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Aristolochic Acid Nephropathy — ESENeph MCQ

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ModerateChronic Kidney DiseaseAristolochic Acid NephropathyESENeph

A 35-year-old woman from Southeast Asia presents with CKD G4 and normal-sized kidneys. She has a history of taking herbal remedies containing aristolochic acid for weight loss. Biopsy shows extensive interstitial fibrosis with tubular atrophy and urothelial atypia. What is the diagnosis?

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Correct answer: B — Aristolochic acid nephropathy (formerly Chinese herb nephropathy/Balkan endemic nephropathy) – a toxic tubulointerstitial nephritis with increased risk of urothelial malignancy

Aristolochic acid (found in Aristolochia species used in traditional herbal remedies) causes progressive interstitial fibrosis with rapid CKD progression. It is directly nephrotoxic and carcinogenic – forming DNA adducts that promote urothelial carcinoma (upper urinary tract). The same toxin is responsible for Balkan endemic nephropathy (environmental exposure from contaminated grain). Urothelial surveillance (cystoscopy, CT urogram) is essential given the 40-46% lifetime risk of upper tract urothelial carcinoma. There is no specific treatment beyond stopping exposure and standard CKD care.

Reference: Debelle et al 2008 – Aristolochic Acid Nephropathy; IARC – Aristolochic Acid Carcinogenicity