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.

Provincial and seasonal influences on heavy metals in the Noyyal River of South India and their human health hazards.

This study was carried out to evaluate the heavy metals (Lead (Pb), Nickel (Ni), Chromium (Cr), Copper (Cu), Cadmium (Cd) and Zinc (Zn)) pollution in the Noyyal River of South India by collecting 130 river water samples (65 each in pre- and post-monsoon). The heavy metals were measured using Atomic Absorption Spectrophotometer (AAS). The data were used to calculate the associated health hazards for the inhabitants consume river water. Correlation analyses and average concentration of heavy metals denoted that post-monsoon metal concentrations were lesser compared to the pre-monsoon due to dilution effect. Modified Contamination Degree (MCD) indicated that 45% of pre-monsoon and 25% of post-monsoon samples were classified under extremely polluted category. Heavy metal pollution index (HPI) showed that all the regions fall under highly polluted category except 'Region I' where 20% of samples were under safe category during the pre-monsoon, whereas 9%,28%, 17% and 26% of samples in Regions I, II, III and IV were highly polluted during the post-monsoon season, respectively. Ecological Risk Index (ERI) revealed that high risks attained in Regions II (78%) and III (82%) during pre-monsoon, and reduced risks found in Regions II (28%) and III (45%) during post-monsoon season due to dilution by monsoon rainfall. Non-carcinogenic risks as inferred by the Hazard Index (HI) indicated that 78% and 52% of samples for infants, 75% and 49% of samples for teens and 71% and 45% of samples for adults exceeded the threshold limits of USEPA (HI > 1) and possessed risks during pre- and post-monsoon, respectively. The cancer risk assessment based on ingestion of heavy metals indicated that the order of risk is Ni > Cr > Cu. The HI for infants and teens was notably high to that of adults in both the seasons. This study will be useful to develop effective strategies for improving river water quality and to reduce human health hazards.

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 (HQfluoride) 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.

Major and trace elements in rice paddy soils in Sri Lanka with special emphasis on regions with endemic chronic kidney disease of undetermined origin.

Environmental exposure to trace elements has been widely suspected as an etiological factor for the emergence of chronic kidney disease of undetermined origin (CKDu) that prevails in certain districts of the dry zone areas of Sri Lanka. Contaminated rice can be act as a host for potentially toxic trace elements that ultimately led to health hazards; thus, rice soils were investigated in detail, giving particular attentions to identified CKDu hotspots. A total of 102 rice soil samples were collected from main climatic zones viz. wet and dry zones including CKDu hotspots. In addition to pH, electrical conductivity and cation exchange capacity, acid extracted major and trace element contents in rice soils were determined by using ICP-MS. Significant differences were observed for Mn, Ni, Cu, Zn, and Pb contents between climatic zones. Arsenic and Pb contents in soils were lower than the levels reported in soils from other regions of the world, though significantly higher contents were observed in CKDu regions compared to non-endemic wet zone regions. Calculation of enrichment factor revealed that soils in both dry and wet zones were moderately enriched with As, Cd, and Pb, suggesting an influence of anthropogenic processes. Twenty percent of the wet zone samples showed significant enrichment of Ni, Cu, and Zn. Geo-accumulation index assorted that the studied soil samples were uncontaminated to moderately contaminated, implying that rice soils in both climatic zones are not alarmingly contaminated with toxic trace elements. However, regular and continuous monitoring of rice soil quality is extremely important.

Micronutrient status and associated factors of adiposity in primary school children with normal and high body fat in Colombo municipal area, Sri Lanka.

BACKGROUND: The prevalence of obesity and associated risk of chronic diseases are increasing among the paediatric population. The effectiveness of preventive measures and interventions are likely to improve when all factors which associate with obesity in a specific target group are considered. Currently such comprehensive data is unavailable for Sri Lankan children aged 8-9 years. METHODS: This paper pertains to the data collected from August-2015 to November-2016 for a case-control study which included cases (high body fat) (N = 160; males-81) and controls (normal body fat) (N = 164; males-80) recruited from primary schools in the Colombo Municipal area. Anthropometry and body composition (Bioelectrical impedance analysis-BIA) were measured. Diet, physical activity and socio-demographic data were collected using validated interviewer administered questionnaires. Serum concentrations of vitamins A, D [25(OH)D], E, folate (serum and red blood cell-RBC), zinc (Zn), selenium (Se), copper (Cu), iron (Fe), magnesium (Mg), calcium (Ca), chromium (Cr), manganese (Mn), cobalt (Co), ferritin, leptin and high sensitivity C-reactive protein (hs-CRP) were assessed using fasting blood samples. RESULTS: Cases were from higher socio-economic strata and spent significantly less time on physical activities, more time on sedentary behaviours and consumed higher energy compared to the controls. Cases from both genders had significantly lower levels of vitamin D [25 (OH)D], Fe and Mg (all p < 0.05) and higher levels of Cu and Ca (all p < 0.01) compared to controls. Higher levels of ferritin and Cr were seen among male (p < 0.001) and female (p > 0.05) cases compared to the controls. However, total serum folate levels were lower in male (p < 0.01) and female (p > 0.05) cases while the RBC folate levels were higher among male (p < 0.01) and female (p > 0.05) cases compared with controls. Vitamins A, E, Se, Mn and Co (p > 0.05) were not significantly different between groups. The inflammatory markers, both hs-CRP and leptin levels were higher among cases (p < 0.001) compared to the controls. CONCLUSIONS: This study highlights higher socio-economic status, lower physical activity, more sedentary behaviours, higher energy intake and inconsistent distribution of micronutrients among the children with high body fat when compared with the control group. Increased levels of inflammatory markers indicate the presence of the risk of chronic inflammation in children with high body fat.

Bioavailability of selenium (Se) in cattle population in Sri Lanka based on qualitative determination of glutathione peroxidase (GSH-Px) activities.

Glutathione Peroxidase activity in whole blood is well correlated with the Selenium (Se) levels in cattle hence can be used effectively to assess the supply of Se to farm animals. In this study, Se status of cattle from five different geographic regions of Sri Lanka were assessed based on glutathione peroxidase (GSH-Px) activity. The GSH-Px activity was determined in whole blood samples collected from 80 cattle from 31 different farms in five districts viz. Kandy, Anuradhapura, Batticoloa, Trincomalee and Jaffna using photometric method. Mean GSH-Px activity was found to be 825, 1239, 1039, 849 and 1307 µkat L-1 in above districts, respectively while the reference value was considered as 665.4 µkat L-1. Among the studied animals, insufficient Se levels were detected in 50%, 17%, 9%, 27% and 5%, respectively, from above districts. Kruskal Wallis test indicated a significant variation among the sampled locations with respect to the GSH-Px activity (p = 0.001). Selenium content in pasture and water collected from studied locations varied from 6.0 to 554 µg kg-1 and < 0.03-1.14 µg L-1, respectively. The lower Se levels in feeds recorded from Kandy region infer the lower GSH-Px activity in the animals from the same region. This variability may be due to differences in nutrient supply, age and species of cattle, and lactation stage. Although the assessing method has some limitations, the activity of GSH-Px of the samples indirectly confirms that considerable numbers of cattle from Sri Lanka are with insufficient selenium levels.

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.

Adsorption kinetics of hexavalent chromium on to natural red-earth: a laboratory simulated study.

Heavy metal contamination of water is a significant threat to organisms and to public health. Among them, chromium is one of the important heavy metals in the environment that originates mainly from anthropogenic activities. Natural red earth (NRE), a ferrous-coated natural sand, is one of the materials that could be used to remove heavy metals from contaminated water. Laboratory-scale simulated experiments were carried out to identify the retention behavior of Cr(VI) on NRE. The effects of solution pH, initial Cr(VI) concentration, the amount of NRE used and the contact time were examined. Almost 63% Cr(VI) was adsorbed within 20 minutes. When particle size ranged from 125 to 180 µm, the Cr adsorption data followed the Langmuir isotherm model, providing a higher R2 value of 0.9523, suggesting monolayer coverage on the homogeneous surface with a uniform distribution of energetic adsorption sites. The monolayer coverage of Cr on NRE is estimated as 11.35 mg/g. The data showed that NRE can be used to remove Cr(VI) from aqueous solutions effectively, and this method is found to be simple, effective, economical and environmentally friendly.

Mineralogical, compositional and isotope characterization of human kidney stones (urolithiasis) in a Sri Lankan population.

In order to understand the processes of stone formation, compositional, spectroscopic, mineralogical and crystallographic characteristics of human urinary stones collected from patients in Sri Lanka were investigated in detail. The data showed that the majority of urinary calculi were calcium oxalate, either whewellite or weddellite. Other solid phases of stones were composed of struvite, uricite and hydroxylapatite. However, mixed compositions were common except for whewellite stones which occur frequently in pure form. Scanning electron microscope observations and associated energy-dispersive X-ray analyses revealed that whewellite or weddellite was well crystalized compared to other stones types, while phosphate stones were mostly cryptocrystalline. The average δ13C and δ18O of stones were - 32.2‰ (- 37.3 to - 17.4‰) and - 24.2‰ (- 26.7‰ to - 8.9‰), respectively. The δ13C values were highly depleted compared to North American and European urinary stones. This may be due to food habits of Asians who consume rice as the staple food.

Geoenvironmental factors related to high incidence of human urinary calculi (kidney stones) in Central Highlands of Sri Lanka.

An area with extremely high incidence of urinary calculi was investigated in the view of identifying the relationship between the disease prevalence and the drinking water geochemistry. The prevalence of the kidney stone disease in the selected Padiyapelella-Hanguranketa area in Central Highlands of Sri Lanka is significantly higher compared with neighboring regions. Drinking water samples were collected from water sources that used by clinically identified kidney stone patients and healthy people. A total of 83 samples were collected and analyzed for major anions and cations. The anions in the area varied in the order HCO3 (-) > Cl(-) > SO4 (2-) > NO3 (-) and cations varied in the order Ca(2+) > Mg(2+) > Na(+) > K(+) > Fe(2+). The dissolved silica that occurs as silicic acid (H4SiO4) in natural waters varied from 8.8 to 84 mg/L in prevalence samples, while it was between 9.7 and 65 mg/L for samples from non-prevalence locations. Hydrogeochemical data obtained from the two groups were compared using the Wilcoxon rank-sum test. It showed that pH, total hardness, Na(+), Ca(2+) and Fe(2+) had significant difference (p < 0.005) between water sources used by patients and non-patients. Elemental ratio plots, Gibbs' plot and factor analysis indicated that the chemical composition of water sources in this area is strongly influenced by rock-water interactions, particularly the weathering of carbonate and silicate minerals. This study reveals a kind of association between stone formation and drinking water geochemistry as evident by the high hardness/calcium contents in spring water used by patients.

Has irrigated water from Mahaweli River contributed to the kidney disease of uncertain etiology in the dry zone of Sri Lanka?

The Mahaweli is the largest river basin in Sri Lanka that provides water to the dry zone region through multipurpose irrigation schemes . Selenium, arsenic, cadmium, and other bioimportant trace elements in surface waters of the upper Mahaweli River were measured using ICP-MS. Trace element levels were then compared with water from two other rivers (Maha Oya, Kalu Ganga) and from six dry zone irrigation reservoirs. Results showed that the trace metal concentrations in the Mahaweli upper catchment were detected in the order of Fe > Cu > Zn > Se > Cr > Mn > As > Ni > Co > Mo. Remarkably high levels of Ca, Cr, Co, Ni, Cu, As, and Se were observed in the Mahaweli Basin compared to other study rivers. Considerably high levels of Cr, Mn, Fe, Co, Ni, Cu, Zn, As, and Se were found in upstream tributaries of the Mahaweli River. Such metals possibly originated from phosphate and organic fertilizers that are heavily applied for tea and vegetable cultivations within the drainage basin. Cadmium that is often attributed to the etiology of unknown chronic kidney diseases in certain parts of the dry zone is much lower than previously reported levels. Decrease in these metals in the lower part of the Mahaweli River could be due to adsorption of trace metals onto sediment and consequent deposition in reservoirs.

Whole-exome sequencing reveals genetic variants associated with chronic kidney disease characterized by tubulointerstitial damages in North Central Region, Sri Lanka.

OBJECTIVES: The familial clustering observed in chronic kidney disease of uncertain etiology (CKDu) characterized by tubulointerstitial damages in the North Central Region of Sri Lanka strongly suggests the involvement of genetic factors in its pathogenesis. The objective of the present study is to use whole-exome sequencing to identify the genetic variants associated with CKDu. METHODS: Whole-exome sequencing of eight CKDu cases and eight controls was performed, followed by direct sequencing of candidate loci in 301 CKDu cases and 276 controls. RESULTS: Association study revealed rs34970857 (c.658G > A/p.V220M) located in the KCNA10 gene encoding a voltage-gated K channel as the most promising SNP with the highest odds ratio of 1.74. Four rare variants were identified in gene encoding Laminin beta2 (LAMB2) which is known to cause congenital nephrotic syndrome. Three out of four variants in LAMB2 were novel variants found exclusively in cases. CONCLUSION: Genetic investigations provide strong evidence on the presence of genetic susceptibility for CKDu. Possibility of presence of several rare variants associated with CKDu in this population is also suggested.

Unexpected contributions by carbonates and organic matter in a silicate-dominated tropical catchment: An isotope approach.

The understanding of global carbon has rarely extended to small-scale tropical river basins. To address these uncertainties, this study aims to investigate the importance of rock weathering and organic matter turnover in the carbon cycle in a terrain dominated by crystalline silicate rocks. The geochemical composition of the dissolved and particulate carbon phases (DIC, DOC and POC) and their stable carbon isotopes were studied in the Deduru Oya River in Sri Lanka. Dissolved inorganic carbon (DIC) was the most dominant carbon phase and its contribution to the total carbon pool varied between 67 and 89 %. Furthermore, the δ13CDIC values in the river varied between -1.1 and -16.5 ‰. The lithological characteristics and molar ratios between Ca2+, Mg2+ and HCO3- indicated rock weathering mainly by CO2 and carbonic acid. The δ13CDIC values for groundwater input were -15.9 ‰, while for carbonate weathering, mainly due to fertiliser input, they reached a value of -12.7 ‰. This input was fed into an isotope mass balance to determine the relative contributions. However, the isotope mass balance was only plausible after correcting for the effects on δ13CDIC caused by degassing and photosynthesis. Our study demonstrated that carbonate weathering and organic matter turnover are essential components of the river carbon cycle even in a silicate dominated catchment. They can represent up to 60 % of the DIC pool. Combined with the higher organic matter turnover and high pCO2 in the river water, it can be suggested that the Deduru Oya River acts as a net source of CO2 in the atmosphere. Our study shows that CO2 degassing and in-stream photosynthesis in tropical river systems need to be considered along with chemical weathering to account for carbon transport and turnover in tropical rivers.

Urinary MicroRNA Analysis Indicates an Epigenetic Regulation of Chronic Kidney Disease of Unknown Etiology in Sri Lanka.

BACKGROUND: Chronic kidney disease of unknown etiology (CKDu) is reported among male paddy farmers in the dry zone of Sri Lanka. The exact cause of this disease remains undetermined. Genetic susceptibility is identified as a major risk factor for CKDu Objectives: In this study, small urinary RNAs were characterized in CKDu patients, healthy endemic and non-endemic controls. Differently expressed urinary miRNAs and their associated pathways were identified in the study population. METHODS: Healthy and diseased male volunteers (n = 9) were recruited from Girandurukotte (endemic) and Mawanella (non-endemic) districts. Urinary small RNAs were purified and sequenced using Illumina MiSeqTM. The sequence trace files were assembled and analyzed. Differentially ex-pressed miRNAs among these three groups were identified and pathway analysis was conducted. RESULTS: The urine samples contained 130,623 sequence reads identified as non-coding RNAs, PIWI-interacting RNAs (piRNA), and miRNAs. Approximately four percent of the total small RNA reads represented miRNA, and 29% represented piRNA. A total of 409 miRNA species were ex-pressed in urine. Interestingly, both diseased and endemic controls population showed significantly low expression of miRNA and piRNA. Regardless of the health status, the endemic population ex-pressed significantly low levels of miR-10a, miR-21, miR-148a, and miR-30a which have been linked with several environmental toxins Conclusion: Significant downregulation of miRNA and piRNA expression in both diseased and healthy endemic samples indicates an epigenetic regulation of CKDu involving genetic and environmental interaction. Further studies of specific miRNA species are required to develop a miRNA panel to identify individuals susceptible to CKDu.

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.

Preparation of matrix-matched standards for the analysis of teeth via laser ablation-inductively coupled plasma-mass spectrometry.

Mineralised tissue such as teeth can serve as a retrospective, chronological bioindicator of past exposure to toxic metals. Laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) can be used to determine the presence and spatial distribution of toxic metals in teeth, giving a record of when an exposure occurred. Concentrations of these metals are often determined by a one-point calibration against NIST glass using an equation that requires an internal standard factor that accounts for differences in ablation behaviour between the glass and the tooth. However, an ideal external calibration would contain multiple matrix-matched standards to obtain a calibration curve. Here, we investigated optimal procedures for preparing synthetic hydroxyapatite (HA) doped with elements of interest as a calibration material. The materials were examined for homogeneity of metal incorporation, matrix-matched ablation characteristics, linearity, and limits of detection. A homogenised and pelleted HA was the most suitable material, providing improved ablation characteristics over previous HA materials and NIST glass for the analysis of teeth. An ablation yield of 1.1 showed its suitability to analyse teeth, the metals were homogeneously incorporated, and it produced excellent linearity with limits of detection ranging from 0.1-2 µg kg-1 for magnesium, aluminium, nickel, copper, zinc, cadmium, barium and lead. A juvenile incisor from a remote indigenous community in Australia and an adult molar from Sri Lanka were assessed for toxic metal exposure. The molar showed evidence of exposure to cadmium and lead. The synthetic HA material was straightforward to prepare, and will improve confidence in the analysis of teeth and other biomineralised material when assessing toxic metal exposure.

Leptospirosis: A Potential Culprit for Chronic Kidney Disease of Uncertain Etiology.

PURPOSE: Chronic kidney disease of uncertain etiology (CKDu) is an environmental nephropathy in which the etiological factors are yet uncertain. Leptospirosis, a spirochetal infection that is common among agricultural communities, has been identified as a potential etiology for CKDu beyond environmental nephropathy. Although CKDu is a chronic kidney disease, in endemic regions, an increasing number of cases are reported with features suggestive of acute interstitial nephritis without any known reason (AINu), with or without background CKD. The study hypothesizes that exposure to pathogenic leptospires is one of the causative factors for the occurrence of AINu. METHOD: This study was carried out using 59 clinically diagnosed AINu patients, 72 healthy controls from CKDu endemic region (endemic controls [ECs]), and 71 healthy controls from CKDu non-endemic region (non-endemic controls [NECs]). RESULTS: The seroprevalence of 18.6, 6.9, and 7.0% was observed in the AIN (or AINu), EC, and NEC groups, respectively, from the rapid IgM test. Among 19 serovars tested, the highest seroprevalence was observed at 72.9, 38.9, and 21.1% in the AIN (AINu), EC, and NEC groups, respectively, by microscopic agglutination test (MAT), particularly for serovar Leptospira santarosai serovar Shermani. This emphasizes the presence of infection in AINu patients, and this also suggests that Leptospira exposure might play an important role in AINu. CONCLUSION: These data suggest that exposure to Leptospira infection could be one of the possible causative factors for the occurrence of AINu, which may lead to CKDu in Sri Lanka.

Early Ultrastructural Changes in Biopsies From Patients With Symptomatic CKD of Uncertain Etiology.

Introduction: Although the investigation of chronic kidney disease of uncertain etiology (CKDu) has identified many possible influencing factors in recent years, the exact pathomechanism of this disease remains unclear. Methods: In this study, we collected 13 renal biopsies from patients with symptomatic CKDu (Sym-CKDu) from Sri Lanka with well-documented clinical and socioeconomic factors. We performed light microscopy and electron microscopic evaluation for ultrastructural analysis, which was compared with 100 biopsies from German patients with 20 different kidney diseases. Results: Of the 13 Sri Lankan patients, 12 were men (92.3%), frequently employed in agriculture (50%), and experienced symptoms such as feeling feverish (83.3%), dysuria (83.3%), and arthralgia (66.6%). Light microscopic evaluation using activity and chronicity score revealed that cases represented early stages of CKDu except for 2 biopsies, which showed additional signs of diabetes. Most glomeruli showed only mild changes, such as podocyte foot process effacement on electron microscopy. We found a spectrum of early tubulointerstitial changes including partial loss of brush border in proximal tubules, detachment of tubular cells, enlarged vacuoles, and mitochondrial swelling associated with loss of cristae and dysmorphic lysosomes with electron-dense aggregates. None of these changes occurred exclusively in Sym-CKDu; however, they were significantly more frequent in these cases than in the control cohort. Conclusion: In conclusion, our findings confirm the predominant and early alterations of tubular structure in CKDu that can occur without significant glomerular changes. The ultrastructural changes do not provide concrete evidence of the cause of CKDu but were significantly more frequent in Sym-CKDu than in the controls.

Describing Natural History and Exploring Risk Factors for Kidney Function Decline in Persons With CKD of Uncertain Etiology in Sri Lanka.

Introduction: Chronic kidney disease of uncertain etiology (CKDu) is a leading cause of death of adults in Sri Lanka's dry region. Methods: We initiated the Kidney Progression Project (KiPP) to prospectively follow 292 persons with Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) 20 to 60 ml/min per 1.73 m2 living in a CKDu endemic area. Using data from 3-year follow-up, we assessed kidney function decline (>30% from baseline eGFR), and the composite outcome of >30% eGFR decline, eGFR <15 ml/min or death, and explored the association of the 2 outcomes with baseline demographic, residential, and clinical parameters accounting for baseline eGFR. Results: Median eGFR at enrollment was 28 ml/min among 71 women; 30 ml/min among 221 men; 91% to 99% had trace or no proteinuria during follow-up. At enrollment, median serum sodium, uric acid, and potassium were 143 mmol/l, 6.3 mg/dl, 4.5 meq/l, respectively among women; and 143 mmol/l, 6.9 mg/dl, 4.3 meq/l among men. Mean slope of eGFR decline was -0.5 (SD 4.9) ml/min/yr. In exploratory analyses, men with greater years of education and those living in northern region of the study area experienced lower likelihood of disease progression (hazard ratios [HR] 0.87 [0.77-0.98] per additional year and 0.33 [0.12-0.89] for northern versus other subregions, respectively). There was a suggestion that men drinking well water had higher likelihood and men living further away from reservoirs had lower likelihood of >30% decline in eGFR (HR 2.07 [0.95-4.49] for drinking well water versus not, and HR 0.58 [0.32-1.05] per kilometer distance, respectively). Conclusions: The overall rate of kidney function decline was slow in this CKDu cohort, similar to other nonalbuminuric CKD, and event rates were similar among men and women. Further etiologic investigations could focus on specific residence locale and water use.

Risk factors associated with disease progression and mortality in chronic kidney disease of uncertain etiology: a cohort study in Medawachchiya, Sri Lanka.

BACKGROUND: The alarming rise in the prevalence of chronic kidney disease of uncertain etiology (CKDu) among the low socioeconomic farming community in the North Central Province of Sri Lanka has been recognized as an emerging public health issue in the country. METHODS: This study sought to determine the possible factors associated with the progression and mortality of CKDu. The study utilized a single-center cohort registered in 2003 and followed up until 2009 in a regional clinic in the endemic region, and used a Cox proportional hazards model. RESULTS: We repeatedly found an association between disease progression and hypertension. Men were at higher risk of CKDu than women. A significant proportion of the patients in this cohort were underweight, which emphasized the need for future studies on the nutritional status of these patients. CONCLUSIONS: Compared with findings in western countries and other regions of Asia, we identified hypertension as a major risk factor for progression of CKDu in this cohort.