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21 March 2019

Researchers call for international collaboration to prevent kidney injury caused by botanicals

Call for a generalised framework to monitor and measure kidney damage caused by botanicals.


Botanicals are substances derived from plants, including herbs and herbal products that contain active ingredients from plants. They are widely used in cosmetics, herbal medicines and foods. These materials are used regularly in traditional medicine and have recently demonstrated benefits in conditions where there are currently no medical interventions.

Although botanicals may have medical benefits, some of them can have adverse effects, for example, causing kidney damage or further damage to the kidneys in patients with existing kidney problems, collectively known as botanical-induced kidney injury (BIKI). BIKIs are like adverse drug reactions (ADRs) however the scale and severity of BIKI are often hard to understand as records of BIKI are often not well documented. There is an international system for monitoring ADRs maintained by the World Health Organisation (WHO) however no such system exists for BIKIs.

There are well-established examples of BIKI. For instance, plants that contain aristolochic acids (AA) can cause kidney damage and urothelial cancers and there is a robust and well-established criterion for diagnosing AA-induced damage. However, a generalised framework to monitor and measure BIKI is lacking.

Dr Qihe Xu from the School of Immunology & Microbial Sciences and colleagues have proposed a framework for categorising the different ways BIKI is presented in patients and what has caused the injury. They believe their systems will create the basis for a well-structured database of BIKI, which will greatly boost monitoring of BIKI and promote safe use of botanicals worldwide.

They have described four categories of mechanisms which cause BIKI including general toxicity of the plant, individual responses, cumulative and delayed onset such as cancer-causing in the future or can damage DNA. The authors also described six phenotypes, or ways the injury presents itself for BIKI to be classified into, including acute kidney injury, nephrolithiasis (kidney stones), tubular dysfunction (damage or changes to the tubules of the kidney), glomerular disorder (damage to the glomeruli, where blood is filtered in the kidney), chronic kidney disease and renal or urothelial cancers.

The authors hope that by using their classification systems described above an international database can be created to document phenotypes, mechanisms and evidence of kidney injury associated with botanical use. By adding this to other databases and drug reaction monitoring programmes, an international monitoring system can be set up for BIKI, like the ADR system set up by the WHO.

Botanicals, just like any other drugs, are like fire. If we know their effects and mechanisms of action and use them properly, they can benefit us and become an important part of our civilisation. Otherwise, we would miss the opportunities they offer and could even be harmed. Given the complexity of botanicals and weakness in research so far, I’d cordially invite investment and collaborations in this important research field

Dr Qihe Xu, lead author
Diagram of the relationship between BIKI and fire
Diagram of the relationship between BIKI and fire