Taming the fire of nephrotoxic botanicals

Abstract

Criteria for diagnosing nephropathy and urothelial neoplasms induced by botanicals containing aristolochic acids (AAs) are well established. Highlights of recent research on AAs include mechanisms of AA intrarenal transport and metabolism and vigorous debate on whether AAs may also cause liver cancers. Many other botanicals may also cause renal injury, but a generalized framework for diagnosing botanical-induced kidney injury (BIKI) is lacking. Based on what we have learnt about the wide spectrum of phenotypes of BIKI attributed to AAs and a recently published standardized phenotypic framework of drug-induced kidney disease, we propose that BIKI may be categorized into six phenotypes (acute kidney injury, tubular dysfunction, glomerular disorders, nephrolithiasis, chronic kidney disease, and neoplasms) and four mechanistic types (A, predictable; B, idiosyncratic; C, chronic; and D, delayed). We call for international cooperation assembling a task force to develop, refine, and regularly appraise an online BIKI database, documenting botanical use, phenotypes, mechanisms, and levels of evidence. Once established, such a database may be linked with electronic patient records and pharmacovigilance channels to generate alerts, guide clinical decision-making, direct future research, and support evidence-based regulation of herbal medicines and education of healthcare professionals and the public. Finally, to prevent BIKI, we propose that a proactive approach integrating the triad of botanicals, users, and stakeholders will be needed.

Keywords

• Adverse effects
• database
• herbal
• kidney
• mechanisms
• phenotypes
• prevention