Chronic kidney disease:

Causation due to several factors

by Thulasi MUTTULINGAM

Scientists working inSri Lanka and abroad might have found the preliminary cause of Chronic Kidney Disease, prevalent in the North Central district - although the results are not yet out.

Dr. Navaratnasingam Janakan

According to Dr. Navaratnasingam Janakan, Consultant Epidemiologist of the Epidemiology Unit, Ministry of Health multipronged studies have been conducted and are being conducted here and abroad, on various aspects of the issue and the findings will be reviewed in a scientific committee meeting, sometime this month.

However, he cautions that the disease might not be due to just one particular factor, and that several contributing factors might have come together for causation.

"There are several different theories, that triphosphate fertiliser containing heavy metals such as cadmium, lead and arsenic are the cause, that high amounts of fluoride in water are the cause, and also that using poor quality aluminium utensils (which might react with the fluorides in the water) might be the cause," says Dr. Janakan.

"However, there is no evidence to pinpoint just one particular etiological factor. It might be a multifactored one. There are similar cases in the Balkan region that had been identified as early as the 1950s. It's called Balkan Endemic Nephropathy and its aetiology is still not well established."

Sri Lanka's neighbouring countries do not seem to have a problem of this nature. According to Dr. Janakan, the problem was first noted in 2000 when doctors working in Anuradhapura and Polonnaruwa noticed an unusually high level of chronic kidney disease (CKD) patients.

He says that the most striking thing about the CKD cases identified was that there didn't seem to be any underlying cause.

"Usually, CKD is secondary to some other chronic illness such as diabetes or hypertension or otherwise, snakebites. However in most of the cases identified from the North Central province, that is not the case."

Studies that were uncoordinated with each other were carried out by clinicians as well as academics, according to the doctor but no concrete evidence of causation was found.

In 2008, the then Health Minister Nirmal Siripala de Silva launched an official research program in collaboration with the World Health Organisation, coordinated by the Epidemiology Unit of the Ministry of Health.

'The program had two objectives; to find the cause of the disease as well as to provide services, mainly treatment facilities to the diagnosed patients," says Dr. Janakan.

"We have a number of studies going on in parallel, funded by the WHO and overseen by an International Advisory Committee. At present, there is a population prevalence study to get an estimate of the disease burden in high risk areas. The worst hit areas are Anuradhapura and Polannaruwa along with Trincomalee, Girandurukotte and Ampara, especially in areas bordering the North Central province.

We have also just completed studies of Environmental factors, by a team from the Peradeniya University and Sociological factors affecting the patients, such as social stigma (funded by the UNDP and coordinated by Disaster Management Centre) by a team from the University of Colombo.

There is also a post mortem study being conducted by researchers in the University of Antwerp, Belgium. We send them specimens from bone, liver and kidneys of patients of CKD (of both known and unknown etiological factors) as well as patients who have died of other causes as a control group.

The researchers there do histological studies (studying tissues under the microscope) and metal mapping to see if any metals have got deposited in the tissues."

The results of most of these findings will be released only at the scientific meeting, which is planned for sometime this month though it has apparently not yet been scheduled.

"CKD is slowly progressive disease but especially in the North Central province, the symptoms are atypical and non specific. The patients suffer from backaches and loss of appetite in the initial stages. Being mostly farmers, they might not be bothered about something like backache as they suffer from it frequently. On a side note, it could be noted that frequent use of painkillers might be a cause.

It is only in the latter stages of the disease, that they get more serious and specific symptoms such as the swelling of legs or anaemia. It is then that they come for treatment, by which time, it might be too late." According to the doctor, the patients would not have noticed a difference in their urinal flow as that is not necessarily a symptom of CKD.

"They can still pass urine but the kidneys have been damaged and so do not carry out their filtering functions well. The only remedy for this is dialysis or organ transplant."

He also noted that while the disease could not be cured, its progress could be slowed through treatment. "Some people do not attend clinics as they think the disease can't be cured anyway. As a result, though we had 8400 patients registered in the North Central province since 2003, the numbers seem to have dropped now, though that is not the case."

The latest statistics are not available but in 2007, diseases of the urinary system was the ninth leading cause of death (in hospitals) island wide while in Anuradhapura it was the first leading cause and in Polannaruwa and Vavuniya, the second leading cause. In Moneragala, it was the fourth leading cause.

The doctor believes that Vavuniya too has a significant amount of cases though he says statistical evidence and studies in the area are lacking.

Asked if the stress due to war could be a factor, he notes that stress might lead to mental health and heart related problems but not kidney related problems.

Figures of 2006 show that 22% of cases and 17% of deaths due to renal failure are from the North Central province while its population amounts to only 6% of the country.

He declined to comment on the findings that would be released at the scientific meeting but said that the objective was to differentiate the CKD of known causes with the CKD of unknown causes.

Tea and coffee 'protect against heart disease'

Drinking several cups of tea or coffee a day appears to protect against heart disease, a 13-year-long study from the Netherlands has found.

It adds to a growing body of evidence suggesting health benefits from the most popular hot drinks.

Those who drank more than six cups of tea a day cut their risk of heart disease by a third, the study of 40,000 people found.

Consuming between two to four coffees a day was also linked to a reduced risk.

While the protective effect ceased with more than four cups of coffee a day, even those who drank this much were no more likely to die of any cause, including stroke and cancer, than those who abstained.

The Dutch tend to drink coffee with a small amount of milk and black tea without.

There have been conflicting reports as to whether milk substantially affects the polyphenols - believed to be the most beneficial substance in tea.

Coffee has properties which could in theory simultaneously increase and reduce risk - potentially raising cholesterol while battling the inflammatory damage associated with heart disease.

But the study in the Journal of the American Heart Association finds those who drank between two and four cups a day lowered the risk of the disease by 20%.

"It's basically a good news story for those who like tea and coffee.

These drinks appear to offer benefits for the heart without raising the risk of dying from anything else," said Professor Yvonne van der Schouw, the lead researcher.

Ellen Mason, Senior Cardiac Nurse at the British Heart Foundation, said: "This study adds further weight to the evidence that drinking tea and coffee in moderation is not harmful for most people, and may even lower your risk of developing, or dying, from heart disease.

"However, it's worth remembering that leading a healthy overall lifestyle is the thing that really matters when it comes to keeping your heart in top condition.

"Having a cigarette with your coffee could completely cancel any benefits, while drinking lots of tea in front of the TV for hours on end without exercising is unlikely to offer your heart much protection at all."

-BBC

Male menopause is 'rare' but it's not a myth

The male menopause does exist - but it is rare, researchers have concluded.

Just days after it was dismissed as a myth, the European team said the male menopause did exist - but that it affects only 2% of middle-aged men.

Over 3,300 men from across Europe were assessed for the New England of Journal study.

A men's health expert said testosterone therapy could be beneficial, but doctors had to be cautious about its use.

Depression can be a symptom of male menopause

Continue reading the main story We need to be very cautious about the prescribing of testosterone therapy Dr. Ian Banks, President, Men's Health Forum Scientists led by a team from the University of Manchester looked at the testosterone levels of 3,369 men aged 40 to 79 from eight European centres.

The men were also asked about their sexual, physical and mental health.

Three sexual symptoms - poor morning erection, low levels of sexual desire and erectile dysfunction were linked to low testosterone levels.

Depression, fatigue and an inability to perform sexual activity were also linked.

But some symptoms commonly cited as being indications men are going through a "menopause" including changes in sleeping patterns, poor concentration, feeling worthless, and anxiety were found to have no link to low testosterone levels.

The condition, also called late-onset hypogonadism, was also found to be linked to poor health and obesity.

Hypogonadism is a condition where the testes fail to work properly, affecting hormone levels.

'Excessive diagnosis' warning

Professor Fred Wu, from the University of Manchester's school of biomedicine, who led the study, said unlike classical hypogonadism where similar symptoms were accompanied by an diagnosable condition, that was not the case for late-onset hypogonadism.

"This well-practised diagnostic approach is frequently found wanting when dealing with the age-related decline of testosterone in elderly men who are prone to have a significant background of non-hormone-related complaints."

He added: "Our findings have for the first time identified the key symptoms of late-onset hypogonadism and suggest that testosterone treatment may only be useful in a relatively small number of cases."

Professor Wu said sexual symptoms were relatively common even in men with normal testosterone levels.

"It is therefore important to specify the presence of all three sexual symptoms of the nine testosterone-related symptoms we identified, together with low testosterone, to increase the probability of correctly diagnosing late-onset hypogonadism.

"The application of these new criteria should guard against the excessive diagnosis of hypogonadism and curb the unwise use of testosterone therapy in older men."

Earlier this month, an editorial on Drug and Therapeutics Bulletin said many men who report symptoms have normal hormone levels and warned giving synthetic testosterone as it could increase the risk of prostate cancer.

Dr Ian Banks, president of the Men's Health Forum, said: "We need to be very cautious about prescribing testosterone therapy, and doctors need to balance the benefits against the risks.

"This research acknowledges it's a complex issue, and that caution is needed."

- BBC