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Environmental Pollution & Environmental Pollution &
Chronic Kidney Disease of Chronic Kidney Disease of
“Multi Factorial Origin”“Multi Factorial Origin”
in in Sri LankaSri Lanka
Sunil J. Wimalawansa, MD, PhD, MBA, DSc
Professor of Medicine
Endocrinology Metabolism & Nutrition
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Outline
• Water, sanitation, pollution and diseases
• Definition of Chronic Kidney Disease (CKD)-
of multi factorial origin (CKD-mfo)
• What causes CKD-mfo
• Engineering solutions for CKD: Clean water
• Reverse osmosis method to overcome CKD
• Sustainable solutions to overcome the
problem
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90% of these deaths
occur in economically
poor countries
Why this disparity? 120 Children are
Dead
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How Does Water Get
Polluted?
• Domestic: disposals, chemicals...
• Industries: agriculture, manufacturing..
• Production: gasoline, chemicals, etc..
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Natural Disasters are Destructive and Lead to Water Pollution
Post-Tsunami environmental and water pollution
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Floods Lead to Water Contamination
Flood Causes Water pollution
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Main Causes of Water Polution
“Microbial” contaminants ― bacteria and viruses:
– Contamination via sewage and septic systems
– Agriculture, livestock operations, and wildlife
“Inorganic” contaminants ― salts and metals:
– Can be naturally occurring, or
– Agrochemicals; storm water runoff
– Industrial or domestic wastewater
– Oil and gas production, mining, and farming
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Preventable
Water Pollution
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Poor Sanitation and
Water Pollution
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Toxins & Chemicals Affect The
Whole Body
• Brain
• Cardiovascular system
• Intestine
• Skin and eye/sensory system
• Immune system
• Liver and Kidneys
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Consequences of Drinking
Contaminated Water
• Acute illnesses
–Water-borne diseases
–Diarrheal diseases
–Dehydration and death
• Chronic illnesses
–Fluorosis
–Chronic liver diseases
–Chronic kidney disease
• High morbidity and mortality
Chronic Kidney Disease
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Anatomy & the Functions of The Kidney
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Preferred Terminology for CKD
• CKD of Multi-Factorial Origin (CKD-mfo)
(the term, I have been using since 2007)
• CKD-mfo is an “Environmental” Disease
that cause by - several factors
• When the “conditions” are unfavorable
to kidneys, it begin to fail
• It causes tubulo-interstitial sclerosis;
Thus, it is irreversible
• Prevention is the only cure
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Rajarata Kidney Disease: Causes?
• No one is certain what is going on
• Too much speculations: Inadequate research
data to make meaningful conclusions
• Multiple interactions escalate toxic effects
• Unregulated / illicit medicine and alcohol
• Role of NSAID, leptospirosis, smoking, and
others―totally neglected
• Unforeseen, unpredicted, or neglected reasons
• Combination of various unhealthful issues
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Prevalence of Chronic
Kidney Diseases in NCR
• In certain villages in NCP, the
prevalence of CKD is between
8 – 10 %, of the population
• Region-wide, the average
prevalence is ~ 5%
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Geographical
Distribution of CKD
in Sri Lanka
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CKD-mfo:
Endemic Areas
Predominantly Affected Districts:
• Anuradhapura
• Polonnaruwa
• Badulla
• Hambantota
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Distribution of CKD in SL
Also now in: Southern
Wellawaya,
Thanamalvila,
Lunugamvehera,
Tissamaharama, etc.
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Occupational Distribution of CKD Pts.
Category Number %
Farmers (male) 174 56 [71%]
House wife 29 9.4
Labors 15 4.9
Businessmen 05 1.6
Carpenters 05 1.6
Postman 03 1.0
Gramasewaka 02 0.6
Others 13 3.9
Missing data's 63 20
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Age Distribution
AGE / YEARS NO %
0-10 00 00.0
11-20 04 01.3
21-30 29 09.4
31-40 57 17.4
41-50 73 23.6
51-60 73 23.6
61-70 51 16.5
71-80 10 03.2
Missing data's 12 03.9
Total 309 100.0
63%
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Multiple Aetiologies Leads to
Development of Chronic Renal Failure
Potential Culprits:
Lack of adequate hydration (chronic
dehydration) – GI absorption issue
Heavy Metals: Cadmium /Arsenic /Lead
Fluoride / aluminium / hard water
Pesticides / herbicides / Nitrates
NSAID / leptospirosis /illicit alcohol & drugs
Unidentified toxins
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Agrochemicals
Cadmium
Hard water
Petrochemicals
Arsenic Fluoride
Algae ionocity
Leptospirosis and others
Tobacco,
alcohol
NSAIDs
Others
Causes of CKD-mfo
Combination of some of these are
more likely to cause CKD-mfo
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Rajarata CKD Epidemic
• Pathological feature of CKD-mfo is
“interstitial nephritis”
• The aetiology of it is unclear
• CKD-mfo is not an immune, congenital,
genetic, or an infectious disease
• It is a disease that is acquired by
“environmental” exposure
• Real time bio-surveillance is necessary
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Probable Causes for CKD-mfo
Algae/ ionocity
Hard water
Cadmium
Fluoride
Agrochemicals Petrochemicals
Arsenic
CKD-mfo
Excusive use of NSAIDs
Leptospirosis and others
Use of locally grown tobacco
Illegal drugs Illegal alcohol
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Potential Water Pollutants
in NCP that Cause CKD
Heavy Metals
Agro-Chemicals
Fluoride
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Heavy Metal Toxicity
Cadmium
Arsenic
Lead Mercury
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Evidence on Toxins
from Algae as a Cause
of CKD?
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War-related
pollution and
bio-terrorism in
previously
endangered
villages are
NOT causes of
Rajarata kidney
disease
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Water Hardness is Unlikely a
Major Source for CKD
• Hardness of water is mostly caused due to
presence of cations, Ca2+ and Mg2+ ,
prevailing across the island for hundreds of
years.
• It may be interact with Fluoride, Cadmium
or Arsenic; but unlikely to be a cause for
the epidemic of CKD.
• The natural ground water hardness does
NOT correlates with CKD distribution
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Distribution of
Ground Water
Hardness
Distribution of
CKD Patients
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Role of Pesticides and Others
Agrochemicals Causing CKD
Role of Pesticides and Others
Agrochemicals Causing CKD
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Agricultural Fields Are A key Source of
Water Contamination in NCP
Synthetic fertilizers
Pesticides, Weedicides
& Fungicides
Excessive and
Indiscriminate Uses of
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Agricultural Fields Are A key Source of
Water Contamination in NCP
Artificial fertilizers
Pesticides, weedicides
& Fungicides
Excessive uses of Government subsidy:
Miss information;
Advertisements; Fashion /
Desires!
Water Pollution CKD
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Annual Chemical Fertilizer Consumption
in South Asian Region 2012
Country Fertilizer consumption
(Kg/hectare of arable land)
Sri Lanka 284.3
Bangladesh 164.5
Pakistan 163.3
India 153.5
Bhutan 9.0
Nepal 7.7 Source :http://data.worldbank.org/indicator/AG.CON.FERT.ZS
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We Can Control Pests Without Toxins
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Ways of Purifying Water
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Ways of Purifying Water Need to develop an affordable
methodology to purify water applicable to:
• Domestic use: for less fortunate
communities
• Community-based small local plants
• Filtration vs. chemical purification
• Predictable, easy to operate & maintain
• Household vs. larger scale purification
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What Works in the Field?
• The use of charcoal, sand, and brick
(individually or in combination) do not
meaningfully remove heavy metal or
fluoride.
• Anything given free, people will
consider worthless; hence some
nominal amount should be charged to
make them feel responsible and taking
the ownership.
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We Have Tasted Several Commercial Water
Purification Filters for Efficiency in the Lab
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Efficacy of the Locally available
Filters in Removing Heavy
Metals, Fluoride, Agro-
chemicals, and Bacteria
None of the filter material we tested
in the laboratories was efficient or
useful in removing potentially
serious water contaminants in NCP
region. We need a New Method.
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CKD -mfo
Interactions of multiple factors
Inadequate consumption of water, dehydration, pollution
Changing lifestyles, food, and farming habits
Deviation form well-established healthy ancient agricultural and
food habits
CKD-mfo ― Causation Pyramid
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Real World Water Solutions (in order of long-term cost-effectiveness)
• Natural spring water
• Rainwater harvesting
• Wells, and deed tube wells
• Provision of pipe-borne water
• Water transportation
• Boiled, cooled water
• Desalination
• Bottled water (the most expensive)
Reverse osmosis: The most applicable
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What is Happening Now
• Every month, over 400 people are dying of CKD-mfo
• i.e., Approximately 13 deaths per day!
• Should we continue neglecting those who are affected, suffering and dying form the CKD?
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Do We Really Need to Confirm Causative
Factors Before Taking an Action?
• Over 10 years of CKD-related
investigations, failed to come to a
conclusion of the cause of CKD.
• No substantial actions have been
taken.
• Yet people are dying every day.
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We Need Long-Term Solutions
• Intense public awareness
• Effective water purification methods
• Prevention of water contamination
– (agriculture, waste, and sewage disposal)
• Use of environmentally friendly agricultural practices
• Reverse osmosis methodology
• Provision of centrally purified pipe-borne water supply to every one
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Educational Posters
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Educational Posters
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Water is Everybody’s Business
Water
Government
Local Governments
Municipalities Departments
Private sector Public sector
Central Government
Ministries
Authorities
NGOs / CBOs
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We Must Provide Clean Water for All
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Dialysis Units are not the
Answer to Solve this Issue
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Setting up Large-Scale Dialysis
Units is NOT the Answer to This
Ongoing Problem:
We Must Take Preventative
Actions:
Actions Needed to Prevent
Healthy People Acquiring CKD
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Prevention of CKD
in The NCP Region
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Functions and Failure of the Kidney
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• Recognition of the impact of different
environmental conditions
• (In)appropiate continued spending on
authorities like Mahaweli (and others)?
• Re-allocation of resources to:
– Restoration of cascade of ancient tank
system, and
– Village-level activities to re-vitalize the
rural societies
Focus Should Be on Prevention and
Sensible Reallocation of Resources
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Solution to CKD Problem Must Include
Science &
Research Medical
Engineering Environmental
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Think of
Conservations,
and not
destruction
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Provision of Reverse Osmosis Would
• Prevent new occurrence of CKD in healthy
farmers
• Also decrease other chronic diseases that
prevalent in the region
• Clean water consumption should reverse
the trend of sicknesses, and thus, enhance
productive lives
• Installation of Reverse Osmosis plants are
the best way to achieve these goals
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Focus Should Be on Preservation,
Improve Access, and Prevention of
Water Pollution
• Preservation of waterways, canals,
underground water, and tanks
• Regulation and maintenance of the
quality of the water in tanks, wells
and tube-wells
• Prevention of water pollution and
alleviation of its adverse effects
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Practical Steps to Be Taken
• Explore alternative water
conservation methods
• Empowerment of women & youth
• Rainwater harvesting
• Attention to sanitation
• Provision of sustainable
drinking water and toilets in public
places, schools, and workplaces
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Current Priorities:
Commitments and Raising Funds
• Regional and country-wide awareness
programs on prevention of water and
environment pollution.
• Provision of clean, safe drinking water to
all CKD-affected villages in Sri Lanka.
• Region-wide, geo-water-health study.
• Obtaining funds, and corporation from
all stake-holders to rapidly implement
this worthwhile project.
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What We Need to Do ?
• SLGo to categorically authorize the CCPO, The Consortium to carry our region wide:
– Education on prevention of water and the environmental contamination
– Provision of clean water to all villages
– Carryout region-wide geo-water study
– Allocate funds for the project
• In parallel, individuals, organizations, and
corporations should raise funds for the project
• CCPO is READY to implement the project
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Overcoming The CKD Issue in NCP
• Never doubt what a committed group of
people can do for the country
• When resources and expertise are
inadequate, evolve & adapt to the situation
• Need to provide an economic viability to
the region
• Change the fundamental
• Need unbiaed leadership and investments
to overcome poverty and diseases
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Thank you………
Questions
and
discussion
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Conserve Our Precious Water Recycle All Material
Preserve Our Environment