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Aristolochic Acid Urothelial Cancer Risk — ESENeph MCQ

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HardTubular DisordersAristolochic Acid Urothelial Cancer RiskESENeph

A 50-year-old man with no prior kidney disease develops AKI (creatinine 550 umol/L) after taking a herbal supplement containing aristolochic acid for 3 months. Biopsy shows extensive tubular atrophy and interstitial fibrosis with relative preservation of glomeruli. What additional long-term risk must this patient be counselled about?

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Correct answer: B — Urothelial carcinoma of the upper urinary tract

Aristolochic acid nephropathy (formerly Chinese herb nephropathy or Balkan endemic nephropathy) causes a distinctive pattern of proximal tubular damage with rapid progression to CKD/ESKD. Crucially, aristolochic acid is a potent carcinogen that forms DNA adducts, conferring a significantly elevated lifetime risk of urothelial carcinoma, particularly of the upper urinary tract (renal pelvis and ureters). Patients require lifelong annual screening with urine cytology and imaging. The carcinogenic risk persists even after exposure cessation because DNA adducts are permanent. Some centres recommend prophylactic bilateral nephroureterectomy in patients progressing to ESKD.

Reference: Debelle et al 2008 – Aristolochic Acid Nephropathy; Nortier et al 2000 – Urothelial Carcinoma Risk