13 130

R.Rathnasekara1,M.A.U.U.Prasanna1,J.A.Liyanage1

A.P. Mallawatantri2

ID.130

Human kidneys and kidney failure The kidneys produce urine that contains

metabolic waste products, including the nitrogenous compounds urea and uric acid and excess ions.

Kidney failure occurs when the kidneys are partly or completely lose their ability to carry out normal functions. Kidney failure

Acute renal failure Chronic renal failure

Introduction

Chronic Kidney Disease (CKD)

Gradual loss of kidney function is called chronic kidney disease.

This happens very slowly, over a period of months or years.

Stage DescriptionGFR*

mL/min/1.73m2

1 Slight kidney damage with normal or increased filtration More than 90

2 Mild decrease in kidney function 60–89

3 Moderate decrease in kidney function 30–59

4 Severe decrease in kidney function 15–29

5 Kidney failure requiring dialysis or transplantation Less than 15

Chronic kidney disease in North Central province (NCP) Sri Lanka

During the last two decades, alarmingly high incidences of kidney failure and some associated deaths have become very significant in certain parts of the Anuradhapura District.

At present, over 5,000 patients are on treatment for CKD in NCP.

The disease progresses slowly and majority of patients do not have any symptoms until they are in the late stages of the disease

Diabetes and hypertension are the two most common causes of CKD.

The chronic kidney diseases in NCP is not associated with diabetes and hypertension.

To date, the etiology of the chronic kidney diseases in the farmer communities in the NCP is still remains a mystery

ObjectivesTo analyze the water quality of selected wells in

problematic areas in Anuradhapura District.

To understand the indirect relationship of heavy metals, Fluoride, Phosphate, Nitrate, Carbonate and Sulfate with CKD in Sri Lanka.

To establish the geochemical or any other causes which may be responsible for such disease.

Clinical Survey

The data about CKD positive patients in Anuradhapura district was taken from the District Medical Officer, Anuradhapura.

The patients were categorized according to the MOH areas and GN Divisions (Grama Niladaree Divisions).

Sampling areas and the number of samples taken from each area were determined based on these data.

Clinical Survey

MOH Areas Total Patients

NPENPC (Nuwaragampalatha)RmbawawaMadawachchiyaRajanganayaNochchiyagamaThalawaThabuththegamaGalnewaPalagalaIpalogamaKekirawaMihinthaleThirappaneKahatagasdigiliyaGalenbidunuwawaHorowpathanaKebithigollawaPadaviya

150182274931 17 57 74 33 22 8 28 46 58 56121 93 96271

1119

The total number of CKD patients reported from each MOH area in Anuradhapura district from 20/10/2006 till 01/06/2008

Distribution pattern of patients

Padaviya

Madawachchiya

Kabithigollawa

NPC

Distribution pattern of patients

Field survey at Madawachchiya Padaviya Nuwaragampalatha Central (NPC) and Kabithigollawa

To understand the current situation of the disease.

To identify the related social environmental factors of the area.

A survey was conducted among the patients who are suffering from CKD.

Patients and their family members in selected villages were interviewed.

Collection of Water samples

Area Number of Samples

Madawachchiya area 109

Padaviya area 124

Nuwaragampalatha Central (NPC)

30

Kabithigollawa area 15

Ampara (Reference) 31

Chemical Analysis

Dissolved metal concentrations were measured using Atomic absorption spectrophotometer (GBC 932 plus compact AAS).

The concentrations of Cd, Fe, Mn Cr, Cu, Ni, Pb, and Zn in each sample were determined by using Graphite furnace atomic absorption spectrophotometer (GFAAS) .

Ca, Al and Mg concentrations in the water sample were determined by using Flame atomic absorption spectrophotometer (FAAS).

Fluoride, Phosphate, Sulfate, Nitrate and Carbonate anion concentrations were determined using a Multi parameter bench photometer (HI 83200) and appropriate reagents.

pH and the conductivity of the water samples were measured at the sampling site.

Visual MINTEQ version 2.6 software was used for the determination of the speciation in water in affected areas and the reference area.

Ca concentration

CaSO4 and CaHCO3+ species were shown higher percentage distribution.

Ca is essential for the formation of teeth and structural constituent of bones.

Diseases associated with excess Calcium in the body are Cataract, gall stones and atherosclerosis.

Maximum concentration level= 240ppm

Mean Calcium concentration in drinking water

01020304050607080

Area

Co

nce

ntr

atio

n(p

pm

)

Mg concentration

MgHCO3+, MgF+ species were present in higher percentages in drinking

water in affected areas compared to Ampara.

Magnesium involves in the regulation of a number of vital biological processes including enzymic reactions.

Disease associated with excess Magnesium in the body is Anesthesia.


Mean Magnesium concentration in drinking water

0102030405060

Area

Co

ncen

trati

on

(p

pm

)

Zn concentration


Zn functions involves mainly in enzymatic processes and DNA replication.

Very high levels of Zn can damage pancreas and disturb the protein metabolism.

There is no much more evidence reported on Zn causing CKD.

ZnHCO3+, ZnCO3 and ZnHPO4 species were present in higher percentages

in drinking water in affected areas compared reference.

Mean Zinc concentration in drinking water

02468

10121416

Area

Co

ncen

trati

on

(p

pb

)

Pb concentration

Higher percentages of Lead species were present in the form of PbOH+ and PbCO3 in drinking water in all affected areas.

Lead causes necrosis of neurons.

Some Lead derivatives are carcinogenic.

Continued excessive exposure can affect the kidneys.

Maximum concentration level= 50ppb

Mean Lead concentration in drinking water

02468

10121416

Yakawew

a

Mad

awachc

hiya

Etawee

rago

llawa

Poona

wa

Rambawewa

Athav

atunuv

awa

Bogah

avewa

Kiriibb

anve

wa

Mah

asenpu

ra

Padav

iya

Ruwanpu

ra

Sudar

sana

gama

Track

B

Ampa

ra

Kundiy

anku

lama

Thanth

hrim

alaya

Alapat

hthu

wa

Kabith

igolla

wa

Area

Co

nce

ntr

atio

n (

pp

b)

Cd concentration

CdF+, CdHCO3+, CdCO3 and CdHPO4 species were present in higher

percentages in drinking water in affected areas compared to reference.

Exposure to cadmium over several years can result in a buildup of Cadmium in kidneys and lead to kidney disease.

Cd has long half-life in the body and it mainly deposit in the liver and kidney.

Cd2+ can replace Zn2+ in s- containing enzymes.

It also can cause bones to become weaker.


Mean Cadmium concentration in drinking water

05

10152025

Area

Co

ncen

trati

on

(p

pb

)

Fe concentration

Fe(OH)4- and Fe(OH)2

+ species were present in higher percentages in drinking

water in affected areas compared to reference.

Iron is the central component of the hemoglobin and Iron is a part of several essential enzymes.

High concentrations of Iron are absorbed and stored in the pancreas, the liver and the heart and damage these organs.

Long term exposure to excess Iron can cause haemochromotosis, siderosis and liver cirrhosis.


Mean Iron concentration in drinking water

020406080

100

Area

Co

ncen

trati

on

(p

pb

)

Al concentration

Maximum concentration level= 0.2ppm

Al(OH)3 and Al2(OH)2CO32+

percentage distributions were high in drinking

water in Ampara.

Al and its salts in water normally have very low toxicity.

Large Aluminum intake may cause nerve damage and kidney damage.

Aluminum is probably mutagenic and carcinogenic.

Mn concentration


MnSO4 percentage distribution was high in drinking water in Ampara.

Manganese is a toxic essential trace element.

Manganese effects occur mainly in the respiratory tract and the brain.

Relationship between Mn and the CKD is not well understood.

Mean Manganese concentration in drinking water

0

50

100

150

200

Area

Co

ncen

trati

on

(p

pb

)

Cr concentration

CrOH+ percentage distribution was high in drinking water in affected areas compared to reference.

Trivalent Chromium is an essential trace element for humans.

Hexavalent Chromium is extremely toxic.

Health effects related to Hexavalent Chromium exposure include intestinal bleedings, cramps and liver and kidney damage.


Mean Chromium concentration in drinking water

02468

101214

Area

Co

ncen

trati

on

(p

pb

)

Ni concentration

NiHCO3+, NiCO3 species were present in higher percentages in drinking water

in affected areas compared to reference.

Nickel is important for the function of the urease enzyme.

Nickel compounds may be toxic in high concentrations.

The soluble Ni ions are strong skin allergens.


Mean Nickel concentration in drinking water

05

1015202530

Area

Co

ncen

trati

on

(p

pb

)

Cu concentration


Higher percentage distribution of CuCO3 was shown in the drinking water in

affected areas.

Cu is a part of the free radical scavenging enzymes, mainly in Super oxide dismutase (SOD).

Long term exposure to copper can cause liver and kidney damage.

F- concentration


Because the kidney accumulates more fluoride than all other soft tissues there is concern that excess fluoride exposure may contribute to kidney disease.

In humans, elevated rates of kidney damage are frequently encountered among populations with skeletal fluorosis.

Mean Fluoride concentration in drinking water

00.5

11.5

22.5

Yakawew

a

Mad

awachc

hiya

Etawee

rago

llawa

Poona

wa

Rambawewa

Athav

atunuv

awa

Bogah

avewa

Kiriibb

anve

wa

Mah

asenpu

ra

Padav

iya

Ruwanpu

ra

Sudar

sana

gama

Track

B

Ampa

ra

Kundiy

anku

lama

Thanth

hrim

alaya

Alapat

hthu

wa

Kabith

igolla

wa

Area

Co

nce

ntr

atio

n (

pp

m)

SO42- concentration


PO43- concentration


Mean Sulfate concentration in Drinking water

010203040506070

Area

Co

nc

en

tra

tio

n (

pp

m)

Mean Phosphate concentration in Drinking water

00.5

11.5

22.5

33.5

4

Area

Co

ncen

trati

on

(p

pm

)

NO3- concentration


CO32- concentration

Mean Nitrate concentration in Drinking water

01234567

Area

Co

nce

ntr

atio

n (

pm

)

Mean Carbonate concentration in drinking water

010203040506070

Area

Co

ncen

trati

on

(p

pm

)

pH in water

Recommended level= 6.5-9.0

Conductivity in water

maximum level= 3500µs/cm

pH of the drinking water

02468

10

Area

pH

Conductivity in Drinking water

0500

10001500200025003000

Area

Co

nd

ucti

vit

y (

mic

ro S

)

Mean values of waterquality parameters in Anuradapura and Ampara

Metal Madawachchiya Padaviya NPC Kabithigollawa Ampara SLS 614:1983ppm

Ca ppm 44.2(±20.7) 18.6 (±15.2) 37.9 (±16.9) 47.7 (±48.4) 3.15 (±1.73) 240

Mg ppm 30.8 (±6.9) 17.7 (±12.9) 32.7 (±11.6) 29.6 (±17.9) 3.12 (±4.40) 140

Mn ppb 0.18 (±0.93) 0.68 (±1.95) 21.2 (±23.8) 17.1 (±23.3) 90.6 (±82.3) 0.5

Pb ppb 2.31 (±3.72) 8.26 (±5.50) 3.24 (±1.64) 3.19 (±3.17) 1.99 (±1.50) 0.05

Al ppm 1.15 (±0.73) 0.29 (±0.36) 1.16 (±0.73) 1.63 (±1.14) 7.01(±4.71) 0.2

Zn ppb 3.04 (±3.52) 7.69 (±6.04) 4.35 (±4.02) 4.85 (±2.17) 3.58 (±1.06) 15

Cd ppb 13.5 (±5.5) 7.10 (±2.77) 7.36 (±3.80) 7.75 (±5.39) 4.24 (±1.73) 0.005

Cr ppb 5.35(±3.31 ) 3.67 (±3.39) 7.18 (±3.37) 6.04 (±4.09) 1.34 (±0.79) 0.05

Cu ppb 0.09(±0.37 ) 0.25 (±0.28) 11.5 (±6.1) 6.84 (±4.80) 46.3 (±19.7) 1.5

Ni ppb 2.58(±5.02 ) 3.49 (±2.93) 10.6 (±10.4) 19.4 (±19.7) 3.01 (±3.92) 0.10

Fe ppb 17.9(±18.9 ) 0.20 (±0.17) 49.6 (±21.4) 47.0 (±15.9) 74.8 (±20.1) 1

F- ppm 1.25 (±0.5 ) 0.45 (±0.24) 0.76 (±0.72) 0.86 (±0.68) 0.64 (±0.63) 1.5

SO4 2- ppm 27.2(±15.2 ) 25.4 (±15.9) 14.5 (±10.4) 33.3 (±31.9) 39.5 (±34.5) 400

PO43- ppm 1.18(±1.12 ) 0.85 (±0.49) 0.6 (±0.7) 0.36 (±0.08) 0.7 (±0.5) 2

NO3- ppm 3.72(±1.04 ) 4.12(±4.15 ) 1.74(±0.74) 1.58(±0.98) 3.17(±2.45 ) 10

CO32- ppm 30.5(±12.4 ) 20.3(±11.2 ) 35.2(±9.34 ) 24.3(±18.3 ) 15.2(±8.4 ) -

pH 7.59(±0.37 ) 6.99 (±0.27) 7.50 (±0.11) 7.45(±0.12) 6.63 (±0.5) 6.50-9.00

Conductivity (μS/cm)

1946(±3170.35 )

652(±258.55 )

965(±303.6)

1321(±357.95)

908(±610 )

3500

Conclusions

The mean concentrations of the analyzed Ca, Mg, Pb, Zn, Cd, Cr and Ni in water samples from affected areas show higher values than the reference area Ampara.

Cd concentration in water samples from affected

areas exceeds the MCL set by the SLS (614:1983).

F- Concentration in affected areas was higher than F- concentration in Ampara.

PO43- and NO3

- concentrations were higher in Padaviya and Madawachchiya areas than in Ampara.

Even though most of the substances do not exceed the MCL set by SLS it cannot be concluded that these substances do not relate to the CKD prevailing in NCP.

Since Ca, Mg, Pb, Zn, Cd, Cr and Ni metal ions found in high concentrations than the reference samples long term exposure to them may affect the kidneys.

Cadmium and its species may have a significant effect on CKD.

Higher Fluoride level may also has some significant effect on CKD.

There was a significant deviation among concentrations of analyzed metals and anion concentrations within each area which leads to higher standard deviation

Kidney failureKidney failure occurs when the kidneys are

partly or completely lose their ability to carry out normal functions.

Acute renal failure There is a sudden and severe reduction in the

glomerular filtration rate and kidney function that is usually reversible over days or weeks when treated.

Chronic renal failure (CRF) This occurs when there is irreversible damage to about 75% of

nephrons. Onset is usually slow and asymptomatic, progressing over several years.

The main causes are glomerulonephrits, diabetes mellitus, reflux nephropathy and hypertention.

Stage DescriptionGFR*

mL/min/1.73m2

1 Slight kidney damage with normal or increased filtration More than 90

2 Mild decrease in kidney function 60–89

3 Moderate decrease in kidney function 30–59

4 Severe decrease in kidney function 15–29

5 Kidney failure requiring dialysis or transplantation Less than 15

Results Metals in Drinking water

Ppm Ppm Ppm Ppb Ppb Ppb Ppm Ppb Ppb Ppb Ppb

Ca Zn Mg Pb Fe Cd Al Cu Ni Mn Cr

Pb3 25.325 1.32 34.875 6.948 12.266 3.054 0.252 ND ND 0.063 2.888

PB 04 33.625 1.325 35.65 6.971 16.45 12.346 0.0467 ND 8.644 0.079 10.962

PB 08 58.725 7.4 35.175 5.255 11.775 15.627 1.793 ND ND 0.051 9.29

Pb 1 35.625 2.54 33.25 0.273 9.34 4.321 0.462 ND ND 0.026 5.876

PB07 46.725 2.5 36.7 6.59 8.64 10.254 1.357 ND ND 0.063 2.905

Pb2 25.625 2.4 34.75 9.13 10.54 8.364 0.558 ND ND 0.058 2.929

PB5 28.325 2.1 35.825 6.133 12.25 9.855 0.273 ND ND 0.053 13.369

PB6 38.3 0.756 31.9 ND 14.27 12.16 0.327 ND ND ND 4.864

Po1 37.85 2.15 39.275 7.532 5.912 14.24 0.573 ND 1.036 0.031 2.734

Po10 36.425 9.18 38.35 ND 0.678 16.384 0.946 ND 12.075 0.02 12.034

Po2 26.125 11.5 35.5 4.68 16.95 6.24 0.353 ND 6.02 0.034 3.87

Po3 46.325 2.78 36.3 ND 14.61 7.36 0.259 ND ND 0.026 8.623

Po4 50.15 2.126 36.025 4.969 15.26 2.651 0.185 0.221 ND 0.054 6.036

Po5 39.7 3.174 35.8 4.987 14.27 4.225 0.069 0.892 ND 0.033 5.874

Po6 58.35 3.254 33.75 ND 16.35 7.614 0.927 ND ND ND 4.448

Po7 23.6 2.124 36.475 ND 14.61 9.359 1.594 ND ND 0.043 4.679

Po8 43.75 0.84 34 - 14.26 8.246 1.482 ND ND - 6.544

Po9 53.625 3.22 32.375 0.791 7.016 7.024 0.048 ND 3.848 0.058 7.768

Metal concentrations in water samples of poonawa area

Pb, Po- Sample codes for Poonawa ND- Not detected

MOH area Madawachchiya Padaviya NPC and Kabithigollawa

Number of patients interviewed

125 140 50

Health & Medicine

13 130