CKD of Uncertain Etiology Sri Lanka

A population study at Girandurukotte, Uva Province,

Preliminary Report

Background

The observation of rising numbers of patients seeking health care for CKD is a resent
phenomenon. It was noteworthy that not only the prevalence appeared to be increasing since 8-
10 years but the disease also appears to have a geographical bias towards the NCP of the country.
Unlike the west, where the prevalence is escalating due to increasing number of patients with
chronic long standing hypertension, diabetes and increasing elderly populations, the CKD of
NCP is not associated with these risks.

Thus population based studies were carried out in different geographical areas in Sri Lanka to
understand the disease profile and to identify the possible risk factors.

The Uva province is situated south of NCP and has two districts; Badulla and Monaragala. GK is
an area situated in the northern tip of Uva province bordering the NCP. Therefore, even though
administratively GK is an area belongs to Uva geographically it may be part of NCP.

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GK has attracted the notice of the health personnel because of the high number of patients with
CKD of uncertain etiology, getting registered in the hospitals. The data from the provincial
ministry of Health of Uva revealed that CKD numbers recorded in Badulla district (GK) was
1605* while from the Monaragala district was 60. It is noteworthy that the majority of the
population of GK is settlers from other parts of the country and has come from the south of the
province approximately 20 years ago.

Thus it is reasonable to hypothesize that the CKD observed in GK could be due to environmental
factor/s. Thus a population based study was carried out to identify the possible risk factors and
the disease profile. We considered proteinuria assessed by dipstick method, in an early morning
urine sample as a disease marker.

Objectives

1. To identify the prevalence of proteinuria in GK

2. To identify clinical, biochemical and haematological charachteristics of proteinuric
patients
3. To identify the ultrasonographic changes of kidneys of proteinurics
4. To identify the histological appearance of the kidney tissues in a sample of population
with proteinuria
5. To identify possible lifestyle and environmental risk factors.

Materials and Method

The total population of GK is 37,470 and is divided to 17 administrative divisions. We randomly

selected 8 GN divisions and a cluster of 50 families were randomly selected from each unit. The
Public Health Midwife was trained to carry out assessment of urine by dipstick method who then
conducted a house to house assessment of proteinuria in early morning samples of urine of the
household members over 5 years who were apparently normal (females not menstruating) for 3
occasions. Those who were already diagnosed to have Kidney disease were also included in the
study. These patients’ records were studied by the research team

Those who were positive for protein in urine were examined clinically and kidneys were
assessed ultrasonographically at a field clinic. Those with proteinuria positive more than two
occasions and those with ultrasonographic evidence of kidney damage were referred to GK base
hospital for further investigations.

Results and Analysis

General characteristics

The total number of population screened 1345. Among the population screened the percentage of
adult population that have settled in GK for more than 20 years is 45%.** The age distribution of
the overall population ranged from 5-91 years and observed >70 % were below 60 years of age.
The male to female ratio was 1: 1.3 and the main occupation of the population was paddy

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farming. Almost 85% of the population use garden well water as source of drinking water.
Approximately 44% of adult population is exposed to different types of agrochemicals.

The prevalence of proteinuria

The experience of the nephrologists is that the CKD of NCP has mild proteinuria and could be
intermittent in nature. Therefore we classified the proteinurics in to the following categories
based on the degree of proteinuria.

Degree of proteinuria Population Percentage

(n==1345)
Trace once 261 19.4 %
Trace twice or more 109 8.10%
+1 ones 72 5.35 %
+1 > twice 37 2.75 %
Trace ones and above 479 35.6%

Characteristics of proteinurics who are trace and above and those who are +1 (twice) and above

Feature Once trace & Above Twice +1 & Above

(n = 479) (n = 37)
The Male to Female ratio 1: 0.81 1: 0.09
The BMI 21 (SD ± 4.04) 19.1 (SD ± 3.37)
The mean systolic & 121mmHg/78mmHg 135mmHg/88mmHg
diastolic BP (SD ± 21/14 mmHg) (SD ± 25/17mmHg)
Weight(>18yr. population) 51 kg (SD ± 10) 49.5 kg (SD ± 7)
Height 147 cm ( SD ± 21.41) 169 cm
Age 32 Yr (SD ± 18) 47Yr. (SD ± 16)
Fundoscopy Normal Normal
Associated diseases 82 % - No disease 48% - No disease (18pt./37)
0.8% - Skin diseases 5.4% - Skin diseases(2pt/37)
4.2%- respiratory tract 13.5%- respiratory tract illness
diseases (5pt/37)
3.8% - Other 16.2% - Other (6pt./37)
HT 4.4 % 13.5% (5pt./37)
DM 1.3 % 2.7 % (1pt./37)
Age distribution 5 – 84 yrs. 8 – 73 yrs.
Population <20yrs of age 34.04% 8.1%

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Lifestyle factors

Water source 84.3% Garden well 91.9% - Garden well

Alcohol consumption 28.5 % Consumers 41.8% Consumers

(Among males)
Exposure to agrochemicals 79.1% Agrochemical 77.14%
(Among males) use Agrochemical use
Smoking (Among males) 69.12% 58.1%
Non smokers Non smokers

Investigation Once trace & Above Twice +1 & Above

(n = 479) (n = 37)
Urine deposits No deposits No deposits
24 Hr urine protein <1g/ 24 hr collection <1g/24 hr collection
Serum Protein 7.6 (SD ± 0.63) 7.6 (SD ± 0.68)
Serum Albumin 4.53 (SD ± 0.48) 4.4 (SD ± 0.44)
Serum Globulin 3.06 ( SD ± 0.56) 3.2 (SD ± 0.69)
Serum Alkaline phosphate 200.03 (SD ± 93.9) 196.3 (SD ± 67.5)
Serum Na 136.9 (SD ± 5.7 ) 137.6 (SD ± 5.84)
Serum K 4.6 ( SD ± 0.78) 4.9 (SD ± 0.81)
Serum Creatinine 0.96 (SD ± 1.04) 1.6 (SD ± 1.00)
Serum Uric acid 4.42 (SD ± 1.29) 5.07 (SD ± 1.57)
Serum Ca 8.69 (SD ± 0.94) 8.5 (SD ± 0.05)
Serum phosphate 4.07 (SD ± 1.06) 3.6 (SD ± 0.83)
Hb 13.99 (SD ± 1.89) 13.6 (SD ± 2.56)
SGPT 14.02 (SD ± 5.8) 16.2 (SD ± 7.33)
Creatinine clearance 108.11 (SD ± 45.51) 60.70 (SD ± 37.19)
(Cockroft – Gault)
Creatinine clearance 102.57 (SD ± 49.26) 50.89 (SD ± 32.22)
(MDRD)

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Ultrasound results

Once trace & Above Twice +1 & Above

(n = 380) (n = 29)
Normal 172 4
Abnormal 208 25

Biopsy

Grade Once trace & Above Twice +1 & Above

(n = 54) (n = 9)
Normal 2 0
Grade I 37 3
Grade II 9 3
Grade III 6 3

People living in the present address (<20yrs vs. >20yrs) –

Trace and above group (n = 479, missing data n = 35)

Investigation <20yrs >20yrs.

(n = 239) Total (n = 205)Total??
Serum Protein 7.53 (SD ± 0.60) 7.66 (SD ± 0.65)
Serum Albumin 4.5 (SD ± 0.44) 4.55 (SD ± 0.53)
Serum Globulin 3.01 (SD ± 0.53) 3.15 (SD ± 0.58)
Serum Alkaline phosphate 208.6 (SD ± 94.9) 172.9 (SD ± 61.3)
Serum Na 136.4 (SD ± 5.8) 136.83 (SD ± 5.67)
Serum K 4.59 ( SD ± 0.79) 4.71 (SD ± 0.79)
Serum Creatinine 0.84 (SD ± 1.05) 1.15 (SD ± 1.07)
Serum Uric acid 4.11 (SD ± 1.12) 4.82 (SD ± 1.41)
Serum Ca 8.65 (SD ± 0.94) 8.71 (SD ± 0.95)
Serum phosphate 4.56 (SD ± 2.96) 3.83 (SD ± 1.22)
Hb 13.74 (SD ± 1.71) 14.26 (SD ± 2.11)
SGPT 12.9 (SD ± 3.93) 15.10 (SD ± 7.1)
Creatinine clearance 98.47 (SD ± 25.5) 90.83 (SD ± 38.1)
(Cockroft – Gault)
Creatinine clearance 114.92 (SD ± 34.8) 85.88 (SD ± 35.06)
(MDRD)

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The following could be concluded

1. Trace proteinuria cannot be ignored in areas where the CKD is prevalent. This is proven
by the positive biopsy reports.
2. The proteinuria of CKD of NCP of Sri Lanka is minimum (<1 gm/24 hrs) Even though ,
trace proteinuria at screening programme overestimates the CKD, when combined with
US changes should be considered as markers of kidney disease until a specific marker is
developed.
3. Including only +1 (on two occasions) severely underestimates the problem of CKD
4. Male preponderance is observed.
5. The population affected is younger than Medawachchiya which was investigated in 2003
6. When considering the CKD patients, amongst the recent settlers and those who have been
living in the area for a longer duration we did not observe significant differences.
7. There are no significant association with long standing HT or DM
8. There were no rbc/active deposits in urine
9. Urine protein excretion is <1gm/24 hrs
10. Biochemical analysis no major changes
11. US scan show differences in patients with trace proteinuria and those with more than +1
12. Biopsy of trace proteinuria and +1 and above show evidence of kidney disease
13. It is possible trace proteinuria is a marker of early disease. However as it overestimates
needs a special marker to identify the disease