phenanthrenes and Nephritis--Interstitial

A 58-year-old woman with calcinosis Raynaud esophageal sclerodactyly telangiectasia (CREST) syndrome presented with slowly progressive renal dysfunction. She was normotensive with normal plasma renin activity and lacking symptoms of vasculitis. Mild proteinuria was of tubular origin, but serological tests and an absence of sicca symptoms excluded the possibility of Sjögren's syndrome. Light microscopic study of renal biopsy showed interstitial fibrosis with ectasia and degeneration of proximal tubule and lymphocyte infiltration. There were no remarkable changes in the glomeruli. Chromatographic analysis of the Chinese herbs regimen that she had been taking for several years demonstrated aristolochic acid. She was diagnosed as Chinese herbs nephropathy. Therapy with oral prednisolone was markedly effective in improving renal function and anemia. To our knowledge, this is the first report of Chinese herbs nephropathy complicating connective tissue disease. It is important to consider the possibility of Chinese herbs nephropathy when patients treated with Chinese herbs develop renal dysfunction.

Topics: Aristolochic Acids; Biopsy; Chromatography, High Pressure Liquid; CREST Syndrome; Disease Progression; DNA; Drugs, Chinese Herbal; Female; Fibrosis; Humans; Middle Aged; Mutagens; Nephritis, Interstitial; Phenanthrenes

Chinese herbs nephropathy is characterized by an extensive interstitial fibrosis and by a rapid evolution to end-stage renal failure. We thus decided to try steroid therapy (prednisolone 1 mg/kg for 1 month, tapered off 0.1 mg/kg every 2 weeks) in cases with moderate renal failure and evidence of deterioration in renal function. Our steroid group (SG) consisted of 12 female patients with biopsy-proven renal fibrosis who were followed for at least 12 months after the initiation of steroids. Plasma creatinine level (Pcreat) ranged from 1.8 to 3.9 mg/dL (mean +/- SEM, 2.8 +/- 0.2 mg/dL) when steroids were initiated at t = 0. Renal failure was in progression since Pcreat was 2.1 +/- 0.1 mg/dL (P = 0.022) 3 months before t = 0. Our control group (CG; N = 23) was selected retrospectively from among the 81 patients in the Belgian Register of Chinese Herbs Nephropathy. Compared with the CG, renal function was better preserved in the SG (Pcreat; mean +/- SEM): SG v CG, 2.9 +/- 0.3 mg/dL v 5.3 +/- 0.5 mg/dL at 6 months (P = 0.0024) and 4.0 +/- 0.7 mg/dL v 7.1 +/- 0.5 mg/dL at 1 year (P = 0.001). The slope of the reciprocal serum creatinine concentration was similar in both groups before t = 0 (-0.0463 mg/dL/mo in the SG v -0.0438 mg/dL/mo in the CG; P = 0.83), but it became less steep after initiation of steroid therapy (between 0 and 6 months, -0.000742 mg/dL/mo in the SG v -0.0284 mg/dL/mo in the CG; P < 0.001). Finally, only two of the 12 patients in the SG required dialysis at 1 year compared with 16 of the 23 patients in the CG (P = 0.0045). We conclude that steroid therapy slows the progression of renal failure in a disease characterized by an interstitial fibrosis that progresses quickly despite the fact that the insulting agent has been withdrawn. This supports the hypothesis that renal interstitial fibrosis may be an immune-mediated process.

Topics: Aristolochic Acids; Case-Control Studies; Disease Progression; Drugs, Chinese Herbal; Female; Fibrosis; Follow-Up Studies; Glucocorticoids; Humans; Kidney; Middle Aged; Nephritis, Interstitial; Phenanthrenes; Pilot Projects; Prednisolone; Renal Insufficiency; Time Factors

Topics: Aristolochia; Aristolochic Acids; Bone Marrow; Drugs, Chinese Herbal; Humans; Male; Middle Aged; Nephritis, Interstitial; Phenanthrenes

Chinese herbs nephropathy (CHN) is a new type of subacute interstitial nephritis that is attributed to aristolochic acid (AA), which inadvertently has been included in slimming pills. The contribution of other simultaneously prescribed drugs remains disputed. In the present study, the effects of a chronic intake of AA given as a single drug was evaluated through renal histology and function in rabbits.. Female New Zealand White rabbits were injected intraperitoneally with either 0.1 mg AA/kg or with saline 5 days a week for 17 to 21 months. Body weight, renal function, and urinary excretion of glucose and low molecular weight proteins were monitored prior to sacrifice at the end of the study period.. All animals given AA developed renal hypocellular interstitial fibrosis, which was classified into three patterns. Fibrosis was confined to medullary rays (MRs) in pattern I (N = 3), extended to the outer cortical labyrinth (OCL) in pattern II (N = 2), and eventually to the inner cortical labyrinth (ICL) in pattern III (N = 6). Fibrosis in MR and OCL was associated with mainly proximal tubular epithelial cell flattening. All treated animals displayed urothelial atypia. Three of them also developed tumors of the urinary tract. No significant pathologic changes were found in control rabbits. AA-treated animals differed from controls by an impaired growth, increased serum creatinine, glucosuria, tubular proteinuria, and anemia.. The observed pattern of renal histopathological lesions and disorders of the renal function, as well as urothelial atypia and malignancy, are very reminiscent of CHN. Our observations therefore support a causal role of AA alone in the genesis of this new nephropathy.

Topics: Animals; Aristolochic Acids; Disease Models, Animal; Drugs, Chinese Herbal; Enzyme Inhibitors; Female; Fibrosis; Kidney; Nephritis, Interstitial; Organ Size; Phenanthrenes; Rabbits; Stomach

To study chronic renal interstitial fibrosis induced by aristolochic acid (AA) in animal models.. Female Wistar rats were divided into two groups: AA group (n = 42) peritoneally injected with AA (5 mg.kg-1.d-1) for 16 weeks and control group (n = 5) peritoneally injected with normal saline (2 ml/d) for 16 weeks. The body weight of rats was taken. At week 8, 12, 16, and 24 six rats were killed in the AA group. The five rats in the control group were killed at week 24. Specimens of lood and urine were taken before the animals were killed. Specimens of renal tissue were taken after the animals were killed. Twenty-four hour urine protein, urine beta 2 microglobulin (beta 2-MG), and renal function were tested regularly. Pathological examination, including tubulo-interstitial area calculation, was made to the renal specimens.. The body weight of rats in AA group became significantly lower than that of the control rats after 16 weeks' AA injection (P < 0.01). The blood urea nitrogen (BUN) and serum creatinine (Scr) in AA group increased significantly than those of the control group at the 16th, 20th, and 24th weeks (P < 0.05). Optical microscopy showed tubular-interstitial damage in AA group in 16 weeks. Renal tubular atrophy and multifocal renal interstitial fibrosis were shown in 24 weeks. The area of renal tubule increased and the area of the lumen remarkably decreased at week 16 compared with those in the control group. The area of renal tubule decreased remarkably and the area of renal interstitial greatly in the AA group at week 24. Electrical microscopy showed increase of primary and secondary lysosomes and diasappearence of part of brush border of tubular endothelial cells at week 16, and accumulation of secondary lysosome in cytoplasm at weeks 20 and 24 in the AA group. Histoimmunofluorescence showed that IgG, IgA, IgM, C3, and C1q were negative in the renal tissue of experimental animals.. Animal models with chronic renal tubuloointerstitial nephropathy induced by aristolochic acid were successfully established. Aristolochic acid may have chronic toxicity to renal tissues, and cause chronic renal interstitial fibrosis in rats.

Topics: Animals; Aristolochic Acids; Blood Urea Nitrogen; Body Weight; Carcinogens; Chronic Disease; Creatine; Disease Models, Animal; Female; Fibrosis; Kidney Tubules, Proximal; Nephritis, Interstitial; Phenanthrenes; Rats; Rats, Wistar

To realize and classify the aristolochic acid nephropathy (AAN) according to its clinical and pathological manifestations.. Fifty eight cases in our Division during October 1998 to August 2001 were reviewed, and their clinical, laboratory and pathological manifestations as well as the response of therapy were analyzed. The aristolochic acid (AA) component in some Chinese traditional drugs taken by our patients was detected with thin-layer chromatography (TLC) scan.. AAN might be divided the following three types: (1) acute AAN (n = 4): acute tubular necrosis and acute renal failure were its pathological and clinical characters, respectively. (2) tubular dysfunctional AAN (n = 7): tubular degradation with atrophy, and renal tubular acidosis and/or Fanconi syndrome were its main pathological and clinical manifestations, respectively. (3) chronic AAN (n = 47): renal interstitial fibrosis with few infiltrated mononuclear cells, and chronically progressive renal failure were its dominant pathological and clinical findings, respectively. Steroid therapy was tried to treat some patients with AAN, and a few patients in the first two types obtained some good effects. AA component was demonstrated by the TLC scan in the drugs taken by our patients.. Chinese traditional drugs containing AA are able to cause a special tubulointerstitial nephropathy which may be classified three types with different outcome. To definite effects of steroid on AAN still need to be proved by further studies.

Topics: Adult; Aristolochic Acids; Carcinogens; Chronic Disease; Drugs, Chinese Herbal; Female; Humans; Kidney Tubular Necrosis, Acute; Male; Middle Aged; Nephritis, Interstitial; Phenanthrenes

Chinese herbs nephropathy (CHN), a rapidly progressive interstitial fibrosis of the kidney, has been described in approximately 100 young Belgian women who had followed a slimming regimen containing some Chinese herbs. In 4 patients multifocal transitional cell carcinomas (TCC) were observed. Aristolochic acid (AA), suspected as the causal factor of CHN, is a well known carcinogen but its ability to induce fibrosis has never been demonstrated. The objective of this study was to evaluate the latter using doses of AA, durations of intoxication and delays of sacrifice known to yield tumours in rats. We also tested the hypothesis that a possible fibrogenic role of AA was enhanced by the other components of the slimming regimen. Male and female rats were treated orally with 10 mg isolated AA/kg per day for 5 days/week, or with approximately 0.15 mg AA/ kg per day 5 days/week contained in the herbal powder together with the other components prescribed in the slimming pills for 3 months. The animals were killed respectively 3 and 11 months later. At sacrifice, animals in both groups had developed the expected tumours but not fibrosis of the renal interstitium. Whether the fibrotic response observed in man is due to species and/or strain related differences in the response to AA or to other factors, remains to be determined. Interestingly, despite the addition of fenfluramine and diethylpropion, two drugs incriminated in the development of valvular heart disease, no cardiac abnormalities were observed.

Topics: Animals; Anti-Obesity Agents; Aristolochic Acids; Carcinogens; Drugs, Chinese Herbal; Female; Fibrin; Male; Nephritis, Interstitial; Phenanthrenes; Rats; Rats, Wistar; Stomach Neoplasms

Aristolochic acids are nitrophenanthrenes with a carboxylic acid fanction which have been found only among the Aristolochiaceae. In 1993, rapidly progressive interstitial renal fibrosis has been reported in women have been on a slimming regimen including Chinese herbal medicines in Belgium. In Japan, at the Kansai district, several cases of Chinese herbs nephropathy have been reported quite recently. In both cases, aristolochic acids was detected in the Chinese herbal medicines taken by the patients. We have Asiasarum Root, a species of Aristolochiaceae, in Japanese Pharmacopoeia. Therefore, we quantitatively analysed aristolochic acids in these herbal medicines and related plants.

Topics: Antineoplastic Agents; Aristolochic Acids; Drugs, Chinese Herbal; Female; Humans; Nephritis, Interstitial; Phenanthrenes; Plants, Medicinal