Although the first description of a rapidly progressive nephropathy associated with the consumption of aristolochic acid (AA) found in Chinese herbs was first reported 20 years ago, AA-induced nephropathy remains a worldwide health concern due to the lack of regulation on herbal medication and the easy availability of such medications online, according to a review published in the Annals of Internal Medicine (2013;158:469-477).

M. Refik Gokmen, PhD, MBBS, of King’s College London and Imperial College London, and colleagues used an evidence-based approach to review the epidemiology, diagnosis, and management of AA-induced nephropathy.

According to the authors, herbal medicinal products containing AA have been, and continue to be, used worldwide for various indications such as eczema, acne, liver symptoms, arthritis, and chronic pain. The exact mechanisms of AA-induced nephrotoxicity are not fully characterized. Most patients diagnosed with AA-induced nephropathy showed an unusually rapid progression toward end-stage renal disease.

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Cumulative AA dose is likely associated with the degree of renal insufficiency and the rate of decline in renal function. No serum or urinary biomarkers have been shown to aid in the diagnosis of AA-induced nephropathy. Definitive diagnosis can only be made with histological examination. There are no known therapeutic agents that can reverse or delay progression of AA-induced nephropathy.

“We have attempted in this review to fill in the many evidence gaps about all aspects of this disease on the basis of our clinical experience and consensus, but future research should seek to determine noninvasive biomarkers of exposure and disease and optimum agents and surgical treatments that might alter the course of the disease,” the authors write. “Perhaps most important, improved regulation of herbal medicines could help eradicate this entirely preventable illness.”