WHO report on Kidney disease-lnvestigation and Evaluation of Chronic Kidney Disease of Uncertain Aetiology in Sri Lanka -Final Report
Posted on April 22nd, 2013

lnvestigation and Evaluation of Chronic Kidney Disease of Uncertain Aetiology in Sri Lanka -Final Report

You don’t have to argue any more. It is written in very simple language in black and white.

As, Cd, Pb and other elements in urine –

Arsenic excretion in urine was significantly higher in the  healthy subjects in the endemic are(mean 92.443, median 36.99,
min 0.02, max 966.29 Microg/g) compared to those living in the controlled area.

However, urine Arsenic excretion in CKDu subjects was significantly lower compared with urine AS excretion in normal subjects in the endemic area.

In subjects with CKDu  urine Cd Cadmium excretion was significantly higher (mean 1.039, median 0.(95,min 0.005, max 8.93 pglg) compared to healthy subjects in the endemic area (meaa 0.646,
median 0.18, min 0.005, max 5.13 pg/g) (p < 0.05). These results indicate a higher exposure of people in the endemic area to Cadmium and arsenic.

Cd and As in hair and Nails.
A significantly higher Cd Cadmium  concentration was seen in the nails of CKDu cases (mean 0.017, median 0.007, min 0.001, max 0.347 ug/g) compared to controls (mean 0.009, median 0.001,
min 0.001, ma-x 0.091 ug/g) fu < 0.05).

Arsenic  levels in hair were significantly higher in CKDu cases ( mean 0.144, median 0.139, min 0.00,max 0.452 ug/g ). compared to healthy subjects from the endemic area {mean 0.125. median
0.103, min 0.006, ina-\ 1.214 rglg ) (P < 0.05). There was no significant difference in the As concentration in nails in CKDu subjects compared to controls.

As. Cd and Pb in bone, kidney and liver (post mortem tissue)
The concentration of As, Cd and Pb (ug/l) in kidney, liver and bone wore as follows:
Cadmium: Kidney – mean 885.54, median 752.62, range 19.28-7458.54i Liver – mean
165.39, median 117.19, range 22.22-1471.41t Bone – mean 8.68, median 4.87, range
. Arsenic: Kidney – mean 4.04, median 2.34, range0.0384- 14.16; Liver – mean 5.38,
median 2.42, r4nge 0. 13 -26.16; Bone-mean 6.41 , median 4.34, range t.47 -28.84
. Lead: Kidney – mean 0.89, median 0.6, range 0.0i-2.54; Liver – mean 4.56, median 3.93,
range 0.98-13.33; Bone – mean 64.04, mediaa47.13, range 2.11-23392

The mean cadmium and lead contents in bone were higher than the currently reported levels in
healthy subjects

Full Report


7 Responses to “WHO report on Kidney disease-lnvestigation and Evaluation of Chronic Kidney Disease of Uncertain Aetiology in Sri Lanka -Final Report”

  1. Lorenzo Says:

    What are NORMAL ACCEPTABLE HIGHEST LEVELS of As, Cd and Pb in bone, kidney and liver?

  2. Fran Diaz Says:

    I am re-printing below the article by local scientists on how Cadmium poisoning happens in water used by NCP farming community. Pollution of the Mahaweli River has to be addressed asp. Pollution of all Rivers of Lanka must also stop. To this end a Science Advisory Committee ought to be set up for the Parliament to ensure clean air, water & food and sea waters allocated to Lanka.

    The war with the ltte and harassment of Lanka abroad via the Tamil Diaspora & various foreign organisations had brought development & health issues assessments and action to a virtual halt in Lanka. This harassment must stop so that good governance can commence. However, GoSL is giving free dialysis treatment to all those affected by CKD in the NCP area.


    Environ Geochem Health. 2011 Oct;33(5):439-53. doi: 10.1007/s10653-010-9344-4. Epub 2010 Oct 28.
    Pollution of River Mahaweli and farmlands under irrigation by cadmium from agricultural inputs leading to a chronic renal failure epidemic among farmers in NCP, Sri Lanka.
    Bandara JM, Wijewardena HV, Bandara YM, Jayasooriya RG, Rajapaksha H.
    Department of Agricultural Biology, University of Peradeniya, Sri Lanka.
    Chronic renal failure (CRF) associated with elevated dietary cadmium (Cd) among farming communities in the irrigated agricultural area under the River Mahaweli diversion scheme has reached a significantly higher level of 9,000 patients. Cadmium, derived from contaminated phosphate fertilizer, in irrigation water finds its way into reservoirs, and finally to food, causing chronic renal failure among consumers. Water samples of River Mahaweli and its tributaries in the upper catchment were analyzed to assess the total cadmium contamination of river water and the possible source of cadmium. Except a single tributary (Ulapane Stream, 3.9 μg Cd/l), all other tested tributaries carried more than 5 μg Cd/l, the maximum concentration level accepted to be safe in drinking water. Seven medium-sized streams carrying surface runoff from tea estates had 5.1-10 μg Cd/l. Twenty larger tributaries (Oya), where the catchment is under vegetable and home garden cultivation, carried 10.1-15 μg Cd/l. Nine other major tributaries had extremely high levels of Cd, reaching 20 μg Cd/l. Using geographic information system (GIS), the area in the catchment of each tributary was studied. The specific cropping system in each watershed was determined. The total cadmium loading from each crop area was estimated using the rates and types of phosphate fertilizer used by the respective farmers and the amount of cadmium contained in each type of fertilizer used.
    Eppawala rock phosphate (ERP), which is mostly used in tea estates, caused least pollution. The amount of cadmium in tributaries had a significant positive correlation with the cadmium loading of the cropping system. Dimbula Tea Estate Stream had the lowest Cd loading (495.9 g/ha/year), compared with vegetable-growing areas in Uma Oya catchment with 50,852.5 g Cd/ha/year. Kendall’s τ rank correlation value of total Cd loading from the catchment by phosphate fertilizer used in all crops in the catchment to the Cd content in the tributaries was +0.48. This indicated a major contribution by the cropping system in the upper catchment area of River Mahaweli to the eventual Cd pollution of river water. Low soil pH (4.5-5.2), higher organic matter content (2-3%), and 18-20 cmol/kg cation exchange capacity (CEC) in upcountry soil have a cumulative effect in the easy release of Cd from soil with the heavy surface runoff in the upcountry wet zone. In view of the existing water conveyance system from upcountry to reservoirs in North Central Province (NCP) through diversion of River Mahaweli, in addition to their own nonpoint pollution by triple superphosphate fertilizer (TSP), this demands a change in overall upper catchment management to minimize Cd pollution through agriculture inputs to prevent CRF due to elevated dietary cadmium among NCP farmers.

  3. David Appuhami Says:

    I am really surprised to see the so called scientific community’s inability to read and understand a scientific report. Why they have to go for alternate explanation to the report when the whole North Central population is under Cadmium and arsenic poisoning and dying. GOSL should fire these fake scientists without any hesitation.

  4. David Appuhami Says:

    Please read this article by Samarasinghe
    Samarasinghe Says
    Arsenic contamination is becoming an increasingly common problem not only in the developing world, but also in the most industrialised nations.

    Any urban water distribution system in Sri Lanka may contain arsenic in the pipe water. Well water may also contain high arsenic content depend upon the location and hardness of water. The content will not be known until proper tests are carried out. Bottled water is not necessarily any safer than tap water. Often, it is nothing more than tap water that may or may not have been filtered.

    Arsenic poisoning brings with it other complications: liver and spleen enlargement and cirrhosis of the liver; myocardial degeneration and cardiac failure; peripheral neuropathy affecting primary sensory functions; diabetes mellitus and goitre; and skin cancers.

    Three types of skin cancers are observed: Bowen’s disease (form of squamous cell carcinoma); basal cell carcinoma and squamous cell carcinoma. These cancers develop primarily from keratosis.

    “Another unfortunate and complicating fact about arsenic poisoning,” Hiroki Hashizume adds, “is that it generally takes from seven to 10 years, sometimes longer, for the disease to be recognized. When it finally is, it may be too late to treat.” Professor Robert Goyer, who headed a nine-member commission of the US National Academies of Science, says its findings bolster a 1999 study by the Academy that found that men and women who drink every day water with 10 ppb of arsenic have an increased risk of more than 3 in 1000 of developing bladder or lung cancer during their lifetime. That risk rises to 7 in 1000 at 20 ppb.

    Arsenic is a compound that should be more closely monitored by parents, teachers and children because of its fatal results. The three main methods of exposure are contact, ingestion and inhalation. Regardless of the method of exposure all can produce basically the same symptoms.

    If your village or the town has high rate of these diseases, get your ground water tested by a certified authority.(or use a recommended Arsenic Field test kit -Evaluation of arsenic field test kits for drinking water naalysis -By J. Mitchell Spear, You Mark Zhou, Charles A.Cole and Yuefeng F.Xie http://www.sensafe.com/arsenictests/AWWA%20Arsenic%20field%20tests%20Dec06%20article.pdf)
    New legislation In the US

    On Jan 22.2001, the US Enviromental Protection Agency (USEPA) published the final Aesenic Rule, which specified an effective compliance date of Jan23,2006 (USEPA,2001). This rule lowers the maximum contaminant level (MCL) for arsenic from 50 to 10 ppb. It is estimated that nearly 4000 water utilities in the United State are affected, and about 97% of them are small public drinking water systems serving fewer tan 10,000 people.(Komminneni et al, 2002;Frey & Edwards, 1997). The USEPA also published best available technologies and small system compliance technologies (SSCT) to aid small water system in complying with the new arsenic MCL of 10 ppb.

    Drinking water provided by most water utility companies in US meets or falls below the current national standard for arsenic, which is 10 parts per billion (ppb). However, some water systems may exceed this level. While arsenic levels may fluctuate over time, what is most significant from the standpoint of cancer risk is long-term exposure. For water systems in the 25 states that reported arsenic data to the EPA, we have calculated two estimates of average long-term levels: one is a very conservative estimate, the other our best estimate, based on what we believe to be the most reasonable analytical techniques (details on how we arrived at the estimates are included with the charts).

    While arsenic levels may fluctuate over time, what is most significant from the standpoint of cancer risk is long-term exposure. For water systems in the 25 states that reported arsenic data to the EPA, we have calculated two estimates of average long-term levels: one is a very conservative estimate, the other our best estimate, based on what we believe to be the most reasonable analytical techniques (details on how we arrived at the estimates are included with the charts).

    The table below shows the lifetime risks of dying of cancer from arsenic in tap water, based on the National Academy of Sciences’ 1999 risk estimates (see our report for details on how we calculated total cancer risk).
    Arsenic Level in Tap Water
    (in parts per billion, or ppb) Approximate Total Cancer Risk
    (assuming 2 liters consumed/day)
    0.5 ppb 1 in 10,000
    1 ppb 1 in 5,000
    3 ppb 1 in 1,667
    4 ppb 1 in 1,250
    5 ppb 1 in 1,000
    10 ppb 1 in 500
    20 ppb 1 in 250
    25 ppb 1 in 200
    50 ppb 1 in 100

    Carcinogen category notice: Category 1. Established human carcinogen known to be carcinogenic to humans. There is sufficient evidence to establish a causal association between human exposure to these substances and the development of cancer.

    Degrees of toxicity:
    As (III) > As (V) > Organic arsenic compounds.

    Arsenic poisoning does cause a variety of systemic problems when and if an individual does get the toxic of arsenic poisoning. The typical symptoms are; diaphoresis, muscle spasms, nausea, vomiting, abdominal pain, garlic odour to the breath, diarrhoea, anuria, dehydration, hypertension, cardiovascular collapse, aplastic anaemia and death. The degree to which symptoms a person has will be determined by the severity of the exposure.

    Regardless of the method of the exposure toxic event can end in the same result, death!
    Grade I Mild a) Diffuse melanosis.
    b) Suspicious spotty depigmentation / pigmentation over trunk/limbs
    c) Mild diffuse thickening of soles and palms.
    Grade II Moderate a)Definite spotty pigmentation /depigmentation on the trunk and limbs, bilaterally distributed.
    b) Severe diffuse thickening (with/without wart like nodules of the palms and soles).
    Gradelll Severe a) Definite spotty pigmentation/depigmentation as above with few blotchy pigmented/depigmented macular patches over trunks or limbs
    b) Pigmentation involving the undersurface of tongue and/or buccal mucosa.
    c) Larger nodules over thickened palms and soles occasionally over dorsal aspect of hands and feet. Diffuse verrucous lesions of the soles with cracks and fissures and keratotic horns over palms/soles.

    Guha Mazumder et. al 2001

    Tani, 1999 classified affected villagers as 1 were suffering from malanosis (hypopigmentation and hyperpigmentation). Villagers in category 2 were suffering from melanosis and keratosis on the hands and/or feet. Villagers in category 3 were the most severely affected and were suffering from melanosis and developed (late stage) keratosis on the hands and/or feet. This classification is similar to that proposed by A.W Khan (WHO 1997). He suggested that arsenicosis could be categorised into 3 sequential stages:

    · 1. Melanosis;
    · 2. Keratosis with or without anaemia, conjunctivitis, bronchitis, gastroenteritis and blackfoot disease;
    · 3. Developed keratosis and skin cancer.

    Arsenic is a metal compound that can easily find its way into the environment and the human population. The substance is found in our water, soil, food products. Even though we have governmental guidelines for controlling such toxic “substances” or “compounds” on a daily basis, we drink contaminated water and eat contaminated food products. This will lead to some degree of arsenic poisoning in each of us, according to Joe Harrison the technical director of Water Quality Association. Daily consumption of water with greater than 50 micrograms per liter of arsenic less than 1 % of the fatal dose, can lead to problems with skin, circulatory and nervous systems3. Greater problems can occur if the arsenic poisoning is of a chronic nature and resulting in neural disorders, vital organ damage and eventually death.

    Arsenic is a compound that should be more closely monitored by parents, teachers and children because of its fatal results. The three main methods of exposure are contact, ingestion and inhalation. Regardless of the method of exposure all can produce basically the same symptoms. For more info. go to http://www.sos-arsenic.net/english/contamin/index.html

    Chronic Arsenic Poisoning:History, Study and Remediation

    Several arsenic test kits and sensors have been evaluated by the EPA Environmental Technology Verification program in USA. Information on these technologies can be found at http://www.epa.gov/etv/verifications/vcenter1-21.html.

    ACCURATE ARSENIC TESTING-Test strip technologyy advances make difficult arrseniic detection a thing of the past.

    Industrial Test Systems, Inc. features an array of Arsenic Quick™ test kits that provide accurate results at affordable prices. Designed using cutting edge chemistry, our easy-to-use test kits report results for Arsenic(III&V) from 0.3ppb in as few as 12 minutes without the need for technical training. Performance and accuracy of these kits have been verified by the USEPA though

    the ETV program (www.epa.gov/etv). We invite you to see why the Quick™ line of Arsenic test kits from ITS are recognizedthroughout the world as premium Arsenic field test kits.

    Inorganic Arsenic in Rice – An Underestimated Health Threat

    China: Inorganic Arsenic in Rice – An Underestimated Health Threat ?
    A Chinese research group now investigated the health risks for the Chinese population. Twenty-two rice samples from 13 provinces of China were analyzed for their arsenic content. Total arsenic content was determined by ICP-QMS after microwave-assisted digestion. Total As concentration ranged 65.3-274.2 ng g-1, with an average value of 114.4 ng g-1.

    Surprisingly high concentrations of toxic arsenic species found in U.S. rice

    Rice grown in the USA has up to five times higher levels of arsenic than those found in rice grown in Europe, India and Bangladesh, says a report in the August 2005 edition of Environmental Science and Technology.

    Arsenic. An environmental problem limited by solubility*

    M. Clara F. Magalhães‡

    Department of Chemistry, University of Aveiro, P-3810-193 Aveiro, Portugal

    The aqueous solutions in equilibrium with these metal arsenates have extremely high arsenic concentrations [6,17,28]. These, in general, can be 200 times the maximum contaminant level for total arsenic in potable water and often exceed the maximum contaminant level for total arsenic content in treated sewage effluents and wastes.

    Some dissolved arsenic can be precipitated as a rich calcium arsenate solid whose composition will be related to the composition of the aqueous solutions [7]. As can be seen from data in Table 1, these solids are moderately soluble to be effective in the reduction of arsenic mobility in the environment. Table 1 only reports the solubility of well-defined solid phases. Other values exist in the literature, but the solid phases are not well defined. The lowest value for arsenic concentration in equilibrium with solid calcium arsenates, 0.01 mg/L arsenic, was found by Bothe and Brown [9] at pH 12.6 in closed systems. The introduction of air that contains carbon dioxide in the Ca–As–H2O system causes significant instability of calcium arsenates for pH > 8.3 [7], and calcium carbonate will be the stable solid phase above this pH value. The change of calcium arsenate to calcium carbonate will release arsenic in the environment. For pH ranging from 4.5 and 8.5, the total arsenate concentrations in aqueous solutions in equilibrium with calcium arsenates are around 200 times higher than the maximum contaminant level for total arsenic in potable water and treated sewage effluents and wastes.

    The presence of the rare calcium arsenate minerals weilite (CaHAsO4), pharmacolite

    (CaHAsO4·2H2O), haidingerite (CaHAsO4·H2O), and phaunouxite [Ca3(AsO4)2·11H2O] must indicate high concentrations of total dissolved arsenate, taking into account that calcium concentrations in the environment are usually controlled by equilibria with other less-soluble, calcium-containing solid phases.


  5. Fran Diaz Says:

    The Reverse Osmosis Water Filter systems cleans water quite effectively. There are home models as well models for entire cities. The RO systems are not cheap for the people in a country like Sri Lanka, the cheapest model being around US$40 ( I don not know how effective the cheaper models are). So Preventive Care for Clean Water a must for developing countries.

    Google “Reverse Osmosis filters sale’ for more information.

    Here is a write up on one of RO models :

    “Five Stage Residential Reverse Osmosis System (50 GPD) features double o-ring housings and a clear pre-filter housing for quick inspection of the sediment filter, system utilizes 1/4″ compression fittings, includes membrane separation, activated carbon absorption and conventional filtration to reduce the entire spectrum of contaminants that can be found in water. RO systems substantially remove heavy metals, such as barium, cadmium, chromium, lead and mercury; radium 226/228 selenium, cysts, chlorine, salts, turbidity and more! Reduce a broad spectrum of contaminants using 4-stages of treatment, 50 GPD membrane. STAGE 1 – 5 micron sediment prefiltration for mechanical reduction of rust and particulate, and provides membrane protection STAGE 2 – granular activated carbon pre-treatment filter STAGE 3 – activated carbon block for reduction of tastes, odors, chlorine, & organic impurities STAGE 4 – thin film composite reverse osmosis membrane for reduction of dissolved solids, including the range of toxic heavy metals, plus Giardia & Cryptosporidium cysts STAGE 5 – activated in line carbon postfiltration for final polishing of off-tastes & odors Maintenance & Warranty: Pre and post filters recommended change every six months for regular usage, or once a year in light usage. RO membrane: Change recommended based on periodic TDS rejection tests. Typical is every two years. Warranty: Components are warranted for one year from date of purchase, excluding membrane, pre & post filters. System comes with complete installation instructions and installation diagram. Wrench for convenient filter housing removal. System dimensions: Main unit 18″H X 16″W X 6″D, Storage tank 11″ dia. X 15″ tall TDS rejection: 94%+ Operating pressure range: 40-100 psi Operating temperature range: 40° – 100° F Water conditions: 2000 ppm TDS max. 400 ppm hardness max. ph 4 to 11. Note: Reverse osmosis typically wastes 3 to 4 gallons of water for every gallon it produces”.

  6. Lorenzo Says:

    Thanks Walter.

    We need SOLUTIONS now. Fran’s solution, if LOW COST should be popularized.

    ISLANDWIDE chemical check of water should be done.

    However, the RISK is NOT ALARMING at least for now. SL has NOT seen an arsenic driven cancer INCREASE.

    ONE BIG WAY of polluting the environment with Arsenic is some agro chemicals. These arsenic chemicals should be banned.

  7. Fran Diaz Says:

    The Reverse Osmosis method is also used to de-salinate sea water and make it pure for drinking. The middle east uses this method extensively to provide drinking water.

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