Articles and issues

Background. Chronic kidney disease of uncertain etiology (CKDu) is a leading cause of kidney failure among farming communities in the dry zone of Sri Lanka, but community-based estimates using confirmatory testing are limited. Methods. A cross-sectional survey was conducted in 2025 among adults aged 18–70 years engaged in agricultural work in 40 Grama Niladhari divisions of the Anuradhapura and Polonnaruwa districts, selected by two-stage cluster sampling. Participants completed a structured questionnaire and provided blood and urine samples. CKD was defined as an estimated glomerular filtration rate below 60 mL/min/1.73 m² or a urine albumin-to-creatinine ratio of 30 mg/g or more persisting for 3 months, and CKDu was defined with the national case definition. Associated factors were examined with multilevel logistic regression. Results. Of 3,200 adults invited, 2,946 (92.1%) participated. The prevalence of CKD was 12.3% (95% CI 10.8–13.8) and that of CKDu 9.1% (95% CI 7.8–10.4), and 82.5% of participants with CKDu were unaware of their disease. CKDu was more common in men (11.6% vs 6.2%) and increased with age. It was independently associated with drinking water from shallow dug wells (adjusted OR 2.04, 95% CI 1.47–2.83), low water intake during field work, long working hours in hot weather, agrochemical spraying without protective equipment and a family history of CKD (adjusted OR 2.37, 95% CI 1.75–3.21). Conclusions. CKDu affects about 1 in 11 agricultural workers in the North Central Province and is largely undiagnosed. Safe drinking water, measures to prevent heat stress and dehydration, protective equipment and community screening should be prioritized.

Ureteric stones are a common cause of emergency presentation, and most stones in the distal ureter that are smaller than 10 mm can be managed without intervention. Medical expulsive therapy (MET), most often with the α1-adrenoceptor antagonist tamsulosin, aims to increase the likelihood and speed of spontaneous passage by relaxing ureteric smooth muscle. Early small trials suggested large benefits, but subsequent large multicenter placebo-controlled trials reported little or no overall effect, which led to conflicting guideline recommendations. This review summarizes the pharmacological basis of MET, appraises the evidence from randomized trials and meta-analyses, and offers practical recommendations for clinicians. Current evidence indicates that α-blockers have no meaningful benefit for stones smaller than 5 mm, which usually pass spontaneously, but increase the stone passage rate by about 20 percentage points for distal ureteric stones of 5–10 mm, shorten the time to passage and reduce analgesic requirements and the number of colic episodes. Tamsulosin 0.4 mg daily for up to 4 weeks is the best-studied regimen, and silodosin may be at least as effective. Calcium channel blockers and phosphodiesterase type 5 inhibitors are less effective or less well studied. MET is appropriate only for patients with controlled pain, adequate renal function and no signs of infection, and should be accompanied by clear safety-netting advice and follow-up imaging. Patients should be informed that its use for this indication is off-label in many countries and that dizziness and ejaculatory dysfunction may occur.