Khella induced nephropathy: a case report and review of literature

Abstract

Khella (Ammi visnagais) was used in Ancient Egypt as a herbal remedy for renal colic. Khella contains group of coumarins, xanthotoxin, ammidin, furoquinoline alkaloids and, dihydroseselins with varying cytotoxic activity. The most common is Khellin and visnagin. Khellin was found to be a smooth muscle relaxant, induces diuresis, increases excretion of citrate and decreases the excretion of oxalate in urine, which improves nephrolithiasis and passage of ureteric stones. Synthetic derivatives of khellin include amiodarone, the anti-arrhythmic drug, and cromolyn, an anti-asthma drug. Khellin is not as safe as it seems to be. Its oral use is limited by its potential toxicity (eg, elevated liver enzymes, phototoxicity, dermatitis). In experimental animals, the median lethal dose (LD50) was 3.6 g/kg for intra-peritoneal administration and 10.1 g/kg for oral administration. In humans, nausea and vomiting were observed frequently in 29% and transaminitis in 7-14% of the patients. Other potential adverse reactions include dizziness, constipation, headache, itching, insomnia, photosensitivity and lack of appetite. We report for the first-time, acute kidney injury following use of khella in a CKD patient with a 5-fold increase in his serum creatinine level from 1.9 to 9.2 mg/dl. His renal biopsy revealed eosinophilic interstitial nephritis. He responded well to pulse methylprednisolone followed by short course of oral steroids. We believe this is the first case describing Khella nephropathy. Herbal nephropathy is not uncommon and herbal remedies are not as safe as it is believed. Accurate diagnosis and early management are the key in improving the renal outcome.