice, and vegetables grown in NCP are sent to many other districts of Sri Lanka. In NCP too the distribution of CKD affected people varies considerably. For example, according to MOH data in 2010, there were 42 cases in Kekirawa DS division, but 2783 cases in Medawachchiya DS division. Both DS divisions are in NCP.
The WHO report on CKD did not establish that most food items grown in NCP had high levels of arsenic, cadmium and lead. In this study cadmium in rice in both endemic and non- endemic areas was less than the allowable limit. The only "vegetable" analysed in the WHO study was lotus root. GM also says that chena farmers are more affected by CKDu than the others because they consume more yams. There is no data which substantiate such a hypothesis. In fact, unlike a few decades ago, the extent of land under chenas is not much, and most farmers cultivate their uplands with vegetables, chili and yams not on a shifting cultivation basis.
According to the papers presented at a number of seminars/ symposia in 2013 and 2014, CKDu is caused by a toxic element/ s or compound/ s in drinking water. Among these are aluminum, arsenic, cadmium, fluoride, toxins released by Blue Green Algae, pesticides etc. However, there is no conclusive evidence to indicate the actual causal factor/s of CKDu.
CKDu and Agrochemials
Some are of the opinion that cadmium, arsenic and lead in fertilisers cause CKDu. A number of different types of fertilisers -- Urea, Muriate of Potash, Triple Super Phosphate (TSP) -- are used in Sri Lanka. A paper presented on the issue of fertiliser use and CKDU at a symposium organised by the National Academy of Science in Dec. 2013 showed that it is unlikely that cadmium in Triple Super phosphate (TSP) could be a causal factor of CKDu. At the recent Colombo symposium organised by Crop Life - Sri Lanka on "Toxicological Aspects of Pesticides and CKDu in NCP Sri Lanka", a professor of toxicology and environmental health, in his presentation, concluded that arsenic is an unlikely cause of CKDu. The WHO report shows no relationship with arsenic and CKDu.
It is important to point out that if the source of the toxic elements/ ions in water is fertilisers and/ or agrochemicals, then water in other agricultural areas such as Kandy, Nuwara Eliya , Hambanthota etc. where large amounts of fertilisers are used should also have high contents of these toxic elements/ ions, and the people in those areas should also be affected by CKDu. Even in NCP, some divisions where agrochemicals are used in large amounts (eg. Huruluwewa), the incidence of CKDU is low compared to other divisions in NCP.
It is relevant to point out that fertilisers and pesticides are not the only sources of heavy metals. Rocks in some areas, and therefore the soils derived from such rocks may also contain heavy metals. Some organic fertilisers such as compost may also contain these heavy metals if solid wastes have been used in the manufacture of these organic fertilizers.
If CKDu is to be controlled, the Ministry of Health in collaboration with the Provincial Ministries of Health, Education and Agriculture in the affected regions need to implement an integrated programme to carry out the following. 1. To collect relevant data from the DS/GN divisions where CKDu is prevalent. This could be easily done with the GNs, Samurdhi and Development Assistants in DS divisions in collaboration with the MOH offices. 2. Close monitoring of the creatinine content of urine of the people in the relevant DS Divisions affected by CKDu and provide proper treatment including dialysis to those who are affected. 3. Conduct awareness programmes on water quality and its effect on CKDu in schools in the affected provinces, in collaboration with the respective Departments of Education. 4. Implement a programme to distribute good quality water to the people in the affected areas. The Ministry of Water Supply and Drainage has already initiated such a programme. About 10 Reverse Osmosis ( RO) plants, each costing around Rs. 1 million have been installed. However, the provincial government authorities need to take a more active role in this regard. 5. A multi-disciplinary comprehensive research study needs to be conducted to identify the causal factors/ s of CKDu. Such a study is better carried out by the National Science Foundation or National Research Council. 6. A fund should be established to assist the patients and their families to procure the necessary services, medicine, and travel to hospitals for dialysis. It is creditable that the new government has initiated a programme to provide financial assistance to CKDu patients.