endemic nephropathy and hypertension · 2012. 3. 28. · jelakovi ćet al kidney int 2012 the...
TRANSCRIPT
ENDEMIC NEPHROPATHY AND
HYPERTENSION
Bojan Jelakovi ć
University of ZagrebSchool of Medicine
Department of Nephrology, Hypertension and Dialysi sUniversity Hospital Center Zagreb
ESH European Hypertension Center of Excellence
1. ENDEMIC NEPHROPATHY FOR BEGINNERS
ENDEMIC (BALKAN) NEPHROPATHY IS ARISTOLOCHIC ACID NEPHROPATHY AND IS A WORLDWIDE PROBLEM
2. ENDEMIC NEPHROPATHY AND HYPERTENSION
ENDEMIC NEPHROPATHYENDEMIC NEPHROPATHY
- Chronic tubulointerstitial nephritis
- Danube river tributaries(South East Europe- Balkan)
-Known since 1950s
- WHO 1964 and 1974 ENDEMIC NEPHROPATHY
-- Chronic tubulointerstitial Chronic tubulointerstitial
nephritisnephritis
-- Danube river tributariesDanube river tributaries
(South East Europe(South East Europe
-- Balkan)Balkan)
--Known since Known since 1951950s0s
-- WHO 1964 and 1974 WHO 1964 and 1974
ENDEMIC NEPHROPATHYENDEMIC NEPHROPATHY
- certain villages- mosaic distribution- family aggregation - households
ENDEMIC NEPHROPATHYENDEMIC NEPHROPATHY-- Prevalence diseased ~ 2 Prevalence diseased ~ 2 -- 3 % (!)3 % (!)
suspect of having EN ~ 1suspect of having EN ~ 100 --1515 % (!)% (!)
- approx 25.000 diseased and approx. 100.000 at risk
-- m : f = 1 : 1.2m : f = 1 : 1.2
-still present in all endemic villages (?)
-never in children (> 18 y.o.)
-the age distribution was shifted to older ages
(is etiological agent still present/active ?)
ENDEMIC NEPHROPATHYENDEMIC NEPHROPATHY
1. DISEASED of EN:- proteinuria < 1 g/day and / or LMW (beta2m or alfa1m) - anemia Hb < 120 g/l (m) < 113 g/l (f)- renal impairment Serum creatinine > 132.6 µmol/l- positive family history
2. “SUSPECT” of having EN- proteinuria and/or LMW - anemia or positive family history
3. “AT RISK” of EN- positive family history
4. OTHERS
1.1. DISEASED DISEASED of EN:of EN:
-- proteinuria < 1 g/day and / or LMW (beta2m or alfa1m) proteinuria < 1 g/day and / or LMW (beta2m or alfa1m)
-- anemia Hb < 120 g/l (m)anemia Hb < 120 g/l (m) < 113 g/l (f)< 113 g/l (f)
-- renal impairment Serum creatinine > 132.renal impairment Serum creatinine > 132.6 6 µµmol/lmol/l
-- positive family historypositive family history
22. . ““ SUSPECTSUSPECT”” of having ENof having EN
-- proteinuria and/or LMW proteinuria and/or LMW
-- anemia or positive family historyanemia or positive family history
33. . ““ AT RISKAT RISK ”” of ENof EN
-- positive family historypositive family history
4. OTHERS4. OTHERS
per exclusionemper exclusionemper exclusionem
residence in endemic area for more than 15 years
Proximal renal tubule cells �leading to interstitial fibrosis and chronic renal failure
urothelium � cancer
Two target tissues
- good preservation of glomeruli - a gradient of tubular atrophy - interstitial fibrosis that decreases in severity from outer-to-inner cortex
Endemic Nephropathy
• hypocellular interstitial fibrosis decreasing from outer to inner cortexdecreasing from outer to inner cortex
cortical tubular atrophytubular atrophy involving the proximal proximal tubule tubule
juxtaglomerular juxtaglomerular cells arecells are atrophicatrophic in early in early phase of diseasephase of disease
•the medulla appears relatively well preserved
•glomeruli relatively spared compared to the severity of tubulointerstitial fibrosis
Endemic Nephropathy
Insidious onset, progression to ESRD
Polyuria, nocturia
Normal BP, hypertension rareNormal BP, hypertension rare
Anemia (more severe than the CKD stage)
Upper urothelial cancers Tubular proteinuria (beta2, alfa1)
Tubular enzymuria (NAG, AAP)
Renal salt wasting
Impaired concentrating capacity
Decreased GFR
Final answerFew questions
Cosyns first called attentionto SIMILARITIES in the pathologic features of
ARISTOLOCHIC ACID NEPHROPATHYand
ENDEMIC NEPHROPATHY
Misidentification of the plant/substitution by anot her more toxi c compound.
In 1990 Aristolochia fangchi GUANG FANG JIFANG JI
was inadverently put into the slimming tea
INSTEAD OF
Stephania tetrandra HAN FANG JIFANG JI
In 1992, ~100 young women following a “slimming” regime at a Brussels spa clinic presented with end stage renal failure and, later, many of them developed urothelial cell dysplasia or cancer.
HOW ???
ETIOLOGY OF ENDEMIC NEPHROPATHY
1969
M. Ivić
Liječnički vjesnik 1969; 91:1273
investigation in Niš, Serbia
published for the first time in Liječnički vjesnik, Zagreb, Croatia
M. Ivić, Liječnički vjesnik 1969
M. Ivić, Liječnički vjesnik 1969
FIELD INVESTIGATION
... some fields of wheat in nephropathy area in the watershed of the river Južna Morava were heavily contaminated by a weed that I had never seen in the corn-fields of Vojvodina
...there were many fields without of stem of A.clematitis, but there were also fields highly contaminated by A.c., sometimes so much that the whole field became green with weed...
The wheat is used only by the peasants, the owners of the fields.(familial occurrence of EN)
... during the harvest on no occasion did I see that reapers remove the cut A.c...
... furthermore the peasants do not even know that this herb is poisonous...
... the peasants brought grain contaminated by A.c. for grinding into flour.
“Obviously, the bread of those peasants was also poisonous.”
Remarkably, over next 35 years NO ATTEMPT was madeto confirm or follow-up Ivić s prescient observation !
What a pity !What a pity !
You are a fool until your idea becomes a success.
Mark Twain
OR = 7.2
95% CI: (1.8, 29.0)
p-value < 0.01
Aristolochia in Farm Fields
Always or SometimesNever
Fre
quen
cy
20
18
16
14
12
10
8
6
4
2
GROUP
case
outside_control
Q: A. clematitis in farmfields 20 yrs ago?
Hranjec, 2005
1. Seeds of Aristolochia clematitis co-mingle with the wheat grainused by villagers in endemic regions to prepare bread.
OR = 12.1
95% CI: (2.7, 55.5)
p-value = 0.002
Aristolochia in Wheat
Always or SometimesNever
Fre
quen
cy
20
10
0
GROUP
case
outside_control
Q: A. clematitis in harvestedwheat 20 years ago?
A. clematitis Wheat
Hranjec, 2005
1. Seeds of Aristolochia clematitis co-mingle with the wheat grainused by villagers in endemic regions to prepare bread.
>>> 1 seed (1 gr 6.5 mg AA) / 1 kg bread10-15 years
Aristolactam - DNA adducts in renal cortex of Croatian patients with EN
PNAS, 20070.8 – 5.9 dA-AA adducts/10 7 Nt.0.2 – 6.2 dG-AA adducts/10 7 Nt.
PNAS, 2007
p53 mutational spectra in transitional cell carcinomasEN vs. the IARC p53 database
The Incredulity of Saint Thomas
Caravaggio, 1601 - Sanssouci, Potsdam
No PT SEX BORN VILLAGE COUNTRY DG
1MB F 1927 KANIŽA CROATIA
CA URETERIS LAT DEX
2AG M 1940 SL.KOBAŠ CROATIA
CA PYELONIS LAT SIN
3DM F 1930 SL.KOBAŠ CROATIA
CA PYELONIS ET URETERIS LAT DEX
4 EB F 1923 SL.KOBAŠ CROATIA
CA PYELONIS ET URETERIS LAT DEX
5PM M 1929 TOLISA BOSNIA
CA URETERIS LAT DEX
6 JČ F 1921 PRUD BOSNIACA PYELONIS LAT DEX
7 AF F 1934 SL.KOBAŠ CROATIACA PYELONIS LAT DEX
8 IG M 1945 SL.KOBAŠ CROATIACA PYELONIS LAT SIN
9 TF M 1932DOMALJEVAC BOSNIA
CA PYELONIS LAT SIN
10 KI F 1930 KANIŽA CROATIA
CA PYELONIS LAT SIN
11
RĐ F 1935
DOMALJEVAC BOSNIA
CA PYELONIS ET URETERIS LAT DEX
ARISTOLACTAM -DNA ADDUCTS IN RENAL CORTEX OF
SERBIAN PATIENTS WITH UPPER UROTHELIAL TRACT CANCERS
dA adducts/10 9 nts nd9 nd nd9 5 26971000 10 nd
std AZ ZMMR RP DB RB SK SM ZT AM SMSample ID
dG-AL
dA-AL
Nikolić, 2010
Croatian patient with EN (paraffin embedded tissue)
20 25 30 35Time (min)
0
50
100
0
50
100
Rel
ativ
e A
bund
ance
0
50
100
m/z200 300 400 500
412.2
292.4
395.3280.3
259.1
412.2
292.2
395.2
384.2
369.2
tR: 27.08A: 1,005
tR: 27.22A: 16,673
dA-AL-IMS3 427 →
dA-AL-IMS3 427 →
Exposed kidney DNA
Exposed kidney DNANegative control (unexposed kidney DNA)
Positive Control(dA-AL-I0ligonucleotide)
Positive Control(dA-AL-I 0ligonucleotide)
dA-AL-IMS3 427 →
Jelaković et al Kidney Int 2012
The chemical Identification and Quantitation of ALThe chemical Identification and Quantitation of AL--DNA Adducts was DNA Adducts was performed by LCperformed by LC--ESI/MS/MSESI/MS/MS33
Mass spectroscopic characterization of DNA-aristolactam (AL) adducts in the renal cortex
MUTATIONAL SPECTRA OF TP53 GENE
unpublished data
Endemic nephropathy Aristolochic acid nephropathy
Pathology identical
Clinical course difference - dose dependent
Prevalence 2-4% 3-5%of exposed population
Incidence of 30 - 50%urothelial cancer
Familal aggregation yes noyes
chronic type - China
initially normal blood pressureearly, severe anemiaaseptic leukocyturiamild LMW proteinuraprogression to ESRD
AAN and EN
1. ENDEMIC NEPHROPATHY FOR BEGINNERS
ENDEMIC (BALKAN) NEPHROPATHY IS ARISTOLOCHIC ACID NEPHROPATHY AND IS A WORLDWIDE PROBLEM
2. ENDEMIC NEPHROPATHY AND HYPERTENSION
HYPERTENSION IN ENDEMIC NEPHROPATHY
... Blood pressure is normal , and in some subjects hypertension develops in the uraemic phase
Cvoriscec et al. Clin Chem Clin Lab 1998;36:271
... patients do not suffer from edema, and their blood pressure is usually normal .Djukanovic and Radovanovic, Clinical Nephrotoxins 2003
... progressive renal failure unaccompanied by salt retention or hypertension .Stefanovic et al, Am J Nephrol 2006;26:1
... the disease is characterized by tubular proteinuria,... profound anemia and abscence of hypertension and edema. Batuman Kidney Int 2006;69:644
Mild and labile hypertension is occasionally observe d in the early stage of the disease, but becomes more frequent 30-40% in advanced renal failure
Stefanovic and Cosyns, Oxford Textbook of Nephrology 2003
Endemic Nephropathy
Why is hypertension rare in early phase ?
1. chronic tubulointerstitial nephritis that starts in cortex and gradually spread to inner parts (proximal tubule)
2. salt wasting nephropathy
3. destruction of juxtaglomerular cells(decreased renin synthesis)
4. renal medulla is not affected(preserved synthesis of PGE2 and PGI2)
Could aristolochic acid be related to later developement of hypertension in EN ?
1. epidemiologic evidence-both in “Chinese herbs nephropathy” and in EN hypertension is not characteristic of early phase and occurs in advanced stages of CKD !
2. pathologic evidence - it starts from outer cortex(PGE2 and PGI2 synthesis preserved)
3. aristolochic acid damages proximal tubule (especially S3 segment - place where ACE is mostlysynthesized in the kidney)
4. aristolochic acid destroys macula densa
Is prevalence of hypertension lower in endemic vill ages compared to other rural areas in Croatia ?
6 endemic, 2 non-endemic villages
Door-to-door (consecutive sample)Participation rate 91%> 18 y.o
Cross-sectional epidemiologic survey
1728 inhabitants (693 men 1035 women)
Dika et al, Kidney Blood Press Res, submitted
Exclusion criteria
Pregnancy
Terminal illnes (bed-ridden)
Severe disability
Limb amputation
Mental illnes
Dementia
DiabetesNephrotic proteinuira
Dika et al, Kidney Blood Press Res, submitted
Epidemiologic questionnaire
- past medical history,- family history- past exposure to aristolochic acid- life style habits- socioeconomic status
Clinical examBP – mercury sphygmomanometer (and Omron device)
(home and outpatient measurements)- ESH/ESC guidelines
LaboratoryeGFR – MDRD formulaAlbuminuria - Morning spot urine sample Alpha1 MG - Morning spot urine sample
Dika et al, Kidney Blood Press Res, submitted
Criteria for classification of inhabitants of endemic villages:a) positive family (household) history of EN; b) tubular proteinuria (α1-microglobulin >10 mg/L or >14 mg/g creatinine); c) serum creatinine >132.6 µmol/L; d) anemia (hemoglobin <120 g/L in males; <113 g/l in females); e) exclusion of other chronic kidney diseases
Diseased of EN a+b+c+d+e, or b+c+d+e, or a+b+d+e. Suspect of having EN a+b+e or b+d+e At risk for EN healthy subjects who have been living in the EN a)“Others“ inhabitants of EN villages who did not fulfillcriteria
Hypertension = BP≥140/90 mmHg, and/or current use of antihypertensive drugsTreatment of hypertension = usage of antihypertensive medication Control of hypertension =BP< 140/90 mmHg (under pharmacological treatment
Low income = monthly income < 400 EurosLow educational level = < 8 years of schooling
Dika et al, Kidney Blood Press Res, submitted
Control villages(X±SD)
Endemic villages(X±SD)
t p
Sex M/F (n) 145/211 496/ 750 0.098* 0.754
Age (years) 53.71± 17.24 50.87 ± 16.94 2.781 0.005
SBP (mmHg) 148.26 ± 28.74 145.43 ± 26.08 1.673 0.095
DBP (mmHg) 85.04 ± 12.89 85.24 ± 12.84 -0.259 0.795
BMI (kg/m2) 27.65 ± 5.35 27.01 ± 5.04 1.993 0.046
Hbg (g/L) 136.93 ± 14.30 136.13 ± 15.33 0.880 0.379
Cr (s) (µmol/L) 84.66 ± 53.63 93.07 ± 73.65 -2.386 0.017
eGFR (ml/min/1.73 m2) 71.74 ± 16.70 69.49 ± 19.17 2.002 0.045
Demographic and laboratory characteristics of the study population1602 inhabitants were considered eligible
Dika et al, Kidney Blood Press Res, submitted
EN villages Control villages χ2 P
Prevalence (%)
Total 50.8 46.5 1.879 0.005
Male 52.6 53.5* 0.058 0.811
Female 49.7 42.1 6.107 0.014
Treatment (%)
Total 36.2 37.9 0.276 0.6
Male 28.4* 27.3* 0.116 0.734
Female 41.6 46.4 2.415 0.12
Control of all hypertensives (%)
Total 7.1 7.6 0.042 0.837
Male 7 8.1 0.348 0.555
Female 7.2 7.2 0.014 0.908
Control of treated hypertensives (%)
Total 19.7 20 0.002 0.96
Male 24.7* 29.6* 3.222 0.073
Female 17.4 15.5 0.581 0.446
Prevalence, treatment and control of hypertension in endemic and control villages
*P<0.05 for differences between men and women Dika et al, Kidney Blood Press Res, submitted
DiseasedN=40
SuspectedN=76
At riskN=385
OthersN=745
Controlvillages N=356
F P
SexF/M
25/15 35/41 244/141 446/299 211/145 8.177* 0.085
Age
(years)
72.78(6,44)
61.54(15,69)
48.26(15.29)
49.95(17.05)
53.71(17.24)
30.840 <0.001
SBP
(mmHg)
163.2(27.2)
160.2(28.3)
144.5(23.6)
143.4(26.1)
148.2(28.7)
12.537 <0.001
DBP
(mmHg)
85.3(13.9)
90.1(15.2)
85.9(12.1)
84.3(12.7)
85.0(12.8)
3.899 0.004
BMI (kg/m2)
26.80(5.25)
26.79(4.85)
27.51(5.10)
26.78(5.01)
27.65(5.35)
0.060
Demographic characteristics of included subgroups
Dika et al, Kidney Blood Press Res, submitted
Diseased(N=40)
Suspected(N=76)
At risk(N=385)
Others(N=745)
Controlvillages (N=356)
F P
Cr (s)µmol/L
379.45(271.29)
103.84(49.88)
82.27(14.28)
82.18(16.21)
84.66(53.63)
315.813 <0.001
eGFR ml/min/1.73 m2
19.69(15.6)
56.38(15.7)
71.84(15.1)
72.29(17.23)
71.74(16.7)
111.247 <0.001
α1MGNmg/L
Med. 79.3 16.15 5.18 5.18 5.37
324.015 <0.001Min -Max
10.2-398 10.1-91.8 2.2-23 2.25-133 5-119
Albumin mg/L
Med. 56.2 16.35 5.47 6.12 5.78
135.561 <0.001Min -Max
3.7-700 2.59-208 2-342 2-482 2-300
Laboratory characteristics of included subgroups
Dika et al, Kidney Blood Press Res, submitted
Diseased Suspected At risk Others P
Total 86.0 72.7 54.3 45.8 <0.001
Male 87.5 70.8 58.4 46.6 <0.001
Female 85.2 75 52 45.3 <0.001
Total 56.8 32.8 36.2 35.0 0.061
Male 50.0 20.6* 29.8 27.4* 0.218
Female 60.9 46.7 40.1 40.3 0.243
Total 0 4.7 6.6 8.3 0.21
Male 0 2.9 7.7 7.9 0.528
Female 0 6.7 6 8.6 0.391
Total 0 14.3 18.4 23.8 0.061
Male 0 14.3 25.8* 28.8* 0.362
Female 0 14.3 14.9 21.4 0.204
Prevalence, treatment and control of hypertension in EN village subgroups
Prevalence (%)
Treatment (%)
Control of all hypertensives (%)
Control of treated hypertensives (%)
Dika et al, Kidney Blood Press Res, submitted
Hypertension prevalence in endemic population according to WHO criteria (only subjects with GFR > 60 ml/min)
Hypertension prevalence is higher in suspects of havi ng EN than in other farmers.
Prevalence of obesity (BMI > 30) in endemic populat ionand control non EN village
Obesity was the most prevalent in suspects.
Prevalence of hypertension regarding to BMIin EN population
Obesity influences HT prevalence in EN population
Women vs. Men
Women Men pPrevalenceEN villages 49.7 52.6 NS
TreatmentEN villages 41.6 28.4 <0.001control villages 46.4 27.3 <0.001
Control of treated HTEN villages 17.4 24.7 0.002 control villages 15.5 29.6 0.002
Education level < 8y 67.6 48.9 <0.001Income < 400Eu 73.4 61.8 <0.001
RR for hypertensionLow level of education 1.48 (CI 95% 1.35 – 1.62) P<0.001Low income 1.23 (CI 95% 1.12 – 1.62) P<0.001
No differences in age and BMI
Dika et al, Kidney Blood Press Res, submitted
1. The prevalence of hypertension is high in the Croatian endemic rural area.
2. Hypertension is not only a clinical feature of the advanced phase of EN, but also of all EN subgroups.
3. Low income and level of education, besides renal impairment and BMI, are important risk factors for hypertension in endemic villages.
4. Low socioeconomic status is a strong risk factor for hypertension and contributes not only to higher prevalence, but also to poorer control of hypertension, especially in women from EN villages
CONCLUSION
The evolution of changes in hypertension in EN is a nice example and a good lessonof how important environmental factors for development of hypertension are.
PAST
1.More exposure to aristolochic acid
2.->Proximal tubule damageDestroyed macula densa
3. ->Salt wasting nephropathyRAS
4. Late development of hypertension
---> HT is not an early feature of EN
PRESENT
1.Advances in agriculture-> exposure to nephrotoxin diminished
disappeared2. -> No tubular damage3. -> No salt wasting
4. Changes in lifestyle- obesity- stress (poor socioeconomic status)
--> Higher (earlier) prevalence of HT in EN
Acknowledgement sZvonimir Medverec urology General Hospital Sl.Brod, CroatiaKrunoslav Jakovina pathology General Hospital Sl.Brod, CroatiaTratinčica Jakovina pathology General Hospital Sl.Brod , CroatiaMato Vukelić pathology General Hospital Sl.Brod, CroatiaNinoslav Leko nephrology General Hospital Sl.Brod, CroatiaAnte Cvitković epidemiology Marica Miletić-Medved epidemiology Insitute for Public Health, County of Sl.Brod, Croatia
Croatian Center for Endemic NephropathyDamir Dittrich urology General Hospital S. Brod, CroatiaFran Borovečki functional genomics School of Medicine, University of Zagreb, CroatiaSandra Karanović nephrology School of Medicine, University of Zagreb, CroatiaIvana Vuković Lela nephrology School of Medicine, University of Zagreb, CroatiaŽivka Dika nephrology School of Medicine, University of Zagreb, CroatiaDubravka Čvorišćec clinical laboratory University Hospital Center Zagreb, CroatiaIvan Pećin internal medicine University Hospital Center Zagreb, CroatiaAnamarija Kovač Peić nephrology General Hospital Sl.Brod , Croatia Jelena Kos nephrology University Hospital Center Zagreb, CroatiaMaja Mišić cytology General Hospital Sl.Brod, CroatiaKarla Tomić pathology General Hospital Sl.Brod , Croatia Branko Brdar molecular biology Institute Ruđer Bošković, Zagreb, CroatiaNeda Slade molecular biology Institute Ruđer Bošković, Zagreb, CroatiaIvan Habuš organic chemistry Institute Ruđer Bošković, Zagreb, Croatia
Francis Johnson organic chemistry SUNY, USARob Turesky mass spectrometry U of Albany, USAKate Dickman epithelial cell biology SUNY, USATom Rosenquist genetics SUNY, USAShinya Shibutani rodent model of AAN SUNY, USAHeidi Einholf drug metabolism Novartis, USAFred Miller pathology SUNY , USA
Jiri Zavadil microarray analysis NYU, USABruce Weir biostatistics U of Washington, USAKaren Edwards genetic epidieiology CDC U of Washington, USA
Želimir Stipančić nephrology General Hospital Odžak, Bosnia and HerzegoviniaJovan Nikolić urology Urology Clinicl Belgrade, Serbia
Supported by NIEHS, the Fogarty Center and the Ministry of Science (Croatia)
Co PI Arthur P GrollmanBojan Jelaković
Croatian endemic area, harvest 2007
Aristolochia clematitis