High water hardness associated with high water fluoride and the geographical distribution of Chronic Kidney Disease of unknown etiology (CKDu) in Sri Lanka are well correlated. We undertook this study to observe the effects of high water hardness with high fluoride on kidney and liver in rats and efficacy of distilled water in reducing the effects.
Test water sample with high water hardness and high fluoride was collected from Mihinthale region and normal water samples were collected from Kandy region. Twenty-four rats were randomly divided into 8 groups and water samples were introduced as follows as daily water supply. Four groups received normal water for 60 (N1) and 90 (N2) days and test water for 60 (T1) and 90 (T2) days. Other four groups received normal (N3) and test (T3) water for 60?days and followed by distilled water for additional 60?days and normal (N4) and test (T4) water for 90?days followed by distilled water for another 90?days. The rats were sacrificed following treatment. Serum samples were subjected to biochemical tests; serum creatinine, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and elemental analysis. Histopathological examinations were carried out using kidney and liver samples.
Test water treated groups were associated with acute tubular injury with loss of brush border and test water followed with distilled water treated groups maintained a better morphology with minimal loss of brush border. Serum creatinine levels in T1 and T2 groups and urea level in T2 group were significantly (p?<?0.05) increased compared to control groups. After administration of distilled water, both parameters were significantly reduced in T4 group (p <?0.05) compared to T2. Serum AST activity was increased in T4 group (p <?0.05) compared to control group with no histopathological changes in liver tissues. The serum sodium levels were found to be much higher compared to the other electrolytes in test groups.
Hard water with high fluoride content resulted in acute tubular injury with a significant increase in serum levels of creatinine, urea and AST activity. These alterations were minimized by administering distilled water.
Excerpt & References
Chronic kidney disease (CKD) is viewed as part of the rising worldwide non-communicable disease burden. Hypertension and diabetes mellitus are the important risk factors for this disease in all developed and many developing countries . In early nineties, there has been a rising incidence and prevalence of chronic renal failures that has emerged in the North Central region (NCR) of Sri Lanka where the disease is not associated with any known risk factors . Due to the elusive nature of the disease, it has been named “Chronic Kidney Disease of unknown etiology” (CKDu). Because of its slow progressive loss of kidney function, CKDu often gets worst slowly and remain undiagnosed over a long period of time .
Ground water source is considered as a causative factor for CKDu [4, 5]. The elevated levels of fluoride, which is defined as above 0.5?mg/L by the World Health Organization in groundwater sources is observed in CKDu endemic regions . Therefore, fluoride has received increased attention as a risk factor in the etiology of CKDu [7, 8]. Jayasumana et al (2014) and other groups reported that water hardness could contribute to the etiology of CKDu due to exceeding the levels of ideal water hardness of between 150 and 250?mg/L CaCO3 [9,10,11]. Moreover, the hydrogeochemical investigations in CKDu endemic areas revealed that both fluoride and hardness is elevated in all CKDu endemic regions .
Previous studies revealed that high concentrations of groundwater fluoride distributed in the dry zone, whereas minimal fluoride levels were reported in the wet zone (Fig. 1a). Further, Chandrajith et al. (2011), reported high fluoride levels from 1.3–5.3?ppm in CKDu endemic areas such as Girandurukotte, Nikawewa, Madawachchiya and Padaviya in Sri Lanka . These findings were further confirmed by the occurrence of clinically diagnosed dental and skeletal fluorosis in these areas [13, 14]. In contrast, CKDu occurrence was less even in the areas with high concentrations of groundwater fluoride such as Huruluwewa and Wellawaya .
The hardness of drinking water is mainly dependent on the concentration of dissolved cations namely, calcium and magnesium predominantly in combination with the anions, bicarbonate, sulphate and chloride . Other cations such as Al, Zn, Ba, Fe, Sr, and Mn have minor contribution for the total hardness of water [16, 17]. Increased total water hardness is common in northern and northern central parts of Sri Lanka (Fig. 1b). Jayasumana et al (2014), reported high water hardness (up to 820?mg/L) in CKDu endemic areas which showed a correlation with the prevalence of CKDu [3, 18]. But, unexpected low occurrence of CKDu was found in Jaffna and Puttalam districts even with reported higher water hardness (approximately 1500?mg/L) [19, 20].
When we overlapped the high fluoride areas with high water hardness areas surprisingly, the same areas were overlapped with the reported high occurrences of CKDu namely Medawachchiya, Girandurukotte, Kabithigollawa, Padaviya, Medirigiriya, Dehiattakandiya and Nikawewa regions in the dry zone of Sri Lanka (Fig. 1c) .
Therefore, we hypothesized that both high fluoride and high water hardness together contributes to the pathogenesis of CKDu. In our previous study, the effect of fluoride alone on kidney and liver were investigated and proved that there is a possibility of inducing renal damage by elevated serum creatinine levels with exposure to extremely high fluoride levels (20ppmF) for longer period but not with low concentrations . In this study, we performed a comparative study of the effect of both high fluoride and high water hardness on kidney and liver in rats by treating orally a water sample collected from CKDu endemic area. And also, we examined whether the distilled water could reverse the damage created by these factors…
*Read the full article online at https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-020-01763-3
- Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382(9888):260–72.
- Jayasekara JMKB, Dissanayake DM, Adhikari SB, Bandara P. Geographical distribution of chronic kidney disease of unknown origin in north central region of Sri Lanka. Ceylon Med J. 2013;58:6–10.
- Gunatilake SK, Samaratunga SS, Rubasinghe RT. Chronic kidney disease (CKD) in Sri Lanka – current research evidence justification: a review. Sabaragamuwa Univ J. 2014;13(2):31–58.
- De Silva PMCS. Chronic kidney disease of unknown etiology: mystery unsolved. J Univ Ruhuna. 2014;2:1–3.
- Kumari MKN, Rathnayake RMCP, Kendaragama KMA, Gunarathna MHJP, Nirmanee KGS. Drinking water quality in chronic kidney disease of unknown Aetiology (CKDu) prevalent and non-prevalent areas in Giradurukotte, Sri Lanka. Int J Adv Agric Environ Eng. 2016;3(1):57–60.
- Dharmaratne RW. Fluoride in drinking water and diet: the causative factor of chronic kidney diseases in the north Central Province of Sri Lanka. Environ Health Prev Med. 2015;20(4):237–42.
- Dissanayake CB, Chandrajith R. Groundwater fluoride as a geochemical marker in the etiology of chronic kidney disease of unknown origin in Sri Lanka. Ceylon J Sci. 2017;46(2):3–12.
- Chandrajith R, Dissanayake CB, Ariyarathna T, Herath HMJMK, Padmasiri JP. Dose-dependent Na and ca in fluoride-rich drinking water —another major cause of chronic renal failure in tropical arid regions. Sci Total Environ. 2011;409(4):671–5.
- Ahn MK, Chilakala R, Han C, Thenepalli T. Removal of hardness from water samples by a carbonation process with a closed pressure reactor. Water. 2018;10(54):1–10.
- Board of Investment of Sri Lanka, (BOI). Drinking water standards; 2013.
- Jayasumana C, Gunatilake S, Senanayake P. Glyphosate, hard water and nephrotoxic metals: are they the culprits behind the epidemic of chronic kidney disease of unknown etiology in Sri Lanka? Int J Environ Res Public Health. 2014;11(2):2125–47.
- Wickramarathna S, Balasooriya S, Diyabalanage S, Chandrajith R. Tracing environmental aetiological factors of chronic kidney diseases in the dry zone of Sri Lanka—a hydrogeochemical and isotope approach. J Trace Elem Med Biol. 2017;44:298–306.
- Tennakoon TMMH. Dental fluorosis in Anuradhapura District, Sri Lanka. Colombo: 4th International Workshop on Fluorosis Prevention and Defluoridation of Water; 2004. p. 19–22.
- Dissanayake CB. Water quality in the dry zone of Sri Lanka – some interesting health aspects. J NatnSciFoundation Sri Lanka. 2005;33(3):161–8.
- World Health Organization, WHO. Hardness in drinking-water, background document for development of WHO guidelines for drinking-water quality; 2011.
- Lethea L. Impact of water hardness on energy consumption of geyser heating elements. Water SA. 2017;43(4):614–25.
- Malakootian M, Yousef N. The efficiency of electrocoagulation process using aluminum electrodes in removal of hardness from water. Iranian J Environ Health Sci Eng. 2009;6(2):131–6.
- Fonseka S, Jayasumana C, Jayalath K, Amarasinghe M, Senanayake K, Wijewardhane C, et al. Arsenic and hardness in ground water from chronic kidney disease of unknown etiology (ckdu) prevalent areas and non-ckdu prevalent areas in Sri Lanka symposium proceedings, international symposium on water quality and human health: challenges ahead. Peradeniya: PGIS; 2012.
- NIFS. Mini symposium on outlook on chronic kidney disease of unknown etiology. Kandy: National Institute of Fundamental Studies; 2016.
- Wimalawansa SJ. Effect of water hardness on non-communicable diseases, including chronic kidney disease of multifactorial origin (CKDmfo/CKDuo). J Environ Health Sci. 2016;2(1):1–11.
- Chandrajith R, Nanayakkara S, Itai K, Aturaliya TN, Dissanayake CB, Abeysekera T, et al. Chronic kidney diseases of uncertain etiology (CKDue) in Sri Lanka: geographic distribution and environmental implications. Environ Geochem Health. 2010;33(3):267–78.
- Perera T, Ranasinghe S, Alles N, Waduge R. Effect of fluoride on major organs with the different time of exposure in rats. Environ Health Prev Med. 2018;23(1):17.
- World Health Organization, WHO. Guidelines for drinking water quality. 4th ed. Geneva: WHO; 2011.
- CIOMS-ICLAS. International guiding principles for biomedical research involving animals: Council for International Organization of Medical Sciences and International Council for Laboratory Animal Science; 2012.
- Charan J, Kantharia ND. How to calculate sample size in animal studies? J Pharmacol Pharmacother. 2013;4(4):303–6.
- Arifin WN, Zahiruddin WM. Sample size calculation in animal studies using resource equation approach. Malaysian J Medi Sci. 2017;24(5):101–5.
- Bancroft JD, Gamble M. Theory and practice of histological techniques. China: Churchill Livingstone; Elsevier Health Sciences; 2008.
- Khalid U, Pino-Chavez G, Nesargikar P, Jenkins RH, Bowen T, Fraser DJ, et al. Kidney ischaemia reperfusion injury in the rat: the EGTI scoring system as a valid and reliable tool for histological assessment. J Histol Histopathol. 2016;3(1):1.
- Hoffman WP, Ness DK, van Lier RB. Analysis of rodent growth data in toxicology studies. Toxicolo Sci. 2002;66(2):313–9.
- Xiang Q, Liang Y, Chen B, Chen L. Analysis of children’s serum fluoride levels in relation to intelligence scores in a high and low fluoride water village in China. Fluoride. 2011;44(4):191–4.
- WHO. Guidelines for drinking-water quality; 2008. p. 1.
- Weber WJ, Stumm W. Mechanism of hydrogen ion buffering in natural waters. J Am Water Works Ass. 1963;55(12):1553–78.
- Schwalfenberg GK. The alkaline diet: is there evidence that an alkaline pH diet benefits health? J Environ Public Health. 2012;2012:727630.
- Harikumar PS, Aravind A, Vasudevan S. Assessment of water quality status of Guruvayur municipality. J Environ Prot. 2017;08(02):159–70.
- Graf GC, Holdaway CW. A comparison of “hard” and commercially softened water in the ration of lactating dairy cows. J Dairy Sci. 1952;35(12):998–1000.
- Tsunoda M, Aizawa Y, Nakano K, Liu Y, Horiuchi T, Itai K, et al. Changes in fluoride levels in the liver, kidney, and brain and in neurotransmitters of mice after subacute administration of fluoride. Fluoride. 2005;38(4):284–92.
- Choudhury P, Gnanasundaram N, Bajoria A. Fluoride toxicity in rabbits and the role of calcium in prevention of fluoride toxicity. Biomed Pharmacol J. 2018;11(1):445–52.
- Bailey SA, Zidell RH, Perry RW. Relationships between organ weight and body/brain weight in the rat: what is the best analytical endpoint? Toxicol Pathol. 2004;32(4):448–66.
- Michael B, Yano B, Sellers RS, Perry R, Morton D, Roome N, et al. Evaluation of organ weights for rodent and non-rodent toxicity studies: a review of regulatory guidelines and a survey of current practices. Toxicol Pathol. 2007;35(5):742–50.
- Dimerel R, Baran M, Bilal T, Cevrim U. Effects of different calcium levels on broiler performance and tibia bone parameters. Medycyna Wet. 2007;63(4):432–4.
- Gowda S, Desai PB, Kulkarni SS, Hull VV, Math AA, Vernekar SN. Markers of renal function tests. N Am J Med Sci. 2010;2(4):170–3.
- Szebenyi K, Furedi A, Kolacsek O, Csohany R, Prokai A, Kis-Petik K, et al. Visualization of calcium dynamics in kidney proximal tubules. J Am Soc Nephrol. 2015;26(11):2731–40.
- Moeckel GW. Pathologic perspectives on acute tubular injury assessment in the kidney biopsy. Semin Nephrol. 2018;38(1):21–30.
- Basile DP, Anderson MD, Sutton TA. Pathophysiology of acute kidney injury. Compr Physiol. 2012;2(2):1303–53.
- Bonventre JV, Yang L. Cellular pathophysiology of ischemic acute kidney injury. J Clin Invest. 2011;121(11):4210–21.
- Nanayakkara S, Senevirathna STMLD, Karunaratne U, Chandrajith R, Harada KH, Hitomi T, et al. Evidence of tubular damage in the very early stage of chronic kidney disease of uncertain etiology in the north Central Province of Sri Lanka: a cross-sectional study. Environ Health Prev Med. 2012;17:109–17.
- Anjum KM, Mughal MS, Sayyed U, Yaqub A, Khalique A, Rashid MA, et al. Influence of increasing fluoride dose rates on selected liver and kidney enzymes profile in domestic chicken (Gallus domesticus). J Anim Plant Sci. 2014;24(1):77–80.
- Zhan X-A, Wang M, Xu Z-R, Li J-X. Toxic effects of fluoride on kidney function and histological structure in young pigs. Fluoride. 2006;39(1):22–6.
- Ludlow M, Luxton G, Mathew T. Effects of fluoridation of community water supplies for people with chronic kidney disease. Nephrol Dialysis Transplant. 2007;22(10):2763–7.
- Blaine J, Chonchol M, Levi M. Renal control of calcium, phosphate, and magnesium homeostasis. Clin J Am Soc Nephrol. 2015;10(7):1257–72.
- Quadri JA, Sarwar S, Sinha A, Dinda AK, Bagga A, Roy TS, et al. Fluoride-associated mitochondriopathy in human renal cells: an ultrastructural analysis. Fluoride. 2018;51(1):44–57.
- Spencer H, Lewin I, Fowler J, Samachson J. Effect of sodium fluoride on calcium absorption and balances in man. Am J Clin Nutr. 1969;22(4):381–90.
- Puranik CP, Ryan KA, Yin Z, Martinez-Mier EA, Preisser JS, Everett ET. Fluoride modulates parathyroid hormone secretion in vivo and in vitro. Cells Tissues Organs. 2015;200(6):413–23.
- Wang Y, Duan XQ, Zhao ZT, Zhang XY, Wang H, Liu DW, et al. Fluoride affects calcium homeostasis by regulating parathyroid hormone, PTH-related peptide, and calcium-sensing receptor expression. Biol Trace Elem Res. 2015;165(2):159–66.
- Bonventre JV. Mechanisms Acute Kidney Injury Repair. 2017;2(1):13–20.
- Murao H, Sakagami N, Iguchi T, Murakami T, Suketa Y. Sodium fluoride increases intracellular calcium in rat renal epithelial cell line NRK-52E. Biol Pharm Bull. 2000;23(5):581–4.
- Young EW, Humes HD. Calcium and acute renal failure. Miner Electrolyte Metab. 1991;17(2):106–11.
- Bonventre JV. Mechanisms of ischemic acute renal failure. Kidney Int. 1993;43(5):1160–78.
- Zhan M, Brooks C, Liu F, Sun L, Dong Z. Mitochondrial dynamics: regulatory mechanisms and emerging role in renal pathophysiology. Kidney Int. 2013;83(4):568–81.
- Klaassen CD. Casarett and doull’s toxicology the basic science of poisons. 7th ed. New York: McGraw-Hill; 2008.
- Dong Z, Saikumar P, Weinberg JM, Venkatachalam MA. Calcium in cell injury and death. Annu Rev Pathol. 2006;1:405–34.
- Kitiyakara C, Chabrashvili T, Chen Y, Blau J, Karber A, Aslam S, et al. Salt intake, oxidative stress, and renal expression of NADPH oxidase and superoxide dismutase. J Am Soc Nephrol. 2003;14(11):2775–82.
- Huang HS, Ma MC. High sodium-induced oxidative stress and poor Anticrystallization defense aggravate calcium oxalate crystal formation in rat Hyperoxaluric kidneys. PLoS One. 2015;10(8):e0134764.
- Shortt C, Flynn A. Sodium-calcium inter-relationships with specific reference to osteoporosis. Nutr Res Rev. 1990;3(1):101–15.
- Yatabe MS, Yatabe J, Takano K, Murakami Y, Sakuta R, Abe S, et al. Effects of a high-sodium diet on renal tubule Ca2+ transporter and claudin expression in Wistar-Kyoto rats. BMC Nephrol. 2012;13:160.
- Park SM, Jee J, Joung JY, Cho YY, Sohn SY, Jin SM, et al. High dietary sodium intake assessed by 24-hour urine specimen increase urinary calcium excretion and bone resorption marker. J Bone Metab. 2014;21(3):189–94.
- Bellizzi V, De Nicola L, Minutolo R, Russo D, Cianciaruso B, Andreucci M, et al. Effects of water hardness on urinary risk factors for kidney stones in patients with idiopathic nephrolithiasis. Nephron. 1999;81(Suppl 1):66–70.
- Wijkstrom J, Jayasumana C, Dassanayake R, Priyawardane N, Godakanda N, Siribaddana S, et al. Morphological and clinical findings in Sri Lankan patients with chronic kidney disease of unknown cause (CKDu): similarities and differences with Mesoamerican nephropathy. PLoS One. 2018;13(3):e0193056.
- Li LC, Zhang YS, Hu RZ, Zhou XC. Inhibitory effect of fluoride on renal stone formation in rats. Urol Int. 1992;48(3):336–41.
- Shuster J, Finlayson B, Scheaffer R, Sierakowski R, Zoltek J, Dzegede S. Water hardness and urinary stone disease. J Urol. 1982;128(2):422–5.
- Basiri A, Shakhssalim N, Khoshdel AR, Pakmanesh H, Radfar MH. Drinking water composition and incidence of urinary calculus: introducing a new index. Iran J Kidney Dis. 2011;5(1):15–20.
- Taylor JM, Kieneker LM, de Borst MH, Visser ST, Kema IP, Bakker SJL, et al. Urinary calcium excretion and risk of chronic kidney disease in the general population. Kidney Int Rep. 2017;2(3):366–79.
- Mirazi N, Movassagh SN, Rafieian-Kopaei M. The protective effect of hydro-alcoholic extract of mangrove (Avicennia marina L.) leaves on kidney injury induced by carbon tetrachloride in male rats. J Nephropathol. 2016;5(4):118–22.
- Barry EL, Mott LA, Melamed ML, Rees JR, Ivanova A, Sandler RS, et al. Calcium supplementation increases blood creatinine concentration in a randomized controlled trial. PLoS One. 2014;9(10):e108094.
- Mokhtar HEL. Histological and ultrastructure study of toxic effect of sodium fluoride on the renal cortex of adult albino rats and the possible role of calcium therapy. British J Sci. 2014;11(1):36–60.
- Wu L, Zhu X, Fan L, Kabagambe EK, Song Y, Tao M, et al. Magnesium intake and mortality due to liver diseases: results from the third National Health and nutrition examination survey cohort. Sci Rep. 2017;7(1):17913.
- Aslam MN, Bassis CM, Zhang L, Zaidi S, Varani J, Bergin IL. Calcium reduces liver injury in mice on a high-fat diet: alterations in microbial and bile acid profiles. PLoS One. 2016;11(11):e0166178.
- Limdi JK, Hyde GM. Evaluation of abnormal liver function tests. Postgrad Med J. 2003;79(932):307–12.
- Sette LH, Lopes EP. The reduction of serum aminotransferase levels is proportional to the decline of the glomerular filtration rate in patients with chronic kidney disease. Clinics. 2015;70(5):346–9.
- Hallberg L, Brune M, Erlandsson M, Sandberg AS, Rossander-Hulten L. Calcium: effect of different amounts on nonheme- and heme-iron absorption in humans. Am J Clin Nutr. 1991;53(1):112–9.
- Ems T, Huecker MR. Biochemistry, iron absorption: StatPearls; 2018.
- Whitford GM. Effects of plasma fluoride and dietary calcium concentrations on GI absorption and secretion of fluoride in the rat. Calcif Tissue Int. 1994;54(5):421–5.
- Whitford GM. Fluoride metabolism when added to salt. Schweiz Monatsschr Zahnmed. 2005;115(8):675–8.
- Berger K, Moeller MJ. Mechanisms of epithelial repair and regeneration after acute kidney injury. Semin Nephrol. 2014;34(4):394–403.
- Kozisek F. Health risks from drinking demineralised water. World Health Organization. 2004;12:148–63.
- Council NR. Intentional human dosing studies for EPA regulatory purposes: scientific and ethical issues. Washington, DC: The National Academies Press; 2004. p. 226.