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S. P. Dunuweera, R. M. G. Rajapakse*, Masaru Shimomura, Viraj Jayawera Priyankarage, Pathmakumara Jayasingha and Sunil J. Wimalawansa


Chronic Kidney Disease of Uncertain Aetiology seems to be caused by several factors and hence it could be best described as Chronic Kidney Disease of Multifunctional origin (CKDmfo). CKDmfo is confined to a particular geographical location of Sri Lanka, viz., the North-Central Province and some nearby Areas where vulnerable people are mostly rice paddy farmers. The CKDmfo distinguishes from common CKDs in the sense that the former patients lack the common symptoms of CKDs. As it has been well established, the modes of initial attack are different in the two cases where the tubuli are the parts of kidneys that are first affected by the CKDmfo while in the latter cases either the contraction or expansion of the glomerular basement membrane results in, respectively, retention of simple and unwanted molecules such as creatinine in blood or filtration of even large molecules like albumin to result in albumin present in urine. Therefore, glomerular filtration rate (GFR), blood creatinine level (BCL) and albumin to creatinine ratio (ACR) in urine are accurate indicators for the diagnosis of common CKDs but these indicators are not suitable to detect early stage CKDmfo patients. This fact is highlighted in this review and suitable tubuli specific tests recommended for the early stage diagnosis of CKDmfo. In order to understand the disease in detail, a brief account of the kidneys with its functions are reviewed and the common CKDs are highlighted. Attention is then focused on the CKDmfo and facts of CKDmfo are revealed. There are several existing theories as to the possible causative factors and their pros and cons will then be evaluated. As the disease is propagated by the initiation through tubular damage, the environmental factors pertinent to tubular reabsorption are discussed. From the points of view of interferences to the tubular reabsorption, the disease seems to correlate well with environmental factors typical of the region, i.e, excess fluoride ions in the drinking water and high hardness, both temporary and permanent hardness. While the temporary hardness is due to soluble bicarbonates of both calcium and magnesium ions, which can easily be removed by boiling water, the permanent hardness that is due to soluble ions which are not removed by boiling are mainly excess of sodium, potassium and ammonium cations and their soluble anions such as nitrate and chloride. As such, as a preventive measure, the need to supply good-quality drinking water is suggested. In providing drinkable water, it is of utmost importance to provide them with treated pipe-borne water though the difficulty in providing such waters to houses scattered in a vast area of the region is recognized. At least as a temporary measure, it is suggested to provide good quality water from reverse osmosis (RO) plants or through rain water harvesting. However, it is stressed that these solutions are only temporary measures to control the disease and eventually a proper supply of pipe-borne water has to be supplied to every human being of the country. In the case of CKDmfo, it is suggested to avoid chlorination to purify water because chlorine residues that are present in the treated water may be highly harmful to the vulnerable people. Most recent evidence converge towards fluoride to be the most likely causative factor of CKDmfo and all other ions and dehydration are also responsible for this disease.

Keywords: Chronic Kidney Disease of Unknown Origin (CKDU), multi-functional origin (mfo), tubules, causative factors, preventive measures.

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