Beginning of a journey: unraveling the mystery of chronic kidney disease of unknown aetiology (CKDu) in Sri Lanka

Abstract

BackgroundGlobally, chronic kidney disease of unknown aetiology (CKDu) is observed in several areas and among specific ethnic or occupational groups. Given the widespread environmental pollution and the proportions of agriculture workers world-wide, CKDu may be the next global public health issue demanding attention. Recent escalation of CKDu in Sri Lanka has caused a serious public health crisis in the country, made worse by lack of national data.Main textThe specific geographic distribution, preponderance among farming population, similar histology findings and absence of usual risk factors for kidney disease indicate undetected nephrotoxic agents playing a role in causation. Some of the challenges for the country are uncoordinated preventive efforts, diverse opinions among stakeholders on causality and fragmented research efforts with limited focus on potential causes of CKDu. As a result, accurate estimation of the CKDu burden, identification of causative agents and implementation of effective actions have been delayed. Stakeholder engagement, with involvement of international experts has been the starting point for finalizing a working case definition to establish community based surveillance as a future platform to conduct long-term research.ConclusionThe country is now poised to contribute to global knowledge by solving the mystery of ‘u’ in CKDu. This commentary highlights the importance and the mechanisms of making an effective breakthrough as early as possible; failing which CKDu can progress rapidly as demonstrated by the situation in Sri Lanka.

Glyphosate’s Synergistic Toxicity in Combination with Other Factors as a Cause of Chronic Kidney Disease of Unknown Origin

“…In a more recent study, Wijkström et al (2018) [13] found that the morphology and biochemical characteristics of CKDu patients in Sri Lanka have many resemblances with the MeN epidemic in Central America, indicating a similar diagnostic entity and possibly a similar etiology. With these fairly consistent pathological findings of chronic interstitial nephritis and glomerular sclerosis, there is enough agreement that the Sri Lankan CKDu is a toxic nephropathy [11,14,15,16,17,18,19]. However, there is much less agreement among researchers as to what combination of occupational exposures and environmental toxicants manifest to CKDu.…”

Taiwan renal care system: A learning health‐care system

“…Endemic nephropathy with the presentation of CKDmfo/CKDu has reported across the world. Unlike diabetes and hypertension‐related CKD, which damages glomeruli first, renal tubule is damaged during early stage of CKDmfo . In order to overcome this situation, urinary markers, such as cystatin C, collagen III, kidney injury molecule‐1, monocyte chemotactic protein‐1, N ‐acetyl‐β‐ d ‐glucosaminidase were developed for screening and diagnosis of renal tubule disease .…”

A Systematic Review of Renal Pathology in Chronic Kidney Disease of Uncertain Etiology

“…As highlighted in numerous publications, 12 , 79 , 80 , 81 the lack of a proper clinical definition has led to an overestimation of the disease and has possibly resulted in many patients with CKD being labelled as CKDu. 82 In Sri Lanka, case definitions of CKDu were continually revised by the World Health Organization and Ministry of Health 83 , 84 , 85 with the most recent update done by the Sri Lanka Society of Nephrology in 2018. 86 The majority of patients analyzed in these studies were selected well before these revisions took place; therefore, some of them may not fall within the currently accepted CKDu definitions.…”