Toxic truths

Chronic kidney failure has become an everyday reality for many families but what causes it still remains a mystery, though cadmium is increasingly being identified as a dominant culprit:

by Dhaneshi Yatawara

CKDu unit functioning at the Anuradhapura hospital

Chronic kidney disease which hit the headlines of late where a common causative factor cannot be attributed, is placing a heavy burden on the farming community in particular and the country as a whole. Chronic Disease of unknown etiology (CKDu) is detected in parts of other provinces such as Uva, North, and Eastern apart from concentrated areas in and around the North Central and North Western Provinces.

Experts in the field and many concerned Sri Lankans continue to discuss and debate the issue. Attention at this time of the year on kidney disease is focussed more as we just marked World Kidney Day a few days ago. Every year, the second Thursday in March is set aside for World Kidney Day, bringing special attention to this life-threatening condition.

Cause

However, many scientists argue otherwise about the cause of the disease. They question as to whether identifying Cadmium as being the cause and whether the method by which it enters the body is the reason for this deadly disease. They say that if this was the reason, then the whole country should be affected by CKDu like the NCP (Rajarata), because the Rajarata is the main rice producing area in the country.

The research by Myles F. Elledge, Jennifer Hoponick Redmon, Keith E. Levine, Rajitha J. Wickremasinghe, Kamani P. Wanigasariya, and Roshini J. Peiris-John in 2014, revealed that although Sri Lanka is known for its strong public health system, data on Non Communicable Disease, CKDu deaths and disease show a severe shortfall. According to researchers, investigations done so far have narrowly viewed only one variable or potential risk factor. A recent study was undertaken by Dr. Anjali Shastri from the US State Department on the connectivity between policies and research done so far in Sri Lanka. "CKDu is curable and preventable if the cause is known," Dr. Shastri said.

Based on a field survey done over two months in affected areas in the NCP, NWP, Western and Uva Provinces, Dr. Shastri was of the view that the efforts taken by the Government and interested parties to find a solution to the problem was not effective due to the unknown cause of the disease.

Kidney patients awaiting treatment

"The Government has done much to bring relief to those affected.

But scientists and the Government mechanism must network, to find the cause and cure without delay," she said.

She advocated several steps, including control over the use of fertiliser, pesticides and weedicides to prevent CKDu occurence, regulation over the use of agrochemicals, establishing laboratory facilities to frequently test fertiliser, pesticides and weedicides, strengthening awareness.

A legal framework to combat the indiscriminate use of pesticides and promote environment-friendly agriculture was also a pre requisite, she said.

In her study with the Coordinating Secretariat for Science and Technology Innovation (COSTI), she was informed that there were nearly 180 publications on CKDu but only 17 of them have been reviewed by peer groups.

Shortage

"It was evident that a shortage of medical staff was a huge barrier for the Ministry of Health to conduct screening and tests for early detection," she said adding that, however, there must be a mechanism for early detection as it is essential to slow the disease from progressing.

Today, CKDu, although

detected in parts of the Uva, North, and Eastern Provinces, is also prevalent in and around the North Central Province(NCP) and the North Western Provinces (NWP) as well.

According to a spokesperson of the Presidential Task Force on Chronic Kidney Disease, a new phase of screening for patients islandwide has been initiated by the Health Ministry. With the new screening, 11 districts have been identified as risk areas so far. i.e. Anuradhapura, Polonnaruwa, Moneragala, Badulla, Matale, Kurunegala, Vavuniya, Mulaitivu, Trincomalee, Ampara and Hambantota. "The number of patients will change as the screening progresses to more districts," the spokesman said.

"Following earlier research plus screening programs conducted mainly in the NCP and NWP, the number of patients was estimated to be around 40,680 and the new program will enable a better picture of the situation," he said. Based on a WHO finding, Dr. Kamal Gammanpila, a retired medical scientist based in the UK with a keen interest on the Sri Lankan CKDu situation blamed the cause for CKDu in the (NCP) Rajarata to toxic diets. "Cadmium is the dominant toxic agent," said Dr. Gammanpila. As a solution, he recommended a change in the diet.

Dialysis patients at the Anuradhapura hospital.

"There is enough research done on water, food and soil in these areas for any scientist to analyse and reach a conclusion. By going through these figures a better understanding can be reached," Dr. Gammanpila said.

He argued that Cadmium gets into the body by consuming locally grown rice, vegetables and yams grown in highly toxic soil as well as by drinking water from these areas.

He explained that heavy metals get infused into the soil and the food chain which begins with fertiliser being applied to the fields and irrigation water entering the body.

Dialysis

"Although canal and reservoir water is low in heavy metal toxic levels, using it as irrigation water makes it a toxic contributor," he said. All these elements are harmful to the body and cause multiple ailments. Cadmium is a well-established agent which causes kidney failure, he said.

"Our failure to address this issue is causing avoidable deaths. It has been so for some time now," Dr. Gammanpila said.

Thousands of CKDu patients currently depend on dialysis machines to clean their blood from accumulating toxics. The available machines do not support the patient demand. The nearest hospital for the CKDu hot spot Rajarata is the Anuradhapura Teaching Hospital.

The dialysis ward of the renal unit is equipped with 25 beds and performs nearly 1980 dialysis per day, according Dr. Lionel Muhandiramge, Anuradhapura Teaching Hospital Director.

The hospital's transplant unit has performed nearly 48 kidney transplants between 2012 and 2015, according to hospital statistics. The unit registers 200 to 250 new patients monthly.

The renal unit and the transplant unit cater to patients from the NCP, the Northern Province and the Eastern Province, said Dr. Muhandiramge explaining the big demand the hospital has to cater to, despite government support to start kidney transplants at the Polonnaruwa General Hospital.

The Anuradhapura Teaching Hospital will get a new building providing accommodation for patients who need to wait a day or two for dialysis, said Dr. Muhandiramge. Accordingly funds are allocated through the Provincial Ministry of Health.

Today CKDu is a global public health concern. Following numerous investigative efforts, testing for levels of Cadmium, Arsenic and many other heavy metals and for chemicals such as floride in water and soil and studies on rice, vegetables and yams, researchers and medical experts are still unable to find a clear reason for CKDu prevalence in the country.

Pix: Mahinda Vithanachchi