Dr. Swayam Prakash

Post Doctoral 

Institute of Immunology
University Hospital Essen,

It’s a health puzzle waiting to be solved. For over two decades, pockets of farmlands in four different corners of the country i.e., Cuttack in Odisha; Srikakulum in Andhra Pradesh, South Goa, and Amaravati in Maharashtra have reported a high prevalence of chronic kidney disease (CKD). While hypertension and diabetes are known to be common causes for kidney ailments, chronic kidney disease of unknown etiology (CKDu) falls outside that ambit. CKDu is a fatal progressive loss of kidney function that has killed more than 20,000 people in a single decade in Central America alone with over 20,000 more dead in Sri Lanka, and uncounted more in different regions of India. While Ebola has killed around 14,000 since its discovery in 1976, receiving billions in resources, CKDu has killed many times more, but has received insufficient funding with which to confront a dire public and occupational health crisis affecting many times more people.

The grave situation

The occurrence is mainly among the paddy farmers and agriculture laborers of age group 30-60 years engaged in agriculture. Almost 80% of these patients eventually die from kidney failure within the first two years after diagnosis. Many of these poor farmers cannot afford the cost of treatment. Apart from the cost, it’s the lack of availability of dialysis facilities in nearby hospitals that makes it extremely difficult for the poor to avail treatment. This grave situation calls for mobilization of public support for fund raising activities as the morbidity and mortality of these patients are often related to their state of poverty. High prevalence of CKDu has become an environmental health issue of national concern in South Asian peninsular region like India and Sri Lanka. Extensive study has been carried out to evaluate the probable causes of CKDu in Sri Lanka as of now with the collaboration of W.H.O. However, no significant study has been taken up till now in the Indian context.

In this report we focus on the problems of CKDu among patients belonging to Cuttack District of Odisha. The Odisha Health and Family Welfare minister Shri. Pradeep Kumar Amat has admitted in March, 2017 on the floor of Odisha Legislative Assembly that 822 CKDu subjects have been identified in the Narsingpur block of Cuttack District. As per the official records, 21 villages in Narsinghpur block and 17 in Badamba block are the worst-affect in Cuttack. The condition is so worrisome that in the last two years, over 257 people have died due to kidney related ailments in Narsinghpur alone.

I had an opportunity to lead a scientific team constituted by the SGPGIMS, Lucknow. The conclusion was so worrisome that there exist villages like Mallaka and Bankadhara in Narsingpur blocks where more than 90% females are widowed. All of them lost their husbands to CKDu. The story is a little better in Mahigada, Durgaprasad, and Hatiapalli with a lower death rate. The image below shows one Rabi Behera from Hatiapalli village who is lying on bed since last 3-4 years with a high serum creatinine, and protein-urea. Like Rabi most of the patients are unable to go through the expensive kidney transplantation procedure or even maintain themselves on dialysis regularly.

Ying & yang of CKDu disease

The disease process appears to mainly affect the proximal tubules and the interstitium giving rise to characteristic, recognizable histopathological and clinical features. Clinically, the disease is characterized by tubular proteinuria, usually β-2‐microglobulinuria, and the absence of hypertension and edema. The histological appearance of the disease is ‘tubulointerstitial’ that can commonly be observed in toxic nephropathies. The presence of high levels of fluoride, widespread use of agrochemicals, presence of heavy metals like cadmium, lead and arsenic and uranium in soil and water are postulated as contributory factors. In some studies, mycotoxins, use of herbal/ayurvedic medicines, smoking and snakebite are some other factors that have been considered. Up to now, there is no unequivocal evidence to recognize the possible environmental causative factors that could lead to a nephrotoxins responsible for the disease.

The water connection

As per former agriculture minister of Odisha Mr. Surendranath Nayak, and scientific experts from the Odisha University of Agriculture and Technology CKDu in the dry zone may be due to high cadmium content in the environment such as water, and fish. Dr. Zia Sheikh from the Indian Institute of Technology, Delhi has suggested exposure to cadmium may be through the food chain. He further attributed high cadmium in the environment to the heavy use of cadmium contaminated phosphate fertilizer. Trace metals in the environment are considered as a major geo‐environmental factor that could contribute to the etiology of renal damage. Several international studies done in the past have shown significantly high content of metals such as cadmium, mercury, lead, vanadium, uranium and chromium in phosphate fertilizer. These findings were contradicted by another study which showed that cadmium levels in water were higher in the non‐endemic regions compared to the endemic regions. The clinical evidence too did not show any symptoms in CKDu patients that were commonly associated with cadmium exposures such as bone disease (itai‐itai), renal calculi and respiratory effects that manifest before renal effects, among others.

However, drinking water is at the base of most of the reports studied in relation to CKDu in Sri Lanka and South American countries. Most of the scientists agree that hard water could be a causative factor. Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow with the technical support from the Indian Institute of Technology, Delhi and Bose Institute, Kolkata have suggested that total hardness of drinking water of CKDu patients is very high as the geographical distribution of patients overlapped with distribution pattern of high ground water hardness.

Citing the findings of an unpublished study of mine has suggested a strong positive correlation between the arsenic content and groundwater hardness in CKDu prevalent areas when compared to the other areas that showed a weak correlation between the two variables. The Secretary of the Indian Society of Nephrology Prof. Dr. Narayan Prasad also says that the association of arsenic with elevated levels of hardness could reasonably be one of the potential causes of CKDu. The preliminary finding by the SGPGIMS also suggests high levels of calcium, magnesium, zinc, lead, mercury, arsenic, and cadmium in the water from the endemic region where as water from non-endemic regions have showed normal levels of heavy elements. Further they also found heightened level of cadmium, arsenic, and lead in the urine of CKDu cases. Adding concern to this finding, the rice sample collected from fields of Narsingpur and Badamba blocks also showed increased incidence of Cadmium.

At this stage Prof. Narayan Prasad assumes that heavy usage of agrochemicals, fertilizers, and pesticides for rice cultivation may pollute the ground water when come in its contact. They believe that rice produced from the usage of this polluted water contains a higher amount of Cadmium. To the concern of the scientific and clinical team local farmers and agriculture labors admitted that they consume water from the polluted tube-wells, and ground-well facilities present in their farmlands since ages which is causing CKDu. This Indian pilot study was conducted on a small sample size. To further validate and justify their findings the team is at present carrying out the inductively coupled plasma mass spectrometry (ICP-MS) and gas chromatography mass spectrometry (GC-MS/MS) experiments in a large sample size.

Saving lives

Prof. Narayan Prasad states that the findings of the study will be made available to the policy makers and different pressure groups on its completion within next two-three months. The chairman of the Utkal Gandhi Smarak Nidhi, and eminent gandhian Shri. Prahallad Kumar Sinha said that the state government has plans to provide pure drinking water through a mega water supply project which is yet to take shape. If findings in support of water pollution related deaths will be further confirmed, then different social organizations will pressurize the government to speed up the water supply project so that people will get pure drinking water. More-so, Sinha also stated that heavy usage of agrochemicals should be prohibited in the CKDu endemic area by spreading public awareness campaigns. The team from SGPGIMS has relied on local non government organization Mukti, which is also very vocal against prohibition.

Photos Source  : Dr. Swayam Prakash