Prevalence of renal disorders among the residents of Canacona in India: Analysis of the data from a free urological medical camp

Abstract

The high incidence of renal disorders/diseases in Canacona tuluk of Goa in India has been a matter of great concern. We analyzed the pattern of genitourinary problems in patients attending a free medical camp organised by the Department of Urology, KLES Kidney Foundation at Canacona. 298 patients attended the camp, which included 166 males and 132 females. 40.9% had urolithiasis, 12.9% had chronic renal failure and 12.8% had LUTS secondary to Benign Prostatic Hyperplasia. There is a high prevalence of renal disorders among the inhabitants of Canacona taluk. These disorders include urolithiasis and chronic renal failure.

Full text

Indian Journal of Science and Technology Vol. 3 No. 3 (Mar 2010) ISSN: 0974- 6846
Research communication “Epidemiological study of renal disorder in India” Nerli et al.
©Indian Society for Education and Environment (iSee) http://www.indjst.org Indian J.Sci.Technol.
296
Prevalence of renal disorders among the residents of Canacona in India: analysis of the data from a free
urological medical camp
R.B. Nerli, Tanmaya Metgud, M.B. Hiremath, Ajay Guntaka, Shivagouda Patil and Vikram Prabha
Dept. of Urology, KLE University’s JN Medical College & KLES Dr. Prabhakar Kore Hospital & MRC,
Belgaum 590 010, India
rajendranerli@yahoo.in
Abstract
The high incidence of renal disorders/diseases in Canacona tuluk of Goa in India has been a matter of great concern.
We analyzed the pattern of genitourinary problems in patients attending a free medical camp organised by the
Department of Urology, KLES Kidney Foundation at Canacona. 298 patients attended the camp, which included 166
males and 132 females. 40.9% had urolithiasis, 12.9% had chronic renal failure and 12.8% had LUTS secondary to
Benign Prostatic Hyperplasia. There is a high prevalence of renal disorders among the inhabitants of Canacona taluk.
These disorders include urolithiasis and chronic renal failure.
Keywords: Health monitoring, Urolithiasis; renal disorders, mycotoxins, India
Introduction
The high incidence of renal disorders/diseases in
Canacona taluk of Goa has been a matter of great
concern for the local people for several decades. This
problem has vexed the local medical practioners as well
as health administrators. The local people have made
several representations to the Director of health services,
Goa. This matter has also been raised in the discussions
of Rajya Sabha. Answering to queries raised by the
member of parliament, Mr. Shantaram Naik in the Rajya
Sabha, then, Union Minister of State for Health and
Family Welfare Panabaka Lakshmi (Anon, 2007)
admitted that according to ICMR (Indian Council for
Medical Research), there was a high prevalence of renal
diseases in the Canacona taluk and had been a matter of
concern. The team from ICMR, NIOH (National Institute
of Occupational Health, Meghaninagar, Ahmedabad) had
visited and carried out environmental cum biological
monitoring in February 2005 and had stated that clinically
the disease seemed to be similar to Balkan Endemic
Nephropathy (BEN), which was an environmentally
acquired disease, possibly caused by mycotoxin
produced by fungi in mouldy cereals and food products
and aromatic compounds in drinking water (NIOH, 2005).
Materials and methods
A free medical examination camp was organised by
the Dept of Urology, KLES kidney foundation at Dr.
Dhavalikar Hospital, Canacona on 20th Dec 2009. Pre-
camp advertisements were displayed at various public
locations in the Canacona town. The camp was targeted
towards patients with genitourinary complaints. Patients
attending the free camp were questioned regarding their
symptoms. They were examined in detail, underwent
screening ultrasonography, basic laboratory tests and
Uroflowmetry if needed. A preliminary diagnosis was
made and patients advised regarding treatment and
further management. Patients were offered free samples
of drugs wherever possible.
Results
A total of 298 patients attended the camp, of which
132 (44.3%) were females and 166 (55.7%) were males.
The age distribution of the patients was as shown in
Table 1, with 90 (30.2%) patients being above the age of
50 years. The mean per capita income of the patients
was above 36,000 per annum. Most of the patients
belonged to middle income group. Through all the age
groups the most common presenting symptom was pain
in the loins/lumbar area. All these patients had history
suggestive of urolithiasis. Of these, 20 (6.7%) patients
had been treated for urolithiasis in the past, and the
treatment included endoscopy, ESWL (Extracorporeal
shock wave lithotripsy) and open surgery. 54 (18.1%) of
the patients were using herbal/ayurvedic/allopathic
treatment for the treatment/prevention of urinary stones.
Urinary examination revealed abnormalities in 72 (24.2%)
patients which included pyuria, microscopic hematuria,
crystaluria and bacteriuria. Ultrasonography revealed
evidence of urolithiasis in 122 (40.9%) patients. Of these
20 (6.7%) showed evidence of hydronephrosis and
hydroureter suggesting ureteric urolithiasis. 102 (34.2%)
patients showed evidence of renal calculi on
ultrasonography . Most of these calculi were multiple,
small (<5 mm) in size and distributed bilaterally. In 16
(5.4%) patients the calculi were big in size (>10 mm)
needing some form of therapy. The second most common
group of complaints included lower urinary tract
symptoms (LUTS) .These included both irritative as well
as obstructive symptoms with the former being more

Indian Journal of Science and Technology Vol. 3 No. 3 (Mar 2010) ISSN: 0974- 6846
Research communication “Epidemiological study of renal disorder in India” Nerli et al.
©Indian Society for Education and Environment (iSee) http://www.indjst.org Indian J.Sci.Technol.
297
common. 24 (8.1%) females had irritative symptoms, with
urine examination showing pyuria, bacteriuria and
microscopic hematuria. Ultrasonography revealed cystitis
like picture of the bladder. All these women were advised
Urine culture sensitivity and put on urinary antiseptics. 38
(12.8%) men, most of them above the age of 50 years
had enlargement of prostate on their ultrasonography
pictures. 26 of them were put on drugs which were a
combination of α-blockers (Tamsulosin) and 5α-reductase
(Dutasteride) inhibitors The remaining who had very poor
flow (Qmax < 10 ml/sec) were advised to undergo
cystometry and further treatment. 4 (1.3%) other women
had history suggestive of overactive bladder. All were
counselled and advised bladder relaxants, failing which
they were advised to undergo cystometry and further
treatment.
A total of 36 (12.1%) patients had evidence of chronic
renal failure (CRF). Of these 4 were already on
hemodialysis, eight needed creation of a vascular access
for hemodialysis. The rest were having evidence of CRF
in the form of raised renal parameters, echogenic and
small kidneys on ultrasonography. Most of these patients
were in their 4th to 5th decade of life. All were advised
medications, counseled about their renal status and need
for dialysis/renal transplantation.
One adult male was diagnosed to have renal mass
and two others had bladder mass on ultrasonography. 26
(8.7%) of the patients had normal ultrasonography and
urine examination.
Discussion
The lifetime prevalence of kidney stone disease is
estimated at 1% to 15%, with the probability of having a
stone varying according to age, gender, race, and
geographic location. In the United States, the prevalence
of stone disease has been estimated at 10% to 15%
(Norlin
et al.,
1976; Sierakowski
et al,
1978; Johnson
et
al.,
1979). Stone disease typically affects adult men more
commonly than adult women. By a variety of indicators,
including inpatient admissions, outpatient office visits,
and emergency department visits, men are affected two
to three times more frequently than women (Hiatt,
et al.,
1982; Soucie,
et al.,
1994; Pearle
et al.,
2005). However,
there is some evidence that the difference in incidence
between men and women is narrowing. The geographic
distribution of stone disease tends to roughly follow
environmental risk factors; a higher prevalence of stone
disease is found in hot, arid or dry climates such as the
mountains, desert, or tropical areas. However, genetic
factors and dietary influences may outweigh the effects of
geography. Seasonal variation in stone disease is likely
related to temperature by way of fluid losses through
perspiration and perhaps by sunlight-induced increases in
vitamin D (Prince & Scardino, 1960) noted the highest
incidence of stone disease in the summer months, July
through September, with the peak occurring within 1 to 2
months of maximal mean temperatures (Prince
et al.,
1956). Heat exposure and dehydration constitute
occupational risk factors for stone disease as well. The
association of body size and incidence of stone disease
has been investigated. In two large prospective cohort
studies of men and women, the prevalence and incident
risk of stone disease were directly correlated with weight
and body mass index in both sexes, although the
magnitude of the association was greater in women than
men (Curhan
et al.
, 1998; Taylor
et al.
, 2005). The
beneficial effect of a high fluid intake on stone prevention
has long been recognized. In two large observational
studies, fluid intake was found to be inversely related to
the risk of incident kidney stone formation (Curhan
et al.,
1993; Curhan
et al.,
1997). Geographic differences in the
incidence of stone disease have been ascribed in some
cases to differences in the mineral and electrolyte content
of water in different areas. Although several investigators
reported a lower incidence of stone disease in geographic
regions with a ‘hard water supply compared with a ‘soft’
water supply, where water ‘hardness’ is determined by
content of calcium carbonate (Churchill
et al.,
1978;
Sierakowski
et al.,
1979) others found no difference.
Schwartz and co-workers (Schwartz
et al
., 2002) found
no association between water hardness and incidence of
stone episodes, although they did observe a correlation
between water hardness and urinary magnesium,
calcium, and citrate levels.
With 40.9% of the patients attending the camp having
evidence of urolithiasis on ultrasonography, it only
confirms the fear that there is a high prevalence of
urolithiasis among the residents of Canacona taluk. Of
these 20 (6.7%) had ureteric calculi and 16 (5.4%) had
renal calculi >10 mm in size, needing intervention. With
most of the factors such as diet, ancestry, climate,
geography and quality of water being similar in the
southern districts of Maharashtra (Sindhudurg), North
Goa and North Karnataka (Karwar), this high prevalence
of urolithiasis in the residents of Canacona is noteworthy.
Certain local factors must be prevailing to explain the
high incidence of urolithiasis.
The incidence of chronic renal failure in patients
attending the camp was 12.1%. This high prevalence of
renal failure in the residents of Canacona is well
established (NIOH, 2005). Studies done in the past, as to
the reason for this high prevalence, is that clinically this
disease seems to be similar to Balkan Endemic
Nephropathy (BEN). BEN is an environmentally acquired
disease and the most plausible environmental agents
responsible are the mycotoxins produced by fungi. These
mycotoxins are natural products produced by the fungi
that evoke a toxic response when consumed in low
concentration by higher vertebrates. Ochratoxin A (OTA)
is mainly produced by the species
Aspergillus ochraceus
and
Penicillium verrucosum,
which is mutagenic,
oncogenic and nephrotoxic (NIOH, 2005). OTA is
responsible for chronic nephropathy in pigs and also may
be the cause of BEN and some interstitial nephropathies

Indian Journal of Science and Technology Vol. 3 No. 3 (Mar 2010) ISSN: 0974- 6846
Research communication “Epidemiological study of renal disorder in India” Nerli et al.
©Indian Society for Education and Environment (iSee) http://www.indjst.org Indian J.Sci.Technol.
298
seen in North Africa and France (NIOH, 2005).
Ochratoxin A has been associated with BEN and
urothelial tumors (UT). Although a direct link between
BEN/UT and OTA remains to be established,
epidemiological data correlates a moderate increase in
serum OTA levels with a significantly higher incidence of
nephropathy and urothelial tumors in humans. Studies
carried out in several countries including Tunisia, Egypt
and France have indicated a link between dietary intake
of OTA and the development of renal and urothelial
tumors (NIOH, 2005). A study done by Gilbert
et al
.
(2001) shows the correlation between urinary OTA conc.
and dietary intake appears stronger than the
corresponding relationship between plasma OTA level
and intake. Humans consume OTA by ingesting
contaminated cereals, coffee, beer, wine, foods of animal
origin etc. European Union has set the maximum
permissible limit for OTA in raw cereal grains and cereal
products at 5 and 3 μg/Kg, respectively and in dried fruits
at 10 μg/Kg (EC, 2002).
It is for the benefit of the residents of Canacona that
either Governmental or non-governmental organisations
come forward to identify these avoidable toxins so that
the prevalence of these disorders comes down.
Conclusions
There is a high prevalence of renal disorders including
urolithiasis and chronic renal failure among the residents
of Canacona.
References
1. Anon (2007) Concern over kidney disease in
Canacona taluk of Goa. The Hindu.
http;//www.thehindu.com/2007/08/18/stories/2007081
853120300.htm.
2. Churchill D, Bryant D, Fodor G and Gault MH
(1978) Drinking water hardness and urolithiasis.
Ann.
Intern. Med.
88, 513-514.
3. Commission Regulation (EC) (2002) No 472/2002.
Official J. Eur. Commun.
1-10.
4. Curhan GC, Willett WC, Rimm EB and Stampfer MJ
(1993) A prospective study of dietary calcium and
other nutrients and the risk of symptomatic kidney
stones.
N. Engl. J. Med.
328, 833-838.
5. Curhan GC, Willett WC, Rimm EB,
Speizer FE
and Stampfer MJ (1998) Body size and risk of kidney
stones.
J. Am. Soc. Nephrol.
9, 1645-1652.
6. Curhan GC, Willett WC, Speizer FE, Donna
Spiegelman and Meir J Stampfer (1997) Comparison
of dietary calcium with supplemental calcium and
other nutrients as factors affecting the risk for kidney
stones in women.
Ann. Intern. Med.
126, 497-504.
7. Gilbert J, Brereton P and Mac Donald S (2001)
Assessment of dietary exposure to ochratoxin A in UK
using a duplicate diet approach and analysis of urine
and plasma samples.
Food Addit. Contam.
18, 1088-
1093.
8. Hiatt RA, Dales LG, Friedman GD and Hunkeler EM
(1982) Frequency of urolithiasis in a prepaid medical
care program.
Am. J. Epidemiol.
115, 255-265.
9. Johnson CM, Wilson DM, O'Fallon WM,
Reza
S Malek and Leonard T Kurland (1979) Renal stone
epidemiology: A 25-year study in Rochester,
Minnesota.
Kidney Int.
16, 624-631.
10.
National Institute of Occupational Health (NIOH)
(2005) Annual report (executive summary).
p:49-52.
11. Norlin A, Lindell B, Granberg PO and Lindvall N
(1976) Urolithiasis: A study of its frequency.
Scand. J.
Urol. Nephrol.
10, 150-153.
12. Pearle MS, Calhoun EA and Curhan GC
(2005) Urologic diseases in America project:
urolithiasis.
J. Urol.
173. 848-857.
13. Prince CL and Scardino PL (1960) A statistical
analysis of ureteral calculi.
J. Urol.
83, 561- 565.
14. Prince CL, Scardino PL and Wolan CT (1956) The
effect of temperature, humidity and dehydration on the
formation of renal calculi.
J. Urol
. 75, 209-215.
15. Schwartz BF, Schenkman NS, Bruce JE,
Leslie SW
and Stoller ML (2002) Calcium nephrolithiasis: Effect
of water hardness on urinary lectrolytes.
Urology.
60,
23-27.
16. Sierakowski R, Finlayson B and Landes R
(1979) Stone incidence as related to water hardness
in different geographical regions of the United
States.
Urol. Res.
7, 157-160.
17. Sierakowski R, Finlayson B, Landes R, Finlayson CD
and Sierakowski N (1978) The frequency of
urolithiasis in hospital discharge diagnoses in the
United States.
Invest. Urol.
15, 438-441.
18. Soucie JM, Thun MJ, Coates RJ,
McClellan W
and Austin H (1994) Demographic and geographic
variability of kidney stones in the United
States.
Kidney Int.
46, 893-899.
19. Taylor EN, Stampfer MJ and Curhan GC
(2005) Obesity, weight gain, and the risk of kidney
stones.
JAMA.
293, 455-462.
