Balkan Endemic Nephropathy Research Articles

Urine Metabolomic Signature of People Diagnosed with Balkan Endemic Nephropathy and Other Types of Chronic Kidney Disease Compared with Healthy Subjects in Romania

Metabolomic analysis methods were employed to determine biomarkers for various chronic kidney diseases (CKDs). Modern analytical methods were developed and applied successfully to find a specific metabolomic profile in urine samples from CKD and Balkan endemic nephropathy (BEN) patients. The aim was to explore a specific metabolomic profile defined by feasible/easy-to-identify molecular markers. Urine samples were collected from patients with CKDs and BEN, and from healthy subjects from endemic and nonendemic areas in Romania. Metabolomic analysis of urine samples, extracted by the liquid-liquid extraction (LLE) method, was performed by gas chromatography-mass spectrometry (GC-MS). The statistical exploration of the results was performed through a principal component analysis (PCA) evaluation. Urine samples were statistically analyzed using a classification based on six types of metabolites. Most urinary metabolites are distributed in the center of a loading plot, meaning that these compounds do not represent significant markers for BEN. One of the most frequent and higher-concentration urinary metabolites in BEN patients was p-Cresol, a phenolic compound that implies a severe injury of the renal filtration function. The presence of p-Cresol was associated with protein-bound uremic toxins, which have specific functional groups such as indole and phenyl. In prospective studies for future investigation, prevention, and disease treatment, we suggest a larger sample size, sample extraction using other methods, and analysis using other chromatography techniques coupled with mass spectrometry, which can generate a more significant data set for statistical analysis.

Effects of Diet on Aristolochic Acid-DNA Adduct Formation: Implications for Balkan Endemic Nephropathy Etiology.

Prolonged exposure to aristolochic acids (AAs) through AA-containing herbal medicine or AA-contaminated food is associated with the development of aristolochic acid nephropathy (AAN) and Balkan endemic nephropathy (BEN), both public health risks to which the World Health Organization is calling for global action to remove exposure sources. The AA exposure-induced DNA damage is believed to be related to both the nephrotoxicity and carcinogenicity of AA observed in patients suffering from BEN. While the chemical toxicology of AA is well-studied, we investigated in this study the understated effect of different nutrients, food additives, or health supplements on DNA adduct formation by aristolochic acid I (AA-I). By culturing human embryonic kidney cells in an AAI-containing medium enriched with different nutrients, results showed that cells cultured in fatty acid-, acetic acid-, and amino acid-enriched media produced ALI-dA adducts at significantly higher frequencies than that cultured in the normal medium. ALI-dA adduct formation was most sensitive to amino acids, indicating that amino acid- or protein-rich diets might lead to a higher risk of mutation and even cancer. On the other hand, cells cultured in media supplemented with sodium bicarbonate, GSH, and NAC reduced ALI-dA adduct formation rates, which sheds light on their potential use as risk-mitigating strategies for people at risk of AA exposure. It is anticipated that the results of this study will help to better understand the effect of dietary habits on cancer and BEN development.

Investigation of Organic and Inorganic Contaminants in Water Sources around Elbistan Lignite Beds

The household and industrial use, as well as mining of coal, pose various environmental and health risks including lung and kidney diseases such as Balkan Endemic Nephropathy (BEN). BEN is a kidney disease and it is geographically confined to Balkan countries where extensive lignite deposits are located. The most accepted cause of BEN is the use of untreated waters contaminated by lignite-derived organic contaminants. Afşin-Elbistan basin contains approximately 50 % of the lignite reserves of Turkey which makes it an ideal location for the current study. In this work, water samples were taken from 10 different locations in the Afşin-Elbistan basin and they were analyzed for organic and inorganic contaminants. Results showed that none of the water samples were contaminated with inorganic contaminants and indeed met the Turkish drinking water standards. GC-MS analyses of the water samples revealed similar chromatograms. Briefly, all the water samples have similar organic compound types such as n-alkanes, chlorophyll-derived phytols, and plant- and animal-derived acids (i.e. palmitic acid). On the other hand, none of the samples were contaminated with carcinogenic and/or nephrotoxic organic compounds such as polyaromatic hydrocarbons and aromatic amines, which is contrary to many, but not all of the previous works conducted in Balkan countries. All these results may indicate that the influence of coal deposits on the groundwaters is minimal.

Research and application of herbal medicine in the treatment of chronic kidney disease since the 21st century: A visualized bibliometric analysis.

Background: Here, a bibliometric and knowledge-map analysis was used to analyze the research status and application of herbal medicine for the treatment of chronic kidney disease (CKD). By looking for research hotspots and key topics, we provide new clues and research directions for future research. Methods: Articles and reviews regarding herbal medicine in the treatment of CKD were retrieved from the Web of Science Core Collection on 23 May 2022. The R-bibliometrix, VOSviewer, and CiteSpace software were used to conduct the bibliometric and knowledge-map analysis. Results: In total, 5,920 authors at 1,330 institutions from 68 countries published 1,602 papers in 355 academic journals. China is the leader and pioneer in the research and application of herbal medicine in the field of CKD treatment. Beijing University of Chinese Medicine contributed the most publications. Ping Li (China-Japan Friendship Hospital) published the most articles, while Yingyong Zhao (Northwest University) had the most cocitations. However, cooperation among countries and the research institutions is not sufficient. Journal of Ethnopharmacology published the most research and application of herbal medicine in the treatment of CKD and was the most commonly co-cited journal. The most influential research hotspots about herbal medicine in the treatment of CKD focused on diabetic nephropathy-related research, Balkan endemic nephropathy, and pharmacokinetic study. Conclusion: Herbal medicine has a wide range of pharmacological activities and therapeutic value. The research and application of herbal medicine for the treatment of CKD, especially diabetic nephropathy, will remain a hot topic in the future.

Wheatgrass (Triticum aestivum) as an Efficient Phytoremediation Plant for Aristolochic Acid-Contaminated Water and Arable Soil

Dietary exposure to aristolochic acids (AAs) through AA-tainted wheat has long been identified as one of the main causes of Balkan endemic nephropathy (BEN), a slowly progressive renal fibrotic disease affecting numerous residents of farming villages alongside tributaries of the Danube River. Only recently though have we begun to appreciate that AAs, released from the decay of a common weed Aristolochia clematitis, are contaminating farmland soil and groundwater of endemic areas. To reduce the risk of human exposure to this class of highly potent phytotoxins, it is imperative to develop remediation methods for AA-polluted water and arable soil. In this study, we explored the potential use of some commonly used phytoremediation plants for the phytoextraction of AAs from AA-contaminated water and soil. Among the tested plants, results showed that wheatgrass is highly efficient in extracting AAs from both contaminated water and soil and metabolizing them to the less toxic aristolactams. Furthermore, both the phytoextraction and plant metabolism efficiencies increased in an acidic environment, which is typical of endemic villages, highlighting the applicability of the developed method for affected areas.

BALKAN ENDEMIC NEPHROPATHY, PULSE WAVE VELOCITY AND INCREASED TELOMERE LENGTH-ASSOCIATED CARDIOVASCULAR MORTALITY IN PATIENTS UNDERGOING CHRONIC HEMODIALYSIS

Objective: Balkan endemic nephropathy (BEN) is characterized with later onset, milder forms of hypertension and lower pulse wave velocity (PWV)). We hypothesized that telomere length (TL) would be longer in BEN patients and associated with lower PWV and less cardiovascular (CV) mortality. Design and method: On total 124 hemodialysed (HD) patients (68 BEN, 56 non-BEN; 48.4% men; 65 ± 14 years) were enrolled and followed-up for 25 months. Blood pressure and PWV were determined before mid-week dialysis. TL was determined by telomere restriction fragment analysis. Results: Age-sex adjusted TL was significantly longer in the BEN group (7.19 vs 6.79; p < 0.001) despite being significantly older. In the BEN group TL was associated with PWV (beta = -0.373, p < 0.05), and in the non-BEN group with age (beta = -0.680, p < 0.01). In the full-adjusted model of multivariate linear regression analyses significant predictors of TL were systolic BP/PWV, and age in the BEN and the non-BEN group, respectively. BEN patients died significantly less frequently from CV events than non-BEN patients (p < 0.001) and lived significantly longer (log-rank p = 0.04). Patients who died had significantly shorter TL than survivors (p < 0.001). In the Cox Regression analysis older age, diagnosis of non-BEN and shorter TL were determinants of shorter survival in the entire cohort. In the BEN group shorter TL was the only determinant of shorter survival (HR 0.11 [95% CI 0.03, 0.35]). To analyze the diagnostic value of TL for CV mortality we used ROC analysis that revealed TL < 6.21 Kb to be useful for prediction of CV mortality in patients undergoing chronic HD. Conclusions: Shorter TL is associated with CV mortality in patients undergoing chronic HD. BEN patients had longer TL and longer survival than other ESKD patients. PWV was significant predictor of TL in BEN patients. This study confirmed our hypothesis that BEN is associated with slower vascular aging.

MO497: Upper Tract Urothelial Cancer and Balkan Endemic Nephropathy: 65 Years of Follow UP

Abstract BACKGROUND AND AIMS All researchers dealing with Balkan endemic nephropathy (BEN) talk about the association of BEN with malignant tumours of the upper urothelium (UTUC). Long-term research of UTUC obtained various results depending on the period and region of observation, depending on the stage of renal failure, degree of malignancy, surgical or autopsy treatment. The aim of this paper is to monitor UTUC in certain parts of the Republic of Serbia in a long period of time and what is the frequency of tumours in relation to the observed endemic and non-endemic built-up areas for BEN. METHOD Occurrence of UTUC was analyzed for the period 1953–2017 on the basis of operational protocols of the Institute of Urology and Nephrology KCS Belgrade, Clinic of Urology Nis, Department of Urology and Haemodialysis Leskovac. The categorization of built-up areas into (A) endemic, (B) hypoendemic, (C) non-endemic rural and (D) non-endemic urban built-up areas was used. For practical reasons, the groups of built-up areas (A) and (B) united in the group of endemic and (C) and (D) in the group of non-endemic built-up areas. The average annual incidence rate (AAIR) is calculated/100 000 inhabitants. RESULTS In his summary series of UTUC, which included a large number of urological centres in Serbia, Petkovic found in a period of 20 years (1953–1973) that the frequency of tumours is 100 times higher in an endemic than in a non-endemic built-up area. In a 40-year study (1978–2017), Glogovac found that the incidence of tumours in Jablanica district was 14.24 times higher in endemic (AAIR-11.82) than in non-endemic built-up areas (AAIR-0.83) in the last 20 years (1998–2017). The frequency is 4.14 times higher. The linear trend of UTUC in the Jablanica district in the endemic built-up area for BEN in the observed 40-year period was in a statistically weak decline (y = –0.0276x + 55.691; r2 = 0.1718) while for BEN it was in a statistically significant decline (y = –0.2127x + 6.6966; r2 = 0.8529). CONCLUSION The high frequency of UTUC in regions with BEN may indicate a common nephropathogenic and carcinogenic etiological factor and confirms the existence of a positive correlation between BEN and UTUC. The reason for the decline in the frequency of UTUC in the observed built-up area in the observed period should be sought in the drastic decline in BEN, which is explained by changes in the course of the disease, better screening, water supply, health education, lower toxicity, micromigration and possibly misdiagnosis.

Synergistic Interaction of Polycyclic Aromatic Hydrocarbons, Phthalate Esters, or Phenol on DNA Adduct Formation by Aristolochic Acid I: Insights into the Etiology of Balkan Endemic Nephropathy.

Balkan endemic nephropathy (BEN) is a multifactorial environmental disease, with chronic exposure to aristolochic acids (AAs) through AA-contaminated food being one of the major etiological mechanisms. However, the bulk of previous research has only focused on investigating the possible roles of individual pollutants in disease development and the etiological mechanism of BEN remains controversial. In this study, we investigated the exposure concentration and duration dependence of coexposure to phthalate esters and lignite coal-derived phenol and polycyclic aromatic hydrocarbons (PAHs) on the metabolism and DNA adduct formation of aristolochic acid I (AAI). Results showed that both the metabolic activation and DNA adduct formation of AAI in cultured human kidney cells were affected by their coexposure to the above-mentioned environmental pollutants. Furthermore, our results suggest that chemicals leached from lignite coal likely played a role by triggering AA-activating enzymes to produce more of the promutagenic DNA adducts, thus further elevating the nephrotoxicity and carcinogenicity of AAs and increasing the risk of BEN. It is believed that the results of this study provide a better understanding of the etiological mechanism of BEN and offer insights into methods and policies to lower the risk of this devastating disease.

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

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.

Cyclophilin D Promotes Acute, but Not Chronic, Kidney Injury in a Mouse Model of Aristolochic Acid Toxicity.

The plant-derived toxin, aristolochic acid (AA), is the cause of Chinese Herb Nephropathy and Balkan Nephropathy. Ingestion of high dose AA induces acute kidney injury, while chronic low dose ingestion leads to progressive kidney disease. Ingested AA is taken up by tubular epithelial cells of the kidney, leading to DNA damage and cell death. Cyclophilin D (CypD) participates in mitochondrial-dependent cell death, but whether this mechanism operates in acute or chronic AA-induced kidney injury is unknown. We addressed this question by exposing CypD-/- and wild type (WT) mice to acute high dose, or chronic low dose, AA. Administration of 5 mg/kg AA to WT mice induced acute kidney injury 3 days later, characterised by loss of kidney function, tubular cell damage and death, and neutrophil infiltration. All of these parameters were significantly reduced in CypD-/- mice. Chronic low dose (2 mg/kg AA) administration in WT mice resulted in chronic kidney disease with impaired renal function and renal fibrosis by day 28. However, CypD-/- mice were not protected from AA-induced chronic kidney disease. In conclusion, CypD facilitates AA-induced acute kidney damage, but CypD does not contribute to the transition of acute kidney injury to chronic kidney disease during ongoing AA exposure.

Co-Exposure to Aristolochic Acids I and II Increases DNA Adduct Formation Responsible for Aristolochic Acid I-Mediated Carcinogenicity in Rats.

The plant extract aristolochic acid (AA), containing aristolochic acids I (AAI) and II (AAII) as major components, causes aristolochic acid nephropathy (AAN) and Balkan endemic nephropathy (BEN), unique renal diseases associated with upper urothelial cancer. Recently (Chemical Research in Toxicology 33(11), 2804–2818, 2020), we showed that the in vivo metabolism of AAI and AAII in Wistar rats is influenced by their co-exposure (i.e., AAI/AAII mixture). Using the same rat model, we investigated how exposure to the AAI/AAII mixture can influence AAI and AAII DNA adduct formation (i.e., AA-mediated genotoxicity). Using 32P-postlabelling, we found that AA-DNA adduct formation was increased in the livers and kidneys of rats treated with AAI/AAII mixture compared to rats treated with AAI or AAII alone. Measuring the activity of enzymes involved in AA metabolism, we showed that enhanced AA-DNA adduct formation might be caused partially by both decreased AAI detoxification as a result of hepatic CYP2C11 inhibition during treatment with AAI/AAII mixture and by hepatic or renal NQO1 induction, the key enzyme predominantly activating AA to DNA adducts. Moreover, our results indicate that AAII might act as an inhibitor of AAI detoxification in vivo. Consequently, higher amounts of AAI might remain in liver and kidney tissues, which can be reductively activated, resulting in enhanced AAI DNA adduct formation. Collectively, these results indicate that AAII present in the plant extract AA enhances the genotoxic properties of AAI (i.e., AAI DNA adduct formation). As patients suffering from AAN and BEN are always exposed to the plant extract (i.e., AAI/AAII mixture), our findings are crucial to better understanding host factors critical for AAN- and BEN-associated urothelial malignancy.

Aristolochic acid nephropathy: A scientometric analysis of literature published from 1971 to 2019.

Background:Aristolochic acid nephropathy (AAN) is a type of drug-induced nephropathy that may result in acute kidney injury and is associated with a potentially progressive course of kidney fibrosis and upper tract urothelial carcinoma. Aristolochic acids (AAs) are a group of toxins commonly present in plants of the genera Aristolochia and Asarum, which are found worldwide. AAN still occurs in Asian and Balkan regions. The progressive lesions and mutational events initiated by AAs are irreversible, and no effective therapeutic regimen for AAN has been established. Furthermore, more people are at risk of this disease due to casual exposure to AAs. This study performed a scientometric analysis of global research literature focusing on AAN.Methods:The Web of Science database was searched to identify all publications pertaining to “aristolochic acid nephropathy” or “Balkan endemic nephropathy” using these terms as key words to search the literature from 1971 to 2019. The collected data included the document type, author, journal, publication year, citation reports, and country of publication, and were analyzed using the VOSviewer software.Results:A total of 1251 records were initially obtained. Publication types, including “meeting abstract,” “letter,” “editorial material,” and “proceedings paper” were excluded, which left 1083 publications comprising 923 articles and 160 reviews. English was the predominant language of the publications. China had the most number of articles published with 217 (20.0%), followed by the USA with 186 articles (17.2%), and Germany with 138 articles (12.7%). Kidney International, Food and Chemical Toxicology, and Toxins were the 3 most active journals in publishing articles related to AAN. The total number of citations received by all publications was 39,970, with an average of 36.91 citations per article (range: 0–1769). The literature mainly focused on apoptosis, oxidative stress, and inflammation in AAN.Conclusion:This study indicated that AAN is a significant topic in nephrology research, as shown by the large number of publications. The literature has mainly focused on the mechanisms of AA-induced nephropathy.

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.

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.

MO374DISCLOSURE OF THE RESULTS OF A 40-YEARS RESEARCH OF UPPER TRACT UROTHELILAL CANCER AND BALKAN ENDEMIC NEPHROPATHY

Abstract Background and Aims The general significance of Balkan endemic nephropathy (BEN) is the association with upper tract urtohelial cancer (UTUC). In published papers studying these two entities, there is large difference between the obtained results. By UTUC research, obtained results are the most diverse in relation to the period and region of research. The aim of the research is to show the discrepancy between the results of the research of UTUC of Jablanica district in relation to the observation period and the type of settlement. Method The research period lasted from 1978-2017. During the analysis of the frequency of UTUC, we used the operative material of Urology Department, Health Care Center, Leskovac , and Urology Clinic, Clinical Center, Nis, Clinical Center, Nis. For practical reasons, this period was devided into two periods, the first (1978-1997) and the second (1998-2017). In order to make classification of settlements we used the data of the Institute of Nephrology and Hemodialysis in Nis (A-endemic regions, B-hypo-endemic, C-non-endemic urban, D-non-endemic rural regions). Data on the total number of Jablanica region population were obtained on the basis of the censuses from 1991 and 2011. The average annual incidence rate (AAIR) was calculated per 100 000 people. Finally, we jointly observed groups A and B (endemic areas) C and D (non-endemic areas) for UTUC. Results The average annual incidence rate (AAIR) in the period of 1978-2017 in endemic settlements of Jablanica region was (11.82), while in hypo-endemic was (4.49) and non-endemic (0.83). The data demonstrated that inhabitants of endemic settlements has 14.24 times higher UTUC frequency in comparison to non-endemic settlements in time span of research. Our research in Jablanica region also demonstrated unexpectedly high frequency of on UTUC not only in endemic settlements with BEN (Kutles village- 1 tumor per 99.63 and AAIR 40.15), but also in some of the non-endemic area (Brejanovac village-1 tumour per 98.75 people and AAIR of 40.50; Rudare village-1 tumour per 139.50 people and AAIR of 28.67; Bogojevce village-1 tumour per 187.63 people and AAIR 21.32). This occurrence of UTUC frequency in some non-endemic settlements refers to the first observed period until no occurrence was recorded in the second observed period. There is a higher UTUC frequency in endemic settlements of 11.37 in the first period (A- AAIR 21.95), while in hypo-endemic (B-AAIR 11.82) is 3.64 higher incedence. In non-endemic settlements (C,D-AAIR 1.09) there is 1.63 higher incidence in comparison to the second period. Observing the periods, there is a higher UTUC frequency of five times in endemic settlements (A, B) of Jablanica region in the first period comparing to the second. The linear trend of UTUC in the 40-year period demonstrates a slow decrease (y= -0.0797x + 4.2846; r2 = 0.2028) in Jablanica region. In the same observed period, linear trend of BEN is in corelation of decreased linear trend of UTUC (y= -0.164x+6.0669; r2 =0.748). Conclusion A forty-year study of UTUC in the Jablanica region showed a discrepancy between the results in relation to the observation period and the type of settlement, which coincides with the generally accepted view that epidemiology is the most fascinating part of BEN. In endemic settlements, in the second observed period, the frequency of UTUC was registered five times lower than in the first, which coincides with the decrease in the frequency of BEN in these settlements.

Prognostic value of Balkan endemic nephropathy and gender on upper tract urothelial carcinoma outcomes after radical nephroureterectomy: A cohort study

BackgroundTo identify the prognostic impact of residence in a BEN-endemic area and gender on upper tract urothelial carcinoma (UTUC) outcomes in Serbian patients treated with radical nephroureterectomy (RNU). MethodsThe study included 334 consecutive patients with UTUC. Patients with permanent residence in Balkan endemic nephropathy (BEN) or non-endemic areas from their birth to the end of follow-up were included in the analysis. Cox regression analyses were used to address recurrence-free (RFS) and cancer-specific survival (CSS) estimates. ResultsFemale patients were more likely to have preoperative pyuria (P = 0.01), tumor multifocality was significantly associated with the female gender (P = 0.003). Gender was not associated with pathologic stage and grade, lymph node metastasis, lymphovascular invasion, adjuvant chemotherapy, bladder cancer history, tumor size, distribution of tumor location, preoperative anemia and demographic characteristics. A total of 107 cases recurred, with a median time to bladder recurrence of 24.5 months. History of bladder tumor (HR, 1.98; P = 0.005), tumor multifocality (HR, 3.80; P < 0.001) and residence in a BEN-endemic area (HR, 1.81; P = 0.01) were independently associated with bladder cancer recurrence. The 5-year bladder cancer RFS for the patients from areas of BEN was 77.8 % and for the patients from non-BEN areas was 64.7 %. The 5-year CSS for the men was 66.2% when compared to 66.6% for the women (P = 0.55). ConclusionsResidence in a BEN-endemic area represents an independent predictor of bladder cancer recurrence in patients who underwent RNU. Gender cannot be used to predict outcomes in a single-centre series of consecutive patients who were treated with RNU for UTUC.

Aristolochic acid I: an investigation into the role of food crops contamination, as a potential natural exposure pathway.

Aristolochic acid I (AAI) is a potent nephrotoxic and carcinogenic compound produced by plants of the Aristolochiaceae family and thoroughly investigated as a main culprit in the etiology of Balkan endemic nephropathy (BEN). So far, the AAI exposure was demonstrated to occur through the consumption of Aristolochia clematitis plants as traditional remedies, and through the contamination of the surrounding environment in endemic areas: soil, food and water contamination. Our study investigated for the first time the level of AAI contamination in 141 soil and vegetable samples from two cultivated gardens in non-endemic areas, A. clematitis being present in only one of the gardens. We developed and validated a simple and sensitive ultra-high-performance liquid chromatography-ion trap mass spectrometry method for qualitative and quantitative AAI analysis. The results confirmed the presence of AAI at nanogram levels in soil and vegetable samples collected from the non-endemic garden, where A. clematitis grows. These findings provide additional evidence that the presence of A. clematitis can cause food crops and soil contamination and unveil the pathway through which AAI could move from A. clematitis to other plant species via a common matrix: the soil. Another issue regarding the presence of AAI, in a non-endemic BEN area from Romania, could underlie a more widespread environmental exposure to AAI and explain certain BEN-like cases in areas where BEN has not been initially described.

Rat Tumour Histopathology Associated with Experimental Chronic Dietary Exposure to Ochratoxin A in Prediction of the Mycotoxin's Risk for Human Cancers.

Mammalian animal toxicity of ochratoxin A (OTA) has focused largely in the past half-century on pigs because of initial recognition of it as a principal cause of intermittent growth suppression and renal disease caused by mouldy feed. Subsequent classical toxicology has used laboratory rodents because renal pathology in pigs raised questions concerning possible involvement in the human idiopathic bilateral renal atrophy of Balkan endemic nephropathy for which OTA was a focus of attention for human nephropathy through 1980s and into 2000s. Emphasis on human nephropathy has more recently concerned the plant metabolite aristolochic acid. Recognition that agricultural management can often minimise food and feed-stuff spoilage by OTA-producing Aspergilli and Penicillia has moderated some of the risks for animals. Legislation for human food safety combined with sophisticated analysis generally provides safety in the developed world. Chronic experimental exposure of male rats, in the absence of clinical dis-ease, specifically causes renal cancer. The possibility of this as a unique model for the human has generated considerable experimental evidence which may be more directly relevant for carcinogenesis in the complex kidney than that obtained from biochemical toxicities in vitro. Nevertheless, there does not appear to be any case of human renal or urinary tract cancer for which there is verified etiological proof for causation by OTA, contrary to much claim in the literature. To contribute to such debate, histopathology review of OTA/rat renal cancers, augmented where appropriate by immune profiles, has been completed for all remaining tumours in our research archive. Overall consistency of positivity for vimentin, is matched with occasional positives either for CD10 or the cytokeratin MNF 116. The current situation is discussed. Suggestion that OTA could cause human testicular cancer has also been challenged as unsupported by any experimental findings in rats, where the Leydig cell tumour immune profile does not match that of human germ cell neoplasms.

C-Jun Amino Terminal Kinase Signaling Promotes Aristolochic Acid-Induced Acute Kidney Injury.

Aristolochic acid (AA) is a toxin that induces DNA damage in tubular epithelial cells of the kidney and is the cause of Balkan Nephropathy and Chinese Herb Nephropathy. In cultured tubular epithelial cells, AA induces a pro-fibrotic response via the c-Jun amino terminal kinase (JNK) signaling pathway. This study investigated the in vivo role of JNK signaling with a JNK inhibitor (CC-930) in mouse models of acute high dose AA-induced kidney injury (day 3) and renal fibrosis induced by chronic low dose AA exposure (day 22). CC-930 treatment inhibited JNK signaling and protected from acute AA-induced renal function impairment and severe tubular cell damage on day 3, with reduced macrophage infiltration and expression of pro-inflammatory molecules. In the chronic model, CC-930 treatment inhibited JNK signaling but did not affect AA-induced renal function impairment, tubular cell damage including the DNA damage response and induction of senescence, or renal fibrosis; despite a reduction in the macrophage pro-inflammatory response. In conclusion, JNK signaling contributes to acute high dose AA-induced tubular cell damage, presumably via an oxidative stress-dependent mechanism, but is not involved in tubular atrophy and senescence that promote chronic kidney disease caused by ongoing DNA damage in chronic low dose AA exposure.

Simultaneous ipsilateral rhabdoid renal cell carcinoma and multifocal urothelial carcinoma of the ureter in a patient from the region of Balkan endemic nephropathy: Case report and literature review

Introduction. Simultaneous ipsilateral coexistence of renal cell carcinoma (RCC) and upper urinary tract urothelial carcinoma (UTUC) rarely occurs. Balkan endemic nephropathy (BEN) is a chronic degenerative tubulointerstitial renal disease, strongly associated with UTUC. Case outline. ? 60-year-old man from the region of BEN was referred to our clinic due to right flank pain, fever, and purulent discharge from the cutaneous fistulous opening in the right lumbar area. Multislice computed tomography urography scan showed right-side pyonephrosis and nephrocutaneous fistulous tract between the kidney and the skin in the right lumbar region. Cystoscopy detected a papillary tumor protruding from the right ureteric orifice. Right-side nephroureterectomy with bladder cuff excision was performed. Histopathological examination revealed rhabdoid RCC of the kidney and multifocal urothelial carcinoma of the ureter. Conclusion. Our case report and literature review indicate that due to rising incidence of multiple primary malignant neoplasms (MPMNs), when treating patients with RCC or UTUC, and especially those from the region of BEN, one should keep in mind the likelihood of synchronous or metachronous occurrence of these tumors.

Predictive Markers for Malignant Urothelial Transformation in Balkan Endemic Nephropathy: A Case-Control Study.

Simple SummaryBalkan endemic nephropathy (BEN) is chronic kidney disease caused by intoxication with Aristolochia plant. Apart from subtle decline of renal function that eventually results in kidney failure, the patients are at increased risk for urothelial carcinoma (UC) development. Based on the observed UC markers, the aim of this study was to examine urinary and plasma levels of some these markers in BEN patients without carcinoma, in order to potentially identify those with predictive value. Our study revealed either plasma or urinary survivin levels as a potential predictors of future malignant transformation of urothelium. Balkan endemic nephropathy (BEN) is a chronic tubulointerstitial disease frequently accompanied by urothelial carcinoma (UC). In light of the increased UC incidence and the markers observed in BEN patients with developed UC, the aim of the current case–control study is to assess survivin, p53 protein, growth factors and receptors (VEGF, VEGFR1, IGF I, IGF-1R and IGFBP5), tumor marker (TF)/CD142, circulating soluble Fas receptor and neopterin, as potentially predictive markers for UC in patients with BEN (52 patients), compared to healthy, age-matched subjects (40). A threefold increase was registered in both circulating and urinary survivin level in BEN patients. Especially noticeable was the ratio of U survivin/U Cr level five times the ratio of BEN patients associated with standard renal markers in multivariate regression models. The concentrations of VEGF, VEGFR1, (TF)/CD142, (sFas) were not significantly different in BEN patients, while urinary/plasma level demonstrated a significant decrease for VEGF. The levels of IGF I, IGFBP5 and IGF-1R were significantly reduced in the urine of BEN patients. Plasma concentration of neopterin was significantly higher, while urinary neopterin value was significantly lower in BEN patients compared to healthy controls, which reflected a significantly lower urine/plasma ratio and low local predictive value. As BEN is a slow-progressing chronic kidney disease, early detection of survivin may be proposed as potential predictor for malignant alteration and screening tool in BEN patients without the diagnosis of UC.