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Lee JH, Calcagno C, Feuerstein IM, Solomon J, Mani V, Huzella L, Castro MA, Laux J, Reeder RJ, Kim DY, Worwa G, Thomasson D, Hagen KR, Ragland DR, Kuhn JH, Johnson RF. Magnetic Resonance Imaging for Monitoring of Hepatic Disease Induced by Ebola Virus: a Nonhuman Primate Proof-of-Concept Study. Microbiol Spectr 2023; 11:e0353822. [PMID: 37184428 PMCID: PMC10269877 DOI: 10.1128/spectrum.03538-22] [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: 09/01/2022] [Accepted: 04/14/2023] [Indexed: 05/16/2023] Open
Abstract
Severe liver impairment is a well-known hallmark of Ebola virus disease (EVD). However, the role of hepatic involvement in EVD progression is understudied. Medical imaging in established animal models of EVD (e.g., nonhuman primates [NHPs]) can be a strong complement to traditional assays to better investigate this pathophysiological process in vivo and noninvasively. In this proof-of-concept study, we used longitudinal multiparametric magnetic resonance imaging (MRI) to characterize liver morphology and function in nine rhesus monkeys after exposure to Ebola virus (EBOV). Starting 5 days postexposure, MRI assessments of liver appearance, morphology, and size were consistently compatible with the presence of hepatic edema, inflammation, and congestion, leading to significant hepatomegaly at necropsy. MRI performed after injection of a hepatobiliary contrast agent demonstrated decreased liver signal on the day of euthanasia, suggesting progressive hepatocellular dysfunction and hepatic secretory impairment associated with EBOV infection. Importantly, MRI-assessed deterioration of biliary function was acute and progressed faster than changes in serum bilirubin concentrations. These findings suggest that longitudinal quantitative in vivo imaging may be a useful addition to standard biological assays to gain additional knowledge about organ pathophysiology in animal models of EVD. IMPORTANCE Severe liver impairment is a well-known hallmark of Ebola virus disease (EVD), but the contribution of hepatic pathophysiology to EVD progression is not fully understood. Noninvasive medical imaging of liver structure and function in well-established animal models of disease may shed light on this important aspect of EVD. In this proof-of-concept study, we used longitudinal magnetic resonance imaging (MRI) to characterize liver abnormalities and dysfunction in rhesus monkeys exposed to Ebola virus. The results indicate that in vivo MRI may be used as a noninvasive readout of organ pathophysiology in EVD and may be used in future animal studies to further characterize organ-specific damage of this condition, in addition to standard biological assays.
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Affiliation(s)
- Ji Hyun Lee
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Claudia Calcagno
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Irwin M. Feuerstein
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Jeffrey Solomon
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, Maryland, USA
| | - Venkatesh Mani
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Louis Huzella
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Marcelo A. Castro
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Joseph Laux
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Rebecca J. Reeder
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Dong-Yun Kim
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Gabriella Worwa
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - David Thomasson
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Katie R. Hagen
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Danny R. Ragland
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Jens H. Kuhn
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
| | - Reed F. Johnson
- Integrated Research Facility at Fort Detrick, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
- Emerging Viral Pathogens Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fort Detrick, Frederick, Maryland, USA
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Dittrich D, Maskalan M, Kastelan Z, Palenkic H, Grubic Z. The role of HLA in Balkan endemic nephropathy. Gene 2020; 767:145179. [PMID: 33002571 DOI: 10.1016/j.gene.2020.145179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022]
Abstract
Balkan endemic nephropathy (BEN), a progressive chronic tubulointerstitial disease, occurs in the endemic focus of Croatia in a population of about 10,000 inhabitants. One of its most peculiar characteristics is a strong association with upper tract urothelial carcinoma (UTUC). Despite a high number of studies, currently there are insufficient data about the association of BEN and HLA genes. The aim of this study was to investigate the polymorphism of HLA-A, -B, and -DRB1 alleles and haplotypes among BEN patients and to determine whether an association between HLA and BEN exists. In this study, we investigated HLA-A, -B, and -DRB1 alleles and haplotypes in a population of patients with BEN (N = 111) and matched healthy controls (N = 190). All individuals were tested by PCR-SSO and PCR-SSP methods to assess the possible contribution of HLA alleles and haplotypes to the development of/protection from BEN. Our results showed a positive association between the presence of HLA-B*35:02 and DRB1*04:02 alleles and BEN (P = 0.0179 and P = 0.0151, respectively) in contrast to the protective effect of HLA-A*01:01, B*27:05 and B*57:01 alleles (P = 0.0111, P = 0.0330 and P = 0.0318, respectively). Moreover, when BEN patients' HLA haplotypes were compared to controls, two haplotypes were associated with BEN susceptibility among Croatians (HLA-A*02:01~B*08:01~DRB1*03:01 and HLA-A*02:01~B*27:02~DRB1*16:01, P = 0.0064 and P = 0.0023, respectively), while haplotypes HLA-A*02:01~B*27:05~DRB1*01:01 and HLA-A*02:01~B*38:01~DRB1*13:01 each showed a possible protective effect (P = 0.0495). Our results point toward genetic susceptibility to BEN and observed differences in both susceptible/protective HLA profiles indicate the necessity of further studies in order to elucidate the pathogenesis of this disease.
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Affiliation(s)
- Damir Dittrich
- Department of Urology, General Hospital "Dr. Josip Bencevic", Slavonski Brod, Croatia
| | - Marija Maskalan
- Tissue Typing Centre, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Zeljko Kastelan
- Department of Urology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Hrvoje Palenkic
- Department of Surgery, General Hospital "Dr. Josip Bencevic", Slavonski Brod, Croatia
| | - Zorana Grubic
- Tissue Typing Centre, University Hospital Centre Zagreb, Zagreb, Croatia.
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Jelaković B, Dika Ž, Arlt VM, Stiborova M, Pavlović NM, Nikolić J, Colet JM, Vanherweghem JL, Nortier JL. Balkan Endemic Nephropathy and the Causative Role of Aristolochic Acid. Semin Nephrol 2019; 39:284-296. [DOI: 10.1016/j.semnephrol.2019.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Gruia AT, Oprean C, Ivan A, Cean A, Cristea M, Draghia L, Damiescu R, Pavlovic NM, Paunescu V, Tatu CA. Balkan endemic nephropathy and aristolochic acid I: an investigation into the role of soil and soil organic matter contamination, as a potential natural exposure pathway. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2018; 40:1437-1448. [PMID: 29288399 DOI: 10.1007/s10653-017-0065-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 12/22/2017] [Indexed: 06/07/2023]
Abstract
Aristolochic acids (AAs) are carcinogenic and nephrotoxic plant alkaloids present in Aristolochia species, used in traditional medicine. Recent biomolecular and environmental studies have incriminated these toxins as an etiological agent in Balkan endemic nephropathy (BEN), a severe kidney disease occurring in the Balkan Peninsula. The questions on how the susceptible populations are exposed to these toxins have not yet been clearly answered. Exposure to AAs through the food chain, and environmental pollution (soil/dust), could provide an explanation for the presence of BEN in the countries where no folkloric use of the plant has been documented (Bulgaria, Croatia). Additional exposure pathways are likely to occur, and we have shown previously that AAs can contaminate crop plants through absorption from soil, under controlled laboratory environment. Here, we attempt to provide additional support to this potential exposure pathway, by revealing the presence of AAI in soil and soil organic matter samples collected from BEN and non-BEN areas. The samples were processed in order to be analyzed by high-pressure liquid chromatography, and ion trap mass spectrometry. Our results showed the presence of AAI in small concentrations, both in BEN and non-BEN soils, especially where Aristolochia plants and seeds were present.
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Affiliation(s)
- Alexandra T Gruia
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
| | - Camelia Oprean
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania.
- Department of Environmental and Food Chemistry, Faculty of Pharmacy, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, 300041, Timisoara, Romania.
| | - Alexandra Ivan
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
- Department of Biology and Environmental Health, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, 300041, Timisoara, Romania
| | - Ada Cean
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
| | - Mirabela Cristea
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
| | - Lavinia Draghia
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
- Department of Immunology, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, 300041, Timisoara, Romania
| | - Roxana Damiescu
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
| | | | - Virgil Paunescu
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
- Department of Immunology, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, 300041, Timisoara, Romania
| | - Calin A Tatu
- OncoGen Centre, County Hospital "Pius Branzeu", Blvd. Liviu Rebreanu 156, 300736, Timisoara, Romania
- Department of Biology and Environmental Health, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. 2, 300041, Timisoara, Romania
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Cukuranovic R, Ignjatovic I, Visnjic M, Velickovic LJ, Petrovic B, Potic M, Stefanovic V. Characteristics of Upper Urothelial Carcinoma in an Area of Balkan Endemic Nephropathy in South Serbia. A fifty-year Retrospective Study. TUMORI JOURNAL 2018; 96:674-9. [DOI: 10.1177/030089161009600505] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Upper urinary tract transitional cell carcinoma, a relatively rare tumor, is up to 100 times more frequent in regions with Balkan endemic nephropathy. Characteristics of transitional cell carcinoma in the endemic South Morava Region in Serbia in the previous 50 years were evaluated. Patients We analyzed 477 cases with pathologically confirmed transitional cell carcinoma who underwent surgery from 1957 to 2006: 91 from endemic, 106 from adjacent and 280 from control settlements. Cases in the study came from 10 endemic villages, 46 adjacent villages, 51 control villages and the city of Nis. Results The increase in number of transitional cell carcinoma from 1957 was followed by a peak between 1967 and 1978 (yearly incidence 21.9 per 100,000) and a slow decrease thereafter to 7.4 (1997–2006). In the control settlements, the increase was steady. Reduced kidney function at surgery was found in 58% of patients from endemic and in 20% from control settlements. Age at surgery has significantly increased from 52.3 and 51.5 (1957–1966) to 70.9 and 66.1 (1997–2006) for endemic and control settlements, respectively. The female sex was predominant in endemic and adjacent settlements and the male sex in control settlements. Transitional cell carcinoma from endemic settlements was of a lower grade in the period from 1957–1986, but in the period from 1987–2006 they were predominantly high grade. Low tumor stage (pTa-pT1) predominated in transitional cell carcinoma from the endemic and adjacent but not the control settlements in the period from 1957 to 1986. However, in the last 20 years, upper urinary tract transitional cell carcinoma stage increased, the highest in the period from 1997 to 2006 in all settlements studied. Conservative surgery was advocated for transitional cell carcinoma in Balkan endemic nephropathy areas up to 1996. Transitional cell carcinoma are now more malignant and more advanced than before, and a less aggressive approach is used only for absolute indications. Conclusions An increased number of transitional cell carcinoma in endemic settlements was observed, markedly decreasing in the last decade. An increasing age and a shorter survival were recorded in patients both from Balkan endemic nephropathy and control settlements. Sporadic cases upper urinary tract transitional cell carcinoma in settlements adjacent to endemic settlements were demonstrated. Free full text available at www.tumorionline.it
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Jelaković B, Vuković Lela I, Karanović S, Dika Ž, Kos J, Dickman K, Šekoranja M, Poljičanin T, Mišić M, Premužić V, Abramović M, Matijević V, Miletić Medved M, Cvitković A, Edwards K, Fuček M, Leko N, Teskera T, Laganović M, Čvorišćec D, Grollman AP. Chronic dietary exposure to aristolochic acid and kidney function in native farmers from a Croatian endemic area and Bosnian immigrants. Clin J Am Soc Nephrol 2015; 10:215-23. [PMID: 25587102 DOI: 10.2215/cjn.03190314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Improvements in agricultural practices in Croatia have reduced exposure to consumption of aristolochic acid-contaminated flour and development of endemic (Balkan) nephropathy. Therefore, it was hypothesized that Bosnian immigrants who settled in an endemic area in Croatia 15-30 years ago would be at lower risk of developing endemic nephropathy because of reduced exposure to aristolochic acid. To test this hypothesis, past and present exposure to aristolochic acid, proximal tubule damage as a hallmark of endemic nephropathy, and prevalence of CKD in Bosnian immigrants were analyzed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this cross-sectional observational study from 2005 to 2010, 2161 farmers were divided into groups: indigenous inhabitants from endemic nephropathy and nonendemic nephropathy villages and Bosnian immigrants; α-1 microglobulin-to-creatinine ratio >31.5 mg/g and eGFR<60 ml/min per 1.73 m(2) were considered to be abnormal. RESULTS CKD and proximal tubule damage prevalence was significantly lower in Bosnian immigrants than inhabitants of endemic nephropathy villages (6.9% versus 16.6%; P<0.001; 1.3% versus 7.3%; P=0.003, respectively); 20 years ago, Bosnian immigrants observed fewer Aristolochia clematitis in cultivated fields (41.9% versus 67.8%) and fewer seeds among wheat seeds (6.1% versus 35.6%) and ate more purchased than homemade bread compared with Croatian farmers from endemic nephropathy villages (38.5% versus 14.8%, P<0.001). Both Croatian farmers and Bosnian immigrants observe significantly fewer Aristolochia plants growing in their fields compared with 15-30 years ago. Prior aristolochic acid exposure was associated with proximal tubule damage (odds ratio, 1.64; 95% confidence interval, 1.04 to 2.58; P=0.02), whereas present exposure was not (odds ratio, 1.31; 95% confidence interval, 0.75 to 2.30; P=0.33). Furthermore, immigrant status was an independent negative predictor of proximal tubule damage (odds ratio, 0.40; 95% confidence interval, 0.19 to 0.86; P=0.02). CONCLUSIONS Bosnian immigrants and autochthonous Croats residing in endemic areas are exposed significantly less to ingestion of aristolochic acid than in the past. The prevalence of endemic nephropathy and its associated urothelial cancers is predicted to decrease over time.
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Affiliation(s)
- Bojan Jelaković
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | - Ivana Vuković Lela
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | - Sandra Karanović
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | - Živka Dika
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | - Jelena Kos
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | - Kathleen Dickman
- Department of Pharmacological Sciences, State University of New York at Stony Brook, Stony Brook, New York
| | - Maja Šekoranja
- Faculty for Natural Sciences, University of Zagreb, Zagreb, Croatia
| | | | | | - Vedran Premužić
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | | | | | | | - Ante Cvitković
- Institute for Public Health County Brodsko-Posavska, Slavonski Brod, Croatia
| | - Karen Edwards
- Department of Epidemiology, Genetic Epidemiology Research Institute, School of Medicine, University of California, Irvine, Irvine, CA; and
| | - Mirjana Fuček
- Clinical Laboratory Diagnostics, School of Medicine, University of Zagreb, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ninoslav Leko
- General Hospital, "Josip Benčević", Department of Internal Medicine, Dialysis Unit
| | - Tomislav Teskera
- General Hospital, "Josip Benčević", Department of Internal Medicine, Dialysis Unit
| | - Mario Laganović
- Departments of Nephrology, Hypertension, Dialysis and Transplantation and
| | - Dubravka Čvorišćec
- Clinical Laboratory Diagnostics, School of Medicine, University of Zagreb, University Hospital Center Zagreb, Zagreb, Croatia
| | - Arthur P Grollman
- Department of Pharmacological Sciences, State University of New York at Stony Brook, Stony Brook, New York
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Jelaković B, Nikolić J, Radovanović Z, Nortier J, Cosyns JP, Grollman AP, Bašić-Jukić N, Belicza M, Bukvić D, Čavaljuga S, Čvorišćec D, Cvitković A, Dika Ž, Dimitrov P, Đukanović L, Edwards K, Ferluga D, Fuštar-Preradović L, Gluhovschi G, Imamović G, Jakovina T, Kes P, Leko N, Medverec Z, Mesić E, Miletić-Medved M, Miller F, Pavlović N, Pasini J, Pleština S, Polenaković M, Stefanović V, Tomić K, Trnačević S, Vuković Lela I, Štern-Padovan R. Consensus statement on screening, diagnosis, classification and treatment of endemic (Balkan) nephropathy. Nephrol Dial Transplant 2014; 29:2020-7. [PMID: 24166461 PMCID: PMC4288114 DOI: 10.1093/ndt/gft384] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 08/07/2013] [Indexed: 11/14/2022] Open
Abstract
Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.
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Affiliation(s)
- Bojan Jelaković
- School of Medicine, University of Zagreb, Department for Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
| | - Jovan Nikolić
- Clinic of Urology Institute of Urology and Nephrology, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Joelle Nortier
- Department of Nephrology, Erasme Hospital Universite Libre Bruxelles, Bruxelles, Belgium
| | - Jean-Pierre Cosyns
- Department of Pathology, Cliniques Universitaires St-Luc Université Catholique de Louvain Medical School, Brussels, Belgium
| | - Arthur P. Grollman
- Department of Pharmacological Sciences, State University of New York at Stony Brook, New York, USA
| | - Nikolina Bašić-Jukić
- School of Medicine, University of Zagreb, Department for Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mladen Belicza
- Department for Pathology, Clinical Hospital ‘Sestre Milosrdnice’ University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Danica Bukvić
- Institute for Endemic Nephropathy, Lazarevac, Serbia
| | - Semra Čavaljuga
- Institute for Epidemiology, University of Sarajevo, Sarajevo, Bosnia and Hercegovina
| | - Dubravka Čvorišćec
- Department of Clinical Laboratory Diagnostics, University Hospital Center Zagreb, University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Ante Cvitković
- Institute for Public Health, Brodsko Posavska County, Slavonski Brod, Croatia
| | - Živka Dika
- School of Medicine, University of Zagreb, Department for Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
| | - Plamen Dimitrov
- Department of Biostatistics and Social Epidemiology, National Center for Public Health Protection, Sofia, Bulgaria
| | | | - Karen Edwards
- Department of Epidemiology and Institute for Public Health Genetics, School of Public Health and Community Medicine University of Washington, Seattle, WA, USA
| | - Dušan Ferluga
- School of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ljubica Fuštar-Preradović
- Department for Pathology and Forensic Medicine, General Hospital ‘Dr.Josip Benčević’ Slavonski Brod, Croatia
| | | | - Goran Imamović
- University Medical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Tratinčica Jakovina
- Department for Pathology and Forensic Medicine, General Hospital ‘Dr.Josip Benčević’ Slavonski Brod, Croatia
| | - Petar Kes
- School of Medicine, University of Zagreb, Department for Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ninoslav Leko
- Department for Nephrology, General Hospital ‘Dr.Josip Benčević’ Slavonski Brod, Slavonski Brod, Croatia
| | - Zvonimir Medverec
- Department for Urology, General Hospital ‘Dr. Josip Benčević’ Slavonski Brod, Slavonski Brod, Croatia
| | - Enisa Mesić
- University Medical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | | | - Frederick Miller
- Department of Pathology, State University of New York at Stony Brook, New York, USA
| | - Nikola Pavlović
- Institute for Nephrology and Hemodialysis, Clinical Center, University of Niš, Niš, Serbia
| | - Josip Pasini
- Department for Urology, School of Medicine University of Zagreb, University Hospital Center Zagreb, Zagreb, Croatia
| | - Stjepko Pleština
- Department for Oncology, University Hospital Center Zagreb, University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Momir Polenaković
- Department of Nephrology, University ‘Sts Ciril and Methodius’ Faculty of Medicine and Macedonian Academy of Sciences and Arts, Skopje, Republic of Macedonia
| | | | - Karla Tomić
- Department for Pathology and Forensic Medicine, General Hospital ‘Dr.Josip Benčević’ Slavonski Brod, Croatia
| | | | - Ivana Vuković Lela
- School of Medicine, University of Zagreb, Department for Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ranka Štern-Padovan
- Department for Radiology, University Hospital Center Zagreb, University of Zagreb, School of Medicine, Zagreb, Croatia
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Stiborová M, Bárta F, Levová K, Hodek P, Frei E, Arlt VM, Schmeiser HH. The influence of ochratoxin A on DNA adduct formation by the carcinogen aristolochic acid in rats. Arch Toxicol 2014; 89:2141-58. [PMID: 25209566 DOI: 10.1007/s00204-014-1360-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 08/28/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Exposure to the plant nephrotoxin and carcinogen aristolochic acid (AA) leads to the development of AA nephropathy, Balkan endemic nephropathy (BEN) and upper urothelial carcinoma (UUC) in humans. Beside AA, exposure to ochratoxin A (OTA) was linked to BEN. Although OTA was rejected as a factor for BEN/UUC, there is still no information whether the development of AA-induced BEN/UUC is influenced by OTA exposure. Therefore, we studied the influence of OTA on the genotoxicity of AA (AA-DNA adduct formation) in vivo. AA-DNA adducts were formed in liver and kidney of rats treated with AA or AA combined with OTA, but no OTA-related DNA adducts were detectable in rats treated with OTA alone or OTA combined with AA. Compared to rats treated with AA alone, AA-DNA adduct levels were 5.4- and 1.6-fold higher in liver and kidney, respectively, of rats treated with AA combined with OTA. Although AA and OTA induced NAD(P)H quinone oxidoreductase (NQO1) activating AA to DNA adducts, their combined treatment did not lead to either higher NQO1 enzyme activity or higher AA-DNA adduct levels in ex vivo incubations. Oxidation of AA I (8-methoxy-6-nitrophenanthro[3,4-d]-1,3-dioxole-5-carboxylic acid) to its detoxification metabolite, 8-hydroxyaristolochic acid, was lower in microsomes from rats treated with AA and OTA, and this was paralleled by lower activities of cytochromes P450 1A1/2 and/or 2C11 in these microsomes. Our results indicate that a decrease in AA detoxification after combined exposure to AA and OTA leads to an increase in AA-DNA adduct formation in liver and kidney of rats.
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Affiliation(s)
- Marie Stiborová
- Department of Biochemistry, Faculty of Science, Charles University, Albertov 2030, 128 40, Prague 2, Czech Republic.
| | - František Bárta
- Department of Biochemistry, Faculty of Science, Charles University, Albertov 2030, 128 40, Prague 2, Czech Republic
| | - Kateřina Levová
- Department of Biochemistry, Faculty of Science, Charles University, Albertov 2030, 128 40, Prague 2, Czech Republic
| | - Petr Hodek
- Department of Biochemistry, Faculty of Science, Charles University, Albertov 2030, 128 40, Prague 2, Czech Republic
| | - Eva Frei
- Division of Preventive Oncology, National Center for Tumor Diseases, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - 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
| | - Heinz H Schmeiser
- Division of Radiopharmaceutical Chemistry (E030), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
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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; 34:1688-1705. [PMID: 24954501 PMCID: PMC4199864 DOI: 10.1111/risa.12239] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [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: 1.1] [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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Upper urothelium carcinomas in Croatian endemic area. Wien Klin Wochenschr 2013; 125:529-36. [PMID: 23928938 DOI: 10.1007/s00508-013-0412-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 07/22/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND/AIMS Endemic nephropathy (EN) is a chronic tubulointerstitial disease. Strong association between EN and urothelial carcinoma was noted as early as 40-50 ago. The aim of the study was to determine and compare specific mortality and morbidity of renal pelvis and ureter (upper urothelium) carcinoma (UUC) among Croatia as a whole, Brod-Posavina County, and Croatian endemic area. METHODS Data on UUC mortality and morbidity were analyzed. Indirect standardization was employed on data comparison by calculating standardized mortality ratio and morbidity ratio. RESULTS Our study results showed the specific mortality rate in the endemic area to be 26.3-fold and 7.3-fold the rate recorded in Croatia and Brod-Posavina County, respectively. The mean standardized mortality ratio obtained by indirect standardization yielded an 8-fold and 32-fold risk of death from UUC in the endemic area vs. Brod-Posavina County and Croatia as a whole, respectively. These data revealed the specific morbidity in the Croatian endemic area and Brod-Posavina County to be 13.95-fold and 3.78-fold the morbidity recorded at the national level, respectively. The standardized morbidity ratio also showed the risk of developing UUC in the Croatian endemic area to be 3.75-fold the risk in Brod-Posavina County and 16.4-fold the risk in Croatia. CONCLUSIONS These results showed that specific mortality and morbidity as well as standardized morbidity ratio and standardized mortality ratio were higher in Croatian endemic area than in Brod-Posavina County and Croatia.
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Grollman AP. Aristolochic acid nephropathy: Harbinger of a global iatrogenic disease. ENVIRONMENTAL AND MOLECULAR MUTAGENESIS 2013; 54:1-7. [PMID: 23238808 DOI: 10.1002/em.21756] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 11/16/2012] [Accepted: 11/19/2012] [Indexed: 06/01/2023]
Abstract
This review constitutes an overview of our investigations of aristolochic acid nephropathy, a chronic kidney disease associated with carcinomas of the upper urinary tract. Our studies began by confirming the hypothesis that chronic dietary poisoning by aristolochic acid was responsible for endemic (Balkan) nephropathy. A unique TP53 mutational signature in urothelial tumors and the presence of aristolactam-DNA adducts in the renal cortex, defined in the course of this research, proved to be robust biomarkers of exposure to this potent nephrotoxin and human carcinogen. Armed with this information, we used molecular epidemiologic approaches and novel mechanistic information to establish the causative role of aristolochic acid in upper urinary tract carcinoma in Taiwan, where one-third of the population had been prescribed herbal remedies containing Aristolochia, and the recorded incidence of upper urinary tract cancers is the highest in the world. As traditional Chinese medicine is practiced similarly in Taiwan and China, it is likely that upper urinary tract carcinomas and their attendant aristolochic acid nephropathy are prevalent in China and other Asian countries where Aristolochia herbs have been used for centuries in the treatment and prevention of disease, creating a potential public health problem of considerable magnitude.
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Affiliation(s)
- Arthur P Grollman
- Laboratory of Chemical Biology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, New York 11794, USA.
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Capriotti AL, Caruso G, Cavaliere C, Foglia P, Samperi R, Laganà A. Multiclass mycotoxin analysis in food, environmental and biological matrices with chromatography/mass spectrometry. MASS SPECTROMETRY REVIEWS 2012; 31:466-503. [PMID: 22065561 DOI: 10.1002/mas.20351] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 10/11/2011] [Accepted: 10/11/2011] [Indexed: 05/31/2023]
Abstract
Mold metabolites that can elicit deleterious effects on other organisms are classified as mycotoxins. Human exposure to mycotoxins occurs mostly through the intake of contaminated agricultural products or residues due to carry over or metabolite products in foods of animal origin such as milk and eggs, but can also occur by dermal contact and inhalation. Mycotoxins contained in moldy foods, but also in damp interiors, can cause diseases in humans and animals. Nephropathy, various types of cancer, alimentary toxic aleukia, hepatic diseases, various hemorrhagic syndromes, and immune and neurological disorders are the most common diseases that can be related to mycotoxicosis. The absence or presence of mold infestation and its propagation are seldom correlated with mycotoxin presence. Mycotoxins must be determined directly, and suitable analytical methods are necessary. Hundreds of mycotoxins have been recognized, but only for a few of them, and in a restricted number of utilities, a maximum acceptable level has been regulated by law. However, mycotoxins seldom develop alone; more often various types and/or classes form in the same substrate. The co-occurrence might render the individual mycotoxin tolerance dose irrelevant, and therefore the mere presence of multiple mycotoxins should be considered a risk factor. The advantage of chromatography/mass spectrometry (MS) is that many compounds can be determined and confirmed in one analysis. This review illustrates the state-of-the-art of mycotoxin MS-based analytical methods for multiclass, multianalyte determination in all the matrices in which they appear. A chapter is devoted to the history of the long-standing coexistence and interaction among humans, domestic animals and mycotoxicosis, and the history of the discovery of mycotoxins. Quality assurance, although this topic relates to analytical chemistry in general, has been also examined for mycotoxin analysis as a preliminary to the systematic literature excursus. Sample handling is a crucial step to devise a multiclass analytical method; so when possible, it has been treated separately for a better comparison before tackling the instrumental part of the whole analytical method. This structure has resulted sometimes in unavoidable redundancies, because it was also important to underline the interconnection. Most reviews do not deal with all the possible mycotoxin sources, including the environmental ones. The focus of this review is the analytical methods based on MS for multimycotoxin class determination. Because the final purpose to devise multimycotoxin analysis should be the assessment of the danger to health of exposition to multitoxicants of natural origin (and possibly also the interaction with anthropogenic contaminants), therefore also the analytical methods for environmental relevant mycotoxins have been thoroughly reviewed. Finally, because the best way to shed light on actual risk assessment could be the individuation of exposure biomarkers, the review covers also the scarce literature on biological fluids.
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Cvitković A, Vuković-Lela I, Edwards KL, Karanović S, Jurić D, Cvorišćec D, Fuček M, Jelaković B. Could disappearance of endemic (Balkan) nephropathy be expected in forthcoming decades? Kidney Blood Press Res 2011; 35:147-52. [PMID: 22116163 DOI: 10.1159/000333836] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 09/20/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS An epidemiological survey of endemic nephropathy (EN) was performed in endemic Croatian areas and the current prevalence was compared to that reported for the same villages several decades ago. METHODS A total of 2,487 adult farmers from 6 endemic villages and 3 non-endemic villages were enrolled. An extensive epidemiological questionnaire, clinical examination and laboratory analyses of blood and urine were performed. According to the modified WHO criteria, participants were classified into diseased, suspected of having EN, and those at risk of developing EN. RESULTS The overall prevalence of EN in the Croatian areas was 1.0%, ranging between 0.3 and 2.3% in different villages. Those suspected of having EN amounted to 3.9%. In the endemic villages a decreasing trend in the prevalence of EN was observed comparable to the results obtained in previous surveys. It is interesting to note that no EN patients were recorded in the endemic village of Dubočac. CONCLUSION The prevalence of EN in the endemic Croatian areas appears to be decreasing. For the first time, we failed to detect any EN patients in a village that was previously considered endemic, which might indicate that EN is diminishing.
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Affiliation(s)
- Ante Cvitković
- Institute for Public Health, County Brodsko Posavska, Slavonski Brod, Croatia
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Aristolactam-DNA adducts are a biomarker of environmental exposure to aristolochic acid. Kidney Int 2011; 81:559-67. [PMID: 22071594 DOI: 10.1038/ki.2011.371] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endemic (Balkan) nephropathy is a chronic tubulointerstitial disease frequently accompanied by urothelial cell carcinomas of the upper urinary tract. This disorder has recently been linked to exposure to aristolochic acid, a powerful nephrotoxin and human carcinogen. Following metabolic activation, aristolochic acid reacts with genomic DNA to form aristolactam-DNA adducts that generate a unique TP53 mutational spectrum in the urothelium. The aristolactam-DNA adducts are concentrated in the renal cortex, thus serving as biomarkers of internal exposure to aristolochic acid. Here, we present molecular epidemiologic evidence relating carcinomas of the upper urinary tract to dietary exposure to aristolochic acid. DNA was extracted from the renal cortex and urothelial tumor tissue of 67 patients that underwent nephroureterectomy for carcinomas of the upper urinary tract and resided in regions of known endemic nephropathy. Ten patients from nonendemic regions with carcinomas of the upper urinary tract served as controls. Aristolactam-DNA adducts were quantified by (32)P-postlabeling, the adduct was confirmed by mass spectrometry, and TP53 mutations in tumor tissues were identified by chip sequencing. Adducts were present in 70% of the endemic cohort and in 94% of patients with specific A:T to T:A mutations in TP53. In contrast, neither aristolactam-DNA adducts nor specific mutations were detected in tissues of patients residing in nonendemic regions. Thus, in genetically susceptible individuals, dietary exposure to aristolochic acid is causally related to endemic nephropathy and carcinomas of the upper urinary tract.
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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: 1.8] [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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Yang L, Su T, Li XM, Wang X, Cai SQ, Meng LQ, Zou WZ, Wang HY. Aristolochic acid nephropathy: variation in presentation and prognosis. Nephrol Dial Transplant 2011; 27:292-8. [PMID: 21719716 DOI: 10.1093/ndt/gfr291] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Aristolochic acid nephropathy (AAN) is a worldwide problem and one of the common causes of chronic kidney disease (CKD) in China. METHODS Three hundred patients diagnosed as AAN from 1997 to 2006 were enrolled. Medical histories of Chinese herb ingestion, clinical-pathological features and risk factors for renal failure were recorded. Patients were followed up for 2-156 months. Factors involved in the prognosis of AAN were investigated. RESULTS The 300 patients with AAN manifested three clinical subtypes, including acute kidney injury (acute AAN) in 13 patients, abrupt tubular dysfunction with normal serum creatinine (Scr) levels in seven cases and chronic tubulointerstitial nephropathy with decreased estimated glomerular filtration rate (eGFR) (chronic AAN) in 280 cases. The acute AAN cases had the highest aristolochic acid (AA)-I intake per day and developed progressive kidney failure during 1-7 years follow-up. The tubular dysfunction AAN patients had the lowest cumulative AA-I intake and were able to keep normal Scr levels during 2-8 years follow-up. The chronic AAN patients took the lowest AA-I dose per day but with the longest period and the highest cumulative dosage and exhibited a very large range of eGFR changing rate (from -21.6 to 5.2, median -3.5 mL/min/year). The cumulative AA-I intake (r = 0.330, P = 0.045) and the time course from the termination of AA medication to the start of follow-up (r = -0.430, P = 0.009) were found to be independent factors correlated with the decrease rate of eGFR in the chronic AAN patients. AA and the metabolites could be detected in a high frequency in patients who had stopped herbal medication for 1 year, which indicates a rather long washout time for these chemicals. CONCLUSIONS AAN has variant phenotypes with distinct prognosis, which is determined by the variable AA medications. With better understanding of toxic and environmental causes for kidney injury, there would be a better chance to uncover the causal factors of cases of 'CKD without known causes' which is crucial for improving the disease outcomes.
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Affiliation(s)
- Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University, Beijing, People’s Republic of China
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Pepeljnjak S, Klarić MŠ. «Suspects» in etiology of endemic nephropathy: aristolochic acid versus mycotoxins. Toxins (Basel) 2010; 2:1414-27. [PMID: 22069645 PMCID: PMC3153240 DOI: 10.3390/toxins2061414] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 06/07/2010] [Accepted: 06/10/2010] [Indexed: 11/23/2022] Open
Abstract
Despite many hypotheses that have been challenged, the etiology of endemic nephropathy (EN) is still unknown. At present, the implications of aristolochic acid (AA) and mycotoxins (ochratoxin A-OTA and citrinin-CIT) are under debate. AA-theory is based on renal pathohistological similarities between Chinese herbs nephropathy (CHN) and EN, findings of AA-DNA adducts in EN and in patients with urinary tract tumors (UTT), as well as the domination of A:T®T:A transversions in the p53 mutational spectrum of UTT patients, which corresponds with findings of such mutations in AA-treated rats. However, exposure pathways of EN residents to AA are unclear. Experimental studies attempting to deduce whether nephrotoxins OTA and CIT appear at higher frequencies or levels (or both) in the food and blood or urine of EN residents support the mycotoxin theory. Also, some molecular studies revealed the presence of OTA-DNA adducts in the renal tissue of EN and UTT patients. In this review, data supporting or arguing against AA and mycotoxin theory are presented and discussed.
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Affiliation(s)
| | - Maja Šegvić Klarić
- Department of Microbiology, Faculty of Pharmacy and Biochemistry, University of Zagreb, Schrottova 39, HR-10000 Zagreb, Croatia
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Živčić-Ćosić S, Gržetić M, Valenčić M, Oguić R, Maričić A, Đorđević G, Balen S, Orlić L, Rački S, Fučkar Ž. Urothelial Cancer in Patients with Endemic Balkan Nephropathy (EN) after Renal Transplantation. Ren Fail 2009; 29:861-5. [DOI: 10.1080/08860220701595882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Slade N, Moll UM, Brdar B, Zorić A, Jelaković B. p53 mutations as fingerprints for aristolochic acid: an environmental carcinogen in endemic (Balkan) nephropathy. Mutat Res 2009; 663:1-6. [PMID: 19428366 DOI: 10.1016/j.mrfmmm.2009.01.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 01/14/2009] [Accepted: 01/26/2009] [Indexed: 01/31/2023]
Abstract
The activation of protooncogenes and inactivation of tumor suppressor genes are considered to be the main molecular events in the multistep process of carcinogenesis. Mutations of the TP53 tumor suppressor gene have been found in nearly all tumor types and are estimated to contribute to more than 50% of all cancers. Most mutations lead to the synthesis of highly stable, inactive proteins that accumulate in the nucleus of cancer cells. Among the 393 codons of the human p53 gene, 222 are targets of 698 different types of mutations. Alterations of codons 175, 248, 273 and 282 correspond to 19% of all mutations and are considered general hot spot mutations. Dietary exposure to aristolochic acid (AA), an established nephrotoxin and human carcinogen found in all Aristolochia species was shown to be the causative agent of aristolochic acid nephropathy (previously called Chinese herbs nephropathy). This syndrome is characterized by proximal tubular damage, renal interstitial fibrosis, slow progression to the end stage renal disease and a high prevalence of upper urinary tract urothelial carcinoma (otherwise a highly unusual location). AA preferentially binds to purines in DNA and is associated with a high frequency of A-->T transversions in the p53 gene. Rats treated with AA develop A:T-->T:A mutations in codon 61. The pathological and clinical features of endemic (Balkan) nephropathy closely resemble those associated with aristolochic acid nephropathy except for the slower progression to end stage renal disease and longer cumulative period before the appearance of urothelial cancer. Recently, we reported the presence of AA-DNA adducts in renal cortex and A-->T p53 mutations in tumor tissue of patients from Croatia and Bosnia with endemic nephropathy. These data support the hypothesis that dietary exposure to AA is a major risk factor for endemic (Balkan) nephropathy.
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Affiliation(s)
- Neda Slade
- Division of Molecular Medicine, Ruder Bosković Institute, Zagreb, Croatia.
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Mycotoxic and aristolochic acid theories of the development of endemic nephropathy. Arh Hig Rada Toksikol 2008; 59:59-65. [PMID: 18407872 DOI: 10.2478/10004-1254-59-2008-1865] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Despite many efforts of scientists and epidemiologists, the aetiology of endemic nephropathy (EN) is still unknown. This disease occurs in the rural population of geographically limited areas of Bulgaria, Bosnia and Herzegovina, Croatia, Romania, and Serbia, and a number of theories have been proposed about its aetiology. The mycotoxin theory has prevailed until now, based on the studies of nephrotoxic mycotoxin ochratoxin A (OTA) that revealed higher frequency of OTA-positive food and blood samples in endemic than in non-endemic areas.However, a new aristolochic acid (AA) theory of EN origin has been proposed recently, due to the histological similarities in kidney lesions between patients suffering from EN and patients suffering from Chinese herbs nephropathy caused by AA. Until now it has not been unequivocally proved that the inhabitants of EN areas are exposed to higher concentration of AA than in other regions and the exposure pathways are rather uncertain. This paper presents most important studies supporting both theories, indicating also the inconsistencies of each.
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Stefanovic V, Radovanovic Z. Balkan endemic nephropathy and associated urothelial cancer. ACTA ACUST UNITED AC 2008; 5:105-12. [PMID: 18259188 DOI: 10.1038/ncpuro1019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2007] [Accepted: 11/07/2007] [Indexed: 11/09/2022]
Abstract
Balkan endemic nephropathy (BEN) is a chronic tubulointerstitial disease described only in some rural parts of southeastern Europe. One of its most peculiar characteristics is a strong association with upper urothelial cancer (UUC). BEN-related UUC has the same histological features as other forms of UUC in general, but is more frequently bilateral, less frequently affects the bladder and has a sex ratio close to 1. BEN and BEN-associated UUC share the same etiology. Over time, incidence of these conditions has been declining. Since BEN was first described, around half a century ago, socioeconomic changes (in housing, farming, living standards, etc.) have been profound and have obscured the factors responsible for the observed reduction in incidence. Whatever the causes of BEN, the disease might not be restricted only to southeastern Europe. Rather, the intensity of exposure to risk factors for BEN and, consequently, clustering of cases has more likely determined our knowledge of topographical distribution of an etiological entity that is much more widespread, or that might even be ubiquitous in its sporadic form.
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Affiliation(s)
- Vladisav Stefanovic
- Institute of Nephrology, Faculty of Medicine, Bul. Zorana Djindjica 81, 18000 Ni, Serbia.
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Grollman AP, Jelaković B. Role of environmental toxins in endemic (Balkan) nephropathy. October 2006, Zagreb, Croatia. J Am Soc Nephrol 2007; 18:2817-23. [PMID: 17942951 DOI: 10.1681/asn.2007050537] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An international symposium, held in Zagreb, Croatia, in October 2006, brought together basic scientists and clinical investigators engaged in research on endemic (Balkan) nephropathy, a chronic renal tubulointerstitial disease of previously unknown cause that often is accompanied by upper urinary tract urothelial cancer. Although this disease is endemic in rural areas of Bosnia, Bulgaria, Croatia, Romania, and Serbia, a similar clinical entity occurs throughout Europe, Asia, and North America. Recent advances in the understanding of endemic nephropathy now favor the causative role of aristolochic acid over the ubiquitous mycotoxin known as ochratoxin A. Specifically, aristolactam-DNA adducts have been found in renal tissues and urothelial cancers of affected patients. A "signature" p53 mutation in the upper urothelial cancer associated with this disease provides evidence of long-term exposure to aristolochic acid. In addition, the renal pathophysiology and histopathology observed in endemic nephropathy most closely resemble the entity known as aristolochic acid nephropathy. Public health authorities in countries harboring this disease are encouraged to reduce the potential for dietary exposure to Aristolochia clematitis.
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Affiliation(s)
- Arthur P Grollman
- Laboratory of Chemical Biology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY 11794, USA.
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Grollman AP, Shibutani S, Moriya M, Miller F, Wu L, Moll U, Suzuki N, Fernandes A, Rosenquist T, Medverec Z, Jakovina K, Brdar B, Slade N, Turesky RJ, Goodenough AK, Rieger R, Vukelić M, Jelaković B. Aristolochic acid and the etiology of endemic (Balkan) nephropathy. Proc Natl Acad Sci U S A 2007; 104:12129-34. [PMID: 17620607 PMCID: PMC1913550 DOI: 10.1073/pnas.0701248104] [Citation(s) in RCA: 410] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Indexed: 12/22/2022] Open
Abstract
Endemic (Balkan) nephropathy (EN), a devastating renal disease affecting men and women living in rural areas of Bosnia, Bulgaria, Croatia, Romania, and Serbia, is characterized by its insidious onset, invariable progression to chronic renal failure and a strong association with transitional cell (urothelial) carcinoma of the upper urinary tract. Significant epidemiologic features of EN include its focal occurrence in certain villages and a familial, but not inherited, pattern of disease. Our experiments test the hypothesis that chronic dietary poisoning by aristolochic acid is responsible for EN and its associated urothelial cancer. Using (32)P-postlabeling/PAGE and authentic standards, we identified dA-aristolactam (AL) and dG-AL DNA adducts in the renal cortex of patients with EN but not in patients with other chronic renal diseases. In addition, urothelial cancer tissue was obtained from residents of endemic villages with upper urinary tract malignancies. The AmpliChip p53 microarray was then used to sequence exons 2-11 of the p53 gene where we identified 19 base substitutions. Mutations at A:T pairs accounted for 89% of all p53 mutations, with 78% of these being A:T --> T:A transversions. Our experimental results, namely, that (i) DNA adducts derived from aristolochic acid (AA) are present in renal tissues of patients with documented EN, (ii) these adducts can be detected in transitional cell cancers, and (iii) A:T --> T:A transversions dominate the p53 mutational spectrum in the upper urinary tract malignancies found in this population lead to the conclusion that dietary exposure to AA is a significant risk factor for EN and its attendant transitional cell cancer.
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Affiliation(s)
- Arthur P Grollman
- Laboratory of Chemical Biology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY 11794, USA.
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