Additional perspectives on chronic kidney disease of unknown aetiology (CKDu) in Sri Lanka--lessons learned from the WHO CKDu population prevalence study.

Jennifer Hoponick Redmon,Donna S Womack,Myles F Elledge,Roshini J Peiris-John,Kristin Smith,Rajitha Wickremashinghe,James H Raymer,Joseph Lunyera,Kamani P Wanigasuriya,Keith E Levine

doi:10.1186/1471-2369-15-125

Abstract

The recent emergence of an apparently new form of chronic kidney disease of unknown aetiology (CKDu) has become a serious public health crisis in Sri Lanka. CKDu is slowly progressive, irreversible, and asymptomatic until late stages, and is not attributable to hypertension, diabetes, or other known aetiologies. In response to the scope and severity of the emerging CKDu health crisis, the Sri Lanka Ministry of Health and the World Health Organization initiated a collaborative research project from 2009 through 2012 to investigate CKDu prevalence and aetiology. The objective of this paper is to discuss the recently published findings of this investigation and present additional considerations and recommendations that may enhance subsequent investigations designed to identify and understand CKDu risk factors in Sri Lanka or other countries.

Highlights

Sri Lanka recently transitioned from a low- to middleincome nation, and its disease pattern has shifted from infectious and maternal/childhood diseases towards non-communicable diseases (NCDs)
Jayatilake et al brought greater attention and understanding to the emerging chronic kidney disease (CKD) of unknown aetiology (CKDu) crisis in Sri Lanka. Their investigation concluded that multiple agents, including chronic exposure to low levels of cadmium, and genetic predisposition may play a role in the genesis of CKDu
Based on the critical analysis of the Sri Lankan Ministry of Health (MoH) World Health Organization (WHO) study, we recommend the following: 1) Further evaluate the CKDu case definition and refine medical testing procedures, as needed – For the benefit of future studies, it is important that Jayatilake et al detail the sensitivity and specificity of their CKDu medical testing procedures and indicators

Summary

Introduction

Sri Lanka recently transitioned from a low- to middleincome nation, and its disease pattern has shifted from infectious and maternal/childhood diseases towards non-communicable diseases (NCDs). As toxin-associated kidney injury primarily affects the tubules (TIN), not the glomeruli, NGAL may be a better marker for early evidence of kidney damage in CKDu [9] As such, it is recommended as a more sensitive primary parameter for the CKDu case definition and staging compared to ACR, which should be considered during study design for future investigations. As part of any subsequent publication based on the Sri Lanka MoH and WHO study, additional field method documentation detailing the sample media types listed below will help to develop conceptual site models, identify potential environmental hazards in the surrounding area, and interpret the overall analytical results. Residues from a suite of predominantly organochlorine pesticides were determined in urine samples and heavy metals were measured in some phosphate fertilizers, but additional information about agricultural practices, including specific agrochemical use, and about CKDu case and control nutritional status, diet, and drinking water sources will be useful in interpreting results

Conclusions and recommendations

11. Wanigasuriya KP

34. Ministry of Environment Sri Lanka

47. Final Mission Report