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The recent study from Taiwan which definitely connected their world-record upper urinary tract cancer rate to the high use of artistolochic acid-containing Chinese herbal formulas has me thinking a lot about the ethical issues involved.  Unfortunately, I suspect that most patients who took the batches of Seven Forests Stephania Tablets, etc. known to have contained Aristolochic Acid (and contributed to kidney failure in a some cases) were never contacted and informed about their vastly increased lifetime risk of bladder cancer and chronic kidney disease (CKD).  If any readers have evidence to the contrary, please share it and I’ll update this post.

This is wrong on so many levels…  There are early signs of kidney disease and kidney failure that are hard to put together for most people.  If they know it’s from kidney damage, they can manage it with diet.  If they don’t know, and treat rashes with creams, fatigue with stimulants, and swelling with diuretics, it will probably get worse until they collapse due to kidney failure.  With luck they would be on dialysis or get a kidney transplant.  Without luck, they just die.

Many herbal toxicity problems are temporary.  Ephedra, for example, just causes temporary increase in blood pressure.  If someone with high blood pressure took too much, it could contribute to a stroke.  But after they stop taking it, it clears out of their system and they should be fine if they managed to avoid a cerebrovascular event when they were buzzed on Ma Huang.

Aristolochic Acid (AA) is another story–it causes permanent and cumulative kidney damage and irreversible genetic mutations that dramatically increase upper urinary tract cancer (UUC) risk.  So the people who took a few tainted bottles of Stephania Tablets in 1997 or Minor Bluegreen Dragon with Asarum in it have not gotten better over time.  They’ve probably gotten worse–any other chemicals they took which hurt their kidneys just add to the likelihood of kidney failure.  What should they know about the early signs of kidney disease and bladder cancer so they can take preventative steps and get early treatment?

LifeOptions has a nice list:

1.  Changes in urination–either less and darker or more and clearer.  Foamy or bloody urine are big signs.
2. Swelling, especially the legs, ankles, and feet.  Also puffy face.  Fluid retention and related high blood pressure.
3. Fatigue–significant constant exhaustion.
4. Skin rash and itching.  Due to uremia and build up of phosphorus, etc. in the blood.
5. Metallic taste in mouth or ammonia breath.  Loss of desire to eat some foods, things tasting like iron/rust.
6. Nausea/vomiting.  Loss of appetite.
7. Shortness of breath.  Due to fluid buildup in lungs and anemia.
8. Feeling cold.
9. Concentration difficulties and dizziness.  Due to lowered oxygen.
10. Leg and flank pain.  Pain in the kidney area.  Also muscle twitches and cramps.

Perhaps you can see how if someone doesn’t connect these symptoms and tries to self-prescribe or goes to a practitioner who doesn’t pick up on the bigger picture, they could be chasing symptoms all over the place.

Here I have to put in this ancient Chinese alchemical medicine quote again, so you can compare it to the above list.  It looks like a great description of kidney failure, but the conclusion is not what we’d recommend to tell to a modern patient:

After taking the elixir, if your face and body itch as though insects were crawling over them, if your hands and feet swell with dropsy, if you cannot stand the smell of food and bring it up when you eat it, if you feel sick, if your limbs are weak, if you are prone to diarrhoea or vomiting, or if you have stomach aches, do not be disturbed, these are merely proofs that the elixir is succeeding in driving out the illness.

–an ancient text quoted in _Chinese Alchemy_ by J.C. Cooper

How can chronic kidney disease be managed with diet to reduce chances of kidney failure?

Here’s a nice summary:

Diet is an important consideration for those with impaired kidney function. Consultation with a dietician may be helpful to understand what foods may or may not be appropriate.

Since the kidneys cannot easily remove excess water, salt, or potassium, these may need to be consumed in limited quantities. Foods high in potassium include bananas, apricots, and salt substitutes.

Phosphorus is a forgotten chemical that is associated with calcium metabolism and may be elevated in the body in kidney failure. Too much phosphorus can leech calcium from the bones and cause osteoporosis and fractures. Foods with high phosphorus content include milk, cheese, nuts, and cola drinks.

Some medications, including specific minerals like calcium carbonate, can help prevent or delay the need for dialysis.

What are early signs of upper urinary tract cancer?

The most important is blood in the urine (hematuria).  However, this can be microscopic.  People with increased risk of UUC should have regular screenings at their urologist.  Depending on where the tumors grow, there may be no blockage to urine flow.  They may be significant pain in the kidney area and low back, similar to the pain from kidney stones.  This may be accompanied by nausea.

As you can see, knowledge is power for those at higher risk of kidney disease and AA-related cancers.  I hope that acupuncturists who passed along tainted formulas with Guan Fang Ji, Ma Dou Ling, Xi Xin, etc. have been made aware, and passed this important information on to the patients who took the herbs. Of course there are some significant dietary supplement product liability issues here.

As a final note for this post, I was disappointed to see a link in an evidence-based medicine blog to an page for Chinese herbs with very incorrect, outdated info about Guan Fang Ji (Aristolochia fangchi).  It doesn’t help our profession at all to have such harmful, incorrect info out there.  It makes it worse to be ‘scientific-sounding’ than just be traditional Chinese functions.  Here’s what it says (please note, this is BAD info and Aristolochic Acid causes kidney failure and cancer–it is not a treatment for cancer!):

Herb: Guan Fang Chi

Latin name: Aristolochia fangchi

Family: Aristolochiaceae (Birthwort Family)

Medicinal use of Guan Fang Chi:

The root is antirheumatic and diuretic. It is used in the treatment of rheumatic arthritis, lung disorders, oedema and oliguria. The plant contains aristolochic acid, which is an active antitumour agent but is too toxic for clinical use. Aristolochic acid has anti-cancer properties and can be used in conjunction with chemotherapy and radiotherapy. It can also be used in the treatment of acute and serious infections such as TB, hepatitis, liver cirrhosis and infantile pneumonia. It also increases the cellular immunity and phagocytosis function of the phagocytic cells.