The Tragic Paradigm of Chinese Herbs Nephropathy

Subacute renal failure leading a young woman to renal replacement therapy within a few months is a sad,
though rare, reality of nephrology practice. Puzzlement is added when biopsy discloses a most unusual lesion characterized by intense, paucicellular interstitial sclerosis.

However, the simultaneous identification of several similar cases in the same area transforms medical
puzzlement into a public health concern. Worse, the discovery that the common link between these patients
is the attendance of the same slimming clinic where doctors have recently included Chinese herbs in their
'therapeutic' capsules, transforms the victims' concern into an anguishing nightmare.

Whether the recently described epidemic of Chinese herbs nephropathy (CHN) [1] will spread to a significant
extent is as yet unknown, although recent reports suggest that similar cases have been encountered
abroad. Still, this dramatic experience teaches us a series of lessons well beyond the tragedy affecting now
over 80 young women. It is certainly our responsibility to make sure that as much as possible is learned, not
only to avoid the repetition of such catastrophes but also to use the possible clues revealed by CHN to
understand the pathogenesis of renal interstitial sclerosis and, possibly the links between renal destruction
and carcinogenesis.

Chinese herbs nephropathy

The clinical picture of CHN is characteristic: virtually all affected patients are women aged 23-65 years.
Blood pressure is initially normal in over half of them. Anaemia is often present and more severe than might
be anticipated from the degree of renal failure. Proteinuria is mild and of tubular origin. The urinary
sediment is unremarkable. Renal failure is usually not suspected and, when present, discovered only by routine blood testing. All patients have in common attendance at the same slimming clinic and the consumption between 1990 and 1992 of pills containing two Chinese herbs, namely Stephania Tetrandra and Magnolia officinalis. Despite the interruption of this treatment, progression of renal failure is usually relentless over a period of a few months to a few years and has already led half of these patients to renal replacement therapy, and eventually a few to renal transplantation.

The pathological aspects include an intense, paucicellular, interstitial fibrosis with a corticomedullary gradient, atrophy and loss of tubules, a relative sparing of the glomeruli and focal, irregular thickening of interlobular and afferent arterioles. More worrying is the discovery in nephroureterectomy specimens of extensive cellular atypias of the urothelium extending from the papilla to the ureterovesical junction. In one patient these atypias evolved into microinvasive urothelial carcinoma. A similar case has been
observed by one of us (JLV).

The fibrotic process may extend beyond the kidneys as demonstrated by an intense periureteral fibrosis in
a young woman and by a marked submesothelial fibrosis of the peritoneal membrane in two patients
with an attendant alteration of peritoneal permeability. Puzzling is the observation of aortic insufficiency
in approximately one-third of the patients.

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