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Wang C, Liu Y, Han J, Li W, Sun J, Wang Y. Detection and Removal of Aristolochic Acid in Natural Plants, Pharmaceuticals, and Environmental and Biological Samples: A Review. Molecules 2023; 29:81. [PMID: 38202664 PMCID: PMC10779802 DOI: 10.3390/molecules29010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Aristolochic acids (AAs) are a toxic substance present in certain natural plants. Direct human exposure to these plants containing AAs leads to a severe and irreversible condition known as aristolochic acid nephropathy (AAN). Additionally, AAs accumulation in the food chain through environmental mediators can trigger Balkan endemic nephropathy (BEN), an environmental variant of AAN. This paper presents a concise overview of the oncogenic pathways associated with AAs and explores the various routes of environmental exposure to AAs. The detection and removal of AAs in natural plants, drugs, and environmental and biological samples were classified and summarized, and the advantages and disadvantages of the various methods were analyzed. It is hoped that this review can provide effective insights into the detection and removal of AAs in the future.
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Affiliation(s)
- Changhong Wang
- School of Environmental Science and Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250353, China; (C.W.); (Y.L.); (J.H.)
| | - Yunchao Liu
- School of Environmental Science and Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250353, China; (C.W.); (Y.L.); (J.H.)
| | - Jintai Han
- School of Environmental Science and Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250353, China; (C.W.); (Y.L.); (J.H.)
| | - Wenying Li
- College of Geography and Environment, Shandong Normal University, Jinan 250000, China;
| | - Jing Sun
- School of Environmental Science and Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250353, China; (C.W.); (Y.L.); (J.H.)
| | - Yinan Wang
- Key Laboratory of Fine Chemicals in Universities of Shandong, Jinan Engineering Laboratory for Multi-Scale Functional Materials, School of Chemistry and Chemical Engineering, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250353, China
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Lukinich-Gruia AT, Nortier J, Pavlović NM, Milovanović D, Popović M, Drăghia LP, Păunescu V, Tatu CA. Aristolochic acid I as an emerging biogenic contaminant involved in chronic kidney diseases: A comprehensive review on exposure pathways, environmental health issues and future challenges. CHEMOSPHERE 2022; 297:134111. [PMID: 35231474 DOI: 10.1016/j.chemosphere.2022.134111] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 06/14/2023]
Abstract
Described in the 1950s, Balkan Endemic Nephropathy (BEN) has been recognized as a chronic kidney disease (CKD) with clinical peculiarities and multiple etiological factors. Environmental contaminants - aromatic compounds, mycotoxins and phytotoxins like aristolochic acids (AAs) - polluting food and drinking water sources, were incriminated in BEN, due to their nephrotoxic and carcinogenic properties. The implication of AAs in BEN etiology is currently a highly debated topic due to the fact that they are found within the Aristolochiaceae plants family, used around the globe as traditional medicine and they were also incriminated in Aristolochic Acid Nephropathy (AAN). Exposure pathways have been investigated, but it is unclear to what extent AAs are acting alone or in synergy with other cofactors (environmental, genetics) in triggering kidney damage. Experimental studies strengthen the hypothesis that AAI, the most studied compound in the AAs class, is a significant environmental contaminant and a most important causative factor of BEN. The aim of this review is to compile information about the natural exposure pathways to AAI, via traditional medicinal plants, soil, crop plants, water, food, air. Data that either supports or contradicts the AAI theory concerning BEN etiology was consolidated and available solutions to reduce human exposure were discussed. Because AAI is a phytotoxin with physicochemical properties that allow its transportation in environmental matrices from different types of areas (endemic, nonendemic), and induce CKDs (BEN, AAN) and urinary cancers through bioaccumulation, this review aims to shed a new light on this compound as a biogenic emerging pollutant.
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Affiliation(s)
- Alexandra T Lukinich-Gruia
- OncoGen Centre, Clinical County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300723, Timisoara, Romania.
| | - Joëlle Nortier
- Nephrology Department, Brugmann Hospital & Laboratory of Experimental Nephrology, Faculty of Medicine, Université Libre de Bruxelles, Belgium.
| | - Nikola M Pavlović
- Kidneya Therapeutics, Klare Cetkin 11, 11070, Belgrade, Serbia; University of Niš, Univerzitetski Trg 2, 18106, Niš, Serbia.
| | | | - Miloš Popović
- Department for Biology and Ecology, Faculty of Natural Sciences and Mathematics, University of Niš, Višegradska 33, 18000, Niš, Serbia.
| | - Lavinia Paula Drăghia
- OncoGen Centre, Clinical County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300723, Timisoara, Romania.
| | - Virgil Păunescu
- OncoGen Centre, Clinical County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300723, Timisoara, Romania; Department of Immunology, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, Timisoara, 300041, Romania.
| | - Călin A Tatu
- OncoGen Centre, Clinical County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300723, Timisoara, Romania; Department of Immunology, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, Timisoara, 300041, Romania.
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Guo W, Zhang J, Sun Z, Orem WH, Tatu CA, Radulović NS, Milovanović D, Pavlović NM, Chan W. Analysis of Polycyclic Aromatic Hydrocarbons and Phthalate Esters in Soil and Food Grains from the Balkan Peninsula: Implication on DNA Adduct Formation by Aristolochic Acid I and Balkan Endemic Nephropathy. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:9024-9032. [PMID: 34125507 DOI: 10.1021/acs.est.1c00648] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Balkan endemic nephropathy (BEN) is a chronic tubulointerstitial nephropathy affecting residents of rural farming areas in many Balkan countries. Although it is generally believed that BEN is an environmental disease caused by multiple geochemical factors with much attention on aristolochic acids (AAs), its etiology remains controversial. In this study, we tested the hypothesis that environmental contamination and subsequent food contamination by polycyclic aromatic hydrocarbons (PAHs) and phthalate esters are AA toxicity factors and important to BEN development. We identified significantly higher concentrations of phenanthrene, anthracene, diethyl phthalate (DEP), dibutyl phthalate (DBP), and benzyl butyl phthalate (BBP) in both maize and wheat grain samples collected from endemic villages than from nonendemic villages. Other PAHs and phthalate esters were also detected at higher concentrations in the soil samples from endemic villages. Subsequent genotoxicity testing of cultured human kidney cells showed an alarming phenomenon that phenanthrene, DEP, BBP, and DBP can interact synergistically with AAs to form elevated levels of AA-DNA adducts, which are associated with both the nephrotoxicity and carcinogenicity of AAs, further increasing their disease risks. This study provides direct evidence that prolonged coexposure to these environmental contaminants via dietary intake may lead to greater toxicity and accelerated development of BEN.
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Affiliation(s)
- Wanlin Guo
- Department of Chemistry and Division of Environment and Sustainability, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon 000000, Hong Kong
| | - Jiayin Zhang
- Department of Chemistry and Division of Environment and Sustainability, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon 000000, Hong Kong
| | - Zhihan Sun
- Department of Chemistry and Division of Environment and Sustainability, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon 000000, Hong Kong
| | - William H Orem
- U.S. Geological Survey, Reston, Virginia 20192, United States
| | - Calin A Tatu
- Department of Immunology, University of Medicine and Pharmacy ″Victor Babes″ Timisoara, Pta. E. Murgu No.2, 300041 Timisoara, Romania
| | - Niko S Radulović
- Faculty of Sciences and Mathematics, University of Niš, 18000 Niš, Serbia
| | | | | | - Wan Chan
- Department of Chemistry and Division of Environment and Sustainability, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon 000000, Hong Kong
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Wimalawansa SJ. Public health interventions for chronic diseases: cost-benefit modelizations for eradicating chronic kidney disease of multifactorial origin (CKDmfo/ CKDu) from tropical countries. Heliyon 2019; 5:e02309. [PMID: 31720441 PMCID: PMC6838989 DOI: 10.1016/j.heliyon.2019.e02309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/29/2019] [Accepted: 08/12/2019] [Indexed: 11/29/2022] Open
Abstract
Background In the mid-1970s, an unusual chronic kidney disease of multifactorial origin (CKDmfo), also known as CKD of unknown aetiology (CKDu), began to manifest in several economically poor, tropical, agricultural countries. This preventable, environmentally induced, occupational disease affects several peri-equatorial countries; it first manifested in Sri Lanka in the mid-1990s. The study goal was to estimate the costs of eradicating CKDmfo and the resulting cost savings, using CKDmfo in Sri Lanka as an example. This chronic disease model is applicable to CKDu and few other chronic diseases in other countries. Methodology Eight cost-effective, key interventions were identified that are essential to eradicate CKDmfo. A systematic assessment was performed on these interventions (including providing clean water, behavioural and lifestyle changes, alleviating malnutrition, reducing irresponsible and overuse of agrochemicals, and cost-effective treatment options), the cost of prevention, and the resultant cost savings. A cost–benefit analysis was based on the data collected during the past 20 years of work in Sri Lanka. Findings The yearly cost required to eradicate the disease was approximately one-tenth of the current annual operating and opportunity costs due to CKDmfo. Analysis indicates that implementation of a focussed chronic disease-prevention plan using essential multiple interventions, CKDmfo can be eradicated within 15 years. This includes provision of potable water; real-time disease surveillance program; public and professional education; prevention of environmental pollution; alleviation of poverty and associated malnutrition; sustainable self-sufficiency in food, clean water, energy, and security; diversification of economy and job opportunities; sustainable economic development; regionwide programs of effective screening, early diagnosis and intervention to reverse the disease progression at earliest possible; and effective treatment of CKDmfo. Interpretation This analysis is based on multiple population-level, chronic disease-eradication strategies that include an interdisciplinary, geographic information system (GIS)-based, regionwide, long-term research and intervention program; economic diversification; and environmental, socioeconomic, and behavioural improvements. Such an approach will facilitate identification of root causes and key risk factors, enabling implementation of cost-effective longer-term interventions to eradicate chronic diseases, applicable to other countries as well.
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Stiborová M, Arlt VM, Schmeiser HH. Balkan endemic nephropathy: an update on its aetiology. Arch Toxicol 2016; 90:2595-2615. [PMID: 27538407 PMCID: PMC5065591 DOI: 10.1007/s00204-016-1819-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/04/2016] [Indexed: 02/02/2023]
Abstract
Balkan endemic nephropathy (BEN) is a unique, chronic renal disease frequently associated with upper urothelial cancer (UUC). It only affects residents of specific farming villages located along tributaries of the Danube River in Bosnia-Herzegovina, Croatia, Macedonia, Serbia, Bulgaria, and Romania where it is estimated that ~100,000 individuals are at risk of BEN, while ~25,000 have the disease. This review summarises current findings on the aetiology of BEN. Over the last 50 years, several hypotheses on the cause of BEN have been formulated, including mycotoxins, heavy metals, viruses, and trace-element insufficiencies. However, recent molecular epidemiological studies provide a strong case that chronic dietary exposure to aristolochic acid (AA) a principal component of Aristolochia clematitis which grows as a weed in the wheat fields of the endemic regions is the cause of BEN and associated UUC. One of the still enigmatic features of BEN that need to be resolved is why the prevalence of BEN is only 3-7 %. This suggests that individual genetic susceptibilities to AA exist in humans. In fact dietary ingestion of AA along with individual genetic susceptibility provides a scenario that plausibly can explain all the peculiarities of BEN such as geographical distribution and high risk of urothelial cancer. For the countries harbouring BEN implementing public health measures to avoid AA exposure is of the utmost importance because this seems to be the best way to eradicate this once mysterious disease to which the residents of BEN villages have been completely and utterly at mercy for so long.
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Affiliation(s)
- Marie Stiborová
- Department of Biochemistry, Faculty of Science, Charles University, Albertov 2030, 128 40, Prague 2, Czech Republic.
| | - Volker M Arlt
- Analytical and Environmental Sciences Division, MRC-PHE Centre for Environmental and Health, King's College London, 150 Stamford Street, London, SE1 9NH, UK
- NIHR Health Protection Research Unit in Health Impact of Environmental Hazards at King's College London in partnership with Public Health England, Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, UK
| | - Heinz H Schmeiser
- Division of Radiopharmaceutical Chemistry (E030), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
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Kataria A, Trasande L, Trachtman H. The effects of environmental chemicals on renal function. Nat Rev Nephrol 2015; 11:610-25. [PMID: 26100504 DOI: 10.1038/nrneph.2015.94] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The global incidence of chronic kidney disease (CKD) is increasing among individuals of all ages. Despite advances in proteomics, genomics and metabolomics, there remains a lack of safe and effective drugs to reverse or stabilize renal function in patients with glomerular or tubulointerstitial causes of CKD. Consequently, modifiable risk factors that are associated with a progressive decline in kidney function need to be identified. Numerous reports have documented the adverse effects that occur in response to graded exposure to a wide range of environmental chemicals. This Review summarizes the effects of such chemicals on four aspects of cardiorenal function: albuminuria, glomerular filtration rate, blood pressure and serum uric acid concentration. We focus on compounds that individuals are likely to be exposed to as a consequence of normal consumer activities or medical treatment, namely phthalates, bisphenol A, polyfluorinated alkyl acids, dioxins and furans, polycyclic aromatic hydrocarbons and polychlorinated biphenyls. Environmental exposure to these chemicals during everyday life could have adverse consequences on renal function and might contribute to progressive cumulative renal injury over a lifetime. Regulatory efforts should be made to limit individual exposure to environmental chemicals in an attempt to reduce the incidence of cardiorenal disease.
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Affiliation(s)
- Anglina Kataria
- Department of Pediatrics, Clinical and Translational Science Institute, New York University School of Medicine, 227 East 30th Street, Room #733, New York, NY 10016, USA
| | - Leonardo Trasande
- Department of Pediatrics, Clinical and Translational Science Institute, New York University School of Medicine, 227 East 30th Street, Room #733, New York, NY 10016, USA
| | - Howard Trachtman
- Department of Pediatrics, Clinical and Translational Science Institute, New York University School of Medicine, 227 East 30th Street, Room #733, New York, NY 10016, USA
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Escalating chronic kidney diseases of multi-factorial origin in Sri Lanka: causes, solutions, and recommendations. Environ Health Prev Med 2014. [PMID: 25239006 DOI: 10.1007/s12199‐014‐0395‐5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
During the last two decades, Sri Lanka, located close to the equator, has experienced an escalating incidence of chronic kidney disease (CKD) of unknown aetiology (CKDue) in dry zonal areas. Similar incidences of unusual CKDs have been reported in the dry zonal, agricultural areas of several other equatorial countries. In Sri Lanka, the incidence of CKDue is highest in the North Central Province (NCP), where approximately 45 % of the country's paddy fields are located. However, in recent years, the disease has spread into areas adjacent to as well as distant from the NCP. The cause of CKD in Sri Lanka is unknown, and may likely due to interactions of different potential agents; thus, CKD is of multi-factorial origin (CKD-mfo). These factors include, the negative effects from overuse of agrochemicals. Nevertheless, the potential interactions and synergism between probable agents have not been studied. This systematic review discusses the proposed hypotheses and causes of CKD-mfo in Sri Lanka, and ways to decrease the incidence of this disease and to eradicate it, and provide some recommendations. During the past decade, a number of groups have investigated this disorder using different methodologies and reported various correlations, but failed to find a cause. Research has focussed on the contamination of water with heavy metals, agrochemicals, hard water, algae, ionicity, climate change, and so forth. Nevertheless, the levels of any of the pollutants or conditions reported in water in NPC are inconsistent not correlated with the prevalence of the disease, and are too low to be the sole cause of CKD-mfo. Meanwhile, several nephrotoxins prevalent in the region, including medications, leptospirosis, toxic herbs, illicit alcohol, locally grown tobacco, and petrochemicals, as well as the effects of changed habits occured over the past four decades have not been studied to date. Taken together, the geographical distribution and overall findings indicate that combinations of factors and/or their interactions are likely to precipitate CKD-mfo, which kills more than 5,000 people annually in Sri Lanka; most victims are middle-aged male farmers. Much anecdotal evidence from this region suggests that consumption of contaminated water is the most likely source of this deadly disease. Although the aetiology is unknown, prevention of this "environmentally acquired" disease seems relatively straightforward. Solutions include (a) preventing environmental pollution, (b) stopping the irresponsible use and decreasing the usage of agrochemicals, and encouraging the use of environmentally friendly agricultural methods, (c) taking proper precautions when using agrochemicals and safe disposal of their containers, (d) changing the risky behaviour of farmers and educating them to preserve the environment, and (e) providing clean potable water to all affected regions. Implementing a well-coordinated, in-depth, region-wide, broad-based research study together with a long-term effective surveillance programme across the country is essential to curbing this disease. Unless firm actions are taken promptly, more than three million healthy people in the country, live in agricultural regions, are at risk for contracting CKD-mfo and succumb to premature deaths, which are preventable.
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Escalating chronic kidney diseases of multi-factorial origin in Sri Lanka: causes, solutions, and recommendations. Environ Health Prev Med 2014; 19:375-94. [PMID: 25239006 DOI: 10.1007/s12199-014-0395-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/04/2014] [Indexed: 10/24/2022] Open
Abstract
During the last two decades, Sri Lanka, located close to the equator, has experienced an escalating incidence of chronic kidney disease (CKD) of unknown aetiology (CKDue) in dry zonal areas. Similar incidences of unusual CKDs have been reported in the dry zonal, agricultural areas of several other equatorial countries. In Sri Lanka, the incidence of CKDue is highest in the North Central Province (NCP), where approximately 45 % of the country's paddy fields are located. However, in recent years, the disease has spread into areas adjacent to as well as distant from the NCP. The cause of CKD in Sri Lanka is unknown, and may likely due to interactions of different potential agents; thus, CKD is of multi-factorial origin (CKD-mfo). These factors include, the negative effects from overuse of agrochemicals. Nevertheless, the potential interactions and synergism between probable agents have not been studied. This systematic review discusses the proposed hypotheses and causes of CKD-mfo in Sri Lanka, and ways to decrease the incidence of this disease and to eradicate it, and provide some recommendations. During the past decade, a number of groups have investigated this disorder using different methodologies and reported various correlations, but failed to find a cause. Research has focussed on the contamination of water with heavy metals, agrochemicals, hard water, algae, ionicity, climate change, and so forth. Nevertheless, the levels of any of the pollutants or conditions reported in water in NPC are inconsistent not correlated with the prevalence of the disease, and are too low to be the sole cause of CKD-mfo. Meanwhile, several nephrotoxins prevalent in the region, including medications, leptospirosis, toxic herbs, illicit alcohol, locally grown tobacco, and petrochemicals, as well as the effects of changed habits occured over the past four decades have not been studied to date. Taken together, the geographical distribution and overall findings indicate that combinations of factors and/or their interactions are likely to precipitate CKD-mfo, which kills more than 5,000 people annually in Sri Lanka; most victims are middle-aged male farmers. Much anecdotal evidence from this region suggests that consumption of contaminated water is the most likely source of this deadly disease. Although the aetiology is unknown, prevention of this "environmentally acquired" disease seems relatively straightforward. Solutions include (a) preventing environmental pollution, (b) stopping the irresponsible use and decreasing the usage of agrochemicals, and encouraging the use of environmentally friendly agricultural methods, (c) taking proper precautions when using agrochemicals and safe disposal of their containers, (d) changing the risky behaviour of farmers and educating them to preserve the environment, and (e) providing clean potable water to all affected regions. Implementing a well-coordinated, in-depth, region-wide, broad-based research study together with a long-term effective surveillance programme across the country is essential to curbing this disease. Unless firm actions are taken promptly, more than three million healthy people in the country, live in agricultural regions, are at risk for contracting CKD-mfo and succumb to premature deaths, which are preventable.
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Bui‐Klimke T, Wu F. Evaluating weight of evidence in the mystery of Balkan endemic nephropathy. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2014; 34:1688-705. [PMID: 24954501 PMCID: PMC4199864 DOI: 10.1111/risa.12239] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Balkan endemic nephropathy (BEN) is a chronic, progressive wasting disease of the kidneys, endemic in certain rural regions of the Balkan nations Croatia, Serbia, Bulgaria, and Romania. It is irreversible and ultimately fatal. Though this disease was first described in the 1950s, its causes have been a mystery and a source of much academic and clinical contention. Possible etiologic agents that have been explored include exposure to metals and metalloids, viruses and bacteria, and the dietary toxins aristolochic acid (AA) and ochratoxin A (OTA). AA is a toxin produced by weeds of the genus Aristolochia, common in Balkan wheat fields. Aristolochia seeds may intermingle with harvested grains and thus inadvertently enter human diets. OTA is a mycotoxin (fungal toxin) common in many foods, including cereal grains. In this study, we analyzed the weight of evidence for each of the suspected causes of BEN using the Bradford Hill criteria (BHC): nine conditions that determine weight of evidence for a causal relationship between an agent and a disease. Each agent postulated to cause BEN was evaluated using the nine criteria, and for each criterion was given a rating based on the strength of the association between exposure to the substance and BEN. From the overall available scientific evidence for each of these suspected risk factors, AA is the agent with the greatest weight of evidence in causing BEN. We describe other methods for testing causality from epidemiological studies, which support this conclusion of AA causing BEN.
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Affiliation(s)
- Travis Bui‐Klimke
- University of Pittsburgh, Department of Environmental and Occupational Health100 Technology Dr.PittsburghPA15219USA
| | - Felicia Wu
- Department of Food Science and Human NutritionMichigan State UniversityEast LansingMI48824USA
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Maharaj SVM. Limitations and plausibility of the Pliocene lignite hypothesis in explaining the etiology of Balkan endemic nephropathy. INTERNATIONAL JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HEALTH 2014; 20:77-91. [PMID: 24075451 DOI: 10.1179/2049396713y.0000000046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Balkan endemic nephropathy (BEN) is a chronic, tubulointerstitial renal disease often accompanied by urothelial cancer that has a lethality of nearly 100%. INTRODUCTION One of the many factors that have been proposed to play an etiological role in BEN is exposure to organic compounds from Pliocene lignite coal deposits via the drinking water in endemic areas. OBJECTIVES The objective of this study was to systematically evaluate the role of the tenets of the Pliocene lignite hypothesis in the etiology of BEN in order to provide an improved understanding of the hypothesis for colleagues and patients alike. METHODS A comprehensive compilation of the possible limitations of the hypothesis, with each limitation addressed in turn is presented. RESULTS The Pliocene lignite hypothesis can best account for, is consistent with, or has the potential to explain the evidence associated with the myriad of factors related to BEN. CONCLUSIONS Residents of endemic areas are exposed to complex mixtures containing hundreds of organic compounds at varying doses and their potentially more toxic (including nephrotoxic) and/or carcinogenic metabolites; however, a multifactorial etiology of BEN appears most likely.
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Maharaj SVM, Orem WH, Tatu CA, Lerch HE, Szilagyi DN. Organic compounds in water extracts of coal: links to Balkan endemic nephropathy. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2014; 36:1-17. [PMID: 23515665 PMCID: PMC3880671 DOI: 10.1007/s10653-013-9515-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 03/02/2013] [Indexed: 06/01/2023]
Abstract
The Pliocene lignite hypothesis is an environmental hypothesis that has been proposed to explain the etiology of Balkan endemic nephropathy (BEN). Aqueous leaching experiments were conducted on a variety of coal samples in order to simulate groundwater leaching of organic compounds, and to further test the role of the Pliocene lignite hypothesis in the etiology of BEN. Experiments were performed on lignite coal samples from endemic BEN areas in Romania and Serbia, and lignite and bituminous coals from nonendemic regions in Romania and the USA. Room temperature, hot water bath, and Soxhlet aqueous extraction experiments were conducted between 25 and 80 °C, and from 5 to 128 days in duration. A greater number of organic compounds and in higher concentrations were present in all three types of leaching experiments involving endemic area Pliocene lignite samples compared to all other coals examined. A BEN causing molecule or molecules may be among phenols, PAHs, benzenes, and/or lignin degradation compounds. The proposed transport pathway of the Pliocene lignite hypothesis for organic compound exposure from endemic area Pliocene lignite coals to well and spring drinking water, is likely. Aromatic compounds leached by groundwater from Pliocene lignite deposits in the vicinity of endemic BEN areas may play a role in the etiology of the disease. A better understanding of organic compounds leached by groundwater from Pliocene lignite deposits may potentially lead to the identification and implementation of effective strategies for the prevention of exposure to the causative agent(s) for BEN, and in turn, prevention of the disease.
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Stefanovic V, Polenakovic M, Toncheva D. Urothelial carcinoma associated with Balkan endemic nephropathy. A worldwide disease. ACTA ACUST UNITED AC 2011; 59:286-91. [DOI: 10.1016/j.patbio.2009.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 05/15/2009] [Indexed: 11/15/2022]
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Structural and functional characteristics of urinary tract in offspring of Balkan endemic nephropathy patients. SRP ARK CELOK LEK 2010; 138:204-9. [DOI: 10.2298/sarh1004204r] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Balkan endemic nephropathy (BEN) is a familial chronic progressive tubulointerstitial disease of unknown aetiology that occurs with high prevalence in endemic rural environments of Serbia, Bosnia and Herzegovina, Croatia, Bulgaria and Romania. It has been documented only in adults. Objective. The aim of this study was to examine clinical markers of BEN in children and adolescent offspring of BEN patients. Methods. Prospective clinical trial involved two groups of children and adolescents: I consisted of 30 offspring of BEN patients and II of 29 offspring of non-BEN dialysis patients, both of them living in the same South Morava region of Serbia. All of them were healthy at the time of the investigation, not receiving any drugs. The study included personal and family history, physical examination, comprehensive laboratory analyses and renal ultrasound. Blood pressure (BP) was determined by using casual BP and 24 h ABPM in subjects older than 5 years. Urinary proteins were investigated by analysing microalbumin, alfa 1 microglobulin, beta 2 microglobulin and SDS-PAGE electrophoresis. GFR was measured by estimated creatinine clearance and by serum Cystatin C concentrations. Results. There were no statistically significant differences in age, gender, history of urinary tract infections or functional voiding disorders between these two groups. All of the studied subjects had normal BP and GFR. Renal ultrasound was abnormal only in BEN offspring (6.66%) as well as increased urine concentrations of microalbumin (3.3%), alpha 1 microglobulin (10%) and beta 2 microglobulin (13.3%) while low molecular protein (<66,000 D) was prevalent in BEN compared with non- BEN offspring (21.43% vs. 3.7%). Conclusion. Renal abnormalities in offspring of BEN patients may be an early marker of BEN. This has to be confirmed in long term follow-up of a greater number of BEN paediatric offspring.
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Genetic clues to the etiology of Balkan endemic nephropathy: Investigating the role of ACE and AT1R polymorphisms. ARCH BIOL SCI 2010. [DOI: 10.2298/abs1004957k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Balkan endemic nephropathy (BEN) was recognized as a distinct entity more
than 50 years ago, but the exact environmental and genetic causes of the
disease remain elusive. Considering the role of the renin-angiotensin system
(RAS) in the emergence of various nephropathies, in the present study we
evaluated the possible association with BEN of polymorphisms in two RAS
genes: I/D ACE (an angiotensin-converting enzyme) and A1166C AT1R (an
angiotensin type 1 receptor). The study groups consisted of 48 BEN patients
from the endemic region in the district of Kolubara, Serbia, 33 patients with
other nephropathies and 42 healthy individuals. The ACE DD genotype was
significantly more represented in the NBEN group (OR=5.447;
95%CI=1.862-15.932, p<0.01). The frequency of the AT1R CC genotype was higher
in BEN patients compared to controls (0.104 vs. 0.048), but the difference
was not significant. Though the analyzed polymorphisms are associated with
certain nephropathies, we found no support for their specific role in BEN
susceptibility.
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Bamias G, Boletis J. Balkan nephropathy: evolution of our knowledge. Am J Kidney Dis 2008; 52:606-616. [PMID: 18725017 PMCID: PMC7115735 DOI: 10.1053/j.ajkd.2008.05.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 05/08/2008] [Indexed: 11/24/2022]
Abstract
Balkan endemic nephropathy (BEN), originally described in the late 1950s as a chronic tubulointerstitial kidney disease, is identified by its unique epidemiological features. The most remarkable characteristic of BEN is the focal topographical nature that characterizes its occurrence at the global, national, and even household level. BEN affects only certain endemic rural foci along tributaries of the Danube River in the Balkan countries of Bosnia, Bulgaria, Croatia, Romania, and Serbia. The spatial distribution has remained astonishingly unchanged with time because the disease affects the same endemic clusters as 50 years ago. The natural course of the disease is characterized by universal development of end-stage renal disease and the frequent development of upper urinary tract tumors, posing a substantial disease burden to the afflicted areas. The greatest challenge in the study of BEN has been the elucidation of its cause. The unique features of the disease, in particular its endemic nature and the long incubation period required for the disease to develop, have led to the proposal that BEN represents a unique environmental disease. The quest for the responsible environmental factor has been long and diverse, and although no definitive answer has been provided to date, converging lines of evidence support the theory that long-term consumption of food contaminated with aristolochic acid underlies the pathogenesis of BEN. The present review describes the evolution of our knowledge of BEN in relation to the development of the main theories for its pathogenesis.
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Affiliation(s)
- Giorgos Bamias
- First Department of Propaedeutic Medicine, Laikon Hospital, Athens, Greece
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