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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 533-536
A complicated chinese herbal medicine nephrotoxicity

1 Department of Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
2 Department of Physiology, College of Medicine, King Khalid University, Abha, Saudi Arabia
3 Intensive Care Unit, Aseer Central Hospital, Abha, Saudi Arabia

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Date of Submission21-Mar-2019
Date of Acceptance02-May-2019
Date of Web Publication09-May-2020


Chinese herbal medicine is widely used globally. In many instances, it is associated with severe adverse outcomes. We report case of a Chinese herbal nephropathy occurring in a 43-year-old woman showing renal impairment, metabolic acidosis, Stokes - Adams syndrome, hypernatremia, and hypokalemia, characteristics not usually encountered in published cases.

How to cite this article:
Omer Mohamed HA, Osman OM, Ali HH, Asiri MN, Hassan AA, Almangah IM, Elkarib AO, AbBshabshe A. A complicated chinese herbal medicine nephrotoxicity. Saudi J Kidney Dis Transpl 2020;31:533-6

How to cite this URL:
Omer Mohamed HA, Osman OM, Ali HH, Asiri MN, Hassan AA, Almangah IM, Elkarib AO, AbBshabshe A. A complicated chinese herbal medicine nephrotoxicity. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2022 Nov 26];31:533-6. Available from: https://www.sjkdt.org/text.asp?2020/31/2/533/284032

   Introduction Top

The use of medicinal herbs for the treatment of various diseases is a widespread practice globally. The WHO report estimated that 80% of the world population is dependent on herbal medicine.[1] Chinese herbal medicine has a wide reputation and belief in treating various conditions (e.g., weight control, skin diseases, infertility, sexual disorders, gastric disorders, hypertension, and hepatitis).[2] The use of Chinese herbal medicine has been linked to various renal diseases.[3],[4] The nephrotoxic agent was identified as aristolochic acid.[5] It was even reported to be carcinogenic.[6] The renal lesion is a noninflammatory interstitial fibrosis.[7] However, the nephrotoxic effect of herbal medicines is not confined to Chinese herbal medicine; about one-third of all cases of acute kidney injury in Africa is related to the use of herbal remedies.[8] In many parts of the world, there is a general belief that herbs are natural and therefore harmless. Hence, it is easy to get and sell. We are reporting a case which developed a life-threatening severe renal insult after only a short period of using Chinese herbal medicine for infertility.

   Case Report Top

Informed consent was obtained from the patient before publishing the case.

A 43-year-old woman presented to the emergency room at Aseer Central Hospital, Abha in southwest Saudi Arabia with a three weeks history of persistent vomiting and fatigability. The symptoms started a week after she began to take Chinese herbal remedies for infertility.

She did not report history of chronic pain or the use of nonsteroidal anti-inflammatory drugs or other analgesic medication. She did not report any personal or family history of renal disease, cardiovascular disease, systemic hypertension, or diabetes mellitus and except for uterine fibroids myomectomy a year earlier she had been entirely well.

On examination, she was unwell, pale and dehydrated, generalized weakness. Heart rate 104/min. Blood pressure was 90/60 mm Hg.

Laboratory investigations revealed: creatinine 2.1, Na+ 161 mmol/L, CL- 158 mmol/L [Figure 1], K+ 2.2 mmol/L [Figure 2], Ca++ 8.9 mg/100 mL, Mg++ 2.5 mmol/L; acid-base status: pH 7.28, PCO2 28.8 mm Hg, HCO3 15.1 mm Hg, with a normal anion gap. She had glycosuria with normal blood glucose concentration.
Figure 1: Serum sodium and chloride chart.

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Figure 2: Serum potassium chart.

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Hours after admission her consciousness deteriorated and she developed generalized tonic-clonic convulsions. The monitor reported a heart rate of 23 beats/min. She was intubated and put on mechanical ventilation. Magnetic resonance imaging showed bilateral lentiform fork sign [Figure 3]. A pathognomic sign for metabolic acidosis.
Figure 3: Brain magnetic resonance imaging showing lentiform sign.

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On the 10th day in the ICU, she was respon-ding to verbal stimuli, but not moving her limbs.

After 16 days in the intensive care unit (ICU), the patient was extubated, started physiotherapy and was discharged after 30 days from admission. She was able to walk with support.

Medications during her admission included IV fluids, NaHCO- 3, slow K, diazepam, and atropine.

The patient was seen in the follow-up clinic after one month and she was clinically stable with stable renal function.

   Discussion Top

This case represents one of the rare manifestations of the spectrum of Chinese herbal medicine nephropathy (CHN), (now replaced by the title aristolochic acid nephropathy. The primary laboratory abnormalities in this pa-tient included metabolic acidosis with normal anion gap, hyperchloremia, hypokalemia, renal glycosuria, and hypernatremia with mild renal impairment. The hyperchloremic metabolic acidosis with renal glycosuria points to a diagnosis of Fanconi’s syndrome. Most of the cases reported following the intake of Chinese herbal medicine developed end-stage renal failure.[9] Few cases escaped with reversible forms of renal tubular acidosis including Fanconi’s type.[10] One striking feature about this case was the hypernatremia, which could not be explained by the persistent vomiting alone neither was it iatrogenic secondary to the starting of the treatment. Licorice is one of the compounds detected in East Asian herbal medicine. Licorice can cause severe hyper- natremia.[11] However, licorice poisoning symptoms include edema and hypertension due to the fluid retention which features was not seen in this patient. The severe hypernatremia may point to the fact that the administered Chinese herbal medicine could have multiple effects on different parts of the renal tubular segments. Another feature about this case was the rapid onset of the nephropathy only a week after she started the intake of the herbal medicine. Other reported cases of CHN occurred after a few months of taking medicine.[9] These differences might be related to the dose taken. The patient failed to bring a sample of the herbal medicine for the analysis and quantitation of the amount taken. However, for this particular, patient given her age and the reason for which she was taking the herb, most probably she was taking a large quantity. Moreover, Chinese herbal medicine is not one entity but rather a cocktail of different herbs; therefore, the nephrotoxic agent may vary from one type to another.

Hypernatremia can cause convulsions. However, in this patient most probably the cause of the seizures was due to Stokes-Adams syndrome since the monitor at the time of the convulsions recorded severe bradycardia. Acidosis depresses ventricular pacemaker and may precipitate complete heart block.

The weakness and decreased muscle power at the time of presentation were attributed to the hypokalemia. During her stay in the ICU, she developed quadriparesis. Her serum potassium levels were normalized, but creatine phospho- kinase was high at that time [Figure 4]. Therefore, critical care myopathy was the working diagnosis.
Figure 4: Serum creatine phosphokinase level.

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Considering the critical condition of the patient, renal biopsy and some confirmatory tests were not done.

A message from this case to nephrologists and medical practitioners, that patients presenting with renal dysfunction should be asked about the intake of herbal medicines. Most patients will not volunteer this information on the assumption that herbs are natural and harmless. Another message is for the need to increase public awareness about the potential danger of all kinds of herbal medicines, which, unfortunately, are easily available and widely used by our society. Some of the herbal medicines, which have been used for decades without causing harm, may also be potentially harmful because of the deliberate or the accidental addition of some toxic substances.

Conflict of interest: None declared.

   References Top

Farnsworth NR, Akerele O, Bingel AS, Soejarto DD, Guo Z. Medicinal plants in therapy. Bull World Health Organ 1985;63: 965-81  Back to cited text no. 1
Jadot I, Decleves AE, Nortier J, Caron N. An Integrated View of Aristolochic Acid Nephropathy: Update of the Literature. Int J Mol Sci 2017;18: pii: E297  Back to cited text no. 2
Depierreux M, Van Damme B, Vanden Houte K, Vanherweghem JL. Pathologic aspects of a newly described nephropathy related to the prolonged use of Chinese herbs. Am J Kidney Dis 1994;24:172-80  Back to cited text no. 3
Meyer MM, Chen TP, Bennett WM. Chinese herb nephropathy. Proc (Bayl Univ Med Cent) 2000;13:334-7  Back to cited text no. 4
Vanhaelen M, Vanhaelen-Fastre R, But P, Vanherweghem JL. Identification of aristolochic acid in Chinese herbs. Lancet 1994;343:174  Back to cited text no. 5
IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Some traditional herbal medicines, some mycotoxins, naphthalene and styrene. IARC Monogr Eval Carcinog Risks Hum 2002;82:1-556  Back to cited text no. 6
Depierreux M, Van Damme B, Vanden Houte K, Vanherweghem JL. Pathologic aspects of a newly described nephropathy related to the prolonged use of Chinese herbs. Am J Kidney Dis 1994;24:172-80  Back to cited text no. 7
Adelekun TA, Ekwere TR, Akinsola A. The pattern of acute toxic nephropathy in Ife, Nigeria. West Afr J Med 1999;18:60-3  Back to cited text no. 8
Vanherweghem LJ. Misuse of herbal remedies: The case of an outbreak of terminal renal failure in Belgium (Chinese herbs nephro- pathy) J Altern Complement Med 1998;4:9-13  Back to cited text no. 9
Yang SS, Chu P, Lin YF, Chen A, Lin SH. Aristolochic acid-induced Fanconi’s syndrome and nephropathy presenting as hypokalemic paralysis. Am J Kidney Dis 2002;39:E14  Back to cited text no. 10
Negro A, Rossi E, Regolisti G, Perazzoli F. Liquorice-induced sodium retention. Merely an acquired condition of apparent mineralocorti- coid excess? A case report. Ann Ital Med Int 2000;15:296-300.  Back to cited text no. 11

Correspondence Address:
Haider Ali Omer Mohamed
Department of Medicine, College of Medicine, King Khalid University, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.284032

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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