Metals and Metallothionein Expression in Relation to Progression of Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka.

Chronic kidney disease of unknown etiology was investigated for metal relations in an endemic area by a cross-sectional study with CKD stages G1, G2, G3a, G3b, G4, G5 (ESRD), and endemic and nonendemic controls (EC and NEC) as groups. Subjects with the medical diagnosis were classified into groups by eGFR (SCr, CKD-EPI) and UACR of the study. It determined 24 metals/metalloids in plasma (ICPMS) and metallothionein (MT) mRNA in blood (RT-PCR). MT1A at G3b and MT2A throughout G2−G5 showed increased transcription compared to NEC (ANOVA, p < 0.01). Both MT1A and MT2A remained metal-responsive as associations emerged between MT2A and human MT inducer Cr (in EC: r = 0.54, p < 0.05, n = 14), and between MT1A and MT2A (in EC pooled with G1−G5: r = 0.58, p < 0.001, n = 110). Human MT (hMT)-inducers, namely Zn, Cu, As, Pb, and Ni; Σ hMT-inducers; 14 more non-inducer metals; and Σ MT-binding metals remained higher (p < 0.05) in EC as compared to NEC. Declining eGFR or CKD progression increased the burden of Be, Mg, Al, V, Co, Ni, Rb, Cs, Ba, Mn, Zn, Sr, Σ hMT-inducers, and Σ MT-binding metals in plasma, suggesting an MT role in the disease. MT1A/2A mRNA followed UACR (PCA, Dendrogram: similarity, 57.7%). The study provides evidence that proteinuric chronic renal failure may increase plasma metal levels where blood MT2A could be a marker.

Risk of needing completion thyroidectomy for low-risk papillary thyroid cancers treated by lobectomy.

Background: Low-risk differentiated thyroid cancers may, according to the American Thyroid Association (ATA) 2015 guidelines, be managed initially with lobectomy. However, definitive risk categorization requires pathological assessment of the specimen, resulting in completion thyroidectomy being recommended when discordance between preoperative and postoperative staging occurs. This study sought to establish the expected rate of completion thyroidectomy in patients with papillary thyroid cancer (PTC) treated by lobectomy. Methods: Patients with PTC treated over 5 years (2013-2017 inclusive) and meeting the ATA criteria for lobectomy were identified from the prospectively developed database of a high-volume, university department of endocrine surgery. Concordance between the ATA initial and final recommendation, and the putative rate of completion thyroidectomy were calculated. Multivariable analysis was used to assess preoperative factors as predictors of the need for total thyroidectomy. Results: Of 275 patients with PTC who met ATA preoperative criteria for lobectomy there was concordance between this and the final recommendation in 158 (57·5 per cent) and discordance in 117 (43·5 per cent). Most common reasons for discordance were: angioinvasion (30·8 per cent), local invasion (23·9 per cent) or both (20·5 per cent). Four patients (1·5 per cent) had permanent hypoparathyroidism. On multivariable analysis, age, sex, tumour size and family history did not independently predict the final treatment required. Conclusion: Although many patients may be treated adequately with lobectomy, just under half would require completion thyroidectomy. Further work is needed on preoperative risk stratification but, before this, total thyroidectomy remains the treatment of choice for low-risk 1-4-cm PTC in the hands of high-volume thyroid surgeons who can demonstrate low complication rates.

Structural violence and chronic kidney disease of unknown etiology in Sri Lanka.

Research published on Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka has been undertaken largely from biomedical and epidemiological perspectives. The main objective of these studies has been to identify the etiology of the disease, which affects as much as 15-21% of the population in some regions and is associated with kidney failure. Few studies have sought to address how CKDu is socially and behaviorally situated in the affected districts. The present study, informed by structural violence theory, utilized a mixed-method approach that analyzed primary and secondary data for Medawachchiya District Secretariat Division in Anuradhapura District for 2010 and 2015, and examined CKDu as a manifestation of social inequality and exclusion and the creation of a marginalized group of agricultural laborers. Data include historical analyses, a case-control study, ecologic analysis of features of communities and CKDu prevalence, and direct observations and interviews with people in affected communities. In 2010, the most important factor associated with CKDu was private dug wells that were used for supplying water to homes. In 2015, when the number of patients had increased, CKDu was more closely linked to occupation, especially male wage labor. The male wage laborer, being the poorest of the poor, has become a particularly vulnerable social category in agricultural settlements in Medawachchiya. The co-occurrence of this social category and CKDu can be regarded as unintended consequences of the official agricultural colonization policy that started during British colonial times and has continued since independence.

Geographical distribution of chronic kidney disease of unknown origin in North Central Region of Sri Lanka.

OBJECTIVES: In early nineties investigators noticed an alarmingly high incidence of an apparently new form of chronic kidney disease of unknown aetiology (CKD-U) in some parts of Sri Lanka. The aim of the study was to investigate the geographical distribution of CKD-U using GIS and GPS mapping. METHODS: Community based information was collected from 11,630 patients for GIS mapping using ARC 9.2 software. Based on GIS mapping, two locations were selected for GPS mapping to locate the households of 863 CKD-U patients with reference to reservoirs, irrigation canals and the topography of the areas. RESULTS: GIS mapping indicated five high prevalence areas of CKD-U. Communities who consumed water from natural springs showed a low prevalence of the disease. GPS mapping showed that most of the affected villages were located below the reservoirs and canals with stagnant irrigated water. CONCLUSION: Epidemiological data on geographical distribution infers that while older foci of CKD-U are persisting, there is an emergence of new foci with time. The location of the affected villages below the level of the reservoirs/canals may indicate the possibility of draining of irrigated water to the shallow wells of the households, which is the source of drinking water.

Community nurses: an urgent need.

When families could not manage to care for the sick, they turned to people who could provide home nursing care. Gradually, however, the sick were moved to institutions and nursing became institution-based. This trend accelerated in almost all countries around the world. Today we see that nurses participate in curative functions, and are concerned with uncommon and/or complex diseases. Very few nurses work in the community to provide services such as illness prevention, encouraging and supporting communities and individuals to participate in their own health care, health promotion and maintenance, and assisting with rehabilitation that address the health needs outside of institutions aimed towards achieving an optimal quality of life.