The recent emergence of an apparently new form of chronic kidney disease of unknown aetiology (CKDu) has become a serious public health crisis in Sri Lanka. CKDu is slowly progressive, irreversible, and asymptomatic until late stages, and is not attributable to hypertension, diabetes, or other known aetiologies. In response to the scope and severity of the emerging CKDu health crisis, the Sri Lanka Ministry of Health and the World Health Organization initiated a collaborative research project from 2009 through 2012 to investigate CKDu prevalence and aetiology. The objective of this paper is to discuss the recently published findings of this investigation and present additional considerations and recommendations that may enhance subsequent investigations designed to identify and understand CKDu risk factors in Sri Lanka or other countries.

The emergence of a new form of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka's North Central Province (NCP) has become a catastrophic health crisis. CKDu is characterized as slowly progressing, irreversible, and asymptomatic until late stages and, importantly, not attributed to diabetes, hypertension, or other known risk factors. It is postulated that the etiology of CKDu is multifactorial, involving genetic predisposition, nutritional and dehydration status, exposure to one or more environmental nephrotoxins, and lifestyle factors. The objective of this limited geochemical laboratory analysis was to determine the concentration of a suite of heavy metals and trace element nutrients in biological samples (human whole blood and hair) and environmental samples (drinking water, rice, soil, and freshwater fish) collected from two towns within the endemic NCP region in 2012 and 2013. This broad panel, metallomics/mineralomics approach was used to shed light on potential geochemical risk factors associated with CKDu. Based on prior literature documentation of potential nephrotoxins that may play a role in the genesis and progression of CKDu, heavy metals and fluoride were selected for analysis. The geochemical concentrations in biological and environmental media areas were quantified. Basic statistical measurements were subsequently used to compare media against applicable benchmark values, such as US soil screening levels. Cadmium, lead, and mercury were detected at concentrations exceeding US reference values in many of the biological samples, suggesting that study participants are subjected to chronic, low-level exposure to these elements. Within the limited number of environmental media samples, arsenic was determined to exceed initial risk screening and background concentration values in soil, while data collected from drinking water samples reflected the unique hydrogeochemistry of the region, including the prevalence of hard or very hard water, and fluoride, iron, manganese, sodium, and lead exceeding applicable drinking water standards in some instances. Current literature suggests that the etiology of CKDu is likely multifactorial, with no single biological or hydrogeochemical parameter directly related to disease genesis and progression. This preliminary screening identified that specific constituents may be present above levels of concern, but does not compare results against specific kidney toxicity values or cumulative risk related to a multifactorial disease process. The data collected from this limited investigation are intended to be used in the subsequent study design of a comprehensive and multifactorial etiological study of CKDu risk factors that includes sample collection, individual surveys, and laboratory analyses to more fully evaluate the potential environmental, behavioral, genetic, and lifestyle risk factors associated with CKDu.

CKDu: A Growing Global Concern• CKDu patients are most often men ages 30 to 60, their most productive working years• CKDu symptoms appear in the late stages of the disease• Causes for CKDu are unknown but are multifaceted• Risk factors include environment, agricultural work and farming practices, diet and nutrition, and geneticsAn important global public health concern is unfolding around chronic kidney disease of unknown etiology (CKDu). CKDu presents as kidney disease in patients who do not exhibit common causative factors such as diabetes or hypertension. There appears to be a link to people working in the soil and as agricultural workers. Symptoms include fatigue, panting, lack of appetite, nausea, and anemia. The disease is said to be "chronic" because it takes many years for symptoms to develop. Renal function decline is gradual and often extremely painful.The impact is traumatic on patients and their families, as the ability to work declines, and families are often unable to pay the high cost of renal dialysis treatments.Geographic "hot spots" of CKDu have emerged in a number of countries,

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The anthropogenic release of chemicals from industry, agriculture and the breakdown of consumer wastes constitute a major threat to water resources and public health. Pollution is severe and increasing in the developing world where chemical substances are produced, used, and disposed of in an unregulated manner. The global public health consequences of chemical pollution are comparable to or greater than those of widespread infectious diseases such as HIV/AIDS, tuberculosis, and malaria. However, chemicals have so far been neglected by the WaSH sector. Here, we report the results of a systematic review of the Journal of Water, Sanitation, and Hygiene for Development (2011–2018) and oral/poster presentations given at the UNC Water & Health Conference (2010–2018). The review enumerated studies that focused on water quality and treatment from a chemical perspective, highlighting in particular organic contaminants of emerging concern. Organic chemicals were addressed in only 2% of journal articles and fewer than 0.7% of conference presentations. Geogenic contaminants arsenic and fluoride were only addressed in 2–3% of articles and presentations. The review concludes that a rapid, major effort to address toxic chemicals in WaSH is necessary to meet UN Sustainable Development Goals for universal access to safe and affordable drinking water by 2030.

Objectives. To evaluate lead levels in tap water at licensed North Carolina child care facilities. Methods. Between July 2020 and October 2021, we enrolled 4005 facilities in a grant-funded, participatory science testing program. We identified risk factors associated with elevated first-draw lead levels using multiple logistic regression analysis. Results. By sample (n = 22 943), 3% of tap water sources exceeded the 10 parts per billion (ppb) North Carolina hazard level, whereas 25% of tap water sources exceeded 1 ppb, the American Academy of Pediatrics’ reference level. By facility, at least 1 tap water source exceeded 1 ppb and 10 ppb at 56% and 12% of facilities, respectively. Well water reliance was the largest risk factor, followed by participation in Head Start programs and building age. We observed large variability between tap water sources within the same facility. Conclusions. Tap water in child care facilities is a potential lead exposure source for children. Given variability among tap water sources, it is imperative to test every source used for drinking and cooking so appropriate action can be taken to protect children’s health. (Am J Public Health. 2022;112(S7):S695–S705. https://doi.org/10.2105/AJPH.2022.307003 )

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