CHRONIC KIDNEY DISEASE OF UNKNOWN ORIGIN A MAJOR PUBLIC HEALTH PROBLEM.
By Dr.Georgi Abraham, Latha Kumaraswami TANKER FOUNDATION
Chronic kidney disease of unknown origin (CKDu) is an emerging public health problem in
the south asia region with a population of 1.7 billion people. How does it differ from other
forms of kidney disease. It is prevalent in certain geographical areas of the developing
countries, it affects mainly the people belonging to lower socio economic status, the age
group is young adults and middle aged, seen predominantly in farming communities, many
members of the family are affected, it is progressive, the cause is not known. They have no
risk factors such as diabetes mellitus or hypertension.
In the South Asian region it is prevalent in the north central province of Srilanka such as
Anuradhapura,Polonnaruwa and Badulla districts, in the endemic area and Hambantotakl
district in the non endemic area. In India in the state of Andhra pradesh Srikakulam district
(Udhanam) which is a coastal area with beautiful landscape, greenery and fertile land,
Prakasam are predominantly affected with nearly 13% of the population having different
stages of CKDu.Clusters have also been identified in Goa and Orrisa.
The Srilankan President His Excellency Maithripala Siresena has formed a presidential task
force for urgently looking at the screening prevalence and management of the patients
afflicted with CKDu . A fund has been created named ISN Gardiner initiative for training and
research in to CKDu in Srilanka. The stake holders are Srilankan society of Nephrology,
The National Science Foundation of Srilanka Regional WHO and the government of
Srilanka with local , regional and international participations. The patients have been
grouped in to different stages of CKDu. And those who are in Stage V are being provided
Dialysis, Transplantation with the help of the Government in Srilanka. As the Investigations
for risk factors for CKDu Arsenic, cadmium, lead, selenium, pesticides and other elements
were analysed in biological samples from individuals with CKDu and compared with age-and
sex matched controls in the endemic and non endemic areas food, water, soil and
agrochemicals from both areas were analysed for heavy metals. However the issue of
genetic predisposition has not been looked at which is a daunting task due to the expenses
involved. In one of the studies performed by Professor Gangadhar Thaduri Nephrologist
from Andhra Pradesh found high silica content in the water and soil of Udhanam and in the
urine of patients.
While speaking to Professor Muhibur Rahman Nephrologist from Dhaka , Bangladesh
recently stated that they see a fairly large number of patients with Chronic Kidney disease of
unknown cause. He said that the use of agrochemicals as fertilizers in Bangladesh led to
increase content of Cadmium in rice and vegetables available in Bangladesh (published
scientific data) .Cadmium in excessive amount produces kidney disease. However no
studies have been done to identify whether CKDu in regions of Bangladesh exist or not .As
the infrastructure for studying CKDu is unavailable at this time in Bangladesh a consorted
effort by the Bangladeshi Nephrologists will be done in future to look for CKDu. CKDu
information is not available from Pakistan, Nepal, Bhutan.
Just to explain about CKDu : The Kidney has four compartments are shown in the Fig :1
they are the blood vessels which supply and take out blood from the glomerulus (filter), the
glomerulus, the tubules which drain the urine, the interstitium which occupies the area
between the tubules. CKDu is predominantly a disease of the the tubules and interstitium
contrary to diabetes mellitus and hypertension which produce damage to the blood vessels
and glomerulus. The reason for the involvement of the tubule and the interstitium remains a
mystery in CKDu. The tubule undergoes atrophy and interstitium develops scars (fibrosis) a
condition called tubulo interstitial fibrosis (IFTA). Nobody knows why this happens and are
there up regulation of genes in the tubulo interstitial region in producing IFTA in CKDu.
THE CURRENT STATE OF MANAGEMENT IN INDIA
The Government of AP has taken initiative to collaborate with ICMR whose Director General
Dr.Soumya Swaminathan has deligated a scientific team including Dr.Prabdip Kaur to
support the efforts. The TANKER FOUNDATION has been requested to convene a meeting
of the core group of Nephrologists, Pathologists, Epidemiologists,Genetis and other
environmental scientists from South Asia region to identify the cause of CKDu screening
programmes, surveillance, follow up of the patients in already existing regions and new
geographical locations in India and other regions. Professor Chacko Jacob (Vellore),
Professor Sanjay Agarwal (AIMS New Delhi), Professor Ravi Raju (Vice Chancellor AP
Medical University) will lead the different groups for discussion under the leadership of
Professor Georgi Abraham and Latha Kumaraswamy of TANKER FOUNDATION. The
group is joined by experts from Srilanka, Professor Chula Herath (President of Srilankan
Society of Nephrology),Dr.Nalika Sepali Gunavardhana (WHO) who have advanced in their
initiatives in tackling CKDu in Srilanka.
The objectives of the Core group meeting is to define CKDu in India, find out regions with
CKDu which are not identified, look at the different causes which can lead to
CKDu,Management of patients stratifying them in to various stages of CKD 1 – 5 . Provide
Dialysis treatment to patients at stage V CKD.
The Srilankan Government has taken initiatives to prevent environmental contamination by
pesticides and other environmental toxins and provide safe drinking and cooking water.
Professor Georgi Abraham and Dr.Prabdip Kaur from India were invited and involved in
tackling the CKDu in Srilanka as members of the presidential task force and WHO. The
respective state governments in India and health authorities with politicians and beurocrates
philanthropic organizations and scientists should work together to support the society with
CKDu.
There should be special training for Nephrologists and physicians in environmental
Nephrology with epidemiologists and social workers in addressing the issue of CKDu. The
Indian Society of Nephrology under the presidentship of Professor Chacko Jacob and
Secreatary Professior Narayan Prasad and Editor in Chief of the Indian Journal of
Nephrology Professor Sanjay Agarwal will use the Journal for disseminating the knowledge
on CKDu continuously.
The CKDu core meeting supported by TANKER FOUNDATION and MADRAS MEDICAL
MISSION HOSPITAL will hopefully work as a platform for the care of CKDu in the South
Asia Region.
