Dr. Kingsley de Alwis, President, National Academy of Sciences of Sri Lanka

image001

The blind men and the elephant  (wall relief in Northeast Thailand)
See Poem at the end of this article

The deadly disease known as Chronic Kidney Disease of Unknown Aetiology (CKDu), aka Chronic Renal Failure (CRF), is progressively ravaging many poor rural communities in the North Central Province of Sri Lanka. It is now being detected in other areas of the Dry Zone such as the Eastern and Uva Provinces as well. It has resulted in the deaths of a large number of people, variously estimated at between 20 and 22 thousand, over the last 20 years. Some 8,000 persons are currently said to be undergoing treatment for this disease and, according to the Minister of Health, the Government is spending over Rs. 4,000 million annually on treating CKDu patients. This insidious disease which, according to the final WHO report, cannot be ascribed to diabetes mellitus, hypertension, primary glomerular nephritis or other known etiologies, usually progresses without outward symptoms until it reaches an advanced – and often terminal – stage.

What do scientists say about the causes of CKDu?

Many investigations have been launched and studies carried out to identify the causes of this disease, but no definitive answers have yet been found, although theories abound. The possible causes to which CKDu has been attributed by scientists include, among others:

  • hardness and/or high content of fluorides in drinking water;
  • use of cheap aluminium cookware which is easily solubilised by the fluoride in water;
  • excessive use of agrochemicals containing nephrotoxic chemicals, such as compounds of heavy metals like cadmium and arsenic,    and even plant nutrients like phosphate itself (hyperphosphatemia);
  • consumption of food items such as lotus roots and smoking tobacco, which have high Cadmium (Cd) levels;
  • algal and herbal toxins in the drinking water supply;
  • high ionic concentration in groundwater aquifers supplying the wells from which people draw their drinking water;
  • nephrotoxic ingredients (e.g. Sapsanda) in widely used ayurvedic herbal medicines;
  • excessive dehydration in the work environment of farmers; and even
  • genetic predisposition of the affected population to kidney damage from normally harmless levels of nephrotoxins; and
  • multi-factorial causes (i.e. all or most of the above!)

 

Sometimes Scientists Disagree

 

With every theory, a silver bullet or panacea has been suggested as being the solution to the problem. For over two decades, scientists in various institutions in different parts of the country (as well as Sri Lankans living in other countries!) have been doing research and/or propounding theories on these different possibilities. Many have been proposing solutions, often rushing to publish them in newspapers and/or the electronic media, presumably to get maximum publicity for their theory (and themselves).  Often these theories have been defended aggressively, with more heat than light being thrown on the problem.

 

There still remain many gaps, even in defining the scope of the problem. For example we still don’t have adequate information on the profile of the CKDu patients with respect to: age, gender, education, occupation (including participation in farming and other activities if they are housewives), income, kinds of food & water and other substances consumed, cooking utensils used, source of drinking water, work habits (place, hours, outdoors/indoors, etc.),  size of family, position in the family, other family members and members of the immediate neighborhood  affected (if any), nature and quantities of agro-chemicals used if they are farmers, type of farming (e.g. paddy cultivators, chena cultivators, vegetable growers, etc.); location (preferably with GPS coordinates), etc. etc. Nor do we have a map showing the intensity of occurrence of the disease or a map of the ionic content of water bodies (including aquifers) in the country.

 

The urgent need to develop a strategy to rid the country of CKDu was realized by the Sri Lankan Government, which requested the World Health Organization (WHO) to embark on a program of collaborative studies with the Ministry of Health to identify its cause(s). These collaborative investigations have shed some light on various possibilities, but have not yet resulted in a definitive diagnosis of the problem, only the listing of several likely causes.

 

However, we need not be unduly alarmed about the number of different causes to which CKDu is attributed by scientists. In fact, this is the normal way in which science works. Science works through a series of interactions, as well as the clash of ideas. Scientists may analyze different sets of data and come to different conclusions and dispute each other’s ideas. (The proverbial six blind men describing an elephant by feeling different parts of its anatomy come to mind*). Then, as more information is collected or becomes available, scientists refine their interpretations of the new data and, in time, come to conclusions that are closer to the truth. The main thing is that the data they gather and the conclusions they come to are out there and accessible to all others working on the same problem – especially if their findings are published in peer-reviewed scientific journals rather than in the newspapers.

 

Considering the number of factors that could be involved and their interactions, the investigations on the aetiology of CKDu should necessarily be carried out by a team comprising a whole range of specialists including, among others:

 

  • medical scientists (epidemiologists, nephrologists, pathologists, public health specialists),
  • agricultural scientists (soil scientists, agricultural chemists, extension personnel, agronomists, agricultural chemists working on fertilizers  and pesticides, food technologists),
  • analytical chemists,  geologists, hydrogeologists, geohydrologists, hydrologists, water quality specialists and
  • sociologists, economists and statisticians.

The National Academy of Sciences of Sri Lanka (NASSL), being the only body of eminent senior scientists in Sri Lanka covering the whole range of disciplines involved, organized a Symposium on “Chronic Kidney Disease of uncertain origin (CKDu): a scientific basis for future action”, focusing on the current status of knowledge of the disease, its occurrence, manifestation, cause(s) and the short and long-term action needed to combat or mitigate it.

 

The full-day symposium was held on December 10, 2013 at Galadari Hotel, Colombo. The Symposium brought together most of the practitioners in the different disciplines mentioned above who have been working either independently or under the Health Ministry-WHO-sponsored research project. The Tentative Program of the Symposium is given at the end of this article.

 

Expected Outcomes

The expected outcomes of this symposium were:

  1. A clearer understanding of the present status of scientific knowledge concerning the cause or causes of CKDu in Sri Lanka, as opposed to unfounded theories or conjecture;
  2. The identification of short-term measures that would deal with possible factors that might be implicated in the spread of CKDu among population groups at risk, but which would in any case improve the general health and work environments of the rural population in the endemic CKDu areas (e.g. schemes to provide safe drinking water, careful monitoring of the quality of agrochemicals used by farmers, health education programs for the rural population, etc.)
  3. A long-term program to continue the investigations through a structured, multi-disciplinary research project to tackle CKDu in the affected areas, preferably coordinated by an Epidemiologist.
  4. As a follow-up to the Symposium, the National Academy will publish a report on the proceedings and, together with interested organizations/ funding agencies, participate in preparing project proposals for implementing the short- and long-term measures that were proposed.

The Program

 The  program of the symposium was as follows:

Symposium on

“Chronic Kidney Disease of uncertain origin (CKDu): a scientific basis for future action”

10 December 2013, Galadari Hotel, Colombo

Program

Time Topic Speaker
08:30-09:00 Registration
09:00-09:10 Welcome Address and Opening Remarks

Dr.  Kingsley de Alwis

President,  National Academy of Sciences of Sri Lanka

09:10-09:30 Address by Chief Guest

Dr. Tissa Vitarana

Hon. Senior Minister of Scientific Affairs

09:30-10:00 Keynote Address: Chronic Kidney Disease: Global and Sri Lankan Perspectives

Dr Shanthi Mendis,

Director, Management of Non-communicable Diseases, World Health Organization, Geneva

10:00-10:15 Tea
Technical Program – For Registered Participants only

Session I – Epidemiology of CKDu 

Co-Chairs: Prof. Rezvi Sheriff & Dr. Kingsley de Alwis

10:15-10:35 Geographical Distribution & Epidemiology of CKDu in Sri Lanka Prof. A.M.S. Dhammika Menike Dissanayake, Dept.  of Pathology, Faculty of Medicine, University of Peradeniya
10:35-10:55 Medical Features of CKDu Dr. Tilak Abeysekera, Consultant Nephrologist and Head, Dept. of Nephrology & Transplantation – Teaching Hospital, Kandy
10:55-11:15
Discussion

Session II – Economic, Social & Environmental Aspects

Chairs: Prof. A.V.deS. Indraratne & Dr. Locana Gunarantne

11:15-11:35 Financial and Economic costs of CKDu

Dr. P.G. Mahipala

Director General of Health Services

11:35-12:00 Social and Economic Impact of Chronic Kidney Disease of Unknown Etiology in Sri Lanka Prof. K. Tudor Silva, Senior Professor of Sociology, University of Peradeniya
12:00-12:15
Discussion
12:15-13:30
LUNCH

Session III – Theories & Silver Bullets

Co-Chairs: Prof. Rizvi Sheriff & Prof. Eric Karunanayake

13:30-14:00 Water quality in the Dry Zone in relation to the occurrence of CKDu Prof. C.B. Dissanayake, Director, Institute of Fundamental  Studies, Kandy
14:00-14:20 Fluoride in the water and its possible health impacts Prof.  Oliver Ileperuma, Snr. Prof. of Chemistry, University of Peradeniya
14:20-14:40 Heavy metals, particularly, arsenic (As) and cadmium (Cd) in the water and/or food chain Prof. Priyani Paranagama, Snr. Prof. & Chair of Chemistry, University of Kelaniya
14:40-15:00 Algal and herbal toxins in relation to the Epidemiology  of CKDu Prof. A.M.S. Dhammika Menike Dissanayake, Dept. of Pathology, Faculty of Medicine, University of Peradeniya
15:00-15:20 Challenges in the estimation of trace elements – As,  Cd & Hg Dr. A. M. Mubarak, Director/CEO of Industrial Technology Institute (Rtd.)
15:20 -15:40 Pesticides – a possible source of nephrotoxic chemicals in the environment? Prof. Vijaya Kumar, Retired Chairman, ITI
15:40-16:00 Fertilizer use in Sri Lanka with special reference  to CKDu Dr. C. S. Weeraratne, Vice Chairman, National Community Water Trust,  Ministry of Water Supply and Drainage
16:00-16:15
Discussion
16:15-16:30
TEA

Session IV – Short-term & Long-term Measures –

Co-Chairs: Mr. Nalaka Gunawaredene & Prof. Arjuna Aluwihare

16:30-16:50 Short-term measures – 1: Improving Community health services  Dr. Palitha Bandara, Regional Director of Health Services. Anuradhapura
16:50-17:15 Short-term measures – 2: Community Water Supply Projects Mr. A. Abeygunasekera, Secretary, Ministry of Water Supply & Drainage
17:15 -17:30 Long – term measures – Multi-disciplinary Research Program on Aetiology of CKDu Prof. Janaka de Silva, Chairman, National Research Council
17:30-18:10

Panel Discussion on short- and long-term action needed:

Moderator: Prof. Vijaya Kumar

Panelists: Dr. Shanthi Mendis,  Prof. Tudor Silva, Dr. P. G. Mahipala,  Prof. C. B. Dissanayake, Mr. A. Abeygunasekara (NWSDB),  Mr.  Ranjit Mulleriyawa, Dr. Herath Manthritilake

18:10-18:25 Suggested Short- & Long-term Action Programs  based on Panel Discussion Mr. Nalaka Gunawardene
18:25- 18:30 Vote of Thanks Prof. Nilanthi de Silva, General Secretary, NASSL

The Blind Men and the Elephant
John Godfrey Saxe (1816-1887)

It was six men of Indostan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.

The First approached the Elephant,
And happening to fall
Against his broad and sturdy side,
At once began to bawl:
“God bless me! but the Elephant
Is very like a WALL!”

The Second, feeling of the tusk,
Cried, “Ho, what have we here,
So very round and smooth and sharp?
To me ’tis mighty clear
This wonder of an Elephant
Is very like a SPEAR!”

The Third approached the animal,
And happening to take
The squirming trunk within his hands,
Thus boldly up and spake:
“I see,” quoth he, “the Elephant
Is very like a SNAKE!”

The Fourth reached out an eager hand,
And felt about the knee
“What most this wondrous beast is like
Is mighty plain,” quoth he:
“‘Tis clear enough the Elephant
Is very like a TREE!”

The Fifth, who chanced to touch the ear,
Said: “E’en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a FAN!”

The Sixth no sooner had begun
About the beast to grope,
Than seizing on the swinging tail
That fell within his scope,
“I see,” quoth he, “the Elephant
Is very like a ROPE!”

And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!