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Chronic Kidney Disease of Unknown Origin in Sri Lanka and Its Relation

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Chronic Kidney Disease of Unknown Origin in Sri Lanka and Its Relation Chronic Kidney Disease of Unknown Origin in Sri Lanka and its Relation to Drinking Water Supplies A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy D.G Amara Paranagama BSc. MSc. School of Civil Environmental and Chemical Engineering College of Science Engineering and Health RMIT University August 2014 Declaration I certify that except where due acknowledgement has been made, the work is that of the author alone; the work has not been submitted previously, in whole or in part, to qualify for any other academic award; the content of the thesis/project is the result of work which has been carried out since the official commencement date of the approved research program; any editorial work, paid or unpaid, carried out by a third party is acknowledged; and, ethics procedures and guidelines have been followed. D. G. Amara Paranagama August 2014 I ABSTRACT Chronic Kidney Disease (CKD) is a major health issue in North Central Province (NCP) of Sri Lanka. Anuradhapura and Polonnaruwa are the two most affected districts in NCP. This research was designed to identify possible causative agents of CKD in those two districts and to propose suitable harm minimisation techniques to counter CKD. Water quality parameters related to CKD were identified from literature. Drinking water samples were collected from drinking water sources of shallow wells of CKD patients and non-patients in Anuradhapura and Polonnaruwa districts and they were tested for chemical parameters of - - - 3- 2+ chloride (Cl ), fluoride (F ), nitrate (NO3 ), phosphate (PO4 ), calcium (Ca ), magnesium (Mg2+), sodium (Na+), cadmium (Cd2+) and arsenic (As3-). Soil samples were also collected from the vicinity of drinking water wells and analysed for the same parameters. An analytical framework was developed to examine water quality of primary and secondary data using statistical methods namely, Univariate Analysis of Variance (ANOVA) and Dunnett’s T3 post-hoc test, Kruskal-Wallis (KW) and Mann-Whitney’s post-hoc test followed by Factorial and Discriminant analyses. ANOVA and Kruskal-Wallis tests with their post-hoc tests indicated significant differences in water quality parameters between sampling groups with respect to their mean and median values. Factorial analysis results on CKD patient samples showed that sodium and fluoride pooled into a common factor which was significant and reliable at p < 0.05 and Cronbach’s α > 0.7 respectively. On the other hand in non-patient samples, sodium and fluoride as a combined factor was non-existent or less significant than magnesium and fluoride. Total results indicated that sodium and fluoride combination was the probable factor in drinking water of CKD patients. Factorial analysis results were compatible with group classifications according to Discriminant analysis. Literature suggests sodium fluoride (NaF) to cause acute and chronic kidney damage in experimental animals. Also fluoride toxicity to human kidney cells leading to CKD situations have been reported from other countries where similar groundwater fluoride levels exist. The results of primary and secondary data were also analysed for fluoride correlation with sodium percentage, alkalinity, calcium, pH and hardness in water. These results were indicative of fluoride in groundwater to be related to hydrogeology in the CKD endemic area. Even though Cd2+ and As3- were suspected to be II causing CKD, As3- was not detected in Anuradhapura and Polonnaruwa samples and Cd2+ was insignificant in Polonnaruwa samples. Rainwater harvesting was proposed as a mitigation measure to the CKD endemic areas as an alternative to groundwater supplies. Rainwater tank estimations were carried out for eight rainfall stations in Anuradhapura and Polonnaruwa districts. Mass Curve analysis was carried out to estimate optimum tank sizes using recent ten years rainfall data. Dimensionless graph can be used as a tool to determine tank sizes which is specific to a given rainfall station. Dimensionless graphs were constructed for each rainfall station using daily and monthly rainfall data. Daily and monthly rainfall models showed significant differences in tank size estimations and daily models gave bigger tank sizes than monthly models for the same demand levels. The reason was that daily rainfall variations were also counted in daily models which were not accounted in monthly models. Thus it was concluded daily models were preferable over monthly models for tank estimation to the proposed areas. For a four member household with average 6 L/capita/day consumption, the rainwater tank sizes varied between 2900 and 5100 L in the eight rainfall stations. Minimum runoff surface area for each station was estimated to be between 6.7 to 18.2 m2. Volumetric reliability of the estimated tanks were analysed for 60, 80 and 100% demands out of supply situations and results showed that volumetric reliability varied depending on tank size. Sensitivity analysis results showed that tank sizes were sensitive to runoff surface characteristics, household numbers and per capita consumptions. Estimated tank sizes were of manageable size and can be applied in Anuradhapura and Polonnaruwa districts at household levels to supply drinking water as an alternative to groundwater sources. Removal of fluoride from drinking water obtained from groundwater sources was the other CKD mitigation technique proposed to the research area. Key criteria for the selection of natural adsorbents were low cost and availability of material in the CKD endemic area as well as simplicity of application at domestic level. Materials tested for fluoride removal were turmeric, ginger and curry leaves. Out of them turmeric powder showed the highest adsorption capacity and 20% removal at fluoride concentrations between 2 and 20 mg/L. Lab experiments were designed for characterization of turmeric powder to remove fluoride using batch and column experiments. To assess the adsorption mechanisms, batch test data III were applied to Freundlich and Langmuir Isotherms. Langmuir Isotherm was found better fitted to experimental data indicating monolayer adsorption. Kinetics of adsorption was examined using Lagergren pseudo first- and second-order kinetic models. Pseudo first-order kinetic model showed a better fit of experimental results. Intra-particle mass transfer diffusion equation indicated the adsorption which is governed by diffusion within the pores of the adsorbent contributing to the rate determining steps. Column experiments were used to assess the adsorption of fluoride on turmeric depending of flow rate, initial concentration of fluoride solution and column heights of turmeric powder. Using breakthrough analysis, model parameters for Bed depth service time (BDST model), critical bed depth, Bohart- Adams model and Tomas model were determined. Fluoride adsorption by turmeric could be attributed to the processes of ion-binding and ion-exchange between turmeric and fluoride. After column experiments turmeric was regenerated with 1.0M NaOH. With the test results it was concluded that turmeric powder is a potential material for effective removal of fluoride. IV ABBREVIATIONS Ache - Acetyl cholinesterase ANOVA - Univariate Analysis of Variance APHA - American Public Health Association BDST - The Bed Depth Service Time BGS - British Geological Survey CBSL - Central Bank of Sri Lanka CEA - Central Environmental Authority CKD - Chronic Kidney Disease CYN - Cylindrospermopsin DA - Discriminant Analysis DCYN - Deoxy-Cylindrospermopsin DAPH - Department of Animal Production and Health DMSL - Department of Meteorology Sri Lanka EuC - European Commission EC - Electrical Conductivity EDA - Exploratory Data Analysis FA - Factorial Analysis GFR - Glomerular Filtration Rate GI - Galvanised Iron IEV - Initial Eigen Value KMO - Kaiser-Meyer-Olin and Bartlett’s KW - Kruskal-Wallis MAgri - Ministry of Agriculture MCL - Maximum Contaminant Level NHANES - National Health and Nutrition Examination Surveys NIPHEP - National Institute for Public Health and Environmental Protection V NRC - National Research Council NCP - North Central province PV - Percentage Variance PCA - Principal Component Analysis RWH - Rain Water Harvesting SIRKBP - Second Interim Report on Kala Oya Basin Comprehensive Plan SMCL - Secondary Maximum Contaminant Level SL - Sri Lanka SLR - Sri Lankan Rupees TDS - Total Dissolved Solids TISAB - Total Ionic Strength Adjustment Buffer TMV - The Muslim Vegetarian TSP - Triple-Super Phosphate TWDB - Texas Water Development Board USEPA - US Environmental Protection Agency USPHS - US Public Health Service WHO - World Health Organization WRBSL - Water Resources Board of Sri Lanka VI SYMBOL LIST A Runoff surface area (m2) b Langmuir adsorption constant (L/mg) C Consumption per capita per day in the household (L/capita/day) CB Desired concentration of solute at breakthrough (mg/L) Ce Fluoride concentration at equilibrium (mg/L) Ci Initial fluoride concentration (mg/L) Co Initial concentration of solute (mg/L) Ct Fluoride concentration at time t (mg/L) D Yearly water demand for all users in a household (L/year) h Bed depth (cm) ho Critical bed depth (cm) k2 Pseudo second-order kinetic rate constant (g/mg/min) ka Adsorption rate constant (mL/mg/min) kAB Bohart-Adams model kinetic constant (mL/mg/min) kf Freundlich constant -1 kl Lagergren pseudo first-order rate constant (min ) kp Intraparticle diffusion rate constant (mg/g/min) kTH Thomas rate constant (mL/min/mg) N Number of people in household using water n Empirical parameter
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