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I appreciate the thoughtful letter from Professor Illeperuma and his focussed commentaries on (A) the usefulness of the review in EHMP; (B) the critical evaluation in the review of the roles of all proposed potential causative factors and the ‘‘multi-factorial’’ nature of the disease; (C) the scientific rejection of the flawed glyphosate hypothesis; (D) the use of the most appropriate terminology for the disease— ‘‘CKD of multi-factorial origin’’ [CKD-mfo], and (E) identifying the potential roles of fertilizer and the Mahaweli diversion, etc., in Sri Lanka, in the multi-factorial concept of causation of CKD-mfo [1–4]. Professor Illeperuma is the originator of the hypothesis of the association between fluoride and CKD-mfo [5]. He confirmed that data and detailed maps of Sri Lanka on the distribution of fluoride, hard water, and the prevalence of CKD in the North Central Province (NCP) and elsewhere have been available for more than a ‘‘decade’’. This independently refutes the claims made by Drs. Jayasumana and Siribaddana. The overlaps of groundwater fluoride content and the distribution of the prevalence of CKD-mfo that Professor Illeperuma and others elegantly illustrated provided evidence of an ‘‘association’’, but are not sufficient yet to establish causation [6–11]. I also agree with the comments by Professor Illeperuma on the negative socio-medical-economic impact of CKDmfo in Sri Lanka [2, 3], which has been ignored by the authorities and, is largely underestimated. Failure to address this will have a detrimental socio-economic impact in the country for years to come [1–3]. The problem is compounded by egos and conflicts of interest, and the lack of understanding about the disease among various groups, including government departments and ministries that failed to implement programmes proposed by this author and other reputed scientists, globally, over the past several years. The programmes recommended by the author include focussing on early identification of the disease using appropriate screening methods (i.e. using tubularspecific urine markers), provision of clean water to all affected and surrounding villages, broader environmental protection, and countrywide real-time surveillance programme, and actions leading to the elimination of CKDmfo from Sri Lanka. However, fundamental issues, myths and misguidance, and obstructions must be overcome before progress can be made in preventing this disease.

Escalating chronic kidney diseases of multi-factorial origin (CKD-mfo) in Sri Lanka: causes, solutions, and recommendations—update and responses