CKDu REVISITED
R.M.G. Rajapakse (Ph.D., D.I.C., C. Chem., FNASSL)
Senior Professor in Chemistry
Department of Chemistry
University of Peradeniya
Peradeniya
CONTENTS
• Chronic Kidney Diseases
• CKDu in Sri Lanka
• Geochemical Aspects and Chronic Renal Failure: FHypothesis
• Hypothesis of F- and Aluminofluorides
• Cd2+ Hypothesis
• Cyanobacteria Hypothesis
• Arsenic Hypothesis
• Role of Glyphosate
• “Soft Ions” and Ionic Strength
• Dialysis
• Renal Substitutional Therapy
• Regenerative Medicine
CHRONIC KIDNEY DISEASES (CKDs) [1]:
Definition: Any condition that causes reduced kidney
function over a period of time is a chronic kidney disease.
CKD is present when a patient’s glomerular filtration rate
remains below 60 mL min-1 for more than 3 months, or when
a patient’s urine albumin-to-creatinine ratio is over 30 mg of
albumin for each g of creatinine (30 mg g-1).
Glomerular filtration rate
Glomerular filtration rate (GFR) is a test used to check how well the kidneys are working.
Specifically, it estimates how much blood passes through the glomeruli each minute. Glomeruli
are the tiny filters in the kidneys that filter waste from the blood (MEDLINE PLUS).
Albumin is a protein found in the blood. A healthy kidney does not let albumin pass into the
urine. A damaged kidney lets some albumin pass into the urine. The less albumin in your urine,
the better. (National Kidney Disease Education Program of USA.)
1. Kidney Disease Statistics for the United States, National Kidney and Urologic Diseases
Information Clearinghouse (NKUDIC),
http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#16, Accessed on July 5th, 2014.
SKIP
Creatinine is removed from the blood chiefly by the kidneys, primarily by glomerular
filtration, but also by proximal tubular secretion.
Little or no tubular reabsorption of creatinine occurs.
If the filtration in the kidney is deficient, creatinine blood levels rise.
Therefore, creatinine levels in blood and urine may be used to calculate
the creatinine clearance (CrCl), which correlates with the glomerular filtration
rate (GFR).
Blood creatinine levels may also be used alone to calculate the estimated GFR
(eGFR).
CHRONIC KIDNEY DISEASES (CKDs)
ARE NOT UNCOMMON [1-5]
• One in 10 American adults, more than 20 million, have
some level of CKD [1-3] due to diabetes or
hypertension.
• Around 1.7 million Australians (1 in 10) aged ≥ 18
years have clinical evidence of CKD [4,5] due to
diabetes or hypertension .
[1] Kidney Disease Statistics for the United States, National Kidney and Urologic Diseases
Information Clearinghouse (NKUDIC),http://kidney.niddk.nih.gov/ kudiseases /pubs /kustats/#16.
[2] National Kidney and Urologic Diseases Information Clearing House (NKUDIC), U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES.
[3] Centers for Disease Control and Prevention, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES , NIH Publication No. 12–3895, November 15, 2012.
[4] STATE OF THE NATION: CHRONIC KIDNEY DISEASE IN AUSTRALIA, MAY 2014,
KIDNEY HEALTH AUSTRALIA: Accessed 03rd July, 2014.
[5] ANZDATA, Summary of Australian and New Zealand Dialysis and Transplantation Registry, South
Australia, Adlaide, 2013.
CKDu IN SRI LANKA
• CKDu: Chronic Kidney Disease of unknown
Aetiology
Affected Areas
• Girandurukotte in the Badulla District
• Medawachchiya and Padaviya in the Anuradhapura
District
• Medirigiriya and Hingurakgoda in the Polonnaruwa
District
• Nickawewa in the Kurunagala District
MAP OF CKDu IN SRI LANKA [6]
[6] SOURCE: www.share-pdf.com
FACTS ABOUT CKDu IN SRI LANKA
• Discovered since mid 1990’s.
• Affected patients are mostly rice paddy farmers.
• The estimated age-standardized prevalence of the disease is 15%
[7].
• According to the Ministry of Health, the estimated number of
CKDu cases is 69,258 as of June 2014 [8, 9].
• Estimated death toll is 20,000 [8].
• Affected patients were of age categories over 55 years [10].
• The age category is shifting towards younger ages [10].
• It has been predicted that even the school children could be
affected in the near future [10].
[7] N. Jayathilaka, S. Mendis, P. Maheepala and F.A. Metha, “Chronic Kidney Disease of Unknown Aeitiology: Prevalence and Causative Factors in
a Developing Country”, BMC Nephrology, 14 (2013) doi:10-1186/1471-2369-14-180.
[8] Channa Jayasumana, Sarath Gunathilaka and Priyantha Senanayake, “Glyphosate, Hard Water, and Nephrotoxic Metals: Are They the Culprit
Behind the Epidemic of Chronic Kidney Disease of Unknown Etiology in Sri Lnka?”, International Journal of Environmental Research and
Public Health, 11 (2014) 2125-2147.
[9] Private Communication with Dr. Channa Jayasumana
[10] Channa Jayasumana, Lakbima, Sunday Edition, 22nd June, 2014.
UNIQUE FEATURES OF CKDu
It is said that CKDu aetiology does not include commonly
known risk factors for a chronic kidney disease.
• No Diabetes mellitus
• No Hypertension
• No Glomerulonephritis [8, 11]
SO, IT IS A VERY SPECIAL DISEASE!!!
Glomerulonephritis, also known as glomerular nephritis, is a term used to refer to
several renal diseases (usually affecting both kidneys). Many of the diseases are
characterised by inflammation either of the glomeruli or small blood vessels in the
kidneys, hence the name.
[8]
Channa Jayasumana, Sarath Gunathilaka and Priyantha Senanayake, “Glyphosate, Hard Water, and Nephrotoxic Metals: Are They the Culprit Behind
the Epidemic of Chronic Kidney Disease of Unknown Etiology in Sri Lnka?”, International Journal of Environmental Research and Public Health, 11
(2014) 2125-2147.
[11] N.T. Athuraliya, T.D. Abeysekara, P.H. Amerasinghe, R. Kumarasiri, P. Bandara, U. Karunaratna, A.H. Milton and A. L. Jones, “Uncertain etiologies of
Proteinuric Chronic Kidney Disease in Rural Sri Lanka”, Kidney International, 80 (2011) 1212-1221.
•
•
•
CRITERIA FOR CASE DEFINITION OF
CKDu [12]
No past history or current treatment for diabetes mellitus, chronic or severe hypertension,
snake bites, urological disease of known aetiology or glomerulonephritis.
Glycosylated haemoglobin levels in blood (HbA1c) of < 6.5%.
Blood pressure < 160/100 for untreated patients and < 140/90 for treated patients.
Category
Systolic
BP/mmHg
Diastolic
BP/mmHg
Normal
110- 120
70-80
Prehypertension
120-139
80-89
Stage 1 Hypertension
140-159
90-99
Stage 2 Hypertension
160
100
The reference range of Glycosylated haemoglobin levels in blood is about
20 - 40 mmol mol-1 (4 – 5.9 DCCT %) in a healthy patient .
[12] Ministry of Health. Chronic Kidney Disease of Unknown Aetiology, Circular No. 0110/2009, Ministry of Health, Colombo, Sri Lanka (2009).
SKIP
CORRELATION BETEEN GLYCATED HAEMOGLOBIN LEVEL IN BLOOD AND
MEAN BLOOD SUGAR CONCENTRATION OVER THE PREVIOUS FOUR
WEEKS [13]
A1c%
Conc. Of Blood Sugar
(Mean Value)/mg dl-1
6
135
7
170
8
205
9
240
10
275
11
310
12
345
6.5% Glycated haemoglobin means
~ 150 mg dL-1 blood sugar!
[13] http://www.medicinenet.com/hemoglobin_a1c_test/article.htm; Accessed 03rd July, 2014.
[14] Table 2: Iftikhar Ahmad Asim Syed and Waqar Ahmed Khan , “Glycated Haemoglobin � a
Marker and Predictor of Cardiovascular Disease”, J. Pakistan Medical Association, 16 (July 2011)
690-695.
IMPORTANT POINTS TO CONSIDER
(i) Patients are confined to a unique geographical
area of the country.
(ii) Disease was not found about 25 years ago.
(iii) Number of patients is continuously increasing
very rapidly now.
(iv) Affected people are mostly rice paddy farmers.
(v) Patients are mainly males.
(vi) The disease is prevalent in the region where
fluorosis is also prevalent.
(vii)In general, drinking water has high salinity.
IMPLICATIONS!
• The aeitiology of the disease may be associated with local environmental
and occupational conditions, food habits or may be due to genetic reasons .
• Occupation of the patients is already known. They are mostly rice paddy
farmers.
• Look for unique environmental conditions of the region and consequences
of farming.
• Farming communities in NCP and EP of Sri Lanka comprise of native people
of the region plus those migrated from other areas, such as, Gampaha,
Kurunegala, Kegalle, Galle, Matara, Hambantota, Kotmale etc. during the
colonization period. Better to see whether there are any Genetic or
Hereditary Factors such as the Patients are of Particular Tribe Living in this
Area and so on.
• Better to investigate their food habits, habits such as chewing
“BULATHWITA”. Consumption of illicit alcohols and inadequate water
consumption during hard work of farming. Do they smoke? Smoking is the
biggest source of cadmium intake.
GEOCHEMICAL ASPECTS-CHRONIC RENAL FAILURE [15]
First Study by C.B. Dissanayake in 2005.
• Dental fluorosis and Kidney Diseases are commonly observed in
Sri Lanka in the same geographical area.
• Chronic Renal Failure has been observed in the Areas of
Anuradhapura and Polonnaruwa Districts.
• Geochemically, water in these areas are Na/K type with Clsubtype predominating due to increasing drought conditions and
consequent salt building up (This means water hardness is mostly
due to permanent hardness and most of the compounds of
sodium and potassium are water soluble!).
• The Total Dissolved Solids and Electrical Conductivity are high.
• Unique feature is that F- in ground waters of some areas is 10 mg
L-1 which is much higher than maximum tolerable Fconcentration in drinking water of 1.5 mg L-1 which has now
reduced down to 0.5 mg L-1 (WHO Limit, vide infra).
[15] C.B. Dissnayake, “Water Quality in the Dry Zone of Sri Lanka-Some Interesting
Health Aspects”, J. National Science Foundation of Sri Lanka, 53 (2005) 161-168.
14
The F- Map of Sri Lanka [16]
Concentration of fluoride (mg/L = ppm) and Its
Impact on Health
0.0 − 0.5 Limited growth and fertility, dental caries.
0.5 − 1.5 Promotes dental health, prevents tooth
decay
1.5 − 4.0 Dental fluorosis (mottling of teeth)
4.0 − 10.0 Dental fluorosis, skeletal fluorosis (Pain in
back and neck bones)
> 10.0 Crippling skeletal fluorosis
[16] Rohana Chandrajith, J. P. Padmasiri, C.B. Dissanayake
and K. M. Prematilaka, “SPAITIAL DISTRIBUTION OF
FLUORIDE IN GROUND WATER OF SRI LANKA”, J. National
Science Foundation of Sri Lanka, 40 (2012) 303-309.
CKDu STUDIES
•
•
•
•
SECOND STUDY BY O. A. ILEPERUMA et al. [17, 18]
Hypothesis on the connection to excess fluoride ions
in drinking-water.
Use of low-quality aluminium cooking pots.
Possibility for the formation of water-soluble AlF4and AlF63- ions under cooking conditions.
Subsequent intake of F- and fluoroaluminate ions.
[17] O.A. Ileperuma, Keynote Speech: In Ileperuma, O.A., Priyantha, N., Chandrajith, R.,
Perera, A., Yatigammana, S.K. and Wijesundara, C. (Editors) (2013): Symposium
Proceedings, Second International Symposium on Water Quality and Human Health:
Challenges Ahead, 15-16 March, PGIS, Peradeniya, Sri Lanka .
[18] O.A.Ileperuma, H.A. Dharmagunawardhane and K.P.R.P Herath, “Dissolution of
aluminium from sub-standard utensils under high fluoride stress: A possible risk factor
for chronic renal failure in the North-Central Province, J. Natn. Sci. Foundation Sri Lanka,
37 (2009) 219—222
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FLUORIDE IN DRINKING-WATER
EXCELLENT REVIEW OF WHO [19]
[19] J. Fawell, K. Bailey, J. Chilton, E. Dahi, L. Fewtrell
and Y. Magara, Fluoride in Drinking-Water , World
Health Organization, IWA Publishing, London, First
Published 2006.
WORLD MAP WITH RESPECT TO FLUORIDE IN
GROUND WATER SKIP
MAP WAS PREPAED BY Mr. CHARITH ANURUDDHA, ONE OF MY RAs, BASED ON DATA GIVEN IN [19] .
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Fluoride in Australian Waters [20]
• Very Low.
• Fluoridization of drinking water is required to
prevent dental caries among small and teenage
children.
• The recommendations for fluoride levels in
Australian water fluoridation programs should
comply with those set out in the National Health
and Medical Research Council’s public statement .
The efficacy and safety of fluoridation is 0.5 ppm.
[20] “Fluoride concentration in Australia’s Drinking Waters”, Victoria,
Department of Health,
http://docs.health.vic.gov.au/docs/doc/FC530C0F87F821F6CA257868007AD57
8/$FILE/US%20HHS%20proposal%20WEB.pdf, Accessed on 06/07/2014
WHO STANDARDS OF FLUORIDE IN
DRINKING-WATER: SKIP
• WHO noted that mottling of teeth (i.e. dental fluorosis) is
sometimes associated with fluoride levels in drinking-water
above 1.5 mg L–1 and crippling skeletal fluorosis can ensue
when fluoride levels exceed 10 mg L–1.
• A guideline value of 1.5 mg L–1 was, therefore, recommended
by WHO as a level at which dental fluorosis should be
minimal (WHO, 1984).
• The 1.5 mg L–1 fluoride guideline value that was set in 1984
was subsequently re-evaluated by WHO and it was concluded
that there was no evidence to suggest that it should be
revised (WHO, 1996, 2004).
• The 1.5 mg L–1 guideline value of WHO is not a “fixed” value
but is intended to be adapted to take account of local
conditions (e.g. diet, water consumption, etc.).
FLUORIDE METABOLISM
FLURIDE ABSORPTION BY THE HUMAN BODY
• Approximately 75–90% of ingested fluoride is absorbed.
• In an acidic stomach, fluoride is converted into hydrogen
fluoride (HF) and up to about 40% of the ingested fluoride is
absorbed from the stomach as HF (Discuss corrosiveness).
• Fluoride not absorbed in the stomach (60%) is absorbed in
the intestine and is unaffected by pH at this site.
• Relative to the amount of fluoride ingested, high
concentrations of cations that form insoluble complexes with
fluoride (e.g. calcium, magnesium and aluminium) can
markedly decrease gastrointestinal fluoride absorption.
FLUORIDE DISTRIBUTION IN THE HUMAN BODY
• Once absorbed into the blood, fluoride is readily distributed throughout
the body.
• Approximately 99% of the body burden of fluoride is retained in calcium
rich areas such as bones and teeth (dentine and enamel).
• Fluoride is then incorporated into the hydroxyapatite [Ca10(PO4)6(OH)2]
lattice through ion-exchange.
Porous Ca10(PO4)6(OH)2(s) + xF-(blood) ⇌
Denser Ca10(PO4)6(OH)2-xFx(s) + xOH-(blood)
• Out of eleven important functions of bones, detoxification is one of the
most important functions.
• Toxic anions such as aresenite and arsenate in the blood are adsorbed by
the hydroxyl groups of hydroxyapatite and thereby the supply to other
organs is prevented.
• These anions are then slowly released to the kidney for safe discharge.
• When the OH groups are substituted with F- anions this mechanism is not
possible.
• Ca2+ can be exchanged for Cd2+ in Cd2+ toxicity causing weak bones
(osteoporosis) (vide infra)
STRUCTURE OF NATURAL BONE
NANOTECHNOLOGICAL ARCHITECTURE OF BONES
COMPACT AND SPONGY PARTS
OF BONE
A femur head (highest part of the thigh bone) with
a cortex of compact bone and medulla of trabecular bone.
Tailor-made Prosthesis by the Bio-Chemical-Computer ScienceEngineering- Medical Research Group of University of Peradeniya
EFFECTS OF FLUORIDE ON HUMANS
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• A number of studies have reported on the acute
effects of fluoride exposure following fluoridation
overdosing.
• However, the effects of long-term exposure to
naturally occurring fluoride from drinking-water and
other environmental sources (Chronic effects) are
the major concern with regard to human health.
• A large number of epidemiological studies have
been conducted in many countries concerning the
effects of long-term exposure to fluoride.
DENTAL AND SKELETAL FLUOROSIS
FACTS ON SKELETAL FLUOROSIS SKIP
Paraestheria: Sensation of tingling, tickling, prickling, pricking, or burning of a person's skin with
no apparent long-term physical effect.
Poker Back: Arthritis and osteitis deformans involving the spinal column.
EXOSTOSIS: Formation of new bone on the surface of a bone.
MUTAGENECITY AND RELATED ENDPOINTS. SKIP
• Studies have been carried out with bacteria, insects,
laboratory animals and in vitro studies with human
cells.
• Number of positive results in a variety of mammalian
cell types for chromosome damage (USNRC 1993, WHO
1996, IPCS 2000) have been observed.
• Effects are due to interferences with protein synthesis
rather than by any direct interaction between F- and
DNA.
• THIS IS TRUE SINCE F- IS EXTREMELY INTERT IN ITS’ FFORM.
FLUORIDE AND CANCER SKIP
My Opinion: THE POSSIBILITY IS DUE TO VERY HIGH CORROSIVENESS OF HYDROGEN FLUORIDE
SOLUTION. HF CAN ATTACK ANYTHING. Can Even Dissolve Glass! F- can precipitate certain
important metal ions such as Ca2+ as CaF2(s). F- can attack enzymes inhibiting their catalytic
functions.
In the body, hydrofluoric acid reacts with the ubiquitous biologically important ions such as
Ca2+ and Mg2+. Formation of insoluble calcium fluoride is proposed as the aetiology for both
precipitous fall in serum calcium and the severe pain associated with tissue toxicity [21].
[21] Hoffman, Robert S. et al. (2007) Goldfrank's Manual of Toxicologic Emergencies. New York:
McGraw-Hill Professional, p. 1333, ISBN 0071509577.
ENZYME INHIBITION BY
FLUORIDE
@ 1 ppm or less [22]
[F]/pp
m
% Inhibition
Acetylcholinest
earase
1
61%
Glutamine
synthetase
1
100%
DNA Repair
Enzyme
Systems
1
50%
Lactoperoxidase
1
Pterin
deaminase
0.6
Alkaline
phosphstase
0.3
Enzyme
Accumulation of Fluoride
Resulting From F- Exposure
Organ
[F-] before
[F-] after
fluoridation of fluoridation
drinking water of drinking
in USA/ppm
water in
Before 1939
USA/ppm
1960-1965
Brain
0.53
1.5
Heart
0.51
1.8
Kidney
0.68
2.3
Liver
0.54
1.4
50%
Lung
0.27
2.1
50%
Spleen
0.28
1.8
Pancreas
NR
NR
Thyroid
NR
NR
52%
[22] John Liyamouyiannis, “Fluoride: The Aging Factor, How to Recognize and Avoid Devastating
Effects of Fluoride” , Health Action press, Ohio, United States, 3rd Edition, 1993, 292 Pages.
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TOXICITY OF FLUOROALUMINATES
STUDIES WITH Nostoc linckia and Chlorella vulgaris
BLUE-GREEN ALGAE
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UPTAKE OF FLUOROALUMINATE SPECIES
BY BLUE-GREEN ALGAE [23]
• Have pH-dependent Mg2+ and Ca2+-ATPase (Class
of enzymes that catalyze the decomposition of ATP
into ADP and a free phosphate ion) activities.
• Toxicity increases with increasing acidity.
• Toxicity of fluoroaluminate is reduced in the presence of
EDTA and citrate (THESE ARE BETTER CHEALATING AGENTS
THAN AlF4-).
• AlF4− inhibits the ATPase activity by acting as a functional
barrier without affecting the structure of the enzyme. This
upsets the cell metabolism and the removal of toxins.
[23] Yasmin Husaini, L. C. Rai, Nirupama Mallick,”Impact of aluminium, fluoride and
fluoroaluminate complex on ATPase activity of Nostoc linckia and Chlorella
vulgaris”,Biometals 9 (1996) 277-283.
UPTAKE OF FLUOROALUMINATE
SPECIES BY HUMANS
• Laboratory investigations have often used aluminofluoride
complexes for stimulation of various guanine nucleotide binding
proteins.
• These complexes form spontaneously in aqueous solutions
containing fluoride and traces of aluminum and appear to act as
phosphate analogous.
• In view of the ubiquity of phosphate in cell metabolism and
together with the dramatic increase in the amount of reactive
aluminum now found in ecosystems, aluminofluoride complexes
represent a strong potential danger for living organisms including
humans.
• Fluoride anions in the presence of aluminum affect the liver as an
organ involved in glycogenolysis, fatty acid oxidation, and lipolysis.
• Enormous possibilities for multiple molecular interactions of
aluminum and fluoride exist in the brain.
EFFECT OF FLUOROALUMINATE
COMPLEXES ON KIDNEYS [24] SKIP
• The effects of aluminofluoride complexes on the kidneys have
been studied using glomerular mesangial cells, proximal
tubular cells, and inner medullar collecting tubule cells of rat
kidneys.
• Fluoride and aluminum in kidney tubular cells affect the ion
transporting processes.
• The kidneys from rats drinking water containing NaF exhibited
glomerular hypercellularity, renal mesangial proliferation, and
the deposition of proteins in the renal tubules.
Mesangial proliferative glomerulonephritis (MPGN) is a rare kidney disorder characterized
by blood in the urine caused by a particular type of inflammation inside the kidneys.
[24] Anna Strunecká and Jiří Patočka, “PHARMACOLOGICAL AND TOXICOLOGICAL EFFECTS OF
ALUMINOFLUORIDE COMPLEXES”, Fluoride, 32 (1999) 230-242.
MY OPINION
• Fluoride or Fluoroaluminte complexes being directly
responsible for CKDu is quite unlikely but blocking of
glomeruli with precipitated CaF2 and proteins is
possible.
• However, fluorosis
mechanism of bones.
prohibits
the
detoxification
• Therefore, patients with fluorosis are more prone to get
their kidneys damaged by other toxic chemicals such as
cadmium and arsenite ions.
• F- can inhibit various enzymes and HF can etch anything
causing cancers.
CADMIUM ION HYPOTHESIS [25-27]
• Hypothesis of Cd2+ causing CKDu by Sarath Bandara et al.
appears to the third such hypothesis.
• Elevated Cd2+ Levels in rice and Freshwater Fish.
• Both Rice and Inland Fish are a popular food among the
farming community in this area.
• Cd2+ is a common poison present in TSP fertilizers.
• Atomic Absorption Spectroscopic determination of Cd2+ in
rice and freshwater fish.
• Concentration of Cd2+ in roots of Nymphaea lotus L (Lotus
roots)
[25] J.M.R.S. Bandara et al. “Chronic Renal Failure among Farm Families in Cascade Irrigation
Systems in Sri lanka Associated with Elevated Dietary Cadmium Levels in Rice and Freshwater
Fish (Thilapia)”, Environmental Geochemistry and Health, 30 (2008) 465-478.
[26] J.M.R.S. Bandara et al., “Chronic Renal Failure in Sri Lanka caused by Elevated Cadmium
Levels: Trojan Horse of the Green Revolution”, Toxicology Letters, 198 (2010a) 33-39.
[27] J.M.R.S. Bandara et al., “Pollution of River Mahaweli and Farmlands unde Irrigation by
Cadmium from Agricultural Inputs Leading to a Chronic Renal Failure Among Farmers in
NCP”, Environmental Geochemistry and Health, DOI 10.1007/S10653-010-9344-4.
PROBLEMS OF THE ANALYTICAL
TECHNIQUE
• Calibration plot drawn in a concentration range higher than
those in the analyte samples.
• Calibration plot is in the Linear Dynamic Range.
• Beer-Lambert Law: A = εlc, where A is the absorbance, ε the
molar absorption coefficient of the sample, l the path length
and c is the concentration of Cd2+.
• No guarantee for the holding of the law below or above the
linear dynamic range.
• As such, the magnitudes of values may be different to actual
values. This has been pointed out by Chandrajith et al. [28].
• USE OTHER TECHNIQUES SUCH AS ANODIC
STRIPPING VOLTAMMETRY!
[28] Rohana Chandrajith, Shanika Nanayakkara, Kozuyoshi Itai, T.N.C. Aturaliya, C.B. Dissanayake, Thilak
Abeysekara, Kouji Harada, Takao Watanabe and Akio Koishumi, “Chronic Kidney Diseases of Unknown
Aeitiology in Sri Lanka, Geographical Distribution and Environmental Implications”, Environmental
Geochemical Health, 33 (2011) 267-278.
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DEMONSTRATION OF THE PROBLEM
EXTRAPOLATION OF THE STRAIGHT LINE IS INCORRECT PARTICULARLY IN THE HGH
CONCENTRATION SIDE. IN THIS CASE THE TREND IN THE LOW CONCENTRATION SIDE MAY BE
CORRECT SINCE THE LINE GOES TO THE ORIGIN. THIS IS NOT THE CASE ALWAYS!
BIOACCUMULATION OF CADMIUM
IONS SKIP
• Although Cd2+ levels in surface water may be lesser
than what Bandara et al. have reported, Cd2+ has a
notorious bioaccumulation and a very long
biological half life (vide infra).
• Therefore, inland fish may have high concentrations
of continually accumulated Cd2+.
• Once Cd2+ is ingested continuously, they remain in
the human body for a long time causing chronic
problems.
CADMIUM IN FISH
• Measured in flesh extract.
• Cd2+ concentrates in the bones by exchanging for
Ca2+ ions.
• In this way, Cd2+ accumulates in fish bones.
Ca10(PO4)6(OH)2(s) + yCd2+(blood) ⇌ Ca10-yCdy(PO4)6(OH)2(s)
+ yCa2+(blood)
Cd2+ may be found in liver and kidneys as well.
Mechanisms will be discussed later.
CADMIUM POISONING
• Cadmium toxicity occurs when a person breathes in high levels of
cadmium from the air, or eats food or drinks water containing high
levels of cadmium.
Cadmium is found in
• Batteries: Ni/Cd Batteries: Major Cadmium Source.
• Pigments
• Metal coatings
• Plastics
• Some metal alloys
• Fertilizers: IMPORTED TSP: [Cd2+] = 71.7 mg Cd2+/kg P2O5 [29].
Since 1973 to 1984, 68.9 tonnes of Cd has been added to
agricultural lands. EPPAWELA PHOSPHATE HAS VERY LOW Cd2+
CONTAMINATION!
• Cigarettes
• Stabilizer in PVC
RISK FACTORS SKIP
• Smoking.
• Living near hazardous waste sites or industrial
factories that emit cadmium into the air.
• Working in a metal smelting and/or refining plant.
• Working in a plant that produces cadmium products
(e.g., batteries, coatings, plastics, pigments).
• Having a nutritional deficiency in calcium, iron,
protein, and/or zinc [THESE PEOPLE USUALLY DO
NOT TAKE A HEALTHY DIET].
SYMPTOMS OF CADMIUM
POISONING SKIP
Eating food or drinking water contaminated with high
levels of cadmium can result in:
Vomiting/nausea, Stomach cramps, Diarrhea,
Kidney damage, Fragile bones and Death.
SYMPTOMS OF THE ITAI-ITAI DISEASE
Breathing in cadmium can result in:
Lung damage (chest pain or shortness of breath),
Kidney diseases, Fragile bones and Death.
DIAGNOSIS (SKIP DUE TO TIME
LIMITATIONS)
Your doctor will ask about your symptoms and
medical history, and perform a physical exam.
Tests may include the following:
• Blood tests
• Urine tests
• Hair or nail analysis
• Neutron activation analysis—a test to measure
cadmium levels inside your liver and kidneys.
TREATMENT (SKIP DUE TO TIME
LIMITATIONS)
• There is no effective treatment for cadmium
toxicity.
• Avoid exposure.
• Your treatment will be designed to help manage
and relieve your symptoms.
• You may be given vitamin D for the weak bones.
To help reduce your chances of getting cadmium
toxicity, take the following steps: SKIP
• Do not smoke. Smoking is the single most important source of cadmium
intake for most persons.
• Identify potential sources of cadmium in and around your home, at work,
and where your children play.
• If you maintain a vegetable garden, consider having fertilizers tested for
cadmium. Some fertilizers have been found to be high in cadmium, which
may then concentrate in your vegetables. Avoid any use of cadmium
containing fungicides near your vegetable gardens.
• Eat a balanced diet that provides enough calcium, iron, protein, and zinc.
• Take inventory of and properly store (out of the reach of children)
cadmium-containing products in your home (e.g., fungicides, batteries,
metals, fabric dyes, ceramic/glass glazes, fertilizer); check the label for
cadmium.
SKIP
Keep nickel-cadmium batteries out of the reach of small
children and find out how to properly dispose of these
batteries.
Read instructions for safely using cadmium-containing
fungicides or fertilizers on your lawn or garden.
If you have a water well, have your water tested for the
presence of cadmium.
If cadmium is present in your well water, consider using
bottled water for drinking or install a water filter that
removes cadmium and other metals from drinking water.
Do not allow young children to play in or around hazardous
waste sites.
ITAI-ITAI DISEASE: DUE TO CADMIUM
POISONING
Itai-tai disease is caused by cadmium
poisoning due to mining in Toyama
Prefecture of Japan. Cd2+ goes in through
rice and cereals!
This is a multi-factorial disease but
cadmium is a necessary agent to result in
severe kidney damage and osteomalacia
(Osteomalacia is derived from
Greek: osteo- which means "bone",
and malacia which means "softness". ).
LIGNIN
Latifoliate: Plants with broad leaves.
Cadmium ions have a high affinity to rice and cereals. Recent discovery of Cd2+
accumulation in red onions is also a sensible finding.
Allyl propyl disulfide
can coordinate with Cd2+.
Nelum roots have glucose, fructose, sucrose, mannitol, galacturonic acid, raffinose, 10 amino
acids and fibers [29]. Cadmium ions can form coordination complexes with them.
[29] S. Hujjatullah, A. K. Bloch and A. Jabbar, ” Chemical composition and utilisation of the roots
of Nymphaea lotus L”, Journal of the Science of Food and Agriculture, 18 (1967) 470-473.
Cadmium and the Kidney [30] SKIP
History and Aetiology of Cadmium-induced Kidney Dysfunction and
Related Disorders
Chronic cadmium exposed battery workers had major signs
in kidneys: Tubular and Glomerular dysfunction with
proteinuria.
A high prevalence of kidney stones in Swedish and British
Workers.
Glomerular dysfunction: Damaging glomeruli and letting red blood cells leak into
urine.
Proteinuria: Presence of an excess of serum proteins in urine
[30] L. Friberg, “Cadmium and the Kidney”, Environmental Health Perspectives, 54 (1984) 1-11.
Cadmium Metabolism,
Metallothionein and Kidney Dysfunction
• After the ingestion, cadmium is transported to the liver
where it stimulates the synthesis of metallothionein.
• Cadmium is then bound to metallothionein and
transported via blood to kidneys.
L-Cysteine
Metallothionein (MT) is a family of cysteine-rich, low molecular weight (MW ranging from 500
to 14,000 Da) proteins. In the human body, large quantities are synthesized primarily in
the liver and kidneys.
KIDNEY DAMAGE BY CADMIUM
• Cadmium bound to metallothioneins are filtered with the primary urine and
reabsorbed into the tubular cells.
• A considerable catabolism of cadmium-metallothionein can take place.
• Complexes break and cadmium ions bind to newly formed metallothionein in the
tubular cells.
• Kidney damage takes place when the kidney no longer produces metallothionein.
• The biological half-life of cadmium is very long: 10-30 Years!
• Chronic cadmium exposures of 50 µg m-3 (10 times the new OSHA permissible
exposure limit) for 10 years may cause kidney dysfunction with proximal tubular
damage [30].
[30] Human Toxic Chemical Exposure-Cadmium, “Bulletin of Pacific Toxicology
Laboratories”, http://www.pactox.com/library/article.php?articleID=31
RENAL TOXICITY OF CADMIUM IONS
• The kidney is the major target organ of cadmium.
• The critical concentration for toxic effects appears to be between 200 and
250 µg/g of kidney tissue (200-250 ppm) [31]
• When the renal tubular cells become saturated with cadmium (because
the storage capacity of metallothionein is exceeded) free cadmium is
released.
•
It is widely believed that this free cadmium ion is the cause of the renal
damage.
• Free cadmium ions may replace zinc in some systems, especially those
enzymes involved in the reabsorption and catabolism of proteins.
[31] Roels, H., Bernard, J., Goret, A., Lauwerys, R. Chettle, D., Harvey, T., Al Haddad, I., "Critical
concentration of cadmium in renal cortex and urine" Lancet i, 221, 1979.
RENAL TOXICITY OF CADMIUM IONS
Con.td. SKIP
• This may cause the tubular damage and proteinuria characterized
by an increased urinary excretion of low molecular weight proteins,
which come from the glomerular filtrate but are not reabsorbed
[32].
•
Some evidence suggests that cadmium- induced proteinuria may
also be the result of glomerular damage [33].
• The first detectable adverse effect of cadmium on the kidney is an
increased excretion of specific proteins in the urine.
[32] Bernard, A., Roels, H.A., Hubermont, G., Buchet, J.P. Masson, P.L., Lauwerys, R.
"Characterization of the proteinuria in cadmium exposed workers" Int. Arch. Occup. Environ.
Health 38 (1976) 19.
[33] Kawada, T., Kayama, H. and Suzuki, S. "Cadmium, NAG activity and ß2-microglobulin in
the urine of cadmium pigment workers" Brit. J. Ind. Med. 46 (1989) 52.
MITROCHONDRIAL DAMAGE [34]
SKIP DIAGRAM
The nephrotoxic metal ion, Cd2+, causes
mitochondrial damage and apoptosis of kidney
proximal tubular cells.
[34] Wing-Kee Lee, Malte Spielmann, Ulrich Bork and Frank Thèvenod, “ Cd2+-induced
swelling-contraction dynamics in isolated kidney cortex mitochondria: role of Ca2+ uniporter,
K+ cycling and protonmotive force”, American Journal of Physiology: Cell Physiology, 289
(2005) C656-C664.
SUBSTITUTION OF Cd2+ FOR Zn2+ IN
Zn2+-CONTAINING ENZYMES
In a variety of metalloenzymes, the active site contains a
catalytically-essential, tetra-coordinated Zn2+ ions.
Three of the ligands to the metal ion are provided by amino
acid side chains, generally in distorted geometrical
relationships, while a water molecule serves as the fourth
ligand.
Chief examples of such enzymes are carboxypeptidase A,
thermolysin, carbonic anhydrase, alcohol dehydrogenase and
alkaline phosphatase.
•The male farmers usually drink excessive amounts of illicit
alcohol! The water used to dilute spirit may contain anything.
Hint for male patients? They work hard under hot sun.
•Dehydration results in concentration of species present in
blood. Alcohol consumption further aggravates dehydration.
•Cadmium ions, if ingested, can replace the Zn2+ in alcohol
dehydrogenase and thereby can affect detoxification
mechanism of toxic ethanol from the liver.
•Cadmium ions bound to alcohol dehydrogenase can go to
kidneys and damage them.
•Alcohol taking farmers who have got Cd2+ through food
and/or drinking water are more susceptible to several
illnesses including kidney damage.
•Besides, male farmers are the people who spray toxic
chemicals to paddy fields without having protective clothing
and face masks.
ANALYSIS OF Cd2+-INDUCED RENAL
TUBULAR DAMAGE
Several proteins including retinol binding protein
and NAG have been suggested as markers for
proteinuria, but ß-2-microglobulin in urine appears
to be the most widely used and best characterized
analyte to evaluate cadmium-induced renal tubular
damage [35].
[35] U.S. Department of Labor OSHA, 29 CFR Parts 1910, 1915, 1920
"Occupational Exposure to Cadmium; Final Rules" Federal Register vol. 57, no.
178, Monday, September 14, 1992, Rules and Regulations.
FOURTH HYPOTHESIS-CYANOBACTERIA
By Dhammika M. Dissanayake et al.
SKIP DESCRIPTIPON
Cyanobacteria also known as Cyanophyta, is aphylum of bacteria that obtain their
energy through photosynthesis.
They release O2 to the atmosphere an hence they have changed the early reducing
atmosphere into oxidizing atmosphere for other biological species to evolve.
FACTS ABOUT CYANOBACTERIA: SKIP
• Aquatic cyanobacteria are known for their extensive
and highly visible blooms that can form in
both freshwater and marine environments.
• The blooms can have the appearance of blue-green
paint or scum.
• These blooms can be toxic, and frequently lead to the
closure of recreational waters when spotted.
• Marine bacteriophages are significant parasites of
unicellular marine cyanobacteria.
WHAT CYANOBACTERIA BLOOMS
LOOK LIKE: SKIP
• Look like foams, scum or mats of the surface of
fresh water lakes and ponds.
• The blooms are blue, bright green, brown or red.
• They may look like paint floating on water.
• As algae in cyanobacterial blooms die, the water
may smell bad.
CYANOTOXINS SKIP
• Some cyanobacteria produce toxins,
called cyanotoxins.
• Among cyanotoxins are some of the most powerful
natural poisons known, including poisons which can
cause rapid death by respiratory failure.
• The toxins include
potent neurotoxins,hepatotoxins, cytotoxins,
and endotoxins.
Nephrotoxicity of Cyanobacteria [36]
SKIP
• Nephrotoxic potential of laboratory cultures of freshwater
cyanobacterium (blue-green alga) Microcystis aeruginosa PCC
7806 (Pasteur Institute) has been assessed in male rats.
• The animals have been injected intraperitoneally with 0.5, 1.0 and
2.0 LD50 doses of lyophilized cell extract.
• Elevated plasma urea and creatinine levels have been
accompanied by decrease in protein and albumin levels, followed
by hematuria, proteinuria and bilirubinuria.
• Also decrease in kidney lactate dehydrogenase and glutamic
oxaloacetic transaminase indicated possible nephrotoxic potential
of the cyanobacteria.
• The extract also produced various hematological changes
associated with stagnant type of hypoxia (Deprived of adequate O2
supply).
[36] Bhattacharya R, Sugendran K, Dangi RS, Rao PV, “Toxicity evaluation of freshwater
cyanobacterium Microcystis aeruginosa PCC 7806: II. Nephrotoxicity in rats.”,
Biomedical and environmental sciences : BES 10:1 1997 Mar pg 93-101.
FURTHER STUDIES ON CYANOBACTERIAL
TOXICITY TO KIDNEYS SKIP
• Some results suggest that kidney impairment from
chronic exposure of toxic cyanobacterial blooms
might be the first step, and then followed by
hepatic failure [37].
• Studies are also underway at the Institute of
Fundamental Studies. Group Leader is D. N.
Magana-Arachchi.
[37] Qiu T, Xie P, Li L, Guo L, Zhang D, Zhou Q, “Nephrotoxic effects from chronic toxic
cyanobacterial blooms in fishes with different trophic levels in a large Chinese lake.”,
Environmental Toxicological Pharmacology, 33 (2012) 252-261.
THE CYANOBACTERIAL TOXINS: A HIDDEN HEALTH
HAZARD: By Dhammika M. Dissanayake [38]
• According to their ongoing research studies, it is substantiated that toxins
produced by the cyanobacteria may have a role in the pathogenesis of
CKDu in Sri Lanka.
• Further, they have found that the cyanobacterial toxins could be the
causative agents for the nephropathy in Balkan countries because there
are very close similarities between Balkan Nephropathy and CKDu in Sri
Lanka.
• Environmental factors such as global warming and admixing of Nitrogen,
Phosphate and Potassium of chemical fertilizers with run off water
provide a favorable ecological background for the blooming and toxin
production of cyanobacteria.
• The management of patients with renal disease is expensive and need
long term care.
• This is an unbearable burden to the economy of the country.
As such , short-term and long -term preventive strategies like introduction of new water
sources, measures to control the usage of chemical fertilizers and control of global
warming are mandatory to alleviate the disease in addition to early detection.
THIS IS A GOLDEN SUGGESTION!!!!
SKIP
BALTIC CDK [39]
Fluoride in Drinking Water is
Less.
Fluoride is added to salt .
Fluoride is added to drinking
water.
Balken Nephropathy affects only
certain endemic rural foci along
tributaries of the Dangue River
in Balken Countries of Bosnia,
Bulgaria, Croatia, Rumania and
Serbia [39].
IS IT GENETIC DISEASE THEN?
[39] G. Bomias and J. Boletis, “Balken
Nephropsthy, Evolution of Our
Knowledge, American Journal of
Kidney Disease, 52 (2008) 606-616.
CYANOBACTERIA WORLD MAP
OBJECTIONS FOR CYANOBACTERIA
AND SRI LANKAN CKDu
• Apparently, these farmers drink dug well (92%) and
tube well (8%) waters [40].
• The cyanobacteria levels in these waters are marginal
[41].
[40] Priyani paranagama, “Potential Link between Ground Water Hardness, Arsenic and Prevalence of
CKDu”, http://nas-srilanka.org/wp-content/uploads/2013/08/Session-3-Priyani-Paranagama.pdf.
[Not a standard peer reviewed journal reference.]
[41] CKDu and Arsenic by the Arsenic Group [Not a Standard Journal Article]
COULD NOT FIND RELIABLE STANDARD JOURNAL
ARTICLES!
PLEASE SEE LATER: THIS DUG AND TUBE WELL WATERS
CAN NOT HAVE GLYPHOSATE ALSO. THIS GOES
AGAINST THEIR GLYPHOSATE HYPOTHESIS.
FIFTH HYPOTHESIS-ARSENIC SPECIS
GROUP OF RESEARCHERS: “THE ARSENIC GROUP”
From Kelaniya and Rajarata Universities and Government Hospitals
• Professor Nalin de Silva (Mathematician)
• Professor Priyani Paranagama (Organic Chemist)
• Professor Mala Amarasinghe (Botanist)
• Dr. Kithsiri Senanayake (MBBS)
• Dr. Kumudu Dissanayake (MBBS)
SKIP
• Dr. Channa Jayasumana (MBBS)
READING
• Dr. Chinthaka Wijayawardhana (MBBS)
• Dr. P. Mahamithawa (MBBS)
NAMES
• Dr. L. Rajakaruna (MBBS)
• Dr. D. Samarasinghe (MBBS)
• Mr. S. Fonseka (University of Kelaniya)
LITTLE BIT OF ARSENIC CHEMISTRY
Compounds of Arsenic exists in four Oxidation States; +5, +3, 0 and -3.
• As is not a true metal. It is a metalloid.
• In water, +3 and +5 Oxidation States DO NOT EXIST as As3+ and As5+
bare cations [That is why we write them as As(III) and As(V)] but they
exist as oxyanions: arsenite (AsO33- or AsO2-) and arsenate (AsO43-).
• As such, Arsenic does not form coordination complexes as other
cations do since As does not exist as a cation.
• Arsenes can act as ligands and can donate electrons to metal ions.
• Compounds of Arsenic are Covalent rather than Ionic.
• Arsenite salts are more soluble in water than arsenate salts.
• Solubility of Ca3(AsO4)2 in water is 0.13 g L-1 at 25 °C.
• Ca3(AsO4)2 is soluble in acids. If ingested, can dissolve in the liver.
• Ca3(AsO3)2 is soluble in water.
CKDu AND ARSENIC
This group says:
• CKDu is NOT associated with known risk factors of CKD such
as diabetes, hypertension and glorulonephritis.
• Clinically, the disease is associated with β-2microglobulinuria.
• High levels of β-2-microglobulinuria is a feature of arsenic
induced nephrotoxicity [43]. PLEASE SEE THE REFERENCE
PROVIDED!
[43] F. Homg, T. Jin, A. Zhan, “Risk Assessment on Renal Dysfunction caused by Co-exposure to Arsenic
and Cadmium using Benchmark Calculation in Chinese Population”, BioMetals ,17 (2004) 573-580.
All other articles in the same journal, same volume, are about β-2-microglobulinuria as a feature of
Cd2+-induced nephrotoxicity [44].
[44] George Kazantzis, “Cadmium, Osteoporosis and calcium metabolism”, BioMetals, 17 (2004)
493-498.
Several other papers are about Cd2+ poisoning, kidney dysfunction and β-2-microglobulinuria . We
have described this previously [35]!
THERE ARE OTHER CAUSES ALSO SKIP
[45]
Rodriguez J, Cortes J, Talpaz M, et al: Serum
β-2-microglobulin levels are a significant
prognostic factor in Philadelphia chromosomepositive chronic myelogenous leukemia. Clinical
Cancer Research 6 (2000) 147-152. Available
from URL:
http://clincancerres.aacrjournals.org/cgi/content/
full/6/1/147. As accessed February 10, 2005.
[46] Henry JB: Clinical Diagnosis and
Management by Laboratory Methods, 20th ed.
Saunders,
HYPER-PIGMENTATION AND
KERATOSIS
• Photographs of patients Palms and Soles with hyperpigmentation and keratosis are provided in an undated
report.
• Photographs of the Full Bodies of the Patients are NOT
provided.
• Dassanayake et al. have stated that arsenic-related skin
changes were seen in 30 patients but they are NOT CKDu
patients [47, 48].
[47] Noble, A.; Amerasinghe, P.; Manthrithilake, H.; Arasalingam, S. 2014. Review of literature on chronic
kidney disease of unknown etiology (CKDu) in Sri Lanka. Colombo, Sri Lanka: International Water
Management Institute (IWMI). 41p. (IWMI Working Paper 158). doi: 10.5337/2014.206
[48] C. B. Dassanayake, S. Rajeewa Hulangamuwa and D.T.D.J. Abeysekara, “Arsenic-related Skin Manifestations
in Patients with CKDu in the NCP of Sri Lanka, The Ceylon Medical Journal, Sri Lanka Medical Association, 57
(2012) Supplement 1.
JAYASUMANA et al.’s RESULTS [38, 40] SKIP
Dermal Manifestation
No. of
Patients
% of Patients
No. of
Individuals in
the Control
Group
%of
Individuals in
the Control
Group
Hyper-pigmentation of palms
68
54.9
34
18.8
Hyper-pigmentation of soles
49
39.2
26
14.4
Keratosis of palms
29
23.2
19
10.5
Keratosis of soles
22
17.6
15
8.3
POOR RSEARCH PRESENTATION: AGE GROUPS OF PATIENTS AND OF CONTROL INDIVIDUALS
ARE NOT GIVEN MAKING THE COMPARISON DIFFICULT IN A CHRONIC CASE!
[49] Noble, A.; Amerasinghe, P.; Manthrithilake, H.; Arasalingam, S. 2014. Review of literature on
chronic kidney disease of unknown etiology (CKDu) in Sri Lanka. Colombo, Sri Lanka:
International Water Management Institute (IWMI). 41p. (IWMI Working Paper 158). doi:
10.5337/2014.206.
[50] M.A.C.S Jayasumana., P.A.Paranagama, M.D. Amarasinghe, K.M.R.C. Wijayawardena, K.S.
Dahanayake, S.I. Fonseka, K.D.L.M.P. Rajakaruna, A.M.P. Mahamithawa, U.D. Samarasinghe and
V.K. Senanayake, “ Possible Link of Chronic Arsenic Toxicity with Chronic Kidney Disease of
Unknown Etiology in Sri Lanka.”, J. Natural Science Research, 3 (2013) 64-73.
DERMATALOGISTS VIEW
FROM THE RESULTS OF CKDu PATIENTS DIAGNOSED,
THERE ARE NO EVIDENCE TO INDICATE THE
PRESENCE OF PIGMENTATION AND KERATOSIS ON
THE SKIN. NO EVIDENCE FOR MEES’ LINES THAT ARE
COMMON TO PERSONS SUFFERING FROM ARSENIC
TOXICITY [49].
MEES’ LINES
[49] Noble, A.; Amerasinghe, P.; Manthrithilake, H.; Arasalingam, S. 2014. Review of
literature on chronic kidney disease of unknown etiology (CKDu) in Sri Lanka. Colombo,
Sri Lanka: International Water Management Institute (IWMI). 41p. (IWMI Working Paper
158). doi: 10.5337/2014.206.
MECHANISM OF CELL DEATH
PROPOSED BY THE ARSENIC GROUP
• Binding of Ca3(AsO4)2 to arsenic transporters in the liver and transport to
the kidneys. What are these transporters? Metallothinine is to transport
Zn2+ but Cd2+ interferes strongly. Arsenate or arsenite can not bind to
metallothionines.
• Deposition of Ca3(AsO4)2 crystals in the kidney tissues.
• Release of arsenate groups. This is an ionic compound. Release should
depend on water solubility. This compound is NOT water soluble.
• Replacement of Phosphate Groups by Arsenate Groups and DNA Damage.
THESE ARE ONLY SPECULATIONS WITHOUT ADEQUATE DATA OR LITERATURE
SUPPORT! SOME ARE THERMODYNAMIC IMPOSSIBILITIES!
Replacement of PO43- by AsO43- in DNA is thermodynamically forbidden and
hence can not take place. DNA does not contain arsenic as an element even
in “Arsenic Loving Bacteria” found in the California lake.
SKIP
Chronic inhalation exposure to elevated levels of inorganic
arsenic in humans is associated with irritation of the skin and
mucous membranes (dermatitis, conjunctivitis, pharyngitis,
and rhinitis).
Chronic oral exposure to elevated levels of inorganic arsenic
in humans has resulted in gastrointestinal effects, anemia,
peripheral neuropathy, skin lesions, hyperpigmentation,
gangrene of the extremities, vascular lesions, and liver or
kidney damage.
Some recent studies have reported an association between
elevated arsenic levels in drinking water and neurocognitive
or behavioral test results in school age children.
SKIP
Ingestion of inorganic arsenic in humans has been associated
with an increased risk of nonmelanoma skin cancer and also
to an increased risk of bladder, liver and lung cancer.
The Reference Dose (RfD) for inorganic arsenic is 0.0003
mg/kg/day (i.e. 0.0003 ppm per day, very low, it is such a bad
poison!) based on hyperpigmentation, keratosis, and possible
vascular complications in humans.
The RfD is an estimate (with uncertainty spanning perhaps an
order of magnitude) of a daily oral exposure to the human
population (including sensitive subgroups) that is likely to be
without appreciable risk of deleterious noncancerous effects
during a lifetime.
SKIP
Arsenic-containing pesticides may still be found in some U.S.
farms and homes [ATSDR 2007].
Gallium arsenide is used in integral components of discrete
microwave devices, lasers, light-emitting diodes,
photoelectric chemical cells, and semiconductor devices.
Other industrial processes that use arsenic include coal-fired
power plants, hardening metal alloys, and purifying industrial
gases (removal of sulfur).
Inorganic arsenic is found in industry, in copper chromated
arsenate treated lumber, and in private well water in some
parts of the USA.
ARSENIC IN FOOD
SKIP
Seafood (especially bivalves [clams, oysters, scallops,
mussels], crustaceans [crabs, lobsters], and certain cold water
and bottom feeding finfish, and seaweed/kelp.
The organic forms of arsenic found in seafood (mainly
arsenobetaine and arsenocholine, also referred to as “fish
arsenic”) are generally considered to be nontoxic, and are
excreted in urine within 48 hours of ingestion [ATSDR 2007].
However, inorganic forms of arsenic have been found in some
types of seaweed.
Recent literature suggests hijiki seaweed has very high levels
of inorganic arsenic (MMA) [Rose et al. 2007].
SKIP
Lead Arsenate Pesticides
Both lead and arsenic can be toxic at high concentrations in
soils.
Lead: Preventing lead exposure in infants and young children
is important because lead can affect their developing brain
and nervous system. High levels of lead can adversely affect
the nervous system and kidneys of adults and children.
Lead hydrogen arsenate, also called lead arsenate, acid lead
arsenate or LA, chemical formula PbHAsO4, is an
inorganic insecticide used primarily against the potato beetle.
Arsenobetaine
or fish arsenic
Country
2012 As2O3 Production
Belgium
1,000 T
Chile
10,000 T
China
25,000 T
Morocco
6,000 T
Russia
1,500 T
Other
300 T
Countries
World
Total
44,000 T
Much of the production is for the
semiconductor industry, Beware of Cell
Phone DANGER!! LEDs etc.
INORGANIC ARSENIC SPECIS ARE HIGHLY TOXIC
SKIP
There is much debate on Napoleon's death, whether he was poisoned
by arsenic-tainted wine during his exile on the Island of St. Helena.
More than 20 Arsenic Species are present in the Natural Environment
and Biological Systems.
Although the trivalent arsenic species, such as inorganic arsenite (AsIII),
monomethylarsonous acid (MMAIII), and dimethylarsinous acid
(DMAIII) are highly toxic, arsenobetaine (AsB), the predominant arsenic
species present in most crustaceans, is essentially non-toxic [51].
[51] X. Chris Lee, “Arsenic Exposure, Metabolism and Health Effects”, Home Page: Analytical and
Environmental Toxicology, Department of Laboratory Medicine and Pathology, University of
Alberta
ARSENIC METABOLISM [52] SKIP
Biomethylation was thought to be
a detoxification mechanism of
arsenic species. However, these
organoarsene compounds are
soluble in fat and in blood serum.
Biomethylation in the liver is the main mechanism for the metabolism of inorganic
arsenic. It involves alternate steps of two-electron reduction followed by oxidative
addition of a methyl group.
[ 52] http://www.ualberta.ca/~xcle/arsenic.html
ARSENIC SPECIES ARE BOTH HEPATOTOXIC AND
NEPHROTOXIC [53]
OXIDATIVE STRESS
AsO2-(aq) + 2H2O(l) + O2(aq) → AsO43-(aq) + H2O2(aq)
+ 2H+(aq)
H2O2 → 2OH. Catalyzed by Fe(II), Mn(II) or Cd2+ ROS
ARSENIC SPECIES ARE MORE HEPATOTOXIC
THAN NEPHROTOXIC.
[ 53] A.P. Singh, R.K. Goel and T. Kaur, “Mechanisms Pertaining to Arsenic Toxicity”, Toxicology
International, (2011).
GLYPHOSATE AND CKDu
• Glyphosate (N-(phosphonomethyl)glycine) is a broadspectrum systemic herbicide used to kill weeds, especially
annual broadleaf weeds and grasses known to compete
with commercial crops grown around the globe.
• It
was
discovered
to
be
a
herbicide
by
Monsanto chemist John E. Franz in 1970. SKIP
• Monsanto brought it to market in the 1970s under the
trade name "Roundup", and Monsanto's last commercially
relevant United States patent expired in 2000.
In alkaline conditions this exists as an anion.
GLYPHOSATE ACTION SKIP
Glyphosate kills plants by interfering with the synthesis of
the aromatic amino acids phenylalanine, tyrosine and tryptophan.
It does this by inhibiting the enzyme 5-enolpyruvylshikimate-3phosphate synthatase (EPSPS), which catalyzes the reaction
of shikimate-3-phosphate (S3P) and phosphoenolpyruvate to form 5enolpyruvyl-shikimate-3-phosphate (ESP) [55].
[55] H.C. Steinrücken, N. Amrhein , "The herbicide glyphosate is a potent inhibitor of 5enolpyruvyl-shikimic acid-3-phosphate synthase“, Biochemistry and Biophysics Research
Communications, 94 (1980) 1207–1212.
[56] Image : http://en.wikipedia.org/wiki/Glyphosate
BREAKDOWN MECHANISMS OF GLYPHOSATE [57]
[57] J.P. Giesy, S. Dobson and K. R. Solomon, "Ecotoxicological Risk Assessment for Roundup®
Herbicide“, Reviews of Environmental Contamination and Toxicology,167 (2000) 35–120.
[58] Image: http://en.wikipedia.org/wiki/Glyphosate
ENVIRONMENTAL FATE OF
GLYPHOSATE [59 ]
• Glyphosate adsorbs to soil down to 6 inches of soil layer.
• Readily degraded by microbes to aminomethylphosphonic
acid and carbon dioxide.
• Glyphosate and residues can not contaminate ground water
because they do not move that down due to adsorption by
surface soil. The Arsenic Group says that these patients
drink/drank well waters {92% Dug Wells and 8% Tube Wells!}.
• Can contaminate with surface waters.
• The half-life of glyphosate in soil ranges between 2 and 197
days; a typical field half-life of 47 days has been suggested.
• The median half-life of glyphosate in water varies from a few
days to 91 days.
[ 59] National Pesticide Information Center npic@ace.orst.edu
COORDINATION CHEMISTRY OF GLYPHOSATE [60-64]
SKIP
• With divalent metal ions such as Cu2+, Zn2+, Mn2+, Ca2+ and Mg2+, 1:1
adducts have been reported [60].
• Further study revealed the possibility for glyphosate to form 1:1 and 2:1
metal complexes with divalent alkaline earth and transition metal cations
and with trivalent cations [61].
• Bis(glyphosate)metal(III) complexes have been reported. [63-64]
• Crystal structures were elucidated for 1:1 Ca2+ and 1:1 Cu(II) complexes
and shown them to be polymeric [65].
•
•
•
•
•
[60] Daniel Heineke, Jonya J. Franklin and Kinneth N. Raymond, “Coordination Chemistry of
Glyphosate, Structural and Spectroscopic Characterization of Bis(glyphosate)metal(III) complexes”,
Inorganic c Chemistry , 33 (1994) 2413-2421.
[61] H.E.L. Madsen, H.-H. Christensen and C. Gottlieb-Peterson, Chimica Scandinavia, Section A,
(1978) A 32, 79.
[62] R.J. Motekaitis and A.E. Martel, J. Coordination Chemistry, 14 (1985) 139.
[63] P.H. Smith and K.N. Raymond, Inorganic Chemistry, 27 (1998) 1056.
[64] P.R. Rudolf, E.T. Clarke, A.E. Martel and A. Clearfield, Inorganica Chimica Acta, 164 (1989) 58.
GLYPHOSATE AND CADMIUM
• Glyphosate reacts with Cd2+ forming water soluble
complexes [65].
• Cd2+ adsorbed on soil binds glyphosate through
complexation [65].
[65] D.M. Zhou, Y.J. Wang, L. Chang, X.S. Hao and X.S. Luo, “Adsorption and cosorption of
cadmium glyphosate on two soils with different characteristics, Chemosphere”, 57 (2004)
1237-1244.
• Solid phase Cd9(Glyphosate)6(H2O)10.6H2O crystals have
been synthesized and their crystal structure has been
determined. [66]
[66] Medeleine Ranstedt, Caroline Norgren, Julia Sheals, Dan Bostöm, Steffan Sjöberg and
Per Persson, “Thermodynsmic and Spectroscopic Studies of Cadmium(II)N(Phosphomethyl)glycene Complexes”, Inorganica Chimica Acta, 357 (2004) 1185-1189.
GLYPHOSATE AND ARSENIC
• THERE IS AN OPEN ACESS JOURNAL PAPER.
[67] Channa Jayasumana, Sarath Gunathilaka
and
Priyantha Senanayake, “Glyphosate, Hard Water and
Nephrotoxic Metals: Are They the Culprits Behind the
Epidemic of Chronic Kidney Disease of Sri Lanka?”,
International Journal of Environmental Research and Public
Health, 11 (2014) 2125-2147.
This Glyphosate scandal came out due to THIS paper [67]!
They talk about glyphosate-divalent and trivalent metal
complexes. The reference given is a DFT Computer Simulation
Study. Only theoretical possibilities [68].
IMPORTANT POINT IS THAT “None of these complexes have
arsenic even as arsenate. I have the paper. You know that
arsenic does not form complexes by behaving as a metal ion.
Replacement of phosphate by arsenate is not possible either!
[68] Caetano, M.; Ramalho, T.; Botrel, D.; da Cunha, E.; de
Mello, W., “Understanding the inactivation process of
organophosphorus herbicides: A DFT study of glyphosate
metallic complexes with Zn2+, Ca2+, Mg2+, Cu2+, Co3+, Fe3+, Cr3+,
and Al3+.”, International Journal of Quantum Chemistry, 112
(2012) 2752–2762.
I have requested Dr. Udayanga Ranatunga to do the
DFT study on possible complexes of metal ions,
arsenic and glyphosate.
Even if theoretically predicted, that does not mean
that the compounds are practically synthesizable.
SKIP
Other reference quoted for glyphosate-arsenic
polymeric complex is
http://www.abcplus.biz/Images/Catalogs/GRP%
20for%20Dogs%20Booklet%20PD1312-2.pdf
THIS IS A BUSINESS REPORT ON ORGANIC DOG
FOODS. AN ADVERTISEMENT!
The polymeric complex in [67] is not contained
in this pdf as well!
AS A CHEMIST’s POINT OF VIEW!
At high pH, Glyphosate exists as anion with carboxylate and phosphate groups.
Arsenate and Arsenite are also an anions. Naturally, they have no affinity to
each other.
In the high acidic environment of the liver, glyphosate carboxyl group and the
phosphate group can get protonated. Arsenate or arsenite also get protonated.
Some hydrogen bonding between them are possible in the liver.
However, blood has almost neutral pH [pH = 7.4, tightly regulated between
7.35 and 7.45]. These hydrogen bonds are not stable then.
So, I DO NOT understand how glyphosate is carryings arsenic species from liver
to kidneys.
Glyphosate can carry Cd2+ by forming coordination complexes with
metallothionines.
However, glyphosate can make better coordination complexes with other
metal ions such as Zn2+, Mn2+, Co3+, Fe(II) and Fe(III) which are present in
relatively higher concentrations when compared to that of Cd2+ in human
body.
Therefore, glyphosate can induce essential metal ion deficiencies. It can be
IONIC STRENGTH THEORY
• Theory of Dharma-wardana et al. [68].
• Increased ionicity due to all ionic species present in drinking water collectively
responsible for denaturing of proteins of the kidneys through a Hofmeistertype mechanism is predicted.
Hofmeister series:
Cations: NH4+ > K+ > Na+ > Mg2+ > Ca2+
Anions F- > H2PO4- > or = SO42- > HCO3- > Cl- > NO3• Matches very well with existing data on drinking water quality.
• Fertilizer runoff through accelerated Mahaweli Programme has increased Nand P-containing ions.
• Increased drought conditions prevailing in these areas increase the
concentration of everything dissolved in drinking water..
• Dehydration increases the ionic strength in blood. Alcohol consumption can
aggravate the problem.
• This could be substantiated with increased concentrations of nephrotoxic metal
ions in blood.
•
[68] M.W.L. Dharma-wardhana, Sarath L. Amarasiri, Nande Dharmawardana and
C.R.Panabokke, “Chronic Kidney Disease of Unknown aetiology and ground-water ionicity,
study based on Sri Lanka”, Environmental Geochemistry and Health(2014); http://dhweb.org/place.names/posts/#ckduEGH1
BETTER AVOID SYNTHETIC FERTILIZERS AND
AGROCHEMICALS, ANYWAY!
• Whether they contribute to CKDu or not, they are poisons.
• It is indeed better to avoid them, if possible.
• Organic farming is good but the yields are less. Better to
cultivate increased amounts.
• Cost of organically grown food stuffs are high though there is
no certificate that these were grown without agrochemicals.
• Weed picking by hands as the way it was done in the past is
NOT practical now.
• Feeding 21 million population in this country is also a prime
concern or they will die due to starvation.
• If possible, better to grow vegetables and fruits in your own
garden!
RENAL DIALYSIS
A Patient Receiving Dialysis
A process for removing waste and excess water from the blood.
Used as an artificial replacement for lost kidney function in people with renal failure.
The kidneys have important roles in maintaining health.
When healthy, the kidneys maintain the body's internal equilibrium of water and minerals
(sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate).
The kidneys also function as a part of the endocrine system,
producing erythropoietin and calcitriol.
Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in bone
formation.
Dialysis is an imperfect treatment to replace kidney function because it does not correct the
compromised endocrine functions of the kidney.
Diffusion through concentration gradient and ultrafiltration are the principles involved. Semi permeable membrane with different pore sizes is used. http://en.wikipedia.org/wiki/Dialysis
ROLE OF NANOTECHNOLOGY IN
RENAL SUBSTITUTION THERAPY
• Two Membranes called G Membrane and T Membrane.
• G membrane resembles the function of the glomerular basement membrane.
• G Membrane is a fully porous membrane which removes solute up to the
molecular weight of albumin.
• Ultra-filtrate passing through the G Membrane passes through the T Membrane.
• T Membrane is meant to emulate the tubular membrane in the renal tubules.
• T membrane will reabsorb all of those substances we want to retain, some sodium,
some potassium, calcium, a little bit of phosphorous, and so on.
• T Membrane is Nano-technologically Developed Membrane with very small pores ~
1 nm length and the distance between pores is 1 – 5 nm.
Dean G. Johnsonemail, Tejas S. Khire, Yekaterina L. Lyubarskaya, Karl J.P. Smith, JonPaul S. DesOrmeaux, Jeremy G. Taylor, Thomas R. Gaborski, Alexander A.
Shestopalov, Christopher C. Striemer, James L. McGrath, ‘Ultrathin Silicon
Membranes for Wearable Dialysis”, Advances in Chronic Kidney Disease, 20 (2013)
508-515.
DEVELOPING IMPLANTABLE ARTIFICIAL
KIDNEYS
[70] http://www.contracostatimes.com/ci_23098516/artificial-kidney-offers-hope-patientstethered-dialysis-machine
REGENARATIVE MEDICINE
• Current trend in Medical Research as an Alternative
to Transplants.
• Recently, some heart cells of a monkey have been
removed and human stem cells injected.
• After two weeks, monkey’s heart began to beat by
regenerating it with human stem cells [71, 72].
[71] “Stem cell therapy regenerates heart muscle damaged from heart attacks in primates”,
Science Daily, April 30, 2014.
[72] Charles Murry et al., "Human embryonic-stem cell derived cardiomyocytes regenerate
non-human primate hearts." Nature, April 30, 2014, Advanced Online Edition.
MONKEY HEART REPAIRED
This image shows an implanted graft of cardiac cells derived from human stem cells (green)
meshed and beat with primates' heart cells (red).Credit: Murry Lab/University of Washington
[73] Murry et al., April 30, 2014, Advanced Online Edition of the Journal Nature in a Paper
Titled, "Human Embryonic-Stem Cell Derived Cardiomyocytes Regenerate Non-human Primate
Hearts."
SKIP
Charles E. Murry
Joint Professor of Pathology, Cardiology, and
Bioengineering
murry@u.washington.edu
Phone: (206)616-8685
South Lake Union campus:
Office: 850 Republican St. Rm 453
RESEARCH INTERESTS
Myocardial infarction
Stem cells
Tissue repair and regeneration
Tissue engineering
Angiogenesis
STEM CELL-BASED KIDNEY REPAIR
• The Harvard Stem Cell Institute is developing new
therapies to repair kidney damage, reducing the need
for dialysis and transplantation.
• The Harvard Stem Cell Institute (HSCI) Kidney Group
has short, medium, and long-term strategies to develop
new therapies for diabetes-related kidney damage
(diabetic nephropathy).
• This multi-pronged approach aims to capitalize on
promising translational achievements in the near
future, while pursing potential drugs and the ultimate
goal of creating an entirely artificial kidney using stem
cells.
• HSCI Kidney Program Leader is Professor Benjamin
Humphreys, MD, PhD.
STEM CELL-BASED KIDNEY REGENERATION
[74] S. Yokote and T. Yokoo, “Stem cells in kidney regeneration”, Current
Medicinal Chemistry, 19 (2012) 6009-6017.
[75] Brian A. Yeagy & Stephanie Cherqui , “Kidney repair and stem
cells: a complex and controversial process”, Review, Pediatric
Nephrology
DOI 10.1007/s00467-011-1789-x, Published Online 19 February, 2011.
Kidney grown from stem cells by Australian scientists
Australian scientists grow world's first kidney from stem cells in a
breakthrough that could alleviate the demand for organ
transplants, Journal Nature Cell Biology,
"This is the first time anybody has managed to direct stem cells into the
functional units of a kidney," Professor Brandon Wainwright, from the
University of Queensland, told The Telegraph.
[76] Kidney disease: how could stem cells help? Last updated: 12 Aug
2013
SUMMARY
• CKDu is a serious epidemic in Sri Lanka.
• F- Hypothesis: HF can damage liver. Fluorosis prohibits bone’s
detoxification mechanism. F- can cause kidney damage.
• Fluoroaluminate complexes are toxic. Reports on Renal Failure are
available.
• Cd2+ is present in TSP fertilizers and in some weed killers. Cd2+ is a well
known nephrotoxic ion. Cd2+ is present in cigarette smokes.
• Arsenic species are poisons. Speculations are not scientific research.
• Metal ion-arsenate-glyphosate polymers have not been synthesized.
• No evidence to suggest connections between arsenic species and
glyphosate being responsible for CKDu.
• This does not mean that they are not toxic.
• It is very likely that increased concentrations of all the ions in the blood is
responsible for the denaturing of glomeruli proteins. Ions at the top of
Hofmeister series are more dangerous than other ions.
• Research on Implantable Kidneys is important.
• Regenerative Medicine may be a possible way to treat CKDu Patients.
However, it is still at the research level.