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Letter to the Editor

A Letter to the Editor to this article was published on 19 February 2015

The Original Article was published on 20 September 2014

Dear Editor/EHPM

I am pleased to read the major effort and perhaps the best review article to date in the field of chronic kidney disease (CKD) of multi-factorial origin in Sri Lanka in the EHPM journal [1]. In this review, he succinctly and unbiasedly illustrated all the potential contributing factors postulated to date (Figs. 2, 3). These include heavy metals (lead, cadmium, arsenic, mercury, and uranium), aristolochic acid, infectious etiology (leptospirosis, hantavirus, malaria, leprosy, schistosomiasis), exertion/heatstroke, agrochemical and pesticide exposure, etc. [1, 2].

In Sri Lanka, CKD of multi-factorial origin (CKD-mfo; also known as CKD of unknown aetiology; CKDu/CKD-uo) was first described in the mid-1990s, but the cause is unknown [1, 2]. A multi-year research program by the National Research Team in Sri Lanka has failed to identify a single cause for this disease [3], but acknowledges that it is most likely due to multiple agents and supports the terminology of CKD-mfo that has been used by Professor Wimalawansa for many years and presented in an sophisticated, authoritative national oration in 2013 [4].

In his review articles, Professor Wimalawansa also elegantly illustrates that CKD-mfo is likely due to synergistic efforts of several factors and is an “environmentally acquired, occupational disease” [1, 5, 6]. This is also supported by the geographical dissemination of the disease and the locations of hard water in Sri Lanka that have been available since the early 2000 [3, 4].

None of the data available to date, however, support several of the currently dominating hypotheses including the effect of glyphosate, fluoride, heavy metals, aristolochic acid, or ionicity [24]. These hypotheses have been presented without validated scientific evidence or experimental data. We appreciate the vast singlehanded contribution of Professor Wimalawansa to the CKD-mfo field [1, 46].


  1. Wimalawansa SJ. Escalating chronic kidney diseases of multifactorial origin in Sri Lanka: causes, solutions and recommendations. Environ Health Preventive Med. 2014;19:375–94.

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  2. Jayatilake N, Mendis S, Maheepala P, Mehta FR. Chronic kidney disease of uncertain aetiology: prevalence and causative factors in a developing country. BMC Nephrol. 2013;14:180.

    Article  PubMed Central  PubMed  Google Scholar 

  3. WHO Group full report, Jayathilaka N, et al., Investigation and evaluation of chronic kidney disease of uncertain aetiology in Sri Lanka, WHO (Ed.), 2013; Colombo, Sri Lanka.

  4. Accessed 1 Jan 2015.

  5. Wimalawansa, et al. Agrochemical related environmental pollution: effects on human health. Glob J Biol Agriculture Health Sci. 2014;3(3):72–83.

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  6. Wimalawansa SA, Wimalawansa SJ. Changing agricultural practices in dry zonal areas and escalating incidences of chronic kidney disease of multi-factorial origin. Wudpecker J Agric Environ. 2014;3(5):110–24.

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Correspondence to Ravindra Fernando.

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Fernando, R. Letter to the Editor. Environ Health Prev Med 20, 151 (2015).

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