Reframing Chronic Kidney Disease of Unknown Etiology (CKDu): A Hydrogeochemical and Technological Perspective on Water Extraction Practices

Chronic Kidney Disease of Unknown Etiology (CKDu) represents one of the most persistent unresolved epidemics in global environmental health, affecting rural agricultural communities in Sri Lanka and comparable tropical regions. Here, we propose a conceptual shift in CKDu research by linking the disease not only to chemical exposure but also to technological transformation in water extraction. Synthesizing epidemiological evidence, groundwater chemistry, and historical water-use practices, we show that the transition from surface and shallow sources to deep-well pumping has systematically increased long-term consumption of mineral-dense and trace metal–enriched groundwater. This altered exposure pathway provides a coherent explanation for the recent emergence of CKDu despite long-standing natural groundwater hardness. We further demonstrate that widely adopted reverse osmosis interventions may generate unintended risks by eliminating essential minerals alongside toxic contaminants. We therefore propose surface-layer water extraction as a low-cost, scalable, and culturally compatible alternative that preserves beneficial mineral content while reducing nephrotoxic exposure. This framework reframes CKDu as an unintended consequence of technological modernization and offers a testable pathway for integrating hydro geochemistry, public health, and water policy in addressing unexplained chronic disease.