Is aristolochic acid nephropathy a widespread problem in developing countries?: A case study of Aristolochia indica L. in Bangladesh using an ethnobotanical–phytochemical approach

Johanna Michl,Hannah M Jennings,Geoffrey C Kite,Martin J Ingrouille,Monique S.J Simmonds,Michael Heinrich

doi:10.1016/j.jep.2013.06.028

Abstract

Ethnopharmacological relevanceSpecies of Aristolochia are associated with aristolochic acid nephropathy (AAN), a renal interstitial fibrosis and upper urinary tract cancer (UUC). Aristolochic acid nephropathy has been reported in ten countries but its true incidence is unknown and most likely underestimated. By combining an ethnobotanical and phytochemical approach we provide evidence for the risk of AAN occurring in Bangladesh. More specifically, we assess the intra-specific variation of aristolochic acid analogues in medicinally used Aristolochia indica samples from Bangladesh. Materials and methodsEthnobotanical information was collected from 16 kavirajes (traditional healers) in different study locations in Bangladesh. Plant samples were obtained from native habitats, botanical gardens, herbal markets and pharmaceutical companies. The samples were extracted using 70% methanol and were analysed using LC-DAD-MS and 1H-NMR. ResultsRoots as well as leaves are commonly used for symptoms such as snake bites and sexual problems. Among the informants knowledge about toxicity or side effects is very limited and Aristolochia indica is often administered in very high doses. Replacement of Aristolochia indica with other medicinal plants such as Rauvolfia serpentina (L.) Benth. ex Kurz was common. Aristolochia indica samples contained a variety of aristolochic acid analogues such as aristolochic acid I, aristolochic acid II, cepharadione A and related compounds. ConclusionsAAN cases are likely to occur in Bangladesh and more awareness needs to be raised about the health risks associated with the use of Aristolochia indica and other species of Aristolochia as herbal medicines.

Highlights

Species of Aristolochia are known to cause aristolochic acid nephropathy (AAN), a renal interstitial fibrosis, which is associated with a high incidence of upper urinary tract cancer (UUC) (Nortier et al, 2000)
AAN and aristolochic acid associated UUC has been identified as an important health risk in some countries, but the wide distribution of the genus globally requires a systematic assessment of regions where AAN or UUC may be of concern
We demonstrate that Aristolochia indica is widely available on herbal markets and through healers’ networks in Bangladesh, a country from which so far no cases of AAN have been reported

Summary

Introduction

Species of Aristolochia are known to cause aristolochic acid nephropathy (AAN), a renal interstitial fibrosis, which is associated with a high incidence of upper urinary tract cancer (UUC) (Nortier et al, 2000). It was initially reported in a Belgian cohort of over 100 patients after the intake of slimming pills containing a Chinese herb, Aristolochia fangchi Wu ex L.D. Chow & S.M. Hwang (Vanherweghem, 1998). Following this tragic incidence, species of Aristolochia were banned in many countries, including Germany, the UK, USA, Australia and Canada. AAN has only been reported in 15 countries but its true incidence is unknown and probably underestimated (National Toxicology Program, 2008)

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