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Ground Water Quality Parameters in Relation to Chronic
Kidney Disease of Unknown Etiology (CKDu) in
“Monaragala” Sri Lanka
PROPOSAL FOR DISSERTATION STUDY

By
Under the Supervision of Eng.Charuni Wijerathne

May, 2015

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Contents

Chapter 01 Introduction ......................................................................................................................... 4

Purpose of the Sturdy ......................................................................................................................... 4
Aim ...................................................................................................................................................... 5
Dissertation Objectives ....................................................................................................................... 5
Hypothesis........................................................................................................................................... 5
Delimitations ....................................................................................................................................... 5
Limitations .......................................................................................................................................... 6
Chapter 2 Review of Literature ............................................................................................................... 6
CKDu in Sri Lanka ................................................................................................................................ 6
Distribution of causes of chronic kidney disease worldwide .............................................................. 6
CKDu Impact to health ........................................................................................................................ 8
Chapter 3 Methodology and Procedure ............................................................................................... 10
Research Design ................................................................................................................................ 10
Phase 01 (Quantitative) .................................................................................................................... 11
Data Collection .............................................................................................................................. 11
Data Analysis ................................................................................................................................. 12
Reliability and Validity................................................................................................................... 12
Phase 02 (Qualitative) ....................................................................................................................... 12
Data Collection .............................................................................................................................. 12
Data Analysis ................................................................................................................................. 13
Proposed Dissertation Content ......................................................................................................... 13
Dissertation Work Plan ..................................................................................................................... 14
Reference .............................................................................................................................................. 15

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Chapter 01 Introduction

Purpose of the Sturdy

The quality of water, what publics used for domestic purposes, drinking, or food making has a
significant impact on health. Poor quality water can origin numerous types of disease. Over the
last ten years or so a new system of kidney disease of unknown etiology has been stated in the
dry zone of Sri Lanka (wijerathne , et al., 2014).

This is also discussed to as Chronic Renal Failure (CRF) in some literature on this theme.
CKDu is not confined to Sri Lanka, but arises elsewhere globally, as an example India and
Central America. Occasionally this issues might not be arising due to one cause. It can be blend
of many factors. To date CKDu has been informed from the Central Province, Eastern Province,
North Central Province, Northern Province, North West Province, Southern Province,
Sabaragamuwa Province, Uva Province, and the Western Province. In certain areas 5% to 10%
of the population is affected and the disease is on highly growth. There were 18,000 incidents
of CKDu are stated ( Abeygunasekera & Wickremasinghe, 2013).

Etiology of this disease has since been recognised to a range of causes, counting presence of
the heavy metal cadmium in water that would potentially have presented to water from
inorganic fertilizer used in paddy fields, presence of excessive amounts of fluoride in drinking
water and prevalent use of low quality aluminum utensils, presence of toxins produced by
microorganisms such as cynobacteria in water (de Silva, n.d.) .

The contributing factors and etiology of this chronic kidney disease is still considered
indeterminate or unknown and abbreviated as CKDu with recommendations of the National
Research Programme for CKD of the Ministry of Health in Sri Lanka (de Silva, n.d.) . Endemic
occurrence of the disease was firstly recognized in the 1990s in certain areas of North Central
Province, and this has been on the increase histrionically over a period of 10-15 years.

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Aim

To determine water quality parameters which may cause to CKDu in Monaragala.

Dissertation Objectives

 Undertake a literature review of published information and journals related to CKDu.

 Critically analyse and evaluate the previous research water samples in different areas
in dry zone.
 Proceed the lab practical’s and questionnaire to evaluate and compare the results with
“Monaragala”
 Evaluate the water quality parameters related to CKDu in “Monaragala”.

Hypothesis

The reason for the CKDu in Monaragala can be combination of several water quality
parameters such as Fluoride, Heavy Metals, etc.

Delimitations

Delimitations of the sturdy includes,

 The sturdy will be confined only to the Monaragala Provincial area. There was
approximately 440,000 people lived in Uva Province. Therefore it is difficult to expand
the area.
 The sturdy will provide only ground water quality parameters which caused to CKDu.
It may not review other types of water sources.

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Limitations

Limitations of the sturdy includes,

 20 – 30 ground water samples may collect to this sturdy and evaluate the 5 – 8 water
quality parameters of each and every sample. Because of the instruments availability
and cost.
 Access to the people for questionnaire is a hard process in this area, therefore it will
limit for 30 – 40 replies.

Chapter 2 Review of Literature

CKDu in Sri Lanka

The quality of water, what publics used for domestic purposes, drinking, or food production,
presently has a significant impact on health. Poor quality of water can source for several
categories of health disease. Over the last ten years or so a new form of kidney disease of
unknown etiology has been reported in the dry zone of Sri Lanka ( Trust, 2013). The disease
is mostly prevalent in North Central Province, parts of North Western, Uva, Central, Eastern
and Northern provinces. In certain areas 5% to 10% of the population is affected and the disease
is on increase (Chandrajith, et al., 2012).

According to the WHO the prevalence is 12% to 15%. In Anuradhapura District alone 18,000
cases of CKDu are reported with over 200 deaths verified yearly (Abeygunasekera &
Wickremasinghe, 2014) as well as CKD is a growing world health issue. Unlike most other
trace elements, much of the fluoride entering the human body is obtained from water
(Dissanayake, 1991).

Distribution of causes of chronic kidney disease worldwide

This is also mentioned to as Chronic Renal Failure in some literature on this subject is more
prevalent among men, typically around the age of 40-60 years, involved in agriculture. In few

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literature on this topic has clearly mention about As and Cd which can be the main cause in
considerably. Many people who subjected to CKDu are farmers ( Trust, 2013).

Apart from the Sri Lanka CKDu may extremely affected to the all over the nations in the world.
Many international literature has mention it’s due to hypertension and diabetes (Vivekanand,
et al., 2013). There also unknown criteria in every country still people don’t have reason on it.
Below mention figure describes distribution of CKD in worldwide due to many reasons.

Figure 1Distribution of causes of chronic kidney disease worldwide

CGN=chronic glomerulonephritis. HT=hypertensive nephrosclerosis. CIN=chronic interstitial nephritis.

RVD=renovascular disease.

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According to above analysis diabetes causes in many countries at high level in to CKDu. But
significant issue is analysis clearly mention other & unknown section at considerably high
amount which still doesn’t know the particular reason. Therefore in worldwide many
researchers investigate to discover what the hidden factors which affect to CKDu.
El Salvador, Nauru, Somalia, Sudan, Fiji, and Angola etc, considered as high death rate in
world rankings due to this issue. Sri Lanka ranked as 71 which is having considerably high
death rate (WHO, 2011).
The Sri Lanka CKDu citations refer to cases linked to around 1,999 of patients receiving
treatment at Kandy and Anuradhapura General Hospitals. With the establishment of special
nephrology clinics and units within each of the aforementioned hospitals, an increasing style
in the diagnosis of the disease was observed (Noble, et al., 2014).

CKDu Impact to health

Figure 2 CKDu affected areas and Patient distribution

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Many Literature has clearly mentioned this impact due to Fluoride, Arsenic, Cadmium,
Aluminium, Hardness water, cyanobacterial toxins, bioaccumulation and pesticides etc. Apart
from these factors liquor, medication and few food types may also impact to this issue and as
well as long term usage of one of these factors may lead to affect (Johnson, et al., 2012).

High Fluoride intakes generates huge influence to human body. Mostly from tropical countries,
are vulnerable to dental and or skeletal fluorosis. While the essentiality of fluoride for human
health is still being debated, its toxicity has caused considerable concern in many countries
where fluoride is found in excessive quantities in drinking water.

Figure 3 A case of dental fluorosis

High fluoride in drinking water particularly in the Dry Zone of Sri Lanka, touches over 8
million people and is a serious matter. During the last two decades, most of the Dry Zone
people have shifted from surface water sources to groundwater resources and it is noted that
both shallow and deep wells indicate similar levels of natural contamination with fluoride
(Chandrajith, et al., 2012).

According to many literature, Arsenic and Cadmium can be found as a chief role to this issue
(Noble, et al., 2014). Over the past two decades, the rate of high levels of arsenic in drinking
water has been recognized as a important public health issue, which is global in extent. The
adverse health effects of arsenic depend strongly on the dose and duration of exposure. Specific
dermatological effects are characteristic of exposure to arsenic. Various food categories are

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having considerable amount of Cadmium. Long term intake of these food types may lead to
kidney disease (Johnson, et al., 2012). Cow milk, Lotus, Tilapia fish etc, may lead to Cadmium
intakes (Noble, et al., 2014).

Apart from above discussed findings such as snake bites, Ayurvedic medicines, consumption
of alcohol and a flotoxins also have been take placed in to this (Noble, et al., 2014). In many
studies of groundwater samples collected from areas identified as important for CKDu, Arsenic
& Cadmium levels were found to be normal. Furthermore, long term usage of these can be
directly impact to this issue and depend on human behavior. Most of the cases has been found
from the famers who are in mid age ( Trust, 2013).

Chapter 3 Methodology and Procedure

Research Design

This study will use a mixed method (Michael, et al., 2004) design, which is a procedure for
gathering, analyzing and mixing both quantitative and qualitative statistics at some stage of the
research procedure within a single study, to understand a research problem more completely.
When used in combination, quantitative and qualitative methods complement each other and
allow for more complete analysis (Michael, et al., 2004).
This study will proceed one of the most popular mixed methods designs in educational research,
sequential explanatory mixed methods design, consisting of two distinct phases (Creswell,
2002). In the first phase, the quantitative, numeric, data will be collected first, using lab
practical’s. The goal of the quantitative phase will be to identify potential analytical variables
of lab results. In the second phase, a qualitative multiple case study,questionnaire survey,field
work approach will be used to collect text data through individual questionnaire survey.

Primary Data

Data Collection

Secondary data

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Raw data Final Data

Statistical analysis

By using,

 Graphs
 Tables
 Curves
 Formulas

Phase 01 (Quantitative)

Data Collection

Before start the water quality testing procedure it is essential to identify the critical pockets
around Monaragala by using questionnaire survey. Proposed ground water collection method
is using wells around Monaragala. Prior to obtaining a water sample it is essential to create a
clean surface area onto which sampling equipment (bottles, cans etc.) can be positioned and
work can be performed.
Water level measurement will be complete by using an electronic water level detector.
Typically, all depth measurements should be made from top (the highest point) of the inner
well casing.
Place protective plastic material around monitoring well, attach line to a new or clean bottle
suitable for the diameter well-being sampled. Lower bailer slowly and gently into well and
wash bottle before collect water sample to test. Bottle need to wash from sample water itself.
Then collect the required amount of water in to the bottle and it should be labeled with relevant
data. Then water samples need to place in a cooler to ensuring that the bottles are in ice. Then
samples need to subject to the check the required water quality parameters.

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In this process includes duplicate & replicate techniques. Which is performing the analysis of
a sample twice to determine reproducibility. Also, two samples taken at the same time from
one location (wijerathne , 2015).

The percent difference is calculated by dividing the difference between the two results by their average
as follows (Association, 1999)

Percentage difference = (x - y) / ((x + y)/2) x 100%

Where x = result of first analysis

y = result of second analysis

Data Analysis

Before the statistical analysis of the quantitative survey results, the screening of the data will
be conducted on the univariate and multivariate levels. Because several water quality
parameters are interrelated with other parameters. During the analysis section it essential to
combine other primary data related to Monaragala which can clearly define the updated
situation. To analysis of data which obtain from the samples, tables, graphs, maps and other
useful software’s are essential to proceed.

Reliability and Validity

In quantitative research, reliability and validity of the instrument are very important for
decreasing errors that might arise from measurement problems in the research study. Reliability
refers to the accuracy and precision of a measurement procedure.

Phase 02 (Qualitative)

Data Collection

After pilot testing procedure finished next step should be proceed the questionnaire survey to
the people in Monaragala, Main focus should be gathered relevant data to identify the CKDu
patients. Therefore over 50 questionnaires planned to be distribute among the peoples, then by

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expecting minimum 30 questionnaires in return. Questionnaire may distribute with the help of
Provincial area head. Few simple questions may ask to answer with ordinary level of
knowledge. It will be giving during evening time and it will be taken back after two days. In
the evening time availability of peoples are high in the houses, therefore it is easy to instruct
them to how important this survey for Monaragala.

Data Analysis

Around 30 returned questionnaires, it can be divide for several sections which may easy to
analysis. The analysis is performed at two levels, within each case and across the cases.
Because main aspect is to determine distribution of CKDu patients as well as there should be
a relationship between water quality according to hypothesis. To analysis data graphs, tables,
and software’s can be used. When critically analyzing this will show the extent to which the
identified internal and external factors have similar or different effect on the study participants
as related to their academic persistence. From quantitative analysis it may critically revived
from qualitative method.

Proposed Dissertation Content

Chapter 1 – Introduction

Chapter 2 - Review of Literature

Chapter 3 – Analysis of the secondary data

Chapter 4 – Methodology and Procedure

Chapter 5 - Results and Discussion

Chapter 6 – Conclusion and Further Recommendations for further research

Chapter 7 - Reference

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Dissertation Work Plan

Date Task
02.04.2015 Finalise the research topic
03.04.2015 Start with literature review
26.04.2015 Finalise the literature review and discussed
with supervisor
26.04.2015 Start with research proposal
26.04.2015 Identify the limitations of the research
01.05.2015 Submit the research proposal
20.05.2015 Prepare the questionnaire
21.05.2015 Pilot test the questionnaire
02.06.2015 Visit to monaragala to collect data
04.06.2015 Start the lab testing
08.06.2015 Analysis of questionnaire data
01.07.2015 Discuss with supervisor
02.07.2015 Start dissertation report writing
30.07.2015 Discuss with supervisor

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Reference

Abeygunasekera, A. & Wickremasinghe, T., 2013. Short Term Measures to control Chronic Kidney
Disease of Uncertain, Colombo: Ministry of Water Supply & Drainage.

Trust, K., 2013. Providing Safe Drinking Water to CKDu affected areas, Homagama: Karuna Trust,.

Abeygunasekera, A. & Wickremasinghe, T., 2014. Short Term Measures to control Chronic Kidney
Disease of Uncertain Aetiology (CKDu), s.l.: Ministry of Water Supply & Drainage.

Association, A. W. W., 1999. Standard Methods for the Examination of Water and Wastewater.
s.l.:Water Environment Federation.

Chandrajith, R., Padmasiri, J., Dissanayake, C. & Prematilaka, K., 2012. Spatial distribution of fluoride
in groundwater of Sri Lanka, s.l.: Natn.Sci.Foundation Sri Lanka.

Creswell, j., 2002. Qualitative, Quantitative, and mixed. 2nd ed. s.l.:s.n.

de Silva, n., n.d. Chronic Kidney Disease of unknown etiology (CKDu) and Arsenic poisoning due to
Illegal pesticides, s.l.: s.n.

Dissanayake, C. B., 1991. The fluoride problem in the ground water of Sri Lanka-environmental
management and health , s.l.: International Journal of Environmental Studies.

Johnson, S., Misra, S., Sahu, R. & Saxena, P., 2012. Environmental contamination and its association
with Chronic Kidney Disease of Unknown Etiology in North Central Region of Sri Lanka, New Delhi:
CENTRE FOR SCIENCE AND ENVIRONMENT.

Michael, D., Nataliya, V. & John , W., 2004. Designing A Mixed Methods Study, Lincoln: Research,
University of Nebraska-Lincoln,.

Noble, A., Amerasinghe, P., Manthrithilake, H. & Arasalingam, S., 2014. Review of Literature on
Chronic Kidney Disease of Unknown Etiology (CKDu) in Sri Lanka, s.l.: IWMI.

Vivekanand, J. et al., 2013. Chronic kidney disease: global dimension and perspectives, online:
Postgraduate Institute of Medical Education and Research, Chandigarh, India.

WHO, 2011. world life expectency. [Online]

Available at: http://www.worldlifeexpectancy.com/cause-of-death/kidney-disease/by-country/

wijerathne , c., 2015. replication duplication techniques [Interview] (28 04 2015).

wijerathne , c., weragoda, s. & kawakami , t., 2014. A Review of Chronic Kidney Disease Due to
Unknown Etiology and Groundwater Quality in Dry Zone , Sri Lanka. International Journal of
Environmental Engineering, 1(4), pp. 1-3.

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