Dr. Shanthi Mendis, Director Department of Management of Non-Communicable Diseases, World Health Organization, Geneva
Kidney disease is emerging in different parts of the world as a public health problem. In all countries the most important underlying causes are uncontrolled hypertension and diabetes. In Sri Lanka as well as in some other countries various environmental factors are also implicated in the causation of kidney disease. Defining the aetiological role of these factors in kidney disease in any population requires painstaking research. The Ministry of Health, with technical support from the World Health Organization and funding from the National Science Foundation recently conducted a study to investigate the prevalence and aetiology of chronic kidney disease of unknown aetiology (CKDu) in Sri Lanka.
Further, there is evidence that herbal remedies prepared with Aristolochia ladica (Sasanda or Sapsanda), containing nephrotoxic aristolochic acid are ingested as remedies for certain ailments.The government plan, to reduce exposure to environmental nephrotoxins which is already underway, will consist of a set of multisectoral public health measures including access to safe drinking water, quality control and appropriate use of fertilizers and other agrochemicals, regulation of hazardous waste disposal, tobacco control and promotion of the use of organic fertilizer.
In the 15-70 year age group, the age standardized prevalence of CKDu is 16.9% in females and 12.9% in males. Severe stages of CKDu are more frequently seen in males. The prevalence of CKDu increases with age. Results also indicate that multiple agents are playing a role in the pathogenesis of CKDu. There is evidence of chronic exposure of people in the endemic area to low levels of cadmium, through food and also to potentially nephrotoxic pesticides and other agents. Significantly higher excretion of cadmium in urine in CKDu cases compared to control subjects and the dose effect relationship between urine cadmium and CKDu stages indicate that cadmium is a risk factor for the pathogenesis of CKDu in Sri Lanka. There may also be exposure to arsenic and lead. There was no dose effect relationship for arsenic, lead and CKDu. The concentration of arsenic, cadmium and lead in water are within international reference limits. Cadmium levels in soil and certain food items and tobacco in the endemic area are higher compared to non-endemic areas. High levels of cadmium, arsenic and lead were found in some samples of phosphate fertilizer and pesticides/weedicides. Deficiency of selenium and genetic susceptibility may be predisposing factors for the development of CKDu, when people are exposed to nephrotoxins. It is most likely, that oxidative stress and tubular damage which develop with low cadmium exposure is aggravated by nephrotoxic pesticides, other heavy metals such as arsenic and lead, deficiency of protective factors such as selenium and genetic susceptibility.
Further, there is evidence that herbal remedies prepared with Aristolochia ladica (Sasanda or Sapsanda), containing nephrotoxic aristolochic acid are ingested as remedies for certain ailments.
The government plan, to reduce exposure to environmental nephrotoxins which is already underway, will consist of a set of multisectoral public health measures including access to safe drinking water, quality control and appropriate use of fertilizers and other agrochemicals, regulation of hazardous waste disposal, tobacco control and promotion of the use of organic fertilizer.
CKDu has made its biggest impact in farming populations in North Central, Uva and North Western Provinces. The social epidemiology of the disease in respect of gender age, ethnic and social class differences in the prevalence of disease is yet to be fully understood. To the extent the disease is widespread in newly developed areas with heavy agrochemical use; this may be seen as a development-induced disease.
Further research is needed in actionable areas which can provide affordable and pragmatic solutions for addressing this public health issue. They include i) implementation research related to the above policy measures ii) methods to reduce the intake of cadmium by plants iii) use of local rock phosphate and environment-friendly organic fertilizer iv) development of rice strains which require less fertilizer and are resistant to pests v) nephrotoxicity of pesticides and weedicides vi) total diet studies on heavy metals and other nephrotoxins vii) role of protective factors such as selenium viii) ways to reduce pollution of the environment including air pollution ix) longterm prospective and interventional studies to make conclusive aetiologic interpretations and x) barriers that prevent translation of scientific evidence to multi-sectoral action and policy.
Social and Economic Impact of Chronic Kidney Disease of Unknown Aetiology in Sri Lanka
Kalinga Tudor Silva, Department of Sociology University of Peradeniya, Senior Professor Siri Hettige, Ramani Jayathilake and Chandani Liyanage of Department of Sociology, University of Colombo and K. Karunathilake Department of Sociology University of Kelaniya
CKDu has made its biggest impact in farming populations in North Central, Uva and North Western Provinces. The social epidemiology of the disease in respect of gender age, ethnic and social class differences in the prevalence of disease is yet to be fully understood. To the extent the disease is widespread in newly developed areas with heavy agrochemical use; this may be seen as a development-induced disease. The social impact of the disease includes sudden disruption of livelihood following the onset of disease in typically the chief breadwinner of the household, moral panic concerning what causes the epidemic, disruption of children’s education, stigma encountered by the patients and their families, and lack of support mechanisms for the families affected. In coping with the high cost of medical treatment, sudden disruption of their livelihoods and increased loss of renal functions, the affected families resort to multiple coping strategies such as mortgaging and selling of assets, soliciting of funds and kidney donations from the public as renal failures reach a crisis point. In order to minimize the adverse impact of the disease, effective interventions are needed for prevention of the disease including early diagnosis, raising public awareness, promoting patient activism and legal measures against aggressive marketing of and inappropriate use of agrochemicals.
Financial and Economic Costs of CKDu P.G. Mahipala, Director General of Health Services, Ministry of Health
The common causes of CKD in Sri Lanka are similar to those of global CKD (diabetes, hypertension etc), except for certain regions of the dry zone, where the primary cause is not known. Management is Conservative (Symptomatic) Management of associated problems and Renal Replacement Therapy (Renal Transplantation, Chronic Haemodialysis, and Chronic Ambulatory Peritoneal Dialysis). The disease causes premature mortality, high morbidity, burden on the family and the community and to the government through expenditure and resource allocation.
There has been an increase in numbers and an uneven distribution of CKD cases since it affects mainly a low socio-economic group, young male farmers. It is a slow progressive disease with patients seeking treatment at late stages, when dialysis/ transplantation is required. There is a high economical cost to the patient and family and to the state which spent 350 million rupees in 2005 for management of renal disease (dialysis, transplant etc.). Annually about 2000 new patients seek treatment for end stage kidney disease (ESKD), i.e. dialysis and/or transplantation. A failure to find solutions is costly with millions of rupees of productivity lost through premature morbidity and mortality. About 4% - 5% of the annual health budget is spent on the management of patients making a collaborative national research effort which would cost comparatively less and use less resources COST EFFECTIVE !!
The costs of clinical visits are direct (over Rs 1000 to patient and institution) and indirect (over Rs 2500/day in loss of income and cover up payment). Hospitalization also has direct and indirect cost to family and patients of around Rs 2000/day and to the hospital of Rs 3500/day, mainly personnel cost. Dialysis costs about Rs 7500/ day. Detailed analysis of about 1200 patients/ month has been done and also a comparison of family effects in Padaviya (lower income) and Medawachiya areas. If the system is better equipped to cope with such contingencies, there could be a reduction in the burden to households of travel, consultation and treatment costs. The illness has changed resource allocation and consumption patterns within the family unit and influenced the setting of priorities, maintenance of social relationships, and participation in community activities. Education of children is badly affected and the stigma associated with the disease contributes to social and emotional cost. Model income range is Rs 7501-15,000 (mid-point Rs 11,250) and Rs 2501-7500 (mid-point Rs 5000) and unemployment rate 4.2 and 7.3 % respectively in Medawachchiya and Padaviya, based on survey data. Patients are generally in the 40 to 60 age group. An individual who could work if not for illness up to 60 now leaves the workforce at 50. The loss in financial terms to the labour force is estimated to be Rs 1,034,909 in Medawachchiya and Rs 445,076 in Padaviya.
The health system needs to respond to the continuing direct costs by ensuring an efficient and effective service. The country should also invest in urgent measures to prevent the epidemic and moderate the economic impact of CKD.
(The article is based on the writings presented at the symposium on CKDU, a scientific basis for future action organised by National Academy of Science of Sri Lanka)