Surgery

The burden of Chronic Kidney Disease (CKD) continues to rise globally with an estimated 500 million people suffering worldwide, of whom majority live in LMIC like Sri-Lanka. Estimated 60,000 (0.3%) of the population of Sri Lanka suffer from CKD with nearly 3000 in end-stage renal failure (ESRF). Despite the rise in trends of CKD, the causes are yet to be clearly defined due to variability in quality of reporting, inconsistent methods of defining and absence of a centralized reporting system. Although the etiology of the disease is heterogeneous, prevalence of chronic kidney disease of unknown etiology (CKDu), is unique to countries such as Sri-Lanka. Since the first reporting of this group of patients in 1990 the incidence has escalated dramatically. In Sri-Lanka CKDu is mainly seen in the north central and northwest provinces, affecting more than 15% of its population mainly in the 20-30- year age group. They are predominantly agricultural workers with a male preponderance. Etiology may be attributed to quality and presence of arsenic and cadmium in the water, and frequent droughts affecting these areas. CKD has become a huge burden to the country with 4% of the public health budget being spent on non-curative aspects of CKD alone. In 2007 there were only about 180 dialysis machines in the entire country when the requirement was over 1000. Renal transplantation is probably the more tenable longterm treatment option for ESRD in LMIC as it is both cheaper and provides a better outcome for these patients. In Sri-Lanka less than 5% of this group receives a transplanted kidney. Besides the technical challenges of surgery and consequences of immunosuppression, LMIC like Sri-Lanka have the need to improve the deceased-donor program, which is currently at its infancy due to an ill-defined

legal framework, taboos, and multicultural, multi-religious believes.